J Community Health (2011) 36:431–437 DOI 10.1007/s10900-010-9325-7
ORIGINAL PAPER
Traditional Healers (mor pheun baan) in Southern Thailand: The Barriers for Cooperation With Modern Health Care Delivery Dusanee Suwankhong • Pranee Liamputtong Bruce Runbold
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Published online: 2 November 2010 Ó Springer Science+Business Media, LLC 2010
Abstract Although the cooperation between modern and traditional medicine (TM) is increasingly promoted in health care system of nationwide, there remains many barriers. In this study, we examined the barriers and possible ways of promoting cooperation between traditional healers and modern health system. Ethnographic method including participant observations, in-depth interviews, focus groups, and unobtrusive methods were employed for data collection. Sixty six key participants of six stakeholders participated in this study. There are many barriers existing in relation to promote the legal role of traditional healers. This is because modern and traditional healers recognise health legalities differently. Modern health professionals try to motivate and require traditional healers to meet their standards, whereas traditional healers face integration difficulties and resist those approaches; rather, they are concerning with preserving their own traditions. Their traditional health practices do not meet the ‘‘best practice’’ standards necessary for them to gain the trust of modern doctors. Importantly, the licensing issue is key barrier creating difficulties for traditional healers. However, traditional healers are recognised for their benefit role in health care if cooperated with modern health professions. To make cooperation possible, all stakeholders need to understand cultural beliefs of traditional healers relating to cooperation with modern medicine. Supporting power for promotion of cooperation at the community level is the key strategy to suit community needs and contexts. In
D. Suwankhong P. Liamputtong (&) B. Runbold School of Public Health, La Trobe University, Bundoora, VIC 3086, Australia e-mail:
[email protected]
addition, cooperation requires clarification of the responsibilities of all stakeholders at the local and central levels. Keywords Traditional healers Southern Thailand Indigenous healthcare system Cooperation with modern health care Barriers
Introduction Thai national health system had incorporated traditional healing models into national health policy to promote local knowledge of self care resources. It was believed that this would ensure that people would not only rely on Western medical systems, but would also use traditional medical resources. This policy began as the Fourth National Health Development Plan (1977–1981) [1]. The Bureau of Indigenous Thai Medicine [2] report that this initial policy had continued developing under the Fifth to the Ninth National Health Development Plan, 1982–2006, and it had increased the use of plants and herbs in methods of health promotion. The current Tenth National Health Development Plan, 2007–2011, supports the integration of TM into the formal health system because it does not consider modern medicine to be the best model to increase the overall well-being of the Thai people. Modern medical services are expensive, but using inherited resources and sharing expenses can effectively increase the health of the Thai people. The Tenth National Health Development Plan (2007– 2011) is now in position. The focus of this plan is on a people-centered approach that places a strong emphasis on the development of a sufficient economy to promote an adequate health care system. Forming this ideal health care system is possible by using local wisdom and traditional health resources. The concept of ‘‘sufficiency economy’’ is
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believed by most Thai people who consider it a positive guide for the development of a national health policy [3]. Features of the ‘‘sufficiency economy’’ concept are now used in the Thai sufficiency health system and promote the idea that a good society creates good health for its citizens [4]. Health care practices are developing from the increased level of knowledge about traditional healing in Thai health care that currently exists in Thailand. Chokevivat, the Director-General of Department for Development of Thai Traditional and Alternative Medicine (DTAM), and colleagues [1] point out that their organisation consistently promotes local wisdom in health care. For example, they develop products from herbs, train people in the practice of Thai traditional massage, encourage traditional midwifery career paths to better care for the nation’s mothers and children, promote the use of natural products in daily life, co-opt traditional medicine (TM) into modern therapy, create TM education programs, train traditional medical practitioners, set up indigenous doctors’ associations, and support local research. These activities relate to the policy of the World Health Organization [5] in supporting the use of TM and its resources as a strategy to achieve Healthy People in 2010. Traditional healers who provide health for people by using TM and relying on local wisdom have increased public interest. They are expected to serve the national health policy in relation to form sufficient health care system for Thais [6] because they are primary source of health care for Thai people, especially in rural areas [7]. This paper will discuss existed barriers for promoting cooperation between traditional healers and modern health care system in southern Thailand. The possible ways that traditional healers can cooperate with modern health system is also explored.
