Traditional Healers and their Provision of Mental
Health Services in Cosmopolitan Informal
Settlements in Nairobi, Kenya

WORKING PAPER SERIES No. 67

ATPS (2013): Traditional Healers and their Provision of Mental Health Services in Cosmopolitan Informal Settlements in Nairobi, Kenya.
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ATPS (2013): Traditional Healers and their Provision of Mental Health Services in Cosmopolitan Informal Settlements in Nairobi, Kenya.
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Traditional Healers and their Provision of
Mental Health Services in Cosmopolitan
Informal Settlements in Nairobi, Kenya

David M. Ndetei
Professor of Psychiatry, University of Nairobi and Founding Director, Africa
Mental Health Foundation (AMHF)
Anne W Mbwayo
Research Fellow, Africa Mental Health Foundation (AMHF)
Victoria N Mutiso
Research Fellow, Africa Mental Health Foundation (AMHF)
Lincoln I Khasakhala
Hon. Lecturer, Department of Psychiatry, University of Nairobi & Research
Fellow, Africa Mental Health Foundation (AMHF)
Paul M. Chege
Senior patent examiner, Kenya Industrial Property Institute (KIPI)	  ATPS (2013): Traditional Healers and their Provision of Mental Health Services in Cosmopolitan Informal Settlements in Nairobi, Kenya.
ATPS Working Paper No. 67

3This paper should be cited as:
African Technology Policy Studies, ATPS 2013: Traditional Healers and their Provision of
Mental Health Services in Cosmopolitan Informal Settlements in Nairobi, Kenya, [David M.
Ndetei, Anne W. Mbwayo, Victoria N. Mutiso, Lincoln I. Khasakhala, Paul M. Chege], ATPS
Working paper 67.

© 2013Published by the African Technology Policy Studies Network

ISBN: 978-9966-030-64-1

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Table of Contents
Acknowledgements

6

List of Acronyms

7							Abstract 									

81. Introduction								

92. Objectives

11		

3. Literature Review					

124. Methodolgy								

155. Results and Discussion							

176. Conclusion and Recommendations					

24References								

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Acknowledgement
This paper was produced as part of the implementation of the ATPS phase VI StrategicPlan, 2008-2012 funded by ATPS Donors including the Ministerie van Buitenlandse
Zaken (DGIS) the Netherlands, amongst others. The authors hereby thank the ATPS
for the financial and technical support during the implementation of the Intellectual
Property Program. The authors particularly thank Prof. Kevin Urama, the Executive
Director of the ATPS for his visionary leadership as programme director; Mr. Joseph
Wekundah the Executive Director of the Biotechnology Trust Africa (BTA) and Prof.
Moni Wekesa (Mount Kenya University) who were coordinators of the programme and
Dr. Nicholas Ozor, Senior Research Officer (ATPS) and all the ATPS team members
for their technical support during programme implementation.

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List of Acronyms
AIDS		AMHF
ATPS		DSM IV		
GAD		
HIV		
KEMRI		KIPI		MINI 		OCD		PTSD		
TH		

Acquired Immune-deficiency Syndrome
Africa Mental Health Foundation
Africa Technology Policy Studies Network
Diagnostic and Statistical Manual IV
Generalised Anxiety Disorder
Human Immunodeficiency Virus
Kenya Medical Research InstituteKenya Industrial Property InstituteMini International Neuropsychiatric Interview
Obsessive Compulsive Disorder
Post Traumatic Stress Disorder
Traditional Healer

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Abstract
Traditional healing has been practiced by many cultures in Kenya and for many years. It isan accepted mode of treatment in different cultures. Traditional healers are consulted eventoday and provide treatment to many people. Traditional medicine has been used by large
pharmaceutical industries to produce the western type of medication and at times the traditional
healers are not aware that the knowledge that they give to these firms is used to make a lotof money without the communities where it came from sharing in the benefits accruing fromthe sales. The country lacks proper policies that guide the traditional healers despite the factthat they are highly consulted by people and this could jeopardise the lives of those who seek
help from them. There is therefore need for the government to engage the traditional healersmore so that better practices are observed to ensure that the patients benefit. Objectives:
The broad objective was to determine whether traditional healers treat mental disorders andwhether they are aware of intellectual property rights. Method: This study was carried out
in the urban informal settlements of Kibera, Kangemi and Kawangware. Snowballing modeof sampling was used. An in-depth interview was done with each traditional healer. An indepth interview with each patient of the traditional healer was also done together with the
MINIPLUS to counter check the diagnoses arrived at by the traditional healers. Data wascollected using the self-developed questions for social demographic and in-depth interviews,
and the MINIPLUS for adults. Data was treated using descriptive statistics and some of it
was analysed qualitatively. Results: Results showed that traditional healers are consulted formental illnesses and use various methods for treating these illnesses. However, they haveno or little knowledge on intellectual property and benefit sharing.

