Sierra Leone plural health care system: Why people go to traditional healers rather than modern clinics (PHOTOS).

Why Do People Go to Traditional Healers Rather Than Modern Clinics?

Why Do People Go to Traditional Healers Rather Than Modern Clinics?

Health and medicine explained.
Oct. 3 2014 8:44 AM

Where Do People Go When They’re Sick?

Traditional healers versus modern clinics in Sierra Leone.

Sierra Leonean mother
Where does a Sierra Leonean mother take her children when they get sick? There is more than one option. These photographs, taken in Kambia district of northern Sierra Leone in May and June of this year, illustrate what a plural health system looks like.

Photo by Rich Mallett / SLRC

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?

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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.

community health officer
Peripheral Health Units are government-run health clinics. There are 1,228 of these clinics in Sierra Leone, and are considered the frontline of formal health care delivery. In the larger, more sophisticated clinics, highly trained community health officers such as the one pictured here are usually present.

Photo by Rich Mallett / SLRC

maternal and child health aid
Lower-level PHUs are typically staffed solely by maternal and child health aides, such as Fatmata (pictured here). These staff fall under the purview of the government’s Ministry of Health and Sanitation. According to the World Health Organization, in 2011 Sierra Leone had just 1.9 physicians, nurses, and midwives for every 10,000 people—well below the recommended 23 to 10,000 ratio.

Photo by Rich Mallett / SLRC

community health worker
In an attempt to increase the reach of formal health services into remote communities, the government has actively promoted the role of community health workers (pictured). These are local volunteers who carry out a range of tasks on behalf of the state health service, including home visits and case referrals.

Photo by Rich Mallett / SLRC

Community health workers
Community health workers are supposed to report to the PHU. But our research suggests that the strength of connections between the two varies dramatically from one place to the next. In some cases, for example, community health workers appear to be in far closer contact with the local organizations that trained them. These weak relationships are of particular cause for concern, as is the limited training community health workers currently receive.

Photo by Rich Mallett / SLRC

traditional healer
In recent years, efforts have been made to encourage people’s use of formal health providers, yet a strong reliance on traditional healers (such as the one pictured here) continues. Healers attempt to identify the cause of an illness or pain and prescribe treatments, often involving the use of local herbs.

Photo by Rich Mallett / SLRC

Traditional birth attendants
Traditional birth attendants are women who assist mothers in delivering their babies, and have usually been trained by other traditional birth attendants (and increasingly by NGOs). The government promotes clinic attendance for births and encourages traditional attendants to refer pregnant women to the PHUs for delivery. But the traditional attendants continue to be used quite commonly for home births.

Photo by Rich Mallett / SLRC

powerful local figures such as chiefs
The men of the family also have a strong influence over household decision-making. Sierra Leone is a deeply patriarchal society.

Photo by Rich Mallett / SLRC

Sierra Leone men
What explains whether people use government-run clinics or alternative providers? There are numerous factors at play, including the influence of powerful local figures such as chiefs (pictured).

Photo by Rich Mallett / SLRC

Mother-to-Mother Support Groups
Community-based groups can also shape health-seeking behavior. Mother-to-Mother Support Groups (pictured) are designed to promote good infant and young child feeding practices and maternal health. While there are sometimes problems with the way they are run—for example, our previous research found that the groups sometimes exist in isolation from other health care providers—they are considered important mechanisms for communicating health information.

Photo by Rich Mallett / SLRC

Sierra Leone’s Free Health Care Initiative mosquito nets
Since 2010, a basic package of medicines and items have been provided for free under Sierra Leone’s Free Health Care Initiative, such as essential drugs and mosquito nets (pictured here being unloaded at a PHU). But PHU staff reportedly sometimes still charge for these services. While traditional healers also ask for payment in exchange for their services, the terms are more flexible: Payments can be in-kind and made over time.

Photo by Rich Mallett / SLRC

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.