UNDERSTANDING THE ROLE OF INFORMAL HEALTHCARE PROVIDERS IN PROVIDING NON-COMMUNICABLE DISEASE CARE IN SIERRA LEONE

Abstract

Non-communicable diseases (NCDs) present a significant and increasing challenge to global health, with particularly severe consequences for Sierra Leone's healthcare system. This study explores the critical yet under-explored role of Informal Health Providers (IHPs), such as traditional healers, herbalists, and drug peddlers, in managing NCDs within a resource-constrained context. IHPs frequently serve as the preferred healthcare provider for individuals with NCDs, especially in underserved communities, due to their accessibility and the co-existence of formal and informal healthcare providers. Despite their relatively more widespread presence, the contributions of IHPs are often marginalized within the biomedical framework of Sierra Leone’s health policies. This research seeks to examine this gap by providing a comprehensive understanding of IHPs' utilization, the factors influencing their services, and the implications for healthcare delivery. It also examines the interactions between IHPs and the formal healthcare system, aiming to align their roles to better support the achievement of Universal Health Coverage (UHC) in Sierra Leone The study was conducted across six diverse communities in Sierra Leone and sought to understand healthcare-seeking behaviours and the role of Informal Health Providers (IHPs) in managing non-communicable diseases (NCDs), such as diabetes and hypertension. The research employed a mixed-methods approach, utilizing six focus group discussions (FGDs) with various community stakeholders and conducting 42 indepth interviews (IDIs). These interviews were carefully structured to capture a broad range of perspectives. The IDIs involved 18 IHPs, 12 patients with diabetes or hypertension (or their caregivers), and 12 formal healthcare providers, providing a comprehensive understanding of healthcare dynamics within the pluralistic system of Sierra Leone. The analysis was conducted using the NVivo 11® software, which supported the coding and organization of qualitative data. Through this tool, the study explored the key themes related to healthcare-seeking patterns, specifically identifying who community members sought care from, why IHPs were utilized, and the challenges and opportunities surrounding NCD care provision. The research illuminates the complex socio-cultural and economic factors that influence healthcare decisions, highlighting the reasons why many patients prefer IHPs for managing chronic conditions despite the availability of formal healthcare services. The study also explores the interactions between formal and informal healthcare systems, assessing how the two sectors either complement or conflict with one another in providing care for NCDs. The analysis categorizes IHPs into traditional healers, herbalists, and drug peddlers, each offering different scopes of practice, skills, and interventions. Traditional healers and herbalists, regarded as trusted figures within their communities, blend traditional remedies with biomedical treatments, while drug peddlers provide quick access to medications, though often without formal diagnostic procedures. Despite their different approaches, all face challenges related to limited resources, low incomes, and lack of formal recognition, which hinder the quality and reach of NCD care. These challenges are compounded by the shortcomings of Sierra Leone's formal healthcare system, including medication shortages, resource constraints, and patient dissatisfaction, which push many individuals towards IHPs despite the risks involved. The study reveals that the informal healthcare sector operates in parallel with the formal system, with occasional interactions but little structured collaboration. Notably, some IHPs informally refer patients to formal providers, and certain drug peddlers seek advice from healthcare workers. However, these interactions remain sporadic and unregulated. The research advocates for a more integrated approach, where collaboration between IHPs and formal health providers could strengthen the healthcare system’s capacity to address NCDs. Recognizing the complementary strengths of both sectors can improve patient outcomes by enhancing service Availability, Accessibility, Acceptability, and Quality (AAAQ). The study’s findings have broader implications for health policy in Sierra Leone and other low and middle-income countries (LMICs) where informal healthcare systems play a critical role. The research highlights the urgent need for policy reforms that align the role of IHPs within the national healthcare system. Key recommendations include strengthening regulatory frameworks to ensure safe and effective care, simplifying licensing processes, providing regular training for IHPs, and fostering stronger partnerships between IHPs and formal healthcare providers. Additionally, public awareness campaigns are necessary to inform communities about the roles of IHPs and promote informed healthcare-seeking behaviours. These steps are crucial for enhancing the overall quality of NCD care in Sierra Leone, particularly in underserved areas, and for aligning healthcare delivery with the broader goal of Universal Health Coverage (UHC).