HST Update 37: Traditional Healers - Health Systems Trust

HST UPDATE Issue No. 37 October 1998
Traditional
Healers
1

HST UPDATE Issue No. 37
Table of Contents
October 1998
8
Editorial
Traditional Healers 3
Month in Review 4
Policy in Progress
The Collaboration between traditional healers and
the department of health 5
Traditional Healers in South Africa 6
A Prime Example of Collaboration between Traditional
Healers and Conventional Medicine 8
The Registration of Traditional Medicines -
A New Medicines Bill 9
Traditional Medicine in Mozambique 11
Traditional Medicine in Uganda 12
A prime example of
collaboration between
traditional healers and
conventional medicine
10
Research Hot off the Press
Lower Tugela Situational Analysis - June 1998 13
An Evaluation of the Down Scaling of Red Cross
Children’s Hospital Medical Outpatients Department
in the Western Cape Metropolitan Area 14
ISDS News
ISDS gets EU Tender for District Development 15
Nutrition Training Programme at Mt. Frere 15
HST News
Health Systems Trust Annaul National Conference 16
A New Baby in the HST Family 17
5th Annual Regional Network Essential National Health
Research (ENHR) Conference held in Ghana 18
New Publications 19
The registration of
traditional medicines -
A new medicines bill
17
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2

