Perspective Chapter: Integrating Traditional Healers into the National Health Care System – A Review and Reflection

Abstract

This paper reviews and reflects on the policy efforts to integrate traditional healers in Nepal. Most people in rural Nepal rely on traditional healers for their primary health care needs, not only because health facilities in rural areas are poorly functioning but also because these healers meet various health care needs. The kind of traditional medicine provided by traditional healers (such as herbalists, bone setters, faith healers, and traditional midwives) is much more accessible to them than the practitioners of biomedicine and scholarly traditional medicine (such as Ayurveda, Unani, and Homeopathy). However, traditional healers have not been recognized as legitimate practitioners. Policy initiatives are needed to facilitate recognition, accreditation, or licensing of traditional healers so that they can be integrated into the formal structure of the health care system. Nepal’s recent initiative of registration of traditional healers is an important policy effort in this direction.

1. Introduction

Traditional medicine is widely used and the world today sees its relevance for health and well-being [1]. The issue of integration of traditional healers into the national health care system got prominence around the time of Alma-Ata Conference in Primary Health Care in 1978 [2, 3, 4, 5]. The Alma-Ata Declaration not only highlighted the wide existence of traditional healers including traditional birth attendants but also the importance of engaging them in the formal health system to meet primary health care needs. The Declaration stated that

“With the support of the formal health system, these indigenous practitioners can become important allies in organizing efforts to improve the health of the community. Some communities may select them as community health workers. Therefore, it is worthwhile exploring the possibilities of engaging them in primary health care and training them accordingly” [6].

Following the recommendation of the Alma-Ata Declaration, many nation-states explored the possibilities of integrating them. Those traditional healers who were practicing scholarly traditional medicine (such as Ayurveda, Unani, and Homeopathy) or qualified in any stream of these systems were recognized as practitioners and integrated into the formal health care system. Those traditional healers (who were practicing “folk”, “popular,” or “indigenous” traditional medicine) largely remained outside the state’s purview and regulation. Only 36 countries have regulated “indigenous traditional medicine providers” that include “traditional healers, bone setters, herbalists, and traditional birth attendants” [7].

Though the integration of traditional medicine into the general public health system has been recognized as a “pressing need” [8], no such laudable efforts were made in bringing traditional healers into the fold of the formal health system. Scholars have recognized the important role traditional healers play in primary health care and often they are described as “the principal health care providers”, “primary source of health care”, “first point of contact”, “first treatment of choice”, etc. and appreciated for their healing prowess and herbal knowledge. The contribution of traditional healers in primary health care has been highlighted and scholars argue for their inclusion in the formal health care system [9]. Despite all this, the integration of traditional healers remains to be an unfinished dream in many nation-states.

The scholarly emphasis seems much on traditional medicine, medicinal practices, and medicinal herbs rather than the traditional healers who practice medicine and who have the knowledge of using herbs as medicine. This is something that recognizes the value of medicinal herbs but not the traditional healers who have been using them. This is something that tends to recognize the knowledge but not the (original) knowledge holder.

In many developing countries, health facilities are largely concentrated in urban areas [10] and rural populations are poorly served by the formal healthcare system. Traditional healers are providing at least some form of health care to the rural populations who are underserved by the formal healthcare system [11]. Even in urban areas, formal healthcare services are expensive, and traditional healers work as an affordable substitute. The kind of traditional medicine provided by traditional healers (such as herbalists, faith/spiritual healers, bone setters, and traditional midwives) is much more accessible to them than practitioners of biomedicine and scholarly traditional medicine. Moreover, some traditional healers address the different healthcare needs that patients cannot avail from formal healthcare providers.

Traditional healers, in many settings, lack legitimacy and are practicing informally. The issue of traditional healers’ legitimacy has drawn the attention of scholars and activists. In this context, this chapter looks into Nepal’s efforts to integrate these healers based on the literature, policy documents, periodic plans, and programs. However, some of the descriptive information about the healers are backed by my field experience [12, 13, 14]. The chapter begins with a short note on the health care system of Nepal, looks into the difference between scholarly and popular traditional medicine, and then describes the volume and types of traditional healers and then examines their place in the policy documents and periodic plans. The last part of the paper reviews the recent development of registration standards for traditional healers, reflects on challenges and opportunities, quality concerns, and how government can support traditional healers to provide quality traditional medicine services, and emphasizes the need for the policy initiatives as concluding remarks.