Materials and Methods Methods This study was conducted from 2008 to 2009 in Thung Tong community (fictitious name). We employed ethnographic method because it addresses the most important issue in sociological research; that is how individuals see their world. Ethnographic study allows the use of a mixture of methods, theories, and sources of data to gain triangulation purpose [8–10]. The methods employed were participant observations, focus groups, in-depth interviews, and unobtrusive methods. We included six stakeholders as key informants; traditional healers, customers, community heads, health care providers, health policymakers, and an academic person from a local university.
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The unstructured interviews were used among traditional healers and customers, conducted in the local Thai language. This structure is more like a daily conversation which has an unfixed pattern of interaction. Open questions were asked, which encouraged the participants to give their view freely [11]. All of the conversations took place at participants’ homes at a time that was convenient to them. The participants were given an information sheet, informed consent and withdrawal form before an interview. Their permission was sought for the researcher to tape-record the interview and take photographs. A first conversation with individual could take about 1 hour, and the first author was allowed to revisit at other times for further discussions. Flexible questions were used for different participants even for the same purpose. Also some participants were interviewed many times, while others were interviewed only once. The semi-structured interview is a combination of the structured and unstructured form, which allowed the first author to set the range of question in advance [11]. In the course of the interview, questions were formulated to bring about the discussion of the barriers of encouraging cooperation between two systems. The first author raised a range of issues with various groups including healthcare providers, health policy workers, an academic, and community heads. The semi-structured interviews, without fixed wordings or questions, offered the participants a wider scope for sharing their knowledge and experiences. Even though this typical style of interview is similar to formal conversation, the natural discussion form was maintained as it not only provided a more relaxed setting but the first author could also construct many ideas throughout the conversation. The participants felt comfortable to share their view [12, 13]. Focus groups worked well among the group of community heads as they hold regular meetings. To invite them for discussion in a group, it had little effect on their lifestyles. Therefore, community heads of each village were recruited into the focus group to share their views on the contribution of traditional healers to healthcare. The first author was fortunate to have the support of a community head who would inform the other heads of the focus group discussion as well as allow her the use of the location where they normally conduct their meetings. The focus group included ten community heads [14]. As a gesture of goodwill and to create a friendly ambience, the first author prepared food and drinks for the participants before the discussions. The group discussion ran for one and a half hour with relax atmosphere as they were all familiar with each other [9]. Unobtrusive methods involve looking at the relevant policies or documents that can be useful for gathering data because this method is one important way to understand
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human lives and human perspectives, without disturbing their privacy [9]. Prior to entering the specific community, the first author spent time searching and accessing existing documents from the internet, City Hall, District Health Office, Provincial Health Office (PHO) and District Official Office for information. The current policies and activities related to TM and the health service system were gained from the primary care unit (PCU) and other sources in the province. Other references related to the area of study were sought throughout the period of the fieldwork. With permission from the participants, interviews were tape-recorded. The tapes were then transcribed in Thai for data analysis [9]. All transcripts were coded and subsequently, emerging themes were derived. The emerging themes are presented in the results section. Ethics clearance was obtained from the La Trobe University’s Human Ethics Committee and the Ministry of Public Health (MoPH), Thailand.
Results Chronic Barriers for Cooperation Between Two Systems The integration between traditional and modern medicine has been promoted in the Thai health care system. But many barriers to make smooth cooperation between two worlds, traditional and modern health care, are the concern of all participating groups. Those existed barriers mainly include acceptance of modern doctors, resistance of traditional healers themselves, unclear policy guidelines of promoting cooperation, and license required for traditional healers. Traditional healers are still viewed as healers who have less knowledge and practices in many areas of health compared to modern doctors, who have trained systematically over many years through the academic system. They are legally assigned to act as health care providers in the health care system. But traditional healers are helping people from their local wisdom that was passing down from previous traditional healers. The knowledge and experience are naturally gained by giving people treatment. The reluctance of acceptance stems from the fact that treatment of traditional healers lack sufficient empirical evidence to prove effective healing due to its knowledge stands outside the realm of sciences. It cannot provide the evidence-base of clinical practice. Because of this weakness, modern health care workers do not have a strong trust in the healing but carefully choose some therapeutics to be implemented in the health care service. Thus, community heads are unsure whether traditional healers can play a role in the Thai health care or they should keep to their role providing for their local community like they use to be.