HST UPDATE Issue No. 37 October 1998
Editorial
Traditional Healers
Dr Leslie Pitt, the Valley Trust.
Should traditional healers be recognised as part of the
health care delivery system? This controversy rages
on and is a long way from being answered.
The Valley Trust has considerable experience in the
field. In the first 30 years of the organisation’s existence
up to 1980, a stance of non-interference in the affairs
of traditional practitioners was taken. In 1980 a number
of these practitioners volunteered to be part of the new
Community Health Worker (CHW) or Community Based
Health Education (CBHE) programme. This was the
start of a much closer association between the Valley
Trust and Traditional Healers.
All volunteer Community Health Workers completed a
community based, experiential training curriculum for
a period of approximately three years after which
successful candidates received certification as
qualified Community Health Workers.
Our approach to traditional healers therefore changed
from 1980 onwards to actively involve them in the
health delivery system. Apart from their involvement
in the Community Health Worker programme, meetings
were held with traditional healers to exchange views
and to share knowledge and experiences in a nonjudgmental
way in an attempt to change harmful
practices into safe practices. Healers were encouraged
to bring their patients to our clinic when biomedical
treatment was needed. We in turn reported back to
the traditional healers and in some instances referred
cases with “Zulu” diseases back to them.
Thus through constructive engagement, a good
relationship between the two systems of practice was
fostered in our area of operation, where access to
health care was a problem, not only due to lack of
services, but due to the physical terrain which gave
the area the name “the Valley of 1000 Hills”. It is
estimated that in our operational areas there would
be between 200 and 300 traditional healers. Through
collaboration we therefore have that many more “health
workers” at no extra cost to the health system and
who would have been consulted in any event by 80%
or more of our patients.
We therefore actively involve traditional healers in all
our activities. Some are Community Health Workers.
They are part of our TB control programme. They
dispense oral rehydration fluid. They don’t re-use razor
blades. They help to run our health posts. They are
involved in our social plant use programmes. They
are involved in our nutritional programmes. They
dispense condoms. They are part of our student
training programmes.
Yes, there are the harmful practises which are delivered
by some uninformed or unscrupulous practitioners,
as happens in all professions. However, the gains of
bringing traditional healers into the health care system
far outweigh the negative impact of excluding them.
Dr Les Pitt with two of the traditional healers working
at the Valley Trust.
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HST UPDATE Issue No. 37
October 1998
Month in Review
Stuart Hess
The department of Health is to stop treating pregnant
women with the anti-AIDS drug AZT. The decision was
greeted with much controversy by doctors and AIDS
sufferers. The director of the Prenatal HIV research
Unit at Chris Hani Baragwanath, Glenda Gray, told the
Sunday Times that it appeared as if the government
“preferred incoherent campaigns instead of things that
will really turn the tide against AIDS.” The decision
came in the wake of a launch of a new programme by
the government that placed greater emphasis on AIDS
prevention than actual treatment. In response to the
criticism, health minister Nkosazana Zuma, in an
interview with the Mail & Guardian, said the decision
was based solely on the fact that the costs involved in
treating patients were far too high. “If you have limited
resources, you may decide to put your resources into
preventing mothers getting infected in the first place,”
said Zuma. The distributors of AZT in South Africa,
Glaxo Wellcome, said they were willing to offer the
drug to HIV positive pregnant mothers at drastically
reduced prices.
In a case which could have far reaching ramifications
for the health industry, the Pretoria High Court ordered
the department of health and the Interim medical and
dental council to register 11 foreign qualified doctors
as medical practitioners, without restrictions. The
doctors were all trained in former eastern bloc
countries such as Russia, Hungary, Slovakia and
Poland. The minister and the council argued that the
doctors, who are employed at state hospitals, could
only acquire full registration if they wrote the final year
medical examination. The doctors claim this rule was
unreasonable and unfair and that their qualifications
were equal and even superior to those of locally
qualified doctors. However the judge said the ruling
only applied to the 11 applicants and there should be
no fear that it would “open the flood gates” and cause
all foreign qualified doctors to be registered without
foundation. The Democratic Party welcomed the ruling
saying it has “done health care in this country a great
service.”The ministry of health, the council and ANC
would comment after reviewing the judgement.
(Business Day 7/10/98).
Amid much controversy Parliament’s health committee
passed the department’s Tobacco Products Control
Amendments Bill. The Bill prohibits smoking in all
public places and will eventually lead to a ban on all
forms of Tobacco advertising. The committee’s
decision came in the wake of two days of heated
discussion concerning the Bill’s formulation. Sections
of the media, the hospitality industry and the Freedom
of Commercial Speech Trust voiced their disapproval
of the Bill.
At the end of September the Department of Health
announced the allocation of positions for medical
interns in community service posts. A total of 1220
applications were received. Of these 972 applicants
will be posted to the hospital of their first choice. “The
placement has ensured a fair distribution and mixing
of the graduates from the different institutions
throughout the country,” said the department. Deans
of various medical faculties, student representatives
of medical faculties, provincial health heads, the Junior
Doctors Association of South Africa, the National Intern
Alliance, the South African Medical Health Services and
other stakeholders were involved in the process that
decided on the placement criteria.
Ayanda Ntsaluba was appointed as the new Director-
General of Health. Previously a Medical Officer at
Umtata General Hospital, Ntsaluba was later in charge
of health services for ANC members in exile in various
Southern African states. Since June 1995 he has served
as the Deputy Director General for Policy and Planning
in the Department of Health. Ntsaluba replaces Olive
Shisana, who was blamed for the Sarafina II scandal.
Shisana has since taken up a post with the World Health
Organisation.
Two provinces said they would be overspending on
their provincial budgets for the 1998/99 financial year.
The two provinces (Gauteng and the Eastern Province)
blamed the over spending on salaries to nurses and
administrators. Two major hospitals in Gauteng, Ga-
Rankuwa and Chris Hani Baragwanath, will be
requesting additional financial assistance from the
department.
Internationally, a 48-year-old Australian man was
grafted with a new right hand in the world’s first such
operation by an international team of surgeons in the
French city of Lyon. The surgery will be particularly
significant for the thousands of amputees living in
countries such as Mozambique and Angola.
The Truth and Reconciliation Commission handed in
its final report to the president in October, in which it
heavily critisised the health sector. It found that through
apathy, acceptance of the status quo and acts of
omission, the health sector allowed the creation of an
environment in which the health of millions of South
Africans was neglected and at times actively
compromised. The report says that although the health
sector was not directly involved in gross violations of
human rights, it was structurally ‘part of an overall
system designed to protect the privileges of a racial
minority’. (Business Day, Beeld, 30.10.1998) .
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HST UPDATE Issue No. 37 October 1998
Policy in Progress
The collaboration between traditional healers and
the department of health
Elizabeth Clarke.
Traditional healers play a vital role in the health of the
majority of people in South Africa. They are deeply
interwoven into the fabric of cultural and spiritual life,
they are the first health practitioners to be consulted
in up to 80% of cases (especially in rural areas), and
they are present in almost every community, which
means that they are easily accessible in remote areas
where other health services are not.
They therefore have a very important, and previously
unrecognised, role to play in improving the health of
South Africans. They are an untapped resource which
has enormous potential to treat many prevalent
diseases and to educate the people in all aspects of
preventable diseases.
It is for these reasons that collaboration between the
department of health and traditional healers’
associations would be most beneficial to health in SA,
and why in August this year Parliament decided to
enlist the help of traditional healers in achieving major
goals in primary health care. In the first phase of this
collaboration, it was decided to set up a statutory
council to regulate traditional healers – create a system
of registration, promote their training, develop a code
of practice, and catalogue the medicines they use.
There are currently about 200 bodies in place which
regulate traditional healers, among them the Inyanga’s
A TRADITIONAL HEALER ADVERTISES IN DURBAN’S CITY CENTRE
Facts and figures
· There are over 200 000 traditional
healers in South Africa and only 27
000 allopathic doctors.
· Every year 1 500 tons of traditional
medicines are sold in medicine
markets in Durban alone.
· The traditional medicine industry is
worth up to R2,3 billion per year.
association in KwaZulu Natal, which accepts members
only after they have performed an oral exam in front
of a selected committee. However, the process of
registering traditional healers within these bodies is
not yet uniform.
It is controversial as to whether the traditional healers
should become part of the department of health itself
or belong to their own association in an affiliation with
the department of health. The traditional healers
themselves have differing opinions on this matter (see
our article “traditional healers in South Africa”).
However, all traditional healers spoken to for this
publication agree that some kind of partnership with
the department of health would be beneficial both to
them and to the people they treat. As Mr S.J.Mhlongo,
head of the Inyanga’s Association said, this affiliation
would help traditional healers to “heal the nation”.
Meetings between the department of health and
traditional healers’ associations were scheduled to take
place this year and early next year, however, according
to Mr. Mhlongo, progress is slow. Although results from
these discussions were expected by December, it now
appears that the process will be much longer than
anticipated.
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HST UPDATE Issue No. 37
October 1998
Traditional healers in South Africa
Stuart Hess
Traditional Healers, (in South Africa known as
witchdoctors, sangomas and inyangas) have been
administering health for centuries. Instead of using
medicines like penicillin, panado’s or other western
substances, they use the fruits of the earth, gathering
plants in the mountainous areas of KwaZulu Natal, the
Free State and the Eastern Cape.
Traditional healers play a crucial role in administering
health to the majority of South Africans. However their
role is still not concretely defined and there is much
disparity between western trained or allopathic doctors
and indigenous practitioners. Many from the sector and
outside it feel traditional healers should take up their
rightful place within an integrated medical and dental
council. Not everyone subscribes to this view,
however. The head of the Traditional Healers
Organisation, Nhlavana Maseko, does not believe the
two sectors should be integrated. “This traditional
system is an indigenous one which is totally different
from the modern system so the two cannot be
integrated,” said Maseko. “We want to establish the
traditional system parallel to the modern system.” He
says in South Africa the western health system is well
established and recognised, but similar recognition is
not afforded to traditional medical practice. “If one looks
at the current situation, Traditional healing is looked
down upon by the modern system which is housed in
these large [hospitals].” He believes traditional healing
needs to be upgraded to rank equally with modern
schemes. “[Traditional Healers] are the first contact and
front-line service provider (of health services) and they
also help by referring patients to the modern sector,”
explained Maseko.
Maseko established the THO in the wake of protests
in the 1970’s against the Witch Craft Act promulgated
by the British Colonists in 1818. After approaching the
former Swazi king - King Subuzo II – a council was
formed to address the problems faced by traditional
healers. In 1980 Maseko placed 150 associations
representing traditional healers in South Africa under
a single umbrella body and formed the Traditional
Healers’ Organisation. The organisation currently
represents more than 180 000 traditional healers from
South Africa and a number of neighbouring countries
including Swaziland, Zambia and Zimbabwe.
To qualify as a traditional healer one has to serve an
apprenticeship of between 1 and 5 years, and be well
known within the community and amongst other
traditional healers. Healers then register with the THO
and are given a book to certify that they are qualified
practitioners. The qualifications are valid in Africa, Asia,
Latin America, Europe and Australia. Members pay
an annual subscription fee of R60.
Maseko says the roles of traditional healers need to
be upgraded as they serve a far greater number of
clients than western doctors, especially in rural areas.
The self proclaimed international president of the THO
wants to see traditional healing and western practice
operating equally with both sectors referring patients
to one another.
This view is shared by the president of the National
Traditional Healers Association of South Africa
(NTHASA), Patience Koloko. However, although
NTHASA, which represents 5000 traditional healers,
is affiliated to the THO, Koloko wants to see traditional
healers incorporated into the South African Interim
Medical and Dental Council (SAIMDC) because this
would provide traditional healers with more benefits
such as recognition by hospitals and doctors.
Traditional healers would also be able to draw up
“official” medical reports when referring patients to an
allopathic doctor. “ Because we’re not incorporated into
the SAIMDC we can’t work in hospitals and our patients
can’t receive medical treatment from us there,” says
Koloko.
She believes students who want to become traditional
healers should go to a “traditional healer school” similar
to a medical school. She is currently negotiating with
Mangosuthu Technikon in Umlazi to provide NTHASA
with facilities to train traditional healers.
Besides her work as a traditional healer with the
community in Hammarsdale, Koloko also conducts
awareness programs on primary health care and AIDS/
HIV. The 51-year-old healer wants to use empty, newly
built clinics as “surgeries” for traditional healers. “The
department has built all these clinics in rural areas but
many are standing empty; we should use them,” says
Koloko.
The Department of Health wants traditional healers to
establish a formal council to conduct their affairs saying
this will make management of the sector much easier.
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HST UPDATE Issue No. 37 October 1998
The shelves of Maseko “surgery” are packed with
hundreds of bottles containing traditional medicines
many of them obtained from plants in Kwazulu Natal.
Medicines used by traditional healers belonging to the
THO are administered to the public with the blessing
of the clinic, even though these medicines have not
been formally tested and registered.
Thoko Maseko at work with her students in Tsakane
Situated east of South Africa’s biggest city, in the
Tsakane township outside Brakpan, Thoko Maseko is
busy re-arranging her house for an important
ceremony. Four women are to graduate and become
official traditional healers. The four, including a nurse
from the neighbouring suburb of Benoni are all covered
with red make up and after bathing in a nearby vlei,
they are taken to Maseko’s home where they are set
to complete the ritual.
Maseko started practicing as a traditional healer in 1978
and is well known within the community. She has a
very close working relationship with the nearby
Rockville clinic. Maseko says there is a regular referral
of patients between her and the clinic, especially with
the seven AIDS sufferers living in her neighbourhood.
“When I’ve got patients I send them to the clinic for
check ups, and the clinics always send them back,”
says the 47-year-old healer.
Maseko is a member of the Traditional Healers
Organisation. She not only administers medicinal
treatment but also specialises in providing
psychological aid, the treatment of diabetes, flu and
other common ailments. The Aids Treatment and
Information Centre granted her a certificate last year
for participation in an Aids workshop.
Grace Thuketane a senior nurse at the Rockville clinic
says they have a good relationship with Maseko and
trust her judgement. “If patients don’t get any better
after we treat them we have to refer them to a traditional
healer,” says Thuketane. She trusts Maseko because
she is very experienced and many of the clinic patients
speak highly of her work. Clinic administrators are very
happy with her work especially with AIDS patients.
While the allopathic and the traditional practices are
working closely together in Tsakane, Maseko believes
traditional healers should not be integrated into the
South African Interim Medical and Dental Council
(SAIMDC). Instead an independent traditional healers
council should be established with a similar status as
the SAIMDC.
“The [Medicines Control Council] approves both
orthodox and unorthodox medicines for registration
on the basis of safety, quality and efficacy for the South
African market,” says the registrar of medicines,
Precious Matsoso. The terms of the Medicines and
Related Substances Control Act of 1965 stipulate that
no substances passed by the MCC can be sold by
persons other than doctors, dentists or pharmacists.
The current definition of the Act does not make
provision for Complementary Medicines. However, a
new Bill proposed by the department will make
provision for the listing of all Complimentary Medicines
and all medicines will be listed based on their safety,
quality and proven efficacy. This will only occur once
the act is passed. (see our article “The registration of
traditional medicines”).
The department of health says that medicines must
be made available to be tested by the MCC although
such tests are not yet underway. The chair of the MCC’s
Complementary medicines section, Peter Makhambeni
says medicines are tested and then registered before
they are allowed onto the market. “Those [traditional
healers] currently giving substances to people are not
using registered medicines,” says Makhambeni. The
committee is formulating a new bill that will see all
medicines sold on the market are properly registered
with the department. However despite the growing
number of people using traditional healers for their
medical ailments, neither the department of health nor
the MCC have come up with a definite policy regarding
the sector.
Facts and figures
Negative aspects of traditional medicine.
· The incisions made in some forms of
traditional healing have resulted in the
transmission of HIV/AIDS.
· Fragments of tapeworm have been found as
an ingredient in some traditional medicines
in South Africa and may be the source of
certain cases of cysticercosis.
· The delay caused by consultation of a
traditional healer before a western doctor has
resulted in some fatalities, especially in
children.
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HST UPDATE Issue No. 37
October 1998
A prime example of collaboration between
traditional healers and conventional medicine
Elizabeth Clarke
In the 1950’s, the founder of the Valley Trust Dr Halley
Stott, entered into a partnership with the traditional
healers in the area, which was continued by Dr Irwin
Friedman in the 1980’s.
The traditional healers and western doctors have been
working together in preventing and managing common
diseases in the area for over 40 years now, and as a
result of their successful collaboration they were
recently given an award at a meeting of the Inyanga’s
Association in KwaZulu Natal, for serving as an
example to the rest of the traditional healers and
western doctors in South Africa.
Mrs. Nokusho Bhengu, who graduated as a sangoma
in 1966, was one of the first traditional healers to work
in partnership with the doctors of the Valley Trust. In
the 1980’s, she and a number of other traditional
healers and community members were trained as
community health workers. The traditional healers
have never seen their simultaneous practice of
traditional medicine and western-based primary health
care as conflicting. In fact, Mrs. Bhengu feels that all
traditional healers should be given a course in primary
health care before graduating.
According to Mrs. Bhengu, the patients are happy with
this arrangement as they see the western doctors as
treating the symptoms of the disease and the traditional
healers as treating the cause. With this system, they
perceive their treatment as complete and holistic.
Dr Friedman, who played a major role in developing
this partnership, says, “Traditional practitioners are an
integral part of the culture of the society. Just as with
other individuals they are part of dynamic social
change. My experience has suggested that in many
respects they are leaders of social change and are
early rather than late adapters of new
ideas….Traditional practitioners are enormously
influential in improving people’s health. My own view
is that we, as western practitioners, must come to a
much closer understanding for ourselves of traditional
healers as a prelude to any policy formulation. I don’t
believe we can define a role for traditional practitioners
unless it is done in the spirit of genuine partnership.”
(From “Achieving partnerships with traditional healers/
isangomas” by Dr Irwin Friedman, NPPHCN, 1997).
Facts and figures
The global potential of traditional medicines:
· Traditional medicines are providing new and
frequently cheaper ways of treating certain
illnesses.
· These medicines could be exported all over
the world, giving a boost to the economy.
MRS NOKUSHO BHENGU WITH SOME OF THE SANGOMAS
WORKING AT THE VALLEY TRUST.
· China has shown with its acceptance of
Chinese traditional medicine (acupuncture
and homeopathy) that the global sharing of
one country’s form of traditional medicine is
entirely possible.
As our editorial states, the traditional healers working
within the Valley Trust are involved in numerous
aspects of primary health care. There are currently 90
traditional healers working within the framework of the
Valley Trust, treating patients with traditional methods
if they feel this is appropriate, or referring them to the
clinic doctors if necessary. The patients report back to
the traditional healers after consultation at the clinics.
8

