COLLABORATION WITH TRADITIONAL HEALERS IN HIV AND AIDS PREVENTION AND CARE
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- COLLABORATION WITH TRADITIONAL HEALERS IN HIV AND AIDS PREVENTION AND CARE
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Collaboration with
traditional healers in
HIV/AIDS prevention and care
in sub-Saharan Africa
A literature review
UNAIDS
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UNAIDS/00.29E (English original, September 2000)
© Joint United Nations. Programme on HIV/AIDS
(UNAIDS) 2000. All rights reserved. This document,
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Acknowledgements
'This review was written for I \.\IDS b\ Rachel King, MPI I.
I he author would like to thank, first, all the traditional healers for their tireless work in the
community, and their enthusiasm tor collaborating w ith the biomedical sector; and second, the
clients of healers who were the first to build the bridge between the two health sectors. I’inally,
ibis review would not have been possible without the valuable contributions of the following
individuals who generously gave information about their projects: Idrmina Mberesero, David
Schcinman, Ivric Gbodussu, Rene Burger, Donna Kabatesi, Iklward Green, Debi Lebeau, Mercy
Manci, Sandra Anderson, Noerine Kaleeba and |aco I iomsy.
Traditional healers develop training materials in Mukono, central Uganda.
Table of contents
Introduction
7
AIDS and traditional medicine in Africa
I lealth policy and traditional medicine in sub Saharan Africa
8
8
9
9
Selected examples of collaboration in IIIV/AIDS prevention and care
14
Background
The role of traditional medicine
Botswana
... 15
Central African Republic
... 16
Guinea
... 16
Malawi
.... 17
Mozambique
.... 17
South Africa................................................................................................
.....18
Uganda.....................................................................................................
1.19
United Republic of Tanzania.............................................................................
20
Zambia..............................................................................................................
....21
Conclusions..................................................................
....22
Selected projects reviewed according to UNAIDS Best Practice criteria
I Tfectivencss
Ethical soundness
Efficiency....................................................................................................................
Sustainability
Relevance........................................................................
Additional criteria for collaborative projects
Criteria lor selecting ’genuine' or 'authentic' healers
Approach used to establish trust with traditional healers
Lessons learned
Training methods
Collaboration
Project design and implementation
Further research and action
24
24
26
27
29
30
32
32
33
34
34
34
34
36
Annexes
Questionnaire given to project leaders to determine Best Practices
39
Table 1: Summary of documented examples of collaboration in sub-Saharan Africa (19871999)
40
I able 2: Review of examples of collaboration according to UNAIDS Best Practice criteria
47
Table 3: Specific criteria/approach for collaboration
51
Table 4: Efficiency calculations forTHET/\ Uganda
...54
References and further reading
I
55
I
Introduction
11IV/AIDS is now the number one overall cause of death in Africa, and has moved up to fourth
place among all causes of death worldwide, according to the latest annual W'oiid Health Report.
As the epidemic continues to ravage the developing world, it becomes increasingly evident that
diverse strategies to confront the wide-ranging and complex social, cultural, environmental and
economic contexts in which 111\r continues to spread must be researched, tested, evaluated,
adapted and adopted. 1 he majority of populations in developing countries have access to
Itaditional health care and it is widely accepted (hat about 8()",n of people in Africa rely on
traditional medicine lor many ot their health care needs. Traditional healers arc well known in
the communities where they work lor their expertise in treating many sexually transmitted
diseases' (Green, 1994). Consequently, the World Health Organization (WHO) has advocated
the inclusion of traditional healers in National AIDS programmes since the early 1990s.
The aim of this report w’as to give a brief update on AIDS and traditional medicine in Africa, and
to review initiatives that have attempted collaboration between traditional and bidmedical
practitioners for HIV prevention. There is, however, a dearth of research actually testing the
impact of involving traditional healers in HIV prevention efforts. Most reports—even evaluation
reports—often state only achievements and findings. This review first looked as broadly as
possible at all interventions involving traditional healers in HIV/AIDS prevention and care in
sub-Saharan Africa. Eight projects that most closely met UNAIDS Best Practice criteria {effective
and ethical interventions that arc ef/icicHt^ sustainable, and relevant for HIV prevention in the
resource-constrained settings of sub-Saharan Africa) were then selected and compared.
In addition to the UNAIDS criteria, supplementary standards were defined that are specific to
traditional medicine/biomedicine collaborative projects. Data were collected through published
and unpublished literature, through personal contacts, e-mail correspondence, circulation of a
questionnaire and by attending the hirst International Conference on AIDS and Traditional
Medicine in Dakar, Senegal, in March 1999.
The report is organized into four sections. The first section gives a brief update on AIDS in
Africa and is followed by background information on African traditional medicine. This includes
strengths and limitations of traditional medicine and healers with respect to collaboration with
biomedicine, and the continuing policy debate on the integration, cooperation, and collaboration
of traditional medicine with national health care systems. The second section reviews
collaborations between traditional medicine and biomedicine for HIV prevention, including a
comprehensive table of collaborative initiatives. The third section analyses traditional
medicine/biomedicine collaborative projects with reference to the UNAIDS Best Practice
Criteria of effectiveness, efficiency, relevance, ethical soundness and sustainability, and adds
suggested specific criteria for these types of projects. As many projects had not reported
specifically on these criteria, a list of issues to consider in order to conform to Best Practices was
included in each subsection, finally, since this continues to be an extremely exploratory field, the
last section identifies needs for further research on collaboration between health sectors.
1 Researchers in some countries have noted that some other illnesses and conditions not classified as
sexually transmitted in biomedical nosology may be locally regarded as such by traditional healers and
their clients (Green, 1994).
AIDS and traditional medicine in Africa
Background
Since the beginning of the epidemic, an estimated 34 million people living in sub-Saharan Africa
have been infected with the virus. In 1998, 70% of the people who became infected with HIV
and four-fifths of all AIDS deaths were in sub-Saharan Africa. In addition, at least 95% of all
AIDS orphans have been African2. AIDS was responsible for an estimated 2 million African
deaths, which could account for 5,500 funerals a day. And despite the scale of death, today there
are more Africans living with HIV than ever before: 23.5 million adults and children (UNAIDS,
1999).
The majority of new infections continue to be concentrated in 1 Eastern and Southern Africa,
though no country is spared. In Botswana, Namibia, Swaziland and Zimbabwe, current estimates
indicate that between 20% and 26% of people aged 15-49 arc living with H1V or AIDS.
Zimbabwe for example, is ver}’ hard hit. In 23 of 25 surveillance sites, over 20% of all pregnant
women were found to be infected. About one-third of these women are likely to pass the
infection on to their babies. In Central /Xfrican Republic, Cote d’Ivoire, Djibouti and Kenya, at
least one in ten adults is II1 V-infectcd. In Rwanda, the median prevalence among women
attending antenatal clinics in major urban centres was about 28% and, in Uganda, the prevalence
has dropped in recent years to 15% in the same population. \\ cst Africa is generally less affected
by HIV than Southern or Eastern Africa (UNAIDS, 1998).
Today, interventions to stem the spread of HIV/AIDS throughout the world arc as varied as the
contexts in which we find them. Not only is the HIV epidemic dynamic in terms of treatment
options, prevention strategics and disease progression, but sexual behaviour, which remains the
primary target of HIV prevention efforts worldwide, is widely diverse and deeply embedded in
social and cultural relationships, as well as environmental and economic processes. This makes
prevention of HIV/A1DS very complex.
Most preventive inten-entions have relied on giving correct information about 11IV transmission
and prevention and imparting practical skills to enable individuals to reduce their risk of 111V
infection. More recently, sociocultural factors surrounding the individual have been considered
in designing prevention interventions. In addition, bevond the individual and his or her
immediate social relationships, larger issues of structural and environmental determinants also
play a significant role in sexual behaviour and thus arc addressed in intervention design and
implementation.
Monitoring and evaluation of prevention programmes have shown that prevention does work. In
countries that have implemented quick, well planned efforts with support from political atid
religious leaders, including sex education in schools, treatment of STDs (sexually transmitted
diseases), and widely promoted condom use, 11IV prevalence has been kept consistently low and
has even decreased in some countries in the last five years (UNAIDS, 1998). Yet, cases of
decreased 11IV prevalence arc still the exception and manv developing countries arc struggling to
find innovative, cost-cffcctivc strategics that arc relevant to their AIDS situation. In resourceconstrained settings, one avenue that has still been rarelv travelled is cooperation with the
indigenous health system.
2 UNAIDS defines AIDS orphans as people who lost their mother or both their parents to AIDS when they
were under the age of 1 5.
I h’
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The role of traditional medicine
Traditional healers represent a broad range of practices, including herbalism and spiritualism, as
well as a range of individuals who call themselves di\ iners, priests and faith healers, among other
terms. Although many of the initiatives reviewed here did not differentiate between these
categories, the term ‘traditional healer’ used refers to either herbalists, spiritualists, or to those
(the great majority of healers) involved in both practices.
African traditional healers mirror the great variety of cultures and belief systems on the
continent, and possess equally heterogeneous experience, training and educational backgrounds.
This diversity is further enhanced by their adaptations to the dramatic social changes that have
affected much of the region since colonization, such as urbanization, population migration and
displacement, and civil conflict (Good, 1987). The cost of traditional medical care varies with the
nature of treatment, the type and severity of ailment and the relative wealth of the client (Porter,
1996; King et al, 1992). Whenever African healers’ knowledge, attitudes, beliefs and practices
about STDs and AIDS have been explored, findings have reflected the stage of the epidemic, the
amount of information traditional healers have been exposed to, and their pre-existing belief
systems about health and disease in general, and STDs and AIDS in particular.
Many traditional healers have treated STDs for generations, but their explanations of STDs and
AIDS vary considerably across ethnic backgrounds with regard to the nature, causes and modes
of transmission of these diseases. However, the concepts underlying these explanations appear
remarkably similar across national and cultural boundaries. Perhaps the most striking example is
the origin of STDs: healers in many settings, whether rural or urban, often ascribe these to
transgressions of taboos related to birth, pregnancy, marriage and death (Green, 1992, 1994;
King et al, 1993). At the same time, some of Africa’s most serious diseases, including AIDS and
other STDs, arc often understood within a framework of contagion which could include
invasion of the body by dangerous microorganisms, pollution or environmental dangers (Green,
1999).
While social research has shown that, in many countries, healers could name and describe
numerous types of STDs (which do not always correspond to the biomedical definition of
STDs), few of them consider AIDS an ‘African’ disease (Green, 1992a; Green et al, 1993).
Traditional beliefs about the prevention of STDs or 1IIV/AIDS follow the logic of transmission
and causation, and include limiting the number of sexual partners, wearing protective charms or
tattoos, having ‘strong blood’, using condoms to reduce the risk of ‘pollution’, or undergoing a
‘traditional vaccination’ consisting of introducing herbs in skin incisions (Green, 1992a; Green et
al, 1993; Nzima et al, 1996; Schoepf, 1992). In numerous cases now, condoms have been
acceptable to traditional healers, especially when they fit into their belief system. For example,
many African healers consider semen an important element to nourish a growing foetus and
maintain the mother’s health and beauty, but their concern for family and cultural survival can
override this belief and allow them to promote condom use (Green et al, 1993; Schoepf, 1992).
Health policy and traditional medicine in sub-Saharan Africa
With growing interest and increasing need for expanded health care in the past 20 years, the
governing bodies of WI l() have adopted a series of resolutions. Policies regarding collaboration
with traditional medicine have been shifting since the late 1970s. As early as 1974, the WHO
Regional Committee for Africa decided that the topic for the technical discussions at its
upcoming twenty-sixth session would be "Traditional medicine and its role in the development
of health services in Africa." Three years later, the World 1 lealth Assembly adopted a resolution
promoting training and research related to traditional medicine. In 1978 in Alma Ata, WHO and
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UNICEF adopted
resolutions
supporting the
use of indigenous
health
practitioners
in
government-sponsored health programmes.
In 1984, 1989 and 1990, further resolutions were adopted, encouraging specific measures
governing the practice of traditional medicine to be incorporated within national health
legislation, adequate budgets to allow promotion of traditional medicine, the development of
traditional medicine systems, effective launching of these programmes, and inventories of
medicinal plants. In 1990, the WHO Traditional Medicine Programme and the WI IO Global
Programme on AIDS came together in Botswana to consider ways to involve traditional health
practitioners more actively in measures to prevent and control II1V infection and AIDS in
African communities. In 1994, the WHO offered further observations and direction regarding
traditional healers, suggesting that upgrading their skills made more sense than training new
groups of health workers, such as village health workers.
Since then, changing policies and a growing body of data concerning cooperation with traditional
healers have fuelled an ongoing debate on the public health relevance of investing in efforts for
partnership with traditional healers. In this debate, the following points are made in favour of
collaboration:
Traditional healers often outnumber doctors bv 100 to 1 or more in most African countries.
They provide a large accessible, available, affordable trained human resource pool.
Traditional healers possess many effective treatments and treatment methods.
Traditional
healers provide client-centred, personalized
health
care
that is culturally
appropriate, holistic, and tailored to meet the needs and expectations of the patient.
Traditional healers are culturally close to clients, which facilitates communication about
disease and related social issues. This is especiallv important in the case of STDs.