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81. Introduction
1.1 Background of the Health Sector of Kenya
Immediately after independence, the young Government, in the Sessional Paper No. 1,
1965, declared war against three enemies: poverty, illiteracy and diseases. For the Health
Sector, the Government’s policy objective was to have affordable, effective and accessible
health services that promote well-being, and improve and sustain the health status of all
Kenyans. The Health Sector expanded over the years with several providers offering a wide
range of services. With the expansion, the sector realized a decline in crude death rate from
20 per 1000 person in 1963 to 13 in 1987, and 12 in 1991. Life expectancy increased from40 to 58 years in 1960 and 1994; infant mortality declined from 126 per 1000 in 1962 to 60
per 1000 in 1994, and the immunization coverage rose to 70% in 1994 from less than 40%
at independence in 1963.
The introduction of the Structural Adjustment Programmes by the World Bank in Kenya (1980s)
brought cost sharing in Kenya’s social sector to relieve the Government of the financial burdenof providing public services. In the Health Sector, cost sharing was introduced in December
1989, and this meant that the beneficiaries of public health services, who previously received
almost free medical care, would henceforth contribute substantially to the financing ofhealth care delivery. Declining financial resources adversely affected the quality of services
received from the public health facilities. This was because inadequate financial resources
translated to inadequate supplies of drugs and medicine, reduced personnel training, lowremuneration for health personnel, and non-expansion of health facilities. It is behind this
scenario that there arose the establishment of many private clinics, some of which had nolicenses, selling of expired drugs and even fake drugs (sometimes reported over the media).
Traditional medicine also continued to thrive. It is estimated that about 70% of Kenyans visit
traditional healers.
Status of Traditional Medicine in Kenya
Traditional medicine in all its form was the only mode of treatment in Kenya for the various
communities before the white man came to Kenya. It was practiced in various forms; forexample, use of herbs, animal parts, divination and others. However, with the coming of theChristian missionaries and the colonial settlers’ modern medicine was introduced. With theestablishment of Mission hospitals and clinics, there followed deliberate discrediting and fightagainst the use of traditional medicine in schools and churches. They were considered to beprimitive and so declared illegal by the colonial authorities. After independence, the Kenyan
medical practitioners who took over from Europeans continued to shun traditional medicine
practitioners despite their contribution to meeting the basic health needs of the population,
especially the rural people. However, recent progress in the fields of environmental sciences,
immunology, medical botany and pharmacognosy have led researchers to appreciate in a
new way, the precise descriptive capacity and rationality of various traditional taxonomies aswell as the effectiveness of the treatments employed.
In the 1979-1983 Development Plan 8, the Kenya Government officially acknowledged the
major role of traditional medicine in primary health care, and thus called for research to“evaluate the role and functions and to determine the extent of the usefulness of traditional
medicine. In 1985, the Department of culture recognized traditional medicine as a part of
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9Kenya’s rich cultural heritage and began to identify genuine practitioners with the aim of
distinguishing positive aspects of traditional medicine and discarding the negative ones fordevelopment.
1.2 Problem Statement
With the majority of the population in informal settlement living on less than a dollar a day,the residents might not give health issues and especially mental illness - which does not
hurt - a priority when allocating their income. Kenya has a shortage of psychiatrists, theratio being approximately 1:500000 with many of them operating privately in the Central
Business Districts, with none in the informal settlements and their charges are out of reachfor the people in the informal settlements. There is ample scientific evidence from Kenya
and elsewhere that traditional healers are easily accessible, affordable and accepted by thecommunities and highly consulted including for mental illnesses.

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102. Objectives
The main objective of this study is to find out if traditional healers in the informal settlements
in Nairobi are consulted for treatment of mental illnesses and if the TH is aware that theknowledge that they have on traditional medicine if properly protected and shared can lead
to benefits not only to them but their communities.
Specific objectives
1. To find out if traditional medicine is practiced in urban cosmopolitan informal settlementsof Kibera, Kangemi and Kawangware in modern Kenya
2. To document the various types of mental illness seen and treated by the traditional
healers.
3. To determine the validity of the mental disorder diagnoses made by the traditional healers
4. To document the treatment modalities for mental illness offered by the traditional healers
5. To document the knowledge, attitudes and practice in regard to access, benefit sharing
and intellectual property by the traditional healers in Kenya

