Health System Solution Proposal:
- Patients Preference of Informal Providers for Healthcare: The Utilization of Traditional Healers in rural Uganda
FPs – Formal Providers
IPs – Informal Providers
LGA – Local Government
LMIC – Low-middle-income Country
PCA – People-centered Approach
PCHS – People-centered Health System
SHW – Skilled Health Workers
THs – Traditional Healers
VHW – Village Health Workers
VHT – Village Health Team
WHO – World Health Organization
Informal Providers in LMIC: Prevalence and Utilization
The public health sector is designed to provide a reliable, well-equipped and high-quality healthcare for all(1). However, it can be insufficient especially in low-middle-income countries(LMIC)(1). The result of this failure has encouraged the spread of health service delivery among private healthcare providers(1). In many low-resource settings, the private sector is a crucial source of healthcare, filling the gap where little to no public health service is present(2). Even where low-cost or free public services are offered, private providers are often the main source of healthcare(2). The private health sector comprises of for-profit, not-for-profit, formal and informal healthcare providers(3). In many LMIC, informal providers(IPs) deliver much of the health services, especially for the rural and poor. IPs are classified as traditional healers(THs) and birth attendants, chemists or drug sellers, and bone setters(4). They are generally, unregistered, non-regulated and without formal health service training, functioning in the local healthcare sectors(3, 4). While there is little evidence on the quality of service rendered by IPs, it is generally accepted that they offer substandard care(3). However, reasons for the utilization of IPs in LMIC are the convenience, affordability, social and cultural norms(3). Other influencing factors include shortage of skilled health workers(SHW), high concentration of formal health providers(FPs) in urban areas, poor infrastructure, and high out-of-pocket costs(5).
From one region to another, the presence of IPs widely differs(4). Studies have reported the proportion of providers in a country who are IPs, ranges from 51%-96%(3). In Bangladesh, approximately 87% of providers are IPs, with an increase to 96% in rural Chakaria(3). The informal sector in India was reportedly 51-55% of all providers(3), which translates to two-thirds of the human capital and health facilities being in the private sector. In sub-Saharan Africa, IPs are vastly used. In Ghana, drug sellers account for 47% of the IPs and about 36-49% in Nigeria(3) while, 77% of providers in Uganda are IPs(3).
A systematic literature assessing IPs in developing countries found a utilization of 9%-90% of IPs within healthcare services(3). Across studies, the use of IPs ranged between 60-77% in Bangladesh, 19%-54% in India, 40%-62% in Uganda and between 9%-33% in Kenya(3). The utilization in the scope of IP services also varies. In Bangladesh, consultation with multiple IPs ranges from 52%-60%, 56% in India, and 71% in Nigeria(4). In Uganda, drug seller’s utilization range from 35% for sexually transmitted infection to 62% for diarrhea, with about 40% receiving diarrhea treatment from THs(4).
Informal Providers: The Ugandan Context
The shortage of human resources in parts of Uganda has bred a sector of IPs with inadequate background knowledge on the treatments of common conditions(6). IPs in Uganda, have emerged as key providers of health services for the poor and in rural areas(6). THs are the most commonly used IPs in Uganda and are often known for treating a range of common illnesses(7). The ratio of SHW to population size in Uganda is 1 per 20,000, while the proportion of THs can be as low as 1 per 200(8). Despite the vital role of IPs in their communities, they provided unregulated health services often unaccepted by modern medicine(8). The main entry into the health field in Uganda for THs, birth attendants and drug sellers is by apprenticeship or birthright(6).
However, the shortage of SHWs and the disproportion of their distribution in Ugandan regions, has also contributed to individual’s preference for IPs, especially among the disadvantaged. More THs than FPs are concentrated in the rural areas, with at least one TH per village and 4 out of 5 Ugandans seeking care from THs(8). The availability, proximity and affordability of THs are the main reason for utilization in rural Uganda(6). Other reasons for IPs preference include inaccessibility to available health services, absence of health awareness, high FP costs and cultural aspects like reverence and respect for THs(6). These factors impeded the utilization of FPs in Uganda.
