Exploring Traditional Medicines use by Ghanaian households

Azusa SatoLondon School of Economics, UK

Introduction

• Traditional medicines (TM)/healers: WHO– ‘the knowledge, skills and practices based on the

theories, beliefs and experiences indigenous to different cultures, used in the maintenance of health and in the prevention, diagnosis, improvement or treatment of physical and mental illness’

– Utilisation rates– Uses

Objectives/research Qs

• Explore utilisation of medicines from a household perspective. • Q1:

– How does need for medicines (both modern and traditional) differ from actual utilisation? What characterises those who seek health care from formal institutions and traditional medical practitioners?

• Q2: – What are the perceived benefits and satisfaction levels from TM use?

• Q3:– Given the same need, are the rich more likely to use modern

medicines than the poor, whilst the poor use traditional medicines? • Q4:

– How deep is the inequity in the utilisation of medicines?

Methods (1)• Fieldwork and data collection

– Two regions in Ghana, late 2010 following pilot– Research assistance– Household surveys n=772 using WHO methodology– ‘Household’ and respondents– A few healer interviews

InsRegion

Methods (2)

• Relevant data collected– Socioeconomic background particularly income– Whether utilised TM/H and/or modern care for a

given ‘need’ (self assessed severity, acute or chronic) – need and utilisation

– Satisfaction before and after – satisfaction– EQ5D before and after – perceived benefits

• Mobility; self care; activities; pain; anxiety

Methods (3)• Descriptives to answer Q1 & Q2• Biprobit and Ordered probit to answer Q3

• Joint estimation TC and MC: 4 outcomes• Choice ordering • Both models have appropriate controls included

• Concentration and horizontal indices to answer Q4• Quantifies degree of inequity• Covariance between utilisation and the fractional rank in the living

standards distribution (here, log equivalised household income)• +ve: pro rich utilisation• -ve: pro poor utilisation• 0= perfect equity; 1=perfect inequity• Decomposition

Results to Q1• How does need for medicines (both orthodox and traditional) differ from actual

utilisation?– Need expressed by 741/4713 (16%) individuals, presenting 460 acute and 301

chronic illnesses (some people had both acute and chronic)– Utilisation

• Overall, unmet need is low• Across all recourses 31% (231) used TM/H• Use of modern medicines as a first recourse• Use of TM as a second recourse

• What characterises those who seek health care from formal institutions and traditional medical practitioners?– More likely to use if: older, female, without education, farmer, no religious

affiliation, Waale/Dagaare ethnicity, not insured, have chronic illness, rate it as serious, are poor, live in third radius and in a non urban area

Acute illness(460)

Seek care (445)

Seek outside care (405)

Orthodox medicines provider

(367)

Public providers (162)

Public hospital (73)

Public health centre/dispensary

(51)

Community health practice (38)

Private providers (205)

Private hospital (20)

Private clinic (8)

Private pharmacy (73)

NGO/mission hospital (25)

Drug seller/LCS (66)

Drug Peddler Orthodox (13)

Traditional medicines provider

(28)

Drug peddler TM (1)

Herbal shop (3)

Herbal clinic/hospita (0)

Bonesetter(3)

Fetish priest (0)

Non spiritual herbalist (17)

Spiritual herbalist (3)

Spiritual church/diviner (1)

Other (10)

Seek care at home (40)

Orthodox medicine (23)

Traditional medicine (17)

Do not seek care (15)

First recourse only, acute

Chronic disease (301)Does not take medicines (5)

Takes medicines (296) Orthodox medicines provider (251)

Public providers (150) Pub lic hospital (1 17)

Public health centre/dispensary (15)

Community health practice (18)

Private providers (101)Private hospital (20)

Private clinic (15)

Private pharmacy (25)

NGO/mission hospital (26)

Drug seller/LCS (15)

Traditional medicines provider (38)Drug peddler TM (6)

Herbal shop (4)

Herbal clinic/hospita (4)

Bonesetter(0)

Fetish priest (0)

Non spiritual herbalist (20)

Spiritual herbalist (4)

Spiritual church/diviner (0)

Obtains medicines at home (7)Traditional medicine (6)

O th er (1 )

First recourse only, chronic

Results to Q2• What are the satisfaction levels after TM use?

• Results are confirmed when satisfaction is measured on a numeric scale• EQ5D results

• Acute: only 3 cases where conditions worsened, 100 cases reporting no change or at least a positive change

• Chronic: only a handful where conditions worsened

V satisfied/Satisfied Neutral Unsatisfied/v unsatisfied0

10

20

30

40

50

60

70

80

90

AcuteChronic

Results to Q3• Given the same need, are the rich more likely to use orthodox medicines than

the poor, whilst the poor use traditional medicines?– Most people are very likely to use modern care as a first choice rather than

2nd/3rd/never at any level of income• A 1% rise in income is associated with a:

•5% rise in ever using modern care without traditional care•2.5% fall in ever using traditional care without modern care•1.9% fall in using modern and traditional care together•1.9% , 2.7% fall in using traditional care as a first and second recourse, respectively

0.2

5.5

.75

1P

redi

cted

Pro

babi

lity

0 2 4 6 8log income

first choice is modern second choice is modernthird choice is modern no choice is modern

0.2

5.5

.75

1P

redi

cted

Pro

babi

lity

0 2 4 6 8log income

first choice is traditional second choice is traditionalthird choice is traditional no choice is traditional

Results to Q4• How deep is the inequity in the utilisation of medicines?

– With only modern care accounted for, concentration index is 0.049. With TM, 0.030.

– Modern care is pro rich; traditional care is pro poor but patterns vary by sub category

– Non need and income account for a large proportion of the inequity

  CI HI using LPM

Modern care all

0.049 0.050

  Public -0.057 -0.058

  Private 0.403 0.303

  Self  0.085 0.055

Trad care all

-0.115 -0.079

  TM self 0.090 0.105

  TH -0.234 -0.247 all m

odernPublic

Private

Self m

ed

all tr

aditional

TM se

lf TH-0.3

-0.2

-0.1

0

0.1

0.2

0.3

0.4

0.5

Decomposition of horizontal inequities LPM

residualneednon needincome

HI

Summary, discussion, policy• unmet need is low especially when TM/H use is taken into account

• It is only at the second recourse that its use is more common: TM/H is a back up choice and generally people have a revealed preference for modern medicines.

• Users are very satisfied with outcomes: low expectations and some utility gained from placebo effects and the pure act of utilisation, but some scientific evidence also exists to corroborate the perceived health benefits.

• multiple recourses of care and polypharmacy , some deficiency in the modern health systems, as individuals are compelled to seek care from other and multiple sources.

• The rich are more likely to use modern medicines and at earlier stages of care seeking than the poor. Conversely, the poor are more likely to use traditional sources of care.

• By taking into account TM/H use, equity in utilisation rises. Conventional equity studies are advised to consider use of traditional care, else they may be overstating the depth of inequity.

• Modern care utilisation is pro poor thanks to the public providers but traditional care is strongly pro poor.

• Differences between traditional medicines use by self medication (pro rich) and healer use (pro poor). Policy should therefore resist the temptation to group the two under the same heading, as it is likely that individuals with different characteristics are using them.

Thank you!a.sato@lse.ac.uk

Forthcoming paper: ‘Revealing the popularity of traditional medicine in light of multiple recourses and outcome measurements from a user’s

perspective: a study from two regions in Ghana’ Health Policy and Planning

I would like to give special thanks to individuals in Ghana who helped with this project, including Kojo Arhinful, Kwame Buabeng, Mahama Duwiejua and all research assistants, without whom the study would not have been

possible