Traditional Health Care Practitioners Research Articles

Integrating traditional and allopathic child health: A healthcare transformation opportunity.

Numerous forums both domestically and internationally have discussed integration of allopathic and traditional healthcare. In South Africa, using traditional child healthcare is popular practice. If properly controlled, integrating this aspect of traditional child-health with allopathic healthcare may be advantageous to communities that use both healthcare systems. Allopathic and traditional healthcare remain separate organisations in South Africa despite efforts and discussions to integrate them. The study sought to explore the integration of traditional and allopathic child healthcare from the perspectives of children's caregivers and traditional healthcare practitioners. The study was conducted in a semi-urban area in the city of Tshwane. An exploratory qualitative research study was conducted using semi-structured interviews to collect data from 11 traditional healthcare practitioners and 15 children's caregivers who were sampled using snowball and convenient sampling respectively. The participants expressed their understanding of the usage of traditional healthcare practitioners in the care of children as well as their support for integration, and further indicated its necessity. Religion and its effects in health-seeking behaviour were cited as a factor in why there has not been greater integration between the two healthcare systems. The undocumented and undisclosed use of traditional healthcare potentially hinders the delivery of therapeutic healthcare. As such, integrating the two systems is essential to ensure patients' safety. This article highlights understanding of culture congruence and safe child healthcare that may be brought forward by the integration of the two healthcare systems.

Exploring patient referral practices of traditional healthcare practitioners in Soshanguve, Gauteng Province, South Africa.

It may be necessary for healthcare professionals to refer patients to other professionals and institutions that are able to provide the care needed by patients, depending on the severity each case presents, healthcare requirements, and resources available to offer care. In healthcare generally, patient referral is standard procedure; however, in South Africa, referral patterns between allopathic and traditional healthcare practitioners are unknown, and this is a problem yet to be addressed. The study objective was to explore patient referral practices from the perspectives of traditional healthcare practitioners of South Africa. A qualitative, exploratory and descriptive design was employed to collect data from 11 traditional healthcare practitioners who were sampled using snowball sampling. An individual semi structured interview schedule was used to collect data. Content analysis was used to analyze the data. Patient referral was common practice in traditional health practices, however not reciprocal between the traditional and allopathic healthcare. Several indications for patient referral to allopathic healthcare practitioners included management of chronic conditions amongst others. Patient referral being an important part of healthcare practices should be promoted and regulation and traditional health practices improved to promote safe referral practices and curb unsafe self-referrals by patients.

Exploring Culturally‐safe Dementia Care Policy in First Nation Community of the James and Hudson Bay Region in Northern Ontario, Canada

AbstractBackgroundCulturally‐safe dementia care (CSDC) is new dynamic concept that empowers clinical and traditional health care practitioners to provide culturally respectful care for older adults with dementia. The World Health Organization’s (WHO) recognized diverse Indigenous local community partners, members and leaders as critical community stakeholders for dementia care and prevention worldwide in 2018. However, there is a critical lack of policy framework and evidence‐based research on CSDC globally. As dementia spreads as a global epidemic, the dementia prevalence among First Nations people over the age of 60 is expected to quadruple by 2031, compared to a 2.3‐fold increase among non‐First Nations people in Canada. The Mamow Ahyamowen Partners (2019) study found a higher dementia mortality rate of 7% in the James and Hudson Bay region of Northern Ontario between 1992 and 2014, compared to 23% in Ontario overall.MethodA qualitative research design is employed in conjunction with a community‐based participatory rural dementia action research approach to conduct four participatory Focus‐Group Discussions with physicians, nurses, caregivers, and community partners with 24 to 32 participants to explore the knowledge, experience, barriers and challenges to develop knowledge of CSDC policy. Thematic analysis and the Total Quality Framework will be used for quality rigour, and a two‐eyed seeing framework and explanatory dementia models will be applied in the perspectives and worldviews of the physician‐patient‐community to honour cultural care, diet, language, ethical and spiritual pathways.ResultThis research will lay foundation for policymakers to develop knowledge of CSDC policy, care plan and guidelines. This will guide the development of educational interventions and curricula and community support systems that are aimed at building and sustaining the capacity of healthcare professionals and community partners to begin integrated biomedical and Indigenous traditional dementia care practices.ConclusionThis research endeavours to equip physicians, nurses, allied health care workers, community partners (Elders, knowledge‐holders and traditional healers) and the community support systems to initiate CSDC on a global scale to implement the WHO Global Action Plan on the Public Health Response to Dementia (2017‐2025). Inclusion of Indigenous community partners as community stakeholder are underpinning to bridge the dementia equity gap.