HST UPDATE Issue No. 37 October 1998
The registration of
traditional medicines –
A new medicines bill
Andy Gray
The latest of the department of health’s transformatory
Bills before Parliament is the dauntingly named South
African Medicines and Medical Devices Regulatory
Authority Bill (SAMMDRA bill). This piece of legislation
will, if passed and implemented, bring a totally new
look to the regulation of medicines in this country.
A handbook for
South African
Traditional Healers
The South African Traditional Healers’
Primary Health Care Handbook was
produced in 1997 by the Traditional
Medicines Research Programme of the
University of Cape Town, an established
research group of the Medical Research
Council.
In brief, the Bill establishes a new regulatory authority,
the South African Medicines and Medical Devices
Regulatory Authority (SAMMDRA), to replace the
Medicines Control Council (MCC) which was set up in
1965. This Council has had control over all forms of
medicine, be they of orthodox or complementary
nature. Crucially, however, the MCC held all medicines
(both orthodox and complementary) to the same set
of standards and procedures. These focussed on three
issues: safety, quality and efficacy. In the case of
The book intends to provide advice for the
treatment of common diseases by traditional
healers, both from a western medical and
traditional perspective.
The basic concepts in both traditional and
western medical diagnosis and treatment are
explained, and common physical problems
ranging from nappy rash to cardiac arrest
are discussed. In almost all sections, both
the traditional and the allopathic approaches
are outlined.
There are sections on the anatomy and
physiology of the body systems and
comprehensive explanations of the
treatment modalities used in both traditional
and western medicine.
The book was produced in response to
requests received from traditional healers,
and was compiled after wide consultation
with traditional healers throughout South
Africa. It has been widely distributed to
clinics, traditional healers’ organisations and
individual health workers throughout the
country.
A TRADITIONAL HEALERS’ PHARMACY
9

