INTEGRATION OF TRADITIONAL MEDICINE AND

ALLOPATHIC HEALTHCARE TO STRENGTHEN THE

HEALTH SYSTEM IN MADAGASCAR
 Health system trapped in cycle of political instability

Top-down approach of intervention, relying on a weak

government

Dependence to external funding (from international donors)

Uncoordinated health interventions

Concern for the sustainability of the system

Local communities and resources = The Sleeping giants

Purpose:
To explore an alternative to strengthen
the current health system in
Madagascar

Structure:
Profile of the current health system

Traditional medicine

Integrated health system

Key definitions

Health system

all actors, institutions and resources that

undertake health actions where a health
action is one where the primary intent is to
improve health (WHO)

the combination of resources, organisations,

and management that culminate in the
delivery of health services to the population
(Roemer, 1991)
Key definitions (contd)

Health system building blocks

Key definitions (contd)

Allopathic medicine (biomedicine) /

Allopathic health care

A system in which medical doctors and other

healthcare professionals (such as nurses,
pharmacists, and therapists) treat symptoms
and diseases using drugs, radiation, or surgery.
Also called biomedicine, conventional medicine,
mainstream medicine, orthodox medicine, and
Western medicine (National Cancer Institute
Dictionary)
Key definitions (contd)

Traditional medicine / Traditional

health care

the sum total of knowledge, skills and

practices based on the theories, beliefs and
experiences indigenous to different cultures
that are used to maintain health, as well as
to prevent, diagnose, improve or treat
physical and mental illnesses (WHO, 2013)
Key definitions (contd)

Integrated health system: An organized, coordinated and

collaborative network that: (1) links various health care providers,
via common ownership or contract, across three domains of
integration economic, noneconomic, and clinical to provide a
coordinated, vertical continuum of services to a particular patient
population or community and (2) is accountable both clinically and
fiscally for the clinical outcomes and health status of the population
or community served, and has systems in place to manage and
improve them (Enthoven, 2009)

Integrative health care: The combination of both conventional

and alternative approaches to address the biological, psychological,
social and spiritual aspects of health and illness. It emphasizes
respect for the human capacity for healing, the importance of the
relationship between the practitioner and the patient, a collaborative
approach to patient care among practitioners, and the practice of
Situation of health in Madagascar

Population in 2012: 22,294,000

Life expectance at birth: 55 years

Adult mortality rate (probability of dying between age

of 15 and 60 years per 1,000 pop): 17%

Maternal mortality ratio (deaths per 100,000 live

birth): 440 in 2013

Neonatal mortality rate (deaths per 1,000 live birth):

21
Under-five mortality rate (deaths per 1,000 live birth):

168
Government expenditure on health: 2.5% of GDP

(12.80% of total expenditure)

Per capita expenditure on health: 39.86USD
Profile of the current health system
Health care pyramid
CH
U
Pu
blic
Referral
20
Hospitals
(CHR)
District Hospitals
(CHDII)
Public 31, Private 65
District Hospitals (CHDI)
Public 56 (54 functionning),
Private 4
Community-based health centres (CSBII)
Public 1632 (1610 functionning),
Private 473
Community-based Health centres (CSBI)
Public 956 (875 functionning), Private 120

Community health workers

Main gaps

Geographical accessibility of health care service

35% of people in rural areas are more than 10km away from CSB

Shortage of health professionals

Ratio Physicians/Population = 1.600/10,000 pop (WHO, 2006-2013)
Nursing and midwifery personnel density = 0.316/1,000 pop
Community and traditional health workers density = 0.022/1,000 pop

Affordability of treatment: Free consultation but patients have to pay for

medications
Mechanism FANOME and Equity Fund for the poorest limited number of

beneficiaries; 0 to 0.50% of population identified as beneficiaries

Health mutual funds and private insurance access to social protection exclusive

to people with income

Poor capacity of health care facilities:

