Lesson 1: Traditional practitioners as a group were willing and able to learn how to perform PHC services and were dedicated and effective in carrying out these services when appropriately trained and supported.
Evidence obtained from interviews with health agency staff, TPs, and community members in these four training projects indicated that generally the training programmes had been effective in teaching TPs how to perform primary care services in communities. These services were appreciated by community members, and the provision of these services had measurably improved health behaviours and health conditions of the communities served.
Direct costs of training TPs to perform these services in these projects was relatively low; from a low of US$30 to $40 for TBAs to a high of US$98 to $110 for other TPs. Although these figures did not include costs for administration or follow-up support, they indicated that training TPs might be a cost effective means of providing increased primary health care to communities. Incorporating the use of TPs into the primary health care system appeared to be an effective and sustainable measure to improve health care to these communities. This seems particularly relevant in view of the fact that TPs already live and practice in rural communities and the day to day services they provide to families cost the official health agencies practically nothing, outside of the costs of initial training and follow-up support. Furthermore, TPs, being an integral part of the culture and life of the communities, are highly respected by community members and thus can be very influential in promoting healthy lifestyles.
It is recommended that government and nongovernment health agencies encourage and support the training of TPs to provide more cost effective primary health care in communities.
Lesson 2: Official government policies can effectively promote and guide the scope and nature of how TPs are utilized to provide primary health care services to communities.
The government policies related to the training and utilization of TPs in the three countries varied widely in scope and detail, but all served to guide the direction of the training programmes. In Ghana, the MOH viewed the Dormaa Project as a demonstration to provide information to expand the training in other regions. The Ministry of Health had already begun to formulate general guidelines, but had not yet established specific policies for the training and utilization of TPs for the country as a whole.
The Mexican Government has given strong support to the development of services provided by TPs, and this policy has contributed to the growth of the many traditional practitioner associations that exist in the country and the government's programme to train TPs in primary health care.
The high priority placed by the Government of Bangladesh on training TBAs to cover all villages in the country and their policy to encourage NGOs to participate in this training has led a number of NGOs as well as government centres to train TBAs. These policies have had a positive effect on encouraging NGOs to implement effective training programmes.
It is recommended that governments establish official policies or guidelines for the utilization of TPs in PHC programmes and that these policies and guidelines be based upon knowledge gained from existing studies and on-going training projects and that they be in line with the governments' aim to provide PHC services to all communities. These guidelines should cover specific issues such as:
•how traditional knowledge, values and practices about health can strengthen PHC services to communities;
• the nature and scope of PHC services that TPs can perform;
• selection criteria and the content and methods of training programmes for TPs;
• a process for certification of trained TPs;
• procedures for follow-up, evaluation and regulating the quality of TPs services to communities;
• degree of responsibility by government, NGOs, and communities for providing support to TPs for their services;
• how the involvement of NGOs, indigenous groups, TPs and members of communities can strengthen the planning and implementation of PHC programmes with trained TPs;
• how the traditional and modern health sectors can collaborate effectively together;
• guidelines and/or support for the formation of professional organizations of TPs;
• the use of innovative projects to demonstrate cost effective ways to utilize trained TPs in PHC programmes.
Lesson 3: Non governmental organizations played an important role in innovating training methods and the provision of support services for TPs.
The private sector can assume a very important role in demonstrating new training methods and alternate ways to provide support services to TPs in primary health care programmes. Non-governmental organizations generally have more flexibility to innovate and try out different programmes than does government. Of the four projects studied, two were sponsored by NGOs and one was co-sponsored by a Church organization. The two NGO sponsored projects were the only ones who conducted formal evaluations and that involved TBAs in the process. All three utilized somewhat different methods of training and systems for providing follow-up support, and each was successful in providing PHC services that were appropriate to their respective communities.
Encourage NGOs to share in the responsibility for training of TPs by providing technical assistance and grant monies to them for training programmes.
Lesson 4: Projects which involved the communities in the planning and the decision making achieved a high level of interest and commitment on the part of the TPs and community members.
All four projects sought the involvement of communities at different stages. For example, all projects consulted TPs as to what knowledge and skills they wanted to learn, and these desires were programmed into the workshops. This involvement generated a high level of interest among the TPs as they felt the training would enable them to practise more effectively. And because these projects consulted community leaders in recruiting and selecting TPs, they were able to identify the most respected TPs in the community and the ones which the community believed were most competent. And one project involved an experienced herbalist as part of the training staff.
