Trust – the basis for health and democracy

Since Covid-19, health issues divide people. Those with the power to make change must consider the establishment of trust as a key public health goal and a critical factor for the survival of democracies

Throughout the G7 members we are witnessing a significant trust gap in government and its institutions, including in public health. This is partly a response to the measures taken – or not taken – during the Covid-19 pandemic, but, as recent surveys show, the lack of trust goes much deeper and has been developing over a longer time. A recent report by the Pew Research Center showed that a median of nearly 60% of people surveyed in 24 countries are dissatisfied with how democracy is working. This must be a wake-up call for the G7, which defines itself as a ‘club of democracies’. 

Trust has been the key factor explaining the difference among countries with respect to Covid-19 outcomes. Trust in government improves outcomes, as does interpersonal trust. Research shows little indication that authoritarian regimes performed better than democracies with high levels of trust. The trust gap has strong links to the equity gap and more unequal societies showed higher Covid-19 death rates. This too, has increased in many countries. The country that did best is not a G7 member: it is Taiwan, which ranks high on the democracy index. 

Recent surveys show that democracy has continued to contract worldwide, with declines in at least one indicator of democratic performance. Performance of democracies, especially in periods of crisis, is the concern at stake. Obviously, this includes many different dimensions, but for many people it relates to the issue of whether democracies are delivering on their promise of equity, security and participation. Indeed, in his book How Democracy Ends, David Runciman highlights two factors that are essential: democracies must offer people dignity and long-term benefits. Both are rooted in solidarity. Both are critical for health and well-being.

A long-term exercise

Accordingly, the 2023 Global Preparedness Monitoring Board Annual Report notes that restoring trust is a “long-term exercise and must begin now with the implementation of trust-building measures, including making governance more inclusive, engaging civil society, taking preparedness closer to the populations most in need, and investing in monitoring as the foundation of mutual accountability”. 

Well-functioning health systems are a central feature of the social contract between governments and their people. The World Health Organization’s constitution highlights the right to health and Sustainable Development Goal 3 calls for access to health care without the threat of falling into financial hardship – termed universal health coverage. To deliver on this promise, countries need to have strong, efficient and equitable health systems that are rooted in the communities they serve. 

The G7 countries rank very differently in relation to health equity and performance. The high performers stand apart from the United States in providing universal coverage and removing cost barriers, investing in primary care systems to reduce inequities, minimising administrative burdens and investing in social services among children and working-age adults, according to the Commonwealth Fund in 2021. Most G7 countries are struggling to meet the challenges facing healthcare systems in terms of both delivery and financing, even more so in the wake of Covid-19. 

Since this 2021 analysis, the competition for resources has also increased as a changed geopolitical situation has led to significant shifts in budgetary allocations towards military expenditures. People experience this crunch in significant ways: longer waiting times, increases in premiums and costs of medicines, neglect of prevention and lack of care. Increasingly, health care offers people neither dignity nor security and they experience a lack of fairness as affordability and access decline. 

Systems that inspire trust

Democracies need healthcare systems and public health institutions that inspire trust. Health and well-being in the past have brought people together in a common commitment to a system that serves all people – but following on from Covid-19 health issues now divide people. Measles is back in the world’s most developed countries as parents have lost trust in vaccines. The evidence base of public health actions is questioned as people have lost trust in science. Misinformation and disinformation on many health issues spreads through social media, as people have lost trust in official sources of information. 

Ministers of health, public health institutions and professionals need to consider the establishment of trust as a key public health goal and a central component of pandemic preparedness. Health systems must inspire trust – they are key for the two critical factors for the survival of democracies that Runciman has proposed: dignity and long-term benefits. If the G7 members are serious about democracy, they must urgently address the lack of trust as a risk factor for health.