Traditional healers often see their patients in the presence of other family members, which
sheds light on the traditional healers’ role in promoting social stability and family
counselling.
When traditional healers engage in harmful practices, there is a public health responsibility
to try to change these practices, which is only possible with dialogue and cooperation.
Research has shown that traditional healers abstain from dangerous practices when educated
about the risks.
•
Traditional healers are generally respected health care providers and opinion leaders in their
communities, and thus arc treating large numbers of people living with 111V/A1DS. I lealers
have greater credibility than village health workers (who are often their counterparts in
village settings), especially with respect to social and spiritual matters.
Since traditional healers occupy a critical role in African societies, thev are not likely to
disappear soon. They survived even strict colonial legislation forbidding their practice. Even
with the rapid sociocultural changes occurring in many African societies, traditional healers
continue to play a crucial role in addressing the \arict\ of psvchosocial problems that arise
from conflicting expectations of changing societies.
Numerous studies (sec below) document traditional healers’ enthusiasm for collaborating
with biomedical health providers and show that their activities arc sustainable as they
generate their own source of income.
Man)’ biomedical health providers want such collaboration (Oja & Steen, 1996).
I*.specially since the 1980s, healers have been organizing themselves into traditional healers’
associations, which makes it easier to establish collaborative programmes.
l-fforts at collaboration seem to improve health deliver}’ in a number of ways:
increased knowledge and skills of traditional healers
increased confidence in their practice
increased openness (transparency) towards the community within their work
earlier referral to hospital or health centre
Points against, or weaknesses of, collaboration include:
I he training and licensing of healers is not institutionalized, which makes it difficult to reach
and train them regularly in a standardized manner
Quality control of healers is difficult in the absence of officially recognized licensing
procedures
There is no general monitoring of healers' activities or claims
•
Traditional healers lack detailed anatomical and physiological knowledge
Traditional healers may engage in some harmful practices or cause delays in referral to
biomedical facilities
Promotion and improvement of traditional methods may undermine efforts to increase
access to biomedicine
•
The effects of combining traditional and biomedical treatments are not known and may be
harmful
Official recognition of traditional medicine gives legitimacy to traditional healers when their
treatments and methods arc still largclv untested
Opening up collaboration with traditional healers raises their expectations of greater
recognition from government, which governments may not be able to give.
Many public health experts involved in this ongoing debate have concluded that, despite the
limitations, it makes sense to at least attempt collaboration, given the vast health needs in
developing countries and the numerous realistic and practical advantages. The following section
discusses eight projects that have developed collaboration between biomedical and traditional
health practitioners for II1V/A1DS prevention and care. In addition, Guinea is also discussed as
a supplementary case, since the government has tried to integrate traditional healers into many
different aspects of health care, though not specifically AIDS.
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A healer tends a herbal garden in Mbarara, western Uganda.
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Selected examples of collaboration in
HIV/AIDS prevention and care
The African continent, being the region most affected by AIDS and the poorest in modern
health resources, should be an obvious place for collaborations between traditional and
biomedical health care. However, despite the multitude of health challenges affecting the African
people, very little action has been taken to actually work with healers since the WHO’s
recognition of the importance of traditional medicine to primary health care, and of the need to
include healers in national health strategies and policies (WHO, 1977, 1978, 1991). Certainly,
considerable prejudice remains ingrained among many biomedical health practitioners about the
justification, validity and integrity of traditional medical practices and practitioners. An important
reason for this is the absence of regulatory bodies governing the practice of traditional medicine
in most of Africa, which makes it easier for charlatans to infiltrate the profession and abuse its
reputation.
Nevertheless, the Wl l() recommendations arc based on the premise shared by manv researchers,
physicians and public health experts that, as a highly respected, widelv distributed and highly
consulted group of health practitioners, recognized traditional healers have the cultural
knowledge and skills to make an impact on the prevention of disease (including IIIV/AIDS), as
well as on health promotion and care (Staugaard, 1991; Green, 1992a,b, 1993, 1994, 1995). The
traditional healer is frequently consulted as a religious and spiritual guide, legal and political
adviser, and marriage and family counsellor (Staugaard, 1985). In addition, STDs arc among the
most common reasons for visiting the traditional healers in many African countries where many
people believe that, while biomedicine can cffectivclv cure phvsical svmptoms of ‘modern’
diseases, healers are expected to completely heal the bodv and spirit, and to cure diseases
considered distinctly ‘African’ (i.c. believed to be due to forces bevond modern medicine’s
comprehension) (Staugaard, 1985,1991; Green, 1992a,b, 1994, 1995; Green ct al, 1993; Fink,
1990). In fact, many people in Africa believe that biomedical health practitioners cannot
effectively and complctclv cure STDs (Green, 1999). Finallv, women, whose social, cultural and
economic position in Africa makes them especially vulnerable to STDs and AIDS, often
constitute the majority of traditional healers’ clients (I lomsv
King, 1996).
Since the beginning of the AIDS epidemic, there has been a renewed interest in collaboration
with traditional healers in the hope of finding new, more effective wavs to light and prevent this
disease. Initially, a number of projects attempted to assess the alue of traditional herbal
remedies for the treatment of illnesses associated with AIDS (Musinguzi & Twa-Twa, 1991;
Akerclc ct al, 1993; Ssenyonga, 1994; Ssenyonga & Brehony, 1993a; Sscmukasa & Brehony, 1993;
Sofowora, 1993; I lomsy & King, 1996; Lvnde, 1996). ()ther studies were conducted on
traditional healers’ perceptions of STDs, 11IV and AIDS. With these results, collaborative efforts
have created programmes that trained traditional healers as educators and counsellors to
disseminate HIV/AIDS information and prevention practices among their peers and
communities. As a means of involving traditional healers further, some projects have encouraged
healers to empower and provide emotional support to clients living with HIX' and /XIDS.
With the realization that traditional healers could become effective health workers for 111V
prevention, given their traditional roles as educators and counsellors in their communities, a
number of projects started training healers in IIIX'/AIDS as earlv as the late 1980s (Staugaard,
1991; Green et al, 1993, 1994; Schoepf, 1992). Some initiatives have noted that ‘training’ healers
implies a different approach than that used with conventional health workers, to whom
knowledge tends to be imparted unidirectionally. With traditional healers, only a respectful
attitude of open exchange of ideas and information can win trust and cooperation. The projects
reviewed below used that approach. I'cw have an\ follow-up data.
This report addresses initiali\'es (in alphabetical order) that attempted a collaboration between
traditional and biomedical health practitioners tor I 11\ prevention, education and counselling. It
docs not include collaborative projects solclv focusing on herbal remedies for 111V infection.
1 he nature, objectives, methods, achievements and findings of these initiatives are summarized
in the annexed Table 1.
BOTSWANA
In Botswana, where the 1997 national scrosurveillance data showed an 1IIV prevalence of 38.5%
among pregnant women in urban areas, the government has had for more than 18 years a policy
of actively promoting cooperation between modern and traditional medicine (WHO, 1991;
Staugaard, 1985). Activities of the Ministry of 1 lealth/Xarional AIDS Programme for traditional
healers have included seminars on AIDS, and implementing the Botswana Dingaka AIDS
Aw’areness and 'Training Project. This project took place between 1991 and 1993 wdth the
objective of training traditional healers as trainers who would pass AIDS information on to other
traditional healers in selected pilot areas, and promoting cooperation and collaboration between
traditional and biomedical health sen ices (sec Table 1). The original training of trainers lasted
two weeks and involved 12 healers in six districts of Botswana. Trained healers were then to
travel together to other districts to train 40 other healers in each district. ()ncc trained, newly
trained healers were expected to train more healers, obtain condoms from health centres and
distribute them to their clients and communities (Mbongwe & Mokganedi, 1993).
Tour of rhe five workshops planned for the second-generation healers took place. I lowever,
funding was terminated after the first phase of the project, so neither group of healers was
followed-up or formally evaluated for effectiveness of the training or for accomplishment of
stated objectives within the duration of the project. I lowever, an independent assessment of the
Botswana Dingaka AIDS Awareness and Training Project, conducted in 1994, interviewed 32
traditional healers, 19 nurses and 2(1 medical doctors; 72"o of the traditional healers interviewed
stated that they had changed something in their practice in relation to the new information on
AIDS and 80% said that, after training, they recommended condoms to their patients, while 31
of the 32 stated that they referred patients to clinics or to the hospital (Oja & Steen, 1996).
Interestingly, 17 of 19 nurses interviewed claimed that thev also referred patients to traditional
healers, but only 7°/o of the medical doctors reported doing the same.
In a second assessment in 1995, three of the 12 first-generation healers intervicAved said they
w'ere able to disseminate information in their communities, had referred patients to the hospital
when their treatments failed, and had no hesitation in distributing condoms or talking about
sexual issues with clients (King, 1995). All three healers also claimed they had many STD
patients, yet had not, so far, had a patient whom they believed had AIDS. When asked how they
would manage a person with AIDS, they all said there was nothing they could do, since they
didn't have a treatment for AIDS. 'I’hcy were not aware of the clinical case definition of AIDS,
and were nor referring their clients for I 11V testing and counselling. They did not see themselves
playing a role in home-based care for persons living with 111V/AIDS (King, 1995).
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CENTRAL AFRICAN REPUBLIC
A onc-year project to increase traditional healers’ capacity to deliver preventive messages,
provide support to persons living with H1V/AIDS, and modify their own risk practices was
started in 1995 in the Central African Republic, where HIV seroprevalence among adults was
estimated at 15% in Bangui and 4% in rural areas (Johnson, 1996). Over two months, 103
healers in four locations received six days (36 hours) of STD/AIDS information and training on
community education (Somse et al, 1995; Johnson, 1996). At the end of training assessment,
traditional healers’ knowledge had significantly improved regarding:
the role of STDs in increasing risk of HIV infection
condoms protecting against HIV
•
the causes of genital discharge and ulcers
STD complications
•
the modes of HIV transmission and prevention (Somse et al, 1995).
Knowledge and aliimdes regarding tradilional healers’ risk practices of transmilling HIV and
towards condom use did not improve. The authors suggested that altitudes towards condom use
may not have changed because of the conflict with the desire to have children, but did not
suggest reasons as to why healers’ knowledge did not change with regard to appropriate modes
ofcarc.
The objectives of supporting persons living with H1V/AIDS and changing healers’ practices
were not measured in detail in the first analysis. I lowevcr, of the traditional healers who reported
seeing STD cases, 76% reported integrating partner referral into their S'l'D treatment.
GUINEA
In 1979, the Ministry of Public Health and its Department of Traditional Medicine began to
collaborate with traditional healers on primary health care in Guinea. In the 1990s, when the
prevalence of HIV was still below 1.5% among women in prenatal care, an initiative was aimed
at identifying how traditional medicine could increase the effectiveness of the National AIDS
Programme and answer the following questions:
Tor what STDs arc traditional healers consulted?
How do traditional healers diagnose and treat STDs?
A survey implemented by the Department of Traditional Medicine and a research study
completed by ORSTOM (Institut frangais de recherche scientifique pour le developpementt et
cooperation) both indicated that gonorrhoea was the STD most frequently diagnosed by the
traditional healers.
In addition, the National AIDS Programme financed two training workshops for traditional
healers with the objective of increasing knowledge about HIV/AIDS transmission and
prevention, clinical manifestations of AIDS, and AIDS care. Unfortunately, further training
could not continue due to lack of funding. Investigators suggested that educational messages
should be specifically designed to reinforce, and not to contradict, traditional concepts of disease
and illness (e.g. using the same names of diseases, which helps to gain the interest and trust of
traditional healers). The objectives were "to bring traditional healers as effective educators at the
community level, to give quality treatment, and to refer in time for all conditions he/she cannot
treat." In one district of the country, the AIDS office, in collaboration with healer associations,
organized training sessions for healer association members. It was realized that healers could play
a significant role in health education, promotion and distribution of condoms, treatment of
opportunistic infections, early referral, and participation in research on AIDS and STDs. In
addition, traditional healers arc involved in other primary health care issues such as
immunization, nutrition education and sanitation. The district also did significant research and
documentation on plants used in STD and AIDS treatment by traditional healers (Traditional
Medicine and AIDS report. Ministry of I lealth, Guinea, 1998).
MALAWI
In the Chikw'aw’a District of Malawi, which in 1996 had an estimated HIV seroprevalence of
30.5% among w’omen in antenatal care clinics in major urban areas (UNAIDS, 1998), a series of
orientations and focus group discussions were held with groups of traditional healers. In 1993,
based on requests from traditional healers, AIDS activities were initiated within an already
I
established eye care programme with the following objectives:
to better understand the practices and roles of healers in their communities
-
to promote greater communication between traditional healers and the ‘formal’ health sector
to educate traditional healers about IIIV/AIDS and STD transmission and prevention
to encourage community-based I IIV/AIDS prevention and care activities by traditional
healers.
