Integrating Traditional Healers in the Health System

Last registered on January 22, 2025

Pre-Trial

Trial Information

General Information

Title
Integrating Traditional Healers in the Health System
RCT ID
AEARCTR-0015052
Initial registration date
January 22, 2025

Initial registration date is when the trial was registered.

It corresponds to when the registration was submitted to the Registry to be reviewed for publication.

First published
January 22, 2025, 9:40 AM EST

First published corresponds to when the trial was first made public on the Registry after being reviewed.

Locations

There is information in this trial unavailable to the public. Use the button below to request access.

Request Information

Primary Investigator

Affiliation
IE University, IE Business School, and NOVAFRICA

Other Primary Investigator(s)

PI Affiliation
Nova School of Business and Economics, NOVAFRICA, BREAD, and CEPR
PI Affiliation
University of Alicante and NOVAFRICA.
PI Affiliation
Nova School of Business and Economics and NOVAFRICA

Additional Trial Information

Status
On going
Start date
2024-05-01
End date
2026-06-30
Secondary IDs
Prior work
This trial does not extend or rely on any prior RCTs.
Abstract
Traditional Health Practitioners (THPs) represent the primary source of healthcare for 80% of the African population (WHO, 2019). In rural areas, the number of THPs is much higher than that of doctors and nurses (WHO, 2013). This dominant presence is deeply intertwined with established belief systems (Ashraf et al., 2017; Coutts et al., 2022). Hence, THPs are accessible and share beliefs with the population while running private businesses. At the same time, the formal health system and international institutions have mainly ignored THPs as a central health provider in Africa. Integrating scientific practices into THPs’ work presents a transformative opportunity to bridge the gap between traditional and formal healthcare, addressing critical challenges in underserved communities.

We work in Guinea-Bissau, a country with some of the poorest health indicators worldwide (e.g., in 2022, neonatal mortality was the eighth highest – WDI 2024). Our project centers around introducing a new program to de facto collaborate with THPs to fulfill the role of Community Health Worker (CHW), sponsored by UNDP (which funded the initial phase of the project) and in partnership with the Ministry of Public Health. CHWs are community members (lightly) trained in healthcare by the formal system, who follow a pre-set group of households, undertake simple treatments, and refer pregnant women and children to existing (formal) healthcare services. They are typically volunteers. The main hypothesis of our work is that selected THPs can potentially serve as effective CHWs, given their proximity to the population in different dimensions and their business approach. The hope is that THPs see value in adopting scientific practices and see long-run benefits in collaborating with the formal health sector, including referring patients to health centers.

After running a census of THPs in the Bafatá region (2023), including 1,437 THPs, and undertaking a THP selection process (2024), we have just run a baseline survey of 324 villages in the region with one viable THP and one CHW (each). We plan to run a field experiment in which we randomize one third of the villages to the activation of the THP as a CHW, one third of the villages to the activation of the existing CHW (who is typically dormant), and the remaining third of the villages to control. We plan to survey THPs, CHWs, and households, as well as to collect administrative data from health centers.
External Link(s)

Registration Citation

Citation
Fracchia, Mattia et al. 2025. "Integrating Traditional Healers in the Health System." AEA RCT Registry. January 22. https://doi.org/10.1257/rct.15052-1.0
Sponsors & Partners

There is information in this trial unavailable to the public. Use the button below to request access.

Request Information
Experimental Details

Interventions

Intervention(s)
We work with a program sponsored by UNDP with the collaboration of the Ministry of Public Health of Guinea-Bissau, NOVAFRICA, and VIDA NGO, which aims at integrating THPs into the formal health system in Guinea Bissau (henceforth, the THP integration program). The program focuses on the protocol followed by CHWs for malaria. This includes a set of actions to prevent and treat malaria. For prevention, the adoption of recommended behaviors, such as using long-lasting, impregnated mosquito nets, is encouraged. Referrals to health centers are also an important part of this protocol, both for pregnant women to receive the intermittent preventive therapy recommended by the National Health Plan and for patients presenting malaria symptoms. CHWs are likely to have contributed to recent improvements in maternal, neonatal, and child health in Guinea-Bissau (Fracchia, 2024). However, THPs have the potential to improve on those efforts: they are highly accessible to the population, they share common traditional beliefs, and crucially, they run sustainable private businesses. Hence, the program hopes to attract THPs to the formal system so that they can take the role of CHWs.

The program is directed at the Bafata region in Guinea-Bissau, which UNDP flagged as a region with a high prevalence of malaria and significant challenges regarding access to formal healthcare. By 2023, Bafata had an estimated population of 246,889 people, which corresponds to 14 percent of the population of Guinea-Bissau (INE, 2023). All the THPs in the region, as identified through a recently completed census of THPs, were invited to participate. The census registered 1,437 THPs and assessed their interest in joining the program.