Penerapan Kebijakan Pengawasan Obat Tradisional dalam Perspektif Kesehatan Masyaraat

Traditional medicine is one part of Indonesia's rich culture that has been used by the community for a long time. However, issues surrounding the safety and efficacy of traditional medicines often arise as a concern in the public health domain. This research uses qualitative research methods. The data collection technique was carried out by literature study and from interviews with traditional medicine users, traditional healthcare practitioners, and health officials. Thus, this can assist researchers in understanding their perceptions, experiences, and viewpoints regarding traditional medicine supervision. The data that has been collected is then analyzed using three stages, namely data reduction, data presentation and conclusion drawing. This is done to ensure that the implementation of legal supervision of traditional medicines is carried out through various stages. The process begins with the granting of production licenses to producers after fulfilling predetermined requirements. After that, the Food and Drug Monitoring Agency (BPOM) is responsible for supervising the production process directly on site. Supervision of the production process is carried out at least once a year. However, if there are violations of either CPOTB (Good Traditional Medicine Manufacturing Practice) or GMP (Good Manufacturing Practice) requirements, the inspection will be more intensive. The inspection is carried out until the manufacturer corrects and improves production activities in accordance with applicable standards.

Traditional Health Care Practitioners' Perspectives on Applying Informed Consent During African Traditional Medical Practice in Akwa Ibom State, Nigeria: A Cross-Sectional Qualitative Study.

Introduction: This study explored the perspectives of traditional health care practitioners (THPs) practicing in the areas of herbalism, bone setting, and traditional birth attendance, from Akwa Ibom state, Nigeria, on the possibility and implications of applying informed consent (IC) during African traditional medicine (ATM) practice. Methods: Semistructured interviews were conducted with 11 THPs, consisting of 5 herbalists, 3 traditional bone setters (TBS), and 3 traditional birth attendants (TBAs), who represented the diverse groups that the study intended to cover. In-depth interviews were conducted using a semistructured guide and were recorded, transcribed, and analyzed using thematic analysis with the assistance of NVivo® qualitative analysis software. Results: Participants were seven males (64%) and four females (36%), 35-67 years of age, with 5-25 years of experience as THPs. Forty-six percent of participants were herbalists (27%), TBS, and TBAs (27%). Most participants (82%) were Annang, and (18%) were Ibibio first-language speakers. Three major themes emerged from the data analysis: (i) Existing ethical framework related to IC, (ii) knowledge of consent, and (iii) application of IC during traditional medical practice. These themes and relevant subthemes were explored. All (100%) THPs agreed that it was essential to communicate risks and benefits while allowing patients to ask questions before treatment. All participants (100%) stated that risk communication is essential in ATM, whereas 36% said they communicated all therapy benefits to their patients. Respondents believed patients could make an informed choice if they had complete information disclosure. However, THPs in this study had limited knowledge of formal IC rules and regulations. Conclusions: This study revealed that THPs in this setting disclose a diagnosis, risks, some benefits, and treatment options to patients. Consent/agreement was obtained verbally and voluntarily during ATM practice, consistent with IC doctrine. THPs had limited knowledge of the critical elements of IC. However, they suggested that a form of IC that does not conflict with traditional African norms could be applicable in ATM. IC could facilitate documentation and help reduce risks in ATM practice.

A qualitative study of traditional healthcare practices: evidence from Ilorin less city

The object of research: This study aimed to explore different forms of healthcare practice in Egbejila an Ilorin less city, Nigeria.
 The investigated problem: Throughout the world, traditional healthcare practice leads the edge with regards to healthcare delivery for humanity. It follows that rural inhabitants marshal various forms of healthcare practice. This study investigated peculiar healthcare practices performed by traditional healthcare practitioners in Egbejila a rural Nigeria.
 The main scientific results: The research study unveiled different and various dimensions and approaches of healthcare practice that are visualized and sustained as an indispensable component of continuity and survival of human entity.
 The area of practical use of the research results: The results of this research study gave insight to various traditional healthcare services being sought after by rural inhabitants of variant cultural, religious, socio-political and economic backgrounds aside the orthodox medicine.
 Scope of the innovative technological product: The study adopted purposive sampling procedure for the selection of key informants. A total of twenty-five (25) key informants were purposively selected. Data obtained through the recorded interviews were transcribed into Microsoft Word and was analyzed by using N-Vivo software