A baseline survey was conducted with 89 healers regarding their knowledge, attitudes, beliefs and
practices surrounding AIDS. Using the results of this survey, a curriculum (including modes of
HIV transmission, condom use, and AIDS education messages) was developed for one-day
workshops in 1*1 sites emphasizing community education and condom distribution (Berger &
Porter, 1994; Porter, 1996). Healers were selected through recommendations from community
leaders to participate in training sessions. /\ total of 352 healers were reached in the first of 2
training programmes. Six months after the first training, 61 healers were randomly selected for
an evaluation of the training sessions. The evaluation found that 64% of the healers had
conducted AIDS educational sessions and 89% had distributed condoms. Those conducting
educational sessions were more likely to distribute condoms compared to those who were not
involved in AIDS education. Unfortunately, when traditional healers ran out of condoms, many
did not seek out health centres to replenish their supply. Moreover, the authors comment that
changing community and traditional healers’ values about STDs is more challenging than
changing those about AIDS. Though the aspect of collaboration was not formally evaluated,
investigators suggest that more collaborative referral networks need to be encouraged.
MOZAMBIQUE
In 1996, Mozambique had an official overall IIIV prevalence of 5.8% in major urban areas and
19.2% outside of urban centres (UNAIDS, 1998). As early as 1991, a three-year programme was
initiated by the Ministry of I lealth's Department of Traditional Medicine with the aim of
decreasing the spread of 111V by reducing the incidence of STDs through a collaborative effort
I
J
I
Collaboration with traditional :"'alers io III'. •-■.Il
in ’.uh johardn Africa
with a local healer organization (Circen et al, 1993; Green, 1994). Preliminary qualitative research
on 11 adii i< mal he.ilvis' perceptions <>l SIDs and AIDS revealed a strong bclicl that biomedical
practitioners "do not understand the true cause ol SIDs." I he survey also showed that all
traditional healers had heard of AIDS, had complete faith in their medicines, advised avoiding
biomedicine for STDs, and believed a number of illnesses (but not AIDS) to be sexually
transmitted (Green et al, 1993). A training strategy was proposed whereby new concepts such as
promoting condom use would be integrated into existing notions of protection, and traditional
principles (such as discouraging sex outside marriage or promoting sexual abstinence during
STD treatment) would be reinforced. At the same time, old practices, such as traditional
vaccination involving healer-to-patient or patient-to-patient blood contact, would be discouraged
(Green, 1992a; Jurg et al, 1992).
I
0
I
S
I
I
Based on this strategy, two onc-week workshops were conducted for 30 healers in two provinces
of the country, in 1991 and 1994. An assessment of the 1994 workshop included 70% of the
trained healers and eight patients of trained healers. The evaluation found that most traditional
healers had learned about the sexual transmission of 111V, 75% reported condom use as a way to
avoid AIDS, and 81% claimed to promote condoms with at least their STD patients. However,
confusion remained as to the relationship between SIDs, Hl\ anti AIDS anti about whether
AIDS is curable (Green, 1995a).
SOUTH AFRICA
In South Africa, HIV seroprevalence has been rising rapidly in the past few years, reaching 15%
in 1997 among women in antenatal clinics in urban areas and 18% in more rural antenatal clinics.
Traditional medicine has remained an important component of health sendees, despite a high
rate of modernization. A project was started in 1992 to train 27,000 traditional healers
nationwide about AIDS in three successive cycles (Green, 1994, 1995b; Mgiba et al, 1993; Manci
et al, 1993). The strategy was to train 30 healers as trainers, who would each train a second group
of 30 healers, who would then repeat the cycle. The initial five-day training covered topics similar
to those described in other programmes above, in addition to the issue of death and dying.
Eighteen of the trained traditional healers reported having trained 630 second-generation healers
in different regions of the country seven months after the first training. A preliminary evaluation
of thi^ second generation focused on 70 trained healers selected from 10 geographically
representative sites (Green, 1995b). Ninety, percent of them thought that the demonstration of
correct condom use was the most useful aspect of the workshop. These healers had correctly
retained basic information on gonorrhoea, II1V as an infectious agent, IIIV symptoms, and
modes of HIV transmission and prevention. Gf 18 healers who said they had treated cases of
AIDS, three mentioned giving advice and counselling to their clients without being prompted
(Green, 1995). When prompted, the other 15 described promoting positive attitudes about
people with AIDS, or showing care and understanding as to the type of advice or counselling
given, while eight mentioned advising on condom use (Green, 1995). The assessment concluded
that the first generation of trained traditional healers selected and trained their peers for the
second cycle more effectively than the western-trained trainers of the first generation, as the
traditional healers’ selection was less politically directed and (he training more culturally
appropriate (Green et al, 1995).
UGANDA
111V seroprevalence is among the world’s highest in Uganda. In the early 1990s, two NGOs, the
Ministry of Health and the National AIDS Commission launched an initiative called Traditional
and Modern 1 lealth Practitioners Together against AIDS (TII ETA). The aim was to promote a
true collaboration between traditional healers and biomedical health providers in the area of
treatment, care, support and prevention of STDs and AIDS (1 lomsy & King, 1996). In 1992, the
first THE 1’A project attempted a collaborative clinical study to evaluate herbal treatments for
HIV/AIDS symptoms for which few' or no therapeutic options wrere available in the region
(Homsy et al, 1995). W hen this study began, healers w'ere unwilling to discuss AIDS with their
clients because they feared losing them with this terminal diagnosis. These challenges motivated
a second project to empower traditional healers to provide STD/AIDS counselling and
education. The project had a particular emphasis on the healers' w'omen clients in Kampala,
where the prevalence of HIV had levelled around 30% in pregnant women at that time3
(Ugandan Ministry of I lealth, 1996).
For this study, 48 Kampala healers wrere selected through home and clinic visits to answer a
baseline questionnaire related to their knowledge, attitudes, beliefs and practices surrounding
STDs and AIDS (King, 1994a). Following this survey, 17 healers w'ere recruited to participate in
a 15-month ‘training’ programme including an average of three training days a month. The
original training curriculum was developed in collaboration with The AIDS Support
Organization (TASO) and w ith the input of both healers and community women. Content
focused specifically on STDs and AIDS, but also covered general topics such as cultural beliefs
and practices, counselling, leadership, sexuality, gender, and legal issues (King, 1994b).
Healers’ overall performance was evaluated systematically using various indicators with each
traditional healer, his/her clients and the community. Research methods included oral and
written tests, regular visits to the healers’ workplace, client follow-up interviews, and sessions in
which a trainer observed a healer practising education or counselling (King, 1994b; Nshakira et
al, 1995; Nakyanzi et al, 1996). I 'ach healer w'as found to have applied the training differently,
some using their new skills tor community education, others for counselling and/or initiating
persons living with HIV/AIDS, youth or women's support groups (Homsy & King, 1996).
Community education by healers proved to be a very interactive process whereby traditional
healers designed their own training materials, and developed and used unique approaches such as
story-telling, personal testimonies from persons living with HIV/AIDS, music, dance, poetry
and drama to convey their messages. A preliminary assessment was conducted one year after the
end of the training programme, comparing three communities where healers had completed the
THETA curriculum with one community where traditional healers had not been trained. The
community members with trained healers showed increased knowledge about HIV/AIDS and
reported increased condom use (50% versus 17% where the traditional healer was not trained)
and reduced risk behaviour (Nshakira et al, 1995).
Healers’ counselling was evaluated by interviewing 180 women clients consulting for HIV
symptoms, STDs, or ‘love’ problems, with nine trained healers and following them up three and
six months later (King, 1994b). The proportions of women who reported having both received
counselling from their healer (45 to 72%) and been tested for HIV (46 to 64%) had risen
significantly by the second follow-up. During counselling, women said healers discussed facts
about AIDS, positive living, condom use, and had demonstrated and offered condoms (King,
3 HIV seroprevalence has since declined in Uganda —to a level of 14.7% in antenatal clinics in major urban
areas in 1997.
Collaboration with traditional healers in HIV AIDS pt eventin') and a'C in sub-Saharan Afiica
1994b). Condom knowledge, attitudes and use were found to significantly increase over time
among these women, as did condom negotiation by women with their sex partners. However, at
six months, eight out of 39 (21%) women still said that one could tell someone had AIDS by
"pale skin or eyes".
|i
Finally, within the first year of training, three of the trained healers spontaneously initiated the
formation of ‘persons living with HIV/Al DS’ support groups for their clients, some of whom
achieved local renown for their educational songs, drama and dance on AIDS (Lattu et al, 1994).
Based on these results, the THETA initiative has been expanded to six rural districts of Uganda,
using the framework developed in the Kampala pilot study. A participatory evaluation of
TFIETA conducted in 1997-1998 showed that:
125 healers were trained in the first five districts selected
60% of trained traditional healers (compared to 9% of untrained traditional healers)
reported distributing condoms
II
80% of trained traditional healers (compared to 40% of untrained traditional healers)
reported counselling patients
82% of trained traditional healers (compared to 42% of untrained traditional healers)
reported giving AIDS community education
cross-referral of patients increased, with 97% of trained healers referring patients.
Other benefits of training included: better hygiene, initiation of record keeping, decreased fees,
initiation of patient support groups and improved collaboration with biomedicine (T1 IlCfA, 1998).
In addition to training activities, THETA conducts clinical activities and has initiated the creation
of a resource centre for traditional medicine and AIDS. Clinical activities have included a study
assessing lierbal treatments of traditional healers for specific HIV-associated symptoms, and
training for traditional healers on basic clinical diagnosis. The resource centre contains a library
with material on traditional medicine and /\IDS, and has produced two videos and a newsletter
that comes out three times a year. It also conducts a monthly speakers’ bureau where topics
relevant to traditional medicine and AIDS arc discussed and debated among practitioners of
traditional medicine and biomedicine, as well as patients of both systems.
UNITED REPUBLIC OF TANZANIA
HIV seroprevalence reached 13.7% in 1996 in antenatal clinics in urban centres in the United
Republic of Tanzania. In 1989, the impact of HIV motivated collaboration between traditional
and biomedical health workers in the Tanga region of North Eastern Tanzania. During early
collaborative meetings between traditional healers and biomedical physicians, a spirit of mutual
respect was established, and experiences were shared on care and prevention of HIV/AIDS as
well as other mostly infectious diseases (Scheinman et al, 1992). Due to the enthusiasm of both
sides of the partnership, the collaboration spread to the rest of the region, influencing the
formation of the Tanga AIDS Working Group (TAWG) in 1992. The main goal of the
organization was to stop the spread of HIV and other STDs and to reduce the impact of the
disease in the region (Scheinman et al, 1992). With the assistance of existing village health
projects and sensitization meetings with local leaders and the community, TAWG has been
collaborating with about 120 traditional healers in two districts of Muheza and Pangani. Training
of traditional healers included basic information about STDs, HIV and AIDS, and information
20
on AIDS counselling and care, condom promotion and community behaviour change. In
addition, traditional healers were trained in hygiene and sterile procedures for their equipment.
Field supervision and monitoring followed training.
The results reported by TAW G showed that 60 traditional healers and 60 traditional birth
attendants have been trained and have:
conducted home visits to 237 persons living with IIIV/AIDS
made 1,600 referrals for 111V testing
•
made 5,400 referrals of biomedical health workers to TAW’G for counselling
organized 1,241 educational sessions conducted by traditional healers and biomedical health
providers as a team, reaching more than 19 290 people
promoted and sold condoms (Salama Condom sales increased by 50%).
Based on the lessons learned in Tanzania, which may be useful to other countries attempting
similar collaborative efforts, TAW G makes the following recommendations:
|
•
Sensitization of biomedical and traditional health practitioners, as well as community
leadership, is essential for establishing mutual trust and understanding of roles and
expectations among the key players.
•
Specific training on STDs and AIDS for particular groups, such as biomedical and traditional
practitioners, is essential not only in imparting badly needed information and skills related to
their practice, but also to improve their confidence.
The existence of local medicines for treatment of opportunistic infections provides a basic
ingredient in home-based care services provided by counsellors.
Involvement of traditional healers in identifying community needs for AIDS education leads
to culturally grounded messages that arc relevant, culturally sensitive and have the best
potential for influencing behaviour change (Mbcrcsero et al, 1995).
ZAMBIA
IIIV prevalence in Zambia is now one of the highest in the world, and was estimated at around
26.5% in Lusaka (UNAIDS, 1998). In 1987, the Ministry of Health designed a workshop to train
healers about AIDS, which 40 healers attended (Chirwa &. Sivile, 1989). It was found that their
knowledge about HIV transmission, and their attitudes about people living with HIV and AIDS
improved after the workshop. However, 43% of traditional healers still believed that abortion
could cause AIDS (compared to 58% before training).
HIV prevention activities with traditional healers were not followed up until 1994, when the
Zambian Ministry of I Icalth Traditional Medicine Unit, supported by the Morehouse University
School of Medicine (USA), developed an STD/AIDS training programme for traditional healers.
This consisted of three-day workshops and emphasized follow-up through healers trained in
community education (Anyangwe et al, 1995). In 18 months, the project trained about 2000
traditional healers in basic information on STDs and HIV/AIDS and 120 in community
education. The curriculum, adapted from the THET/\ Uganda project (King, 1994b) with
Zambian traditional healers’ input, included STD/AIDS transmission and prevention, HIV
. 21
Collaboralion with Iradilionnl Imoleo In H1'/ ' H
I ll.vS' ill'
All ir (i
testing, and condom social marketing (Nzima ct.al, 1996; Anyangwe et al, 1995). Traditional
healers trained in community education, together with health centre staff, led monthly follow-up
meetings.
l!'!r
|
II
11 Ji
I
Mid-term survey results showed that trained traditional healers scored significantly better than
non-trained traditional healers on 13 of 17 impact measures, including knowledge about HIV
transmission and prevention, advice for persons living with HIV/AIDS, and condom use
(Anyangwe et al, 1995). At the time of the mid-term review, 250 trained healers reported selling
condoms to patients and community members through a social marketing programme. Trained
traditional healers were also more likely to have discussed with their clients HIV and STD
prevention, HIV testing, condom use and caring for persons living with H1V/A1DS. Most
traditional healers’ patients interviewed confirmed that their trained traditional healers had taught
them basic facts about AIDS, but they showed poor knowledge about how 11IV is not spread,
HIV testing, the difference between 11IV and AIDS, and AIDS symptoms (Anyangwe et al, 1995).