HST UPDATE Issue No. 37
October 1998
efficacy, the standard test was the double-blind
randomised controlled trial. The SAMMDRA Bill, in
contrast, makes provision for different procedures to
be applied when registering orthodox (science-based,
allopathic) medicines and complementary (herbal,
traditional, or homeopathic) medicines. This will be
done by establishing separate expert committees for
the two major types of medicine (in addition to those
for veterinary medicines and medical devices). In the
case of traditional medicines, issues of safety and
quality will take precedence over demonstrations of
efficacy. The aim is to regulate and not to prevent
access to what many people use in preference to
Western, allopathic medicine.
From a traditional healer’s perspective, this testing of
medicines by an independent body may seem
unnecessary. Mr. S.J.Mhlongo, head of the Inyanga’s
Association, says that traditional healers have been
testing their own medicines for the past 4 000 years.
There are still questions about the bill though. Although
the Transformatory Task Team on Medicines
Regulation has suggested that complementary
medicines be divided into three categories (those
available in open shops, those restricted to pharmacies
only, and those available only through registered
practitioners), this is not clearly discernible in the Bill.
The Bill also makes mention only of the
complementary practitioners who are registered in
terms of the Chiropractors, Homeopaths and Allied
Health Professions Act, not of the traditional healers
of South Africa (although it later talks of informing the
Interim Co-ordinating Committee of Traditional Medical
Practitioners of South Africa of the results of
applications for registration of a traditional medicine).
Thus it would seem that the prescribing rights of
traditional healers, as opposed to mainly western
complementary practitioners, have not been settled.
Registration of all forms of medicine is also tailored to
the orthodox setting, and might be unenforceable in
the traditional medicine arena. Thus, while the National
Drug Policy (and National Veterinary Drug Policy) might
have been intended for application to all medicines,
including traditional medicines, this Bill leaves many
issues perhaps as muddy as before. It leaves us with
as many questions as answers.
Public hearings on the Bill have been scheduled for
Monday 26 October. Thereafter the National Assembly
Portfolio Committee will consider any possible
amendments, before the Bill is tabled for its second
hearing, and probable adoption. However, given the
number of unresolved issues in many areas (not just
related to traditional medicine), the possibility of a court
challenge after passage through Parliament cannot be
ruled out.
Traditional healing is capturing the
imagination of the world, and African
traditional medicine is becoming better
known in Europe and the United States. This
book is the story of an American woman
(who had spent her childhood in Durban)
who studied in Johannesburg to become a
sangoma.
Facts and figures
Scientific testing of traditional medicines.
· Traditional treatment of peptic ulcers has
been shown to decrease gastric pH and to
protect rats from aspirin-induced
ulcerogenesis (Nigeria).
· Traditional treatment of sleeping sickness has
been shown to kill Trypanosoma brucei
rhodesiense (the agent of the disease)
(Uganda).
· Traditional treatment of diabetes has been
shown to have a significantly beneficial effect
in Karnataka (India).
10

