Collaborative partnering with traditional healers for improved access to ARVs in rural Malawi
A shortage of health care workers has created a significant bottleneck for HIV/AIDS patients living in rural areas of Malawi who require access to antiretroviral medications (ARV). In contrast, the ratio of traditional healers is considerably higher, and represents a tremendous opportunity to leverage existing community support networks and resources for widening the current health care worker bottleneck in HIV/AIDS prevention and control efforts. In this paper, I propose using rapid assessment procedures (RAPs) to create a fast, effective, decentralized participatory model of engaging local traditional healers with state health care service providers to enhance access to ARVs for HIV/AIDS patients living in rural areas of Malawi.
Malawi is considered one of the least developed countries in the world. Sixty percent of health care services are provided by the Ministry of Health (MOH); 37% by the Christian Health Association (CHAM) and the remaining 3% are comprised of private-for-profit organizations, private services, not-for-profit entities, local government, military and police health services, and small clinics that provide health care for employees and their families (Manafa et al 2009). Currently, the prevalence of HIV/AIDS has infected 960,000 people (10.6%) of the population aged 15 to 49 years old, with an estimated 50,000 new HIV infections annually (WHO 2012). Of an estimated 488,845 people were given antiretroviral (ARV) treatment by late 2011, 296,246 (72%) were retained alive (WHO 2012). Approximately 670,000 people in the Zomba District of Southern Malawi) of which 80% live in the rural areas. The prevalence of HIV/AIDS infection is heaviest in the south with 16.5% infected as compared to 6.5% in the north and 8.6% in the centre of Malawi (MOH 2008: 26).
A Shortage of Health Care Workers
Malawi is considered, by African standards, to have one of the severest shortages of health care workers, with fewer than 4000 doctors, nurses and midwives responsible to approximately 15 million people. The Ministry of Health (MOH) and the Christian Health Association of Malawi currently employs 156 physicians. There are 26 districts in Malawi, ten of which are without a licensed MOH doctor and four districts with no attending physician of any kind. The majority of the districts have between one or two nurses on staff, but some health centres have no available nurses (Manafa et al 2009). There are only two Malawian physicians serving the health posts in the Zomba District, leaving 40% of the health care posts vacant (Chan et al. 2010:91).
Access to ARV treatment is made available through 650 of the 772 public sector health facilities throughout Malawi (MSF 2012). By 2015 Malawi plans to scale up treatment to achieve 550,000 patients alive and on ARV treatment. The adoption of the new WHO guidelines will mean increased patient loads for staff, thus creating a need for an increase in the number of health workers to ensure basic levels of quality service delivery (MSF 2012). However, health care worker shortages are a serious impediment to scaling up antiretroviral treatment, especially in rural areas where the greatest numbers of HIV/AIDS patients live and primary health care is gravely compromised (Manafa et al 2009). Research indicates that Malawi is operating with only 33% of the required health care workers required. The primary reason for this health care worker shortage is insufficient training institutions for mid-level Cadres. The MOH estimates a 65% average vacancy rate for all cadres (MSF 2012). In addition to health care worker shortages, physical distances patients must travel hamper access to ARVs in rural areas. Poverty makes the cost of traveling prohibitive for those HIV/AIDS patients requiring regular medical follow-ups.
Traditional Healers (TM) in Malawi
Throughout the Sub Saharan African region, it is estimated that the ratio of traditional healers in the general population is 1:500 whereas, the ratio of physicians trained in allopathy is 1:40,000 (Truter 2007:56). The International Traditional Healers Association in Blantyre, Malawi, reports that it has 45,000 members and estimates that there maybe as many as 90,000 traditional healers throughout the country (Robison et.al 2002:3). Most villages in Malawi have a least one traditional healer. A study of 1566 traditional healers across five districts (Blantyre, Liongwe, Ntcheu, Mzimba and Mangochi) showed that TMs saw a total 44,109 patients per week or 28 patients per week per healer (Harries et. al 2002:72). In the rural Chikwawa district of Malawi, the ratio of traditional healers is 1:334 and they see over 1 million patients per year (Berger 1994:1512). Due to inadequate biomedical resources, especially in the rural areas, more than 80% of Malawians rely on traditional healers and their herbal medicines because they are easily accessible and charges are modest. Between 60% and 80% of South African people will consult a traditional healer before seeking help from the state health care provider (Truter 2007:56).