2. Health care system of Nepal

Healthcare services are provided by both public and private facilities. The public sector provides health services from 201 public hospitals, 189 primary health care centers (PHCC), and 3,794 health posts (HP), and the private sector provides from 2082 facilities [15]. After entering into the federal system of government in 2017, Nepal has three levels of government (a federal, seven provincial, and 753 local) and the local level governments’ role has become very important in the delivery of health care services. The local government plays an important role in the administration of PHCC and HP and the provision of services to local communities [16].

Traditional medicine services are also provided by both public and private health facilities. Public facilities include a total of 382 Ayurveda facilities (2 Ayurveda hospitals, 14 Zonal Ayurveda Dispensaries, 61 District Ayurveda Health Centers, and 305 Ayurveda Dispensaries), 1 Homeopathy hospital and an Unani dispensary [17]. Several private facilities (hospitals, clinics, and pharmacies) provide Ayurveda, Homeopathy, Sowa-Rigpa, and Naturopathy services.

Nepal is ranked 143 (out of 192 countries) on the Human development index [18] and 98 (out of 163) on the SDG index [19]. Nepal has relatively low health expenditure (around 5% of GDP) and high out-of-pocket spending (around 57% of the total health expenditure) [20] and only 21.35% of the population has been covered by the national health insurance program [21]. People have to pay from their own pockets for traditional medicine services because traditional medicine facilities are yet to be included in the list of service provider institutions.

Nepal has high poverty headcount ratio (32.8% at $3.20/day), high maternal (186/100,000 live births) and under-5 mortality rates (28/1000 live births), and high prevalence of stunting (31.5%) and wasting (12.0%) in under-5 children, and low life expectancy at birth (70.9 years) and low subjective wellbeing score (4.4 in the scale of 0–10, worst-best) [19].

The total population of Nepal is 29.1 million, according to the 2021 census. There are a total of 2,67,891 registered human resources for health (including 28,477 medical doctors, dentists, and specialists; 96,430 nurses and auxiliary nurse midwives; 77,605 health assistants and auxiliary health workers; 14,720 pharmacists, 790 Ayurveda physicians, and 4281 Ayurveda practitioners; 71 Naturopathy and Yoga practitioners, 174 Acupuncture practitioners, and 228 Homeopathy and Unani practitioners) [22]. The Sowa-Rigpa practitioners have not been registered yet but it is likely that they will be registered soon.

The doctor-to-population ratio (0.9 physicians/1000 population) and nurse-to-population ratio (2.1 nurses/1000 population) in Nepal are far less than the SDG index threshold of 4.45 physicians, nurses, and midwives per 1000 population [23]. The concentration of the health workforce in urban areas resulted in an unequal distribution of human resources for health. Although traditional healers are widespread in rural areas, they remain an untapped resource. Traditional healers hold the possibility to contribute to achieving SDG 3, which is about “ensuring healthy lives and promoting well-being for all at all ages.” Moreover, their service is in line with the spirit of universal health coverage in the sense that people can access traditional healer’s services at their doorstep whenever they need, without financial hardship [24].

3. Traditional medicine: scholarly and popular

Following Dunn [25], traditional medicine can be divided into two groups: (i) Scholarly traditional medicines which are distributed over a relatively large area such as Ayurveda, Unani, and traditional Chinese medicine, and (ii) popular traditional medicines, also known as “folk” medicine, are the local or small-scale medicine rooted in the ethnocultural traditions. Scholarly traditional medicines represent the textual tradition and are codified and institutionalized whereas popular traditional medicines represent oral tradition and largely remain in non-codified and noninstitutionalized forms.

The practitioners of scholarly traditional medicine in Nepal hold academic degrees and are registered with Nepal Ayurveda Medical Council (NAMC) or Nepal Health Professional Council (NHPC). Traditional healers lack such degrees and certificates and practice without getting registered. To date, only 19 traditional healers have been registered with NAMC. This means all the healers, except those registered with NAMC, are practicing without being registered. NAMC is the autonomous body to regulate Ayurveda medicine, practitioners, courses, institutions, and traditional healers in Nepal.