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3. Literature Review
Human communities have always generated, refined and passed on knowledge fromgeneration to generation. Such traditional knowledge is often an important part of their cultural
identities. Often, indigenous traditional knowledge systems contain a rich understanding ofplant, crop and tree species, medicines, animal breeds, and local ecological and biologicalresources. They may also include useful technologies and an adaptation to local environments
Traditional knowledge is dynamic. Sophisticated and adaptive, it evolves and responds tochanges in the physical and social environment.
Unlike the western custom of disseminating knowledge through publications, traditional
knowledge systems are transmitted through specific cultural mechanisms such as songs,
proverbs, stories, folklore, community laws, common or collective property and inventions,practices and rituals and also often through designated community knowledge holders,such as elders. The knowledge is considered collective to the community, not private to one
individual or small group.
The importance of traditional medicine as a source of primary health care was first officiallyrecognized by the World Health Organization (WHO) in the Primary Health Care Declarationof Alma Ata (1978) and has been globally addressed since 1976 by the Traditional Medicine
Programme of the WHO. According to WHO, traditional medicine is the sum total of theknowledge, skills and practices based on the theories, beliefs and experiences indigenous
to different cultures, whether explicable or not, used in the maintenance of health, as wellas in the prevention, diagnosis, improvement or treatment of physical and mental illnesses.
The application of diagnosis and treatment methods is largely influenced by the culture andbeliefs dominant in a particular community to the extent that they may be ineffective whenapplied in a different context.
In many countries, traditional medicines provide the only affordable treatment available topoor people. In developing countries, up to 80% of the population depend on traditional
medicines to help meet their healthcare needs. Traditional healers are an important sourceof psychiatric support in many parts of the world, including Africa. They offer a parallel systemof belief to conventional medicine regarding the origins, and hence the appropriate treatmentof, mental health problems. This was recognized in Kenya by Dr Otsyula, who reported in1973 that patients went to hospital only to look for the cure of their illness, whereas they went
to see traditional doctors for both the cure and also to find out the cause of their illness.
Research statistics from Kenya and Uganda suggest that 25–40% of all people seeking
medical care at primary health level have problems purely related to mental health andanother 25–40% have a combination of both mental health problems and physical problems.
Traditional healers are the first professionals contacted for mental illness in many parts ofAfrica. This is because they are sufficient in numbers in the communities; are accepted; dohome visits, do not stigmatise mental illness, are often consulted and have been demonstrated
to see many people with mental disorders. They are enshrined in the minds of the people,
are respected in their community, are often its opinion leaders and are first respondents incase of an emergency.
3.1 Traditional Medicine Therapies
The traditional medicine therapies include the use of the following:
Herbs: Many traditional healers use herbs and a wide range of herbs is used for treatment
purposes. An example of a plant with psychiatric medicinal properties and has been used
for treating severe psychotic conditions going back to 1925 is Rauwolfia, which is rich in

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12reserpine. This plant is found as an ornamental plant in many parts of Kenya and Tanzania,
especially around the Mt Kilimanjaro area, where it also grows in the wild. It is known for thetreatment of ‘madness’, which is psychosis, regardless of the cause or type.
Psychotherapy: The practice of psychotherapy and behavioural therapy is very muchadvanced in traditional practice in East Africa that these therapies, as practised in the Westare not a match to what happens in traditional Africa. This is illustrated by a statement by
Rappoport & Dent (1979) who noted that psychotherapy as practiced in Tanzania was
as effective if not more effective than psychotherapy as practiced in the West. The sameobservation was made by Ndetei.
Surgical: A classic example of a traditional surgical intervention is craniotomy as is practiced
by the Kisii and Turkana people of Kenya for the treatment of psychosis, related to diseases
thought to be located inside the skull. This is, however, not practiced today.
Spiritual therapy: Spiritual therapy attempts to bring peace and harmony between the living
and the spiritual world, especially spirits of the ancestors, which are believed to live on after
death and continue to influence events in the living world.
3.2 Intellectual Property Rights and Access to Benefits Sharing
Whereas most inventions are protected by way of patents or plant breeders’ rights, TK does
not fit neatly into any scheme of intellectual property rights protections. At the same time,
to obtain patents under the existing framework, awareness among indigenous community
is needed and services of qualified professionals are required which is not readily available
locally on most of the occasions. The hurdle is not only in obtaining a patent, but also inmaintaining them and managing the rights profitably. To manage the rights profitably, thecommunity would need to have a market surveillance mechanism to monitor infringements
and take appropriate legal actions where necessary. This would mean incurring costs that
may be beyond the reach of many traditional healers or their communities. However, theTK belongs to the community and does not have joint inventors. Other people can extract
the components from the herbs and then get patency as an inventor; hence the traditional
knowledge is lost.
The global realization on the need to protect the diminishing resources led the international
community to negotiate the Convention on Biological Diversity (CBD). In addressing thisconcern, the CBD asserted the sovereign rights of the states over the genetics resources

