Policy makers ’ perceptions and attitudes regarding incorporation of traditional healers into the national health care delivery system

Correspondence address: Prof. Dr. Minrie Greeff Author Potchefstroom Campus of the North -West University Private Bag X 6001, Potchefstroom 2520 Abstract: Curationis 31(4): 4-12 Based on mixed perceptions which were both negative and positive the policy makers have not been vocal about the process to incorporate traditional healers into the National Health Care Delivery System of South Africa. Negative views were related to the denial that traditional healing does provide a cure and the positive views were identified in the passing of policies from 1994. These policies passed initiated recognition of the existence of traditional healers, but failed to address the important aspect of incorporating the traditional healers into the National Health Care Delivery System. It is these mixed perceptions as well as lack of appropriate policy to facilitate incorporation of traditional healers that urged the researcher to explore the perceptions and attitudes of policy makers regarding this incorporation process, as well as their views on how it should be achieved. An exploratory, descriptive and contextual qualitative research design was followed. Participants were selected by non-probable, purposive voluntary sample. Data was collected by means of conducting semi-structured interviews, as well as taking field notes. Data analysis was achieved by analysing transcriptions through open coding involving a co-coder until consensus was achieved. Results reflect that policy makers are in favour of incorporation.


Introduction and problem statement
The policy makers were not vocal about the incorporation o f the traditional healers into the National Health Care Delivery System o f South Africa.The stance that the governm ent took on traditional healing was associated with the fact that traditional medicine was seen as creating complications based on its raw nature when used by the patients (Levitz, 1992:25;Pinkoane, Greeff & Williams, 2001: 4).There were often reported cases o f mortality arising from use o f these medicinal herbs.Even in cases like these the patient continued to use the traditional healers' services out of the reality that he understands their problems and is always available in times o f need (Pinkoane et al., 2001:78).It is from this premise o f availing health serv ices to the p eople that the government resolved not to be vocal about the traditional healer' practices becau se h is/ her services p artia lly relieved the overburdened health sector (Meissner, 2004:901).All this time the policy m akers w ere aware that the patients use the services of the traditional healer sim ultaneously with those o f biomedical personnel.Oskowitz (1991:15); A bdool K arim , Z iqubu-P age and Arendse (1994:7); Morris (2001Morris ( :1190)), as well as Pinkoane, G reeff and Koen (2005:14a) identified projects that have been in itia te d in South A frica by biomedical personnel, to try working to g e th e r w ith trad itio n al h ealers.According to Freeman andMotsei (1992:1189) in spite o f these attempts made by the biomedical personnel to try and work together with the traditional h ealers, the g o v ernm ent seem ed unperturbed to officially pave a way for an o ffic ia l ag reem en t to have incorporation in place.
From a neutral stance of non committal but w ith due con sid eration for the problem at hand, firstly, cam e the promulgation o f the National Health Plan (ANC, 1994:55); the Homeopaths and Allied Health Professions Act o f 1996 (SA, 1996:25) and the White Paper for the Transformation o f Health Systems (SA, 1997:47) which gave the traditional healers their due recognition but does not specify or describe any type o f working together between them and the biomedical personnel.The second positive move was the indication to form a partnership with the Chinese government to investigate the way in which ideas can be exchanged with regard to traditional m edicines (Bhengu, 2002:6).According to Morris (2001Morris ( :1190)), the South A frican government was aware o f the fact that the Nigerian government is conducting a pilot trial o f traditional medicine from South Africa.To add to these trials by Nigeria, Dr Matsabisa was mandated by the Human Science Research Council to initiate research into traditional medicines even though the governm ent is still hesitant to come forward and officially pave the way for incorporation to be in place (Pinkoane et al., 2001: 84).
However, South Africa faces problems regarding human resource in health care delivery services.This problem arises from various reasons, for instance, the serving o f com m unity services after com pletion o f tra in in g by health professionals.The dissatisfaction o f health professionals evokes in them feelings of rebellion (Prinsloo, 2004:3), which coupled w ith poor w orking conditions, gives them reason enough to continue leaving the country to go overseas (De Vries and Marincowitz, 2004:27).It is this exodus that should prompt the government to realise that there is a human resource potential that is being neglected and not used to its best in the traditional healer.Morris (2001Morris ( :1190) ) and Pinkoane et al.,{200\:78) states that many experts now support the use o f traditional healing knowledge, which is why the WHO (World Health Organization) is supporting its member countries to utilize the traditional healers if their therapies are the source o f health care provision for that community (WHO, 1987:10).
The traditional healers also need to be more controlled and organized as a group of health care providers (Pinkoane et al., 2005:4b).T he T ra d itio n al H ealth Practitioners Bill formulated in 2003 and amended in 2007, enables traditional healers to form their own organization which is to control their practice (SA, 2003:1 -23), but the Bill still does not afford them the legal authority to work with biomedical personnel.The ball is in the court of the South African government to com e up w ith an A ct or policy guidelines on the issue to incorporate traditional healers in the provision of health care services.
From the preceding discussion it remains imperative to investigate perceptions and attitudes of the policy makers regarding incorporation of traditional healers into the National Health Care Delivery System of South Africa, as well as how they feel this incorporation should be achieved.