Evidence on collaboration of traditional and biomedical practitioners in the management of antimicrobial resistance in sub-Saharan Africa over 15 years: a systematic review protocol

BackgroundThe overuse of prescribed antimicrobials, concurrent use of traditional medicine, and prescribed antimicrobials have led to antimicrobial resistance. The absence of collaboration between traditional health practitioners and biomedically trained healthcare professionals can contribute to antimicrobial resistance, treatment failure, overdose, toxicity, and misadministration. This scoping review explores the evidence on collaboration between traditional health practitioners and biomedically trained healthcare professionals to reduce antimicrobial resistance and treatment failure in bacterial and viral diseases.MethodsWe will search for electronic databases such as Science Direct, Google Scholar, PubMed, and MEDLINE via EBSCOhost. We will also search reference lists of included studies. A two-stage mapping procedure will be carried out. Stage one (1) will consist of the title, abstracts, and full article screening, respectively. A pilot screening form guided by the defined eligibility criteria will be used. In stage two (2), data will be extracted from the included studies. Two reviewers will conduct parallel screening and data extraction. Mixed methods appraisal tool (MMAT) will be used to assess the quality of the included studies. NVIVO version 11 will be employed to aid pertinent thematic analysis. The outcomes of interest will be as follows: Primary outcome will be preventing and reducing antimicrobial resistance. The secondary effect is the effective collaboration between traditional healthcare practitioners and biomedically healthcare professionals.DiscussionThis review anticipates uncovering pertinent publications reporting the evidence of collaboration between traditional health practitioners and biomedically trained healthcare professionals to reduce antimicrobial resistance in sub-Saharan Africa. The sum-up of evidence acquired from the included studies will help guide future research. The result of the study will be print and electronically exposed.Systematic review registrationPROSPERO, CRD42017072952

Ethnoveterinary practice followed by Santhal tribes to treat foot and mouth diseases of livestock in Ghatshila Block, Jharkhand, India

An ethnoveterinary study was conducted among the Santhal tribes residing in Ghatshila block of East Singhbhum district in Jharkhand state to document the ethno-medicinal plants, those are used to treat the foot and mouth diseases of livestock. The ethnoveterinary knowledge was documented from the traditional healthcare practitioners in eight villages of the block. The study has resulted use of four plant species belonging to 4 different families to treat foot and mouth disses among livestock. Out of the four plant species, three are tress and one is shrub. The paper describes the plants used for ethno-veterinary practices to treat food and mouth diseases of livestock with botanical names, family, local names, English name, parts used, mode of preparation and administration of herbal drugs.

Antityrosinase and anti-acne potential of plants traditionally used in the Jongilanga community in Mpumalanga

In South Africa, traditional medicine remains a key source of health care, however majority of the plants used as medicines by traditional health care practitioners have not been investigated for their in vitro biological activity. The purpose of the present study was to examine the antityrosinase, anti-acne, antioxidant and cytotoxic potential of 25 ethanolic extracts from 16 different plant families which were collected in the Jongilanga community in the Mpumalanga province. The tyrosinase inhibitory activity was evaluated using the mushroom tyrosinase enzyme to determine potential plant extracts that could treat skin hyperpigmentation. Six of the plant extracts showed a fifty percent inhibitory concentration (IC50) lower than 200 μg/mL, of which Acacia nilotica (L.) Delile (12.97 ± 1.07 μg/mL) showed the highest activity, followed by Schotia brachypetala Sond. (35.07 ± 0.71 μg/mL) and Combretum collinum Fresen. (47.92 ± 1.13 μg/mL). The anti-acne potential of the extracts was evaluated by determining their antibacterial activity against Cutibacterium acnes. The highest activity was noted for Harpagophytum procumbens (Burch.) with a minimum inhibitory concentration (MIC) of 31.25 μg/mL, followed by S. brachypetala (125 μg/mL) and C. collinum, Ozoroa sphaerocarpa R. Fern & A. Fern and Pterocarpus rotundifolius DC. which all showed MIC values of 250 μg/mL. The antioxidant studies revealed that the majority of the plant extracts showed strong DPPH radical scavenging activity. The 2,3-Bis-(2-methoxy-4-nitro-5-sulfophenyl)-2H-tetrazolium-5-carboxyanilide salt (XTT) method was used to assess the cytotoxic effect of the plant extracts, of which only two extracts showed strong cytotoxicity against the non-cancerous human keratinocyte (HaCat) cell line namely; H. procumbens and Ipomoea oblongata Hook. The remaining extracts showed low to moderate cytotoxicity. The promising antityrosinase activity of A. nilotica, S. brachypetala and C. collinum as well as the promising antibacterial activity of O. spaerocarpa, P. rotundifolius and S. brachypetala, together with their low to moderate cytotoxicity against HaCat cells, merits further investigation of these species.