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13within their jurisdiction and to facilitate access through mutually agreed fair and equitableterms. The Convention on Biological Biodiversity (CBD) also explicitly recognizes the rights
of indigenous and local people in traditional knowledge and innovations. Article 8(j) of the
CBD, is the most authoritative provision dealing with traditional knowledge. It provides thateach Contracting Party shall, as far as possible and as appropriate, “subject to its national
legislation; respect, preserve, and maintain knowledge, innovations and practices ofindigenous and local communities embodying traditional lifestyles relevant to the conservationand sustainable use of biological diversity and promote their wider application with theapproval and involvement of the holders of such knowledge, innovations and practices andencourage the equitable sharing of the benefits arising from the utilization of such knowledge,
innovations and practices. The problem is that traditional knowledge is rarely recognized asa matter for intellectual property rights.
At the regional level, members of the African Regional Intellectual Property Organization(ARIPO), at a diplomatic conference held at Swakopmud (Namibia) on 9th August 2010,
adopted the Swakopmud Protocol on the Protection of Traditional Knowledge and expressionsof Folklore. The purpose of the protocol as stated in Section 1.1 of the protocol is:• to protect traditional knowledge holders against any infringement of their rights asrecognized by this protocol; and• to protect the expressions of folklore against misappropriation, misuse and unlawful
exploitation beyond their traditional context.
The development of the Swakopmud Protocol has been hailed as positive and much
welcomed by the countries in the region. Kenya, being a member state of ARIPO needs
to take steps to domesticate the protocol for the benefit of the local communities. This
will provide an environment that enables the traditional healers to develop their traditional
medicine without fear. By taking steps to domesticate the protocol, the government will beassuring the traditional healers of the protection of knowledge and innovations.
3.3 Policies in Place Relating to Traditional Medicine
Several attempts have been made towards development of policies and regulatory framework
for traditional medicine. However, despite the enthusiasm prevailing in initial stages of
dialogue, most of the initiatives seem to hit a debacle or derail as soon as they take off. The
national development plan of 1979-1983 made an attempt to bring traditional medicine in
the agenda of national planning. This attempt led to the introduction of the administrative
regulation of traditional medicine practitioners. The development plans that followed sought
to recognize traditional medicine. The National development plan of 1989 to 1993 made acommitment to the promotion of the welfare of the traditional medicine practitioners. The
Health Policy Framework through the National Drugs Policy sought to encourage traditional
medicines.
The current draft of the National Policy on Traditional Medicine and Medicinal Plants hasaddressed areas of safety and efficacy. The other three areas of attention are: conservation,
production and domestication and finally commercialization. Under commercialization, oneof the goals is to enhance protection of property rights and ensure equity in distribution of
benefits. The policy did not address the issue of how the traditional healers can collaborate
with the western trained doctors in the provision of mental health.

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144. Methodology
4.1 Study Area Description
The study was carried out in Nairobi, the capital city of Kenya. The reason for picking
Nairobi was that as the capital city, it is home to almost all the tribes of the country. Thus,
it has a national representation. Three informal settlements in Nairobi were picked; Kibera,
Kawangware and Kangemi. These are also areas where Africa Mental Health Foundation
already has study projects.
Kibera is situated in Nairobi’s South Western Peri-urban zone, approximately seven kilometresfrom the Nairobi City Centre. Kibera as a whole is an informal settlement comprising of ten
villages with a population of about 260000 people. Most of them work in the industrial areaof the city as casual labourers. Most of the houses are made of mud and roofed with either
corrugated iron sheets or covered with polythene papers.
Kangemi is a cosmopolitan area found in the Western part of Nairobi. The Kangemi informal
settlement is located in Kangemi location, Westlands Division which is found in the western
district of the city of Nairobi in Kenya. The informal settlement is divided into 6 main ‘villages’.
Kangemi Health centre and Gichagi Dispensary serve as the primary government healthcare delivery clinics. Private medical clinics, some of which are owned by individuals, aredistributed across the settlement area. A few are operated by non-governmental organisations,community-based organisations and faith-based organisations.
Kawangware is a mixture of formal and informal settlements. It is in Dagoretti Constituency.
The slum has a population of over 100000 people. This informal settlement is associated withpoor living conditions, no access to piped water, sewage system and it is characterized byshanties, overcrowding, and high rate of crimes due to unemployment. The residents work
as low-income labourers and house helps in the neighbouring affluent areas of Lavington. It
comprises of various villages.
4.2 Study Population
The study population comprised of the traditional healers and their patients drawn from thethree informal settlements.
a) Inclusion criteria
1. All traditional healers residing in the areas of study and who agreed to participate in the
study