Traditional healers in Nepal do not have a formal status. They are not institutionally trained, accredited, or licensed. The current legal framework does not recognize them as legitimate health practitioners. It is important to bring traditional healers into the regulatory framework in order to ensure the safety and efficacy of their practices. The healers have also felt pressure to be registered to serve as valid practitioners and get needful support from the state [26]. Scholars have continuously pointed to the need for the registration of traditional healers. There is an ongoing policy debate to recognize their knowledge and integrate their practices into the formal health care system.

4. The types of traditional healers

Though traditional healers form a major source of health care for many people, they are not a homogeneous category. Various types of traditional healers are catering to people’s health care needs. In this chapter, the term “traditional healers” has been used to refer to herbal healers, bone setters, traditional midwives, massagers, faith healers, or any such practitioners who are experienced enough and recognized as healers by the community people. These healers are the informal providers who are not trained in academic institutions but provide health care services based on traditional knowledge and experience. They hold knowledge of medicinal herbs, healing mantras, traditional midwifery, and massage and are consulted for physical, psychosocial, and emotional health problems. They learn the healing knowledge as a family tradition or work under their gurus, the senior traditional healers. Some of them have expanded their knowledge through long-term practice and self-study. They represent the oral tradition and treat patients with herbal remedies and/or healing mantras, based on lineage inheritance of knowledge and experience. Despite the expansion of healthcare services throughout Nepal, a large number of people take recourse to these healers [27]. These healers command the trust of the community in which they live. The healers and patients share the same culture and worldview. In the villages, they are treated with respect and are consulted for a range of physical, emotional, spiritual, and psychosocial problems.

Traditional healers are invariably described as folk healers, indigenous healers, native healers, or indigenous traditional medicine providers. There is no Nepali equivalent term to refer to traditional healers [28]. They are known by different names in different communities. These healers can be categorized into three broad groups:

4.1 Herbal healers

Herbal healers are informal providers who exclusively rely on medicinal plants for the treatment of different health problems. Though they are also known as vaidya (informal Ayurveda practitioner), amchi (informal Sowa-Rigpa practitioner), and hakim (informal Unani practitioner) but are not qualified from academic institutions. They follow textual tradition by learning privately in the family or with the guru and, therefore, hold no certificates or degrees. There are other categories of herbal healers who do not follow textual tradition but hold the knowledge and know-how of medicinal herbs and deal with specific health problems such as jaundice or bone fracture. These healers use medicinal plants and plant parts, mineral substances, and animal products as medicine. Some of them also purchase manufactured herbal medicine and dispense them keeping a margin of profit. The herbal healers are consulted for physical illnesses and injuries. Some specialist traditional healers are consulted for specific illness problems such as bone fractures, snake bites, jaundice, stomach pain, and joint pain.

4.2 Faith/spiritual healers

Faith/spiritual healers use nonmaterial means for diagnosis, prevention, and treatment, invoking unseen/spiritual forces. Some of them may combine healing mantras with herbal medicines. They are known as dhami-jhankri (shamans), jannne-manchhe (those who know herbal and faith healing), jhar-phuke (healers who sweep down or blow out evil spirits), mata (a woman healer possessed by Goddess), jyotish (an astrologer who foretells star and suggest rituals like grah-shanti), pundit, pujari, lama, gubhaju, or guruwa (who do faith healing and priestly work). Faith/spiritual healers largely follow the ritual methods of treatment. They are consulted for the illnesses, which are locally understood and explained such as daraune (frightening), jhaskine (startling), nidra nalagne (sleeplessness), chhatpati hune (restlessness), and similar other illnesses of emotional, spiritual, and psychosocial nature [12].

4.3 Traditional midwives

Traditional midwives are known as sudeni, who assist in homebirth and provide postnatal care and massage. Traditional midwives also use medicinal herbs and oils, treated with ingredients such as fenugreek, for massage.

