When they need healthcare, writes Sipokazi Fokazi for Bhekisisa, about 70% of South Africans, mostly in rural areas, visit sangomas first before they go to a medical doctor, or they don’t go to a health clinic at all.
But new rules that are likely to start being enforced early next year – and which some are resisting – will see izangoma (diviners) and other traditional healers having to register with the Interim Traditional Health Practitioners Council to align their work to a more formal system, said spokesperson and chairperson of the registration, education and accreditation committee Sheila Mbhele.
The council will oversee how traditional healers operate, similarly to how the Health Professions Council of South Africa (HPCSA) and the South African Nursing Council (SANC) do for other health workers, like doctors, dentists, dieticians and nurses.
The draft regulations that were published in June are meant to set standards for practitioners’ training and practice and closed for public comment on 21 September.
Proof of training
Practitioners will have to pay registration fees to the council every year and show proof of being appropriately trained for the type of service they offer: National Department of Health Spokesperson Foster Mohale said “processes for finalisation (of the regulations) are ongoing and will be implemented on proclamation”, though it’s unclear when exactly this will be.
The suggested rules come more than 15 years after the Traditional Health Practitioners Act was passed into law in 2007. Moving away from traditional medicine being seen as witchcraft, the modern law aligns with the World Health Organisation’s (WHO) view of treating health problems with indigenous know-how and customs passed on through generations as being an alternative to Western medicine, which relies on evidence from scientific studies.
The NDoH said formalising traditional medicine would allow healers to work hand-in-hand with doctors and nurses at primary care level, which, added Mohale, links to the WHO’s Alma-Ata Declaration of 1978 about countries committing to offer everyone this type of health service and so working towards universal health coverage.
Regulation, registration and reticence
But not everyone agrees with instituting formal rules. Zanele Mazibuko, spokesperson of the Traditional Healers Organisation (THO), told Bhekisisa that although the regulations “will protect the sector against charlatan healers”, more consultation was needed.
At the heart of this reticence are the requirements for registration fees, and practitioners having to submit proof of training.
For example, under the new regulations, someone wanting to work as an isangoma or herbalist has to be at least 18, and have undergone 12 months’ training in diagnosing conditions, collecting and storing herbs and preparing treatments, and doing traditional consultations.
Those who want to work as traditional birth attendants or surgeons must be 25 or older and have had one year (birth attendant) or two years (surgeon) of training to learn the ropes in their field of practice.
Training will be handled by experienced healers and Mbhele said the council would be working closely with amakhosi (local chiefs) to certify healers and confirm to them that “we know this healer, we’ve trained him, we’ve seen him practise and we’ve visited him”. She said the Health Department would also be involved and “have its own processes to track the training of traditional healers”.
Having to pay yearly registration fees to get a practice number has also caused unhappiness among healers. Applicants who can show evidence of their education will have to pay R1 000 for the first year on the books, and R500 annually afterwards. Amathwasa (student healers) will pay R200 at first then R100 a year afterwards, while their tutors will pay R5 000 upon first registration then a yearly renewal of R1 500.
With the period for public comment now having closed, the council will start to formally accredit and register healers who qualify for registration.
But in the THO’s view, the fees will be “unaffordable” and, said Mazibuko, though healers “are ready to be taken seriously and integrated in the healthcare sector, this must be without Eurocentric methods dominating and dictating our traditional practices”.
Mbhele counters: “Even though the period for public comment has closed, people can still ask the council to come to them to be shown areas where we need to do things right.”
Can sangomas help tackle HIV?
Research shows power struggles and mistrust are common in efforts to get traditional and Western medicine systems working together.
For example, in a study from KwaZulu-Natal that explored healers’ views on formal registration, practitioners said they were sceptical about the process and saw no benefits, except for their work being officially recognised. Moreover, registration fees were seen as a tactic to bolster the government’s tax revenue.
Elsewhere in Africa (where 39 countries have policies on traditional healing), an analysis of 22 studies shows that when indigenous medicine is part of the formal health system, mistrust and rivalry between conventional doctors and traditional healers stems mostly from doctors considering themselves superior and seeing their role as having to teach healers, and not accepting the spiritual aspects of traditional healing.
But Ryan Wagner, a senior research fellow at Agincourt, a rural health research unit run jointly by the South African Medical Research Council and Wits University, said this needn’t be the case.
He’s leading a five-year study on having traditional healers offer HIV testing and counselling to clients and connecting them to clinics for treatment if their result is positive. Since 2015, he’s been working with practitioners in Bushbuckridge to understand how the two health systems can collaborate to “improve patients’ health and find common ground”.
Mawelele is one of this group of 15 traditional healers. In the past year, he has referred more than 40 patients to local clinics for testing as part of the pilot project.
Getting tested is the first step towards achieving the 95-95-95 goals – the world’s strategy to end Aids as a public health threat by 2030 – because if someone tests positive for HIV, they can start taking ARVs immediately (the second number in the series of 95s).
The 95-95-95 goals aim to, by the end of 2025, have 95% of people with HIV diagnosed. Of those, 95% must be on treatment, and of the 95% on treatment, 95% must be virally suppressed, meaning their HIV levels have dropped such that they can no longer transmit the virus.
In the Ehlanzeni district, where Bushbuckridge is, about 75% of people with HIV were on treatment by the end of 2023, which is close to the national figure of about 78% for the second 95 of the series (according to the Thembisa model, used by the NDoH).
Collaboration
Having conventional and traditional systems work together is possible, research shows.
For example, a study from rural Uganda, where it’s easier for communities to access traditional services than an HIV clinic, found that when an indigenous healer offered people an HIV test, everyone said yes, compared with only about a quarter of people who did so when they were sent to a clinic to get tested.
But for effective co-operation, Wagner said trust between traditional healers and medical doctors and nurses was essential.
“Distrust can only be broken down through frank engagement in safe spaces. Ultimately, both systems strive to improve the health and well-being of people, and by working together, we can get there faster.”
See more from MedicalBrief archives:
HIV fight bolstered by traditional healers’ help
Public comment invited: SABS' releases draft ethics guideline for traditional healers
Traditional healers are modernising but remain unregulated
Involving Uganda's traditional healers improved HIV testing and care