HST UPDATE Issue No. 37 October 1998
Traditional Medicine in Mozambique
Elizabeth Clarke
Adapted from a proposal for a program in public health
and traditional health manpower in Mozambique, by
Edward C. Green (medical anthropologist), Taju Tomas
(Eng. Of Agronomy and pharmaceutical technician) and
Annemarie Jurg (biologist).
In 1991, a proposal was put forward for a three year
programme to establish a foundation for collaboration
between the National Health Service and the traditional
healers of Mozambique.
There were many reasons that this collaboration would
be beneficial, which pertain as much to South Africa
as they do to Mozambique.
1. There were not enough health workers within the
department to treat the entire Mozambican
population, especially in rural areas where health
services were scarce. However, there were
traditional healers in almost every community, to
whom the people had easy access.
2. Many people were dying from treatable and
preventable diseases, because health services
were not available to them. However, if traditional
healers were able to deal with these diseases, their
impact on the population would be drastically
reduced.
3. Traditional healers in Mozambique expressed a
wish to learn more about allopathic medicine and
thus to expand their healing skills.
The proposal suggested that traditional healers should
constitute a separate, parallel and self-regulating health
service that should collaborate with the Mozambique
government in the realisation of specific public health
goals. These would be initially to target childhood
diarrhoea and AIDS/STD’s, but would later include TB,
malaria, infant and maternal malnutrition, mental
health, child spacing and expanded programmes of
immunisation.
Objectives to meet these goals were:
1. To establish workshops to train traditional healers
in the treatment of certain priority diseases
2. To establish a research derived information base
about traditional beliefs and practices
3. To educate government health workers at all levels
in traditional beliefs and practices.
4. To coordinate research in traditional medicines,
although due to a tight budget, this research would
not be funded by the government itself.
How successful was the programme?
The programme was funded by the Swiss
Development Cooperation from 1994 to 1997. During
the first year an adequate number of traditional healers
were trained, but in the following year a new Minister
of Health was appointed, who initially gave a lower
priority to the position of traditional healers in health
than his predecessor. However, the Minister later
realised the public health importance of traditional
healers and collaborative programmes continue to take
place under the umbrella of the department of health.
In addition to these, there are a number of these
programmes on the go sponsored by nongovernmental
organisations, most of which collaborate
with local (either district or provincial) health authorities.
The successful implementation of such a programme
is a long term goal, and perhaps South Africa could
learn from the Mozambican experience, as well as from
other African countries which are in similar situations.
The goals of the programme were to
1. Achieve a working relationship in public health
between the National Health Service and traditional
healers in Mozambique
2. Reduce morbidity and mortality of priority diseases
3. Identify, reinforce and adopt aspects of traditional
medicine found to promote the health of the people
whilst discouraging those found to have a negative
health impact.
11

HST UPDATE Issue No. 37
October 1998
Traditional Medicine in Uganda
An organisation going by the name THETA is
responsible for the collaboration between traditional
healers and conventional health practitioners (CHP’s)
in Uganda.
THETA stands for Traditional and Modern Health
Practitioners Together against AIDS and other diseases.
It is an indigenous NGO initiated by a collaborative
effort between TASO Uganda Ltd and MSF-Switzerland.
It began in 1992 as a clinical study in Kampala
evaluating with traditional healers the effectiveness of
local herbal treatments for selected AIDS-related
symptoms. The success transformed the project into
an organisation working with traditional healers in HIV/
AIDS education and counselling and improved clinical
care. THETA is a mutually respectful collaboration
between THs and conventional health practitioners in
the fight against AIDS and other diseases.
THETA’s Mission statement: Towards improved healthcare
and health promotion through collaboration among
traditional healers, bio-medical workers and communities.
THETA is committed to promoting traditional medicine
to complement modern healthcare services, and to
utilising Traditional Healers as health educators and
counsellors of Sexually Transmitted Infections
(including HIV) and other diseases.
THETA’s Philosophy
THETA recognises that Traditional Healers are a vital
resource in community health care services in Uganda
for many reasons. Firstly, as care providers they vastly
out-number modern doctors in Uganda (as in many
other African countries). Secondly, as an indigenous
resource deeply rooted in culture, they take a holistic
approach and command a unique knowledge and
respect to influence health improvement behaviour.
Thirdly, their work and additional responsibilities are
self-sustaining.
1. Training traditional healers as community
counsellors and educators on sexually transmitted
infections (including HIV), as well as training for
other organisations targeting traditional healers
country-wide.
2. Training traditional healers in basic clinical diagnosis
and supporting their efforts to provide quality health
services.
3. Generating information through documentation and
research about herbal medicine.
4. Establishing and managing a resource and training
centre to facilitate collection and dissemination of
information on traditional medicine.
5. Advocating for traditional medicine among health
professionals and other scientists.
Future Plans
In the next five years, THETA will be developing in 4
directions:
· strengthening its training capacity and expanding
the training programme to more districts in Uganda
· collaborating with healers to develop alternatives
for the treatment of opportunistic infections, and
making them readily available
· expanding community-based support through
membership registration
· promoting acceptance of traditional medicine
among the bio-medical sector and continually
sharing experience and disseminating successful
approaches.
You can email the organisation at msftheta@imul.com
or “snail mail” them (by ordinary mail) at Box 21175,
Kampala, Uganda.
Furthermore THETA recognises that herbs or medicinal
plants are potentially an effective and affordable
alternative for the treatment of many diseases including
those which occur under immuno-suppression.
According to this philosophy, THETA fosters
collaboration between Conventional Health
Practitioners and Traditional Healers in health care
provision and in research, documentation and
dissemination.
Present Activities
12