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On the other hand, many customers that we interviewed seem to be confident that traditional healers can cooperate with modern health care workers. This is because the healers have demonstrated their craft in the Thai health system for a long time. They agree that if both mainstreams can cooperate, they would like to see the cooperation happen. This optional help can provide customers maximum benefit of care seeking. But they have never seen cooperation between modern and traditional healing. They do not know whether modern health care providers can accept traditional healers as their partners. At the same time, some customers do not agree with traditional healers working together with modern health care providers. The traditional healers have a simple lifestyle and their work does not concern systematic management. The resistance of traditional healers is one barrier of cooperation between the mainstreams. Many traditional healers we conversed with perceive that it is difficult for cooperation if individual healers are not willing to do so. The majority of traditional healers in our study are not interested in formally working alongside modern health care staff. They prefer a simple working style in the same way that they are already familiar with. Helping people at their home, their unique pattern, and informal style allows them to practice without the need to change their lifestyles. They have more independence in their work and there are no systems to control their life. Also this original pattern has been followed since traditional healers first began healing people. About two third of health care providers and an academic staff interviewed articulated that traditional healers have individuals’ confidence. They tend not to trust people from other disciplines. Most of the traditional healers still preserve their knowledge and do not want to share their knowledge with the public, especially to modern health care providers. This factor creates a barrier of cooperation between the two mainstreams as well. In fact, they can change themselves to learning more about the pattern of illnesses in recent times and should open their mind to understand the modern health care system. If traditional healers realise this commitment, it could encourage cooperation. The traditional healers do not want to be registered formally. They cannot see the benefit of cooperation due to prior negative experiences from the government health service. This leads them to have little or no trust in this sector, and makes them reluctant to enter cooperation. Nearly all of them complain that the government has never support their role sincerely. On the other hand, this sector tends to take their knowledge and retrains them in new wisdom. They consider that even if they attend the training or work cooperatively, it would do nothing to improve their profession and their role in Thai health. Rather, it would try to change their style to the modern world. However, the
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government institutes do not recognise them, they still exist because their customers support their very existence. All health policymakers interviewed pay great attention to healers obtaining a license. They believe that license is a very important document for all health care practitioners. It confirms the qualifications of people who present their role in health care delivery. Each has to receive this document before starting work. Most traditional healers do not meet this prerequisite, and they end up as illegal health care practitioners. Because of this lack of qualifications, modern health care providers tend not to believe in their knowledge. They perceive that treatments administered by traditional healers are not done in a sterile environment and are, therefore, not safe enough for people’s health. Nearly all of this group then strongly state that traditional healers must have a license to gain trust from modern health care providers. It would also upgrade them to professional practitioners. If they have a license, it encourages them to play their role in the health care system legally, which may lead to an increase in the number of customers in the future. Also an academic staff we interviewed supports the license as a necessary document for health practitioners, a professional license is normally granted by a particular government approved professional association. Because this role has to take responsibility for people lives, he believes that the license authorises and controls the healers. It is generally accepted that healers with an approved license would do less harm. He agrees that existing traditional practitioners should improve their qualifications to meet the criteria of the Ministry of Public Health (MoPH). If traditional healers do not obtain license, modern medical people would hardly believe in the knowledge produced by the traditional healers. He emphasises that traditional healers should receive the license because it enhances the public trust in their capability. Obtaining a license also encourages them to be more professional to a degree as well. Most participants claim that policy level still does not clearly state how the traditional healers can cooperate with modern medicine legally. This is despite them being recognised as a primary health care (PHC) resource which has provided a beneficial role to Thai people for a long time. Rather, it seems to control and limit their role. The policy makers always say that they intend to encourage traditional healers in Thai health care to increase people access to care and preserves Thai traditional medicine (TTM) but implementing guideline to support role of traditional healers is not processing through. All traditional healers consulted remark that they do not understand the policy makers and whether the policy workers would like to promote their role. From their experiences, policy makers seem not to promote them sincerely.