Reviving Healthcare Delivery: Context-Based Issues for Revamping Primary Healthcare in Nigeria

The relationship between health and sustainable development have long been established. Hence the need to rigorously pursue strategies to improve the health status of a nation’s citizenry through functionally effective and efficient delivery systems. However, health and healthcare delivery is a major problem confronting developing nations like Nigeria. In August 1987, Primary healthcare (PHC) was adopted as the cornerstone of health care and health policy in Nigeria. About three decades after, studies have shown that health and healthcare in Nigeria have not significantly improved; and the delivery of health services have become a perennial problem, defying the various solutions that had been advanced to solving it over time. In the face of dwindling economic reality in Nigeria, reviving primary healthcare becomes a viable alternative that will not only produce healthy and productive citizens, thereby generating national wealth; but will also reduce the cost of health care delivery to the average Nigerian. This paper presents a theoretical diagnosis of the state of affairs of healthcare delivery in Nigeria focusing on PHC as the hub of health policy. It examines the problems of PHC, identifying gaps within it that militates against successful implementation and outcomes. The paper concluded that certain deficits in the scope and policy process of PHC in Nigeria accounted for the programme’s incapacitation. It however recommended a thorough situation analysis as a prelude to a bottom-up policy approach, inclusion of the informal health sub-sector especially the traditional health care practitioners as a viable as well as cost effective strategy for the revamping of primary health care in Nigeria. Keywords: Health, primary, context-based healthcare, policy, revamping DOI : 10.7176/JHMN/58-10

Traditional Health Care Systems and Herbal Medicines

The age-old traditional health care practices are still relevant and are followed by communities across the countries. India's contribution remains exemplary in the growth of traditional health care systems. The present study reviews the strength of traditional health care systems and medicinal plants of India that has been contributing in health care not only from time immemorial but also makes it numero uno choice of community for curing many chronic diseases. An extensive literature survey was undertaken for compilation of information on the traditional systems of medicine in India, which include Ayurveda, Unani, homeopathy and Siddha. The careful investigation of information reveals that Ayurveda is one of the oldest systems of medicine evolved in India. It is a holistic system of treatment, which is an amalgamation of regular diet, use of medicine and following practices like exercise and behavior. The contribution of plants, as raw material for making medical formulations, is significant in the Indian systems of medicine, and over 6,500 species of plants are known to occur in India those are used by various streams of traditional health care practitioners. Attempts made by the Government of India in enriching and managing these age-old health care systems are also discussed.

The Role of Spinal Manipulation in the Treatment of Low Back Pain

Although approximately 200 treatment options are available to treat low back pain,1 no single treatment is clearly superior. Furthermore, the etiology of back pain is often unclear, possibly contributing to treatment strategies for low back pain often being determined by preferences of the clinical care practitioner. Spinal manipulative therapy (SMT) is a controversial treatment option for low back pain, perhaps in part because it is most frequently administered by chiropractors. Chiropractic therapy is not widely accepted by some traditional health care practitioners. This may be, at least in part, because some early practitioners of chiropractic care rejected the germ theory, immunizations, and other scientific advances.

Managing Indigenous Knowledge for Corrective and Preventive Cares: The Case of Horro Guduru Wollega Zone, Oromia, Ethiopia

This study aimed to investigate the extent to which knowledge management approaches can be used to manage indigenous knowledge (IK) of corrective and preventive cares in local communities of Horro Guduru Wollega zone. This study used descriptive research design through qualitative research method to collect reliable data about perception of disease and its main cause, the types of IK of traditional healthcare practice, indigenous self-medication and required from traditional healthcare practitioners. The respondents were chosen from local communities (traditional healthcare practitioners and community members) and stakeholders (Health Bureau, Agricultural Bureau and NGO). Accordingly, 84 key respondents were chosen through purposive sampling. The qualitative data was analyzed using thematic content analysis. The analysis results have shown that, people in the local community conceptualize disease as the disequilibrium between body and spirit; whereas God, ancestral spirit and witches and sorcerers are the main cause of disease. The above cause's related diseases can be treated by using traditional healthcare IK such as by traditional medicine, physiotherapy treatment and spiritually treatment by self-medication and traditional healthcare practitioners. Therefore, there is a need to capture and manage IK of traditional healthcare practices to save it from loss by local community, community leader and elders, young generations, governments, higher education institutions and researchers.

