The following represents a summary of information about projects which were identified in the review of the literature. Our intent has been to review projects which have been planned or organized to use traditional practitioners (TPs) as community workers in one or more aspects of primary health care. The following groups of “projects” include situations where TPs were organized and trained to perform specific primary health care (PHC) tasks in communities and where an attempt was made to evaluate or measure the outcomes of the activities. The criteria we used to define a traditional health practitioner was a person who is recognized as practising under various designations that included one or more of the following titles or disciplines:
• Spiritual or faith healer;
• Traditional midwife;
• Traditional birth attendant;
• Traditional Chinese doctor;
• Ayurvedic doctor;
• Unani practitioner.
Location: Sierra Leone
Project: Traditional Birth Attendants Help Reduce Infant Mortality
Description: Traditional birth attendants (TBAs) perform approximately 70% of all deliveries in Sierra Leone. In 1974, the Ministry of Health began a programme4 to train TBAs to reduce the incidence of infant and child mortality. A practical 3-week training programme was conducted to teach women simple antenatal care, safety and cleanliness, how to prevent neonatal tetanus, and to recognize abnormalities during pregnancy and labour.
Results: There were no data reported on the results of the traditional birth attendant trained to practice in communities.
Project: Village Midwives Work in the Community
Description: A WHO/UNFPA-assisted programme5 was begun in 1978 to train village midwives. The course was geared to teach village midwives how to perform specific tasks in the community. In addition to the standard midwifery tasks of antenatal care, delivery, newborn and postpartum care, they were also taught to give advice to mothers on family planning, provide health education on home sanitation, immunization, prevention of accidents and, communicable diseases.
Results: Although the report indicated there were no data available to judge the tasks performed by these midwives, it stated that the proportion of births attended by village midwives increased since the inception of the programme. It was assumed that when a pregnant woman and her newborn baby were under the management of a trained midwife, they both had a far greater chance of survival than if they were under the management of an untrained midwife.
Project: Sudan Community-Based Family Health Project
Description: The University of Khartoum, in cooperation with the Ministry of Health, conducted an operations research project to test the feasibility of involving village midwives in the delivery of maternal and child health and family planning services.6 The project, funded by USAID with technical assistance from Columbia University, was conducted from 1981 to 1983 in an agrarian population living in 90 villages along the banks of the Nile. The focus was to train and supervise village midwives to provide the following:
• information about contraceptives for birth spacing, distribution of oral contraceptives and referral for other methods;
• information for mothers on oral rehydration therapy for children with diarrhoea and distribution of oral rehydration solution packets;
• nutrition education with emphasis on breast feeding and appropriate weaning foods and practices;
• vaccination for children under five years of age.
Results: The project evaluation measured changes in behaviour related to the four child survival interventions: oral rehydration therapy, family planning, nutrition education and vaccination. The article on this project reported data for the first two interventions only.
A post-intervention survey conducted a little more than a year after the project began, found that 87% of the mothers with children under 5 years of age had treated the most recent episode of diarrhoea with oral rehydration solution. One year after the start of the project, the proportion of women ages 30-34 who had ever used contraceptives increased from 25% to 38%, and the proportion currently using them rose from 13% to 21%. The overall pattern of contraceptive use showed a considerable increase. The 1987 survey found that 27% of the women of child-bearing age were current users as compared to 10% in the pre-survey.
The authors concluded that the project proved to be so successful that it now continues to be an integral part of the health services.
Project. DANFA - Traditional Birth Attendants Promote Health Education
Description: The Danfa Rural Health Project (DANFA)7, begun in 1970, was a joint effort of the University of Ghana and the University of California, Los Angeles. Project goals were to improve primary health care and family planning in rural areas. Traditional birth attendants were trained in villages to monitor pregnant women, recognize and refer high risk women to clinics, properly care for the umbilical cord, and promote improved maternal and child health practices through health education. Their participation in the community was an important aspect of the project.
Results: Data is not presented to indicate the effectiveness of TBA training or practices in the community, but it was reported that the TBA training programme had been gradually replicated throughout the country.
Project: PRHETIH PROJECT - Indigenous Healers Cooperate With Ministry of Health
Description: The Primary Health Training for Indigenous Healers (PRHETIH) Project8 began in 1979 with the aim of facilitating cooperation and coordination of Ministry of Health units with various categories of traditional practitioners (TBAs; herbalists; priest/priestess healers), in the Techiman District. A 60-hour training course was designed to teach environmental health, preventive and promotive measures, family planning and simple, readily available allopathic medicines, (i.e. anti-malarial; oral rehydration and basic first aid).
Results: All types of traditional practitioners, as well as their trainers, responded very positively to the programme. Follow-up surveys conducted six months after training showed the following:
• all the traditional practitioners supported the training programme;
• there was a high level of information retention;
• all trainees stored their herbal medicines in clean, plastic bags;
• care of sick children was significantly improved;
• oral rehydration for children was accepted as important;
• information on topics such as oral rehydration was rapidly communicated from trained traditional practitioners to those not yet trained;
• relationships improved between Western allopathic-trained health workers and traditional practitioners;
• the number of referrals between traditional practitioners and other health workers increased in both directions.