Linking Traditional Healers to HIV/AIDS Prevention and Control
Traditional healers in Malawi have a reputation for being sympathetic, more confidential. Moreover, traditional healers are considered guardians of traditional codes of morality and values and therefore, Malawians feel free to discuss sensitive matters (Berger 1994:1512). Thus, considering how important traditional healers are to the general populace, particularly in the rural areas where traditional healers are the only health care source, traditional healers are a valuable link to encouraging safer sexual behaviour. Some of the customary practices of Malawians that contribute to risk of HIV infection include: polygamy, extramarital sexual relations, martial rape, first aid to snakebite victims, ear piercing and tattooing. Other traditional practices that increase risk of HIV infection include: widow-and-widower inheritance, death cleansing, forced sex for young girls coming of age, newborn cleansing, circumcision, ablution of dead bodies, consensual adultery for childless couples, wife and husband exchange and temporary husband replacement (Government of Malawi 2003:21).
When AIDS symptoms manifest, families will look to both traditional and modern forms of care and treatment, commencing first with traditional care and treatment by the family. As the disease progresses and the illness becomes more acute, families will seek the aid and remedies of the local traditional healer and as a last resort, the family will seek modern medical help from a hospital or clinic. However, families often delay seeking modern treatment, even when symptoms are severe, waiting up to six months or even a year before going to a hospital, often because traditional approaches have failed to alleviate the illness (Hatchett et al. 2004:830). Other factors that delay HIV/AIDS diagnosis and treatment include: getting to the nearest hospital or clinic in rural areas such as Khongoni, is difficult to due to long travel distances and in many cases patients are too weak to make the journey. Another problem, which is the focus of this paper, due to misunderstandings between allopathic HIV/AIDS treatment and traditional healing, many patients will discontinue the use of their ARV drugs because they believe in the efficacy of traditional medicinal remedies (Malefetsane 2012).
Government Policy Towards Traditional Healers (TH)
To prevent the further spread of HIV/AIDS infection, the National HIV/AIDS Policy has set the following objectives: "to improve the provision and delivery of prevention, treatment, care and support services for PLWAs; to reduce individual and societal vulnerability to HIV/AIDS by creating an enabling environment; and to strengthen the multi-sectoral and multi-disciplinary institutional framework for coordination and implementation of HIV/AIDS programmes in the country. Furthermore, the Malawi's National AIDS Commission issued the following policy statement to: "ensure that traditional healers and traditional birth attendants have access to and training in HIV-related prevention information and education, as well as care and support for people living with HIV/AIDS" (Government of Malawi 2003:22). The Malawi Government recognizes the vital role traditional healers play in the fabric of Malawian health care, and in an effort to curtail further escalation of HIV/AIDS infection, realizes that through the training and education of traditional healers the bottleneck of health care worker shortages could be alleviated.
According to the Government of Malawi 2003 National HIV/AIDS Policy: "An effective response to HIV/AIDS requires the active involvement of all sectors of society. Thus, a multi- sectoral approach is required, that includes partnerships, consultations and coordination with all stakeholders, particularly people living with HIV/AIDS, in the design, implementation, review, monitoring and evaluation of the national response to HIV/AIDS" (Government of Malawi 2003:12).