5. The size of traditional healers

Traditional healers are found in every village and town in Nepal. Scholars and planners often quote a study [29] that had estimated the number of traditional faith healers to be around four to eight hundred thousand. The number also shows that faith healing is the most widely prevalent tradition in Nepal [30]. The number got an entry in the Ninth Five Year Plan [31], which stated: “to encourage about 800,000 traditional healers (dhami, jhankri, lama, and vaidya) to provide health services.” Till today, no such study has been done to estimate their precise number and types. However, a common understanding is that the number of traditional healers is dwindling, as the young generation is not interested in taking up the profession of traditional healing. In recent times, formal healthcare services are being expanded. Health awareness is increasing and faith healing is fading. There are instances of faith healers who have left their long-standing faith-healing professions. Similarly, traditional midwives’ role has been shrunk with the promotion of institutional deliveries [13]. However, herbal healers have retained their relevance, and even today, traditional healers have a robust presence in Nepal, especially in rural areas. They outnumber the medical practitioners and “85% of the rural population turns to traditional healers as their first point of care” [28].

6. Traditional healers in policy and periodic plans

Ayurveda Medical Council Act 1988 allowed registration for those traditional healers who were 50 years and above and practicing herb-based Ayurveda medicine as a family tradition for the last three generations and [32]. The Section 5.1.1B of the Act states that “In the case of a person who is Fifty years of age, and having obtained recommendation from the concerned District Office with the certification of experiences being involved in the Ayurveda medical science since three generations, such person may carry on Ayurveda medical profession by obtaining permission under separate provisions as specified by the Council within one year from the date of commencement of this Act.” The Act also barred the unregistered traditional healers to practice as this was made punishable offense with “a fine not exceeding 3000 rupees or with imprisonment for a term not exceeding six months or with both.” This provision was criticized as “ridiculous and humiliating” [33]. Indeed, this provision was restrictive for those who were below 50 years of age and even for the eligible healers it was just a one-time opportunity to get registered. This may be the reason why there are only 19 traditional healers registered with the NAMC. The Act illegitimated many traditional healers but they kept practicing without getting registered. Rather, they continued to advocate for their rights and recognition. The scholars and activists also argued in favor of traditional healing/healers and questioned the government’s reluctance, inaction, and skepticism (see Box 1 below). The issue of registration and integration invited much debate and discussion among scholars, activists, planners, and policymakers.

“The government cannot remain silent about those who are providing health care to the people in one way or another. Either it [government] should say that there is no use of traditional healer’s service, with strong reason; otherwise, it should investigate and open a way to legalize traditional healing”—Shantalal Mulmi, RECPHEC; “The knowledge received from their forefathers, the treatment method of preparing medicine at home from naturally obtained herbs and other things is the original method of Nepal and it is the responsibility of the state to build it and properly manage it”—Dr. Sarita Shrestha; “Such treatment methods which are used for the sake of service rather than financial gain are cheap and accessible as well as being close to the way of life should be mainstreamed”—Madhubajra Bajracharya; “Therefore, in order to register the traditional healers, the government should take an initiation to formulate plan and policies focusing on traditional healers” [26].; “Traditional healing deserves its due share in government budgetary allocation” [28].; “The roles and responsibilities of traditional healers must be identified and clearly defined” [34].

Box 1.

Activists and scholars speaking in favor of traditional healers.

6.1 Healers in the periodic plans

An examination of national policies and planning documents reveal inconsistent and insignificant efforts to recognize and integrate healers. In 1998, Nepal Human Development Report [35] wrote, “Traditional healing received little direct support from the state, but in the last 15 years there have been efforts to integrate it with the public health system. But such efforts were peripheral and lukewarm.” This shows that there was only a half-hearted effort to integrate traditional healers. Though some of the periodic plans emphasized traditional healers’ training. For example, the Sixth Five Year Plan [36] had a program to provide training to traditional healers (such as vaidya and jhankri) and then the Eighth FYP [37] also repeated to provide training to traditional healers including birth attendants and mobilize them. The Ninth FYP [31] specified the number of healers and planned to encourage them to provide health care services. Subsequent periodic plans did not mention traditional healers but repeated government’s commitment to protect and expand Ayurveda and other alternative systems. Thus, in the planning documents, traditional healers sometimes got a mention and sometimes did not. Nevertheless, traditional healers’ training remained one of the regular activities of DOAA and at times NGOs also included traditional healers’ training in their programs. The training events were mostly intended to increase knowledge of the formal treatment processes and seek referral support rather than to enhance their knowledge and skills in traditional healing (for example, see [38, 39, 40]).