A major factor which contributed to the success of the programme was the long-standing relationship of mutual trust and respect between the traditional practitioners and the local hospital staff.
Project: BARIDEP - Traditional Birth Attendants Promote Self-Help Projects in the Community
Description: The Brong-Ahafo Rural Integrated Development Project (BARIDEP)9 was carried out from 1975-1980 by the Ghanaian Government with assistance from WHO and UNICEF. The aim was to achieve improvements in the health status of the project area population, and to promote the social well-being of the population through community self-help projects.
These projects were to be organized, implemented, financed and evaluated by the community members themselves. Over 50 TBAs were trained in 1978.
Results: Although no formal assessment was made of changes in infant mortality, or of referrals made to health centres, observations suggested that the training was well-received and had generally been put into practice.
The status of TBAs among villagers was clearly enhanced because of the training.
Project: Traditional practitioners Cooperate With Clinic Nurses
Description: The government of Swaziland Ministry of Health and the Traditional
Practitioners Organization conducted a one-year demonstration project10 from 1984-1985. The goal was to demonstrate how specific primary health care services could be provided to mothers and children by nurses and traditional practitioners cooperating.
During a one-week workshop attended by both traditional practitioners and nurses, the participants developed a more trusting, cooperative relationship and agreed upon primary health goals toward which they could work.
The participant traditional practitioners learned how to: recognize danger signs of common childhood diseases; refer certain patients to clinics; mix and use oral rehydration solution; treat diarrhoeal dehydration; and promote better nutrition, safe water, personal hygiene and sanitation.
Results: An evaluation was conducted two months after the workshop was completed by interviewing participant nurses and traditional practitioners at their clinics, and comparing the results of those who attended the workshop with a control group. Some of the outcomes of this evaluation were:
• reduction of fears and mistrust between nurses and traditional practitioners;
• increased referrals (particularly for children with diarrhoea and vomiting) by traditional practitioners to clinics;
• increased understanding of the treatment and prevention of dehydration and ability to mix oral rehydration solution accurately;
• decrease in the dangerous use of purges and enemas by traditional practitioners;
• increase in health education to patients on subjects of home sanitation, nutrition, immunizations and clinic checkups;
• increased use of wash basins in traditional practitioners’ clinics and latrines in their homes;
• traditional practitioners communicated information about the content of the workshop through their own informal networks to other traditional practitioners, thereby disseminating more information to others.
From 1986-1988 the Health Education Unit of the Ministry of Health continued to conduct workshops for traditional practitioners and nurses to expand the prevention and control of diarrhoeal diseases throughout the country.
Project: Traditional practitioners Promote Primary Health Care
Description: Between 1984 and 1986, the Lagos Board of Traditional Medicine designed and coordinated a collaborative programme in Nigeria11. Traditional herbalists were trained in both community-based distribution of contraceptives, and in preventive/promotive aspects of primary health care.
Results: The constraints to the success of this programme included:
• inherent conflicts between the scientific and magico-religious paradigms of Western-trained versus traditional practitioners;
• economic and prestige competition between the two sectors;
• traditional practitioners feared they might become second-rate paramedical workers, and thereby cease to carry out their important function in the community (e.g., social, psychological, spiritual and health).
Project: Traditional practitioners Help To Prevent Diarrhoeal Disease
Description: A survey conducted in 1986 by the staff of the Diarrhoeal Disease Control Programme of the Ministry of Health, Department of Traditional Medicine in Zambia12 supports the idea that “healers constitute a valuable, virtually untapped manpower resource which could be used to promote oral rehydration therapy and therefore extend the limited resources of the Ministry of Health/Diarrhoeal Disease Control Program.”
Although this is only a survey of traditional practitioners’ attitudes and practices regarding treatment of diarrhoea, it does indicate that traditional practitioners are already carrying out some diarrhoeal disease prevention and control activities in communities.
Results: The results of the study showed that many traditional practitioners were aware of the signs of dehydration in children, advised mothers to give fluids, informed mothers about ways to prevent diarrhoea, and expressed a willingness to use and promote oral rehydration solution.
The study recommended that the diarrhoeal disease control programme produce health education materials and hold training seminars for traditional practitioners on a pilot basis.
Project: Traditional Birth Attendants in General Health Services
Description: The Ministry of Public Health (MOPH) trained TBAs in improved birth and delivery, care to infants and mothers, and family planning services.13 The MOPH recognized the value of indigenous practitioners with special skills, particularly in rural areas. The TBAs, usually older married women with no formal education, had several years of experience in dealing with pregnancy and childbirth, including their own personal experience. Their training included how to provide prenatal care, safeguard the fetus, and ensure easy and safe deliveries.
Results: The experience of the project indicated that the majority of TBAs had positive attitudes toward participating in the training, and in modifying their skills to provide better pre-natal, delivery and post natal care to mothers.
The project recommended that after traditional practitioners are trained, they should have a formal or informal relationship with the existing health system as part of the local health centres, provincial health facilities or as a member of the health team within the community. It was suggested that within the health centres, TBAs could provide basic information on traditional medicine as well as facilitate referrals.
