Ossy MJ Kasilo(2)
1. West African Health Organization
2. WHO Regional Office for Africa
Ossy MJ Kasilo
Since the early 1970s, the WHO has repeatedly advocated for the recognition of Traditional Health Practitioners (THPs) as Primary Healthcare (PHC) providers and for the integration of traditional medicine in national health systems. Several calls have been made on governments to take responsibility for the health of their people and to formulate national policies, regulations and standards, as part of comprehensive national health programmes to ensure appropriate, safe and effective use of traditional medicine. One of the priorities of the African Regional Strategy on Promoting the Role of TM in Health Systems is promotion of collaboration between practitioners of traditional and conventional medicine. However, despite the health benefits such collaboration could bring to the populations, decades of disregard of traditional medicine practices and products has created mistrust between the two sectors hampering all the efforts being made to promote this potentially useful partnership. This article outlines the strategies that have been adopted by the WHO to ensure the integration of traditional medicine into national health systems, examples of ongoing collaboration between research institutions and THPs based on research and management of patients; and between THPs and conventional health practitioners in HIV/AIDS prevention and care and HIV/AIDS/STI/tuberculosis programmes; factors that have contributed to sustaining these partnerships as well as mechanisms for strengthening such collaborations.
Depuis le début des années 1970, l'OMS a maintes fois plaidé en faveur de la reconnaissance des tradipracticiens en tant que pourvoyeurs de soins de santé primaires (SSP). Elle a également plaidé pour l'intégration de la médecine traditionnelle dans les systèmes de santé nationaux. Les gouvernements ont été sollicités plusieurs fois. On leur a demandé de prendre sous leur responsabilité la santé de leurs populations et, dans le cadre de vastes programmes nationaux de santé, d'élaborer des politiques nationales, des règlements et des normes afin d'assurer une utilisation appropriée, sûre et efficace de la médecine traditionnelle. L'une des priorités de la stratégie régionale africaine pour la promotion du rôle de la médecine traditionnelle dans les systèmes de santé est la promotion de la collaboration entre les praticiens de la médecine traditionnelle et ceux de la médecine conventionnelle. Cependant, malgré les avantages qu'une telle collaboration pourrait apporter à la population, des décennies de non-respect des pratiques de la médecine traditionnelle et des produits ont créé une méfiance entre les deux secteurs, entravant ainsi tous les efforts faits pour promouvoir ce partenariat potentiellement utile. Cet article décrit les stratégies qui ont été adoptées par l'OMS pour assurer l'intégration de la médecine traditionnelle dans les systèmes de santé nationaux. Il donne des exemples de collaboration en cours entre les institutions de recherche et les tradipracticiens, basée sur la recherche et la gestion des patients, et également entre les tradipracticiens et les praticiens conventionnels de la santé en matière de prévention et de soins du VIH/SIDA et des programmes de VIH/SIDA/MST / tuberculose. Enfin, cet article traite des facteurs qui ont contribué au maintien de ces partenariats ainsi que des mécanismes de renforcement de ces collaborations.
Desde o início da década de 1970, a OMS tem advogado repetidamente o reconhecimento dos Praticantes de Saúde Tradicional (THP) como prestadores de Cuidados de Saúde Primários (CPS) e a integração da medicina tradicional nos sistemas de saúde nacionais. Foram levadas a cabo junto dos governos várias solicitações no sentido de assumirem a responsabilidade pela saúde das suas populações e de formularem políticas nacionais, regulamentações e normas, como parte de programas completos de saúde nacional para assegurar a utilização apropriada, segura e eficaz da medicina tradicional. Uma das prioridades da Estratégia Regional para a Promoção do Papel da MT nos Sistemas de Saúde Africanos é a promoção da colaboração entre os praticantes de medicina tradicional e convencional. Contudo, apesar dos benefícios para a saúde que tal colaboração poderia proporcionar às populações, décadas de desrespeito nas práticas e produtos da medicina tradicional criaram desconfiança entre os dois sectores, dificultando todos os esforços que estão a ser feitos no sentido promover esta parceria potencialmente útil. Este artigo sublinha as estratégias que foram adoptadas pela OMS no sentido de assegurar a integração da medicina tradicional nos sistemas de saúde nacionais, exemplos de colaboração contínua entre as instituições de pesquisa e os THP com base na pesquisa e gestão de doentes; e entre os THP e os praticantes de saúde convencional na prevenção do VIH/SIDA e nos cuidados e programas de combate ao VIH/SIDA/DST/tuberculose; factores que contribuíram para a sustentabilidade destas parcerias, assim como os mecanismos de fortalecimento de tais colaborações.
