Traditional Medicine Development in Africa: Opinion

Forty years after the Alma-Ata Declaration on primary health care (1978), the Declaration of Astana (2018) states that “the success of primary health care will be driven by knowledge and capacity-building, including scientific as well as traditional knowledge.” It goes on to state, “we support broadening and extending access to a range of health care services through the use of high quality, safe, effective and affordable medicines, including, as appropriate, traditional medicines.” ¹ The question is—how to implement these ideas?

The Declaration of Astana is not fundamentally different from the Alma Ata Declaration; it only “reviewed” and “refocused” efforts on primary health care to ensure that “everyone everywhere is able to enjoy the highest possible attainable standard of health” ¹ The world might make declarations, but primary health care in Africa without Africa's traditional medicine as the basis may not have a significant impact. A majority of Africans, and more especially the rural poor, rely heavily on traditional medicine for their primary health care. ² If this indigenous health care system is strengthened, it will go a long way to help African countries attain the sustainable development goals and universal health care coverage. This will require local contextualization of the Declaration of Astana in African traditional medicine to extend access to a range of health care services by the use of high-quality, safe, effective, and affordable medicines.

Efforts have already led to the integration of herbal medicines into the health care system of many African countries, including Ghana, Mali, ³ Benin, and Nigeria. ⁴

In furthering the spirit of the 1978 Alma Ata Declaration, the African Heads of State and Governments at their Summit in Maputo, Mozambique, 2003, endorsed the institution of African Traditional Medicine Day (ATMD). The decision was premised on the understanding that, since 80% of the African population use traditional medicine for their health care needs, ⁵ the continent must recognize the immense role of traditional medicine in health development in Africa. In Nigeria, for example, the 13th annual commemoration of the ATMD, held in 2015, underscored the need to establish and strengthen regulatory systems in countries by identifying and supporting qualified practitioners and protecting the public against potentially harmful practices, with the theme “Regulation of Traditional Health Practitioners in the WHO African Region.”

The same year (2015), the WHO African Region (WHO/AFRO) indicated that the significance of ATMD was to raise awareness of the critical role that traditional medicine plays in improving the health of the people. For decades, the Federal Government of Nigeria, the largest African nation, and with the highest number of users of traditional medicine in Africa, has made attempts toward the integration of traditional medicine into the formal national health system. In producing the Nigerian Traditional Medicine Policy in 2007, the Federal Ministry of Health indicated that this was meant to “expedite the process towards the integration.” The policy addresses relevant issues such as legislation and regulation; strategy; system management; management information system; human resources development; technology; financing; conservation of the environment; biodiversity; knowledge; skills and culture; protection of intellectual property rights and indigenous knowledge; and fostering partnerships between traditional and conventional medicine practitioners.

The policy is supposed to serve and promote the interests of the various stakeholders of traditional medicine, including traditional health care practitioners (THPs), researchers, regulatory agencies, policy makers, culture practitioners, law enforcement agents, and entrepreneurs. It is envisaged that through the policy, a conducive environment would be provided for Nigerians to derive optimal benefits from traditional medicine, and to generally facilitate the integration of traditional medicine into the national health system. Nigeria has a robust Traditional Medicine Policy. The country equally has a Traditional Medicine Board, ² which regulates traditional medicine practice and THPs. The landscape is similar in most other African countries.

For example, in Botswana, 95% of traditional health practitioners are based in the rural areas and the government is willing to integrate traditional medicines into the health care delivery system. In Namibia, the issues of documentation, laws and administrative structures, public trust, and the lack of recognition of traditional healers hinder the integration of traditional medicines within modern programs. In Madagascar, traditional medicine plays a key role in the health care delivery system. In the Democratic Republic of Congo, patients and their families prefer the use of traditional medicines compared with conventional medicines especially relating to the treatment of leprosy. The Government in Malawi recognizes the use of traditional medicine but could not measure the extent of its use. In Mozambique, the use of traditional medicines is not separated nor against the use of conventional medicines.

In Tanzania, about 31.9% of patients believed that traditional medicines were effective on the basis of their social and cultural beliefs (20.19%–33.3%) and family history (48.8%). In Zambia, studies show that 40% of biomedical health practitioners expressed an interest in working closely with traditional health practitioners. In Zimbabwe, about 50.7% believe in the use of herbal medicines. Also in Mauritius, traditional herbal medicines have a long history of use. ^{6 –14} In Ghana, traditional medicine caters for ∼75%–85% of rural people and 45%–65% of urban dwellers. In Kenya, very little quantitative evidence or literature exists on indigenous medicine, and Traditional Medical Practitioners (TMPs) currently do not have sufficient formal government recognition, and their activities remain unregulated. In Zimbabwe, Uganda, Tanzania, and Kenya, this ratio is 1:600 and 1:6,250, 1:700 and 1:25,000, 1:400 and 1:3000, and 1:143–345 and 1:70,000, respectively.