Based on the responses of participants in the study, it appears that project staff might have done more to obtain community commitments for remunerating or rewarding TPs before the training programmes began. Many of the TPs complained that their communities did not support them enough for the extra time they spent after training to provide health services to families. The TPs wanted clinic rooms where they could practice, help in their farming to raise more income, and help pay for their supplies.
Involve communities (including the TPs) in the planning and decision making to insure that the recipients and TPs are committed to the programme. Community involvement could be encouraged by incorporating specific suggestions in policies and guidelines for recruitment, selection and training of TPs.
Lesson 5: Training programmes for TPs are most effective when they are planned to meet local needs.
The importance of this principle was evident in how all four projects considered the special needs of the TPs and the communities in their regions when planning their training programmes and support systems.
Health and social conditions vary from place to place. Cultural values, beliefs, and lifestyles are unique in every region. And resources of governments and local institutions differ according to economic conditions. These different needs should be carefully considered when utilizing TPs in PHC programmes.
Plan training programmes for TPs according to specific community, regional, and country needs.
Lesson 6: Training programmes that adopted non-formal adult education methods and materials and that were designed for low literate groups were most effective in increasing knowledge and skills.
A key finding of the study was that methods and materials for training TPs must fit the learning styles of the participants. Projects which used more participative and small group methods in classes and had the most variety of diagrams, posters, flip-charts and models to aid in the presentation of information, had fewer complaints from staff and TPs about the ease of understanding the training content. This reinforced a basic principle of adult education - that people learn by doing.
Regular training staff should have a thorough knowledge of how to use participative and experiential teaching methods and how to select and use a wide variety of supplementary teaching aids.
Use participative non-formal learning methods and visual aids that are appropriate for training TPs in PHC skills.
Lesson 7: Programmes that integrated services other than PHC skills into the training measurably contributed to the quality of life of TPs and community members.
Three of the projects incorporated the teaching of income generation and literacy improvement, which gave support to TBAs in their personal lives as well as their professional role as PHC providers.
Two of the projects taught herbalists how to cultivate and preserve herbs and how to keep bees and sell the honey in the markets. Another project taught TBAs how to generate income from small business projects, using loans from savings banks and from other community activities and how to increase their reading and writing skills. In addition to improving their personal lives, these skills enabled the TPs to keep more accurate patient records and communicate more effectively.
PHC training projects should include activities that meet literacy and economic needs of TPs.
Lesson 8: Staff who understood the cultural background and values of TPs were effective in training TPs and more effective in establishing collaboration between TPs and bio-medical health staff than medical staff who had less accepting or negative attitudes toward the TPs.
The Project Director in Ghana had previously participated in an anthropological study of traditional medicine in the same region and had a thorough knowledge of the traditional attitudes and beliefs of TPs. The staff used this prior experience to integrate some of the traditional wisdom into the training programme and to orient the doctors and nurses in the hospital in how to understand and collaborate more effectively with TPs.
To be most effective, staff who participate in training and provide support to TPs should have a respect for and sensitivity to TPs and have a basic understanding of traditional medicine and healing practices. Doctors, nurses, and other professionals should be able to communicate effectively with TPs and to integrate, where possible, the teaching of PHC knowledge and skills with basic beliefs of traditional healing. These attitudes and skills are particularly essential for establishing good collaboration and referrals between modern health staff and the TPs.
Prepare trainers with skills in effective communication and methods of informal adult education and orient all bio-medical staff who work with TPs with a basic understanding of traditional medicine and healing practices.
Lesson 9: Good collaboration between TPs and modern health staff depended upon mutual respect, good communication, and an established referral system.
For the most part, collaboration between TPs and modern health staff was good in the projects. Factors that contributed to this were:
• where TPs were taught how to identify life-threatening and serious health conditions and how to refer these cases to clinics and hospitals;
• where TPs and bio-medical staff understood and respected each other and there was good communication between agency staff and the TPs;
• where projects had developed a formal referral card system that TPs could use to refer patients to clinics and hospitals;
• where nursing staff allowed TBAs to accompany their patients into the delivery room or a learning experience.
• where periodic meetings were held between TPs and clinic/nursing staff to discuss referrals, problem cases and other matters.
Establish an effective referral system for TPs and promote good communication and a professional collegial relationship between TPs and modern health staff.
Lesson 10: Periodic follow-up support was essential to insure that TPs were providing quality PHC services.
All projects provided TPs with follow-up support, primarily through small group sessions in the field, though they differed in the amount of staff time allocated and the scheduling of these sessions. Both TPs and staff regarded these sessions as very important for solving problems and providing continuing education.
