TRADITIONAL HEALTH SYSTEMS and NATIONAL POLICY.

by Gerard C. Bodeker, Chair, Global Initiative For Traditional Systems (GIFTS) of Health, Institute of Health Sciences, University of Oxford, England - see http://users.ox.ac.uk/~gree0179/

BACKGROUND.
According to the World Health Organization (WHO), traditional health care systems constitute the main source of everyday health care for the majority of the population of most developing countries - up to 80% of many countries. They also serve the healthcare needs of indigenous populations in industrial countries, such as Canada, Australia and New Zealand. The ratio of traditional health practitioners to population can be substantially higher than the ratio for trained medical personnel, thus representing an irreplaceable health care infrastructure. At the same time, most traditional systems are outside the formal health sector or often have marginal status if officially represented.

Practices and knowledge systems differ in different parts of the world. In Asia, there are formalized traditions, such as the Ayurvedic health care system of India, Traditional Chinese medicine, Unani and Tibetan medicine. These have an articulated theoretical framework, an established tradition of training, a recorded materia medica and a clinical tradition with a diverse range of preventative and therapeutic modalities. In Africa and Latin America, indigenous health care traditions, as well as being generally encoded in family cooking and health care strategies, are centred more in the particular skills of an individual practitioner. Where training occurs, it is likely to be through apprenticeship to an experienced herbalist or shaman, rather than by means of a formalized educational process.

While traditional health systems in developing countries have typically been the primary health service of rural communities and the poorest levels of society, there is now increasing reliance on traditional health care by urban populations as well (Cunningham, 1993). In Africa, the rapid rate of urbanization is changing the face of traditional medicine. Where previously, the village herbalist or healer would provide services and would draw on nearby forests and fields for herbs, urban markets have many herb sellers, each giving advice and many selling both raw plant material and preparations that they have produced themselves. Quality control is a challenge under these circumstances.

In colonial settings, traditional health systems were frequently outlawed by authorities. In post-colonial times, medical attitudes and stereotypes have served to maintain the marginal status of traditional health care providers, despite their role in providing basic health care to the rural majority of developing countries. Historically, the relationship between modern and traditional medicine has taken four broad forms:

(i) a MONOPOLISTIC situation, in which modern medical doctors have the sole right to practice medicine,
(ii) a TOLERANT situation: traditional medical practitioners although not formally recognized are permitted to practice in an unofficial capacity,
(iii) a PARALLEL or dual health care system: both modern and traditional medicine are separate components of the national health system (e.g. India)
(iv) an INTEGRATED system: modern and traditional medicine are integrated at the level of medical education and practice.(e.g. Vietnam, China).

Many traditional healthcare strategies are effective in meeting everyday health care needs, while the continued existence of some practices which may be ineffective or unsafe draws attention to the need for training, research and policy development in this field. In the interests of equity and standards of care, meaningful reform of the health sector will need to incorporate the status and future of traditional health care systems in a planned and economically sound manner.

UTILIZATION

1. Economics. Contributing to the trend towards increased traditional medicine utilization is the fact that modern medical services and pharmaceutical products are available only intermittently in most rural areas, can be expensive - often unaffordable - and many drugs are known to be variable in their effect) . Macroeconomic factors such as devaluation of currencies, including as a result of externally-imposed structural adjustment programmes, can result in a substantial shift from modern to traditional medicine, even in urban populations (African Development Bank/UNICEF, 1995). There are also reports that the introduction of user fees for government health services is resulting in a substantial shift away from modern medicine towards traditional medicine (Bodeker, 2001)
2. Culture. Cultural factors also play a significant role in the continued reliance of rural communities on traditional medicine, which is familiar and trusted. For example, villagers will often seek symptomatic relief from modern medicine, while turning to traditional medicine for treatment of what may be perceived as the "true cause of the condition".
3. Efficacy. Many traditional therapies have been used for centuries, even millennia in some societies. They have stood the test of time - to the extent that some are under patent challenge from pharmaceutical developers - and are trusted as good medicines by local people
4. Availability. Modern medical services do not reach large sectors of the rural population or if they do are often under-staffed and under-equipped. Under such circumstances, people continue to utilize locally-available traditional health services for common conditions such as injuries and wounds through to infectious diseases such as malaria.
   