6.2 Healers in the health policy

National Health Policy 1991 emphasized the participation of women volunteers and birth attendants (Sudeni). National Ayurveda Health Policy 1996 also emphasized the training of traditional healers and the protection of their knowledge. National Health Policy 2014 continued to repeat “develop, protect, and promote Ayurveda and other complementary medicine.” However, the National Health Policy 2019 states that “the existing traditional health care system shall be enlisted, managed, and regulated as per the standard” [41]. This policy provision seems developed from the Nepal Health Sector Strategy [42], which had iterated the government’s commitment to the protection and promotion of traditional medicine. The strategy accepted the popularity of traditional practices that are being provided by traditional healers and showed the need to study the effectiveness of this method by bringing them into the mainstream. Similarly, the second long term health plan was to provide traditional healers with appropriate training in health, nutrition, and family planning, and use them in health education activities at the local level [43].

7. Registration standard for traditional healers

After a long debate and series of discussions, the Department of Ayurveda and Alternative Medicine (DOAA) drafted registration standard for traditional treatment providers [44] to facilitate local governments in the registration of traditional healers. The registration standard recognizes traditional healers as Paramparagat Upacharak. This Standard has been adopted, approved, and published in the Local Gazette by some municipalities (Palika), the local government body. The Standard provides guidance and criteria for the registration of traditional healers. The Standard aims to provide a regulatory framework to ensure the efficacy, safety, and quality of traditional healing; to provide for the management and control over the registration, training, and conduct of practitioners.

The registration standard is based on the provision of Article 22 of the Public Health Service Act, 2018. Article 22 states that it is mandatory to obtain a license to provide health services. Article 22 (3) of the Act states that “In the case of the traditional treatment service, service shall be provided after obtaining approval pursuant to the standards prescribed by the Local Level” [45]. While the practitioners of Ayurveda, Unani, Homeopathy, Yoga, and Naturopathy are registered with the NAMC or NHPC, traditional healers (except those 19 traditional healers) are practicing without being registered. Since the existing legal framework and regulatory body do not recognize them as legitimate health practitioners, the Standard addresses the registration issue, at least for those traditional healers who meet the requirements.

The registration standard defines traditional healers as “those persons who provide treatment at their home based on the knowledge, skills, technology, and experience acquired from their ancestors or gurukul traditions, examining the patients looking at the cause, nature, and condition of the disease, and using or processing various herbs, minerals, and animal products available naturally at the local level” [44]. The registration standard also recognizes the three categories of healers: (i) Herbal healers, (ii) Spiritual healers, and (iii) Traditional midwives (Sudeni).

7.1 Objectives of the registration standard

The main objective of the registration standard (see Box 2) is to bring traditional healers into the regulatory framework. The Standard recognizes those healers who are involved in providing treatment for certain diseases by using certain herbs or sources, those who have acquired healing knowledge through at least 15 years of closeness to ancestors or gurus, and those who have adopted traditional healing as their main occupation. In addition to having a clear knowledge of the cause and symptoms of the disease to be treated, in case of using herbs or materials, the healers should have a genuine knowledge of the place and source along with properties, process, collection method, and time, processing, storage, preservation, supply, and usage. In the case of those who manufacture medicine from herbs and use it, they should properly follow the manufacturing method, use local resources and prepare medicine themselves, and provide health care services.

Identify, classify, and collect data on traditional healers and their health and cultural knowledge. Assist in documenting and preserving the knowledge, skills, and technology of traditional healers. Document, validate, protect, promote, develop, and expand the knowledge, skills, and techniques of traditional healers. Determine the eligible and capable traditional healers and delimits their role by classifying them based on their qualification, capacity, and geographical and subject area. Make the registered healers work within the prescribed limits and prepare a basis for discouraging and punishing those who do not comply. Bring uniformity in the standards of traditional healers at the local levels. Protect intellectual property rights. Preserve traditional healers’ professions and promote their knowledge, skills, and techniques. Facilitate research studies related to traditional healing.

