Progress in the development of ATM and practice

The period 2000–2018 registered significant progress regarding integration of ATMs and THPs into the national health systems. table 1 shows the specific actions taken by countries in the WHO African Region (WHO-AFRO). The information in table 1 has been compiled from a baseline and subsequent surveys carried out by WHO-AFRO during 1999/2000 and 2002, 2005, 2010, 2012, 2016 and 2018. Among others, policies and legal frameworks for traditional medicine practice are in place in 40 and 38 countries, respectively, while 38 countries established national programmes in ministries of health dedicated to the coordination of traditional medicine activities. National Expert Committees on ATM were constituted in 34 countries. In addition, African institutions made progress in: (A) research and evaluation of TMs, (B) product development, (C) collaboration between THP and CHP, (D) quality assurance, regulation and registration and (E) THP integration into the national health system that are further elaborated below.

Availability of essential medicines and technologies (medical products) to diagnose and treat health problems; a capacitated, well-trained and motivated health workers to provide the services that meet patients’ needs; regulatory systems strengthening for ensuring quality assurance of phytomedicines and services; functional referral systems of patients from THPs to CHPs and vice versa; provision of essential services that are person centred, effective and responsive to expectations; and economic development and selection of essential phytomedicines for integration into national health systems are among the several requirements for a country to achieve UHC. In the UHC context, research and development (R&D) focus on safety, efficacy, quality, strength, reliability and durability of the medical products. Regulatory systems strengthening of phytomedicines has enabled an appropriate national drug regulatory authority (NDRA) to provide an independent review of both the preclinical and clinical data with emphasis on safety, efficacy and quality of the medical product. Registration of new medical products and devices is a mandatory requirement before the medical product becomes accessible to the public. R&D of ATM leading to standardised and quality-assured phytomedicines impacts positively on the three themes of UHC. Access to phytomedicines in poor communities and villages promotes equitable service delivery. The NDRA evaluates both the preclinical and clinical data relating to the phytomedicine to ensure its quality, safety and efficacy before it can be registered. Enhanced referral systems of patients from THPs to CHPs and vice versa resulting from better communication and collaboration of these practitioners also contributes to improving access to essential health services.

The UHC theme of quality of services, among others, includes quality of drugs and essential health services. The registration of the phytomedicine by the NDRA guarantees its quality. Well-trained, accredited or licenced THPs working as part of PHC teams increases the availability of more human resources and contributes to the provision of quality essential services that are person centred, effective and responsive to expectations given the holistic approach of traditional medicine. In addition, creation of awareness and monitoring of appropriate use of phytomedicines during targeted days such as national traditional medicine week or the African Traditional Medicine Day commemorated on 31 August of every year in Africa contribute to patient safety.

The third theme of UHC is people protection against financial risk, which is particularly important for the populations living below or close to poverty who can be pushed into catastrophic situations because of health expenses. The affordability of improved herbal medicines to reduce out-of-pocket health expenditures is one of the strong pillars of ATM. For example, in Ghana, the government reimburses patients’ consultations with THPs through the insurance scheme and is planning to do the same for the phytomedicines included in its national essential medicines lists. In some cases, such as in Nigeria, after the herbal medicine for treating sickle cell disease (SCD) was standardised for the THP by NIPRD, he continued to give his patients the improved herbal medicine without any charge. Economic development emanating from the commercialisation of medicinal and aromatic plants and phytomedicines also contributes to achieving UHC. However, appropriate health expenditures need to be made in a manner that protects people against financial risk for movement towards UHC.

Since the target of UHC is quality health services for all, a collaboration between well-trained, accredited THP and CHP is crucial to attaining such a goal. Such collaboration promotes knowledge and skills of the THP, especially in basic hygiene, proper diagnosis, health promotion, monitoring, mobilisation for immunisation and so on. The services by trained THPs in rural communities where western trained health personnel are not available promotes two of the themes of UHC namely, equity to health services and quality of health services. Integration of THP into the national health services will guarantee improved services coverage and health outcomes and recognition of their services. Also, THPs can practice freely under appropriate government regulations to reach people who believe in ATM and cannot afford health costs in conventional health facilities. Therefore, investing in THP’s integration into PHC, documenting ATM and reporting regularly as part of a well-functioning health information system is the most cost-effective way to ensure access and quality to essential healthcare, which will significantly contribute towards the achievement of UHC.

Specifically, integrating ATM into national health systems including certification of THPs will drastically reduce the fake THPs who only practice for financial benefits with serious adverse effects on their ignorant patients. Consequently, the integration of ATM into national health services directly promotes all the three themes of UHC. Equity to health services is promoted by the availability of trained licensed THPs to provide their expertise to the communities. Quality of health services is guaranteed by training, retraining and monitoring of the THPs. Protection of the population against financial risks is promoted by access to improved herbal medicines that can effectively replace the fake products marketed in poor communities.

