Traditional Medicine in Sub-Saharan Africa 7 medical doctors, psychiatrists and social workers into a one-person therapeutic system." In this sense, the role of traditional practitioners is not backward-looking or fixed, but rather is adaptable to changing circumstances.

# _UJtilization of Traditional Health Care_

19. Patients consult traditional healers rather than modern health care providers for several reasons. First, patients may feel more comfortable with traditional healers who reside in the community and who are familiar with the social context. Modern health care workers, in contrast, may be regarded as foreign and thus threatening. Second, patients are frequently dissatisfied with the quality of modern health care. Modern health care providers are often unsympathetic and unresponsive the concerns and needs of patients (Diesfeld 1974). Third, traditional health services are usually more accessible than modern care. The high out-of-pocket cost of travel to a modern health care facility also affects choice of provider. A study of the demand for health care in Mali found that the greater the distance to a modern dispensary or drug outlet, the higher the probability of the patient selecting a traditional source of care (Birdsall, et. _at._ 1986). That study suggested that the choice between traditional and modern care is determined, at least, in part by their relative costs. Fourdi, the preference of many Africans for traditional health care also reflects the fact that the costs ('f traditional health care are more esily met. Even though the level of fees is often high relative to modern care, these charges may be more easily paid because patients may pay in kind, provide a gift at a later time, or even negotiate the amount. Introducing user charges for modern services may create further incentives to use traditional healers.

20. From household expenditure surveys in Ethiopia, Dunlop and Donaldson (1987) were able to estimate spending on traditional health care. Expenditures on traditional medicine were found to represent approximately 0.3 percent of household budgets (compared to roughly 0.5 percent for private doctors and 0.7 percent for private drugs). They calculated that in 1984 Ethiopians spent a total of 30 million birr (or approximately US$15 million) on traditional practitioners, compared to 50 million birr (US$25 million) on private physician services, 75 million (US$37.5 million) on pharmaceuticals, and 75 million birr on other, unspecified, medical care services. The prices of traditional drugs were found to vary as much as four-fold across regions. Brunet-Jailly (1988), in his study of health expenditure in Mali, found that the average household spends on the average the equivalent of US$12 of its total household health expenditure of $93 on traditional drugs (FCFA 2,000 out of CFCA 15,000 average household health budget).

21. In analyzing the relative costs to the patient of consulting traditional or modem healers, it is not only the quantitative differences that are important; the question as to what extent traditional and modem services are perceived as substitutable is also relevant. The earlier discussion shows that patients have very different expectations of the two types of health care and thus do not regard them as substitutes for one another.