AREAS FOR DEVELOPMENT
Policy development and infrastructure development will be needed according to varying priorities in different countries. Priorities will necessarily reflect the state of development of existing infrastructure for traditional medicine. International donor support for the development of traditional health systems is needed since competition for scarce budgetary resources at the national level will typically place traditional medicine considerations at the bottom of the list of health sector priorities.

1. Legislation and regulation. There is a need for a comprehensive review and development of policy and legislation pertaining to traditional health care, incorporating standards of accreditation, training and research. WHO has made a start on this, but more comprehensive work is needed (WHO, 1998). Self-regulation by traditional medicine associations should be a goal of standards of training and practice, backed by appropriate national and international budgetary support. Formal collaboration between modern and traditional medical sectors should be promoted. Within the Commonwealth, India and Sri Lanka have very developed legislative and policy frameworks for the promotion and development of traditional medicine. Sri Lanka has a ministry of Ayurveda, the classical healthcare system of the sub-Continent. India, after more than a century of grappling with the relationship between Western and traditional health care systems, gave an official place to the Ayurvedic and Unani medical systems through the Indian Medicine Central Council Act of 1970. In 1995, a Department of Indian Systems of Medicine was established, with a permanent secretary within the Ministry of Health and Family. There are now more than 200,000 registered traditional medical practitioners in India and over a hundred degree-granting colleges of Ayurvedic education.
2. Training. This should be a cornerstone of development in traditional medicine. Both training in the traditional system and training in the basics of safe practice, such as hygiene and appropriate referral. Training can be informal or formal, such as that offered by colleges of education such in South Asia (Hoff, 1997). Medical schools can offer training in traditional (or complementary) medicine to prepare medical students to understand the health care practices that the many of their patients will be using and to facilitate collaboration and cross-referral.
   A curriculum could be developed for different categories of health workers and also for community members. Some Health Ministries in Asia produce simple booklets for villagers showing important medicinal plants, how to grow them and how to prepare them for self-treatment of common illnesses. As the curriculum develops, the potential to incorporate this into primary and secondary school Health Education curriculum and into Social Studies courses could be explored.
3. Research. A national drug development strategy in herbal medicines should have safety as a basic premise. While research on herbal medicine has tended to be pharmacological in nature, the outcome of almost three decades of pharmacological research has been very limited, resulting in little change in central drug policies or in the production of new drugs. A results-oriented policy would take the approach of promoting clinical evaluation of existing practice. Priority disease such as AIDS, TB and malaria also must be considered as part of national research policy on traditional medicine (Willcox et al., 2001, Bodeker et al., 2000)
4. Intellectual property rights. International drug development trends looking to traditional medicinal knowledge as a source of new drugs (i.e."bioprospecting"), have raised questions of intellectual property rights and relevance of research priorities to developing country health needs. National legislation is needed to protect the traditional resource rights of customary knowledge holders as well as the rights of sovereign states over their cultural and genetic property (Dutfield, 1997).
5. Guaranteeing supply. International demand for medicinal plants has, in some instances led to unregulated harvesting to the point where WWF and UNESCO have noted that demand for medicinal plants is outstripping supply.
   For herbal medicines to have a future, sustainable medicinal plant harvesting and production practices will need to be the cornerstone of national herbal medicine policy and legislation, including poverty alleviation through medicinal plant micro-enterprise development programmes (Akerele, 1991; FAO, 1997). Local processing and packaging of herbal products is an important means of strengthening micro-enterprise development and capturing value-added in what could otherwise be a low-revenue earning commodity industry. Studies by the UN Industrial Development Organization (UNIDO) indicate that the sale of extracts rather than raw plant materials can increase the value of the product sold by up to tenfold. New thinking is needed to ensure continuous supply of the medicines used by the majority and also to ensure that benefits accrue to those communities involved in the initial stages of herbal medicine development.

CONCLUSION
Ignoring or under-funding the traditional healthcare sector is the most certain way of ensuring that the poor and rural communities have access to less-than-desirable services. "Best practice", self-regulation, and ongoing training are essential cornerstones of policy development in traditional healthcare. In addition, traditional healthcare providers should not be viewed as a cheap resource through which conventional primary healthcare programmes can be channeled as this will erode their traditional role and knowledge base and further contribute to the weakening of the traditional sector. With careful planning and collaboration among different levels of the health sector, a partnership can be built which, in response to public demand, creates a pluralistic healthcare environment based on quality in healthcare and on the provision of services which complement one another.

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July 2001