Conclusions
i
II
I
Id-
Although advocacy for traditional medicine and attempts to involve traditional healers in primary
health care had been undertaken well before the advent of AHOS in several African countries,
there arc still few collaborative efforts between traditional healers and biomedical health
providers for HIV/AIDS prevention or care on this continent (lank, 1990; Bibcau, 1982; Warren
et al, 1982; Hoff & Maseko, 1986; Fassin & Fassin, 1988; Last, 1990; W1 IO, 1991). Nevertheless,
the initiatives reviewed here confirm that there continues to be great enthusiasm on the part of
traditional healers to collaborate with their western-trained counterparts and learn from them
about STDs and HIV/AIDS (Green, 1994; O’Rourke, 1996; Kabatesi et al, 1994). Experiences
across countries show that modern and traditional belief systems arc not incompatible but
complementary. And if we accept with Green that, "traditional healers (in Africa) arc unlikely to
abandon their way of interpreting STDs and other diseases as a result of any education (...)
directly confronting existing beliefs" (Green et al, 1993), then collaboration can create
understanding and respect for both cosmologies so that they become harmonizing, and the
interpretations healers make of them arc beneficial for their communities infected and affected
by 11IV (Schoepf, 1992). In other words, once a common language is established, it is possible to
design, plan, implement and evaluate a collaborative project, as long as traditional healers’ views
and concepts are included.
Many of the programmes reviewed here have used a strategy whereby a core group of traditional
healers is trained as trainers for periods ranging from one day to 15 months. These traditional
healers arc then empowered to educate communities and/or train their peers. Additionally, some
projects have also supported traditional healers in developing educational materials (King et al,
1994b; King, 1995), condom social marketing (Anyangwe et al, 1995), or giving basic counselling
(Anyangwe et al, 1995; Nakyanzi et al, 1996; Nshakira et al, 1995; Kosia et al, 1993). Counselling
may be one of the most essential services traditional healers have traditionally provided to their
communities; since the AIDS epidemic, counselling has been an integral component of both
STD/AIDS prevention and care strategies promoted worldwide. Counselling provides a bridge
between prevention and care projects. Yet, only a few of the projects reviewed above have reported
on the effect of training traditional healers in counselling skills for STDs and AIDS (Homsy &
King, 1996; Berger et al, 1994; Green et al, 1995). And the information available in these reports is
still too limited to compare the elements involved in the counselling components of the training.
Preliminary assessments of some projects have shown that although, in most cases, ‘trained’
traditional healers quickly assimilate the new knowledge and ‘integrate’ it into their practices and
ii
the messages they deliver to communities; misconceptions remain, especially after short-term
training (I lomsy & King, 1996; Nshakira et al, 1995; Johnson, 1996a). Few projects have
planned, or have had the means, to systematically follow up healers after their initial ‘training’.
■\'et, it is important to provide long-term support to healers because, despite being natural
counsellors, traditional healers can face significant difficulties in dealing with the issues of
condom use, care and support, and death and dying elicited by AIDS (I lomsy & King, 1996;
Nakyanzi et al, 1996; Green et al, 1995). How can healers give their clients a diagnosis of AIDS
when it means possibly losing their business/ 1 low can a traditional healer—the traditional
advocate of the clan’s fertility—counsel an HIV-positive woman who wants to have a child?
And how can a traditional healer turn away a sick patient who has become dependent on his or
her care and support? (Green,1994; Nakyanzi, 1999, personal communication). The THRTA
Uganda initiative indicates that, once left on their own, healers who have been regularly
supported after training have sustained and even increased their STD/AIDS activities in the
community longer and more intensively than those who only participated in training (King
1994b).
Evaluations have been infrequent, spaced over long periods of time, and relied too often on
healers’ surveys alone. Only one of the projects reviewed here has completed a comprehensive
evaluation of the different approaches used and of their real impact on the population; Critical
evaluations would be vital not only to assess the effectiveness of these strategies but also to
examine the determinants of their success, or failure. For example, many projects found that
traditional healers did carry out the education and counselling activities they were ‘trained’ for,
but few document the content of these activities and analyse how they impact on traditional
healers’ clients and communities. Not one evaluation included measures of cost-effectiveness of
the programme. Systematic, more in-depth and longer-term evaluations would also help answer
the question of sustainability of traditional healers’ involvement in HIV/AIDS prevention and
care, which is one of the main assumptions behind these collaborations.
Biomedicine and traditional African medicine are based on concepts, languages and cultural
constructs that arc too distant tor a simple mixing to automatically achieve positive results. Even
when traditional or modern health concepts are translated in an attempt to bridge the gap
between the two medical worlds (Green et al, 1993), the lack of solid evaluations, together with a
still pervading scepticism among biomedical health providers against ‘unscientific’ approaches,
cause collaborations to enter a vicious circle whereby the lack of data justifies the lack of
funding, and vice versa, et, despite these difficulties, the projects reviewed here highlight that
traditional healers are capable of performing at least as well as, if not better than, their
biomedical counterparts in their new roles as AIDS educators and counsellors.
Collaboration with traditional
in HIV AIDS prevo-ituM
-jfe in sub-Saharan Africa
Selected projects reviewed according to UNA/DS
Best Practice criteria
■
i
Among the 25 projects reviewed in Table 1, eight with the most evaluation data were selected.
These eight projects are compared in Table 2 with reference to the UNAIDS Best Practice Criteria
(effectiveness, ethical soundness, efficiency, relevance and sustainability). Below is a discussion of
these projects with respect to each of the criteria, as well as a list of issues that collaborative
projects should consider using to assess their performance. Following this discussion is a section
with suggested additional criteria specific to initiatives involving traditional medicine and AIDS.
Effectiveness
Very few projects on traditional medicine and AIDS reviewed in this report have been assessed
thoroughly for effectiveness. Effectiveness is an activity’s overall success in producing desired
outcomes and reaching overall objectives. ’I'hus, to identify a project’s effectiveness, one needs to
know objectives and outcomes, as well as what changed during the time the activity was
implemented and why the change occurred.
Whenever present, stated objectives varied widely, as did reported effectiveness measures (see
Tables 1 and 2). Some projects aimed simply to train healers and measured their effectiveness by
the number of healers trained and the information understood by healers. Others aimed to train
traditional healers to reach fellow-healers, or the community served by healers, with AIDS
information. Other projects aimed to change the sexual practices of healers’ clients or community
members. Lastly, an objective of many projects was to increase collaboration between traditional
healers and their biomedical counterparts. Measures of effectiveness in each of these cases included
numbers of healers or community’ members trained by trained healers, behaviour change among
healers’ clients and/or community members, and collaboration indicators such as referral between
healers and biomedical health facilities or links built between healers and health structures.
Of the eight projects compared in this report, all described a significant increase in knowledge
among trained healers regarding symptoms of 1IIV disease, HIV transmission and prevention and
whether or not AIDS was curable. One project in South Africa reported an increase in positive
attitudes about AIDS.
Other effectiveness measures included detailing how much of the information trained healers
passed on to fellow-healers or clients and community members, hi Botswana, healers trained in a
two-week ‘peer education’ programme not only recalled information they learned two years after
training, but they claimed to be training fellow-healers and community members as well. In
Mozambique, South Africa, and Uganda, evaluation showed that traditional healers were
counselling clients in - HIV/AIDS prevention and care. In Malawi, Uganda and the United
Republic of Tanzania, trained healers were reported to be giving dynamic AIDS education, some
using drama, song, and dance and many developing their own training materials.
In all but one of the eight projects reviewed here (the exception being Central African Republic,
where investigators only measured change in knowledge), traditional healers were reported to be
active condom promoters and distributors. Even after one-day training sessions, healers in Malawi
reported having open discussions about condoms, and female traditional healers reported
distributing condoms as frequently as male traditional healers.
• 24
The objective of increasing collaboration between the two health systems can be difficult to
measure and few data were available. Projects reported increasing patient referral from healer to
health centres, and strong links with local hospitals.. In Uganda, healers have become involved in
policy-making bodies such as the National Drug Authorin’.
In summary, even though most projects showed signs of at least short-term effectiveness, few
completed comprehensive evaluations of long-term impact on traditional healers and/or
communities. For this reason, it is difficult to assess whether they meet the UNAIDS Best
Practice criteria for effectiveness. In order to do so, future projects should use indicators and
tools to address and evaluate the issues shown in Figure 1.
Figure 1. Effectiveness issues
Traditional healers' knowledge about AIDS and STDs
•
What are the measurements of traditional healers' knowledge?
•
Is there a measurable change in traditional healers' knowledge on AIDS and STDs after training?
Client /community A IDS knowledge
•
Is there a measurable change in client and/or community knowledge on AIDS and STDs after
traditional healer training?
•
What are the measurements of this knowledge?
Traditional healers' coverage
•
How wide is the coverage of traditional healers reached by training?
•
How wide is the coverage of trained traditional healers' clients and/or community members (i.e.
final beneficiaries)?
Traditional healers' skills in AIDS counselling and community education
•
Do traditional healers show a change in AIDS counselling and community education skills after
training?
Traditional healers' skills in training fellow traditional healers
•
Do traditional healers show the capacity to train other traditional healers in AIDS and STDs
(including capacity for mobilization, organization, teaching skills and transmission of correct
information)?
I
I
CHent/community risk behaviour
•
Is there a measurable change in client and/or community risk behaviour after traditional healers
training?
•
What are the measurements of this behaviour change?
Traditional healers' risk behaviour
•
Have traditional healers shown a measurable change in personal and/or professional risk
behaviour?
Condom promotion/distribution
•
Are traditional healers willing and able to promote and/or distribute condoms to clients and
community members?
■
I:
Country
Uganda
Project/
institution
Initiated/
supported by
Objectives
Methods
Achievements/findings
Training
programme for
traditional healers
in KwaZulu-Natal,
1994
AIDS
Foundation of
South Africa.
National
Traditional
Healers’
Association of
South Africa
- To increase AIDS prevention,
education and management in
KwaZulu-Natal by providing training and
resources to traditional healers
- Project emphasized strengthening
resources in disadvantaged communities.
- Traditional healers could identify signs
and symptoms of AIDS after training.
Training of
traditional healers
in HIV prevention
and collaboration,
1998
Government of
South Africa
Traditional and
Modem Health
Practitioners
Together against
AIDS (THETA),
1992
Doctors without
Borders, The
AIDS Support
Organization,
NACP, Ministry
of Health,
Uganda AIDS
Commission,
Rockefeller
Foundation
- Traditional healers identified need for
rural AIDS hospices and trained home
care personnel to care for persons living
with HIV/AIDS.
- To help trained traditional healers
become accepted by the biomedical
system in KwaZulu-Natal
- To train traditional healers in every
province of South Africa on AIDS
prevention
- 75% traditional healers believed they
could cure AIDS before training, none
after
- 3-day workshop for traditional healers in
every province of South Africa, using
participatory methods
- Prevention training was successful, but
collaboration was not. Recommends
using traditional healers to train traditional
healers because traditional healers
respect their fellow-members.
- Community mobilization, traditional
healers training in AIDS education and
counselling in 7 districts in Uganda, with
40 traditional healers per district since
1993
- Increased counselling and AIDS
education by trained traditional healers
and increased knowledge and condom
use among clients of trained traditional
healers
- Traditional healers’ training in patient
management with 30 traditional healers in
Kampala in 1 year
- Over 120 traditional healers trained and
more than 96,000 persons benefited in 2
years
- Resource centre collects and
disseminates information on traditional
medicine and AIDS
- Collected a wide variety of materials on
traditional medicine and AIDS
- To build collaboration between
traditional and biomedical health
systems
- To provide training for traditional
healers in community counselling and
HIV/AIDS education, basic clinical
diagnosis and patient management
- To provide a resource centre for
information sharing on traditional
medicine and AIDS
- To advocate for traditional medicine
among health professionals and other
scientists in order to build a true
collaboration
- Promoting collaboration between
traditional medicine and biomedicine
Community
based home care,
1993
CONCERN,
Ireland Ministry
of Health,
Uganda
- To train volunteers to provide care and
support to the sick using a primary care
herbal kit developed by the project
- To disseminate information on herbs
and disease
- Workshops centred on skills and
confidence-building in giving out herbal
medicine
- Produced 2 videos in Uganda and
English for educational and informational
use
- Traditional healers trained 68 volunteers
involved in home care and distributing
herbs for common AIDS-related
symptoms
Country
Project/
institution
Initiated/
supported by
Objectives
Methods
Achievements/findings
Senegal
Promotion of
Traditional
Medicine
(PROMETRA),
1981
Centre for
Experimentation
of Traditional
Medicine,
Senegal
- To promote traditional medicine
- 383 healers organized into an
association called PROMETRA
- 87% of interviewed patients were
satisfied with traditional healers’ services.