Project: Indigenous Healers Work in Community Health Schemes
Description: Roger Jeffrey14 reviewed government policies toward traditional practitioner in India and described how traditional practitioner of the Ayurveda and Unani systems have been used in the community health schemes. Both the Western allopathic doctors and the indigenous practitioners (i.e., Ayurvedic, Hakims and Vaids) are politically strong, and have wide support in communities.
Differences between them led to disputes and interfered in the formation of a unified policy on how to involve indigenous practitioners as community health workers.
In 1977, the Janata Government called for the organization of a cadre of medical and paramedical community health workers (CHWs), among whom the trained practitioners of indigenous systems of medicine would be a part.
It was decided that the community should choose who was to be their CHW.
Results: Roger Jeffrey concluded that (as of 1982) there was no clear
Government policy on the use of indigenous traditional practitioners in India. The reality is that indigenous practitioners of all kinds have strong popular appeal and provide an alternative which the Government must recognize as potentially valuable in training and employing community health workers.
Project: INGRID PROJECT - Traditional Midwives Provide Health Education
Description: India’s New Group for Raichur’s Integrated Development Project,15 (INGRID), started in 1981. The goal of the project was to improve life of the rural and uneducated population by developing leaders in selected villages who would work towards self-help community development. INGRID aimed at setting up health care within ten villages by providing low-cost health facilities and by educating people on health, hygiene and nutrition. Priorities were to establish a medical dispensary, and organize health education in all the villages.
The project used the skills of both medical doctors and traditional midwives, who were supported and trained to do ongoing preventive health education. Mobile clinics were established and a small “native-style” dispensary was set up in one of the villages with a complete selection of both modern medicine as well as local herbal medicines. The dispensary functioned on the veranda of a village healer and was run directly by local villagers.
INGRID began with very few health care resources, but they were able to draw upon assistance from traditional practitioners to help motivate villagers to take a stronger interest in creating their own preventive health schemes. The increased interaction of local villages with established health institutions led to an innovative integration of preventive, curative and traditional forms of health care.
Results: Follow-up observations indicated that health awareness increased and people were more aware of the causes of common diseases and how to control them. These observations also showed that people were making full use of the services of both the central mobile and “native” clinics.
Project: “Dhami Jhankries” Work In Villages To Promote Health Education
Description: A two-and-a-half year action-research project16 in Nepal, conducted in 1980, aimed to see whether “dhami jhankries” could facilitate beneficial changes among villagers.
The strategy was to enlist traditional practitioners as partners by approaching them with respect, not asking them to change their beliefs and practices, and training them in basic family planning and health education skills.
Four-day workshops were conducted for 100 “dhami jhankries” in four districts. These workshops taught family planning methods, basic first aid, how to prepare oral rehydration solution and nutritious weaning foods, and when to refer patients to clinics.
Results: An evaluation was conducted by testing the traditional practitioners before, and six months after, the workshops. All the participants were enthusiastic about the value of the workshops, and 98% recommended that this type of training be given to all traditional practitioners throughout the kingdom.
Results indicated that there were substantial increases in the knowledge and practices of traditional practitioners. In addition, the evaluation of the project found conclusive evidence that these faith healers can play a culturally appropriate and cost-effective role in health education and family planning in Nepal.
Project: Study of Traditional Medical Practitioners in North Eastern Nepal
Description: This project17, conducted in 1980-81, studied the attitudes and practices of Traditional Medical Practitioners (TMPs) in seven health posts in a mountainous region of northeast Nepal. The TMPs were given a two-day training with follow-up sessions over a period of eight months. The training included the purpose of primary health care and the functions of health care staff; how to recognize and manage the endemic conditions of tuberculosis (TB), leprosy, childhood diarrhoea and malnutrition; and how to refer patients with symptoms of TB and leprosy.
Results: The study identified difficulties that existed in communication between health centre staff and the client population. When TMPs were interviewed, they commented upon the cultural inappropriateness of the style of the health centre staff, particularly their impersonal manner, lack of confidentiality, and patronizing attitudes. The TMPs were often able to bridge this gap. The data showed that the TMPs were able to refer patients with leprosy successfully and that they had an important influence in improving the general attendance at rural health facilities.
Project: Traditional Birth Attendants Promote Family Planning and Maternal and Child Care
Description: Due to the inability of the organized health system to meet basic health care needs, the Thai Government implemented a nationwide plan for the training and utilization of TBAs in community health18. The training of TBAs in Thailand dates back to 1952 when the Government embarked upon a programme to reduce maternal and infant mortality through improving rural health services. Nearly 17 000 TBAs received two weeks of training by the end of 1968. The course focused on antenatal care, delivery techniques and postnatal care. In 1970, the government decided to focus on family planning as an approach to reduce maternal and infant mortality.
Results: Findings suggested that it is feasible to train and utilize TBAs to extend maternal and child health services, including family planning services, to rural populations. It was recommended that:
• the training programme be open to all TBAs;
• trainees should be grouped according to age and level of education;
• the method of training should be kept as simple and as clear as possible;
• each TBA should have a pre-training test on knowledge, attitudes and practices, and the results should be used as baseline data against which to measure the results of post-training tests;
• a supervisory system should be set up and maintained on a continuing basis;
• refresher courses should be provided periodically.
