A Study of Conceptualizations and Utilization in Rural Nepal
People use traditional medicine to meet their health care needs in developing countries and medical pluralism persists worldwide despite increased access to allopathic medicine. Traditional medicine includes a variety of treatment opportunities, among others, consultation with a traditional healer or spiritual healer and self-treatment with herbal medicine or medicinal plants. Reliance on traditional medicine varies between countries and rural and urban areas, but is reported to be as high as 80% in some developing countries. Increased realization of the continued importance of traditional medicine has led to the formulation of policies on the integration of traditional medicine into public health care. Local level integration is already taking place as people use multiple treatments when experiencing illness. Research on local level use of traditional medicine for health care, in particular the use of self-treatment with medicinal plants, is however scarce. Thus, this thesis contributes to understanding the extent of traditional medicine use as well as why people use it in rural areas in developing countries. This is important for the formulation of inclusive health care policies which can address the health care needs of people. Using Nepal as a case, the specific objectives of this thesis are; 1) to quantify the reliance on traditional medicine for health care as well as study the determinants of this reliance in rural Nepal; 2) to increase the understanding of why people use traditional medicine for health care in rural Nepal. A mixed methods research design was employed and data were collected in 2012 through 54 semi-structured interviews, 10 group discussions and a household survey in 571 households. Data collection took place in three sites in Nepal representing differences in access to health care and medicinal plants as well as in livelihoods and ethnicities of the populations. The three papers in this thesis address traditional medicine within the pluralistic medical fields of Nepal from different levels of analysis. The first paper consider the various treatment opportunities available to people and contributes to increasing the understanding of how people conceptualize these and how treatment seeking practices are interpreted and experienced differently among people. The second paper quantifies reliance on traditional medicine and medicinal plants whereas the third paper addresses one specific form of traditional medicine and explores self-treatment with medicinal plants and the various ways this treatment is used to fulfill health care and social needs. The findings show that traditional medicine plays an important role in health care in rural areas in Nepal due to its continued utilization as well as through the ways traditional medicine is conceptualized and used to fulfill health care and social needs. Using the concept of therapeutic landscapes, this study suggests that the value of traditional medicine to people and the ways they conceptualize treatments which are “traditional” reflect other conceptualizations than the “modern/traditional” dichotomy. People conceptualized treatments through notions related to time and place, positioning treatments on spectrums ranging from home treatments to city treatments as well as from past to present. Through their conceptualizations and practices of treatment seeking people engaged in creating and sustaining pluralistic therapeutic landscapes variously influenced by everyday contexts and structural constraints. This study found that traditional medicine was used as a treatment in 31% of illness episodes during a one month recall period and self-treatment with medicinal plants was the most important type of traditional medicine used as it was used in 22% of illness episodes. Overall, 78% of households reported to sometimes use self-treatment with medicinal plants to treat ill household members. Importantly, this study points to the potential under-reporting of selftreatment with medicinal plants as many treatments with medicinal plants were reported as common sense treatments rather than as self-treatment with medicinal plants. This study found that being rich was a significant determinant of both use of traditional medicine and self-treatment with medicinal plants. This study hence questions the often held assumption that poor people are most reliant on traditional medicine. Other determinants of traditional medicine use included age, gender of household head, education and having a chronic illness as well as whether someone in the household held knowledge about medicinal plants. Self-treatment with medicinal plants was used in various ways reflecting the various health care and social needs, this treatment was intended to fulfill. Self-treatment with medicinal plants was used in five main ways; as the preferred, the pragmatic, the convenient, the compelled and the auxiliary treatment. Prevalence of use and ways of using self-treatment with medicinal plants varied among sites reflecting differences in social and health care needs as well as everyday realities and people’s experiences of social development or the lack thereof. This thesis expands understandings of the relations between access to various types of health care and use of traditional medicine. It questions often held assumptions about the availability of traditional medicine and about medicinal plants being easily accessible, showing that there was little access to traditional healers and Ayurvedic medicine in the sites and that many people considered medicinal plants less accessible than other types of treatment. Finally, this thesis points out the need for policy makers to address both the current inequitable access to allopathic medicine and to providers of traditional medicine as well as how to enable people’s practices of self-treatment with medicinal plants in order to fulfill their varied health care and social needs.
Department of Food and Resource Economics, University of Copenhagen, 2015