The governance of traditional medicine and herbal remedies in the selected local markets of Kenya

A lot of emphasis has always been placed on modern governance systems and little or no attention is given to traditional governance practices which remain largely undocumented. This study aimed at nding out important traditional and modern governance practices that regulate traditional medicine sector. There is a growing demand for traditional medicine in urban settings in spite of its proximity to conventional health care centres and access to modern medicine. However, questions about their safety and ecacy still remain to be adequately addressed in eight different Purposive sampling design with elements of snow ball techniques were employed in tracing competent traditional medicine ‘experts’ and relevant professional experts. Interviews were conducted upon obtaining prior oral informed consents using semi structured questionnaires. The data collected was entered in Microsoft Excel where descriptive statistics namely, averages/mean, frequencies and percentage descriptive statistics were conducted. The Pearson’s Chi square statistics was performed on the traditional and modern governance data sets using the STATA software and data presented using tables, bar and column graphs.

Little is known about the traditional governance practices that govern and regulate the trade and practice of traditional medicine. Emphasis has always been attached to modern governance practices ranging from constituted laws to policies that regulate traditional medicine. The governance of traditional medicine practitioners and traditional medicine trade in the devolved county market structures is also not known. The study attempted to nd out the traditional and modern governance practices that regulate traditional medicine and to assess the knowledge, attitudes and perceptions (KAP) of the traditional medicine practitioners drawn from the selected market centres in Kenya. Finally, there was need to evaluate the relevance of the traditional governance practices and whether they should be harmonized with modern governance practices.

Governance and Management of the Traditional Medicine in Kenya
Governance expresses the organization of people, exercise of power whether formally or informally and the ability to lay rules on how to attain their objectives and goals at local, social, institutional, national or global level [25]. Traditional medicine practice can be governed to some extent through local customs and indigenous knowledge normally transferred via cultural means in various stages namely collection, consumption and trade. However, there is need to harmonize the traditional systems of governance with the modern formulated policies and legal regulatory frameworks passed by national government jurisdictions. The push for integration of traditional medicine into the general health care has been compounded by the inability of the modern health facilities in meeting the health demands of the increasing population [26].
The increasing demand for medicinal plants opens avenues for con ict caused by over-harvesting and thus the need to have sustainable means of plant resource management [15]. Therefore strong governance is critical for controlled harvesting of medicinal plants particularly from the wild [27]. Functional local institutional policies also play a vital role in the transfer of indigenous knowledge [28]. It has been observed that traditional knowledge is important in the management of natural resources and the decline in the sharing of this traditional knowledge has been blamed on the absence of robust functional regulations [29,30]. The problematization of traditional medicine has been conceptualized in terms of health and safety, threats to sovereignty and their role in national development. Sovereignty de lement has been registered through non-procedural access to plant and genetic resources and incidences of biopiracy. It has been reported that proper documentation aids in curbing biopiracy and preservation of intellectual property rights. Therefore, quality of traditional medicine can be sustained through robust legislations [13,31]. [22]Dut eld, 2014 re-stated and re-de ned biopiracy as 'theft, misappropriation or free-riding on genetic resources and traditional knowledge'. Article 11 of the Constitution of Kenya (CoK) recognizes culture with respect to the "role of science and indigenous technologies in the development of the nation" and entrusts parliament with powers to enact legislation to "recognize and protect the ownership of indigenous seeds and plant varieties, their genetic and diverse characteristics and their use by the communities of Kenya". CoK 2010 also provides for the right to health [32]. Nagoya Protocol advocates for fair and equitable sharing of genetic resources and utilization of the existing knowledge, institutions and practices as held by the members of the local community. The legal and regulatory frameworks so far set in place are thought to be ambiguous and less effective and there is need for clear and de nitive legislation [33]. The leading challenges to good governance were reported to include transparency, accountability and leadership [34].
Traditional Knowledge And Intellectual Property Rights [22]Dut eld, 2014 claimed that there is no intellectual instrument or tool on traditional knowledge (TK) but remained optimistic that a functional instrument can be found in the near future. On the other hand, there are many international instruments (for instance, good laws) on intellectual property rights that protect inventions, innovations and plant varieties. Many jurisdictions have recognized and protected traditional knowledge in their laws, for instance, Peru and Panama.
Dut eld posits that India has shown great strides in the recognition and protection of traditional knowledge through its well established Traditional Knowledge Digital Library (TKDL) containing information on uses of plants.
Modern Governance practices are guided and shaped by good laws and policies. Three key things to consider in formation of good policies include having the right de nition of traditional medicine, creation of rules and robust regulations and preservation of intellectual property rights [9]. The Witchcraft Act of 1925 outlawed any forms of witchcraft practices that was detrimental to the administration of colonial government and any traditional medicine practitioner labelled a witchdoctor or suspected to be in possession of charms risked being convicted, punished or slapped with a hefty ne or even imprisonment. Lawful traditional practices were vetted by the local administrative authorities. Witchcraft laws created fear among traditional medicine practitioners and thus slowed down the growth of traditional medicine. Regrettably, witchcraft law is still active and has not been repealed.