Theoretical statements
The theoretical statements refer to the conceptual definitions used (Chinn and Jacobs, 1995:20;Walker and Avant, 1995:30).They are as follows: The total network or system o f services and provision of health care in a specific country, including all particular health care systems o f whatever nature which occu r in a country (W orld H ealth Organization, 1987:16;van Rensburg, Fourie and Pretorius, 1992:3).

• Traditional Healer
A person who is recognized to provide health care by using vegetable, animal and mineral substances and certain other methods based on the social, cultural and religious background, as well as on the knowledge, attitudes and beliefs that are prevalent in the community regarding physical, mental and social well-being, and the causation o f d isease and disability (WHO, 1978:9).In this research, referen ce to the traditional healer implies both male and female traditional healers.

• Biomedical Personnel
D octors, nu rses, ph arm acists, psychologists/psychiatrists who have been scientifically trained for years as professionals at an institution o f learning, u n iv ersity or co lleg e (H o ld sto ck , 1979:121;Abdool Karim et al., 1994:2; Arthur, 1997:65;Pinkoanee/a/" 2001:11).In this article HE is used to refer to both male and female biomedical personnel.

Incorporation
Incorporation refers to a process o f com bining or b ringing about two separate entities or bodies to function as one.This functioning can be authorized to act as one legal body by passing a law to enhance and legalize its existence.This legal body can be made up of different professionals or practitioners who have the same aim and objective (W HO, 1987:7;DSAE, 1996:507).

• Policy makers
The persons or appointed officials assigned with decision m aking for administration, management and research o f health care provision within health services (Andrews, 1990:34;du Toit, van der Walt. Bayat & Cheminals, 1997:80).
In this article policy makers refer to Regional and or District Health Services Managers.

Research design and method
The research on which this article is based, used an exploratory, descriptive and co n textual q u alitativ e design (Mouton and Marais, 1996:45), to explore and d escribe the percep tio n s and attitudes of policy makers, regarding the process of incorporation, as well as their views on how this should be achieved, with the goal of formulating a model to make this process a reality (Chinn and Jacobs, 1995: 45;Walker and Avant, 1995:12).The research was conducted in identified districts o f Gauteng, North West and the Free State provinces of South Africa.

Sampling and Population
A non-probability purposive voluntary sample (Rubin and Babbie, 1997:226) was used to select a population of policy makers from the identified districts/ regions of the three provinces.

Accessing the participants
The researcher made contact with the participants a day before to arrange for the time and place where the interviews were to be conducted.Confidentiality, anonymity, privacy, risks, withdrawal and possible termination were discussed.The settings were different places where the policy makers worked in the towns of Gauteng, North West and Free State provinces.All the places were natural settings, private, with no distractions (Bums and Grove, 1997:42).

Conducting interviews
The sem i-structured interviews were conducted with all policy makers using an audio tape, one with batteries and the other with electricity.The purpose was to ensure that all inform ation was captured, in case one failed, and the following questions were asked:

Permission to conduct research
Permission to conduct research in the regions or districts of the three provinces was obtained through a letter written to each o f the regional or district health services managers within each province, in Pretoria, Mmabatho and Bloemfontein.Each o f the policy makers gave written inform ed consent w hich allow ed conducting the research, and acting as participants in the research.

Ethical aspects
Ethical aspects specific to this research were taken into consideration as detailed in the Guidelines for the Democratic Nurses' Organisation o f South Africa (DENOSA, 1998:1-7)

Data analysis
The au d io taped interview s w ere transcribed verbatim by the researcher.Content analysis was used employing the method o f open coding as described by Tesch (in Cresswell, 1990:153-155).Double coding was employed whereby a nurse specialist independently coded the data after which the findings o f the researcher and co-coder were discussed, and consensus was reached to finalise the data.