A number of key resolutions were adopted (2,3,4,6) culminating in the development of the landmark document, "Promoting the Role of Traditional Medicine in Health Systems: A Strategy for the African Region" (5), which seeks to promote "integration" of traditional medicine practices and medicines for which evidence on safety, efficacy and quality is available, and the generation of such evidence when it is lacking, into health systems. In this context "integration" means increase of health care coverage through collaboration, communication, harmonization and partnership-building between conventional and traditional systems of medicine, while ensuring the protection of intellectual property rights and indigenous knowledge.
The Regional strategy also calls for institutionalization of TM through the development of mechanisms for official recognition of TM and promotion of effective collaboration between conventional health practitioners (CHPs) and traditional health practitioners (THPs). In addition, the World Health Report 2006, "Working together for health", highlights the importance of human resources for health (7). The shortage of trained health professionals is among the main obstacles to strengthening low-income countries' health systems and to scaling up HIV/AIDS control efforts. THPs have been identified as a vital resource for scaling up comprehensive HIV/AIDS care and prevention strategies in sub-Saharan Africa (8-11). An appropriate and effective response to the HIV/AIDS crisis therefore requires reconsideration of the collaboration between THPs and CHPs as already documented (8-11). However, there needs to be more communities' views on prerequisites for collaboration between modern and traditional health sectors in relation to STI/HIV/AIDS care (12).
Consequently, over the last decade, there has been renewed interest in fostering effective collaboration between practitioners of the two systems of medicine as part of attempts to strengthen control of the AIDS epidemic, which has placed a heavy burden on already weakened health systems in sub-Saharan Africa. In pursuit of this objective, the fourth African Traditional Medicine Day in 2006 was also commemorated with the theme, "Scaling up Collaboration between THPs and CHPs in the Prevention of HIV/AIDS". This was in line with the launch by the African Union and the United Nations system of 2006 as the "Year for Acceleration of HIV Prevention".
However, as a result of the level of mistrust that exists between the two health sectors, innovative strategies that would promote mutually-beneficial collaboration (some of which are summarised in Box 1) (13) would be required.
Box 1. Proposed mechanisms for strengthening of collaboration between traditional health and conventional medicine practitioners:
Given the increasing popularity of traditional medicine globally, it is imperative that medical and other healthcare personnel collaborate with THPs to understand traditional medicine practices and products. There are two main reasons why such collaboration is important. First it is important for health personnel to have an understanding of all the health services their patients may be accessing. Secondly, health personnel (especially general practitioners, nurses and pharmacists) are often used by patients as an information source for all health and health-related issues. An understanding of traditional medicine will therefore enable them to advise their patients appropriately.
Functional collaboration between THPs and biomedical researchers is also required for validation of the claims of THPs. Such collaborations will facilitate the assessment of the quality, safety and efficacy of the plant raw materials and the finished medicinal products. In addition, with the increasing burden of various communicable diseases, particularly HIV/AIDs and malaria on the health systems of Member States, it is imperative that any primary health care (PHC) delivery plans draw on the skills and knowledge of THPs especially because of their close proximity to the community.
Collaboration between THPs and biomedical practitioners is now being encouraged in many African countries. In East Africa, such collaborative links have been utilized in the management of HIV/AIDS. The Entry Point of this collaboration involved consultative meetings with recognized THPs associations and health personnel. Several examples of similar collaborations also exist in some countries on the African continent. Notable among these are the ongoing collaborations in the Ministry of Health's Public Health Research Institute in Mali (14), which is research-based; management of patients in Senegal (15); HIVAIDS prevention and care in Uganda (16); HIV/AIDS/STI/tuberculosis programs in South Africa (17).
