Socio-economic challenges faced by traditional healers in Limpopo province of South Africa: conversations from below

Introduction

In South Africa, the Traditional Health Practitioners Act (Act 22 of 2007) recognises the legality of traditional health practitioners—traditional healers, which include sangomas, diviners, herbalists, faith healers, traditional birth attendants, and traditional surgeons (Republic of South Africa, 2007). It is estimated that approximately 200,000 traditional healers practice in South Africa (Thornton, 2009), though there are traditional healers who are unregistered, which indicates that the estimated figure of practicing traditional healers might be an underestimation. Traditional healers are established healthcare providers within their communities (Magoro, 2008; Mokgobi, 2014). We note with interest that an African traditional health practitioner is also known as a sangoma, according to a tradition that has multiple roots that extend across time, cultures and languages, and derives partly from pre-colonial Africa. According to Thornton (2009), traditional healers “consider themselves to be members of a profession with a distinct intellectual tradition, one that undergoes critique, modification and change in the light of experience and myriad influences.” Traditional healers regard traditional healing as involving a quest for quality of life, and providing access to support and healthcare.

Biomedical healthcare presents a number of challenges for developing nations, including lack of human resources, lack of accessibility, unaffordability and perceived lack of cultural relevance (Kahissay et al., 2020). Consequently, most people in South Africa, and in other low- and moderate-income countries, utilise the services of traditional healers for a variety of ailments, ranging from physiological illness to metaphysical issues (Mokgobi, 2014; Thornton, 2009; World Health Organization, 2004).

One of the reasons why people consult traditional healers is that healers offer treatments that are related to the cultures of patients seeking treatment (Freeman et al., 1994; Mbanga et al., 2002; Patel et al., 1997). Traditional healers tend to be the entry point for care in many African communities, especially for complex diseases associated with mental health, such as mafunfunyane ¹ and general malwetsi a tlhogo, ² which tap into the supernatural realm (Richter, 2003; Zungu, 2013). There is abundant evidence showing that, in Africa, “illness representations are commonly constructed to put an emphasis on external and uncontrollable supernatural factors” (Bogart et al., 2010 p. 182). Thornton (2009) explains succinctly that some of the diseases are caused “by ancestors (amadloti) who are the source of both misfortune and disease but also the source of power to heal these, because the ancestors have suffered violence and death and therefore can transcend it.” Consequently, in most African cultures, a core belief exists that diseases are due to a violation of cultural taboos, or can be attributed to witchcraft (Mufamadi & Sodi, 2010; Urbasch, 2002). Furthermore, it is argued that African traditional healing involves a holistic integration of mental and spiritual guidance, herbs, nutrition and physical therapy and is linked to African cosmology (Mufamadi & Sodi, 2010).

Traditional healing and spirituality, religion, philosophy, culture and society are interconnected as aspects of being, where all of life is a unitary field and wherein the spiritual and physical worlds are one (Thabede, 2008). This forms the foundational doctrine of traditional African morals and ethics and emphasises collective identity (as opposed to the Western emphasis on individual identity), solidarity, caring and sharing, the relatedness between the physical and metaphysical world, the value of interpersonal relationships or humanism—as encapsulated in the saying, “a person is a person through other persons” (umuntu ngumuntu ngabantu). It depicts connectedness between the living and those who have passed on to the spiritual realm, the earth and cosmos, and humanity (Ubuntu) and the cosmos. Ubuntu is an African word for a universal concept (Masoga & Shokane, 2018, p. 9), which is comparable to the Ubuntu of African Indigenous knowledge, which advocates collective responsibility for one another as a value and philosophy for mutual coexistence and compassion. Agreeing with Setiloane (1986), a human person’s worth is inherent and is rooted in belonging: I belong, therefore I am (Mbiti, 1970). Being is belonging, and nothing does not belong. Broadly, as Setiloane and Mbiti argue, the entire spectrum of nature belongs somewhere. Belonging, in this regard, is dynamic, as a being interacts with other beings in and with the cosmos. This, concludes Mulago (1990), means that, “for the Bantu (as for other Africans) human beings maintain intimate relationships with one another” (p. 122). This is a profound statement about the mind–body connection and of the African principle of Ubuntu (co-existentialism), which states that “I am because We are” (Ross, 2018). Viewing the link between consciousness and the physical plane as energy allows us to grasp the relationship between self-esteem, identity and health.