Results, discussion and literature control
The policy m ak ers' perceptions and attitudes are discussed under five main themes, which are: Theme 2: Traditional healers are to be taken seriously and used as a resource person The second theme reflects the traditional healer as a person to be reckoned and be used resourcefully because the World Health Organization (WHO, 1978:5) advocated for them.Abdool Karim, etal., (1994:7) support the findings w ith the ap p lica tio n in Zimbabwe.Fenyves (1994:37) and Molepo (2000:47) support the findings and explain that the traditional healer can avail the services, but should remain in his practice area.

•
The traditional healer shares the culture and belief system of the people and can be used in the treatm ent of HIV/AIDS The following words portray these views.
"These people have been here from Biblical times, they are in the culture o f the people, religion is the same, the people o f the East have the traditional Shaman presiding over every ritual and ceremony " R am okgopa (1993:23), B atem an (2004:804) and Keeton (2004:4) support the findings that the traditional healer is from the people and for ailments like HIV/ AIDS the traditional healer should be used as the people believe that they do have a cure.

Theme 3: Government to facilitate incorporation by policy formulation
T hem e th ree re fle c t the need for government to facilitate incorporation by policy formulation.

Theme 4: Traditional healers to be clarified about terms and conditions necessary to effect incorporation
The results in this theme show the need to clarify traditional healers about terms and cond itions necessary to effect incorporation.These are expressed in this way: "In as much as they should form an organization or association whatever case maybe, they are too many and the only way to control them is this body to be answerable to the government " Molepo (2000:23); Mulaudzi (2001:14) and Peu et al., (2001:49) confirm the findings that org an izatio n is to be answerable to the government for their actions."To be sure we w ork w ith sa fe traditional healers there is a definite way that should be followed, but I feel it will only serve eveiybody' s interest i f the sam e co u ld be done by the very traditional healers s e l f because we cannot set guidelines fo r evaluation over the practice that is alien to us " Mulaudzi (2001:15) and Keeton (2004:4) support the findings and explain that this evaluation is to help with compliance and exclude all atrocities on their part.This is a quotation for ethical control.
" You know there are so many o f them some good others involved in terrible things, fakes o f all kinds, and truly and honestly they need some form o f strong control about their work, we can call it ethics, discipline or whatever, but their code o f practice should be ensured " The findings are confirmed by Muller and Steyn (1999:79) supported by Bodecker andKronenberg (2002:1582) that there is a need for control over traditional healing practice, based on the premise that they are so many and some are not well vested with healing therapies.

* Traditional healers' can work from their own homes
These are the words o f a policy maker.
"It will be more becoming i f they still worked from their homes, it is only that som e sta y a little far, but w hat is important is that they are able to do whatever they want when they are there, no constraints" (1999:25); Molepo (2000:32) and Melato (2000:43) see it as necessary that the traditional healer works from their own places where there is privacy.These are policy m aker's quotation.
"The traditional healer who is in the rural area is like the one in informal settlement, so his presence there is a bonus fo r health care, let him operate from there " Mototo (1999:23) and Jordan (2001:23) support these findings that the traditional healer is accessible when operating near the people.

Theme 5: Two way education and training is important between traditional healers and biomedical personnel
This theme portrayed the policy makers as perceiving education and training as important for both traditional healers and biomedical personnel regarding healing therapies.

* Education and training is important for both traditional healers and biomedical personnel regarding healing therapies
The following words quote these views."There is no doubt in my mind that when the two groups meet they should engage in mutual education which is to focus on all aspects o f health care " Mulaudzi (2001:12) and Pinkoane et al., (2005:3a) support the findings that it is necessary to avoid hazards by two way teaching and learning.

Recommendations
Recommendations are made from this research for education, research and practice.

Recommendations for education
Recommendations for education are for both the biom edical personnel and trad itio n al h ealers and need to be reciprocal.Education courses for the basic nursing course (general, psychiatry, community health) and midwifery (SANC, 1985:45), post basic nursing courses, as w ell as those o f the d o cto rs, p sy c h ia trists, p h arm acists, psychologists, should include some aspects o f traditional healing techniques.Traditional healers are to be taught basic biomedical practices as part o f their initiation process, as well as for those tra d itio n a l h ealers who m ay have completed their training which did not included biomedical practices.

Recommendations for research
Further research can be conducted on the legal aspects o f issuing medical ce rtific a te s by trad itio n al h ealers, ownership rights to traditional healers who avail useful medicinal herbs which are scientifically proved to be effective in preventive and curative health care.

Recommendations for practice
The recommendations for practice are reflected in the form of guidelines that are fo rm u lated to fa cilitate the incorporation o f traditional healers into the National Health Care Delivery System of South Africa.

