Challenges to Successful Integration
Data indicates five challenges to integration can be discerned:
Insufficient Knowledge of Traditional Medicine
Interview data shows biomedical healthcare workers have limited insight into local understandings of health. Often, health workers staffing rural health facilities are not natives of the area/region they serve. Many are graduates or students doing a mandatory internship. A significant number does not speak the local language. Furthermore, ‘alien’ staff is unacquainted with local cultural beliefs and practices that influence health choices. A non-native midwife in the Tolon-Kumbungu district complained that pregnant women continue to use controversial herbal medicine to induce contractions, despite active discouragement. She exclaimed: “I don’t know how, that’s their culture but I really don’t understand it, oh if only I could understand!”.
Discriminatory Approach Towards Traditional Medicine
In line with literature on biomedical perceptions of TM [14, 21], this study suggests insufficient understanding coupled with status differences (based on education) leads to discrimination of healers and their patients. During interviews, some biomedical health care workers linked TM with being underdeveloped or “backward.” Also patients mention insults and the denial of care at biomedical facilities in case of exhibiting signs of the use of TM. Such poor treatment results in reluctance to seek help. It thus complicates diagnoses and increases the risk of complications from interacting (traditional and biomedical) medication/treatment. A nurse working at a remote clinic remarks:
They will not tell you because they know they fail us […]. you know they wait till the thing is complicated, when they come they will not tell you they went to the traditional healer, they will tell you it started like that. But through your observation you know that they did their own thing…
High Turnover of Biomedical Health Staff
The turnover of staff resulting from temporary staff appointments and internships undermines the establishment of a relationship of trust between healers and biomedical health staff. Such turnover is a widely described public health problem in sub-Saharan Africa, usually related to emigration of professionals [22,23,24,25]. In Northern Ghana, internal mobility is the most pressing concern. Health care workers move from public to private health sectors or transfer from rural to urban areas because of career opportunities.
Because of turnover, relations between healers and doctors are generally superficial. This obstructs integration, despite an outspoken desire to collaborate. Of course, there are regional differences regarding the level of familiarity and collaboration. However in certain remote locations, healers are often unacquainted with the local health centre staff. This is a significant deterrent to referral rates as cross-referring and collaboration is often a person-to-person endeavor. The perceived disadvantages of a high turnover are illustrated by one TBA:
…nurses they are not at one place forever, they do transfer them so the new people who are there now, they don’t know of us, so whenever we send a pregnant woman they ask us to stay outside before they deliver the woman. After the delivery they now call us inside. If not those who were there and they know of us, whenever we send a pregnant woman they ask us to come inside and help so that we all deliver the woman.
Declining Interest of Young People to become Healers
Mastering TM requires a period of apprenticeship. Usually such enskillment takes place between father and son (or mother and daughter), as the ‘power’ to heal is thought to pass on through bloodline. Many young people interviewed during this study, expressed an unwillingness to become healers. Such declining interest endangers TM and undermines the potential of integration.
There are several reasons for this declining interest, which is particularly visible among TBAs. One reason is the emergence of educational opportunities and some professional alternatives for girls. A second reason is the loss of status and attractiveness of the profession of TBA. As a result of the advocacy of biomedical superiority, the position of TBAs has shifted from ‘expert’ to ‘unqualified’ [26], harkening back to the second challenge to integration discussed above. A third disincentive for young people to learn/practice TM is that they do not “gain” anything. Traditionally, TM is regulated by a cultural framework of “greeting and asking for favours”. Charging money for medical services is considered immoral and something that will “spoil the medicine” [9]. Confronted with the monetization of life and the growing necessity of cash, unpaid healers increasingly struggle to meet their daily basic needs. In fact, all the healers interviewed during this research, practice traditional medicine as a secondary occupation. They are part-time healers and depend on subsistence farming for their livelihoods, a somewhat untenable set-up, considering the workload of some of the most popular healers who attend to dozens of patients each day. As one TBA said “That is why so many women don’t want to [be a TBA]. Because you struggle and you don’t gain anything”.
Lack of Herbs and Equipment
All interviewed healers mentioned the lack of means to practice TM. First and foremost, acquiring herbs and plants is an increasing challenge as growing populations and expanding settlements mean healers have to travel greater distances to find what they need. Storage also presents a challenge as few bottles and boxes are available. Furthermore, TBAs state they do not have gloves, soap, or clean cloth. All equipment is scarce. The case of a famous bone-setter who attends to dozens of patients every day is illustrative. Although local biomedical health staff routinely refers patients with fractures to him, the healer does not have splints and asks his children to cut wood into splint-like pieces instead.
Opportunities for Integration
Besides challenges, opportunities for integration do exist:
Traditional Medicine Infrastructure
With one traditional healer for every 200 people the traditional health care network offers great potential. The TM infrastructure, rooted in local customs and belief systems, provides easy access to basic care. TMPs and TBAs are trusted within communities. They cross-refer patients, and exchange knowledge and experience. A certain level of formalization and standardization is already in place; an example is GHAFTRAM, which unites selected healers, providing them with ID and referral cards. TM is an existing care infrastructure with tremendous potential that should not be disregarded.
Willingness to Collaborate
Despite challenges, healers and biomedical health care workers are generally willing to cooperate. Healers are eager to improve their medical knowledge and skills, welcome opportunities for communication and education, and appreciate interaction with biomedical health care providers. Interaction/networking already leads to referrals and collaboration. As one healer said: “Before we didn’t even know each other, now we work together”. This collaborative stance of healers reflects findings from other studies [13, 14, 27]. However, whereas literature suggests biomedical practitioners are less eager to collaborate [27], our data shows that most biomedical practitioners are willing to collaborate with certain healers (e.g. bone-setters).
The words of the nurse–manager at the Walewale district hospital are illustrative. Reflecting on “the problem of access of the orthodox [biomedicine],” he advocated collaboration:
The orthodox have to acknowledge the fact that the traditional are working […] and share burden. We need to understand that they have challenges. We need to help each other. Sometimes they just need raw education on how to do things better. Then the integration would be more. […] And if [patients] are going to the bone setter...I don’t see why we should not make an effort to follow the fellow and see what he is doing there. […] We already know that [many people] depend on them. So we should help them to do better.
Promising (Grassroots) Initiatives
Organized efforts to improve collaboration do exist. For instance, the Ghanaian NGO Association of Church-Based Development Projects (ACDEP) has distributed mobile phones to healers and TBAs in an effort to enhance communication and to improve referral rate. Notwithstanding such efforts however, grassroots initiatives are particularly promising. One example is the initiative from a local GHAFTRAM association to air a radio commercial urging healers to join their association and make their expertise publicly known; healers who joined were introduced to the public health manager of the local hospital. Healers thus actively aimed to improve health care through initiating collaboration with biomedical health workers. A second example concerns a healer who established a traditional medicine ‘information centre,’ to efficiently refer patients to suitable healers, distribute information, and sell traditional medication. The same healer was designing a digital database with names and contact numbers of local healers and TBAs, and contact details of health workers and midwives from the nearest clinics and district hospital.
A final example is the cooperation between one district hospital and a bone-setter, with mutual recognition of expertise and authority. The hospital frequently sends patients to the healer, after taking X-rays. The healer can interpret X-rays and treats. Similarly, the healer refers patients with open wounds to the hospital, where they can be given blood, a drip and pain-killers. Most afternoons, the healer visits the hospital to see patients he has referred, and to discuss the treatment of complicated cases with doctors. These efforts are grassroots initiatives with a limited budget and reach. They underscore opportunities for further and systematic integration.