In Mali a very effective collaboration between THPs and CHPs has been developed. The principles which underpin this collaboration include mutual respect and awareness of limits of competence and voluntarism. THPs and CHPs agree to collaborate without receiving remuneration for services rendered.
Research is a major component of the collaboration, while patient referrals are routinely made. Determination of the limits of practice is undertaken by the Department of Traditional Medicine in the Ministry of Health's Public Health Research Institute following a prescribed evaluation process. The success of this partnership is illustrated by the situation in Bandiagara, near Timbuktu, Mali, where collaboration between THPs and CHPs resulted in the decline of the rate of mortality caused by serious malaria, from 5% in 1997 to 2% in 1998. In 2008 collaboration between THPs and CHPs in the treatment of severe malaria resulted in reduction of mortality from 38% to less than 10%. Similarly, in 2007 such collaboration resulted in 18% of referral of tuberculosis patients to health centers by trained THPs (14).
PROMETRA (Promotion of Traditional Medicine), based in Senegal, has for many years been promoting collaboration between modern and traditional systems of medicine. At the PROMETRA International's Experimental Centre for Traditional Medicine (CEMETRA) in Fatick, which consists of 450 member associations of THPs of Sine, known as MALANGO, officially recognized by the government of Senegal, THPs collaborate with western-trained medical doctors. An important characteristic of CEMETRA is that only THPs are authorized to treat patients within the centre. The medical doctor measures the patient's vital signs such as blood pressure, pulse, respiratory cycle, temperature, weight, etc., and makes a diagnosis after analysis of laboratory tests, but the CHP cannot take part in treatment. The role of the medical doctor here is to make an initial diagnosis and send the patient to the qualified THPs (15).
After treatment, the THP sends the patient back to the modern medical unit in order to measure the impact of the traditional medicine treatment. Physical examinations and laboratory tests are carried out before and after the treatment, and the impact and outcome of treatment are determined by comparison of pre-and post-treatment laboratory results, vital signs and physical examination findings. This collaboration helped to reduce health workers' scepticism and strengthened mutual appreciation, understanding and respect between practitioners of the two health systems of medicine.
In Uganda, the Traditional and Modern Health Practitioners against HIV/AIDS (THETA) have demonstrated the positive impact THPs can make on health care delivery. Initiated in 1992 through a partnership between The AIDS Support Organization (TASO) Uganda Ltd and Medicines Sans Frontières (Doctors without Borders), an international humanitarian organization, THETA is a mutually respectful partnership between THPs and Biomedical Health Practitioners in the fight against AIDS and other diseases. It began as a collaborative clinical study with THPs evaluating the effectiveness of local herbal treatments for selected AIDS-related diseases. The success of this initiative transformed the project into an organization working with THPs in HIV/AIDS education, counselling and improved patient care. One of the key projects of THETA is supporting children orphaned by HIV/AIDS. However, despite its importance, it operates with very little resources and under very harsh conditions, although the number of children that are cared for keep increasing (16).
A case study on building partnerships between conventional medicine and traditional African Knowledge and medicines in Kirumba in Rakai District in Uganda also illustrates opportunities for the delivery of improved and affordable primary health care to rural communities. The results of the case study clearly demonstrate that improved and affordable primary health services can be provided through such THP-CHP partnerships. The study was initiated by a community-based crisis management group in Kirumba Sub-County, Rakai District in Uganda, with the main objective of providing home-based health care for the local community, which had been devastated by AIDS and other diseases.
The Kirumba Crisis-Management Group decided to develop a herbal medicine, a first aid kit that could be utilized by the local community to treat common disease symptoms of patients who were bedridden. Through a partnership involving the local community called the Munno mu Kabi (literally translated as "your friend in bad times+), a nongovernmental organization and a government research institute, the Group was able to:
Identify a number of locally available plant species (corresponding to 147 local names) that could be used to treat 29 local disease symptoms;
Identify and prioritize plants with toxic effects and associated side effects by screening 184 samples of medicinal plants, thereby improving the quality and safety of the herbal medicines extracted from those plant species;
Supply improved herbal medicines to more than 600 patients;
Improve public awareness in sanitation and hygiene, thereby reducing the spread of disease and preventing new infections; and
Generate income for the local community through the growing of the plant species, distillation of herbs, use of local preservation methods and the sale of the herbal medicines.