- Conducted training on diarrhoea and
family planning, but not yet on AIDS
- 67% physicians interviewed stated they
referred patients to traditional healers.
- Needs assessment conducted prior to
training.
Tulane School
of Public Health,
USA
Morehouse
School of
Medicine, USA
Sierra Leone
South Africa
Counselling
training for
traditional
healers, 1992
National
STD/AIDS
Control
Programme
- To train traditional healers in HIV/AIDS
counselling
Training of
trainers for
healers, 1992
AIDSCAP, USA
AIDSCOM, USA
- The initial goal was to determine the
level of interest, knowledge, and skills of
traditional healers in HIV prevention and
whether they could serve as effective
agents of behaviour change.
Ministry of
Health, South
Africa
Centre for
Natural and
Traditional
Medicine,
Washington,
DC, USA
-150 traditional healers trained in
HIV/AIDS counselling
- 80% of people with HIV/AIDS prefer
traditional medicine treatment.
• The ultimate goal was to engage
traditional healers in combating
HIV/AIDS in South Africa through
training other healers and incorporating
HIV/AIDS prevention into their
practices.
Pilot survey of
traditional
healers, 1992
1 -day training held with 150 traditional
healers.
- To assess traditional healers’ potential
for AIDS prevention and care
- 1-year feasibility study
- Preliminary 5-day workshop (Nov. 1992)
28 traditional healers
- 630 traditional healers trained by 28
trained traditional healers on basic AIDS
facts.
3 follow-up workshops (July 1993, Nov.
1993, July 1994)
- 7-month follow-up: >80% retained
correct STD/AIDS information and
practised counselling.
No information
- Survey found traditional healers had
high knowledge about AIDS, were
treating symptoms of AIDS; and
concluded that, “traditional healers are a
force that cannot be ignored in the fight
against HIV/AIDS”.
BR£.
Country
Project/
institution
Initiated/
supported by
Objectives
Methods
Achievements/findings
Malawi
Training on AIDS
for traditional
healers, 1992
International
Eye Foundation,
Malawi
International
Centre for Eye
Health, UK
- To better understand the practices and
roles of healers in their communities
- Series of orientations and focus group
discussion were held with traditional
healers
- Increase in community education,
condom distribution, and patient
counselling activities 6 months post
training.
- To promote greater communication
between traditional healers and the
formal health care sector
- To educate traditional healers about
HIV/AIDS and STD transmission and
prevention
- To encourage community-based
HIV/AIDS prevention and care by
traditional healers.
- An eye care programme formed the
initial base of contact and collaboration
between project staff and traditional
healers
- Baseline and follow-up (6 months post
training) were conducted with 89
traditional healers
- One-day training sessions were held in
14 sites in one district (334 traditional
healers)
Anthropological
research and
training on AIDS
and STDs for
traditional
healers, 19911994
Ministry of
Health, Swiss
Cooperation
Namibia
Anthropological
research on
traditional
medicine. 1995
PhD thesis
fieldwork
- To analyse traditional healers'
patients' health-seeking behaviour for
illness in general
- Quantitative and qualitative methods
No information
Rwanda
AIDS research
project (Project
San Francisco),
1990
University of
California. San
Francisco. USA;
Ministry of
Health
- To analyse health-seeking behaviour
of women patients with regard to AIDS
and traditional medicine
- Quantitative and qualitative methods
including questionnaires, and in-depth
interviews among 40 women involved in a
prospective cohort study
- Majority of women used both biomedical
and traditional systems and believed in
greafer effectiveness of traditional
medicine for certain AIDS symptoms.
- 25 traditional healers interviewed on
KABP on AIDS
- All traditional healers had heard of
AIDS, knew modes of transmission, signs
and symptoms and that there was no
treatment or vaccine.
Mozambique
- To improve intersectoral cooperation
in the prevention and treatment of STDs
- To identify and reinforce aspects of
traditional medicine believed to promote
public health, while discouraging those
believed to have negative health
impacts
- To analyse knowledge, attitudes,
practices surrounding AIDS and STDs
- Conducted interviews with 51 traditional
healers specializing in STDs to develop
training strategy
- Developed culturally appropriate
strategy for the NACP involving traditional
healers for STDs.
- 5 focus group discussions were held,
with 7 traditional healers per group
- 30 traditional healers participated in
workshop on STDs in 1991. In 1994,
follow-up with 21 traditional healers; 8
clients were interviewed and showed
increased knowledge on HIV
transmission, condom use and
promotion.
- 2 one-week workshops in 2 provinces
Country
Project/
institution
Initiated/
supported by
Objectives
Methods
Achievements/findings
Ghana
Unit for traditional
medicine
established in
Ministry of Health,
1990
WHO, Ministry
of Health
- To involve traditional healers in
primary health care.
- Establishing a dialogue with traditional
healers
Recommendations for involving
traditional healers in management and
treatment of AIDS
Training manual
for traditional
healers
Save the
Children
- To produce a document to
systematically train traditional healers in
AIDS prevention and care
- Production of training manual
No information
Ministry of Health,
traditional
medicine unit.
Integration of
traditional healers
into health
activities, 1985.
Ministry of
Health
- To identify the factors within traditional
medicine that can increase the
effectiveness of the fight against AIDS
in Guinea
- Survey of STDs known to traditional
healers
- Each district has a physician in charge of
traditional medicine
Traditional healers are registered with
Ministry of Health. Research on 898
traditional healers since the beginning of
the programme found that increasing
numbers of traditional healers refer to
health centres (using referral forms),
hospitals and other traditional healers for
diagnosis and treatment. Biomedical
health providers also refer back.
Traditional healers keep records on
numbers of cases and treatment.
- Focus group discussions with 53
participants
- Traditional healers advise against
prostitutes.
- Conducted interviews with 103
traditional healers
■ Traditional healers should be taught
STD diagnosis and referral because
people believe in traditional medicine for
STDs.
Guinea
Liberia
Anthropological
Research on
STDs, 1988
- To increase traditional healers’
knowledge of modes of HIV
transmission and prevention, clinical
manifestations, care and support.
SOMARC/
USAID
Johns Hopkins
University, USA
•To learn how to promote condoms to
limit the spread of HIV
- Research on traditional treatments for
fertility, AIDS, STDs
- Baseline survey of traditional healers’
knowledge of AIDS
- 2 workshops organized for traditional
healers
Table 1: Summary of documented examples of collaboration in sub-Saharan Africa (1987-1999)
Shading indicates selectionfor Best Practice comparison in Table 2
Country
Project/
institution
Initiated/
supported by
Objectives
Methods
Achievements/findings
Botswana
Seminars for
traditional healers
on AIDS. 1993
Ministry of
Health
- Sensitization of traditional healers to
AIDS
No information
Seminars held sporadically with
traditional healers on various diseases
including AIDS
Botswana
Dingaka AIDS
Awareness and
Training
Programme,
1991-1993
CIDA, WHO,
Ministry of
Health
- 2-week TOT held with 12 traditional
healers on AIDS from 6 districts of
Botswana
- Trained traditional healers trained, on
average, 45 other traditional healers per
district in 2 years
- Independent evaluation interviewed 32
traditional healers, 19 nurses and 20
medical doctors
- 72% of traditional healers said they had
changed something in their practice in
relation to AIDS training
- To coordinate activities of traditional
healers with district health teams
- Providing a forum for exchange of
information and experiences between
traditional healers and biomedical
health practitioners
- Promoting cooperation and
collaboration for health services
- Creating awareness on AIDS among
traditional healers
- 80% said they recommend condoms
-Training core trainers who will, in turn,
pass on the information to other
traditional healers in selected pilot areas
- Flip chart addressing practices of
traditional healers produced
- Educational video produced
Cameroon
KABP survey of
traditional
healers, 1990
NACP National
traditional
medicine
programme
- To sensitize and introduce traditional
healers to HIV/AIDS control.
- National seminar on traditional medicine
and AIDS to be conducted
No information
Central
African
Republic
Action to Define,
Broaden, and
Strengthen the
Role of
Traditional
Practitioners
(ADERT), 1995
Ministry of
Health,
University of
Bangui, World
AIDS
Foundation,
CDC, CIDA,
University of
Washington,
USA
- To identify and reinforce aspects of
traditional medicine believed to promote
public health, while discouraging those
that have negative health impacts
- Focus groups to identify training topics
and methods
Traditional healers’ knowledge improved,
except with regard to their own risk
practices. Repetitive rather than single
training model suggested.
- To enable traditional healers to deliver
preventive messages, support persons
living with HIV/AIDS and modify their
own risk practices
- Working group of traditional healers and
Ministry of Health staff to develop
curriculum
-103 traditional healers at 4 locations
(urban and rural) completed 6-day training
- 96 traditional healers completed preand post- KABP questionnaires
UHAIbS
Questionnaire given to project leaders to determine Best Practices
I. In terms of ethical soundness
In your pioject, arc there safeguards for confidentiality ot patient information?
Has your research/intcrvcntion been approved by scientific and ethical review committees at the national
or local levels?
Have you had jany examples ot harm from any of the herbal preparations? If so, how did the
project/organization deal with it?
Do you disseminate (feed back) results of y( >ur research/intcrvcntion to the community? If so, how?
II. Effectiveness
Do you have any idea about the coverage ot the project in the communities
munities that
that you
yc are working in (i.e.
how many healers do you work with ccjmpared to the estimated total number in the area, and is there an
estimate ot the number of clicnts/community members seen by traditional healers)?
Do you have any measures of effectiveness of the counselling or prevention activities of the traditional
healers that you collaborate with?
Have you done any social science research with your healers (or healer clicnts/community members),
looking at outcomes such as: increased awareness, increased skills, reduction of risk behaviour? If so, are
there any results available?
Are there any results of overall impact, i.e. change in health status, change of 11IV/AIDS/STD morbidity
or mortality?
III. Efficiency
Do you have any measures of cost benefit analysis, or any way to measure efficiency?
How are records kept? Is the information collected used in running the programme?
Are there any systems of monitoring and evaluation set up in the project? If so, what are the indicators?
Arc there results available?
I las the project had to change course due to changing circumstances? If so, how was the process
managed?
IV. Sustainability
Do you think your project is completely dependent on outside funding sources? Would it continue
without outside funding?
Is there a feeling ot local ownership of the project?
How strong arc the links between the biomedical health facilities and the healers? Is the project’s
intervention required for continued collaboration?
In general, what would you say are the lessons you learned with regard to working with traditional healers
tor IIIV/AIDS prevention and care?
Annexes
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Further research and action
I
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II
H.
H
More systematic evaluation of collaborative projects is urgently needed, especially to assess
determinants of success and/or failure. Since many of these projects arc still in an experimental
phase, the information collected could be used to improve existing endeavours and help develop
new ones. A multiplicity of variables needs to be assessed and it is only with systematic and
repeated evaluations, using a variety of methods, that we can hope to answer some of the crucial
questions we are faced with. There is a dearth of rigorous, long-term measures of effectiveness
and sustainability. Of particular interest is the question of cost-effectiveness; not one of the
projects reviewed here officially reported on the efficiency of training with respect to cost
effectiveness. Unfortunately, without cost-effectiveness data it is easier for funding agencies to
deny the usefulness of such projects.
Research, not only into the methods that traditional healers use and the impact of training
projects, but also into the relationship between the traditional and biomedical health care
systems, is crucial if we hope to answer questions about collaboration between the two systems.
Interesting questions, such as how each health system influences the other, and how the
relationship could be mutually beneficial, deserve an in-depth analysis in order to build a
sustainable link between the two sectors.
With greater emphasis on home care since the advent of AIDS, it is possible that traditional
healers may act as a critical link in the continuum of care from hospital to home. Research into
the healer approach to care is another neglected area of research that shows great potential. In
particular, an in-depth analysis of the counselling provided by traditional healers, and how they
integrate biomedical concepts into their traditional belief system and methods of practice, is still
untouched by research. But it is crucial to our understanding of the impact traditional healers
could have in both care and prevention of STDs and IIIV/AIDS.
In the continuing struggle to provide comprehensive health care to a wider population, research
into the role of traditional healers might result in the development of innovative new strategics.
For example, since the mid-1990s, traditional healers have played an increasingly important role
in the promotion of condoms in a few countries in Africa. It is thus possible for them to play a
role in providing greater access to other health care options such as family planning. This area
has been looked at in some countries for primary health care, but has not been expanded to
other areas of health or assessed on a large scale. The goal of maximizing availability of drugs in
poor countries makes research on herbal medicine especially important today.
The question of standardization and regulation of traditional medicine training and traditional
healers’ practice has been debated with respect to creating national policies. Consensus has not
yet been reached, but the issues arc complex as recognition often depends on organization of
traditional healers. There is a danger that regulation and standardization of traditional healers’
practices will cause a loss of diversity within these practices. However, many traditional healers
are still interested in recognition by the biomedical structure and welcome official policy changes
to this end.
ill
•' i
!
Collaborative projects have much to learn from each other. An improved system of
communication among traditional healers, as well as within and between countries, would be
useful. Regular meetings and networking would benefit not only the projects concerned but their
beneficiaries as well.