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2. Patients of the traditional healers who signed the consent.
3. Patients who were 18 years and abovea) Sample size determination
The number of patients treated by the traditional healers was determined using the Fisher et
al 33 sample size calculation. n= Z2 p2 q;				d2
Where; Z is confidence interval; p is the proportion of the population with the mental illness;
q is 1-p and d is the significance level set at 0.05
(1.96)2 *0.13*(1-0.13)
0.052 = 173.793 (174) adult patients in each study site
The patients were distributed among the traditional healers practicing in the study sites
giving: 42*2=84 hence 174/84=2 patients per traditional healer.
4.3 Sampling Method
Using the help of the community health workers, all the traditional healers from the different
tribes living in the three study sites were identified. If a tribe had more than two traditional
healers, the names of the traditional healers were written on separate papers and then two
names were randomly picked to represent that particular tribe. The traditional healers wererequested to identify their patients who, in their own opinion had mental illness and are
currently treating the patients for the same. The patients were adults (18+ years). For eachtraditional healer, the names of the patients were written on ballot papers from which fivewere randomly picked. However, the traditional healers could only identify very few patients
who had mental illnesses. This made us ask them to give us their patients with physicalillnesses. This was due to the fact that physical and mental illnesses do occur together andthe mental illness is missed out during diagnosis.
4.4 Recruitment and Consenting ProceduresWith the help of community health workers, after getting all the necessary clearances,
We were able to identify the THs. The PI explained the nature of the study including all ethicalconsiderations and in particular their right not to participate and also their right to withdraw
the consent any time in the course of the study. Those who signed the consent forms wererecruited. A Focus group discussion was held with them in each of their sites. The THs thenavailed to us their patients who were recruited and consented.
4.5 Data Collection Instruments
1. All the instruments used were translated into Kiswahili.
2. Social demographic for both traditional healers and the patient - described above
3. In depth interviews for both traditional healers and the patients - described above
4. MINI PLUS for the patients. The MINI-International Neuropsychiatric Interview (MINI(-Plus) is a structured diagnostic interview, which was developed by Sheen DV et al in1998 to assess the diagnoses of psychiatric conditions according to DSM-IV and ICD-10
criteria. It takes 20-30 minutes to complete it and assess 23 disorders. It has high validity
and reliability.
5. Focus Group Discussion guides

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165. Results
5.1 Quantitative Data
A total of 59 traditional healers were enrolled in the study and they were distributed asfollows: Kangemi n=16 (27%), Kawangware n=21 (36%) and Kibera n=22 (37%). Table 1
summarizes the social-demographic characteristics of the traditional healers.
Table 1: The social demographic characteristics of the traditional healers

N.I = Not indicatedFrom table 1 above, there were more male than female traditional healers. The majority of
the healers (83%) were over 40 years of age and 62% had practiced for more than 10 years.
A total of 305 patients of the traditional healers accepted to participate in the study. Table 2
summarizes the characteristics these patients. The overwhelming majority of the patientswere females, compared to the traditional healers where the majority were males. 54% of
the patients were currently married. The patients tended to be better educated than theirtraditional healers. Most patients were not in gainful employment.

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Table 2: The social demographic characteristic of the patients of the traditional healers

5.2 Findings by Study Objectives
5.2.1 Objective 1: To find out if traditional medicine is practiced in urban cosmopolitan
informal settlements of Kibera, Kangemi and Kawangware in modern Kenya
305 patients of the traditional healers were recruited. This was a sign that the traditional
healers still practice in the communities in Kenya. They had given various diagnoses to theirpatients as summarized in table 3 below. This indicates that most of the traditional healers
are visited for treatment of physical illnesses.
Table 3: What did the traditional healer say you (the patient) were suffering from?
Type of illness

frequencies%

Physical illness

236

77.37

Mental illness

27

8.85

Epilepsy5

1.63

Spirit/Demonic possession

2

0.65

Witchcraft

13

4.26

Physical and Mental illness

3

0.98

Physical illness and Epilepsy

3

0.98

Somatization

5

1.63

Not told

11

3.60

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Total305
100
A total of 13 (4.26%) patients were described as having been victims of witchcraft christened
kutupiwa. However, it was not clear whether this was a diagnosis on its own or the cause of
the illness, whether physical or mental.
5.2.2 Objective 2: To document the various types of mental illness seen and treated by
the traditional healers
Of a total of 305 patients seen by the traditional healers, only 30 patients were diagnosed
with mental disorders as shown in table 4 below. Only 14 patients were given specific mental
disorders. Nine (9) patients though told they had a mental disorder were not given a specificmental disorder, while 7 were told that they were thinking too much.
Table 4: The type of mental diagnoses the traditional healer gave the patient
Types of mental illness seen by the TH

Frequencies %Madness/psychosis

930

Depression

5

16.66

Thinking too much

7

23.33

General mental illness

9

30

Total

30

100

5.2.3 Objective 3: To determine the validity of the mental illness diagnoses made by
the traditional healers against internationally recognised instruments
305 patients completed the MINI PLUS to be able to find out the types of mental illness thatthey were suffering from. Table 5 shows the types and prevalence of the different types of
DSM IV disorders that were identified in the patients. However, note that DSM IV does notpick epilepsy as epilepsy is a neurological disorder.
Table 5: Types of mental illness by the MINI PLUS
Types of mental illness by the MINI
PLUS