Box 2.

Objectives of the registration standard for traditional healers.

7.2 Rights and duties of healers

The Standard defines the functions, duties, and rights of traditional healers. The healers are required to keep records, not only of the method of collection of herbs, the place of collection, and the manufacturing process but also of patients' symptoms, conditions, services provided, and medicines dispensed, including the quantity and dosage. The healers should be able to identify herbs well and prepare medicines at home from such herbs and should have provided treatment services by making medicines from herbs without using the classical or patent medicines manufactured by different companies. The Standard prohibits healers from using classical or patent medicines of various companies, manufactured by using modern technology or knowledge and skills or those readily available in the market. The Standard allows healers to make medicine required for the treatment but forbid them to produce to sell in the market. The Standard does not allow them to advertise their services and products.

The healers are required to contact and coordinate with the Ayurveda dispensary or municipality in case they have specific knowledge, skill, technique, or original manuscript for verification, protection, enrichment, or printing support. Traditional healers who provide health services without being registered will be prosecuted according to prevailing Nepali laws. The Standard gives authority to the municipality to explain the clause of the Standard, to change and modify the schedule of the Standard, and to issue a notice for the registration of the traditional healers.

8. The challenges and opportunities

Traditional healers are not a homogenous category. Integration of diverse forms of traditional healers is a challenge. There are a variety of traditional healers, classified into three groups, and their practices differ considerably. Some practice herb-based medicine, while others mix with shamanistic and spiritualistic practices making it difficult for scientific validation of their practices. Some healers have adopted healing as their main profession and many others continue as a part-time voluntary service. Some do charge for their sustenance and some accept the nominal amount as an offering, yet others do not accept money as they think charging those who are ill is morally wrong. Some are consulted by their extended family members, relatives, and neighbors but some are also consulted by far-away patients. Some follow oral tradition and some follow textual tradition by doing self-study or learning from gurus or senior practitioners. Some healers specialize in herbal treatment, some in midwifery and massage, some in faith healing, shamanism, and magico-religious and spiritual healing. Some others are consulted for specific health conditions such as jaundice, joint pain, and stomach problem. And there is a mismatch of practices, for example, some of the traditional dhami-jhankri, they are known for faith healing also possess knowledge of herbs and include herbal treatment along with ritual treatment. The registration standard as it appears is favorable to those healers who practice herbal medicine and restrictive to those who provide faith healing.

Another challenge is that we do not have a good understanding of the number and types of these healers. And, we have no idea about the extent of use of traditional healers by the population, the kind of health care needs these healers address, the number of illness episodes they treat, and the quality of care they provide. There is no such mechanism to collect periodic data on traditional healing and healers’ activities. One of the points often gets mentioned is the declining interest in traditional healing and the dwindling number of traditional healers. The young generation is not interested in taking up their parents’ occupation, because healers get neither official appreciation nor any incentives. Traditional healing largely remains an unattractive profession because there is no monetary benefit. Though some healers have started to charge for the services and the medicine they dispense. But a very large number of healers give crude herbs and do not charge or charge nominally or take whatever is given out of happiness.

The young generation lacks knowledge and skills regarding medicinal herbs and traditional healing. The educational system has distracted students away from traditional health knowledge. Most of the healers are elderly, and the young generation is not willing to learn traditional healing (because it takes a long time to learn) and this is leading to the inter-generational loss of health knowledge [12].

Opportunity for integration exists when looked at from two different angles. The first is that ethnic communities form one-third of Nepal’s population and the ethnic communities do have their own healing traditions. The UNDRIP recognizes the importance of indigenous knowledge, and indigenous people’s “right to their traditional medicines and to maintain their health practices” [46]. Similarly, the ILO Convention (169) states that indigenous people’s “traditional preventive care, healing practices, and medicine” shall be taken into account while planning and administering health services. WHO encourages member states to integrate traditional and complementary medicine into health systems “by developing national policies, regulatory frameworks, and strategic plans for T&CM products, practices, and practitioners” [7]. The state policy as enshrined in the Constitution of Nepal is to protect and promote the traditional knowledge and experience of the indigenous people and local communities [47]. These international conventions, WHO strategy, and national constitution also work as background reasons to move towards recognition of traditional healing. Moreover, traditional healers are appreciated for their role in conserving traditional knowledge, biodiversity, and plant resources. Another important opportunity for Nepal is that a large number of traditional healers have been serving informally and struggling for recognition and integration. Moreover, traditional healers have community support and cultural legitimacy to their practice, and many scholars and activists see the potential of popular traditional medicine and traditional healers.