Collaboration with traditional healers in HIV AIDS p-e'.p’i'i -;-! -rr I cce in sub Saha'an Africa
Lessons /earned
Training methods
■ ®
I
-
I
I
R
I
The Government of South Africa recently hired a traditional healer to regularly train fellow
healers. With her many years of experience, this traditional healer suggested that traditional
healers need a participatory approach to training, and need to be shown the utmost respect. She
advised, "Let them burn their incense in training", meaning that if the project respects the
traditional healers' customs, the training will be successful. In addition, she emphasized the
importance of using fellow-healers to train others, as healers are more receptive to hearing new
things from their peers. She cautions against talking about traditional healers’ associations in
training as the politics will distract healers from the training session (Manci, 1999, personal
communication). Other project leaders agreed with Manci about the issue of respect and some
specifically emphasized the importance of respecting healers as professional health care
providers.
With regard to content of training, most initiatives have had liitlc difficulty with issues around
condt
AIDS symptoms, I IIV transmission and prevention, condom use, condom
promotion and
distribution. The areas that provided the biggest obstacles were home care, death and dying,
mother-to-child I IIV transmission and, in the Central African Republic, condom use, which the
authors linked to a high desire to have children.
Collaboration
|
■pl
I ',
V
W-.
!
I
I
Healers in Uganda and the United Republic of Tanzania have been given access to hospitals,
which has motivated them greatly. One project leader in the United Republic of Tanzania
suggested establishing a cooperative relationship with a hospital or clinic to facilitate
collaboration (Scheinman, personal communication). THETA Uganda leaders noted as well that
developing a lasting collaboration between the two health systems involves much effort on both
sides .of the collaborative relationship. Collaborative project designs cannot emphasize only the
efforts required by healers and assume that the biomedical health workers will follow without as
much time and energy input. In Malawi, similar lessons were noted, and authors suggested that
more collaborative referral networks need to be encouraged between traditional healers and the
formal health sector (Porter, 1996). It may be that what is needed is simply a change of attitude
within the biomedical health structures and among personnel. The key is a true dialogue (Webb,
1997).
Finally, THETA has suggested that the type of collaboration they have created in Uganda could
be extended nationwide if emphasis were placed on building strong links at the community level
with local leaders, health authorities, government and nongovernmental key players. These links
ensure sustainability, reduce programme costs and increase healer recognition in their own
communities.
Project design and implementation
One of the most important lessons learned is not only that collaboration is possible, but that it
has yielded valuable public health benefits. As longer-term projects have revealed, it is often not
|l
3-1
until after training that trained healers devise innovative initiatives for HIV prevention. For
example, in Mozambique, it was noted that some trained traditional healers shared the
information they gained from one workshop with other healers in their traditional healers’
association. This may be evidence that the training was valued enough that some healers
expanded the training without asking for resources. It is therefore critical to plan and secure
funding for long-term monitoring, evaluation and follow-up of collaborative projects.
Given the changing epidemic and the dynamic relationship between the two health sectors, this
issue becomes even more crucial it we arc to take advantage of, and learn from, this exploratory
field.
I
I
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itli |ic.i(litioiK!l !i?dl
" ■ J: ' ili'-ncin Allied
Additional criteria for collaborative projects
In addition to the UNAIDS Best Practice criteria, which arc general criteria used to assess a wide
variety of AIDS-related projects, the following arc considerations which apply specifically to
collaborative projects between traditional medicine and biomedicine. (For a summary, see Table
3 at the end of the review.)
Criteria for selecting 'genuine' or 'authentic' healers
I
Due to the lack of regulatory bodies for traditional healers in most countries, selection of
‘genuine’ or ‘authentic’ healers can -be a challenge for most new projects.
ill
In general, these eight projects generally consulted community leaders, traditional healer
associations and the ministries in charge of traditional healer activities for approval and for
recommendations of genuine or authentic healers. Many project leaders commented on the
extensive time needed to select genuine traditional healers who were truly interested in
collaboration.
di
■
III
H
In Senegal, criteria for selection were initially based on healers’ reputations. The selection was
enhanced by the use of children, considered innocent and unbiased. They were asked to which
healer in their community they would refer someone with an ailment.
In South Africa, the project first contacted five traditional healers’ associations to select healers
for training. However, in the second round of training, it was found that the trained healers were
much more effective at selecting genuine healers than the traditional healers’ associations were.
Other initiatives also noted that it was preferable to avoid traditional healers’ associations, as the
internal politics of these associations can sometimes interfere with selection, training, or other
project objectives. Such was the case in Uganda, where the criteria for traditional healers’
selection used by 'Fl 11 LTA arc the following:
being recognized as healers by the community and local authorities
having regular patient attendance
having a clinic or shrine to receive and treat patients
knowing how to prepare herbal remedies.
The list in Figure 6 can be useful in selecting healers to participate in collaborative projects.
Figure 6. Issues in selecting 'genuine' or 'authentic' healers
Community recommendations
•
Did the project consider the community recommendations for genuine or authentic healers?
Traditional healers' associations
•
Did the project consider traditional healers' association recommendations critically?
Uh-'-ii )S
Ministry recommendations
•
Does the country hove on office in the ministry under which traditional healers7 activities fall?
•
If so, did the project collaborate with this office in the selection of traditional healers?
Patient attendance
•
Do the traditional healers selected have regular patient attendance?
•
Herbal preparations
•
Do the traditional healers selected prepare herbal treatments?
Taking time
•
Has the project budgeted enough time to select genuine traditional healers?
Approach used to establish trust with traditional healers
Discussion, interview's and listening to traditional healers’ needs were the most common
methods used for building trust with traditional healers, and it was agreed that doing this slowly,
without rushing the traditional healers, was important.
In Uganda, explicit recognition of healers’ rights to their treatment secrets was emphasized in
order to help gain trust in setting up the initial collaborative clinical research on herbal
treatments tor opportunistic infections. In both the United Republic of Tanzania and Uganda, a
series of workshops were held after initial contacts to share ideas between representatives of the
two health care systems. Other initiatives used repeated visits to healers’ homes/clinics or focus
group discussions as a w'ay of establishing trust. Figure 7 lists issues to be considered in building
trust.
I
Figure 7. Issues in establishing trust with traditional healers
Taking time
•
Has the project budgeted enough time to build strong and lasting relationships with traditional
healers?
•
What methods will the project use to build trust (focus group discussions, visits to traditional
healers' homes/clinics, etc.)?
1
Fostering respect
•
Does the project treat traditional healer participants with respect?
•
Does the project recognize traditional healers' proprietary rights to their treatments?
I
•
How has this recognition been conveyed to traditional healers?
!■>
Recognizing traditional healers' rights to their treatment secrets
!
Collaboration with haditio" J healers in IIIV AIDS p'-n-.
1 ■
in sub-Sahcinin Afiicci
Figure 4. Sustainability issues
Sustainability of results
II
;-i
11
■Irfjl
11
iI
li
iI
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iiS
I
•
Are the results of the intervention permanent or temporary?
•
Will new knowledge and activities (such as counselling and/or community education) continue even
after training has ceased?
Funding
•
Is the project completely dependent on external funding?
•
Would the project continue if external funding were cut?
•
Are there any income-generating activities within the project?
•
Has there been any input of local resources, including volunteer labour or donations?
Capacity-building
•
Are there any measures of capacity-building within the project's goals/objectives?
•
Have traditional healers participated in design, implementation, or evaluation of project activities?
Local ownership
•
How do the staff and community feel about the success or failure of the project?
•
Is there a feeling of personal investment in the project by staff and community?
Links with local health or community systems
•
Has the project built links with the hospital or clinics within the project area?
•
Has the project created links with other community systems?
•
How will these links be maintained over time?
Relevance
IH
■Ht-r,
A
It has been formally recognized since the late 1970s that, for developing countries, it is
imperative to include traditional healers in primary health care (\X1IO, 1978). As discussed
above, since the early 1990s, the same has been agreed upon for AIDS, especially in sub-Saharan
Africa, where ministries of health cannot pay for adequate health care services. In addition, the
debilitating direct and indirect costs associated with AIDS in many countries make the prospect
of cooperating with traditional healers all the more appealing. In general, the basic fact
underlying this approach is that African healers arc accessible, affordable, and culturally
appropriate and acceptable, thereby fulfilling the major criteria for low-cost, effective health care
service delivery in most sub-Saharan African settings. Thus, the relevance of the overall approach
of working with healers will be taken as a given; instead, it is the relevance of specific strategies
used by particular projects that will be assessed.
Relevance is about how closely a project is. focused on the 111V/AIDS response in the context
of the society in which it is implemented. Issues such as cultural and political factors are usually
considered. For the projects compared here, the emphasis was placed on how appropriate the
particular strategy of each project was to the HIV/A1DS situation and how project objectives
related to the prevalence of HIV, needs assessments and the priorities of the National AIDS
Programme. For instance, countries with a mature epidemic should combine prevention with
counselling and care, as was done in the project in the United Republic of Tanzania.
!'.y
I ■.
11I
IO
In the projects reviewed in Table 2, objectives were defined following baseline research with
traditional healers, carried out either through surveys or focus group discussions. In only a few
projects was it mentioned that needs were assessed according to the larger political context—
specifically with reference to the AIDS epidemiology—or the surrounding community needs.
I-lowever, in almost all the countries in this review, rhe prevalence of IIIV was already high when
the projects were initiated. The differences in political will to work with traditional healers
between countries can play a strong role in the overall success of this type of collaborative
project, but this was rarely mentioned in project literature.
THkTA Uganda may be the only project that carried out needs assessment in communities
surrounding the traditional healers. Three projects stated that their objectives were directly based
on National AIDS Programme priorities. The Malawi project noted that its objectives changed as
the AIDS situation did. In the Central African Republic, it was noted that the content of the
training curriculum was relevant to all types of healers trained, as the magnitude of knowledge
and attitude change was not related to traditional healers’ characteristics.
Measures of relevance therefore varied widely in the different contexts of the projects reviewed.
Where the relevance of involving traditional healers in HIV/AIDS control efforts is no longer in
question, it is essenri.il that rhe objectives and strategies used by each project be appropriate for a
given context. Ibis will have a considerable impact on effectiveness. Issues to consider are listed
below.
Figure 5. Relevance issues
Needs assessment
•
Did the project carry out a needs assessment study before developing objectives?
H/V/A!DS context
•
Did the project take into consideration the local HIV prevalence, incidence and other AIDS
interventions?
Relevance to National AIDS Programme priorities
•
Did the project take into consideration the priorities of the National AIDS Programme?
Political context
II
Ij
•
Did the project consider the political, social and cultural context surrounding traditional medicine,
AIDS and other STD issues?
i'
I
Collaboiolion with lrcicliHoiv;| he'.rlers in Hl\'
’ in sub-Solicncm Africa
In the three projects that reported on cost of training, the figures varied, but not significantly. In
Zambia, training costs were US$35 per day per traditional healer, in Botswana US$22, and in
Uganda US$20. Figures available show that healers arc able to attract large numbers of people to
their community AIDS events, which translates into ven- large numbers of people reached for
education, once healers are trained. The Tanzania AIDS Working Group estimated that, in three
years, some 27,000 community members were reached in educational sessions, 4,300 persons
living with H1V/A1DS in home visits and 450,000 people in drama groups. THETA Uganda
estimates that it reaches between 150,000 and 400,000 beneficiaries per year (thus between
450,000 and 1,200,000 in three years). In comparison, another AIDS educational strategy in
Uganda—the AIDS education through Imams initiative—states that they have reached 100,000
homes in five years (UNAIDS, 1998a)—a similar level. The cost per beneficiary was only available
for THETA Uganda, where it was estimated to be between USS0.24 and US$0.71 per year (see
I
Table 4).
i
ii
■i
II
! .
One analysis in Botswana estimated that 30% of persons living with H1V/AIDS would be
admitted to a hospital over the course of their illness. Each user would average one re-admission,
with each stay averaging 8.2 days and costing LTSS42 per day. \\ ithout home- or healer-based care,
hospital treatment would cost US$241 per person living with 111V/A1DS (Cameron et al, 1994).
Indicators that efficiency issues were being addressed included the existence of reporting and
control of finances and administration. At THETA Uganda, accounts arc audited annually and
activity and financial reports arc produced quarterly, financial administration is tightly controlled.
More details on finances and administration were difficult to acquire for other projects.
In conclusion, the only efficiency data available were from projects where the author was
personally involved. In-depth cost-effectiveness analysis would therefore require specific studies
whereby projects would be visited. Some project leaders reported that they did not have the
expertise, resources or time to prioritize cost-effectiveness analysis. Ideally, efllcicncy evaluation
should be planned for, budgeted and supported by funders from the very initial phase of project
design. Such a plan should address the points summarized in Figure 3.
I:
VI Hi l!
Figure 3. Efficiency issues
Monitoring and evaluation
•
Dd all project activities have a monitoring and evaluation component that has been thoroughly
thought out and is realistic according to project timeline and human and financial resources?
Cost-benefit measures
•
Does the project have adequate tools and plans to calculate its costs relative to the benefits
provided to its target audience?
Numbers of traditional healers reached
•
Does the number of traditional healers reached by the intervention justify the amount of resources
used?
Numbers of dients/community members reached
•
Does the number of clients and/or community members reached justify the amount of resources
used?
Use of resources
•
w
Were the human, material and financial resources used in a timely and effective manner?
