Overview of Traditional Medicine in ECOWAS Member States

Kofi Busia1
Ossy MJ Kasilo2

1. West African Health Organization
2. WHO Regional Office for Africa

Corresponding author:
Kofi Busia
E-mail: kbusia@wahooas.org

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ABSTRACT

Traditional medicine has been the main source of healthcare for the vast majority of people in the Economic Community of West African States (ECOWAS). It is currently estimated that between 70-80% of West Africans use traditional medicine for the management of both communicable and non-communicable diseases. In 2007, the West African Health Organization (WAHO) conducted a situational analysis to assess the level of development of traditional medicine in its member states. The findings showed that although there was strong political will from West African governments for the development of traditional medicine, the disparities in the level of development among the countries were very huge. For instance, it was observed that whist some countries had advanced to the stage where they had established training institutions and had herbal medicines on their essential medicines lists, others had not even developed national traditional medicine policies and legal frameworks, codes of ethics and strategic plans for implementation of national policies. Although all countries have made very good progress in the area of sensitization and popularization of traditional medicine, some others have made good progress in the development of national traditional medicine policies (11 out of 15). However, no country has a health insurance coverage for TM, alternative and complementary medicine. Intellectual property is still a relatively new area and this situation delays the development of frameworks for the protection of traditional knowledge and access to biodiversity in majority of Member States.



RÉSUMÉ

La médecine traditionnelle a été la principale source de soins médicaux pour la grande majorité des personnes de la Communauté économique des états de l'Afrique de l'Ouest (CEDEAO). Actuellement, on estime qu'entre 70 et 80% des Africains de l'Ouest ont recouors à la médecine traditionnelle pour le traitement des maladies transmissibles et non transmissibles. En 2007, l'Organisation Ouest-Africaine de la Santé (OOAS) a effectué une analyse de la situation pour évaluer le niveau de développement de la médecine traditionnelle dans ses Etats membres. Les résultats ont montré que, même s'il y avait une forte volonté politique des gouvernements ouest-africains pour le développement de la médecine traditionnelle, les disparités au niveau du développement entre les pays étaient considérables. Par exemple, on a observé que pendant que certains pays avaient progressé en créant des institutions de formation et en incluant des plantes médicinales sur leurs listes de médicaments essentiels, d'autres n'avaient même pas mis au point des politiques nationales de médecine traditionnelle, des cadres juridiques, des codes d'éthique et des plans stratégiques pour la mise en œuvre des politiques nationales. Bien que tous les pays aient fait de grands progrès dans le domaine de la sensibilisation et de la vulgarisation de la médecine traditionnelle, d'autres ont bien progressé dans l'élaboration des politiques nationales de médecine traditionnelle (11 sur 15). Cependant, aucun pays n'a un système de couverture d'assurance maladie pour la médecine traditionnelle, les médecines alternatives et complémentaires. Dans la majorité des Etats membres, la propriété intellectuelle est un domaine encore relativement nouveau. Cette situation retarde l'élaboration de cadres juridiques pour la protection des connaissances traditionnelles et l'accès à la biodiversité.

SUMÁRIO

A medicina tradicional tem sido a principal fonte de cuidados de saúde para a vasta maioria de pessoas da Comunidade Económica dos Estados da áfrica Ocidental (ECOWAS). Estima-se actualmente que entre 70-80% dos habitantes da áfrica Ocidental usem a medicina tradicional na gestão de doenças comunicáveis e não comunicáveis. Em 2007, a Organização Oeste-Africana de Saúde (WAHO) conduziu uma análise situacional para avaliar o nível de desenvolvimento da medicina tradicional nos seus estados-membros. Os resultados mostraram que apesar da forte vontade política dos governos Oeste-Africanos no sentido do desenvolvimento da medicina tradicional, as disparidades no nível de desenvolvimento entre os países eram imensas. Por exemplo, observou-se que enquanto alguns países haviam avançado para a fase em que haviam estabelecido instituições de formação e possuíam medicamentos à base de plantas nas suas listas de medicamentos essenciais, outros ainda nem haviam desenvolvido políticas nacionais e estruturas legais de medicina tradicional, códigos de ética e planos estratégicos para a implementação de políticas nacionais. Embora todos os países tenham operado um progresso muito positivo na área da sensibilização e popularização da medicina tradicional, outros lograram um bom progresso no desenvolvimento de políticas nacionais de medicina tradicional (11 de 15). Contudo, nenhum país dispõe de uma cobertura de seguros de saúde para a MT, e medicinas alternativas e complementares. A propriedade intelectual é uma área ainda relativamente nova e esta situação atrasa o desenvolvimento de estruturas para a protecção do conhecimento tradicional e do acesso à biodiversidade na maioria dos Estados-Membros.