Project: “Barefoot Doctors” Work in Community Health Programmes
Note: In 1984, the Ministry of Public Health of China declared that the title “Barefoot Doctor” would no longer be used. The existing barefoot doctors who pass an examination are authorized to have the name “Rural Doctor,” which means vocational competence equivalent to that of an assistant doctor.
Description: Since 1958, the people’s commune has been the basic unit for organization of social life in rural areas of China.19 The Chinese National Health System provides a three-tiered level of services that integrates Chinese and Western medical services. The lowest level is staffed by “Barefoot Doctors” who are trained in basic concepts and skills of both Chinese and Western medicine and are capable of treating ordinary and relatively minor diseases.
Barefoot Doctors are trained to diagnose and treat without assistance the common or recurrent diseases peculiar to the region in which they work. They provide immunization services, oversee environmental sanitation, give contraceptive advice and carry out health education campaigns.
In 1985, a campaign was initiated to train traditional practitioners to become Barefoot Doctors. Traditional practitioners began to make a genuine contribution to all levels of medical care and Western trained doctors began to accept them as colleagues. The number of clinics in which both types of doctors practised rose and were soon replaced with public rural health centres, where people could choose the type of practitioners they wanted.
New health worker roles also developed in the cities, including the “worker doctor” and the “Red Guard Doctor.” Worker doctors worked mainly in health education and prevention and the treatment of simple ailments, while Red Guard Doctors worked in conjunction with health centres. These were usually housewives who were unpaid for their services and were responsible for carrying out preventive work and disseminating birth control information.
Results: Because Barefoot Doctors remained part of the peasant community, they more easily understood the medical complaints of their people, as opposed to academically trained doctors, who had difficulties in communication and lacked awareness of their patients’ social conditions.
In spite of some problems with the system, Barefoot Doctors did provide medical care for peasants where none existed before. Chinese publications have chronicled the clinical successes of Barefoot Doctors and have commented on the quality of their work.
Project: Traditional Practitioners Strengthen Community-Based Health Programmes
Description: Non-governmental organizations in the Philippines have made significant progress in rediscovering how traditional practitioners can strengthen community-based health programmes (CBHPs).
A research project20 was conducted in 1983 to study the entire traditional medical system in the country. A primary focus was on the extent to which CBHPs were using traditional practitioners to promote primary health care. Of the sixteen programmes that responded, fourteen had trained traditional medical practitioners (TMPs) as CHWs. Of the 102 traditional practitioners who became CHWs: fifty-four were midwives; twenty-nine were herbalists; fifteen were bone-setters; and four were magico-religious practitioners. All were integrated into the PHC training programmes. All the programmes which used TMPs or CHWs gave positive ratings to these retrained workers. They cited TMPs as being “more advanced,” “more confident,” “more interested,” and “more experienced” than their co-workers.
The authors stated that:
“The traditional practitioners all retained their previous skills, integrating them with ‘new knowledge’ or ‘with more scientific basis’. The traditional skills most frequently mentioned were empirical methods such as the use of medicinal plants, massage and ‘cupping’. Magico-religious methods such as divination and prayers were also cited.”
Results: In cases where TMPs did not join CBHPs, referral systems were established. This enabled the TMPs and the staff of CBHPs to make appropriate referrals to each other. Staff of the CBHPs described both negative and positive aspects of using TMPs. Magical and religious beliefs, unhygienic practices and nutritional taboos were some of the obstacles mentioned.
This study found that empirical skills such as bone setting and midwifery were helpful for PHC as well as the holistic nature of traditional medicine. But most importantly, the staff felt that “the traditional medical system’s low cost is the main strength, particularly in relation to the goal of building community self-reliance.”
Project: Training Healers in Oral Rehydration Therapy
Description: In 1984, The Department of Community Health at the Federal University of Ceara began a 2-year research study21 to test the theory that mobilizing and training popular healers in oral rehydration therapy (ORT) and related child survival strategies would produce significant improvement in the health knowledge, attitudes and practices of village mothers, without changing essential elements of the indigenous medical system.
The specific objectives were that the use of trained popular healers would:
1. increase the awareness, preparation and use of oral rehydration solution (ORS), particularly of home-made solutions;
2. curb dangerous food withholding and promote continued feeding during diarrhoea;
3. increase vital breast-feeding during the disease episode;
4. reduce the use of costly, commercially promoted ORS and non-indicated pharmaceuticals.
Forty-six popular healers were recruited for the project. These included twenty “prayers” (resadeiras), seven Afro-Brazilian priests (Umbandistas), four spiritualists, three popular pharmacists, one lay “doctor,” one herbalist and ten visiting Protestant prayers.
The traditional practitioners were taught the basic biomedical concept of dehydration, and how to prepare and use a simple home-made ORS solution. They were also taught five basic health messages:
1. give ORS for diarrhoea and dehydration;
2. continue feeding during diarrhoea and do not withhold food;
3. encourage breast feeding during diarrhoea;
4. eliminate drugs to treat diarrhoea;
5. ask people to seek a traditional practitioner quickly at the onset of diarrhoea.