28
UNAIDS
Flexibility to changing circumstances
•
Has the project recognized the changes in the AIDS situation or in the policy of traditional healers
over time and rethought its objectives accordingly?
•
Record keeping and reporting
•
Are records of activities and finances adequately kept? Are financial and activity reports distributed
regularly and in a timely manner.
Financial control
•
Are finances regularly audited by an outside agency?
•
Are there internal checks and balances in the project's finances?
Sustainability
Sustainability can be seen as the ability of a programme to carry on with a certain degree of
autonomy and to continue being effective over the medium-to-long term. For the projects
reviewed here, sustainability was assessed by finding out whether the information and skills
passed on to healers were remembered, and whether these skills were used over time. For
example, an assessment was made of whether healers were continuing to practise counselling,
condom distribution, and community AIDS education, and whether they were still collaborating
with biomedical health practitioners.
The eight projects generally attempted to ensure sustainability by building relations with health
structures so that traditional healers could continue to receive support for their educational
activities—including condoms for distribution—after completion of the intervention. None of
the projects reported paying healers’ salaries, but they often reimbursed expenses such as
transportation costs to reach training sites. Many projects assumed that even if project activities
were to officially end, healers had gained enough information and skills to continue to use that
information in their practices. 'I bis point has been verified by a number of different projects.
Interviews conducted in Botswana, Central African Republic and Zambia, years after the
completion of training projects, showed that healers recalled information imparted in training
and that they claimed to be still using it through counselling and by educating clients and
communities, as well as referring patients to hospitals and clinics. The South African healers who
were trained by fellow-healers felt they were ready to train a third generation of healers, but some
of them preferred to have the assistance of a project facilitator during training. Project design
generally included information in their curricula, but often failed to recognize the importance of
incorporating into training the necessary skill-building sessions that would enable traditional
healers to teach fellow-healers.
In Uganda, healers who were trained in 1993-1994 continued to give education sessions in their
communities and even started formal training of fellow -calers on their own initiative. Though THETA
is no longer training the same healers it trained in 1993-1994, it is available to act as a guarantor for
traditional healers’ fundraising, or to facilitate occasional workshops organized by healers.
Sustainability is one of the most challenging issues facing IIIV prevention efforts in general, and
traditional medicine collaborative projects are no exception. One major problem is the definition
and importance of sustainability given by different funders. This review has shown that it has
been extremely difficult tor the majority of projects to remain active or to follow up with
participating traditional healers over the long term, even though traditional healers remain active
independently.
more systematic and standardized approach to sustainability is needed in order
to design long-term projects and measure their impact over time. Figure 4 lists the issues to
consider in developing such plans.
!!
Il
I
I
'i
Colktboiahon ••/ifh barii*’ i-vjl 'ip'i
-■ 1IIV
■ ■ • it i 'u|. ’ . J k in ip Afiica
Persons living with HIV/AIDS support
•
Do traditional healers show the willingness and capacity to provide care and support to persons
living with HIV/AIDS?
Collaboration between traditional medicine and biomedicine
•
Has the project set up a formalized referral system between traditional and biomedical health
services?
•
Has the project set up mutual visits between health practitioners?
•
Has the project addressed any policy obsfacles to recognition of traditional healers?
Changes in overall health impact in the communities surrounding traditional healers
Il
j
•
Are there any measurable changes in AIDS morbidity or mortality in the project intervention sites?
•
Can any of these changes be attributed to the activity of the traditional healers?
1
Ethical soundness
j
I
Ink
Ethical soundness is measured according to principles of appropriate and acceptable social and
professional conduct. Important concepts to be considered regarding ethical soundness include:
confidentiality, mutual respect, community and government participation, and informed consent.
Measures of ethical soundness adopted by many of the eight projects reviewed here included
establishing a climate of mutual respect between traditional healers and biomedical health
practitioners, signing agreements or working closely with hospitals or the Ministry of Health, and
ensuring confidentiality of patients. Most projects had some connection with the Ministry of
Health, but only two of them reported that they informed traditional healers and their
communities of the projects' results (i.e. provided feedback). The Malawi project specifically
addressed issues related to the negative or positive images relayed in awareness messages. Some
projects also paid special attention to tailoring their messages to fit the understanding of
traditional healers, or to strengthening resources in disadvantaged communities.
Two issues of particular concern to traditional medicine projects are: (1) whether any patients
experience harmful effects due to traditional methods or treatments; and (2) respect of the
proprietary rights of traditional healers over their herbal preparations. In the survey mailed to
project leaders to gather information for this report (sec Annex), none of the respondents
reported any harmful effects of herbal remedies and only one project discussed the measures in
place to protect healers’ rights over their treatments.
The projects reviewed here generally met the UNAIDS Best Practice criteria for ethical soundness.
However, ethical soundness issues were not necessarily addressed as part of a systematic plan, but
rather out of concern and respect for traditional healers, their clients and communities. A
systematic plan to approach ethical soundness could include the issues in Figure 2.
III1
Ul i-'-lD'}
Figure 2. Ethical soundness issues
Approval by scientific and ethical committees
•
Has the project been approved by scientific and/or ethical committees nationally or locally?
Equity ofparticipation
•
Has the selection of traditional healer participants been balanced geographically by gender and by
type of practice?
Informed consent
•
Were all project participants (traditional healers and clients/community members) sufficiently
informed of the objectives and implications of the intervention before they agreed to participate?
Patient confidentiality
•
Do trained traditional healers understand the principles and importance of confidentiality?
•
Has the project set up a system of patient confidentiality with traditional healers?
Safeguards of traditional healers' proprietary rights to their treatments
•
Has the project ensured that proprietary rights remain in the possession of traditional healers?
Harm from traditional healers' treatments
•
Has there been any indication of harm from herbal or spiritual traditional healers' treatments?
•
If so, how has the project dealt with it?
Feedback of results
Has the project included sufficient time and resources to adequately feed back results to traditional
healers, community members and other key players?
Efficiency
Interest in efficiency has grown in recent years with the realization that resources are scarce and
need to be used in the most cost-effective manner. 'The basic meaning of efficiency is the ability
to produce the desired results with a minimum expenditure of energy, time, or resources. There
are many economic evaluation techniques concerned with measuring cost-effectiveness, but they
all involve knowing the costs involved in project implementation and concrete measures of
effectiveness. Unfortunately, as most of the projects reviewed did not describe measures of
efficiency, costs involved in various activities, or clear measures of effectiveness, it is difficult to
compare and thus to conclude on this aspect.
Of the projects that measured efficiency, indicators included:
cost of training per healer and per client or community member reached4
number of traditional healers’ clients and community members reached by healer initiatives
(community AIDS education, drama, counselling)
number of persons living with IIIV/AIDS reached during home-care visits
number of fellow healers trained by trained traditional healers
financial control
regularity of activity and financial reports.
4 Calculations described in Table 4
Country
Project/
institution
Initiated/
supported by
Objectives
Methods
Achievements/findings
United
Republic of
Tanzania
Tanga AIDS
Working Group
(TAWG), 1990
Initiated by a
physician and
traditional
healers.
- Raise HIV/AIDS/STD awareness
among traditional practitioners in 3
districts to safeguard both practitioners
and clients from being infected during
practices
- Series of sensitization meetings between
local govt, district PHC committees,
village health committees, communities
and traditional healers
-160 traditional healers have been
trained in HIV/AIDS and health
information.
Family Health
International,
Shaman
Pharmaceutical
Company,
Evangelische
Zentralstelle fur
Entwicklungshilfe, GTZ
- Train traditional healers as community
based HIV/AIDS/STD educators and
home-care providers for persons living
with HIV/AIDS and their families
- Promotion of community-based
condom distribution
- 2 types of participatory approaches—
ZOPP and LEPSA—were used to identify
and train key people at the grassroots
level
- Healers are involved in collaborative
clinical work, AIDS education,
counselling, home visits and village
theatre groups.
-Training manual produced
- TAWG trained 120 traditional healers in
3 districts in 1994
- Health personnel at each health facility
were trained to support the programme
Zaire
Workshops with
traditional
healers, 1989
CONNAISSIDA,
Zaire Traditional
Healers’
Association
No information.
- Action research using 2 experimental
risk-reduction workshops with women in
low-income area.
- Demonstrated traditional healers’
pragmatism and the role they can play in
promoting behaviour change for safer sex
practices
Zambia
AIDS workshop,
1987
Traditional
Practitioners’
Association of
Zambia, Ministry
of Health
■ To exchange ideas and experiences
on AIDS and gain traditional healers’
support in fighting its spread.
- Dialogue between the Ministry of Health
Education Unit and the secretariat of the
Traditional Practitioners’ Assn, of Zambia
- 40 traditional healers attended
AIDS research,
training and
follow-up 19941996
Ministry of
Health, USAID,
Morehouse
University
School of
Medicine, USA
- To educate traditional healers about
HIV/AIDS and STD transmission,
prevention and care
- 25-40 prominent traditional healers
selected to participate in 3-day workshops
on AIDS between June 94 and Nov. 95.
- 2000 traditional healers trained on AIDS
facts and 120 traditional healers trained
in community education.
- To enable traditional healers to
educate their patients about these
issues and motivate them to avoid highrisk behaviour
- Trained traditional healers attended
monthly or alternate month follow-up
meetings led by health centre staff
- Knowledge increased, traditional
healers started selling condoms through
a social marketing programme.
AIDS workshops,
1988
Zimbabwe
National
Traditional
Healers
Association
(ZINATHA),
Ministry of
Health
No information
No information
- Workshops organized to train traditional
healers in AIDS and counselling.
Zimbabwe
- Knowledge increased, misconceptions
still strong
- Workshop held with 40 traditional
healers
- Pamphlet in local language designed for
traditional healers and AIDS
Abbreviations:
AMREF
BHP
CDC
African Medical Research Foundation
NACP
National AIDS Control programme
Biomedical health practitioners
Primary health care
CDD
Control of diarrhoeal diseases
PHC
SOMARC
TH
CIDA
Canadian International Development Agency
TM
Traditional medicine
KABP
Knowledge, attitudes, beliefs and practices
TOT
Training of trainers
MOH
Ministry of Health
WHO
World Health Organization
Centres for Disease Control and Prevention
Condom Social Marketing Programme
Traditional healers
I
Table 2: Review of examples of collaboration according to UNAIDS Best Practice criteria
Project*
Effectiveness
Ethical soundness
Efficiency
Sustainability
Relevance of approach
Dingaka AIDS
Awareness,
• Trained traditional healers passed on
information to clients and fellowtraditional healers
- Programme wo’ced
with Ministry of
Health
- Estimated cost
US$22 per traditional
healer trained per
day
- Not sustainable as a
project, but healers have
continued to use the
information they gained.
- Objectives clearly stated, and relevant
to the AIDS situation, but TOT and
collaboration aspects of the project
ambitious for time and resources
allocated.
-103 traditional
healers trained in 4
locations over 2
months
- No measures taken to
ensure sustainability;
activities ceased when
funding stopped.
- No cost
effectiveness
measures
- One healer interviewed in
1999 said he was eager to
be involved in another
project and he was still using
the information gained.
- Objectives clearly stated and relevant to
needs assessed through baseline focus
group discussion and working group of
traditional healers and Ministry of Health
staff.
Botswana
1991-1993
• 80% of traditional healers
recommend condoms to patients
- Traditional healers
trained, on average,
45 other traditional
healers per district
• 31/32 refer patients
• Nurses refer to traditional healers
Action to Define,
Broaden, and
Strengthen the
Role of Traditional
Practitioners
(ADEPT)
Central African
Republic
1994
■ Significant improvement in traditional
healers' Knowledge on STD risk,
condom use, and HIV transmission
after training
- 76% of traditional healers with STD
cases reoort integrating partner
referral into their STD care treatment.
- Programme woxed
with Ministry of
Health
• Specific attentior to
appropriateness cf
training topics an:
methods for
traditional healer
- Magnitude of knowledge and attitude
change was not related to traditional
healers’ characteristics, indicating that
impact of training was uniform among
practitioners. This implies that specific
types of practitioners do not need
targeting, and training content was
relevant to all traditional healers in that
setting and context.
Project*
Effectiveness
Ethical soundness
Efficiency
Sustainability
Relevance of approach
Training on AIDS
for traditional
healers
- Increase in traditional healers’
knowledge
- Collaboration with
Malawi NACP
- Most healers within walking
distance of training.
- 64% conducted AIDS education
events
1992
- 89% distributed condoms
'-’The purpose of the
study was clearly
explained to each
traditional healer
- Goals and objectives clearly stated and
relevant to needs assessed through
baseline survey.
Malawi
- In 6 months, 3000
community members
reached in AIDS
education
- No evaluation of collaboration.
Ministry of
Health/traditional
healers’
association
collaboration
Mozambique
1991-1994
Training of trainers
South Africa
1992
- 85% traditional healers able to
describe HIV symptoms
- Programme started
by Ministry of Health
- 47 traditional
healers trained
- No information on
cost-effectiveness
- 81% traditional healers promoting
condom use
- traditional healers advise clients to
avoid having many sex partners
- Increased positive attitudes
- Project changed significantly in
response to changes in AIDS situation.
- Strategy did not include specific
emphasis on biomedical health sector.
- Specific attention to
positive images in
educational
messages
- 85% knew AIDS transmitted by sex
- Traditional healers training other
traditional healers, counselling clients,
promoting condoms.