Bridging the Gap: Fostering a collaborative approach with THs for HIV/AIDS control and prevention
This paper focuses on, as part of the Malawi growth and development strategy, the implementation of a participatory rural assessment (PRA) program combined with rapid assessment procedures (RAP) to create fast, effective participatory ways for people living with HIV/AIDS to gain greater access to ARVs and treatment of opportunistic infections (Government of Malawi 2012:9). The challenge of making ARVs accessible to a million people infected with HIV/AIDS in Malawi is daunting due to: 1) a shortage of heath care workers and 2) long distance travel impediments for those infected with HIV/AIDS living in rural areas.
Traditional healers, due to their prevalent numbers and that they are often the first line of care for 80% of the population, represent an important and available single source of alternative care workers. In past years, many formally trained allopathic physicians held a prejudicial view of traditional healers as superstitious and "quacks", but today, because of the exponential spread of AIDS and worker shortages, some biomedically trained doctors are now recognizing traditional healers as potential allies in the war against HIV/AIDS and can utilize their vast numbers, credibility and community networks to shift counter-productive behaviours of people living with HIV/AIDS (Liverpool et al. 2004:823).
Consultation and collaboration with the traditional healers is a vital first step in this process, since THs are an integral and respected part of health care in Malawi. Most studies have employed a top-down approach, with researchers studying the application of traditional healing in communities, but only to gather information with little to no translation by traditional healers back to the communities, thus generating little impact (Gqaleni et al. 2011). Collaboration between allopathic physicians and THs were typically conceived, developed and initiated by researchers, with THs laying the ground work for the implementation, but often without their advice or guidance, leaving the immediate needs of the THs and their local communities unaddressed (Gqaleni et al. 2011). Therefore, to achieve a bottom-up approach using participatory rural assessment procedures requires a cordial relationship with all the stakeholders-this means developing the entire program with the involvement of the THs and taking into account their needs. Furthermore, the Malawi Government and the Ministry of Health's (MOH) support is crucial for the implementation any successful collaborative effort.
To initiate the project, a strategic collaboration between MOH clinics and THs will require training and education of THs in prevention and voluntary counseling and testing, and palliative care (Gqaleni et al. 2011). Using Gqaleni et al. (2011) collaborative model, and working in conjunction with the International Traditional Healers Association in Blantyre, Malawi, member THs could be selected to coordinate participating districts as chairs, who would then select THs to act as sub-district coordinators who, in turn, would recruit other THs to attend training workshops (Gqaleni et al. 2011). Additional THs, nurses and biomedical practitioners and researchers pooling their resources would provide assistance in these workshops. Through participatory collaboration, both THs and biomedically trained nurses and community health care workers could learn from each other's practices and foster an environment of better understanding. This participatory approach to learning, would not only develop mutual respect and understanding and the importance of education. Furthemore, because the district chairpersons and their appointed sub-district coordinators chose the THs that participated in the program, the THs themselves would be responsible for driving the planning and implementation process. This tactic would establish, at the district and local government level, the necessary collaboration with clinics, health centres and THs (Gqaleni et al. 2011).
Coordinating TM involvement with the central district hospitals is problematic because they are located far from the majority of rural poor. Recently, because of constraints on human resources at the central hospital clinic, the Zombia District Health Office (DHO) implemented a program of decentralization and task shifting of follow-up ART care to 16 rural health centres. The use of an integrated primary care model, would provide a significantly safe and effective means to scaling up ART with improved geographical accessibility to ARVs garnering enhanced adherence and compliance (Chan et al 2010:91). By task shifting ART care from physician-initiated treatment to primary health care nurses and community health workers, resulted in a significant increase of service users. This was accomplished by using a four-step model: 1) selection of a health centre site, 2) building, training, mentoring and supervision of primary health care nurses and community health workers, 3) implementation of ART services and ART follow-up visits, and 4) ongoing mentorship and supportive supervision. By decentralizing ART care to out-lying health centres that were more accessible to the rural poor, 60% of those patients were less likely to default than those patients not decentralized. Furthermore, mortality rates were lower than those in the central hospital (Chan et al 2010:92). In another study, Fredlund and Nash (2007) showed that mobile clinics could be utilized to reach patients in the most rural areas, but limited human resources hindered staffing these clinics. Once again, a coordinated effort with program trained THs in the area compensate for staff shortages (Fredlund & Nash 2007:S472).