Traditional practitioners were then taught to instruct mothers how to prepare ORS-tea using simple graphic instructions. These simple teaching materials were re-written by the traditional practitioners, and a local artist illustrated them so they could be understood by illiterate mothers. In addition, traditional practitioners learned five high-risk indicators so they could refer children to paediatric health services.
Results: The staff found that in general the traditional practitioners were trusted, astute clinical observers, knowledgeable about anti-diarrhoeal plant remedies, skilled in accurate preparation of ORS, and pragmatic in integrating modern therapies that work.
The survey data clearly demonstrated that traditional practitioners had a substantial impact on vital child survival beliefs and practices of Pacatuba mothers. Specifically, over the study period, the traditional practitioners significantly increased the mothers’ awareness of proper preparation and use of ORS; dangers of withholding food; importance of continued feeding (including breast-feeding) during diarrhoea; and reduced the use of costly commercial ORS and non-indicated drugs.
The authors concluded that traditional practitioners can be effective promoters of ORT and related child survival strategies:
“No longer can we dismiss healers with their prayers, trances, and teas as curiosities unrelated to medical care; for mounting evidence has shown them capable of playing a vital role in child survival.”
REVIEW OF ADDITIONAL LITERATURE
This review of literature is based on general reviews of the literature on the subject of TPs working in PHC, narrative descriptions of how TPs have been used in specific areas of the world, and opinions and views of professionals who have studied or worked in the field. The results of this information are highlighted and summarized in this section.
Topic: Traditional Practitioners Provide PHC Services to Indian and Inuit Communities
Summary: One of the components of PHC for Canada’s Indigenous people is the utilization of traditional ethnomedicine and the recognition of the important role of traditional practitioners in the Indian societies. Marilyn Mardiros22 describes how indigenous healers are being used to provide PHC services to Indian and Inuit communities. Midwives and other traditional practitioners, until recently banned by the health care system, are now being actively identified and used as important members of the health care team.
Other community health representatives, such as health auxiliaries, are also being recruited and trained to provide health services and to serve as a bridge between the various health care providers within communities. Their responsibilities include education regarding child care, nutrition, oral hygiene and immunization.
Location: Papua New Guinea
Topic: Traditional Birth Attendants Promote Community Self-Help Programmes
Summary: Asuccessful training programme for TBAs was organized in 1981.23 The programme aimed at community self-help and self-reliance.
Training took place in rural environments and encouraged beneficial traditional practices as well as introduced modern techniques which were appropriate to local conditions and could be adapted to traditional customs. Use of local materials was encouraged.
Topic: Traditional Birth Attendants Deliver MCH Services
Summary: In Zaire,24 the local hospital in the Rural Health Zone of Karawa began an extensive outreach programme to increase the access of rural women to maternity care and to expand prenatal care. Traditional birth attendants, nurses and midwives played a critical role in the programme by delivering MCH services and by providing a back-up referral system. Community participation was an important part of this programme as the communities contributed money to pay for TBA kits and families were asked to pay a small fee for each delivery.
Topic: Traditional Midwives Provide Pre and Post Natal Care
Summary: The commune health stations in Vietnam25 used traditional medicines and midwives in important ways. The focus of primary health care in the commune was on midwives who worked with a team to provide a variety of services. Traditional medicines, along with western medicines, were generally dispensed by the midwives, in addition to providing pre-and post-natal care and carrying out a number of other health services for families who visit the commune stations.
Location: Sri Lanka
Topic: Ayurvedic Practitioners Assist in Family Planning and Contraceptive Distribution
Summary: In Sri Lanka,26 the Community Development Services trained 1,500 Ayurvedic practitioners in family planning counselling and contraceptive distribution. Initially the project provided the Ayurvedic doctors with free contraceptives to distribute, but as the programme became more self-sufficient, the doctors began buying them at discount rates and selling them to family planning acceptors.
Topic: Traditional practitioners Perform a Variety of PHC Activities
Summary: Robert H. Bannerman1 has pointed out the lack of health manpower resources in developing countries, and how primary health care is often provided by traditional practitioners, herbalists, traditional midwives and other traditional practitioners. These practitioners - experienced, intelligent and respected by the community - have an important role to play in providing PHC.
Citing the PRHETIH project in Ghana, as an example, Bannerman describes how TBAs and other traditional practitioners were trained to perform a variety of PHC activities. Although the training programme focused mainly on child care, environmental health was also given a high priority. Topics covered in the training included:
• hygienic preparation and preservation of medicinal herbs;
• use of oral rehydration to treat dehydration and diarrhoea;
• sanitation of the environment, i.e. proper refuse disposal, use of pit latrines and food sanitation;
• basic nutrition and proper foods for weaning;
• family planning; basic first aid;
• recognizing dangerous signs of measles, typhoid, jaundice, leprosy and convulsions.
A major factor contributing to the success of this project was the longstanding relationship, based upon mutual trust and respect, between indigenous healers and local hospital staff.