Frequencies%

Current Major Depressive Disorder

62

20.3

Current suicide behaviour

56

18.4

Current bipolar 1 mood disorder

13

4.3

Schizophrenia

23

7.5

GAD

32

10.5

Anti-social personality Disorder93.0

Alcohol abuse and dependence

27

8.9

PTSD

47

15.4

Panic Disorder

7

2.3

Social phobia

10

3.3

Agoraphobia

8

2.6

Obsessive disorder

10

3.3

Compulsive disorder

16

5.2

OCD

2

.7

Total

322

105.7

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There were more DSM-IV diagnoses than actual number of patients, implying high comorbidity of mental disorders. This is the reason why there are 322 cases of mental disorders
according to MINI PLUS compared to 305 patients
5.2.4 Objective 4: To document the treatment modalities for mental illness offered by
the traditional healers
The THs use different methods for treating mental illnesses depending on the severity of thedisease and the cause but they include: (i) Counselling - being the most popular method oftreatment; (ii) Use of different types of herbs which can be taken orally, others for washing
while others are inhaled (as shown in pictures 1and 2); (iii) Combining herbal treatment withcounselling; (iv) Consulting the spirit world including the ancestors who then give instructions
on how the patient should be treated; (v) moving to the patients home to help him/her remove
certain items which the TH claims have been used to bewitch the patient.

Figure 1: Samples of raw herbs used for treatment

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20Figure 2: Sample of processed herbs used for treatment
5.2.5 Objective 5: To document the knowledge, attitudes and practice in regard to
intellectual property by the traditional healers in Kenya
All the THs had little, if any, knowledge on intellectual property. However, during the capacity
building on this particular area it became clear that they are wary of researchers who want tofind out about their methods of treatment. This is because they reported that those who havegone to them especially for the treatment of HIV/AIDS only used their findings to advancethemselves (stole their methods of treatments) but never acknowledged the TH. They
(researchers) get rich from the TH’s sweat. They did not want to take any of their information
to any government body. They said that others will use them. They preferred to protect andretain this information within their families by passing it down orally and through ancestral
instructions to specific members of the family.
5.3 Other Important Findings of the Study Drawn From the In-depth Interviews of boththe Traditional Healers and the Patients
5.3.1 Main reasons why people seek help from the traditional healers
All the patients were asked why they sought help from the traditional healers and yet there
were government health centres near them. The responses were as follows; They: (i) do not
get well despite visiting the hospital (30.6%); (ii) are advised by friends to seek help fromthe traditional healers (14.1%); (iii) health workers in the hospitals did not provide adequate
treatment (13.77%); (iv) hospitals being expensive (8.52%); (v) 3.27% of the patients felt thatthey could only be treated by the traditional healers.
5.3.2 Satisfaction with traditional healers’ services
Only 15 (4.9%) patients said that they were not satisfied with the traditional healers’ services.
The rest (95.08) said that they were satisfied with the services of the traditional healers.
5.3.3 Combining traditional healing and modern medicine
Less than 20 (6.55%) patients combine traditional medicine with modern medicine. Someof the patients who combine claim that they only take pain killers when they have sudden
headaches, while others said that they go to hospital for investigations then tell the traditional
healer who then treats them while one or two said that they will go to the hospitals when they
have money. The rest of the patients (93.44%) will stick to one mode of treatment only.
5.3.4 Moving from one TH to another
The patients stick to one traditional healer. Those who consult another traditional healer
claim that they do so when they are not getting well or they have moved upcountry and getsick and so they consult the nearest traditional healer.
5.3.5 How patients pay the TH
The payment to the traditional healer is both in cash and kind. Some combine both cash andkind. It was also reported that many could pay in instalment with those without anything being
treated free of charge. It was also noted that patients could pay when they got well.
5.3.6 Comparing the affordability of the TH to the health facilities
Asked whether the traditional healers were more affordable compared to the hospitals
many patients responded yes, but depends on where one was seeking treatment. A number
responded that though the traditional healers were expensive, the fact that they got well did
not matter. Also, those who felt that the traditional healers were expensive said that they
could pay in instalments.
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5.3.7 Accessibility of the TH
On the question of accessibility of the traditional healers, every patient said that they areeasily accessible with some making home visits. When they travel to look for their herbs,
they can take a while.
5.3.8 Training of the traditional healers
49 (83%) of the 59 traditional healers said that they had been trained. Seven (7) of those nottrained said that they inherited their treating methods from their grandparents or parents,1
said that the healing came to him naturally, while 2 said that they observed as other traditional
healers treated and in the process learnt.
5.3.9 How traditional healers make a diagnosis
Asked on how they get to know that the patient has a mental illness, various responses were
given which included: (i) Examining the patient; (ii) Observing his/her behaviour and modeof talking; (iii) Getting the history of the patient; (iv) Some traditional healers use the mirror
to arrive at a diagnosis (spiritual ‘imaging’); (v) Others pray to get revelations from spirits(divination); (vi) Some beat a drum to get revelation (kupiga ramri)
5.3.10 Whether the TH refer their patients to hospital facilities
Many THs refer their patients to other more experienced THs but if the patient is notgetting well they send them to the hospitals for more tests. They also said that they always
encouraged the AIDS patients on ARV to continue with their medications. A few claimed thatthey can cure HIV/AIDS. They also said that though they refer their patients to the hospitals,
the doctors do not reciprocate. They felt that the doctors do not recognise them.
Discussion
The traditional healers were able to recognize certain mental disorders –p value 0.010 withpsychosis being the most easily recognised. These findings were similar to those in Uganda
16. It is possible that the patients given the diagnosis of “thinking too much” or “stressed”
by the traditional healers could have been suffering from depression. From the focus group
discussion, the traditional healers mentioned patients who think too much. However, few had
the concept of depression. These findings are similar to those found by Sorsdahl et al 2010
14. At the same time, in our African context, there was no name for depression. The only
obvious mental illness was “madness” which could be easily detected from the behaviour ofthe patient.
Of the patients diagnosed by the TH as having depression and madness/psychosis the
MINI PLUS correctly identified them as having those. Of the patients diagnosed by the TH
as having depression and madness/psychosis the MINI PLUS correctly identified them as
having those mental illnesses. Many patients had co-morbid mental illnesses. However,from the results of the MINI PLUS, it is clear that many patients’ with mental disorders were
missed/ misdiagnosed by the TH.
The patients given the diagnosis of thinking too much were probably having depression.
In the African context there was no word for depression from the focus group discussions,many traditional healers mentioned that for them depression was not known “but thinking toomuch” was common. These findings were similar to those found in South Africa.