Integrating traditional healers into the decentralized task-shifting model of ART care would offset health worker shortages. During the training of primary health care nurses and community health care workers, participating THs could be educated in biomedical knowledge of HIV/AIDS and the alternative disease perspective to complement their practices. The success of this approach would depend upon the willingness of the THs to promote HIV/AIDS prevention and control strategies to all of their patients and communities (Gqaleni et al. 2011). Furthermore, the THs willingness to refer patients suspected of HIV/AIDS infection to local clinics for counseling and testing would be required for success.
Past research indicates a high degree of willingness in THs to be trained and educated in HIV/AIDS prevention and control. In 1992, in the Chikwawa district in Malawi, a study of 334 traditional healers was conducted regarding their knowledge, attitudes and practices concerning AIDS and STDs. This study found that 91% were prepared to work with the Ministry of Health in AIDS control, and with 89% willing to hold village educational sessions (Berger 1994:1511). Furthermore, it was found that healers who had received training were more likely to report changes in their practices, initiate community public-health sessions and were 2.5 times more likely to follow-up with HIV/AIDS patients and their families (Berger 1994:1511). Study findings indicated that training with a participatory approach could produce changes in knowledge and practices of traditional healers (Berger 1994:1512). In another study, 98% of THs desired closer working relationships with physicians and nurses, and of note, most were already referring suspected HIV/AIDS patients to clinics (Green & Makhulu 1984:1072). Medical practitioners have learned that the referral systems can greatly enhance patient adherence and compliance to their treatment regime especially when considering taking HIV antiretroviral drugs (ARVs). Gqaleni et al. (2011) found in their study that THs would help encourage patients to hold to their treatment regime as advised by the hospital or clinic and that, when it came to ARVs or TB treatment, patients preferred their THs as their DOTS (Gqaleni et al. 2011). Fredlund and Nash (2007) found that encouraging adherence to ART treatment was greatly enhanced by the "buddy system" whereby a friend or family member could provide support. However, the use of trained THs, in conjunction with user-friendly instructional material outlining steps to ARV prescriptions, drug readiness and enrolment, would be another beneficial way of augmenting the buddy system since THs are already trusted and respected members of the community. Furthermore, patients often receive palliative care service from THs who treat HIV/AIDS signs and symptoms that are no different from "fevers, colds, diarrhea, respiratory infections, and sexually transmitted diseases; and, on occasion, THs have been reportedly relieved, and in some cases even effectively treated, HIV-related symptoms and minor infections (King et al. 2009:302).
Implementing a collaborative program on HIV/AIDS shows that it can bring all interested parties together-researchers, THs, traditional leadership and various levels of government. Moreover, it has been documented that THs, after acquiring training and education in HIV/AIDS control and prevention, have significantly contributed to improvements. For example, a multi-site "bridging gaps" project was conducted in Zambia and Uganda for the purpose of facilitating open dialogue between THs and biomedical health practitioners (BHP), and achieve improved HIV/AIDS care services (King et al. 2007:307). Both, THs and biomedical health workers were able to recognize their limitations in providing community health education, and palliative care and home-based care initiatives. Both groups recognized various skill deficiencies and the need for education and training. Interactive group discussions and training sessions had a significant positive effect generating increased referrals and cross visits between BHPs and THs. These sessions and discussions also, in Uganda increased and improved quality of care provided by the THs (King et al. 2007:308). Furthermore, in both Uganda and Zambia, counseling and provision of condoms by THs improved significantly. Moreover, in both Uganda and Zambia, THs who participated showed a significant reduction in the claims that they could cure and prevent HIV/AIDS with traditional medicines or tattooing (King et al. 2007:308). Another study, about implementing ART in rural communities, showed that by training auxiliary/lay workers (THs could certainly be included in this category), as adherence counselors educated in key processes, such as, service-user support, treatment preparedness, facilitating support groups, arrangement of follow-up visits and teaching patients, who receive ARVs, how to package pillboxes and how to handle problems of compliance, resulted in a rapid scale-up of treatment coverage, enhanced program quality, and improved adherence rates and retention (Bedelu et al. 2007:S466).
