Explanatory Model for the Use of Traditional Medicines in Kilimanjaro, Tanzania

Introduction: Traditional medicines are one of the most important means of achieving total health care coverage globally, and their importance in Tanzania extends beyond the impoverished rural areas. Their use remains high even in urban settings among the educated middle and upper classes. They are a critical component healthcare in Tanzania, but they also can have harmful side effects. Therefore we sought to understand the decision-making and reasoning processes by building an explanatory model for the use of traditional medicines in Tanzania.

Methods: We conducted a mixed-methods study between December 2013 and June 2014 in the Kilimanjaro Region of Tanzania. Using purposive sampling methods, we conducted focus group discussions (FGDs) and in-depth interviews of key informants, and the qualitative data were analyzed using an inductive Framework Method. A structured survey was created, piloted, and then administered it to a random sample of adults. We reported upon the reliability and validity of the structured survey, and we used triangulation from multiple sources to synthesize the qualitative and quantitative data.

Results: A total of five FGDs composed of 59 participants and 27 in-depth interviews were conducted in total. 16 of the in-depth interviews were with self-described traditional practitioners or herbal vendors. We identified five major thematic categories that relate to the decision to use traditional medicines in Kilimanjaro: healthcare delivery, disease understanding, credibility of the traditional practices, health status, and strong cultural beliefs.

A total of 473 participants (24.1% male) completed the structured survey. The most common reasons for taking traditional medicines were that they are more affordable (14%, 12.0-16.0), failure of hospital medicines (13%, 11.1-15.0), they work better (12%, 10.7-14.4), they are easier

to obtain (11%, 9.48-13.1), they are found naturally or free (8%, 6.56-9.68), hospital medicines have too many chemical (8%, 6.33-9.40), and they have fewer side effects (8%, 6.25-9.30). The most common uses of traditional medicines were for symptomatic conditions (42%), chronic diseases (14%), reproductive problems (11%), and malaria and febrile illnesses (10%). Participants currently taking hospital medicines for chronic conditions were nearly twice as likely to report traditional medicines usage in the past year (RR 1.97, p=0.05).

Conclusions: We built broad explanatory model for the use of traditional medicines in Kilimanjaro. The use of traditional medicines is not limited to rural or low socioeconomic populations and concurrent use of traditional medicines and biomedicine is high with frequent ethnomedical doctor shopping. Our model provides a working framework for understanding the complex interactions between biomedicine and traditional medicine. Future disease management and treatment programs will benefit from this understanding, and it can lead to synergistic policies with more effective implementation.

Accessibility, availability and affordability of anti-malarials in a rural district in Kenya after implementation of a national subsidy scheme.

BACKGROUND: Poor access to prompt and effective treatment for malaria contributes to high mortality and severe morbidity. In Kenya, it is estimated that only 12% of children receive anti-malarials for their fever within 24 hours. The first point of care for many fevers is a local medicine retailer, such as a pharmacy or chemist. The role of the medicine retailer as an important distribution point for malaria medicines has been recognized and several different strategies have been used to improve the services that these retailers provide. Despite these efforts, many mothers still purchase ineffective drugs because they are less expensive than effective artemisinin combination therapy (ACT). One strategy that is being piloted in several countries is an international subsidy targeted at anti-malarials supplied through the retail sector. The goal of this strategy is to make ACT as affordable as ineffective alternatives. The programme, called the Affordable Medicines Facility - malaria was rolled out in Kenya in August 2010. METHODS: In December 2010, the affordability and accessibility of malaria medicines in a rural district in Kenya were evaluated using a complete census of all public and private facilities, chemists, pharmacists, and other malaria medicine retailers within the Webuye Demographic Surveillance Area. Availability, types, and prices of anti-malarials were assessed. There are 13 public or mission facilities and 97 medicine retailers (registered and unregistered). RESULTS: The average distance from a home to the nearest public health facility is 2 km, but the average distance to the nearest medicine retailer is half that. Quinine is the most frequently stocked anti-malarial (61% of retailers). More medicine retailers stocked sulphadoxine-pyramethamine (SP; 57%) than ACT (44%). Eleven percent of retailers stocked AMFm subsidized artemether-lumefantrine (AL). No retailers had chloroquine in stock and only five were selling artemisinin monotherapy. The mean price of any brand of AL, the recommended first-line drug in Kenya, was $2.7 USD. Brands purchased under the AMFm programme cost 40% less than non-AMFm brands. Artemisinin monotherapies cost on average more than twice as much as AMFm-brand AL. SP cost only $0.5, a fraction of the price of ACT. CONCLUSIONS: AMFm-subsidized anti-malarials are considerably less expensive than unsubsidized AL, but the price difference between effective and ineffective therapies is still large.