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The traditional healers’ services were not necessarily less expensive than health facilities.
However, the fact that one could pay in instalments and in kind made the people visit them(flexibility in mode of payment). However, of more significance is that pre-payment was nota condition for treatment as there was allowance for payment after one got better and there
was fear of spiritual punishment or recurrence of the illness should one fail to honour theiroral undertaking to pay. No traditional healer sent the patient away due to lack of money. THs
also operate a waiver system strictly on the ability to pay. If the TH sends a patient away on
the basis of genuine inability to pay, the TH will be punished by their spiritual mentors.
The findings that many patients had visited the health centres before visiting the traditional
healers were also similar to findings in Uganda. 16 Many traditional healers have inherited
the skill from their parents or grandparents and this is a common phenomenon as is reported
by Nwoko. 35 The failure to recognize the traditional healers’ role in the provision of medicalcare in the community is not unique in Kenya. It is a similar story in Zimbabwe where
many people still seek help from them, both the poor and the rich, because of their varied
explanation of the cause of disease.
Some of the practices carried out by the traditional healers while making diagnoses are similar
to those done by the western trained doctors, for example, history taking. The traditional
healers also said that they gave their medication depending on the age of the patient. This is
a common practice with western trained doctors.

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6. Conclusions and Recommendations
6.1 Conclusions from the study
1. Traditional healers are consulted by members of the community for various illnesses
including mental illnesses and therefore cannot be ignored. Instead, they should beengaged constructively to promote better understanding of mental illnesses, their diagnosis
and the possible referrals, while at the same time, discouraging harmful practices.
2. Traditional healers recognise mental illnesses though in a limited way leading to
misdiagnosis, under-diagnosis and at best, minimal proper diagnosis.
3. Traditional healers offer counselling as a mode of treatment. The counselling makes thepatients go back to them as they feel that there is somebody willing to talk to them. Thismethod is not offered in the public health centres due to the huge work load on the healthworkers and hence lack of time.
4. To ensure safety of the treatment modalities, where herbs are used for treatment by
the traditional healers, education on having their herbs tested by a recognised body, forexample KEMRI in Kenya is important. However, this must be accompanied by fool proof
assurance that their intellectual knowledge will be safeguarded.
5. The traditional healers get their medication from plants in our forests and evenneighbouring countries hence the need for environmental conservation.
6. THs are not aversive to cooperation with health facilities and therefore are willingand do, in fact refer patients, creating a channel of increased referrals; they could be
empowered through constructive and positive engagement with them and supportive
supervision through continuous education on the various psychiatric disorders and their
manifestations.
7. The traditional healers did not want to share their information with government agencies,
regarding protection of their work which was quite evident. They said that they usedtheir own methods of protection, which involved passing their knowledge to selected
members of their family in form of a child or grandchild. However, this method has therisk of the traditional healers dying with their knowledge if it has not been passed onor maybe the selected person has no interest due to the influence of education. The
other risk is that knowledge needs to be shared so that the community can benefit. The
secrecy held by the Traditional healers’ makes them vulnerable to exploitation as there is
no way that they will come out and defend any knowledge leaked out to outsiders. They
need to be educated on intellectual property and how their shared knowledge can be of
benefit to them. All this was lacking in the field.
8. The traditional healers are not aware of the draft National Policy on Traditional Medicine.
Many are not registered for fear that it is expensive or they will be arrested or theirknowledge taken away. Since the traditional healers are dealing with human life, thereis need for them to be recognized appropriately by the government and be put in therelevant Ministry.
6.2 Policy Recommendations
The following policy recommendations were made and presented:
1. Though the government is aware that the traditional healers exist there is need for them
to be recognised formally and their large clientele. This recognition will help to streamline the operations of the traditional healers and hence protect the clients.
2. Empower the traditional healers on how to recognize the different types of mental
illnesses. This can include showing them how to use simple tests which can be translated
to their mother tongues. They will therefore be able to screen at their level and in the
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process increase referrals and improve on the mental health information system.
3. Strengthen their skills on interventional methods that do not require the use of drugs.
This would include individual therapy, family therapy and group therapy as they use