9. The question of quality in traditional healing

One of the questions often asked is the quality of treatment services traditional healers provide. If we accept that the kind of medicine people use should be of sufficient quality, it is reasonable to ask about the quality of medicine and services traditional healers provide. Since traditional healers lack academic training, doubt over their prowess, experience, and wisdom exists. Though some studies have found medicinal herbs that are being used by herbal healers are consistent with the principles of Ayurveda [26], their practices have not been validated scientifically and the risk of inappropriate use of herbs exists. Traditional healing is not free from harmful practices and needs extra attention and effort to discourage harmful practices and promote beneficial practices. Beneficial practices “should be scientifically validated and integrated into the health system” [26]. As Dr. Margaret Chan stated, “traditional medicines, of proven quality, safety, and efficacy, contribute to the goal of ensuring that all people have access to care” [1], the quality question is far more important when it comes to traditional healing. From the equity perspective, traditional healing needs additional attention and effort from the state to increase its quality. Steps should be taken to validate traditional healers’ knowledge and practices as well as enhance their knowledge and skills.

Popular traditional medicine is the primary source of care for the socioeconomically poor who live in rural areas, and from the equity perspective, it should get priority [48]. However, governments seem reluctant to make a budgetary allocation to address the issue of quality. Traditional healers can be provided with training and modular courses. The registered healers can be recognized by awarding a certificate of appreciation and/or monetary incentives for their outstanding service. They can be incentivized with training, equipment, seed, and saplings to grow medicinal herbs in their home gardens. They can be facilitated to form their associations at local, provincial, and national levels. These associations can be supported to work as a self-regulatory body of traditional healing. An institution can be established to document traditional healing practices and herbal knowledge to build the capacity of traditional healers and promote research activities. Some of the healers can be selected and mobilized as traditional medicine volunteers or Ayurveda health volunteers like the female community health volunteers. There are many things government can and should do to increase access and to enhance/ensure the quality of popular traditional medicine.

People in Nepal often consult traditional healers before consulting formal practitioners [49]. Traditional healers have been making an important contribution to primary healthcare [40] and for the benefit of the community, these healers need to be recognized and integrated into the formal healthcare systems. Integration of traditional healers into the formal healthcare system is likely to contribute to the health and well-being of rural communities. Popular traditional medicine is struggling with the changing socio-economic, educational, legal, and regulatory requirements. The erosion of traditional health knowledge, the young generation’s declining interest in the healing profession, the negative attitude towards traditional practices, and the question of safety, efficacy, and quality are some of the challenges traditional healing faces today. The identification of healers, recognition of their practices, promotion of beneficial practices, registering them as treatment providers, and providing them with necessary support can contribute to the integration process.

10. Concluding remarks

Many nations are struggling with the issues of the integration of traditional healers. Nepal is not an exception. Though scholarly traditions have got official legitimacy and academically qualified traditional medicine practitioners have been authorized to practice, traditional healers, the practitioners of popular traditions, have been struggling to secure a legitimate space in the formal structure of the health care system. The issue of integration of traditional healers is complicated. However, Nepal has at least moved ahead from inaction and skepticism towards a more inclusionary health care system in which traditional healers will have a role to play. The recent development suggests Nepal’s approval of the idea of recognizing and integrating traditional healers. However much remains to be done to see traditional healers integrated into the health care system. Nepal’s example can be a good one if it moves in the desired direction. Policy initiatives are necessary to address issues of recognition, accreditation, or licensing of traditional healers and to help integrate them into the national healthcare system.

Acknowledgments

I would like to thank anonymous reviewer of this chapter who greatly helped to shape this paper in this form. I have received no funding support from any organization for this research. I thank IntechOpen for a publication fee waiver.

Conflict of interest

I declare no conflict of interest.