Globally, there is now a general recognition that traditional medicines, the medicines once described as primitive, could be mankind's saving grace – and, therefore, within the past three decades, the changing view of herbs in particular, as medicines moved from that of "witches brew" to major medicine(1). It is estimated that out of a global population of approximately 6.3 billion, about 4 billion utilize plants to meet their primary health care (PHC) needs, It is also now recognized that about half the people in industrialized countries regularly use what is described as complementary and alternative medicine (CAM). However, this growth in consumer demand and availability of services for complementary medicine has outpaced the development of policy by governments and health professions.

Traditional medicine has been the main source of healthcare for the vast majority of people in the Economic Community of West African States (ECOWAS). It is currently estimated that between 70 and 80% of West Africans use traditional medicine for the management of both communicable and noncommunicable diseases such as cancer, malaria, HIV/AIDS, diabetes, hypertension, and tuberculosis. Available records show that a high percentage of rural populations utilize traditional midwifery for their maternal and neonatal health problems. In several African countries, traditional birth attendants (TBAs) assist in the majority of births. A study carried out by WHO showed that in Ghana, Mali and Nigeria, the first line of treatment for 60% of children with high fever resulting from malaria is the use of herbal medicines(2). As part of the global effort to institutionalize traditional medicine in the health systems of Member States of the WHO, several countries including those of the ECOWAS Region have signed up to various traditional medicine-related declarations and resolutions.

In response to the growing recognition of the potential of traditional medicine, the West African Health Organisation (WAHO), a specialised agency of ECOWAS, at the behest of the Region's Heads of State, established its traditional medicine programme in 2007, with the objective of supporting the ECOWAS countries to institutionalize traditional medicine in their health systems. This decision was epoch-making in the sense that it marked ECOWAS as the first Regional economic community to take concrete steps towards the attainment of the Alma-Ata Declaration of 1978(3). At the 2009 African Traditional Medicine Day held in Lagos, the State Governor Babatunde Fashola reiterated the pivotal role of traditional medicine in healthcare delivery in Africa and its potential to contribute to the attainment of the health-related provisions of the Millennium Development Goals (MDGs), stressing that "reduction of child mortality, improving maternal health and combating HIV/AIDS, malaria, tuberculosis, leprosy, malnutrition, among others, are all linked to how far we are able to harness the hidden potential of our traditional medicine(6).

In addition, the sub-Region identified key priority areas for interventions, taking into account the available resources and challenges faced: establishment of sub-regional associations of traditional medicine practitioners (TMPs) for efficient policy and program implementation; development of guidelines and standards of registration modalities for TMPs; development of an integrated programme for training of TMPs and health personnel; protection of intellectual property rights and traditional medical knowledge; promotion of dialogue between TMPs and orthodox health personnel to enhance mutual trust and respect; promotion of research into traditional medicine,, particularly herbal medicines, as well as promotion of conservation, local production and cultivation of medicinal plants. It is worth noting that the choice of all these priority interventions was informed by the WHO Regional Strategy(3). This article will highlight and discuss the findings of the situation analysis of traditional medicine development in ECOWAS Member States, challenges and propose the way forward with a view to creating awareness to policy makers and stakeholders.

Situational Analysis of Traditional Medicine Developement in the ECOWAS Member States

As a critical first step, WAHO conducted a situational analysis in 2007 to assess the level of development of traditional medicine in the member states; and some of the findings are reflected in Table 1 and are discussed in the following sections.

Organizational structures, national policies, and regulatory frameworks for traditional medicine practice

It was observed that nearly all the countries had established either a National traditional medicine office or a traditional medicine programme in the Ministry of Health (MOH), although with the exception of a few, notably Benin, Burkina, Cote d'Ivoire, Ghana, Mali and Nigeria, many did not have a budget line for traditional medicine activities in their national health budgets. Eleven out of the 15 countries in the sub-Region had a national traditional medicine policy whereas 9 countries had a law and regulation of traditional medicine (Table 1); with only 7 countries having a regulatory framework for traditional medicine practice(7). Even countries such as Guinea, which was the first to develop a national policy in 1994, well before the declaration of the Decade of African Traditional Medicine in July 2001 and the adoption of the WHO Resolution on traditional medicine in August 2000(3), does not have a legal framework and code of ethics and practice to date, but has a strategic plan which was developed in 2005. Cape Verde, Guinea Bissau and Liberia need to join the other countries to develop their traditional medicine sector.