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Many health care providers and health policy workers claim a similar viewpoint, that the current policy does not promote cooperation between the two mainstreams continually; it is occasionally promoted instead. Almost all of them also state that because their work relies on annual budgets, if the budget is used up before the project is complete, work on the project has to either finish or be stopped until the new budget is received. Although a particular project or activity may be able to continue, they have to wait for the next budget before doing so. Areas and Extent of Possible Cooperation Although all participant groups in the study are concerned about many barriers of cooperation between modern and traditional healing, there are several possible ways of cooperation. A large number of traditional healers suggest that a referral customer policy is a suitable way of cooperation. They can provide patients basic help and care before seeking help from the modern doctors. Their role in this regard can decrease the severity of illness and increase patients access to care. Before they can cooperate, they may need to have an understanding between modern doctors and traditional healers using the referral channel. The majority of traditional healers further suggest that the pattern of passing on patients could be a two way referral policy; the traditional healers refer patients to the modern doctor and the modern healers could refer patients back to the traditional healers, depending on health conditions. Some health care providers agree that referring patients is a possible area of cooperation. Some patients with chronic illnesses should refer to traditional healers for rehabilitation or continual care. Nearly all customers agree that it is beneficial if modern doctors can refer patients to traditional healers. It may be useful to cooperate between mainstreams because the cause of illness is more complicated in recent times. Relying only on one healing model may not help people so well. Most customers seem to be confident that one model can complement another, which possibly encourages more successful healing. If healers of any forms are not entirely confident in how to manage some kinds of illness, they should refer or advise patients to seek help from healers in other forms. Referring patients to suitable healers encourages patients to receive appropriate treatment. In practice, they always see the picture of a traditional healer advising patients to ask for assistance from the modern doctors. For the modern doctors, it is a hard decision to refer patients to the traditional healers. Setting a knowledge exchange centre is fundamental in the possibility of cooperation. Limited number of traditional healers and a few community heads suggest that this way could provide modern and traditional doctors with a
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platform to share and exchange knowledge. This opportunity encourages them to understand the opposite discipline more and apply each other knowledge in practice. It could also provide them the opportunity to become more familiar with each other and it could result in a relationship of trust later on. The majority of customers we interviewed support this as a good way to promote both healers in exchanging knowledge because it has benefited a vast number of people. The different disciplines of knowledge can be integrated which would create more advantageous treatment for them. It could help decrease the percentage of disabilities or fatalities. This channel is one important strategy to develop the Thai health care system to suit peoples’ needs. Many of them request that they want to see this system of cooperation improved.
Discussion Many societies integrate specific types of traditional healers for collaboration with their modern hospital systems. Such healers are expected to share in the workload of the modern doctors and provide people with more choices of care [15– 17]. But no single traditional healer in this study who cooperates with modern doctors formally is found. Some modern healthcare organisations at the community level experimented with efforts at cooperation with traditional healers. However, the authority and structure of community healthcare organisations is not designed to accommodate cooperation with traditional healers. Many researchers such as Antweiler [18], Phongphit [19], and Chuengsatiansup and associates [20], are in support of the development of healthcare resources at the grassroots level in order to build the self reliance of communities. These grassroots resources are available to promote the health of Thais, and they are in alignment with Thai culture and beliefs. The supporting roles which traditional healers provide are consistent with the recent and future direction of the national health development plan for Thailand, which promotes the utilisation by communities of existing local wisdom to achieve healthcare development. Kulsomboon and Adthasit [21], Chuengsatiansup [22], Sermsri [7], and Golomb [23] state that the supporting roles of healers at the grassroots level definitely helps with promoting communities’ self-reliance agendas because this strategy allows the communities to rely on their own valuable resources for their people’s health needs, rather than importing remedies. Moreover, this study provides support for and expansion on previous studies which agree that serving as primary health care resources is a salient role of traditional healers [16, 17, 24–27]. In reality, modern healthcare teams have mistrust in the knowledge and roles of traditional healers because they