HST UPDATE Issue No. 37 October 1998
Research Hot off the Press
Lower Tugela situational analysis
June 1998
Department of Community Health, faculty of medicine, University of Natal.
The study area incorporates the Lower Tugela and Maphumulo magisterial areas. Despite the close geographical
proximity of the two areas, they remain two distinct entities in development terms.
Geography and infrastructure
The Lower Tugela is a coastal area and Maphumulo is an inland area. The infrastructure and road access in
Lower Tugela is good and served by all weather roads. The infrastructure in Maphumulo is poor with the majority
of roads being corrugated or gravel roads which become impassable in inclement weather.
The dichotomy between the two districts is highlighted in the table below.
Lower Tugela
Maphumulo
Infrastructure good Poor
Demography Urban:rural Rural
Population size 109 240 270 330
Population structure 30%

HST UPDATE Issue No. 37
October 1998
An evaluation of the Downscaling
of Red Cross Children’s
Hospital Medical Outpatients’
Department in the Western
Cape Metropolitan area
M.Shung-King, Child Health Policy Institute, UCT.
March 1998.
In April 1996 the Regional Director for the metropolitan
region from the health department of the Provincial
Administration of the Western Cape accepted a
proposal to down-scale the OPD at Red Cross Hospital
(RXH). This meant that all unreferred non-emergency
cases would not be seen at RXH but would be
redirected to their nearest primary level facility. Downscaling
began on 2 February 1997.
The evaluation team was requested to report on this
downscaling, and in doing so answer certain
questions. A summary of some of these follows.
1. What was the context in which downscaling
took place?
RXH wanted down-scaling because:
· They wanted children to be treated at appropriate
levels within the health system.
· They wanted to save money because their budget
had been cut
· They wanted to help move resources from tertiary
hospitals to primary care facilities.
2. How well was the down-scaling planned?
The director of the Metropolitan region appointed a
team to plan the down-scaling. Professor David Power
was the chairperson. The team included senior
managers from the various health facilities and
authorities.
The group made a list of what needed to be done to
prepare health facilities. This included making centres
child friendly, providing enough doctors to rotate
through all children’s facilities, providing after hours
security, providing a referral network and making a list
of the equipment required.
3. How well was the plan carried out and how
well are facilities run now?
Down-scaling was not carried out as planned.
The biggest mistake was that doctors were not sent
to facilities that needed them most. Instead they were
allowed to choose where they wanted to work. None
of the doctors wanted to work in informal settlements
or other areas they thought were unsafe.
Also only 5 full time and 6 part time doctors were
moved to the community health centres instead of 11-
15 as planned in the beginning. And none of the
doctors wanted to do their after hours service at the
community health centre.
Very few of the facilities received the equipment and
resources that they needed. Others only got their
equipment many months after down-scaling started.
Many facilities did not have enough space to examine
and treat children properly.
4. What effect did down-scaling have on
workload at health facilities?
There has been an overall increase in workload at
community health centres and local authority clinics.
The biggest increase has been in the 24 hour centres,
especially in the informal settlements.
A lot of children attend after hours and this number
has increased since down-scaling. At Gugulethu there
was an almost 400% increase in the number of children
attending after hours.
Children under 6 make up almost 70% of child
attendance.
5. Has the health of children been made
worse by down-scaling?
Many people report that children arrive at RXH much
sicker than before. However, this may be because only
referred cases come to RXH now, and one would
expect these children to be seriously ill.
6. Did down-scaling save money?
The total cost of RXH OPD decreased by R1,7 million.
This was mainly due to a decrease in staff costs of
about R1,4 million.
However, because the staff were not sent to the
facilities that needed them most, the maldistribution
of doctors increased resource inequities between
primary level facilities.
Based on this evaluation, the researchers came up
with a number of recommendations. Some of them
follow:
· To decide on a minimum standard of child health.
· To use staff efficiently.
· To make sure facilities receive the equipment that
they need.
· To make sure that all role players are involved in
the future.
· To collect basic financial information.
· To investigate why people seem to use primary
level facilities inappropriately.
14

