Sierra Leone’s health system has a lot of problems—it’s underfunded, understaffed, and underequipped. It’s now facing what could be the largest crisis in its history if the Ebola outbreak rages out of control. But the health care system also poses a challenge because of the way it is set up. It’s a prime example of what’s called a plural health system, made up of multiple service providers, from government clinics and hospitals to traditional healers and birth attendants to community health workers and peer support groups.
Plural health systems tend not to function in straightforward ways. Sometimes providers coordinate with one another, at other times they compete. Some are perceived as trusted and legitimate local institutions, while others may be viewed with great suspicion. And these things vary considerably from place to place.
New research we just published for the Secure Livelihoods Research Consortium illustrates how plural health systems in Sierra Leone work. It shows how local communities navigate the health choices available to them—who does a mother turn to when her kid gets sick?—and explains some of the factors driving people’s health-seeking preferences. Why is it, for example, that a family continues to call on the local traditional healer when their community has a relatively sophisticated government-run health clinic?
One factor that comes out particularly strongly is the power of relationships. In some communities we visited, people were extremely hesitant to use the government’s local health clinic. Some people complained of clinic staff being rude and unhelpful or denying women water after a long walk to the clinic. Others explained how clinic staff “look down upon you” if one’s physical appearance suggests a lack of money. On the other hand, traditional healers who have been operating for years and are deeply embedded within the social fabric of communities have often accumulated considerable trust among local people. Although their dynamics differ from place to place, it is social relationships such as these that end up pushing health care seekers towards certain providers and away from others—even if that is not the best outcome for public health.
Our research, and other work like it, suggests policymakers should assess health systems from the perspective of the people who actually use the services. This is as important for long-term efforts to prevent public health challenges like undernutrition as it is for attempts to contain outbreaks of deadly viruses such as Ebola.
Making judgements about whether the continued use of traditional health providers in Sierra Leone is right or wrong misses the point. The fact is it happens. Dealing with long-term health problems, such as undernutrition or outbreaks of viruses such as Ebola, first means understanding how local health systems actually work and why people continue to use the providers they do.