1. INTRODUCTION
2.6 PROJECTS DEVELOPED IN FOUR COUNTRIES TO INITIATE COLLABORATION
2.6 PROJECTS DEVELOPED IN FOUR COUNTRIES TO INITIATE
discussions.
2. 6. 1 Nigeria
In Nigeria one of the earliest collaborative efforts involving medical workers and traditional healers was 'the family and the community based psychiatric programmes' which began in 1954 in Aro, conducted by Dr. T. A. Mlambo. Aro comprises four villages in a rural suburb, the population of which included farmers, fisherman and artisans. According to Mlambo (cited in Good, 1988) the project integrated the best practices oftraditional and contemporary psychology.
It was based on the premise that utilization of the therapeutic practices that already existed in
indigenous culture, including the power of group therapy, could when joined with modern psychiatry create unorthodox but effective hybrid for treating a broad array of mental disorders.
This was done through joint consultation by traditional healers and biomedical trained psychotherapists and participation by the patient's family. Day hospital and boarding out village care programmes, in which the ill had daily unrehearsed and voluntary contact with settled tolerant and healthy people were part of the project. This system was particularly effective with emotionally disturbed and psychotic children. The mean length of stay and recovery in Aro was about six months.
In 1981 another small project for community health education was initiated in Arorami, to choose traditional healers to participate in Ptimary Health Care (PHC) services. The traditional healers in this place were numerous and they included traditional birth attendants (TBAs), herbalist and bonesetters. The goal for the Arorami project was to "sell"the concept of good health to the local people and improve life through non-directive, social means, such as community mobilization and self diagnoses of health problems, identification offelt needs, acceptance of greater responsibility
for health and fostering participation in solving problems. Poor environmental sanitation, personal hygiene, communicable diseases and dental caries were among the identified health problems. A health committee was formulated which included influential people like traditional healers and
TBAs. Arorami was chosen for the project because it is a village with about 10,000 people with
limited biomedical facilities, only one health centre with limited equipment, a poor dispensary and maternal centre which were rarely used because of the lack of faith among the villagers in Western-type health care services. Thus, traditional healers were influential people in the community. (Laoye, 1981, cited in Good, 1988). This project was successful in that traditional healers and TBAs succeeded in learning and participating in PHC activities with the modem health care workers.
Caldwell and Caldwell (1985) (cited in Good, 1988), used programmes which tested the hypothesis that traditional healers could be effective agents for changing attitudes and behaviour related to fertility, Family Planning (FP) and Maternal and Child Health Care (MCH), including the possible reinforcement of traditional forms of fertility control. They believed that if the cooperation of traditional healers could be enlisted in Family Planning programmes, which were widely believed to violate basic values and traditions, the healers could be an extraordinarily powerful-stimulus for change within the general population. Caldwell and Calwell realised that in order to do this, traditional healers needed to be trained and be deployed in communities.
Traditional healers were trained and deployed in certain communities and there was success in that they were able to be influential in terms offamily planning programmes.
2. 6. 2 Swaziland
Most countries when implementing these strategies were looking into the cooperation and inter- sectoral training programmes in health care in Africa. In these aspects some pilot projects were conducted in Swaziland by Green and Makhubu (1984) ( cited in Good, 1988). They stated that for the seminars to be effective:
*
training should be planned well in advance,*
Training seminars should focus on a few topics, including some specifically related to traditional healers which are determined with traditional healers before to finalizing training agendas,*
Traditional healers must be treated in an appropriate manner by seminar organIZers.*
The initial emphasis should be on curative rather than preventive care, indicating the desirability of starting with traditional healers "where they are,"*
Cooperation must be joint and reciprocal Planning must include strategies for educating biomedical personnel about traditional healing methods, overcoming the communication gap, and developing approaches to cooperation.A second phase of intersect oral cooperation began in 1984-1985 when the Swaziland Ministry of Health (MOH) and Traditional Healers Society jointly sponsored a pilot project. This project was a five-day regional workshop demonstrating that specific PHC services to mothers and children could be improved through cooperative efforts between the nurses and the traditional healers. Promotion and evaluation of attitudinal changes of nurses and traditional healers towards one another was also a key interest in PHC activities. The focus of the project was on nutrition, the use of Oral Rehydration Salts (ORS), immunization, personal hygiene and sanitation. It
included teaching traditional healers specific skills to prevent and control diarrhoea, malnutrition, malaria and imm:unizable diseases such as whooping cough and tuberculosis (TB) (Hoff: Shapiro and Maseko in 1986, cited in Good, 1988).