Research and development

Research into ATM drew the interest of at least 34 research institutions in 26 African countries (table 1) by 2018 as compared with 18 and 20 in 2000 and 2012, respectively. These institutes researched the use of ATM products for priority diseases such as HIV/AIDS, SCD, diabetes and hypertension using WHO guidelines.29 A total of 14 countries used research results to authorise the marketing of certain traditional medicine products used for communicable and non-communicable diseases, while eight countries included traditional medicine products in their national essential medicines lists (table 1).

The establishment in 1971 of the International Association for the Promotion of Traditional Medicine (PROMETRA), a non-governmental organisation, in Senegal is one of the earliest efforts to promote the standardisation and use of ATMs in healthcare delivery. PROMETRA conducts scientific research, hosts international conferences and cultural exchanges, publishes a quarterly bilingual journal, Medicine Verte,29 and coordinates a diaspora-wide network on TM in partnership with academic institutions throughout Africa, for example, Noguchi Research Institute of the University of Ghana and University of Venda in South Africa, USA, (eg, Morehouse School of Medicine, Atlanta, and North Caroline Central University, BRITE Institute) among others. PROMETRA subsequently established the Centre for Experimental Traditional Medicine in Fatick, Senegal, to conduct TM research and foster THP–CHP collaboration with respect to patient management, treatment and research. This effort was accorded recognition by the government and facilitated THP–CHP collaboration in Senegal.30

In Ghana, R&D of herbal products for the management of various diseases is undertaken by the government-owned Centre for Scientific Research into Plant Medicine (CSRPM), which boasts of a long-standing collaboration with THPs since 1975. The CSRPM routinely identifies and consults with THPs to diagnose, prescribe, administer and monitor the effects of selected herbal products on outpatients and has at least 35 state-registered products for the management of various diseases.31 32

In a bold initiative, the Faculty of Pharmacy, Obafemi Awolowo University in Nigeria, took the unusual step of appointing, in 1972, a THP as a full-time faculty member with responsibility for training and research in TM, thus taking the THP to the corridors of western apex learning and intellectual discourse and becoming the first consultant herbalist in Africa. The success of that action led to the recruitment of other THPs to enrich the training of pharmacy students and to advance research into ATM using the unwritten knowledge and skills of THPs. The establishment of botanical gardens for growing herbal plants and raising other TM raw materials increased the profile of the institution rather than diminish it as one would have expected given the official disdain for TM by western educated intellectuals who viewed the use of herbs as fetish at best and evil in its worst. Other institutions and individuals were emboldened to seek grants and carry out research into indigenous health practices. The THPs roles were not limited to the collection of recipes. They were involved in establishing validity, evaluation and verification of claims made on medicinal plants by other practitioners. This approach is recommended for the training of pharmacists in Africa, demystifying and removing the confidentiality surrounding the knowledge transfer about TMs and THPs. The faculty membership was mutually beneficial to the THP and the research institution. The THP acquired research skills, contributed to several research initiatives and conferences on TM and its practice and was recognised in the university for outstanding contribution to knowledge including the documentation of the ethnobotanical flora of Western Nigeria.33 34

Mali is the first country to establish a state-owned research institute devoted to investigating TM in Africa. Initially referred to as National Institute of Phytotherapy and TM, in 1968, the name changed to the National Institute for Research on Public Health (NIRPH). The institute provides evidence regarding the safety and efficacy of TM before it can be awarded a marketing authorisation.

Although many African countries including Uganda, Ethiopia, Kenya and Tanzania have evaluated some aspects of traditional health practices, Burkina Faso presents a comprehensive example of how countries have attempted to evaluate THPs. Burkina Faso has a Centre for Experimental Research, which took on the evaluation of TMs that THPs use for the management of opportunistic infections related to AIDS, malaria, SCD and dracunculiasis. A classic example was the screening of 25 000 school children for SCD and the application of extracts from five plants that the THPs had claimed as efficacious for SCD management using in vitro evaluation of their effect. The study concluded that one of the plants, a well-known traditional medicinal herb, provided scientific evidence as safe, efficacious and effective in the management of SCD.35 This approach was modified to evaluate the efficacy of plant extracts claimed to have effect on the management of opportunistic infections related to AIDS. A multidisciplinary team that monitored the patients observed a significant decline in the viral load in the patients.36 In the study, the medical doctor managed opportunistic infections, the pharmacognosy laboratory of the University of Ouagadougou formulated tablets and was responsible for the quality control of TMs. Burkina Faso invested in evaluation of other medicinal plants for their proven pharmacological effects. Burkina Faso evaluation demonstrated that traditional herbal medicines had clinical benefit for the management of people living with HIV/AIDS who were not at the terminal stage. The various collaborative arrangements with THPs strengthened their skills, and facilitated their recognition vis-à-vis their indigenous medical knowledge and unique services in poor communities.