Contextual background

Against this backdrop, traditional healers provide treatment and traditional medicine to their patients. Ross (2018) explains that this service could involve the utilisation of plants, animals and mineral substances, together with methods based in the social, cultural and religious background, as well as prevailing knowledge, attitudes and beliefs about the physical, mental and social well-being of the community. Traditional healing practice is clarified in the Traditional Health Practitioners Act (No. 22 of 2007) (Republic of South Africa, 2007, p. 6) as “the performance of a function, activity, process or service based on a traditional philosophy that includes the utilisation of traditional medicine or traditional practice.” The World Health Organization (2004) affirms that traditional medicine has been used for thousands of years, with great contributions made by practitioners to human health, particularly as primary healthcare providers at the community level. Thornton (2009, p. 21-22) distinguishes three forms of healing that are practised by African traditional healers and their clients: (a) healing practised by those who have “graduated” from a period of tuition and self-healing, and who are called sangomas; (b) healing by those who use or sell herbal remedies (called inyangas); and (c) faith healing.

The researchers have observed that this focal area has not been sufficiently covered by research. Drawing on the investigative process of the proposed study, a hypothesis was developed to investigate how poverty and social and economic processes apply to traditional healers and, specifically, how it can affect traditional healing. Ross (2018) argues that “despite the passage of Traditional Health Practitioners Act (Republic of South Africa, 2007), and possibly due to the hegemony of Western medicine and negative attitudes to traditional healers, traditional healing seldom features within the social welfare sector” (p. 6). It should be noted that, while socio-economic status is important, we cannot focus on that and ignore the scope of spiritual and philosophical dimensions related to traditional healing. Therefore, this article considers some of the socio-economic, spiritual and philosophical dimensions of African traditional healers, with social welfare lenses.

Theoretical framework

In the context of understanding the socio-economic challenges faced by the traditional healers in rural areas of South Africa, we have adopted an Afro-sensed approach to serve as the theoretical underpinning of this study which incorporates a developmental social welfare approach. The Afro-sensed theory was developed by Masoga in 2017 with the intention of guiding traditional healers’ practitioners, to help them to intervene effectively by utilising Indigenous knowledge systems in a local, culturally appropriate and sensitive manner. Furthermore, Masoga and Shokane (2018) emphasised previously that the term “Afro-sensed” differs from “Afrocentric”, as it refers to one’s innate awareness, a “sense” of one’s identity, that is, being African; without making it “centric” (p. 7). According to Masoga (2017) at the exclusion of all else, implicating oneself in another hierarchical regime structure, where one is better than another.

The Afro-sensed theory encompasses using Indigenous knowledges and cultural approaches to discover uniqueness and Indigenous ways of healing (Masoga & Shokane, 2018). Africa is encouraged to move away from models that rely on Western frameworks and philosophies, towards Afrocentric models that are based on Indigenous (ethnic) knowledge systems, community-based interventions and local values and practices (Magoro, 2008, p. 35). Furthermore, the developmental social welfare approach was selected for its pro-poor approach, which promotes people-centred development, social investment in human capabilities and the building of social capital. This approach advocates for economic and social policies being equally important components of the development process (Patel, 2005).

Setting the scene

The study emerged from collaboration in a research project, which was conducted jointly by the University of Virginia (Uva), based in USA, and South Africa’s University of Venda (Univen). UVa and Univen have a close relationship, which has involved several collaborations on matters such as water, health and HIV/AIDS. The research collaboration between UVa and Univen relates to working on policy research, with one of the study’s objectives focusing on social welfare and traditional healing in Limpopo, South Africa. Social welfare refers to conditions of social well-being when social problems are managed satisfactorily, social needs are met and social opportunities are created to meet the needs of individuals, families, groups and communities (Patel, 2005).