Following a quasi-experimental design, a preliminary evaluation conducted two months after the final workshop measured the results of a 5-day workshop with an experimental group of 31 traditional healers and six nurses. A group of 23 traditional healers who did not attend the workshop served as a contro1. The results were that those who participated in the workshop had an increased understanding on the use ofORS, importance of water sanitation, good sanitation, personal nutrition and immunization. They also referred patients to clinics for the treatment of diarrhoea. All traditional healers who attended the workshop were found to have constructed pit latrines. Only 26% of the control group had them. While 48% of the workshop group attenders had wash basins, only 4% of the control group had these wash basins.
Overall, the project demonstrated that traditional healers could, with proper training and support, assist in the development of more effective PHC at the community leve1. In general, attitudes of nurses and traditional healers towards one another grew more positive, and communication and cooperation increased. Traditional healers sent more referrals to clinics where they knew nurses would be able to cooperate with them.
Hoff and Shapiro (1986) (cited in Good, 1988), state that the interviewed nurses were highly enthusiastic about cooperating more with healers to improve patient care. The traditional healers who attended the workshops went back to their home regions and organized meetings with other local traditional healers to communicate the information gained from the workshop.
This workshop's results reinforced the argument that traditional healers should be part of the focus of health education efforts and health education should build upon traditional beliefs rather than directly confront or disintegrate traditional beliefs.
2.6.3 Ghana
In Ghana, Primary Health Training for Indigenous Healers (PRHETIH) programme was introduced in 1979 in Techiman as an intriguing collaborative experiment in health education and skills development for PHe. Prior to designing the program, detailed information was gathered from the local traditional healers concerning their beliefs, techniques, felt needs for training course and their desire to participate in such activities. The programme was organized between a hospital called Holy Family and the traditional healers in Techiman village.
A survey conducted over six months involved 45 traditional healers (69% herbalist and 31%
priests/priestesses) representing 12 ethnic groups. By the end of the survey some traditional healers who were not involved were asking to be included in future training programmes. The common assumption that traditional healers were unwilling to cooperate in such ventures was not found to be the case in Techiman.
Information regarding the community utilization of traditional healers and biomedical services was gathered. Some 69% of the population said they used the services of traditional healers and 94%
said they visited biomedical services. These proportions underscore the overlap and joint use of the two systems. Follow-up visits to the traditional healers used a standardized questionnaire which revealed that the trainees retained more than 60% of the basic material they were taught.
What was noted from this program was the recommendation made that the success or failure of such projects will depend largely on the efforts by the Western side to understand the traditional healers' ideas about health and disease, and the respect they show towards traditional healers, including demanding supervision over traditional healers and their practices. The traditional healers are highly recognized specialists and should not be degraded to health workers with status
at the bottom of the modem health care system ( Good, 1988).
2. 6. 4 Republic of South Africa
Programmes which involved traditional healers and traditional midwives as health workers in primary health care services were launched in South Africa in the 1980's .. One was launched in 1986 by the Department of Health and Population Development in Transvaal. The Orange Free State followed in 1993 and they had 10 primary health care clinics participating in the project. The projects aim was to involve traditional healers in health promotion at grass-roots level of health care. The programmes were based on the needs identified during discussions with traditional healers, they included aspects such as personal hygiene, signs and symptoms of commonly occuning diseases in the area, mother and child care and sexually transmitted illnesses. Traditional healers were trained in these aspects of health care ( Troskie, 1995).
Troskie (1995) states that during interviews with traditional healers who had attended the programme, it was found that they were very positive and stated that they all benefited from the information gained. Traditional healers started to refer clients to the western facilities at an early stage of their illness. Patients who were referred by traditional healers, were referred back to them to ensure that clients continue with their treatments. Traditional midwives were issued with gloves.
Presidents of two traditional healers' associations gave their views about collaboration, where they stated that an umbrella organization controlling the practice of traditional healers would be of benefit. Hence, these programmes encouraged an openness to acknowledge the practice of traditional healers. The establishment of an umbrella body, could assist in early referrals and a trusting relationship between the two systems of health care workers could be enhanced.
These programs aimed at cooperation and collaboration in the above countries, they showed a positive initiative in ensuring collaboration between the Modern Health care system and the Traditional health care system The projects and training that were done showed that the biomedical system realised that traditional healers were very important and influential people who could make positive contributions towards any change that any Health Ministry tried to institute in the community.
All these projects were aimed at educating the traditional healers about preventive aspects of health because most traditional healers are curative oriented. Hence Green and Makhubu (1983) mentioned that collaborative effort has to start with curative aspects since that is what traditional healers understand. This perception to equip traditional healers with knowledge about preventing illnesses by maintaining good sanitation, personal hygiene, building pit latrines and water purification was very good.