In the first intervention, we experimentally vary the way the program is advertised. All THPs watch a video in which an authority from the Ministry of Public Health announces and explains the program. The content of the video is exactly the same for all THPs regarding the program's functioning. However, THPs are randomly assigned to receive different highlights on the program's benefits from the official in the video - two versions of the video featuring the same authority were prepared for that reason.
One version of the job advertisement underlines the potential for community-wide impacts, i.e., improving the community's health outcomes. This is the typical way to recruit CHWs, who are eminently volunteers and are expected to be driven by pro-social motivations. The other version of the job advertisement highlighted the program's potential for improving the private benefits of the THPs, who could improve their practices and, in that way, be better compensated for the services provided. THPs are private healthcare providers whose motivation can include profits.

From the sample of villages where we interviewed at least once from May 2023 to May 2024, we sample all the villages where at least one THP expressed interest in participating, and we know of at least one active CHW. For the baseline, we survey 324 villages with a viable THP and CHW. In the main intervention, we randomly allocate the 324 in equal proportions to Treatment 1 (T1), Treatment 2 (T2), and the Control group (C). We therefore adopt an experimental design that enables comparability between villages with an integrated THP, villages with an activated CHW, and villages with none, as follows:
- T1: THPs promote the adoption of recommended behaviors, such as using long-lasting, impregnated mosquito nets, and refer to health centers pregnant women to receive intermittent preventive therapy and any patient presenting malaria symptoms.
- T2: In this group, CHWs will receive the same training and will be tasked with the same activities as the THPs of T1.

THPs in T1 and CHWs in T2 attend a cycle of workshops at the local health center, where they receive training on health practices and program materials, including visual materials for communication for behavioral change and vouchers to refer households to the health center.
Intervention Start Date
2024-12-16
Intervention End Date
2026-03-31

Primary Outcomes

Primary Outcomes (end points)
• THPs’ willingness to participate in the program and final participation
• THPs’ and CHWs’ health knowledge
• THPs’ and CHWs’ trust in modern health practitioners and traditional health practitioners
• THPs’ and CHWs’ beliefs about health centers, modern medicine, and traditional medicine
• THPs' and CHWs’ collaboration with the health center
• THPs’ and CHWs’ referrals to the health center
• Households' health knowledge
• Households' trust in modern health practitioners and traditional health practitioners
• Households' beliefs about health centers, modern medicine, and traditional medicine
• Households' health practices
Primary Outcomes (explanation)

Secondary Outcomes

Secondary Outcomes (end points)
• THPs' service range, pricing, and revenues in their activity
• CHWs’ participation in other activities of the CHW program and reports delivered
• Households' health outcomes
Secondary Outcomes (explanation)

Experimental Design

Experimental Design
Research questions
- How does business-oriented compare to pro-social messages in motivating THPs to join a (formal) community health program?
- What is the impact of the community health program delivered by THPs?
- How do THPs compare to CHWs in delivering the community health program?

Sampling
The study builds on a census of all THPs in the Bafata region, selected by the Ministry of Public Health and UNDP Guinea-Bissau due to its high malaria prevalence. The study builds on a census of all THPs in the Bafata region, selected by the Ministry of Public Health and UNDP Guinea-Bissau due to its high malaria prevalence. In the census, we assess THPs' interest in joining the program, experimentally varying how the program is advertised. We reach a total of 1,437 THPs. A reinforcement phone contact follows the initial contact. After that, we implement a behavioral measure of interest in participating in the program, as we ask THPs to call the program to express their interest. We also conduct a face-to-face survey at the end of the project, in which we gather a measure of willingness to meet with representatives of the formal health system and traditional medicine. From the sample of villages where we interviewed at least once from May 2023 to May 2024, we sample all the villages where at least one THP expressed interest in participating, and we know of at least one active CHW. For the baseline, we survey 324 villages with a viable THP and CHW. At the endline, we plan to sample six representative households from each village, defined as the catchment areas of the corresponding THP/CHW. Only women aged 18 to 49 will be eligible for interviews, as they are the primary target population of the intervention and the CHWs’ strategy in the region.

Assignment to treatment
This project includes two randomized interventions. In the first set, we randomize messages to the THP population in Bafata, emphasizing (i) the program’s business-improvement benefits or (ii) its community health benefits. The randomized messages on the potential benefits of the THP integration program are submitted at the end of the census.
In the main set of randomized interventions, we assign selected villages in equal proportions to Treatment 1 (T1), Treatment 2 (T2), and the Control group (C). Randomization is conducted at the village level, using three stratification variables: health area, recruitment message type, and village size. Health areas are determined geographically, with some smaller areas aggregated to form larger strata. Within each stratum, we group villages into blocks of six, allowing random assignment to treatment and control groups in a balanced manner. For the remaining villages, those outside initial blocks are sorted by geographic proximity and further grouped into blocks of three based on recruitment message type and village size within each stratified variable construct. We therefore propose an experimental design that enables comparability between villages with an integrated THP, villages with an activated CHW, and villages with none, as follows:

- T1: THPs promote the adoption of recommended behaviors, such as using long-lasting, impregnated mosquito nets, and refer to health centers pregnant women to receive intermittent preventive therapy and any patient presenting malaria symptoms.
- T2: In this group, CHWs will receive the same training and will be tasked with the same activities as the THPs of T1.
- C: The control group will serve as a comparison group to both T1 and T2.