Topic: Traditional practitioners Offer a Valuable Contribution to Extending
Coverage of Health Systems
Summary: Olayiwola Akerele27 also affirms that traditional practitioners, being both culturally acceptable and economically within reach of even the neediest people, can make a valuable contribution to extending the coverage of the health system. He emphasizes, however, the importance of evaluation to obtain safe and effective methods; integration to incorporate traditional practitioners into the national health care system; and training to increase beneficial health skills and practices.
In spite of the differences that exist in local cultural patterns, political systems, and national policies and practices, Akerele claims that certain common factors influence how traditional medicine can affect the health of the population. These factors include:
• strength of national commitment to support traditional practices and practitioners;
• the degree to which this commitment is backed by legislation:
• national research into useful traditional practices;
• the extent to which primary health care plans and strategies incorporate validated traditional practices and make use of traditional practitioners.
Topic: Modern and Traditional practitioners Collaborate for Improved Health Coverage
Summary: In August 1980, the WHO Regional Office for Africa held a Consultation on Traditional Medicine in Health Services Development at Accra, Ghana.28 The primary aim of this meeting was to explore ways in which modern and traditional practitioners (TPs) could harmonize for more efficacious delivery of primary health care. Nine African countries were represented at the meeting.
One of the three objectives of this conference was to formulate realistic approaches on how the modern and traditional systems could collaborate for improved health coverage of the populations. Factors which hindered and which favoured such collaboration were discussed, and recommendations were made for promoting collaboration. Some of these recommendations were particularly relevant for providing better primary health care. These included:
• TPs should be included in primary health care teams, especially at the village level.
• TPs should be given incentives and suitable training so they can report on epidemics and other health hazards.
• Training should also include elementary environmental sanitation, as well as simple appropriate medical technology.
• Practitioners of conventional medicine should learn from TPs something of the physical and socio-cultural basis of the latters’ practice.
Topic: Using Traditional practitioners to Promote Health Education and Provide Primary Health Care Services
Summary: In a study for the Takemi Program in International Health, Harvard School of Public Health, Charles M. Good29 reviews the community’s role in PHC programmes in Africa and describes the potential benefits of TPs in PHC. After studying several African projects, including programmes in Nigeria, Ghana and Swaziland, he concludes that intersectoral cooperation is feasible and has the potential to produce a wide variety of positive impacts, ranging from enhancement of child survival and environmental sanitation, to more effective biomedical procedures.
Since TPs are already an integral part of the social fabric, and they wield great influence in matters of health and community well-being, Good asserts there is a strong argument for using TPs to promote health education, and to provide better health care at the primary level. He also believes that TPs should receive priority in being selected as CHWs.
Topic: Traditional practitioners Assist in Control of Childhood Diseases
Summary: In a paper presented to the National Council for International Health in Washington, D.C. (1986), Wilbur Hoff30 describes the positive outcomes of training TPs to assist in the control of childhood diseases in Swaziland. An important finding of this project was the high level of enthusiasm exhibited by the TPs involved in the project. Traditional practitioners who were trained went back to their own communities, and at their own initiative organized meetings with other traditional practitioners in their respective areas. At these meetings they described what they had learned, thus disseminating health knowledge to other healers who had not attended the workshops.
With respect to methods of training TPs, the paper emphasized two important points:
• the use of culturally relevant training methods;
• the use of methods which were appropriate to the background and education level of participants.
Cultural beliefs about health and disease need to be carefully considered in order to present information in a context which is most easily understood and accepted. Because traditional practitioners often have lower levels of education than training staff, it is important to concentrate on basic knowledge and skills, presented simply and with maximum use of informal group discussion, visual aids, demonstrations, field visits and other experiential learning methods.
The evaluation of the project found that some of the information taught in the workshops, particularly how to mix and use ORS for treating dehydration in children, how to obtain a balanced diet, and the importance of home sanitation and use of latrines, had been widely disseminated to other traditional practitioners through their communication networks.
Topic: Traditional practitioners Trained as Community Health Workers
Summary: David Werner described how, for the last twenty-five years, he has worked with traditional practitioners and trained them as comprehensive community health workers in Mexico.31
He concluded that:
• traditional practitioners continue to work longer and have a better rapport and accountability in the community than do persons selected from the outside to be trained as community health workers;
• traditional practitioners tend to integrate traditional healing and herbal medicine with modern medicine, preventive care and community health promotion;
• when health programmes collapse or fail, traditional practitioners who have received training in other aspects of health care and health promotion tend to continue with their work and retain community support.
Although Werner encountered difficulties trying to teach traditional practitioners about Western approaches to medicine and the use of the scientific method, he nonetheless strongly recommended that guidelines be set up for health workers on how to evaluate the strengths and weaknesses of both traditional and Western medicine.
An important finding that stands out among the hundreds of documents reviewed is that there are relatively few projects that reported good evaluation data. Only seven of the projects reviewed reported any evaluation findings.
While the data provides very helpful information to assess the effectiveness of projects using TPs in community PHC programmes, we need more documented results from demonstration projects that represent different conditions throughout the world. Such data is necessary to answer some of the questions about how to select, train, and utilize TPs in PHC and to evaluate the cost-effectiveness of such activities.