Product development

SCD is a major public health problem in SSA. In many African countries, 10%–40% of the population carries the sickle cell gene resulting in an estimated SCD prevalence of at least 2%.37 It is not surprising that THPs have the knowledge and skill for managing SCD. The National Institute for Pharmaceutical Research and Development (NIPRD) in Abuja evaluated the various extracts obtained from medicinal plants for the prophylactic management of SCD in collaboration with the THP that released the recipe to NIPRD.38 The pilot clinical study showed 73% effectiveness at managing SCD crisis and the remaining had infrequent but less severe crisis over 12 months of medicine use. A randomised placebo-controlled double-blind crossover clinical trial that lasted for 12 months showed that the ATM product, NIPRISAN, significantly reduced the frequency of SCD crisis associated with severe pains. Liver and renal functions were normal thus confirming that NIPRISAN is a safe and efficacious phytomedicine for the management of patients with SCD.38 The Nigerian government subsequently licenced the commercial production and global marketing of NIPRISAN. The product is patented in the USA and 46 other countries.

The Mali research institute carried out a large-scale screening of 66 plants that are in use by THPs for malaria treatment and subjected the extracts to in vitro and in vivo tests. Extracts of the plant, Argemone (A). mexicana indicated significant efficacy in both in vitro and in vivo testing39 subsequently subjected it to a randomised control clinical study. With A. mexicana decoction, there was complete malaria parasite clearance on the seventh day, down from 35 000 per µL and costs only 5% the price of artesunate combination therapies. Madagascar has a patent for a medicinal product used for the treatment of uncomplicated diabetes (type II).40 Similarly, Uganda has patented at least five TM products, two of which are used for the treatment of malaria and relief of benign prostate hypertrophy, whereas the United Republic of Tanzania has filed two patents, being an invention for a herbal juice for use as a nutritional supplement and a pharmaceutical product based on medicinal plants used for treatment of skin fungal infections and allergic skin conditions.41

In Zimbabwe, research into ATM for the management of HIV/AIDS was carried out at the University of Zimbabwe leading to the production of the herbal medicine, gundamiti, with up to 97% reduction of the viral load in patients with HIV/AIDS. Gundamiti also had an appreciable effect on the decrease in HIV/AIDS-related opportunistic infections without affecting kidney and liver function.42 An interesting finding is that several countries have patented their TM products, while others were registered by national regulatory authorities. These new phytomedicines have been added to the global arsenal of medicines for serious disorders. These new medical products promote the quality of health services available to poor communities who may not be able to travel to cities for western health services.

Collaboration between THP and CHP

Fostering collaboration between THPs and CHPs, who often disregard the contribution of THPs to healthcare delivery, is one of the main challenges. However, this situation is changing in many African countries where stakeholders had fostered cooperation between THP and CHP. For example, in South Africa, Rachel etal43 reported evidence-based recommendations to facilitate professional collaboration between CHPs and THPs. Similarly, in Mali, the Department of Traditional Medicine invests in the education of THPs through regular joint capacity building and knowledge sharing workshops for both THPs and CHPs. Such avenues provide opportunities for understanding across practice orientations, facilitate collaborative exchanges on the classification of various diseases, diagnosis, treatment and management procedures.

Another example is Senegal where patients are referred to both THPs and CHPs. The CHPs monitor the patient taking vital signs, diagnosing and analysing laboratory tests before the THP treats the patient within the health facility. The patient is observed at the conventional medical unit for the impact of traditional medical treatment using pretreatment and post-treatment comparisons. The collaboration has promoted mutual respect for both cadre of health practitioners, reduced health workers’ scepticism and increased appreciation and the development of ATM. This approach to collaboration has also been demonstrated to some extent in Uganda,44 Tanzania45 46 and South Africa,47 concerning HIV/AIDS counselling and behavioural change.