It was therefore acknowledged that a sub-Region-specific harmonized policy and regulatory framework suitable for use by member states would help to address some of the problems confronting the traditional medicine sector. Using the WHO Tools for the institutionalization of traditional medicine in health systems(8) and the national policies from countries which already had them, a harmonized document was developed in Accra and validated by all the member states in Lomé in August 2008. It is reassuring to note that since the development of this document, in June 2010, Togo revised its national policy of 1996 and financial support has been given to Guinea Bissau and other countries to develop national policies.

Research and development of improved traditional medicines

Some research institutions in the region have made giant strides in conducting R&D for validating the safety, efficacy and quality of traditional medicines used for priority diseases such as malaria, HIV/AIDS, diabetes, sickle-cell anaemia and hypertension. For example, researchers from countries such as Burkina Faso, Ghana, Mali and Nigeria, have reported that clinical trials on traditional medicines used for malaria compared favourably with the recommended national standard treatment(9). Furthermore, Benin, Burkina Faso, Cote d'Ivoire, Ghana, Mali, Nigeria, Senegal and Togo among others showed that administration of some traditional remedies led to increased CD4/CD8 counts, decreased viral load, increase in weight gain in some patients, improvements in the quality of life and clinical conditions of people living with HIV/AIDS (PLWA)(9).

In yet other scientific investigations conducted in Benin, Ghana, Mali and Nigeria, subjects suffering from Type II diabetes treated exclusively with traditional medicines were reported to have decreased blood glucose level and the low-density lipoproteins; but increased insulin release from the tissues as well as glucose uptake by the tissue(11). Other countries are conducting research on other medicinal plants in addition to the five priority diseases such those used for hepatitis, ulcers, hypertrophy of the prostate, reproductive health and as immune boosters(9). The most frequent reason given by physicians for not accepting the use of traditional medicine is that they perceive such therapies as lacking rigorous scientific support. As the global and regional strategies(2,4) and the Beijing Declaration notes(10), for integration of traditional medicine in national health systems to be achieved, it is important that traditional medicine research be vigorously promoted.

Education and training

Education and training are among the key ingredients required for the institutionalisation of traditional medicine in national health systems. Some countries within the Region have already begun training programmes in traditional medicine. For example, the Kwame Nkrumah University of Science and Technology, Ghana, established a Bachelor of Science Degree in Herbal Medicine in 2001 to train medical herbalists. At the time of its inception, it was thought to be the first of its kind on the African continent, but now countries such as Burkina Faso have also established a Diploma course in Traditional Medicine, while efforts are being made in Guinea and Sierra Leone to develop a Masters Degree(7,9). In Nigeria, which boasts of some internationally renowned plant medicine research scientists, emphasis is being placed on the training of CAM practitioners as they have established a college to offer degree programmes in CAM.

Training materials for THPs have been developed by Burkina Faso, Ghana, Mali, Senegal etc.(9) while Ghana reported that a training manual for THP's developed in 2005 will be reviewed in 2010 in line with WHO training tools(12,13). In collaboration with the non-governmental organization (NGO), Africa First Ltd., in 2006, the Ministry of Health in Ghana, organized a Global Summit on HIV/AIDS, traditional medicine and traditional medical knowledge in Accra(14). Such activities have since been organized in 2008 in Accra, 2009 in Kumasi and 2010 in Cape Coast. Burkina Faso and REJOUMETRA (a network of journalists for promotion of traditional medicine) have trained over 200 THPs and 200 conventional medicine practitioners (CHPs) on good manufacturing practices and on ethnomedical evidence, respectively. Mali organized training workshops on intellectual property rights (IPRs) for THPs and CHPs and researchers in Bamako in 2006 and 2007(9).

Research, education and training are key strategic objectives of WAHO. In pursuit of its objective of strengthening the capacities of both TMPs and CHPs on traditional medicine research, a team of experts from the ECOWAS countries met in 2009 to develop training modules on the six priority diseases (HIV/AIDS, TB, sickle-cell anaemia, malaria, diabetes and hypertension) for TMPs and CHPs. The project will soon be piloted in three countries to assess its strengths and weaknesses to inform future review and validation. At the same time, ongoing training programmes will be supported while efforts are made to support other countries to establish their own. WAHO recognizes the importance of traditional medicine research for the promotion and integration of traditional medicine and will therefore collaborate with the WHO/AFRO to provide both technical and financial support to research institutions to intensify their traditional medicine research activities, particularly on plant medicines for the treatment of priority diseases.