This project brought together faculty and students from the USA and South Africa to conduct research. At the time of the study, both the authors were employed by Univen, as research professor (first author) and senior lecturer (second author), respectively. Both the researchers are in possession of PhDs and have vast experience of conducting qualitative research and working with communities at grass-roots level, though they had no prior relationship with the participants of this study. One of the researchers is a man, the other, a woman. Rapport was established with the participants by the researchers, who explained the reasons for doing the research, that is, to investigate how social and economic capital affects the process of healing by traditional healers. There was a common understanding that the results of the study were intended to inform the approach taken by South African policymakers to public health issues. Arguably, the project has global health implications for developing countries, and could potentially be applied to nations with minority populations of traditional healers and traditionally religious people. The findings of this research will be used to foster stronger relationships between traditional healers and biomedical medicine, so that people in developing nations around the globe can continue to rely on Indigenous healthcare practices in conjunction with biomedical healthcare services.

Finally, drawing on this investigative process of the proposed study, a hypothesis was developed on how poverty and social and economic processes apply to traditional healers and, specifically, how it can affect traditional healing. Research conducted on healing strategies in southern Africa explain how financial constraints limit access to traditional healing, as there are costs associated with visiting traditional healers (Den Hertog & Gilmoor, 2017). Identifying this gap assisted the researchers to formulate the broad objective of this research: To investigate how social and economic capital affect the process of healing by traditional healers. The following exploratory questions were raised:

Who uses services provided by traditional healers? What is their social and economic background? What transactional processes take place between clients and traditional healers? In this context, traditional healing was also examined from the perspective of social welfare, by focusing on how traditional healers sustain themselves.

Research methodology and design

As indicated, this was a joint research project on social welfare and traditional healers in Limpopo, between the UVa and the Univen. The aim of this specific research work was to triangulate quantitative household survey data with new anthropological qualitative research in a mixed-methods study of poverty/wealth, health and traditional healers. Frank Batten School of Leadership and Public Policy undertook the quantitative analysis, and UVa’s Medical School led the biomedical aspects, while Univen undertook the qualitative research, including interviewing traditionally religious people and traditional healing practitioners.

The methodology of this research involved a qualitative approach, which was selected for its suitability to provide ways of understanding experience or phenomena from the perspectives of those who live it (Monnette et al., 2014; Strydom & Delport, 2011).

An exploratory, descriptive and narrative research design was employed to investigate the social capital processes in the healing spaces between clients and traditional healers. Poverty and issues of inequality remained central throughout the process. Based on the outcomes of the interviews and collection and analysis of the data, an investigation was conducted to determine how social and economic capital relate to traditional healers.

Purposive sampling was employed to select 40 traditional healers. The participants were approached face to face and telephonically to participate in the study. All the participants were willing to participate. The demographics of the participants were as follows: They were male and female, their ages ranged between 50 and 80 years and their languages were Xitsonga, Sepedi and Tshivenda, which are all commonly spoken in the Limpopo province.

Data collection

The experiences and positions of 40 selected traditional healers were critical during data collection. The traditional leaders were organised into three focus groups (13 plus persons in a group), and discussions were conducted in Elim police station hall. The focus group discussions were conducted by the first author, who is a man; and the second author, a woman. Gender, age and geo-type variables were not considered when forming the three groups. Participants could converse in the three main languages: Xitsonga, Sepedi and Tshivenda. Code switching dominated the conversational style of these three focus groups. An interview guide was developed to guide the interview questions. Guiding questions were used to kick-start conversations; most of the questions centred on the following key areas:

There was no one else, apart from participants and researchers, present during group discussions. An audio recorder was used to record the interviews. Field notes were taken during the focus group discussions. The focus group discussions lasted over an hour. The interviews were conducted until data saturation occurred and the interviews no longer yielded new information. Member checking was conducted to allow participants to provide feedback on the findings.