The information that has been reviewed in the literature is useful in arriving at the following conclusions:
1. There are a number of positive aspects to the use of TP’s in community health.
a. TPs are available and willing to work in community health. The data supports the conclusion that TPs are available and willing to take on primary health care activities when they are given training and can establish good working relationships with existing health staff. To date, a wide variety of traditional practitioners from a wide array of cultures have been trained to work in PHC projects throughout the world.
Eight of the seventeen projects have trained either TBAs or village midwives. The remaining projects include the training of herbalists and spiritual healers in Africa and Latin America, Ayurvedic and Unani practitioners in India, Dhami Jhankries in Nepal, and bone setters, prayers and other magico-religious practitioners in Latin America. In each case, TPs were willing and available to undergo training and were enthusiastic in accepting their new roles in PHC.
b. TPs can be trained to perform a wide range of PHC tasks. The data reviewed in this study indicate that it is possible to train TPs in a wide range of PHC tasks. The projects varied with regard to the specific tasks for which traditional practitioners were trained. But considering all the projects together, traditional practitioners were trained in one or more tasks covering all eight categories of PHC. The following is a summary of skills taught to traditional practitioners, and is based on the Alma Ata description of the eight basic PHC services:
(1) Promoting education concerning prevailing health problems and methods of preventing and controlling them, including:
•information about local prevailing health problems
• methods of preventing and controlling these problems
• use of posters and other simple health education materials.
(2) Promoting improved food supplies and proper nutrition, including:
• how to obtain a balanced diet
• proper diet for mother and child, (i.e., breast feeding and proper weaning foods)
• growing vegetables and fruits in kitchen gardens.
(3) Promoting adequate supply of safe water and basic sanitation, including:
•how to obtain safe water
• proper construction and use of latrines
• personal hygiene and home sanitation
• clean preparation and storage of food.
(4) Promoting maternal and child health care, including:
• how to monitor pregnancy and recognize abnormalities
• proper ante-natal care
• basic delivery techniques
• when to refer women for abnormal conditions of delivery
• how to advise women for family planning
• distribution of oral contraceptives and referral for other methods.
(5) Promoting immunization against major infectious diseases, including:
•when and how to refer children under five to clinics for immunizations against childhood diseases.
(6) Promoting prevention and control of locally endemic diseases, including:
• how to recognize symptoms of dangerous diseases such as diarrhoea, TB, leprosy, malaria, malnutrition and to refer for treatment
• how to mix and use ORS to treat dehydration and diarrhoea
• distribution of ORS packets
• referring women in high risk groups for treatment
• how to use readily available allopathic medicines, (i.e., anti-malarial prophylaxis, ORS, etc.).
(7) Providing appropriate treatment of common diseases and injuries, including:
•giving first aid
• preventing accidents.
(8) Providing essential drugs, including:
•aspirin and other first aid medications
• operating basic dispensaries.
2. Training TPs has produced several positive outcomes.
Those projects that attempted to evaluate outcomes of training reported a number of positive outcomes.
a. Changes in attitudes, knowledge and behaviour. Projects in Sudan5, Ghana8, Swaziland10, Nepal16, and Brazil21 all indicated that participants had a high degree of interest and enthusiasm in learning new information and skills in PHC.
These same projects were able to demonstrate changes in the practices of traditional practitioners after the training workshops. These changes included the following:
• increased use of ORS and giving fluids to children with diarrhoea
• use of wash basins for cleaning hands in traditional healing clinics
• decreased use of strong purges and enemas for treating diarrhoea
• construction and use of latrines in healers’ homes
• increase referrals to clinics for patients with dangerous symptoms
• increase in births attended by village midwives.
b. Changes in health status of people served by TPs. While there was little data reported on changes in health status of target populations, a number of projects indicated that there was a high degree of acceptance by the communities of the traditional practitioners who had been trained. The Sudan project5 reported that the proportion of women ages 30-34 using contraceptives increased from 25% to 38% over the two-year period, and that overall use of contraceptives rose from 13% to 21%. The Nepal project16 reported that there was an increased attendance at rural clinics after the trained healers began working in local communities.
c. Training TPs along with health staff has produced positive changes in attitudes and behaviour of health sector staff. Many of the projects indicated that there was an increase in trust and respect between the nursing staff and TPs, and that working relationships between the two groups improved. The Swaziland project10 reported that there was an increase in referrals by traditional practitioners to rural clinics, particularly for children with diarrhoea and vomiting.
d. Training traditional practitioners has proven to be cost effective. Ramesh M. Shrestha reports16 that their evaluation of the “dhami-jhankri” training programme in Nepal found conclusive evidence that faith healers can play a culturally appropriate and cost-effective role in health education and family planning. The staff estimated that country-wide, there was a ratio of well over one hundred dhami-jhankries to each health worker, and that these traditional practitioners, as private practitioners, were paid only a modest fee by the people for their services.