Collaboration between practitioners of traditional medicine and conventional medicine

The regional strategy on traditional medicine(4) and plan of action on implementation of the Decade of African traditional medicine(7), call on countries to establish mechanisms of collaboration between CHPs and TMPs in areas such as referral of patients and information exchange at local level to facilitate the institutionalization of traditional medicine in their health systems. Despite these policy orientations, the situation analysis indicated that although there was an informal integration, in the form of cross-referrals, research, training, and prevention of HIV infection, etc., the majority of CHPs still remained uninterested or against integration. However, prescription of herbal medicines by doctors was taking place in Mali, Ghana, Cote d'Ivoire, Senegal and Nigeria. The situational analysis also showed that decades of disregard from governments had created mistrust between THPs and CHPs. Even in countries where serious efforts are being made to promote traditional medicine, co-operation with TMPs existed primarily with TBAs, who are perceived to have much affinity with the practical approach of Western medicine(15). There are several examples of such useful collaboration around the world which could serve as a basis for the promotion of such collaboration in the Region. For example, health care for the multicultural community of Otavalo, Ecuador, which has been provided by the Jambi Huasi clinic established in 1984(16) for over 20 years.

In order to foster collaboration between the two sectors, WAHO has taken steps to engage the custodians of TM, research scientists and clinicians in respective countries in fruitful dialogue. For example, integrated training programmes, which emphasize the therapeutic benefits of a sensible fusion of conventional medical best practices with herbal therapeutics in treating diseases are being developed. In addition, an annual scientific congress between TMPs and CHPs has been institutionalized and has been running for the last two years.

Collaboration between practitioners of traditional medicine and conventional medicine

In 2002, some countries in the Region, such as Liberia, Mali and Sierra Leone, reported being engaged in cultivation of medicinal plants. Burkina Faso had indicated that botanical gardens would be established in all regions in 2008, but is already cultivating Artemisia annua. Ghana also reported that associations for the planting and collection of commercially important medicinal plants e.g. Moringa oleifera, Voacanga africana, Artemisia annua have been formed and are being strengthened. Mali established botanical gardens for THPs in Siby, Kolokani, Badiangara and Bamako, in 2002 and 2005-2007(9). Ghana developed a Manual on Cultivation and Harvesting of Medicinal Plants in 2003 by adapting WHO guidelines on Good Agricultural and Collection Practices (GACP)(17) of Medicinal Plants. However, only Burkina Faso, Ghana and Mali have developed policy documents related to conservation of medicinal plants and other countries efforts need to be made in this regards.

Collaboration between practitioners of traditional medicine and conventional medicine

It was found that manufacturing activities for local production of African traditional medicines were carried out in Benin, Burkina Faso, Ghana, Mali, Nigeria and Senegal. Ghana's Centre for Scientific Research into Plant Medicine established since 1973, produces on a small scale herbal preparations for utilization in a clinical setting. In Mali, several herbal products derived from Euphorbia hirta (for dysentery) (Fig 1), Cassia italica and Combretum micranthum (both for constipation), have been formulated as tea bags by private herbal industries for clinical application(10). The Department of Pharmacognosy of Obafemi Awolowo University, Ile-Ife, Nigeria, has embarked on the manufacture of many standardized herbal preparations, specifically for use in the management of different opportunistic infections in people living with HIV/AIDS. These include antithrush, febrifuge, antidiarrhoeal, antidysentery, anticough, and anti-infective preparations(18). In 2003, researchers found scientific evidence supporting the efficacy of traditional Ghanaian plants for the treatment of wounds(19,20).

Figure 1. - Euphorbia Hirta

Burkina Faso, Ghana, Mali and Nigeria have issued marketing authorization for traditional medicines(10) whereas Burkina Faso, Mali and Niger have reported to have included traditional medicines in their national essential medicines list(10). Ghana has established a national register of essential traditional medicines and monographs on the plants, which constitute the essential traditional medicines have been compiled(21).

Despite some progress made, ECOWAS member states need to enhance the creating of an enabling policy and regulatory environment to ensure that large-scale manufacturing is carried out in line with the African Union Decade of African Traditional Medicine(5), the Pharmaceutical Manufacturing Plan for Africa(22) and the Regional Strategy on Traditional Medicine(4). WAHO in collaboration with the WHO will continue to support countries to document traditional medicines for scientific evidence on safety, efficacy and quality; and to identify herbal medicines of proven safety and efficacy for their large-scale local production through a Public-Private Partnership approach.