In summary, the feasibility of integrating traditional healers in HIV/AIDS interventions in Malawi needs to be seriously investigated based on the results in our SubSarhara African countries. Traditional healers are a vast untapped source of human capacity. If trained and educated in a participatory collaborative manner with biomedical health practitioners, they could complement and strengthen the HIV/AIDS prevention, control and care services in Malawi. As shown, traditional healers are more than eager to improve their comprehension of HIV/AIDS treatment and are motivated to participate in rural areas where patients are most difficult to reach. Furthermore, traditional healers have proven themselves, in many studies throughout SubSaharan Africa, to be worthy allies and would greatly assist Malawi's strategies to curtail the spread of HIV/AIDS infection and provide much needed human resource support for ARV adherence and compliance. The success of integrating traditional healers into Malawi's HIV/AIDS National Action Framework, will require the support and acceptance of policymakers, public health officials and international donors. Furthermore, recognition of the fact that the biomedical health-care system alone is not enough to implement and fulfill every objective, and to scale up ARV distribution will require the commitment of all stakeholders, including traditional healers.
AIDS Weekly. 1994 Healers important tool in preventing AIDS in Malawi. Nov 21-28:10.
Berger, R.A., Porter, L., Mekisini, G., Courtright, P. 1994. Traditional healers in AIDS control. AIDS 1994, Vol. 8, No. 10. pp. 1511-1512.
Bedelu, Martha; Ford, Nathan; Hilderbrand, Katherine; Reuter, Hermann. 2007. Implementing Antiretroviral Therapy in Rural Communities: The Lusikisiki Model of Decentralized HIV/AIDS Care. The Journal of Infectious Diseases, Vol. 196, Supplement 3. The Realities of Antiretroviral Therapy Rollout: Challenges to Successful Programmatic Implementation (Dec. 1, 2007), pp. S464-S468
Chan, Adrienne K.; Mateyu, Gabriel; Jahn, Andreas; Schouten, Erik; Arora, Paul; Mlotha, William; Kambanji, Marion; van lettow, Monique. 2010. Outcome assessment of decentralization of antiretroviral therapy provision in a rural district of Malawi using an integrated primary care model. Tropical Medicine and International Health. Vol. 15, Suppl. 1. pp. 90-97.
Fredlund, Victor G., Nash, Jenny. 2007. How Far Should They Walk? Increasing Antiretroviral Therapy Access in a Rural Community in Northern KwaZulu-Natal, South Africa. The Journal of Infectious Diseases. Vo. 196, Supplement 3. pp. S469-S473.
Gqaleni, N., Hlongwane, T., Khondo, C., Mbatha M., Mhlongo S., Ngcobo, M., Mkhize, V.T., Mtshali, R., Pakade, R., Street, R.A. 2011. Biomedical and Traditional Healing Collaboration on HIV and AIDS in Kwazulu-natal, South Africa. Universitas Forum. Vol.2, No. 2. http://www.universitasforum.org/index.php/ojs/article/view/62/240
Green, Edward C., Makhulu, Lydia. 1984. Traditional Healers in Swaziland: Toward Improved Cooperation Between The Traditional and Modern Health Sectors. Soc. Sci. Med. Vol 18, No. 12. pp. 1071-1079
Harries AD, Banerjee A, Gausi F, Nyirenda TE, Boeree MJ, Kwanjana J, Salaniponi FM 2002. Traditional healers and their practices in Malawi. Tropical Doctor, 2002, Vo. 32, pp. 32- 33.