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have no recognised medical licenses. As Sermsri [7] discusses, modern health providers view traditional healers as illegal healers whose medical knowledge and treatment methods are questionable. This stigmatising of traditional healers makes doctors to hesitate in referring patients to them. Modern doctors would rather promote the use of modern medical services, especially since these facilities are more available to lay people at the community level than ever before. These findings are mirrored in studies of other societies [17, 27, 28]. In the interest of protecting customer safety, Kayne [29] and the World Health Organization [30] are in support of the idea that all medical health practitioners must obtain a license. This is recognised as a supportive factor in building their cooperation with modern health professionals. But this study has clearly shown that such mandatory licensure can also prevent traditional practitioners from cooperating with modern medical practitioners. All traditional healers in this study are against licensure, preferring to remain as they are. They feel they could still contribute to people’s health without receiving a medical license. Their local licenses are granted by customers who want to obtain their treatment. Thus, there may be no benefit to requiring traditional healers to obtain licenses because, as Golomb [23] and Tantipidoke [31] state, healers and their patients not only already have close relationships and honest rapport, but their relationships are rooted in the same beliefs and cultural system. Asking for and receiving help has become a part of these peoples’ lifestyle. Contemporary health policy promotes the current roles traditional healers in the modern medical system. Nevertheless, the policy guidelines and programs created by health policymakers are far from being suited to traditional healers’ lifestyles, their indigenous professions, and their needs. On the other hand, as Raekphinit [32] and Antweiler [18] point out, national policy has tended to shift in focus from centralised administration to community-based organisation. The local communities have been encouraged to design their own healthcare and management systems utilising local resources. Baskind and Birbeck [33] tend to support the policymakers because traditional healers have varying beliefs and differing practices. This makes it difficult for policymakers to form standards of practice for traditional healers. Sugsamran [34] argues that healthcare policymakers can only integrate healers into limited areas of care. Many traditional healers are recognised as illegal practitioners and are not considered at all as being candidates for integration with the modern health system. While the concept of integration between the two health systems is now being promoted, not all participants are in agreement. Many are concerned that such a campaign will bring about some negative effects for indigenous Thai medicine and its practitioners. It could become less unique
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if it is required to adopt knowledge and practices from modern medicine. Data from this study and from earlier studies by Kale [27] and Baskind and Birbeck [33] indicate that there may be public concern with encouraging cooperation between modern medicine and TM. This will certainly modify the indigenous practices of traditional healers, and may also create conflict between the systems. However, it is clear that the public would like to see the development of the best healthcare services possible, although they would also like to see traditional healthcare practices preserved as much as possible. This could provide people with access to multiple healthcare choices. As discussed above, there are many health activities that traditional healers can contribute to and cooperate with modern practitioners regarding. But because traditional healers have significantly different healthcare ideologies and cultural beliefs from modern practitioners, awareness of their treatments and their role in health care is still not as widespread as they would like.
Conclusions Policymakers agree on the importance of encouraging cooperation between modern medicine and TM to benefit the Thai people. However, success seems distant because the systems are based on differing medical knowledge and practical applications. Modern health professionals try to motivate and require traditional healers to meet their standards, whereas traditional healers face integration difficulties and resist those approaches; rather, they are concerning with preserving their own traditions. Also, each side recognises health legalities differently. Obtaining licensure is the biggest issue for modern health practitioners, whereas traditional healers simply practise their profession at their customers’ request. However, although modern medicine appeals to a lot of customers, traditional healers remain attractive to patients because their treatments for a large variety of disorders are more effective than are those of modern practitioners. There is no doubt that traditional healers will continue to be a key resource for promoting community healthcare self-reliance. But the question of lasting cooperation between the two sectors remains unanswered. Acknowledgments We are grateful to all participants who have provided us with deep understanding of their contribution in Thai health. We would also like to thank the Faculty of Health and Sports Science, Thaksin University, Thailand and the School of Public Health, La Trobe University, Australia for the scholarship to support the first author in carrying out the fieldwork in rural Thailand. Additionally, we would like to thank DTAM, MoPH, Phatthalung Provincial Health Office (PPHO), and all local government organisations and their staff who gave the first author their sincere support during the process of our data collection.
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