The other aspect learned from these projects was that traditional healers themselves were willing to organize themselves into societies so they could function as a profession. They showed a willingness to learn and to collaborate with the modern health care system by learning modern health care services as far as PHC was concerned.
From these strategies in Nigeria, Ghana, the Republic of South Africa and Swaziland some general conclusions can be drawn. The researcher feels that, praiseworthy as the attempts were to engage the local traditional healers in certain aspects of PRe, for the greater good of the community, there were shortcomings as might be have been expected in these initial stages.
a) The major flaw was the one sidedness of the collaboration.
The traditional healers were expected to learn about modem health care services and there was no mention of what exactly the modem health care professionals learned from the traditional healers. It is clear that referrals were expected from the traditional healers and not from the modem health care services.
b) The organizers of these projects did not find out how traditional healers practise. They did not find out what illnesses they were capable to manage so that proper collaboration could take place.
From these projects recommendations emerged that a census of traditional healers should be done to provide information about types of traditional healers and their ratio to population, spatial distribution, and organizational patterns. This information could be used to determine the extent to which traditional healers should be taught to diagnose and treat simple ailments along with preventive -promotive activities, or should be limited to screening and referral. From this recommendation one can note that modem health care systems are trying to incorporate the traditional healers as part of modem health care system by training them to do certain limited activities of modem medicine. There is no clear answer as to what the traditional healers status would be when they became part of the biomedical professionals. With such an attitude the researcher doubts if there would be proper willingness on the part of the good traditional healers, who are skilled to cooperate on these terms. It might only be the bogus money searchers who might cooperate, (in anticipation of some monetary gain), rather than those who are real
traditional healers.
2. 6. 5 Limitations of traditional healers in Primary Health Care (PHC)
a) The supply of indigenous biomedical personnel who are interested in understanding and cooperating with traditional healers appeared to be limited,
b) The traditional beliefs about health and disease are set within a holistic social and environmental framework and tend to involve supernatural phenomena,
c) Formal or systematic methods for evaluating the outcome of therapy, i.e. through measurement, verification and validation, are lacking for many traditional practitioners.
Little research has been done on the informal methods that are used,
d) It is not easy to distinguish between credible traditional healers and the charlatans. This tendency to place bonafide traditional healers in the same category as "a con artist"
inhibits movement towards intersectoral cooperation (Good, 1988).
2. 6. 6 Summary
It was a very positive move for countries to follow up on WHO's initiatives about collaboration between different therapeutic systems, but opportunities were missed to look into other alternative medicines instead of only traditional healers. WHO (1977), (cited in Hogle and Prins, 1991) recommended a National Health Care Delivery System which included all other alternative medicines such as homeopathy, acupuncture, aroma therapy, and traditional healing in each country. This was a motion to encourage collaboration among all the systems of health care delivery and to incorporate them into the National Health Care System of each country.
Hall (1998) mentions that the wealth of any inyanga is his medicine (umutsi). Every inyanga has his or her special recipe, a combination of ingredients to produce specific various ailments. The ingredients are infinite. From the projects conducted in these countries it became clear that no single country bothered to investigate these traditional medicines and their uses in the above discussed projects.
Positively, the Organization of African Unity (0. A. U.) has shown interest in finding out about the medicinal heritage of each country in Africa. In Swaziland the survey on medicinal plants began in January, 1998 being led by the late Dr. Mshana the then Assistant Secretary General of the O. A. U. with some Swazi delegates and other delegates from countries like Tanzania Ghana and Nigeria. The University of Swaziland (UN1SWA) is responsible for the conduction and completio1;l ofthis study under the directorship of the Vice Chancellor Professor Lydia Makhubu.
The end result in four year time will be a traditional medicines pharmacopoeia with all the medicine being patented. This is forming a base of information on traditional medicines for the proposed establishment of a medicinal plant and ethnobotanical research centre.
A positive suggestion about collaboration between traditional healers and the biomedical practitioners was made when Good (1988) recommended that new doctors, nurses, and other biomedical personnel should have a curriculum that will enable them to learn about medical pluralism They should be trained in the nature and role of traditional medicine and traditional healers in their own countries and in the value of the ethno-botanical approach. A primary aim for this new, community-relevant medica training is to inculcate a set of values and skills in socia~
adult educationa~ and technical aspects that will facilitate accurate individual and community diagnoses and positive productive interactions with traditional healers.
2.7 STUDIES CONDUCTED IN THE AREA OF TRADITIONAL HEALTH