-Traditional healers
encouraged to acquire .
condoms from health centre.
- At least one follow-up
workshop for traditional
healers organized by the
Provincial Health Dept within
10 months of the initial
workshop.
- Objectives clearly stated and based on
preliminary ethnomedical research,
taking into consideration the national and
local STD/AIDS programme priorities, as
well as the political situation.
- Traditional healers reporter
distributing condoms and
cooperating in other areas
with health department
- Collaboration with
traditional healers’
associations
-1510 traditional
healers trained, all
but 28 by fellowtraditional healers in
almost 1 year
- Second-generation
traditional healers were
prepared to train thirdgeneration healers with
minimal assistance
- Objectives clearly stated and based on
feasibility of engaging traditional healers
in the fight against AIDS
Project*
Effectiveness
Ethical soundness
Efficiency
Sustainability
Relevance of approach
Traditional and
Modern Health
Practitioners
Together against
AIDS (THETA)
- 200 traditional healers trained in 7
districts since 1993
- Research results
are fed back to
healers and
community
- Admin, tightly
controlled and
reports produced
quarterly
- Healers don’t receive
salaries
- Objectives clearly stated and based on
baseline traditional healers’ surveys and
community baseline assessments
Uganda
- Traditional healers gained
counselling, teaching, leadership and
record-keeping skills.
- Patient
confidentiality is
emphasized in
training programmes
- Costs per traditional
healer client range
between US$0.24
and US$0.71
- Agreement signed
with Ministry of
Health
- US$21/day per
traditional healer
trained
-Traditional healers
have worked within
the hospital for
herbal study
- Estimated total
number of
beneficiaries range
from 150, 000 to
400,000 per year ‘
1992
- Traditional healers gained knowledge
in HIV/AIDS and STD transmission,
prevention and care
-Trained traditional healers providing
regular community AIDS education
- Traditional healers distributing
condoms
•Traditional healers make increased
referrals to biomedical health providers
- THETA produces a newsletter,
initiated a speakers’ bureau, contains
a library on traditional medicine and
AIDS, and produced 2 videos
- Conducted a study on the
effectiveness of herbal treatment for
opportunistic infections.
- Patients sign
informed consent
form
- Mutual respect is
emphasized from the
beginning
- Strong links are built with
community leaders in each
district (i.e. local council,
secretaries for women, etc)
for supporting continuing
healer activities
- Traditional healers involved
in the training have formed
their own associations that
undertake various activities,
including community AIDS
education and drama,
training of fellow-healers,
and ‘persons living with
HIV/AIDS’ support groups
- THETA trained traditional
healers involved in national
policy bodies (National Drug
Authority)
- Objectives and implementation follow
the National AIDS Programme strategy
- Implementation of district activities is
area-specific and based on feasibility
assessments carried out in several
possible sites before each new district is
chosen
•..
Project*
Effectiveness
Ethical soundness
Ethical soundness
Sustainability
Relevance of approach
Tanga AIDS
Working Group,
(TAWG)
-120 traditional healers trained since
1994
- Mutual respect is a
main TAWG principle
- Drama group reached 55,000 people
in 4 months
- Counselled patients
are given code
numbers and
confidentiality is
assured
-Traditional
treatments are free
for patients
- As permanent members of
the community, traditional
healers will continue to
practise their new research
and counselling skills even if
the NGO is not present
- Objectives clearly stated and based on
7 years of experience working with
traditional healers.
United Republic
of Tanzania
1990
-1997 survey showed traditional
healers had increased awareness of
HIV/AIDS
- Clients who were counselled reduced - Ministry of Health
• authorised research;
risky behaviour
offices within hospital
- Research results
fed back to healers
and NGO
AIDS research,
training and follow
up
Zambia
1994-1996
- 250 traditional healers promoting and
selling condoms
- Ministry of Health
agreement
- Traditional healers counselling on
HIV and STD prevention, HIV testing
and caring for persons living with
HIV/AIDS at home
- Project planned for
feedback of results to
province, district and
local levels
* For ongoing projects, only starting date given.
* Calculations arc explained in Table 4.
- In 3 years: 27 000
community members
reached in education
sessions
- 237 persons living
with HIV/AIDS
reached in 4,300
home-care visits
- Linking prevention and care provides a
culturally relevant approach for the
Tanga region.
- Healers don’t receive
salaries
- NGO office is in the
hospital; links between
hospital and NGO are strong
-17 supervisors from the
health facilities were trained
to monitor and support
traditional healers.
- USS35/day per
traditional healers
trained
• Links built between
traditional healers and local
biomedical health
practitioner and health
facility
- Objectives clearly stated and based on
• preliminary assessments and national
AIDS programme priorities.
Table 3: Specific criteria/approach for collaboration
Country
Criteria for selecting ‘genuine’ or
‘authentic’ healers
Approach used to build trust
Lessons learned
Botswana
- Leaders from different traditional healers'
associations in 6 districts selected 12
traditional healers for training
- Discussions and seminars with traditional
healers
- Condom promotion easily integrated into traditional healers'
practice
- Home care difficult to integrate into traditional healers’ practice
- Follow-up necessary to sustain the intervention
- Traditional healers see doctors as their counterparts
- The legal status of traditional healers should be dealt with in
order to improve organization of traditional healers and ultimately
improve cooperation between health sectors
- Biomedical health practitioners should be trained to acknowledge
that patients share traditional and modern beliefs and values
Central African
Republic
- The most influential traditional healers were
selected by village leaders from a census list
of traditional healers
- Central African Republic physician
employed persistence, rapport building, and
mobilizing skills to slowly gain trust.
- Traditional healers slowly found that
collaborating with Ministry of Health would
legitimize them in the eyes of the
government.
Malawi
- Older healers were reported to have more
credibility with village leaders
- Community leaders were consulted to gain
approval and to recommend the most
respected and most active traditional healers
in their areas
- Focus group discussions were held with
groups of traditional healers to build
relationships between healers, Ministry of
Health and project.
- Attitudes towards condom use did not change. Investigators
linked this information to a high desire to have children.
■ Authors found that careful design of curriculum adapted for
training of traditional healers is useful for traditional healers’
increase in knowledge; a one-time training cannot achieve a
significant level of change in traditional healers’ practice. Rather a
repetitive model would be most effective for promoting cognitive,
attitudinal and behavioural change.
- Traditional healers were open to condom promotion
- Need for greater collaboration between health centre staff and
traditional healers to maintain community-based education and
condom distribution
I
Country
Criteria for selecting ‘genuine’ or
‘authentic’ healers
Approach used to build trust
Lessons learned
Mozambique
- Traditional healers’ association assisted in
selection of traditional healers, seeking to
provide balance by gender, age and district.
- In-depth interviews and focus group
discussions over 9-month period before
training.
- Much public health knowledge and practice is already found in
beliefs and practices of traditional healers. Difficult to interview
patients of traditional healers due to stigma of STDs. The use of
indigenous disease names proved a great facilitator of
communication as it was taken as a sign of respect.
Senegal
- Selection based on healers’ reputation, and
preschool children 4-6 years old were asked
to identify traditional healers known for
specific conditions
- Consent of local authorities
- PROMETRA considers its work to be cultural research, medical
practice, and views itself as an integral partner in dissemination of
scientific information to a large community.
AIDS Foundation,
South Africa
Traditional healers themselves selected
traditional healers to be trained
- Series of contacts that lasted from several
months to years
- Healers provided names and addresses of
other healers
- Traditional healers approached the AIDS
Foundation of South Africa for training
- Traditional healers identified the need for rural AIDS hospices
and trained home-care personnel
- More work needs to be done to eliminate the tenuous and
strained aspect of the relationship between traditional healers and
biomedical practitioners.
Training of
Trainers,
South Africa
- 5 national traditional healers' associations
selected traditional healers for first workshop
based on gender and geographical balance.
- Trained traditional healers selected healers
for future workshops.
- In-depth interviews and focus group
discussions over 1-year period.
- Misconceptions about AIDS are easily dispelled
- Second-generation traditional healers were as well, if not better,
trained than first-generation healers due to better selection of
trainees by traditional healers
- Training on death and dying was not liked by traditional healers.
- It was advised to discontinue work with traditional healers'
organizations to avoid political conflicts
- Traditional healers wanted explicit condom demonstration
- As traditional healers had access to intimate details of patients'
physical emotional and spiritual lives, they experienced few
problems influencing behaviour in sex and sexuality
Country
Criteria for selecting ‘genuine’ or
‘authentic’ healers
Approach used to build trust
Lessons learned
Uganda
THETA selection criteria:
- Emphasis on healers’ right to ownership of
their treatments.
- Research with traditional healers requires mutual respect and
collaboration with biomedical health practitioner
- Initial contact through the Culture Officer of
the Ministry of Gender and Community
Development as well as through a TASO
doctor and personal visits to traditional
healer’s clinic
- Collaborative work requires time to build trust and continuous
follow-up to monitor and evaluate a changing epidemic, and a
dynamic relationship between the 2 health sectors
- Being recognized as healers by their
community and local authorities
- Having regular patient attendance
- Having a clinic or shrine to receive and treat
patients
- Knowing how to prepare herbal remedies
- This type of collaboration can extend nationwide if strong links
are built at the community level with local leaders, government
and nongovernmental key players and health authorities
- Questionnaire answered by each healer
United Republic
of Tanzania
- Two types of participatory approaches were
used to identify key traditional healers and
health personnel to participate in the training
workshops.
- Traditional healers can come up with innovative ideas for AIDS
prevention long after training is completed
- Meetings were arranged between
expatriate physician and traditional healers.
Healers enjoyed being taken seriously and
being treated like fellow professionals. Initial
dialogues evolved into a series of workshops
on patient care, treatment, education and
cooperation between biomedical and
traditional health practitioners.
- Traditional healers should be respected as health professionals
- Give traditional healers access to hospitals, clinics, and patients
- Involve them in home care and training
- Healers care about their patients and want to learn more
- Traditional healers are keen students.
-Traditional healers love learning about research
-Traditional healers enjoy mutual referral between them and
hospital / clinics
- Develop a cooperative and collaborative relationship between
traditional healers and hospital/ clinic
Zambia
- Traditional leaders assisted health centre
staff in selection process.
- Professional reputation within the
community, willingness and ability to learn
and communication skills.
-Training was highly participatory
- Health workers facilitating workshops
underwent training in participatory methods
- Effort was made to find terms that are more
familiar to traditional healers’ understanding
of health and disease rather than using
biomedical terminology
- Traditional healers came up with symbolic alternatives to high
risk practices
- After culturally appropriate exposure to explanations of public
health, traditional healers can modify ritual practices
Collaboiulion with traditional healers in HIV AIDS prevention and caie in sub-Saharan Africa
Table 4: Efficiency calculations for THETA Uganda
Population in the districts targeted by THETA (1991)*
Mbarara____________________________________
Mukono
Kamuli_____________________________________
Soroti
Hoima_____________________________________
Kiboga
Total
Rural
884,156
725,869
473,200
384,116
193,300
136,330
2,796,971
Urban
46,616
98,735
8,262
46,274
4,616
5,277
209,780
Total Ugandan population 1991*
930,772
824,604
481,462
430,390
197,916
141,607
3,006,751
16,671,705
22,000,000
Estimated total Ugandan population 1998___________________
Estimated population growth 1991-1998
Estimated 1998 population of the 6 districts targeted by THETA
Total
32%
3,690,886
276,826
3,967,712
Traditional healer population estimates
No. of traditional healers in the 6 districts targeted by THETA**_________
No. of traditional healers trained by THETA in all 6 districts (40 per district)
1,407
240
17%
Percentage of traditional healers trained by THETA in all 6 districts
Estimated beneficiaries
Total estimated 1998 pop. of the 6 districts targeted by THETA
Estimated % population using THs
Low estimate***
Estimated number of people.based on_______ Low estimate***
Estimated % population using THs
Estimated number of people based on
High estimate***
High estimate***
Rural
Urban
Total
3,690,886
29%
1,070,357
85%
3,137,253
276,826
20%
55,365
75%
3,967,712
207,619
3,344,873
1,125,722
Estimated 1998 client population of THETA trained THs (17% of traditional healers trained by THETA)
Based on low estimate of pop, using THs
182,577
Based on high estimate of pop. using THs
535,139
9,444
35,415
Estimated costs per beneficiary:
Training programme costs per year (1998 figure)________________
USS
128,722.00
Cost per trained traditional healer per year of training (240 traditional
healers)_______________________ __________________________
Cost per trained traditional healer per day of training (26 days/year)
USS
536.34
USS
20.63
USS
USS
USS
USS
107.27
53.63
0.71
0.24
Cost per trained traditional healer per year of practice post-training
assuming 5 years of practice post training
assuming 10 years of practice post training________________________
Cost per traditional healer client, based on low estimate of pop. using THsbased on high estimate of pop, using THs
* Based on the 1991 National Population and I lousing (.in'-ii*.
B.t-cd < >n Imuri••• ‘-uhniifit. d In v >inmunif\ at count\ lc \ < I lor "individuals
known to treat people spiritually or with herbs". ’ ’‘Based on reference'^: Schcinnian. 19T <|,( fM.iial communication); Dupree et al, 1992;
Barton & Wamai, 1994
192,021
570,554
References and further reading
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}
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