Health centres = 0.30/100,000 pop
Hospital beds = 2 beds/10,000 pop
 Rationale for an integrated
health care system in
Madagascar
Use of traditional medicine: 70% of Malagasy rely on traditional medicine,
mainly in rural areas (Kaehler, 2013)

Integration = collaboration, coordination

Holistic approach to health

Conservation and promotion of culture and traditional practices

Conservation of biodiversity and promotion of local knowledge

Exceptional biodiversity, with levels of endemism among flora and fauna
reaching as high as 83% (Rabenantoandro, et al., 2007)

Accessibility and affordability: geographical proximity, service provided by

traditional health practitioner is free of charge or paid according to patient
willingness
Status of traditional medicine in
Madagascar and potentials for
integration
History of health care, culture and beliefs in
Madagascar
Alma Ata Declaration (1978)
WHO Traditional Medicine Strategy
Legal and structural framework for the practice
of Traditional Medicine in Madagascar: Dcret
2007-805 along with the establishment of related
structures (Department of Traditional Medicine
and Pharmacy within the Ministry of Health,
Association of Traditional Health Practitioners,
Local Committees of Traditional Medicine)
 Framework of integration

Aim of the integration: strengthening health system

for each building block.

Professional integration: complementarity of practices

between allopathic health professionals and traditional
healers, consultation between the two professions
Continuity of care

Public funding to support traditional medicine

Governance framework: integration of traditional

medicine within the health care system structure

Traditional treatment included in the prescribed

medications, not as the main treatment but as a

complement
 Process of integration

Continuum of integration and scale of functional clinical

integration (Browne, 2004)
Experience of integrated health
system

Examples of integrated health care in

Madagascar:

Case of Traditional Birth Attendants

(Reninjaza)

Case of a Pilot clinic in Northwest

Madagascar: Clinic of Manongarivo
Case of traditional birth attendants:

TBAs perform maternal health care (mainly pre-

natal care), attend birth and refer complicated
cases to health centres where they assist health
professionals in the delivery process.

Pre-natal care provided by TBAs helps to reduce

the risk of maternal mortality.

Pre-natal care includes checking the position of

the foetus, changing it by the mean of massage.
Case the Clinic Manongarivo (1993-1997)

Method of working:
Laboratory team

Field team

Diseases were treated by:

medicinal plant(s) only

modern medicine(s) only

the combination of medicinal plant(s) and modern medicine(s).

Of the 36 different diseases encountered at the Clinic: 77.78% were strictly treated effectively
by local medicinal plants; 5.56% by pharmaceutical products while the other 16.66% were
treated using a combination of medicinal plants and pharmaceutical products (Quansah, 2005).

By reinforcing the use of local medicinal plants, which is often free (at worst 5 to 10 times less
expensive than the pharmaceutical product) the Clinic enabled patients to cut down on their
health care costs. People saved money by using medicinal plants for the diseases that these
plants could take care of rather than relying solely on pharmaceutical products for all diseases.
(Quansah, 2005)
 Challenges of integrated
health care system
Resistance and conflicts between allopathic doctors and traditional health
practitioners

Policy and legal framework

Formalities and procedures for joining the association of traditional health

practitioners

Safety, efficacy and quality

Cost-effectiveness: viability and sustainability of free services

Access: services are delivered at the CSBs issue of geographical accessibility

not solved

Rational use: traditional medicine is not replacing biomedicine; they

complement each other; respect of dosage
Conclusion and recommendations

Pros:
Traditional medicine has a potential to

contribute to strengthening the health care

system
Richness of biodiversity and local knowledge

allow the development of traditional medicine

that complement biomedicine
Traditional healers have a cultural and social

value, accepted by the communities

Low cost health service (treatment)
Cons:
Unsafe

Irrational use (dosage)

Slow effect of treatment

Traditional healers are widespread and

hard to identify
Recommendation

Investment in research and development

Formalization of traditional healer and
practice
Census of traditional health
practitioners, keeping records
Integration strategy and
programmes/plans
Budget
Partnerships