Ethical considerations

Ethical approval to conduct this research was granted through Univen, the UVa and the Global Policy Centre at Batten. Informed consent to participate in the research was sought from the traditional healers. The protocol used was approved by the Institutional Review Board for Social and Behavioural Sciences at UVa (IRB-SBS#2018-0156-00). The reasons for conducting the research were explained to the participants, namely, to investigate how social and economic capital affects the process of healing by traditional healers. This invitation was also extended to the combined organisations of traditional healers in and around Elim (Waterval), who were taken through all the steps of this research study and informed accordingly as per the research protocol.

Data analysis

The qualitative thematic analysis approach of Braun and Clarke (2006) was used for “identifying, analysing and reporting patterns” (themes) within the collected data (p. 79). This approach helped the researchers to minimally organise and describe the data set in (rich) detail. Carefully presented themes about traditional healers’ experiences of their socio-economic realities were identified from the data, and analysed. Although the healers’ socio-economic status was the focus, we did not ignore spiritual and philosophical dimensions related to traditional healing.

In analysing the data, the researchers applied the six phases proposed by Braun and Clarke for conducting thematic analysis: (a) becoming familiar with the data, (b) generating initial codes, (c) searching for themes, (d) reviewing themes, (e) defining and naming themes and (f) producing the report.

Findings

Various themes emerged during the analysis of qualitative data. The data comprised the data collected from the three focus group discussions with traditional healers. Five themes emerged from the data, namely, training of traditional healers, consultation, pricing, banking money and interaction among traditional healers. The themes are discussed below.

Theme 1: training of traditional healers

A discussion on the training of traditional healers was introduced, and the theme emerged from the data gathered in the three focus group discussions. There were two perspectives raised in this regard. The first perspective had to do with apprenticeship as a model of training. Participants mentioned that they were directed to a specific trainer (gobela) for their training. In this case, they were subjected to a period of formal training under the guidance of the chosen/selected trainer. After the training, they could return home to practice on their own. The training programme included being taught how to use the divination bones (ditaola or tinhlolo) for diagnosing diseases. Participants also mentioned that they were guided by their ancestors throughout the process of their training (including the selection of an appropriate trainer, using divination bones and knowledge of medicinal plants and diseases related to them).

The second perspective was that traditional healers are guided by their ancestors through dreams and visions to manage divination bones, know about medicinal plants and various diseases and how to cure these diseases. This approach could not be categorised as self-training (go ithutela ka bo wena bongaka), but was centralised around being trained by ancestors (go rutiwa ke badimo).

The findings dispute the research conducted by Truter (2007), who reports that scientists are of the view that traditional medicine has not been proven and, therefore, they generally prefer not to work with traditional healers. Generally, this view originates from a misinterpretation of cultural practices and beliefs related to traditional healers. Truter (2007, p. 10) identifies three categories of traditional healers, namely, ngaka, sangoma and morapeledi (prophet/prophetess). Traditional healers have an ancestral calling that leads to them earning the respect of the communities they live in; whose members believe that the healers hold mysterious powers. Similarly, Mufamadi and Sodi (2010, p. 6) affirm that this calling is determined by spiritual entities (badimo).

Theme 2: consultation

Consultation emerged as a theme during data analysis. Most of the participants indicated that they see about 3–5 patients (vhalwadzi), on average, per day. In addition, the participants elaborated that the pricing ranges from ZAR 150.00 to ZAR 200.00 ³ for specific prescriptions. However, a challenge that was observed was that there is no banking system and financial management in the rural areas where they work. Participants narrated that their money is kept at the sacred healing shrine/site commonly known as ndomba. In determining prices, the participants reported that they agreed prices among themselves, and that they believe the ancestors provide guidance on how patients/clients should be charged.

This study’s findings concerning prices are corroborated by Thornton (2009), who reports that a “sangoma is not a poor man’s doctor; they generally charge as much as a registered medical practitioner would.” Our own research observations were that there was no formal record-keeping, and follow-ups follow oral and memory patterns of managing the affairs of the healing shrine.