In Swaziland, Wilbur Hoff30 reported that the cost to government for materials and training TPs in PHC was relatively low. “The government does not pay for services provided by TPs, since they are private practitioners and are paid by the community.” The Swaziland Traditional practitioners Organization also committed a large amount of its time and resources to the project, which helped reduce the cost to government.
In the Philippines, Michael M. Tan20 reported that the project staff felt the main strength of the community-based health programme was its low cost. This was due to the project’s employing traditional medical practitioners who used low cost traditional therapies. Using traditionally available remedies reduced costs of more costly commercially prepared drugs.
3. Constraints to the Use of Traditional Practitioners in Primary Health Care
The training and use of TPs in community PHC programmes can pose difficulties in some situations. Specific problems, limitations and constraints were reported from projects and in literature reviewed. These are summarized and described as follows.
a. Positive government policies to promote cooperation and use of TPs in PHC are lacking. The lack of clear policy statements by government indicating the potential value and role of TPs in PHC, and the conditions upon which this could take place has generated a negative climate for traditional practitioners and health staff to work together. Lack of government commitment in some projects has discouraged traditional practitioners from coming forward to participate in programmes designed to train them in PHC skills. In those countries which have, until recently, legally prohibited TPs from practising, many traditional practitioners are reluctant and fearful of coming out to participate in government-sponsored health programmes. The absence of government policies which acknowledge the positive role TPs can play in PHC tended to reinforce secretive and guarded practices which prevail in many countries.
b. There is a lack of dialogue between TPs and government health staff. A lack of dialogue between TPs, nurses and other government staff, has created misunderstanding between the two groups. This has prevented open and creative discussions to identify common health goals and agree on ways to cooperate to provide better health care to communities.
c. Some traditional practices may be harmful and difficult to change. Some practices, such as witchcraft and sorcery, can cause dangerous psychological stress and bodily harm. These and other beliefs and practices are clearly in opposition to the modern biomedical system. These beliefs are strong and often quite resistant to change, particularly those involving supernatural phenomena. They are rooted deep in the culture and are set within a spiritual, social and environmental framework.
d. There exists some conflict between traditional and modern medical practices. The paradigm conflict between the traditional holistic, spiritual healing orientation and the modern biomedical treatment-oriented approach poses a basic difference in philosophy regarding the causation of disease and the promotion of health. These differences in orientation and training can cause barriers between traditional and modern practitioners getting together and working cooperatively.
e. Some fraudulent practitioners engender prejudicial feelings against ethical and responsible traditional practitioners. Charlatans and fraudulent practitioners obscure the worthwhile contributions of the large majority of bona fide traditional practitioner. Isolated incidents of witchcraft, malpractice or unscrupulous behaviour are widely publicized by the media, which tends to reinforce the stereotypes many people have that TPs are quacks and “witch doctors”. The fraudulent practice of a few inhibits the genuine movement of the majority to create better understanding and cooperation between the traditional and modern health sectors.
f. There is a general lack of community participation in the planning and implementation of primary health care programmes. Lack of community participation in both the planning and implementation of PHC projects where TPs are used have caused difficulties. Given that the ultimate purpose of PHC programmes is to improve community health, it is imperative that communities be represented in activities where TPs are selected, trained and designated to work in PHC. In addition, local communities should have some say in determining the functions of community health workers and have some input into how they are trained.
g. Many traditional practitioners lack formal education and have low levels of literacy. This can pose difficulties in the training of TPs. In both Ghana and Swaziland, it was found that low levels of literacy and education of some of the traditional practitioner participants required specially designed training methods. Conventional methods of training, such as lectures and use of written materials, were not appropriate.
h. The roles and tasks of TPs in PHC programmes are often poorly defind. When the role of the TP in relation to other members of the PHC team is not clearly defined, and the tasks they are to perform are not specifically described, problems have been created in the training and work setting. For example, poorly defined functions were described as a weakness of many CHW programmes32, and it is probably unreasonable and unrealistic to assign a broad range of PHC tasks to such a worker. This caution also applies to TPs in assigning PHC tasks to them. In Nigeria11, because the role of TPs was not made clear, some traditional practitioners feared their integration in the PHC programme might threaten their status, income and freedom of action in the community
i. There is a lack of cooperation between TPs and health staff. Lack of cooperation impairs coordination of services between the two groups. One example of this is the difficulty of establishing referral systems between traditional practitioners and clinic nurses. The Swaziland project30 discusses this issue, describing how referrals between traditional practitioners and nurses increased when the two groups began to cooperate during and after the TP training project.
j. There are few organized TP societies. Lack of organized traditional practitioner societies has been a barrier to better regulation of TP activities. In many countries, TPs have organized themselves into professional societies and have set up standards for their own training and practice. Similar to Western, private physicians, many of these TP organizations are now beginning to regulate the practice of their members through their own standards and regulations. If TPs are given PHC tasks to carry out as part of their regular private practice, there should be some mechanism for overseeing and regulating their performance in this area.
k. Little or no evaluation has been conducted after training TPs. There has been little, if any, evaluation or follow-up after TP training projects have been completed. Little data is available to indicate how effective their training has been, what they are accomplishing in the community, and how satisfied community members are with TPs performance of PHC activities.