Similar to other LMIC, Uganda is embracing the link between private and public healthcare system, with the intention to promote and improve access to healthcare services(2). However, the diverse range of health providers in the country and extreme variety in training, experience, abilities and quality of services rendered by IPs make it challenging to incorporate them in healthcare planning(2). The lack of collaboration among FPs and IPs is demonstrated by the distribute between traditional and modern medicine(8). To acknowledge the extensive importance of IPs and their role in communities, the WHO developed recommendations for integrating traditional medicine into healthcare system, promoting its use in health delivery(8).
People-Centered Approach: The Rationale
Addressing the preference of IPs in Uganda, particularly within the rural regions require effective governance(4). The most proposed response and recommendation to regulating IPs utilization in LMIC have involved government level initiatives that create or enforce existing policies, trainings that improve the education and service quality of IPs, cultivating the relationship between formal and IPs, and decreasing the preference of IPs by improving access to formal providers(3, 4).
To tackle the overwhelming use of IPs in rural Ugandan regions, their role and motivations need to be examined. The interactions between IPs and the communities they serve should be evaluated with the intention to identify how local health systems can be restructured for quality health service using a people-centered approach(PCA)(9, 10). This approach acknowledges that health systems are comprised of a variety of human actors including health service providers, healthcare users and policymakers whose decisions and actions structure the function of a health system(9). Thus, PCA is an all-inclusive concept that argues for the development of healthcare delivery within the needs of health service users and their communities(10). To accomplish this, the role and integration of health providers and service users in governance is fundamental(11).
The PCA has received heavy momentum and has since been adopted into health systems practice(10). Extensive research on community engagement and the responsibility of healthcare provision among community representatives has shown the development of services that are well-tailored to the community needs, with improved quality and health outcomes(11). This concept of collective governance is vital in establishing a people-centered health system(PCHS) (11), thus this approach can be used to address the preference of IPs in rural Uganda.
This intervention will be conducted in Masaka district, Uganda. This district represents the Central part of Uganda, where a large proportion of the population resides(12). A previous study, reported 5 public facilities, 3 private not-for-profit facilities, and 44 private for-profit facilities, in this districts(2). Another study found that IPs make up 77.1% of all health providers, with THs accounting for 68% of all IPs(7). There are reportedly 352 THs in Masaka according to the LGA statistic(12), hence THs are the most utilized IPs in Masaka(11), and will be the main focus of the proposed solution.
IPs are already embedded in the health system and service delivery in rural Uganda. They are key actors in a PCHS because of their prevalent presence and ability to offer health services close to rural communities(10). To address the preference of THs in Masaka, THs, and the communities they serve are a part of the solution. Understanding the health-seeking behavior of rural communities in Masaka district, the circumstance in which they seek care(7), and the motivations and practices of THs are essential in designing and implementing a people-centered intervention, that also integrates THs in Masaka with FPs, to improve health of their communities. The proposed interventions will encompass health workforce, service delivery and governance of the health system framework.
Intervention 1: Increase the health knowledge of THs in Masaka District Indicator: At least 50% of THs demonstrate an increase in awareness of common illness Outcome: Trained THs retain their knowledge about the causes, prevention and treatments of common illnesses after the intervention.
To achieve this, a training manual in both English and native tribe languages will be developed. Village health workers(VHW) will train THs on the causes and prevention of common illness including malaria which accounts for 42% of the disease burden(12), and HIV/AIDS (prevalence: 11-20% among communities)(12). The training curriculum will incorporate the signs and symptoms, transmission and detection of common illness and sexually transmitted diseases(13). It will also address facts and misconceptions of prevention methods, and the role of THs in the prevention and control of diseases within their community(13). Free first aid kits will be provided to THs after training and a continuing education program will be offered for THs to become VHWs. The hopeful outcome from training is, THs will incorporate more modern than traditional methods when providing care and they will use the first-aid kits when needed in their service delivery. This intervention will be evaluated by measuring THs’ knowledge and perceptions of different aspects of common illnesses including HIV/AIDS. We will monitor this by performing an entrance and exit interview on THs to access the impact of training. Immediately and 6-12months after training a questionnaire will be used to assess increase and recall of health knowledge and usage of first-aid kits.