Hatchett, L.A.; Kaponda, C.P.N.; Chihana, C.N.; Chilemba, E.; Nyando, M.; Simwaka, A.; Levy, J. 2004. Health-seeking patterns for AIDS in Malawi. AIDS CARE. Vol. 16, No. 7, pp 827-833.
Homsy, Jaco: King, Rachel; Balaba, Dorothy; Katatesi, Donna. 2004. Traditional health practitioners are key to scaling up comprehensive care for HIV/AIDS ins sub-Saharan Africa. AIDS, 18:1723-1725.
King, Rachel; Balaba, Dorothy; Kaboru, Bwira; Katatesi, Donna; Pharris, Anastasia; Homsy, Jaco. 2009. The Role Of Traditional Healers In Comprehensive HIV/AIDS Prevention and Care In Africa: Untapped Opportunities. In: Marlink RG, Teitelman ST, eds. From the Ground Up: Building Comprehensive HIV/AIDS Care Programs in Resource-Limited Settings. Washington, DC: Elizabeth Glaser Pediatric AIDS Foundation; 2009. http://ftguonline.org.
Liverpool, Joan EdD, CHES; Alexander, Randell MD, PhD; Johnson, Melba MD; Ebba K. Ebba, MD; Francis, Shelly MPH; and Liverpool, Charles MSA. 2004. Western Medicine and Traditional Healers: Partners in the Fight Against HIV/AIDS. 2004. Journal Of The National Medical Association Vol.96, No.6. pp. 822-825.
Manafa, Ogenna; McAuliffe, Eilish; Maseko, Fresier; Bowie, Cameron; MacLachlan, Malcolm; Normand, Charles. 2009. Retention of health workers in Malawi: perspectives of health workers and district management. Human Resources for Health, 7:65. http://www.human-resources-health.com/content/7/1/65
Government of Malawi 2003. National HIV/AIDS Policy: A Call For Renewed Action. Office of the President and Cabinet National AIDS Commision.
Malawi Ministry of Health 2008. HIV and Syphilis Sero-Survey and National HIV Prevalence and AIDS Estimates Report 2007. National AIDS Commission, Lilongwe.
Government of Malawi 2009. Malawi HIV and AIDS Extended National Action Framework (NAF), 2010-2012 Draft.
Government of Malawi 2012. Global Aids Response Progress Report: Malawi Country Report for 2010 and 2011.
Medecins Sans Frontieres (MSF) 2012. The Development Situation in Malawi. http://www.publications.parliament.uk/pa/cm201012/cmselect/cmintdev/writev/malawi/ mal30.htm
Ndhlalambi, Melusi. 2009. Strengthening The Capacity of Traditional Health Practitioners to Respond to HIV/AIDS and TB in Kwazulu Natal, South Africa. AMREF Case Studies.
Robison, Linda M., M.S.P.H.; Sclar, David A. B.Pharm., Ph.D.; Skaer, Tracy L., Pharm.D. 2002. Medicinal Plant Use by Traditional Healers in Malawi: Focus on Neem, Tephrosia, Moringa, Jatropha, Marula and Natal Mahogany. Malawi Agroforestry Extension Project (MAFE). Pharmacoeconomics and Pharmacoepidemiology Research Unit, College of Pharmacy, Washington State University, Pullman, WA USA
Soai, Malefetsane 2012. Medical practitioner versus traditional healers: implications for HIV & AIDS policy. Cosultancy Africa Intelligence. http://www.consultancyafrica.com/index.php?option=com_content&view=article&id=95 6:medical-practitioner-versus-traditional-healers-implications-for-hiv-a-aids-policy- &catid=61:hiv-aids-discussion-papers&Itemid=268
Truter, Lise 2007. African Traditional Healers: Cultural and religious beliefs interwined in a holistic way. SA Pharmaceutical Journal. pp. 56-60.
World Health Organization 2002. Who Traditional Medicine Strategy 2002-2005. WHO/EDM/TRM/2002.1 pp. 1-74
World Health Organization 2012. WHO Country Cooperation Strategy. http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_mwi_en.pdf