HST UPDATE Issue No. 37 October 1998
ISDS NEWS
ISDS gets EU
Tender for District
Development
The ISDS programme of the Health Systems Trust has
been awarded the European Union tender for District
Development by the Department of Health. This will
enable the ISDS to develop and strengthen its work in
support of effective district development.
Congratulations!
A new ISDS site.
A new ISDS site was recently launched in Virginia, in
the Kopano District of the Free State. It was launched
in a workshop that took place on the 21-22 September.
This site is a “mirror site” of a neighbouring, relatively
old ISDS site, the Tshepo District (incorporating
Bothaville). Lessons learnt from the Tsepho district
would have been passed on to the Virginia site in what
is known as the “knock on” effect.
At the two-day workshop to launch the site, the ISDS
team was introduced and the Kopano Interim District
Management Team was established.
Carmen Baez is the ISDS facilitator of the new site.
Good luck Carmen!
ISDS serving as basis of David
McCoy’s Ph.D. thesis.
David McCoy is currently on sabbatical, studying for
his Ph.D. at the London school of hygiene and tropical
medicine. His thesis will concentrate on the
development and implementation of the District Health
System in different contexts, as well as how different
contexts can affect the success or otherwise of
interventions to improve quality of care. He will focus
on the role of decentralisation in improving quality of
care, and strategies to make interventions in Primary
Health Care more effective.
We wish him all the best!
Nutrition Training
Programme at Mt Frere.
Susan Strasser
Ann Ashworth of the Centre for Human Nutrition of
the London School of Hygiene and Tropical Medicine
recently led a training programme on the care of
severely malnourished children in the Mt. Frere health
district. Dr. Ashworth is a world expert in the field of
human nutrition. Her work focuses on 10 Steps to
Recovery, which have been shown through extensive
research to dramatically reduce the death rate from
severe malnutrition such as marasmus and
kwashiorkor. Medical, nursing and dietary staff from
the two district hospitals as well as regional and
provincial representatives took part in the programme.
This training is one part of the integrated nutrition
programme (INP) currently underway in Mt. Frere. The
INP attempts to look holistically at the many causes of
undernutrition from poor food security in the home to
inadequate sanitation. Future training will focus on
improving growth monitoring at the clinic level so that
children with malnutrition are picked up earlier and
appropriate measures are taken.
This programme is led by Professor David Sanders of
the University of the Western Cape Public Health School
and is a joint project of ISDS and UWC.
For further information on the INP and the work of
Dr. Ashworth please contact Susan Strasser, Nurse
Training Coordinator- ISDS.
susan@healthlink.org.za
ANN ASHWORTH WITH SOME OF THE HEALTH
WORKERS AT MT FRERE.
15

HST UPDATE Issue No. 37
October 1998
HST News
Health Systems Trust Annual National Conference
(29-30 September 1998)
Jane Edwards-Miller
This year’s HST research conference was not just an
academic affair! With the theme, ‘Getting the message
across’ our researchers were all encouraged to present
their work in a non-academic style to the people that
matter! With this in mind, a wide audience of health
managers, policy makers, researchers and the media
were all invited. Our aim was to assist in the
dissemination of HST research, and therefore help in
making sure that useful findings make their way to
management decisions.
The presentations covered a huge range of topics
including:
• Why are we struggling to improve delivery of
primary health care services in South Africa?
• The why and how of designing a rigorous
evaluation of an intervention to improve
tuberculosis care outcome
• Vision and hearing screening in schools : An urgent
need for policy
• Involving the private sector in the management of
sexually transmitted diseases
CONGRATULATIONS to our
New Health Systems
Researchers of the Year:
Spindile Magwaza
Assessing the quality of care delivered to patients with
STDs in Primary Health Care clinics
Community Health Dept.: University of Cape Town
Mpefe Ketlhapile
Preliminary finding of participatory research studies
on clinic staff workload and time-overflow of patients
and staff in two regional clinics in the Northern Province
Women’s Health Project: University of Witwatersrand
• Assessing access to termination of pregnancy
services in the Cape Metropolitan region
• Violence against women: Public health concern in
South Africa
We even had a lesson on how to fly a kite. For more
details and copies of the research, look up the following
address: http://www.hst.org.za/r esearch/conf98/ . A
printed copy of the proceedings will be available later
in the year.
MPEFE ON THE LEFT, TREVOR FOWLER ON THE RIGHT
16

HST UPDATE Issue No. 37 October 1998
Best Poster Presentation:
Ethne Ntshingile & Lungi Shongwe
Inadequate provision for malnourished children.
Social Work Department;
Prince Mshiyeni Hospital:
KwaZulu Natal
Neil Martinson
Best Health Systems
Research Project:
Cervical Screening Study
Gauteng Department of Health
EHTNE ON THE LEFT AND LUNGI ON THE RIGHT.
Best Press Release:
Elma Kortenbout
If you need a nurse, choose your province
University of Western Cape
Best Presentation:
Tanya Doherty & Chantelle Juby
Selecting community health workers: Learning from
the experience
Dept. of Nursing: University of Cape Town
A new baby in the HST family!
Congratulations to Gcinile Buthelezi, deputy director of Health Systems Trust,
who gave birth to her second daughter, Nozibusiso, on 23 rd September.
Who says a woman can’t be a career girl and a mother?
We wish the Buthelezi family quiet nights and joyful days!
17