We will test the following hypotheses:
- H1: T1 improves health-related outcomes over C;
- H2: T2 improves health-related outcomes over C;
- H3: T1 improves health-related outcomes over T2.

Data
Regarding the first part of the project, testing the impact of pro-business and pro-social messages on the adoption of the program by the THPs, we implement a set of phone surveys and behavioral measures of willingness to integrate the program. We will continue assessing the messages’ impacts for the remainder of the project, i.e., the evaluation of the main intervention. Our measurement will include a broad range of data sources, as reported below.

- THPs and CHWs baseline, midline, and endline surveys
The surveys follow a consistent structure across baseline, midline, and endline. At baseline, we collect socio-demographic and professional data, assess service range and pricing for THPs, and document CHWs’ program participation and reports. We administer a knowledge test on malaria and antenatal care, measure diagnosis practices, beliefs about modern and traditional medicine, cooperation with health centers, trust in the health system, and time use, and assess willingness to pay for participating in an event with the MoH and the representatives of THPs.
The midline surveys focus on post-training outcomes, evaluating THPs and CHWs’ understanding of the program’s goals and activities, health knowledge, beliefs about modern and traditional medicine, and intentions to exert effort in the program and collaborate with health centers. We also document implementation costs for a cost-effectiveness analysis. The endline surveys assess THPs’ and CHWs’ awareness of the program’s goals and activities. We repeat the knowledge test on malaria and antenatal care and measure knowledge of health centers’ services. We assess time spent on the program, patients visited, referrals made, adherence to best practices, and cooperation with health centers. We also elicit beliefs about modern and traditional medicine, trust, and motivation. We assess service range, pricing, and revenues for THPs and document CHWs’ program participation and reports.

- Household endline survey
The household endline survey targets women aged 18-49, collecting socio-demographic data and interactions with THPs and CHWs. It includes a knowledge test on malaria and antenatal care, evaluates the adoption of preventive behaviors, antenatal care, health center visits, and follow-up on referrals. The survey also measures individual and household beliefs about modern and traditional medicine, trust in traditional versus formal health providers, and health outcomes.

- Referral vouchers
We will distribute two-way identified patient referral vouchers to THPs and CHWs as part of treatments (T1 and T2) to track referrals to health centers. The vouchers are distributed as part of the intervention and collected at the endline at the health centers to compare the effectiveness of both healthcare providers in making referrals at the village level.

- Health centers' baseline, midline, and endline surveys
The health center survey includes modules about working hours, services offered and their
pricing, equipment available, and personnel employed at all the health centers in the area of our study. We also inquire about the center’s relationship with the THPs and CHWs in the area.

- Health centers' logbooks
We will collect data in all the health centers’ logbooks in our study area at midline and endline. Logbooks with registries on antenatal care, birth-giving, postnatal care, family planning, and vaccination are organized by patient-date entries and homogeneous across facilities.

Outcome variables
We assess treatment effects across multiple outcomes at the THP, CHW, household level, and health center levels. The first intervention focuses on THPs’ willingness to participate in the program and final participation. The main intervention comprises multiple outcomes of interest at the THP, CHW, and household levels. The primary outcomes focus on health knowledge—particularly related to malaria and antenatal care—trust in modern and traditional health practitioners and beliefs about health centers, modern medicine, and traditional medicine. Additionally, we track adherence to best practices, cooperation with health center staff, and overall engagement with the program, assessed through time dedicated to the program, number of patients visited, and referrals to health centers. Secondary outcomes at the THP level include service range, pricing, and revenues in their activity, while CHWs include participation in the other activities of the CHW program and reports delivered.
At the household level, primary outcomes cover health knowledge, trust in modern and traditional health practitioners, beliefs about health centers, modern medicine, and traditional medicine. Moreover, we will assess preventive health behaviors, antenatal care, and visits to health centers. We also monitor follow-up on health center referrals and overall health outcomes. Secondary outcomes include individual and household-level health outcomes.


Experimental Design Details
Not available
Randomization Method
Computer using Stata
Randomization Unit
Individual for the selection intervention, Village for the main intervention, i.e., the program evaluation.
Was the treatment clustered?
No

Experiment Characteristics

Sample size: planned number of clusters
0
Sample size: planned number of observations
324 villages, with 324 THPs and 324 CHWs. At the endline, we plan to interview six households per village, totaling 1,944 households.
Sample size (or number of clusters) by treatment arms
C: 108 villages, 108 THPs and 108 CHWs
T1: 108 villages, 108 THPs and 108 CHWs
T2: 108 villages, 108 THPs and 108 CHWs
Minimum detectable effect size for main outcomes (accounting for sample design and clustering)
IRB

Institutional Review Boards (IRBs)

IRB Name
Comitê Nacional de Ética em Pesquisa na Saúde
IRB Approval Date
2024-04-05
IRB Approval Number
010/CNES/INASA/2024
IRB Name
Scientific Council, Nova School of Business and Economics, Universidade Nova de Lisboa
IRB Approval Date
2023-05-15
IRB Approval Number
202263