The first step is to identify what knowledge, attitudes, and skills THPs will require to perform their PHC services. It is important to emphasize that circumstances in each country are different and it is difficult to establish a set of core functions for any group of THPs that is universally applicable. Decisions about what functions and responsibilities are appropriate will, therefore, need to be based upon local conditions in each country or region. Based upon prior experience, some guidelines can be given:
Functions and responsibilities of TBAs
The use of TBAs has been widely adopted in PHC and their training has been more prescribed than for other types of healers. The WHO guide for master trainers of TBAs12 has recently suggested a criteria for deciding the functions and responsibilities of TBAs:
• Functions must be specific.
e.g., maintaining the cleanliness during delivery, distributing iron folic acid tablets, distributing oral contraceptive pills.
• Functions should be based upon traditional roles.
e.g., teaching the TBA to recognize certain high-risk conditions of pregnancy if she visits/monitors pregnant women during pregnancy, teaching the TBA to support breast feeding of the neonate.
• Functions must be based upon the capacity of the infrastructure to support designated TBA functions.
e.g., TBAs should not motivate clients for family planning unless the appropriate products and support services are available. TBAs should not be taught at-risk screening unless there is access to a referral system.
• Functions should be realistic.
It is not reasonable to expect an elderly TBA to take on a large number of activities which require considerable effort on a very small compensation when similar activities could even overwhelm younger health care workers on regular salaries.
The WHO guide for master trainers12 identifies 6 core functions for TBAs:
1. Antenatal care
2. Labour and delivery
3. Care of the newborn
4. Postnatal care
5. Care of the child
6. Family planning
For further information about the content for training TBAs consult publications listed in References, numbers 12 and 13.
Functions and responsibilities of herbalists, bonesetters, and spiritual health practitioners
The training of herbalists, bonesetters, and spiritual health practitioners in PHC has been more recent and is still being identified and developed. The experience of training these types of health practitioners in projects in Mexico, Swaziland, Ghana, Nigeria, and other countries1,2,14 has included the following activities:
(1) preservation and use of herbal medicines available in the region;
(2) first-aid treatment;
(3) control of flies, mosquitos and other disease vectors;
(4) improvement of water and sanitation;
(5) health education, including personal hygiene and nutrition;
(6) organizing community health activities, such as immunization campaigns and refuse clean up;
(7) Family planning, particularly with men;
(8) AIDS prevention and family counselling.
An important element of the training for herbalists is the teaching of how to identify herbs with healing properties, collect, store and preserve them in a sanitary manner, and use them in a prescribed safe manner. Projects wishing to include elements of traditional medicine into the training of THPs should consult with their nearest WHO Regional Collaborating Centre for Traditional Medicine for information on the availability and use of local herbal medicines.
Another important content area for training this group of THPs is skills in leadership and community organization. Since many herbalists and related types of healers are men, they already occupy positions of respect and leadership in their communities. With additional skills in group leadership and community organization they can facilitate members of communities to assume responsibility and work together on activities that will promote health and prevent disease in their communities.
A basic set of skills that all health workers must know is how to communicate with others. This is equally true for THPs who work closely with community members, other practitioners, and health agency staff. They must be able to listen and empathize with others, obtain information about people's concerns and needs, and to counsel and give advice.
The following communication skills should, therefore, be incorporated into the training of all THPs:
• create a climate of trust, respect and positive regard for others;
• listen with full attention to what others are saying;
• acknowledge and be supportive of others;
• empathize with and understand people's concerns, problems and views;
• speak clearly and in a manner that others can understand;
• resolve disagreements and conflicts through negotiation.