The success of the project has major national policy implications for Uganda. It demonstrates that health-related projects initiated by local communities and which utilize traditional African knowledge and herbal medicines are more likely to succeed if they are based upon partnerships involving conventional medicine. An institutional and legal framework as well as the development of a national traditional medicine policy is critical for Uganda's public health system to benefit from the lessons and success recorded by this case study.
As a result of the success of this approach, other rural communities in Rakai District as well as other districts in Uganda have expressed interest in emulating it.
Collaborative HIV/AIDS, STI, and tuberculosis (TB) programmes involving THPs have been initiated in a number of sub-Saharan African countries (17-22) with varying success. A controlled study of an HIV/AIDS/STI/TB intervention with traditional healers in two rural and two urban areas in KwaZulu-Natal, South Africa, was conducted to determine whether training traditional healers can reduce the risks of their practices and encourage them to provide appropriate information and referral for STI/HIV and TB care. All traditional healers residing in the identified study areas were eligible; 233 (out of 234) participated, 160 in the intervention group and 73 in the control arm. There were some differences between groups: there were more female healers in the intervention group (81% vs. 62% in the control) and from urban areas (41% vs. 23% in the control). Healers were classified as herbalists, diviners, or herbalist-diviners. This later study's findings (23) are similar to those that have previously reported significant improvement of HIV/AIDS knowledge among healers after training.
The largest group of traditional healers in the study was female diviners. Given the gendered nature of the HIV epidemic in South Africa and the need for strategies to enhance the ability of women to protect themselves, it is important to devise interventions that will enable these women to provide more support to other women in their communities.
The possibility of involving traditional healers in areas where they are well respected by the community and attend to clients at risk of HIV, STIs, and TB still needs to be explored. It appears that education programs can improve the healers' general knowledge and ability to counsel clients. However, better interventions need to be developed to change actual risk practices and encourage traditional healers to work with biomedical personnel.
A critical review of all these collaborative initiatives will show that they have all been instigated by certain key factors. These include:
In spite of the huge benefits such collaborations and partnerships offer, considerable challenges still remain. For example, there is often a lack of transparency in the process of actualizing collaboration, resulting in a situation where the so-called "collaboration process" is dominated by one group (often CHPs). The lesson therefore is that any successful collaboration must be based on mutual understanding through dialogue for a free exchange of information on management of illnesses/diseases, materials and technology used in preparation and dispensing. It also involves stressing complementarities of both systems by referral from one health system to another. But most importantly is the selection of genuine THPs, i.e., recognized THPs in the community through competence in managing diseases/ illnesses and trustworthiness.
THPs are generally very knowledgeable with great potential, so that if they are well sensitized, informed and encouraged to work in close collaboration with CHPs, they could make a difference in helping to stem the tide of many of the disease pandemics that afflict the people of Africa. Countries in the African Region must therefore be encouraged to officially recognize THPs and develop mutually-beneficial collaborative programmes. Such collaboration should make it possible for the work of THPs to be taken into account in the compilation of health statistics in the Region.
The importance of such collaboration, which is a necessary pre-requisite for the ultimate institutionalization of traditional medicine in national health systems, is summed up in a speech delivered by the WHO Director General, Dr Margaret Chan, during the WHO Congress on Traditional Medicine held in Beijing, in November 2008 (24). She said: "The two systems of traditional and Western medicine need not clash. Within the context of PHC, they can blend together in a beneficial harmony, using the best features of each system, and compensating for certain weaknesses in each. This is not something that will happen all by itself. Deliberate policy decisions have to be made. But it can be done successfully. Many countries have brought the two systems together in highly effective ways. In several countries where health systems are organized around PHC, traditional medicine is well integrated and provides a backbone of much preventive care and treatment of common ailments…."