Collaborative HIV/AIDS, sexually transmitted infections (STI) and tuberculosis (TB) programmes involving THPs have been initiated in several SSA countries41 48 with varying degrees of success. In South Africa’s Kwazulu Natal province, THPs were trained to assist in practice-related risk reduction techniques and to educate, refer and follow-up patients under STI/HIV and TB care.49 Despite its effectiveness, THP–CHP collaboration in Eastern and Southern African countries have been met with more caution than in Western Africa. Different countries demonstrate that collaboration between THPs and CHPs can occur in various ways but invariably should result in cohesive teams that are willing to harness each other’s potentials for the benefit of the patient, the community and the wider society. When both categories of practitioners collaborate, they can enhance practices within the healthcare system, manage collaborative clinics, undertake collaborative research and continue the development of new medicines.

The collaboration between THPs and CHPs promote access to health services by rural dwellers where most of the THPs practice. The THP–CHP collaboration involves, among others, training of THPs in PHC and early signs for referrals of their patients. Similarly, the CHPs become conversant with ATM pathophysiology of diseases and diagnostic techniques and can then engage in case studies with them. Consequently, such a practice promotes quality of health services by both THPs and CHPs, which aligns with one of the themes of UHC.

THP proficiency evaluation, registration and integration into the health system

Mali introduced several complementary structural and functional approaches for evaluating the competency of THPs, registering them and integrating them into the healthcare delivery system. The TM department registers THPs in coordination with the NIRPH, Bamako. The department certifies and registers THPs who meet stipulated criteria.50 One crucial criterion is the evaluation by the district CHP of the individual’s practice involving 30 cases per disease regarding efficacy and safety for about 4 months. The CHP prepares a report, which is sent to Bamako. Any THP who is not registered is regarded as a quack. The registration criteria that combine scientifically proven evidence of professional competence, local acknowledgement and recognition as well as acceptance by the CHP counterpart are worthy of consideration for adoption by other countries.

Irrespective of the country’s practices, majority of THPs who collaborated with CHPs had been accredited to practice. Mali represents a very vibrant traditional health practice in SSA with 51 THP associations, a national bureau and a THP federation. The association in collaboration with government hosts the annual regional International African Traditional Medicine Week.51 These efforts enhance the integration of THP into PHC and thus accelerate the attainment of UHC. The registration system for THPs is crucial to reducing the widespread sale of fake herbal drugs in villages and rural communities with unsubstantiated claims because only certified THPs are permitted to market their products. As we highlight the role of ATM in UHC, we note that it is not without challenges. The range of services provided by THPs, the costs involved and the quality of their services need to be addressed continually.

Implications for policy and practice

A critical need is financial and human resources to develop standardised phytomedicines for multicentre randomised controlled clinical trials after establishing safety, efficacy and quality of the potential products at preclinical levels. Such wise investments will impact on both policy and practice in specific ways. For example, the policy on functional integration of ATM into national health systems and professional collaboration between THPs and CHPs will be enhanced. The functional integration of ATM into the national health systems will encourage genuine THPs to collaborate with the government leading to technical and financial support for the THP. Subsequently, the infrastructure and capacity to produce herbal medicines are greatly enhanced, while coverage for the public use of the improved herbal medicines is enlarged. Such a trend directly promotes the three themes of UHC. Equity in health services is enhanced when improved herbal medicines are available to a large proportion of the population. Since the quality of the improved herbal medicines must first be certified by the NDRA before their registration, their quality is guaranteed. Furthermore, people protection against financial risks is promoted by the affordability of improved herbal medicines. Intellectual property (IP) protection of innovations of commercial application arising from African Indigenous Medical Knowledge (AIMK) may be challenging using the normal patent protocols. In many cases, the AIMK is held by the entire community. Sometimes, AIMK is held by communities in different countries since biodiversity and cultural affinities defy the artificial borders created by the colonialists. In such cases, sui generis (of its own kind) can be adopted by the country to protect their IMK. Intellectual property protection is crucial to the preservation of AIMK and African medicinal plants and, subsequently, their continued therapeutic applications. Once the medicinal values of the plants are recognised, the national authorities will conserve such plants from deforestation, industrial developments, para cities and so on. The private sector will cultivate such medicinal plants. Thus, without IP protection of AIMK, the positive impacts on the three themes of the UHC will be hampered due to non-availability of the improved herbal medicines.

It is noteworthy that national policies on commercialisation of African phytomedicines with proven safety and efficacy and their global marketing will subsequently generate jobs for young Africans, promote socioeconomic status of communities (especially women) where the medicinal plants will be cultivated and harvested and impart new technical skills to Africans in agronomy and the pharmaceutical sector. The practical outcomes of such a trend is the enhanced quality of life of Africans with evidence in the reduction of communicable and non-communicable diseases, poverty alleviation, increased lifespan and so on. It is well established that investment in health yields profitable returns. Consequently, African countries that adopt these recommendations will also benefit economically, socially and politically from innovations and health products based on ATM.