Past, present and perspectives of Manipur traditional medicine: A major health care system available for rural population in the North-East India

BackgroundTraditional health care practices are still being followed extensively in Manipur, North-East India. This is the major or the only medical facility available in some rural areas of Manipur. Cross cultural ethno-pharmacological survey was conducted to document traditional health care practices by Maiba–Maibi (male–female traditional health care practitioners of Manipur). Materials and methodsAll together 59 traditional practitioners belonging to 12 ethnic communities in nine districts of the Manipur state were interviewed. A predesigned questionnaire was used for interviews, which included queries for type of ailments treating, symptoms, bioresources used, method of preparation, dosage forms, formulation, unit doses. The entire interviews were done in the residence of respective Maiba–Maibi, their patient handing and preparation of medicinal formulations were documented in written and audio–visual format. ResultsThe survey recorded traditional knowledge on 949 formulations used for 66 human ailments. Five hundred forty six plant products, 42 animal products and 22 organic/inorganic materials were found to be used in these 949 formulations. Five plant species – Zingiber officinale (Zingiberaceae), Cocos nucifera (Arecaceae), Oroxylum indicum (Bignonaceae), Curcuma longa (Zingiberaceae) and Allium sativum (Liliaceae) used by maximum number of Maiba and Maibi in maximum number of formulations. RecommendationThis particular method of documentation keeps traditional knowledge alive. The WHO estimated perspective of traditional medicine across the world. These observations support therapeutic worth of Manipur Traditional medicines (MTM). Having generated a large database in course of this survey, next focus targeted for the scientific justification of MTM with an aim to develop commercially viable products.

Indigenous knowledge on health care in high altitude Indian central Himalaya

Constrain by a rigours environment which has fostered physical and social isolation for ages, the Indigenous communities have developed their traditional mode of living. The genre de vie of the isolated communities haves been marginally modified by exogenous force and have a systematic relationship with ecological condition and the resource base of the enclaves of their concentration. Encounter to disease troughs traditional practices are found throughout the world in different societies and culture since time immemorial. “Traditional medicine refers to health practices, approaches, knowledge and beliefs incorporating plant, animal and mineral based medicines, spiritual therapies, manual techniques and exercises, applied singularly or in combination to treat, diagnose and prevent illnesses or maintain well-being” (WHO, 2003). Indigenous plant-based medicines are often favored as they are inexpensive, culturally familiar and readily available. Traditional healer seems to be more accessible than conventional health care services in many rural areas. Number of traditional health practitioners regards the Himalaya as store house of various medicinal herbs. The rich and diversified flora of India provides a most valuable storehouse of medicinal plants. In Uttarakhand majority of traditional health care practitioners are herbal healers (vaidyas); they are easily accessible in the rural area and are useful to the community in absence of modern health services. In the Pauri District of Uttarakhand 60 traditional herbal healers (vaidya) were practicing in the rural area (Kala, 2004). These vaidyas used about 156 medicinal plant species for preparing 243 formulations to treat 73 ailments. He also found that this traditional practice, mainly acquired from generations is declining and lesser number of young people are choosing this profession. “The social aspects of traditional health practices in Central Himalaya found that females were the real custodians of the indigenous knowledge system as 52% of them have the knowledge on thirty practices against that of 26% for males. This indigenous knowledge system of medicine existing as a super structure, effectively serves the people of the region. Further, the indigenous practices being easily administrable and cheaper relieve the practitioners from time and financial hardship ” (Samal et al., 2004). Recognizing the present escalating demand for herbal medicines, and also in order to reduce the possibility of bio-piracy and to protect the rights of traditional herbal healers, there is an urgent need to document the various uses of plant species(Udgaonkar, 2002).