Collaboration between practitioners of traditional medicine and conventional medicine

To date, many countries in the ECOWAS do not have national herbal pharmacopoeias. Although, countries such as Burkina Faso, Cote d'Ivoire, Guinea, Mali and Senegal, have some documented evidence of proper use of their medicinal plants through R&D of national monographs, only Ghana(23,24) and Nigeria(25), have national herbal pharmacopoeias. Since their publication, these pharmacopoeias have helped to promote the responsible use of herbal medicines, both in terms of safety and efficacy and formulated standards of identity, purity and analysis in these countries. However, these documents have clearly shown that whereas sufficient laboratory research has been undertaken to substantiate the ethnomedical uses of many African medicinal plants, information on properly controlled clinical trials is almost non-existent. In all a total of 57 medicinal plants (e.g. Fig. 2(a) and 2(b), common to the countries of ECOWAS, have been chosen to feature in the Pharmacopoeia (details are given elsewhere in this special issue).

Figure 2(a). - Cassia Occidentalis L.

Figure 2(b). - Argemone Mexicana L.

Collaboration between practitioners of traditional medicine and conventional medicine

One of the objectives of the Regional Strategy on Traditional Medicine is to establish mechanisms for the protection of cultural and intellectual property rights(4). In the sub-Region, Cote d'Ivoire carried out a survey among TMPs that has recorded more than 2,000 traditionally used plants. In 2007, Ghana developed a national policy on protection of IPRs which was reviewed in 2008. In 2006 and 2007 Nigeria developed national legislation and Bill on IPRs whereas Mali organized a series of national and sub-Regional workshops for the protection of traditional medical knowledge (TMK). Ghana developed a database on Ethnobotanical Floristic Studies and Traditional Medicine Pharmacopoeia in 2000 and Senegal developed a database of THPs in 2003. Benin and Mali reported to have established in 1999 and 2004 databases related to 7,500 THPs and TMK and access to biological resources respectively. This is an area that WAHO will collaborate with WHO and other relevant partners to support member states develop national policies and regulatory frameworks, carry out national inventories of medicinal plants to ensure that indigenous knowledge is used correctly and continuously over generations, obtain patents protection, establish databases, and Traditional Knowledge Digital Libraries (TKDL) to document formulations used in traditional medicine to prevent misappropriation as it is done in India.


Challenges

Challenges confronting the traditional medicine sector are related to: weak organizational and institutional frameworks for regulating the practice of traditional medicine and for the protection of traditional medical knowledge; limited funding, limited involvement of THPs in the institutionalization process and weak dissemination and information exchange on research results where this is available. There is also limited inventories on medicinal plants and documentation on traditional medicine practice, therefore difficult to know how it functions and poor collaboration between biomedical practitioners and traditional health practitioners.

The Way Forward

At the 11th Ordinary Session of the Assembly of ECOWAS Health Ministers organised by WAHO in Freetown, Sierra Leone in April 2010, a round-table meeting was held during which a presentation titled "Traditional medicine within ECOWAS Region: achievements, prospects and challenges", was made. The presentation generated stimulating discussions at the end of which experts from the member states called on WAHO and its stakeholders to:

It is hoped of all the advocates of good traditional medicine practices attention would be given to these concerns to ensure the realisation of the ideals, which inspired the inception of the WAHO traditional medicine programme.

Conclusion

The situation analysis has shown that member states are at different stages of implementing the regional strategy on promoting the role of traditional medicine in health systems(3) and plan of action on the Decade of African Traditional Medicine. As we enter the second decade of the 21st century, the ECOWAS Member States will have to take total responsibility for the health of their people. Institutions such as the WHO, WAHO and other partners, will obviously provide the needed financial and technical assistance, but in the end the key decisions to drive the traditional medicine sector will have to come from the countries. Additional financial resources for conducting clinical trials and for local production of traditional medicines need to be increased if traditional medicine is to occupy its rightful place and mainstreamed in health systems and services.

We tend to agree with Prof Honolu Konotey, the renowned Ghanaian sickle-cell physician who said: "Unless Africans can find alternative sources of therapeutic measures in traditional medicine, the future is bleak indeed, because even with improvement in public health measures, people will still require drug treatment. We therefore need to collect and record all anecdotes, including the embarrassing and most primitive ones. By sifting through them carefully we can use our scientific knowledge not only to discard harmful practices, but also discover hidden treasures(26).


REFERENCES