counselling to treat certain types of mental illnesses. Therapies have been shown to beeffective even when practised by lay people. This would go a long way in ensuring thesafety of the patients from getting certain herbs which could have serious side effects andalso ensure that human rights observance in relation to practices that may be harmful tothe patients.
4. Empower them on when and where to refer. This can only be possible if they arerecognised and appreciated rather than being shut out.
5. The government to make it easy for the traditional healers to register and practice.
6. There is need for the traditional healers to be engaged in constructive dialogue by bodies
that can fight for the interest of the traditional healers. These include but not limited to;
Kenya Medical Research Foundation, the various Universities, KIPI. Through this kindof dialogue, the traditional healers would be educated on the need to have their herbs
tested, the need to have their work protected using the legal means and even the processthat are involved if collaborative research has to take place and the legal processes thatare required. Through this, the traditional healers are not exploited and neither is theirknowledge used without their consent.
7. There is need for environmental conservation. This is because African medicinal plantresources may be doomed to extinction by overexploitation resulting from excessivecommercialization (unsustainable use of medicinal plants), habitat destruction andother natural and man-made destructive influences unless energetic conservation
measures are taken to ensure their continued availability. This can be done through theestablishment of medicinal plant gardens and farms. The acquisition of large scales ofland required for cultivation can be a serious obstacle.
8. The government should adapt the conventions that have been passed in the region
and customize them so that the THs’ knowledge can be protected and guidelines aretaught to them on when and how to share the information that they have with the outside
world. This will eliminate the secrecy that surrounds traditional healing and which is at
risk of disappearing with the death of the TH and the shunning of traditional medicine by
the younger generation as they go to schools. The instruments of protecting traditional
knowledge and hence medicine so that there can be benefit sharing and protection of
the knowledge must be developed and made simple for the TH to follow. Finally, the THs
need to be given information on the importance of sharing the information that they havewith the right people and bodies in order to avoid bio piracy and also get benefits if their
methods of treating are unique.
6.3 Problems Experienced
1. It took time to get ethical clearance (it was given in May 2010), delaying the start andsubsequent activities.
2. Interviewing the patients at the clinics of the THs was problematic due to lack of space.
Appointments with the patients had to be made to see them in their homes. The THs had
few patients with mental illnesses according to them. This made us enrol patients withphysical illnesses but they turned up to have mental illnesses.
3. Getting the patient to complete the whole questionnaire was time consuming. However
this limitation was minimized by giving short breaks to the patients in between.
4. Not all ethnic groups had TH practices in the respective sites. We had to work with those
we could get.
5. Though we trained the THs (capacity building and sustainability) on simple ways ofidentifying mental disorders and IP, there is need to carry out another study to find out
the effectiveness of the training provided.
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3. Methodology
Study Area
The study area of this research is situated in the upper Blue Nile catchment of Ethiopia.
It is located approximately between coordinate 10033’06’’ to 10050’24’’ North latitude and37042’36’’ to 37058’24’’ East longitude. It covers a total estimated area of 58122.94 hectares
and with the total population of about 132069. Topographically, the area lies in the altitudes
range of 878m to 4000m.a.s.l (Figure 1).
Figure 1: Location of the study area (Source: Choke Mountain Initiative project
document, 2010)

As a result of this the area is characterized by three distinct agro-ecological zones- Dega,
Weynadega, and Kola. According to the traditional classification system, which mainly relies
on altitude and temperature for classification, Ethiopia has five climatic zones (Table 1).
The information which is obtained in Weredas’ Agricultural Offices revealed that the rainfall
amount and temperature of the area ranges from 385 -1300mm, and 10- 26oC respectively.
The area gets monomodal type of rain fall (that is Kirmt rain fall regime). The soil types wereidentified based on their colors (red, brown, black and grey); on the average percentage,
about 60 %, 39 %, 36% and 2.5% are brown, red, black and grey soil respectively. The
cultivated land covers a total area of 34161.93 ha of the area. The major annual crops
cultivated in the catchment are barley, Avena species (Ingedo), wheat, beans, peas, potato,maize, and sorghum. The common domestic animals in the area are cattle, sheep, goats,horses, mules, donkeys, and poultry.
Table 1: Traditional climatic zones and their physical characteristics
Zone

Altitude(meters)

Rainfall(mm/year)

Average temperature(Co)

Wurch(upper highland)

3200 plus

900- 2,200>11.5

Dega(highlands)

2,300- 3,200

900- 1,200

978-9966-030-64-1
ISBN:
17.1/16.011.5

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