The medical ethnobotany of Lesotho: a review

Traditional healing in Lesotho is reviewed, focusing on four aspects: 1, cultural practices; 2, traditional health care practitioners; 3, dosage forms; 4, the materia medica. Cultural practices are strongly associated with the belief that intangible forces are responsible for human happiness and misery. A total of 303 plant species are used medicinally (including 25 alien species), representing eight pteridophyte and 75 angiosperm families, of which the most important are Asteraceae, Fabaceae, Hyacinthaceae, Apocynaceae, Scrophulariaceae, Lamiaceae and Poaceae. Dicoma anomala (used mainly for digestive ailments) and Artemisia afra (used mainly for respiratory ailments) appear to be the best known and most widely used medicinal plants amongst a total of 37 species that have been cited four or more times in the literature. About 50 species are variously employed for magic and sorcery. There are no new species records but 36 new uses are reported. Our conclusion is that the medicinal plants of Lesotho are relatively well recorded and that this review will allow detailed comparisons with other African healing cultures.

Communication Disorders in Patients with Parkinson's disease: Perspectives of Traditional Healers

Two-thirds of the global population consult the services of traditional health care practitioners (THPs) with 80% of the African population using traditional medicine (WHO, 2001a). Western conventional treatment approaches to health and specifically communication disorders in patients with Parkinson's disease (PD) have failed to recognize the significant role that THPs fulfil in the lives of a vast majority of African people and in comprehensive health care. This article contextualizes an exploratory and descriptive study on the perceptions of THPs regarding the treatment of patients with communication disorders resulting from PD. A purposive sample of 20 multilingual THPs was interviewed using a structured interview schedule. Results indicate that THPs and western practices view illness and healing from different frames of reference, yet complimentary, whilst striving for best treatment models of practice for the patient. The study contributed to the knowledge base of the significance of a multi-disciplinary approach when dealing with patients with PD and in health care in general. Limitations of the study include a small sample size and geographical location, impacting on generalisability.

Traditional Healing in South Africa

ABSTRACT Within health-care settings, culturally competent practice presupposes an understanding of the socio-cultural meanings attached to illness and disability and the people who are likely to be consulted with respect to providing health care and restoring well-being. Large numbers of South Africans are known to consult with traditional healers in preference to or in conjunction with western, allopathic health-care professionals. The present study represents a secondary analysis of data from various studies conducted on Black African, Muslim, Hindu and Chinese traditional healing systems in South Africa. Common themes that emerged from the analysis included the attribution of illnesses and disorders to spiritual factors, punishment and superstitious beliefs. Treatment approaches included the use of natural substances, prayer and rituals, and procedures that were designed to restore equilibrium. Theparticipants also articulated their views on medical pluralism, collaboration between western and traditional health-care practitioners, and reasons why people consulted with traditional healers. The findings are discussed in terms of their ethical implications for social work.

The challenges of involving traditional healers in HIV/AIDS care

We read with interest the review article The challenges of involving traditional healers in HIV/AIDS care by E Mills S Singh K Wilson et al. There is now an opportunity for physicians trained in western medicine to engage in fruitful dialogue with other health-care practitioners viz. traditional healers complementary and alternative medicine practitioners. This is not only in matters of HIV/AIDS alone but also in other disease conditions where the traditional care practitioners have claimed success. The burden of HIV/AIDS is highest in sub-Saharan Africa and several of the countries in this region are resource poor and many people live below poverty line. In these resource-poor areas many people have the cultural belief that there is a spiritual or psychological component to any form of disease or illness hence their reliance on prayers alternative and traditional health-care practitioners. Apparently affordability contributes to these people accessing alternative or traditional practitioners though it has not been proven to be cheaper on the long run. Both of us have many years experience of working in developing countries. We have seen patients who came very late into hospitals with serious complications and in life-threatening conditions because the traditional healers were managing them or implementing some traditional practices at home. (excerpt)

Ethical issues in health workforce development.

Increasing the numbers of health workers and improving their skills requires that countries confront a number of ethical dilemmas. The ethical considerations in answering five important questions on enabling health workers to deal appropriately with the circumstances in which they must work are described. These include the problems of the standards of training and practice required in countries with differing levels of socioeconomic development and different priority diseases; how a society can be assured that health practitioners are properly trained; how a health system can support its workers; diversion of health workers and training institutions; and the teaching of ethical principles to student health workers. The ethics of setting standards for the skills and care provided by traditional health-care practitioners are also discussed.