Literature indicates that traditional healing is the most relevant route to addressing health issues for most of the population, because most people live in rural areas. The findings reported above are consistent with research conducted by Watermeyer and Penn (2019), who found that patients in rural settings of South Africa often access both traditional and scientific approaches to healing: their dual belief systems correspond with their treatment-seeking paths. Brandt and Rozin (2013) claim that “the way a society responds to disease reveals its deepest cultural, social and moral values” (p. 148). Puckree et al. (2002) and Truter (2007) estimate that between 60% and 80% of South Africans exercise dual treatment belief systems; however, Indigenous healers are consulted more frequently than their Western-trained counterparts. These findings are corroborated by Thornton (2009), who reports that the traditional healer “offers a wide range of counselling, divination/diagnostic, medical and other services” (p. 17).

According to Thornton (2009), “many sangomas compare themselves with medical and other professionals, and believe that they should be treated in the same way and accorded similar respect, as well as appropriate remuneration” (p. 18). Furthermore, the cost of Western healthcare treatment and its inaccessibility in remote rural villages still presents a challenge even in the 21st century (Truter, 2007). In contrast, traditional healers are forces on the ground, who touch base with the day-to-day health issues affecting the people in their communities.

Theme 3: pricing

Pricing emerged as a theme during data analysis and was focused on the traditional medicines that are prescribed. Interestingly, participants reported that their prices are determined by the respective organisations or associations to which they belong. For example, participants indicated that the first bone-fall (lewa la mathomo), referring to the charge for the divination bone-fall for diagnosis, is priced between ZAR 100.00 and ZAR 150.00, which was the price charged by all traditional healers. This indicates the average charge for this service.

Traditional medicines are commonly referred as mishonga (prescribed medication), which can cost up to ZAR 1,000.00 (prescriptions). The participants collaborated, furthermore, that bottles containing medicinal mixtures cost ZAR 300.00 each, regardless of the patient’s condition. The participants also agreed that cleansing and healing of the entire body (physical healing) costs about ZAR 1,000.00. The participants elaborated that the price of home (mudi/motse) cleansing, and safety and security with herbal (medicinal) mixtures can cost up to ZAR 2,500.00. Vhalwadzi/balwetsi—the term for patients who cannot afford or do not have enough money—are permitted to pay a deposit, which is often half the amount charged for the time of consultation—referred to as umkhombandlela—and the rest is paid at a later stage.

This study’s findings are consistent with research conducted by Truter (2007), who identified a few reasons why traditional healing is called for, three of which are the following:

Sub-theme 3.1: recording system

The recording system traditional healers used for their practices emerged as a sub-theme that was linked to the theme of pricing. In all three focus group discussions, only two traditional healers mentioned that they kept records of their healing shrine, including names of clients and payment records (i.e., outstanding payments). Most of the participants indicated that they used their memories (mihumbulo), which they claimed was a powerful way of keeping records and storing information. Most traditional healers impressed strongly that they use their memories to recall names and other matters related to their clients (nga thoho—muthu wa mo divha— ri shumisha mihumbulo—with memory one can remember a person—we use memory).

Theme 4: banking money

When asked about banking or using facilities such as financial banks to deposit and save the payments made by their respective clients/patients, most research participants raised concerns about unemployment. Some of the participants indicated that they use all the money they receive from the traditional healing for their living expenses – there is nothing left for saving in the bank. They did, however, report that they are supposed to inform their ancestors about the way they spend the money. It emerged clearly that poverty and unemployment are linked to the subject of traditional healing. One of the research participants narrated during a focus group discussion,

[Loosely translated] There is no money. It is a very big problem. Even us, as traditional healers, we are not employed. We live in the rural areas, impoverished by unemployment. How can we then afford going to the banks? These are real challenges. We just continue doing our job because ancestors expect us to do so [meaning that it is their calling].

The participants indicated, furthermore, that they use Indigenous ways of banking, such as burying some of the money in the ground at their shrine and engaging in ritual processes for digging and burying the money.