Intervention 2: Increase the integration and use of formal providers in Masaka district Indicator: An increase of 10% in FP utilization in Masaka district. Outcome: IPs act as a support to the healthcare delivery system in their communities and clearly understand the limits and boundaries of their scope of practice.
To ensure this, we will assess and increase the general health knowledge of the population through community meetings, and health campaigns. We aim to understand and address their health-seeking behavior, enabling TH users to make well-informed decisions on where to seek healthcare. We will also educate the community on the value of FPs and their role in service delivery. To support this shift in health-seeking behavior, we will involve THs by encouraging a referral practice from THs to VHW and clinics, establishing a relationship between IPs and FPs. The anticipated outcome from this intervention is, the use of FPs is adapted within rural communities in Masaka for improved service delivery. In addition, THs can accurately determine when a referral is needed, and can confidently refer patients to the closest FP. This will be assessed by surveying the community on the current use of FPs and behavior practices to establish a baseline. After initial roll-out of the intervention, a questionnaire (i.e. every 3 months) will be used to monitor preference and track increase in the utilization of FPs. Observation sessions of THs and record keeping will also be incorporated to supervise their referral to FPs.
Intervention 3: Establish and strengthen community ownership in healthcare priority setting, accountability and engagement in health service delivery Indicators: At least 20% of THs, women, religious, and traditional leaders in the communities join the Village Health Team(VHT). At least 40% of health service decision-making in the communities and district involves and collaborates with key community representatives and stakeholders. Outcome: The health needs, provision and quality of service delivery is improved among communities in Masaka.
To accomplish this, we will empower communities to ensure their participation in the governance of health services(14), and reinforce community management structures to strengthen health delivery system by enhancing community involvement in the decision-making, priority-setting and planning(15). Additionally, we will urge vital community leaders to join their VHT. VHTs members are volunteers who are entrusted with health promotion, and community engagement in the availability and utilization of health services within their communities(16). VHT is Uganda’s national and government-mandated effort to community mobilization for health(16). The expected result of this intervention is that health outcome among communities is improved as community representatives take ownership of their health needs and quality of service received(17). Also, we hope that community leader membership in the VHT will streamline communication and lobbying of community needs to the district government. To monitor this, we will assess community and district planning meeting attendances and minutes, and VHT recruitment before and after the intervention.
Potential Unintended Consequences
No intervention is perfect as they can result in effects that are both positive and negative, which can be intended and unintended(18). It is imperative to understand the negative effects to properly mitigate them and strengthen any possible effects(18). For the proposed solution, above, some negative unintended consequences to the interventions need to be considered. For instance, some THs may not be open to increasing their knowledge in health if they do not agree with modern medicine. TH is firmly embedded within Ugandan culture and THs may feel undermined as providing training to increase their modern knowledge of health may imply a lack of recognition and respect for their traditional understanding and methods. To minimize this, we will embrace THs motivations to provide care to their communities, providing an understanding that acquiring more knowledge is an extension to the already valuable work they do and ensuring training offered are appropriate, culturally sensitive and recognition certificates are given after completion.
FPs can also be strongly against traditional medicine which can lead to misunderstanding and discrimination against THs(19) and increasing the use of FPs among communities could cause THs to increase their service cost. While THs will be encouraged to refer patients to FPs when needed, this could result to loss of patient and income for THs. To help mitigate this, educating the community members on which service provider is more appropriate for their healthcare needs has been incorporated in the intervention. However, offering a referral fee to THs can also be explored. A potential setback to community involvement and accountability in health system delivery that the community may generally have low expectations for healthcare service delivery and may not express health service priorities(20). Also, FPs and THs may feel that it is beneath their dignity to be held accountable by members of the community. This can be minimized by maintaining a positive functioning relationship between health providers and community members(20).