Mali is the first country to establish a state-owned research institute devoted to investigating TM in Africa. In Senegal, Traditional Medicine (TM) is included in national health policies and strategic plans, and there is a mutual collaboration between TMPs and orthodox medicine practitioners. Similarly, TM is included in national health policies in Burkina Faso, Chad, Congo, Gabon, Gambia, and Cote d'Ivoire, but this is lacking in Benin, Botswana, Angola, and the Central African Republic. ^{15 –19}

In Algeria, the use of traditional medicine is prevalent with more than 85% of the population who rely on its use. In Libya, the population depends on traditional medicines for their primary health care needs. In Morocco, about 68% of the population use traditional medicines. In Egypt, a study conducted accounted for 57.6% of herbal/traditional medicine use among the study population. In Tunisia, there are about 2150 species of wild plants that are considered to be multipurpose, useful for essential oils, in the food, pharmaceutical, and cosmetic industries, and of these species, more than 200 are herbal. ^{20 –25}

The study from Nigeria in this special issue about informed consent for African traditional medicine raises some interesting questions. When people are sick and they visit hospitals, do we ask them to sign an informed consent form? We know that, even consent for surgery is dependent on the type of surgery. So, should we be seeking to include consent in the practice of traditional medicine? The guidelines for the practice of traditional medicine clearly point out when referrals should be made, and the 2000 registered traditional practitioners know this. We need to be careful not to impose stricter rules on traditional medicine than existing for conventional medicine. Doctors trained in biomedicine also have much to learn from the ethical approach of traditional healers to their patients. ²⁶

Ethnopharmacologically, Nigeria is known for its diverse cultures and medicinal plants. ^{27 –33} Nigeria has about 10,000 plant species and arable land of over two million hectares, yet <20% of the plants have been utilized. Plants are known to contain different phytochemicals, which work synergistically to bring about the desired therapeutic effect. ³⁴ These medicinal plants represent a large reservoir for the discovery of phytomedicines and bioactive molecules. There are ongoing efforts at ethnobotanical knowledge collection and preservation, by several research institutions in Nigeria, yet this turns out mainly as an academic exercise, recording the medicinal uses of plants without acknowledging the historic or the holistic health management process, which is integral to successful healing. Although Nigeria has more than 300 research institutions, investigators and funders face the challenge of implementing appropriate research.

Other significant challenges to plant medicine research include the absence of fair and equitable sharing of benefits as propounded by the Nagoya Protocol, the use of spiritual practices that cannot be scientifically validated, “quack” healers, and regulatory issues. ¹⁹ Nigerian scientists have published the pharmacological activities of several plant biomolecules and extracts, and there are more than 200 herbal products approved by the Nigeria FDA (NAFDAC) for the management of different diseases, but very few have undergone clinical trials. ³⁵

Traditional medical research can be boosted with capacity building, ³⁶ and provision of adequate resources, backed also by functional policies. Capacity is needed in Africa for the drug development cycle. This could begin from the capacity to conduct ethnopharmacological field studies, to product development, clinical trials, product registration, and marketing.

Historical African traditional knowledge, which undoubtedly has a strong ecological base, can make significant contributions to primary health care delivery and may be equivalent or even superior to imported knowledge on curing diseases as represented by conventional pharmaceuticals. For example, some herbal medicines appear to be as effective as metformin for glycemic control in type 2 diabetes. ³⁷ The traditional knowledge of phytotherapy is often held by older members of the society and their relatives, farmers, or people with a relationship to the countryside. Validation of traditional knowledge using orthodox approaches may not be sufficient to support the attainment of universal health care in Africa. This will require an innovative approach, which must be adapted to local challenges, and must involve all stakeholders: agriculturists, environmental activists, medical and health researchers, practitioners, regulators, policy makers, and religious and traditional leaders.

Documenting ancestral knowledge of traditions, combined with modern evidence on safety and effectiveness, can be introduced into the curricula of school to enable the continent to achieve the third vision of the Declaration of Astana (enabling and health-conducive environments in which individuals and communities are empowered and engaged in maintaining and enhancing their health and well-being). Not only schools, but all citizens, especially the poor, would benefit from better knowledge of African traditional medicines. This could start with quite economical interventions: indeed, as large parts of traditional medicines are used in self-care (as home remedies) ^38,39 a wide dissemination of already existing clinical information on the safety and efficacy of very accessible products could have very positive effects. ⁴⁰

We opine therefore that, Africa can better benefit from the Declaration of Estana if the importance of the document is highlighted across the continent, and the identified critical areas are focused on for special development. Technology, financing, human resources for health, individuals and community empowerment, knowledge and capacity-building in all areas of health provision, and stakeholder engagement should be holistically and strategically harnessed to propel Africa toward universal health coverage that includes traditional medicine.