HST UPDATE Issue No. 37
October 1998
5th African Regional Network Essential National Health Research
(ENHR) Conference held in Ghana,
October 3-7 th , 1998
Lucinda Franklin
Hotel Cisneros in Sogakope, a leisurely two-hour drive
from Accra, was the idyllic, riverside, tropical setting
for the 5th African Regional ENHR Network Conference
in Ghana.
Essential National Health Research is a global initiative
led by an international NGO known as COHRED. This
conference provided a forum for countries to discuss
their successes and failures with local implementation
of ENHR.
Essential National Health Research - a definition:
ENHR is an integrated strategy for organising and managing
research, whose special characteristics include its goal, focus,
content, and mode of operation.
The Goal of ENHR is to promote health and development on
the basis of equity and social justice.
A Francophone regional meeting formed the first 2
days of the conference agenda. This was the first time
that a bi-lingual meeting on ENHR has been attempted.
There was a call from the seven francophone countries
in attendance to nominate a representative for the
position of ‘sub-regional focal point’ for the West African
Region. This representative would enable
communication between francophone and
anglophone countries active in ENHR, and specifically
between the East/Southern and West African regions,
which is a very positive step.
The main meeting, conducted with simultaneous
French/English translation, included sessions on:
· Country report-back, whereby each country
addressed the 7 ENHR strategies, and discussed
the in-country activities which have been conducted
accordingly.
· Scientific presentations on the role of research to
policy/action/practice.
· Capacity Development activities in specific
countries.
· The implementation of ENHR at the District level.
· Priority Setting for ENHR in Malawi, Zambia and
Swaziland.
· ENHR country Mechanisms.
The session on ENHR Mechanisms generated many
questions on the ‘best’ way to construct a country
mechanism for implementation of ENHR, supporting
the COHRED initiative which identified a need to
develop learning materials around this question, and
innovative ways of packaging these to suit individual
country needs. It is envisaged that this initiative will
further serve to promote the ENHR strategy, as an
organised method of assisting a country to set health
priorities (by suggesting the type of stakeholder who
should be involved in this activity), and assist countries
with the establishment of communication networks,
and establishing themselves as an integral part of their
region.
Networking the networks
Another of the seven elements of Essential National
Health Research, Networking, was accorded special
attention at this conference. The importance of
establishing networks of countries participating in
ENHR within regions of Africa was especially
emphasised. In order to foster communication
between ENHR focal points, each country contact
person is to be connected via an email discussion
group, where communication and the sharing of
experiences can occur outside of the ENHR meetings,
which take place annually, or at best, bi-annually. This
was a very promising development.
In addition to this, Dr Dieter Neuvians from AFRO-NETS
(Zimbabwe) presented a session on the use of email
and internet facilities for communication. The Health
Systems Trust and South African MRC websites
featured in Dr Neuvian’s session, as specific examples
of how effective websites can be used to further ENHR
activities.
Further details regarding HST’s link with COHRED are
available from the HST website.
http://www.hst.org.za/inca/cohred.htm
The Seven Elements for
Implementing ENHR
Promoting and Advocacy
ENHR Mechanism
Priority Setting
Capacity Building and Strengthening
Networking
Financing
Evaluation
18

HST UPDATE Issue No. 37 October 1998
New Publications
Kwik–Skwiz #13
Using Stock Cards to
Improve Drug
Management
The issue
We all know the consequences of running out
of medicines or other essential items: patients
who need treatment don’t get it, they have to
seek help at other facilities (often far away or
more expensive), and they lose confidence in
the ability of the clinic or hospital in question
to meet their needs. It also leads to health care
workers becoming demotivated.
For this reason, effective stock management
systems for drugs are important at all levels
of the health care system. All too often there
is some control over stock at higher levels of
the distribution chain (depots or hospitals) but
poor control at lower levels such as at clinics.
This lack of control can also result in large
financial losses. South Africa spends some R2
billion per year on medicines in the public
sector alone, and how much is lost through
poor control systems remains unknown at this
stage. This Kwik Skwiz will focus on the use
of stock cards in drug management.
Kwik-Skwiz #14
How “programmes” can
support the development
of districts
The Issue
The provision of comprehensive integrated
primary health care (PHC) within the framework
of the District Health System (DHS) is the
cornerstone of health service delivery in the new
South Africa. At the same time, vertical
programmes have been developed to ensure
that priority health issues are tackled in an
appropriate, co-ordinated and focussed way.
How can programmes provide vertical support
in a way that does not undermine the provision
of comprehensive and integrated PHC services?
Check out these publications on the web
(http://hst.org.za/isds/kwikskz).
19

HST UPDATE Issue No. 37 October 1998
New Publications
districts across the country to improve their drug
supply and distribution system. This document
summarises some of the key lessons that have
been learnt in those health districts. It focusses
mainly on the third component described above,
and aims to describe the characteristics of a wellmanaged
drug distribution system.
In order to illustrate some of these lessons, the
experiences from three ISDS sites (Mount Frere
district in the Eastern Cape, Impendle-Pholela-
Underberg district in KwaZulu-Natal and the
Kalahari region of the Northern Cape) are
described.
ISDS Technical report
#9
District Drug Management
Drugs play an important role in the health system
and many patients view access to drugs as an
indication of good health care management.
Drugs also consume about 10% of the total
recurrent expenditure on health in the public
sector, and substantial savings can be made if
drugs are efficiently managed. There are four
components to the provision and use of drugs in
health facilities. These are:
1. Selection – choosing the drugs for use in the
health service in the correct quantities.
Selection is carried out at the national and
provincial levels to ensure maximum discounts
on bulk buying;
2. Procurement – using available funds to buy
the drugs from a supplier;
3. Distribution and stock management – receiving
the drugs from the supplier, storing them,
issuing them to health facilities and health
services, and ensuring stock control.
4. Use – prescribing and dispensing drugs to
patients, and encouraging compliance with the
therapy.
The Initiative for Sub-District Support (ISDS) has
been working with health workers in several
The characteristics of a well managed drug
supply and distribution system
· A constant and reliable supply of drugs
· Assurance of the quality of the available drugs
· Minimal losses through spoilage, expiry, fraud
and theft
· Maintenance of accurate stock records
· Provision of rational and efficient storage
points
· Efficient use of transport resources
Staff involved in the management of drug
supply, distribution and stock control
The following categories of pharmaceutical staff
are usually involved in drug supply, distribution
and stock control: pharmacists, pharmacists’
assistants and auxilliary services officers (often
referred to as pharmacy or dispensary
assistants) 1 . At the district and clinic level
however, the control of drugs is often in the hands
of professional or enrolled nurses. Many rural
hospitals may also not have any specifically
trained pharmacy staff. At the provincial level,
the role of the sub-directorate of Pharmaceutical
Services in providing support and supervision
to district staff to manage their drugs is one of
the key challenges in establishing effective district
health management teams (DMTs) and making
PHC delivery a reality.
1
While pharmacists and pharmacists’ assistants are registered with the
Pharmacy Council, auxillary services officers and nurses are not.
20