Conclusion
The p o licy m akers have v erb ally indicated that traditional healers could be incorporated into the National Health Care Delivery System on condition that they communicate with the biomedical personnel regarding the process o f incorporation.That certain conditions need to be met by traditional healers as a prerequisite for incorporation.The government should formulate policy which describes the way in which both groups should function together in health care settings.
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A E N S2004
The results portray these views as: "The time has come fo r them to show what they have, it does not help in any way f o r them to keep on saying the ancestors will remove their protection.I f they don' t come out who will trust what they do, no one, except o f course their patients " About removing the secrecy Melato (2000:23) and Pinkoane et al., (2005:67b) support the results that the traditional healers are now prepared to show what they have.Brom (2003:9) also supports the findings.
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unication is necessary to explore a realistic approach regarding incorporation
• Theme five, that two way education and training is important between traditional healers and the biomedical personnel.A bullet is used to indicate a subcategory.*CommThesewordssumup these views."Whenyoumeet the traditional healers they are chirpy about going forward, but the doctors are rather not so open, but I know ofsome who fe e l the time fo r a way forw ard is here Jet us meet to talk o f the way fo rw a rd " These results are supported by Tabane(1995:37)andSelinzio (2002Selinzio ( :1563) )who states that it is now the time to move forward and all ideas o f working together should be summed up into a meaningful whole.Discussions to

be an effort of both traditional healers and biomedical personnel who should accelerate them regarding how incorporation should be attained
The policy makers had this to say."It is fe lt as though it is difficult to come with the way traditional healers are allowed to work with doctors, but look at what is happening in the clinics with the nurses calling them to teach them new things "Both groups

need to engage mutually to understand each other's world and work in order that existing relationships can be enhanced
The quotations o f policy m akers to support the results are: "To know each other is to open up, lea n never know you or your work unless you give it to me fo r me to read it, like what you did in your previous work, from now • The

traditional healer is not old fashioned, is enlightened and need to be involved at levels of meetings and discussions
"The old fashioned traditional healer who hid during the day is not here anymore.Now they are young, go to school and even dean.Why not talk directly with him not fo r him "The findings are supported byMelato  (2000:45)andPinkoane et al., (2001:90)that the modem traditional healer rural or urban is younger and need to be acknowledged.•An

existing link between traditional healers, local authorities and biomedical personnel is established in the provinces which enables discussions to resolve the identified problems of initiation schools
• Discussions

should also focus on how best reciprocal referral can be realized whereby biomedical personnel refer to traditional healers and it should not only be traditional healers referring to biomedical personnel
These views are expressed like this:

• The process of incorporation is long overdue and should not be delayed as the WHO advocates for the use of traditional healer whose actions should be viewed positively
•The

Chinese or Zimbabwean method as examples can be applied to use the traditional healer in health care provision
"We left here as a delegate to attend a conference in Beijing, the one fo r HIV/ AIDS, to our shocking surprise they use th eir healers who use tra d itio n a l methods like acupuncture, so it would be g o o d to copy w hat is already

• The people go to the traditional healer before going to the biomedical personnel because they are bound to him by belief and culture
A policy maker had this to say."This peculiar practice has been going on but we all ignored it because when I still practiced I would see that this person is from the traditional healer, but then keep quiet about it.It is part o f cultural practice fo r black people '•The

traditional healer works more on the minds of the people therefore he is useful in solving comm unity problems
• Problems

identified for traditional medicine are no different from those of biomedicine where both sides have fakes, faults and practitioners do not live up to professional expectations
• Scientific

testing of medicines is necessary to conduct more research on herbs and due recognition to be given for herbs already identified as useful in patient treatment
The above views are verbalized like this:

• Policy or act to be formulated by governm ent to legalize traditional healing so that traditional healers are regulated according to the same principles applied to biomedical personnel
These are the words o f a policy maker.•Policy

to clarify the role of the traditional healer in health care provision and to ensure that traditional healing and biomedicine function under one umbrella body
M uller and Steyn (1999:23); Mototo (1999:32) and M ulaudzi (2001:15) support the importance o f policy to spell out what actions are to be undertaken by the traditional healers.

to be in control of traditional healers and be answerable to the governm ent
• Organization

• Organization to ensure that members have licenses which are renewed yearly
This is the quotation."Likea ll p e o p le b elo n g in g toorganizations theirs should be known by government so that they should also pay licenses to work and time and again say yearly or so renew them "• The

• Traditional healers need training to be taught identification of complications and cases above their scope of practice
• Select