Provide continued follow-up support to TPs in their communities.
Lesson 11: Traditional practitioners who were compensated in some way for their PHC services were more committed to providing lasting service to their communities.
Traditional practitioners in these projects were not paid by their sponsoring agencies. They provided PHC services to individual families as part of their commitment to their communities and the sponsoring projects. And they received very little rewards from their clients for these services. As a result, many had a difficult struggle to survive economically and depended upon other sources of income, such as farming and small businesses.
Projects tried to compensate trainees for their time and services in different ways such as by presenting certificates for completion of training; giving a birthing kit or an umbrella or dress with badge to TBAs; giving first aid supplies; reimbursing for transportation costs. These were very much appreciated, but not all felt they were enough. Since community members were the beneficiaries of the TPs' services, both TPs and agency staff members suggested that these communities should commit more of their own resources to compensate the TPs for their services. Suggestions included payments of money, help in working the farms of TPs, building community clinics for TBAs, herbalists and other TPs to practice in.
Project staff should involve communities early in the planning stages to obtain local commitments to provide compensation to TPs for the services they provide to the communities.
Lesson 12: Projects which periodically evaluated their training programmes obtained valuable data from which they could make better decisions for modifying existing programmes and planning future ones.
Two of the projects studied had conducted formal evaluations using outside contractors. These evaluations were quite comprehensive and provided useful recommendations to the staff for improving the curriculum to identify the benefits to community members of the training project.
The most recent evaluation performed by one of these projects used a participatory approach with a team composed of outside members together with TBAs to collect the data. Participatory evaluations have many advantages such as educating local people in the importance of evaluation as a process to aid in decision-making and future planning, and stimulating local evaluators (such as TBAs) to utilize the evaluation process in improving their own practice.
Conduct periodic evaluation of training programmes and involve local staff in the evaluation process.
Lesson 13: Good communication and an exchange of information and experiences between planners of traditional practitioner training projects and other health agencies, (ie. government, non-government, and international health and health related organizations) regarding resources that are available for the training and utilization of TPs could contribute to more successfully planned and conducted programmes in PHC programmes.
In each project studied, the administrative and training staff were not aware of many outside resources that were available to them. Some of these resources existed within their own city or country in offices of the Ministries of Health, WHO Regional Offices, or NGOs conducting similar projects nearby. Project staff seemed to be working in isolation from other projects or organizations from which they could draw upon for technical assistance in the design and evaluation of training projects, obtaining materials on health education, or for other support.
Worldwide there exists a large body of information that, if it could be made available to these and other similar projects, could be of great value in planning and conducting effective projects that utilize TPs in PHC programmes. For example, the four projects in the field study had a great wealth of information which could be shared with each other and with others who desire to achieve similar goals.
Establish a central data base to collect information about existing studies, training programmes, audio-visual materials, and other relevant data and provide this information through a communication network to assist organizations and individuals in formulating policies and strategies for utilizing TPs in PHC, for conducting evaluation and research in this area, and for developing programmes to train TPs to provide PHC services for communities.
Collective recommendations made by health agency staff and their visions for the future. Health agency staff were asked to state their future visions of how Western and traditional practitioners might collaborate to provide a better health service. The following are some of their verbatim responses:
• "Western and traditional practitioners should come together, dialogue, and work hand in hand. Each should treat what they do best and refer to each other what they cannot do."
• "I see traditional practitioners in an equal partnership with Western medicine. I think we need to document what they are doing and perform more research on traditional medicine."
• "Both should be recognized and supported for the best of the community."
• "Traditional practitioners are emphasizing the curative aspects - we should help them strengthen the preventive side."
• "We should support and develop their own model of healing and get more agreements between health agencies and traditional practitioner organizations."
• "We need to continue the programme but improve it. Have the TBAs come to the hospital to learn more. Improve the teaching aids and training methods. Doctors need more training in how to teach adults."
• "The traditional practitioners and hospital doctors should work together in the community. Medical doctors need to know how the community lives."
• "If doctors could share friendship and work as a team with the TBAs it would be much better."
• "Train the TBAs to organize village women into groups or forums where doctors, family planning officers, and others could come to share ideas."
• "We need to teach TBAs how to organize community groups to conduct health education - they could be doing more with the older mother-in-laws and father-in-laws."
• "Because the traditional practitioners are older and more influential, they are able to promote nutrition, sanitation and family planning more effectively than the young nurses assigned to the community clinics."