Current picture of interaction between traditional healers and psychiatrists

In Sudan, traditional healers play a key role in the provision of mental health services, despite the absence of regulations concerning their services. The WHO has strongly advocated collaboration between THPs and primary care physicians since the 1970s, in conjunction with the integration of THPs into national health systems. This integration would lead to improvement in the care provided through regular evaluation of the utility, effectiveness and safety of care delivery by THPs.

Traditional healthcare practices in Sudan have similarities to those in Kenya. For example, counselling rituals have been applied to treat depression. Faith-based healers adopt prayer-based practices and cast out demons to treat neurotic and psychotic symptoms.^{Reference Musyimi, Mutiso and Loeffen3} If an attempt at integration with conventional medical services were made, evaluations would allow improved understanding of THP practices and mitigation of any associated risks, coupled with the ability to determine where safe traditional practices could be implemented by national healthcare systems.^{Reference Busia and Kasilo4}

A small majority of psychiatry consultants and residents in Khartoum believed in the value of collaborating with THPs, and 58% were willing to support the integration of traditional healers in patient-related practices and in influencing stakeholders.^{Reference Hassan and Omer5} Despite traditional healing not being an evidence-based practice, it was found throughout Sudan that psychotic symptoms declined among patients attending traditional healing centres,^{Reference Sorketti, Zainal and Habil6} thus indicating the possible presence of a role for THPs in delivery of mental health services. Furthermore, it was established that a sizeable minority of psychiatrists in Sudan (43%) agreed with the practice of rogia – a form of hypnotism similar to that used by psychologists developing therapeutic alliances – as a means of relieving neurotic symptoms.^{Reference Hassan and Omer5} The practice of rogia is a form of faith-based counselling performed in rural Sudan by the local caliphate, in which Quranic verses are used to treat depression, anxiety and demonic thoughts and persecutions experienced by individuals. These practices are more readily available in rural Sudanese communities with a caliphate style of authority, whereby a caliph presides over the community.

Recommendations

In rural and remote areas in Sudan, THPs are the first points of access to mental healthcare because there is an extremely low coverage of mental health services.^{Reference Sorketti, Zainal and Habil6} At the level of rural communities, basic training programmes, including written communication and basic information technology skills, to enable THPs to escalate to psychiatric care facilities patients whose symptoms are refractory to herbal treatment would yield a considerably stronger interaction between THPs and consultant psychiatrists. This would be facilitated further by the prioritisation of mental health services by the Federal Ministry of Health in Sudan. There should be integration into primary healthcare and subsequent ease of access to mental health services for both THPs and their patients in both urban and rural communities. Elements of integration of mental health services into universal health coverage would necessitate long-term planning, a community-based care package and a compassionate stance to encourage patient and community engagement. Achievement of this integration could begin through health education of rural communities by THPs about the importance of modern psychiatry in treating psychosocial disorders.⁷

Budgeting and stigma are common barriers faced by people with mental disorders in Sudan. These barriers could be combated by providing mental health education training to THPs from established psychiatrists and general practitioners. The trained THPs could then work in collaboration with these experts, delivering their services to rural communities. This proposed way of delivering services would adopt a patient-centred approach and would go some way towards achieving universal health coverage at minimal expense.^{Reference Patel and Saxena8}