Positive effects to the interventions include increased attractiveness to THs services as quality increase, improved motivation among formal providers and wiliness to work in rural areas as integration and support from THs and the communities increase.
Monitoring and Assessment of Positive and Negative Consequences of Solutions
Interventions designed to alter behavior, require measuring effects over time(18). The change in THs practice pattern and community’s health-seeking behavior and preference for THs require monitoring, assessment and a design mechanism that counteracts potential negative consequences over time. Concept mapping and systems dynamic modelling are tools that can be used to prioritize negative consequences in an intervention, mitigate them and amplify positive consequences(18). In addition, indicators can be established and used to track both positive and negative effects of an intervention(18).
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2. Konde-Lule J, Gitta SN, Lindfors A, Okuonzi S, Onama VO, Forsberg BC. Private and public health care in rural areas of Uganda. BMC International Health and Human Rights. 2010;10(1):29.
3. Sudhinaraset M, Ingram M, Lofthouse HK, Montagu D. What Is the Role of Informal Healthcare Providers in Developing Countries? A Systematic Review. PLoS ONE. 2013;8(2):e54978.
4. Abimbola S, Ogunsina K, Charles-Okoli AN, Negin J, Martiniuk AL, Jan S. Information, regulation and coordination: realist analysis of the efforts of community health committees to limit informal health care providers in Nigeria. Health Economics Review. 2016;6:51.
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6. Madinah DN. Challenges and Barriers to the Health Service Delivery System in Uganda. Journal of Nursing and Health Science (IOSR-JNHS). 2016;5(2):30-8.
7. Konde-Lule J, Okuonzi S, Matsiko C, Mukanga D, Onama V, Gitta SN. The Potential of the Private sector to improve health outcomes in Uganda. . Makerere University Institute Of Public Health; 2006.
8. Sight UF. Module 6: Integrative Medicine – Incorporating Traditional Healers into Public Health Delivery: Unite for Sight; 2015 [Available from: http://www.uniteforsight.org/effective-program-development/module6.
9. WHO global strategy on people-centred and integrated health services Interim Report. Geneva: The World Health Organization; 2015.
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12. Masaka District Local Government Statistical Abstract. Uganda Bureau of Statistic; 2012.
13. Poudyal AK, Jimba M, Murakami I, Silwal RC, Wakai S, Kuratsuji T. A traditional healers’ training model in rural Nepal: strengthening their roles in community health. Tropical medicine & international health : TM & IH. 2003;8(10):956-60.
14. Progress on the Ouagadougou and Algiers Declarations African Health Observatory: World Health Organization; [Available from: http://www.aho.afro.who.int/profiles_information/index.php
15. Community ownership and participation African Health Observatory: World Health Organization; [Available from: http://www.aho.afro.who.int/profiles_information/index.php/Uganda:Community_ownership_and_participation_-_The_Health_System.
16. Geoffrey B, Lorna MB, Clare K. Village Health Team Functionality in Uganda: Implications for Community System Effectiveness. Science Journal of Public Health. 2016;4(2):117-26.
17. Rifkin SB. Examining the links between community participation and health outcomes: a review of the literature. Health policy and planning. 2014;29(suppl_2):ii98-ii106.
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19. Krah E, de Kruijf J, Ragno L. Integrating Traditional Healers into the Health Care System: Challenges and Opportunities in Rural Northern Ghana. Journal of community health. 2018;43(1):157-63.
20. Cleary SM, Molyneux S, Gilson L. Resources, attitudes and culture: an understanding of the factors that influence the functioning of accountability mechanisms in primary health care settings. BMC Health Serv Res. 2013;13:320.
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