By reading the above anecdotal statement closely, readers can gain an understanding of the situation of poverty and unemployment in which most traditional healers in this part of the Limpopo province find themselves. Also, consider that the same challenging situations faced by these traditional healers face most of their clientele, who mostly struggle to survive in an economically ravaged environment.

Theme 5: interaction among traditional healers

The last theme that emerged is the interaction among traditional healers in the community of Elim. Most participants responded positively when asked if they have cordial working relations among themselves. In clarification, they indicated that they even refer patients to each other during the performance of their duties. Clearly, trust and appreciation of each other’s traits, gifts, abilities and apprenticeships are what binds these healers together. One of the research participants indicated their view on cooperation in the focus group discussion:

[Loosely translated] We work together. Healing is gift. All of us are gifted. All healers have knowledge about what they are doing.

In substantiating the sentiments reported above, the participants indicated that they have organised themselves into formal groups at local district, municipal and provincial levels. The traditional healers acknowledged and expressed their concern about questions relating to the recognition of traditional healers by the national Department of Health. In addition, they referred to various organisations that look after the affairs of traditional healers. One of the organisations of which most of them are members, is the Traditional Health Organisation (THO), whose founder is the traditional healer, Baba Maseko. Traditional healers who belong to this organisation register formally and should pay a fee for the administration of their affairs to the THO national head office in Johannesburg. Healers receive an official card and a copy of a certificate of membership to indicate that they are members of the THO; they are also supposed to wear specific regalia, which is predominantly red. The red cap they wear distinguishes them significantly from other traditional healers’ groups. Members are expected to wear their regalia when they attend official meetings of the organisation and when they are invited to attend other meetings with, for instance, government representatives. However, a few participants mentioned that they do not belong to any traditional healers’ organisation due to financial constraints. Some of these participants complained that it costs a lot of money to belong to a traditional healers’ organisation.

Implications and conclusion

The previous section of the article carefully presented themes that were sifted from the data about traditional healers’ experiences of their socio-economic realities. It is apparent that, while the socio-economic status of traditional healers is relevant, researchers should not focus solely on that, and fail to pay attention to the scope of the spiritual and philosophical dimensions related to traditional healing. Most traditional healers experience the ravages of poverty and unemployment. Few of these traditional healers have or practice formal recording literacy.

The research that was conducted indicates that traditional-Indigenous healing knowledge and practice involve traditional knowledge and skills that traditional healers and people in local communities have been using over the years to survive. This knowledge includes their knowledge of plants, animals and insects, which are used for food security, nutrition and medicine; as well as their knowledge of agriculture, fishing, managing and protecting natural resources against environmental disasters; conflict resolution and management; childbirth; community governance and so on.

A culture-based approach, and applying Afro-sensed theory, can be utilised in studying traditional healing and enhancing cross-cultural skills. This approach is affirmed by Zungu (2013), who declares that culture is important for understanding how different groups construct health and illness. The intention of this study was to determine the socio-economic challenges faced by traditional healers in Limpopo. This study’s findings should be integrated into future scientific endeavours and regulations to promote research into and development of traditional healing in South Africa and beyond.

It can be concluded that traditional healing remains core to many local communities, also in South Africa. As discussed above, interviewees proposed that traditional-Indigenous healing knowledge and practice involve the knowledge and skills that local people in communities have been using over the years to survive. The following key themes emerged:

The study provides clear evidence that traditional healing remains core to most South African local communities. This is attested by Mokgobi (2014) who notes that “although a free primary healthcare system has been made available to people, preference is still given to traditional healing as people continue to visit traditional healers” (p. 7). This preference can be attributed to it being estimated that there are more practicing traditional healers than Western medical practitioners. These traditional practitioners are more community-based, accessible, available and affordable and have the capacity to educate and counsel (Mokgobi, 2014). To mitigate the socio-economic challenges faced by traditional healers in Limpopo, it is imperative that traditional healers are assisted to gain access to greater financial capacity, assets and economic opportunities. The traditional healers could also be encouraged to be involved in social development programmes which reflect an integration of human capital, social capital and economic capital development.