Alma Ata Declaration, 1978
The international conference held in Alma Ata in the former USSR advanced the agenda for primary health care for all people in the world and declared health a fundamental human right. It referred to gross inequality in health care as unacceptable and a cause of great concern. The declaration tasked governments with a responsibility to formulate policies, strategies, and plans of action that promote sustainability of the primary health care. The provision of a comprehensive health care can be achieved using both local and external resources. Alma Ata recognized and acknowledged the contribution of midwives, community workers and traditional practitioners in the provision of primary health care at local levels.
Convention on Biological Diversity, United Nations, 1992 The 1992 Convention on Biological Diversity (CBD) advocates for the use of indigenous and traditional knowledge harboured by local communities in the conservation of biodiversity, equitable sharing of bene ts and sustainable use of natural resources. Annex I of the convention highlights the importance of identi cation of medicinal plants and more so key indicator species that may be useful in research, conservation or sustainable use.

Kenya National Drug Policy, 1994
The Kenya National Drug Policy acknowledges traditional medicine as a key ingredient of Kenya's culture and thus the need to mainstream it into the general health care system.

Registration/Recognition of Traditional Medicine Practitioners and Medicinal Plant Conservationists, Form DC1, 2003
The Ministry of Gender, Sports, Culture and Social services tasked the Department of Culture with the responsibility to register and recognize traditional birth attendants, bone setters, traditional surgeons, users of herbal extracts and medicinal plant conservationists. The Department of Culture spelt out the eligibility criteria which included approval, appraisal and recommendations from local administrative authorities and submission of three to six drug samples, medicinal plant preparations or plant specimens to recognized government and research institutions or universities for laboratory analyses.
The Department of Culture also outlines the registration guidelines for foreign groups or individuals and also establishes a local mechanism of assessing traditional medicine practitioners.

Challenges and concerns in traditional medicine
The growing use of traditional medicine coupled with limited knowledge on their medicinal properties has continued to pose health and safety concerns. China and Japan lead the way in the integration of herbal medicines (herbs, plant parts and preparations, processed herbal products, active ingredients) into the primary health care system. It was reported that patients do not disclose their use of herbal remedies to physicians when seeking conventional therapies bearing in mind that herbal medicines interactions and herbal-conventional drugs interactions may be a serious health risk. Herbal interactions may alter drug e cacy or cause adverse reactions, whereas herbal-conventional drug interactions may disrupt drug absorption and metabolism (39,13]. In Africa, a case study in Ghana (Kumasi South Hospital) revealed that most biomedical practitioners are skeptical about integration of traditional medicine. Positive integration of traditional medicine needs robust regulatory policies and protocols for integration [40].  [41].
Cooperation between traditional and allopathic practitioners is touted to be bene cial and complementary to health care delivery despite hanging atmosphere of negative attitudes between the two health care systems that hampers collaboration [42]. It has been reported that cultural and spiritual beliefs play a crucial role in the conservation and protection of traditional In South Africa, signi cant progress has been made on the perception of traditional healers from a derogatory witchcraft viewpoint supported by a colonial Witchcraft Suppression Act (3 of 1957) to a more accommodative status supported by a regulatory framework [44]. The association of traditional medicine with witchcraft was meant to discourage the users and slow down the growth of indigenous health care system. Although some patients suffering chronic ailments, for instance, HIV/AIDS prefer combination of allopathic and traditional medicine [45].
In most countries of the Sub-Sahara Africa, the problem of decreasing agricultural and rural land sizes has affected the supplies of traditional medicines [3]. Major threats emanates from an increasing extraction of construction materials (wood, timber, poles) and fuel wood [43].

Secrecy and suspicion
Secrecy of the traditional medicine trade or practice is an impediment to free sharing of traditional knowledge and thus a major challenge in the advancement of traditional knowledge [14,43]. However, secrecy can be violated by traditional

Research design
The study used a purposive sampling where a sample of respondents picked were knowledgeable on traditional medicine as professional experts or traditional 'experts' and were willing to share information in their eld of expertise and experience.
Snow ball technique was used in identifying the willing respondents to be interviewed [3,31,42]. All willing respondents were interviewed upon attaining an oral prior informed consent. Purposive sampling takes care of situations where some members of the target population may not be willing to participate in the subject, in this case, the fear of losing their unpatented traditional knowledge and medicinal products [48]. In this study, a exible semi-structured questionnaire was used to gather the data from the willing respondents in all the identi ed market centres in the country and in the capital city, Nairobi, Kenya [41,49,50].

Sampling frame and Target population
The willing respondents interviewed include 13 professional experts knowledgeable in traditional medicine and 26 traditional medicine practitioners plying their trade in the selected market centres. This sampling frame was designed to capture the professional and traditional knowledge, attitudes and practices in the governance of traditional medicine ( Table 2, Table 3) and also capture their divergent interests in traditional medicine. Data was collected through a mixture of methods which included eld observations, photographs, eld visits and re-visits, interviews using a semi-structured questionnaire after getting an oral prior informed consent. The eld interviews were conducted from February 2019 to September 2019 [4,15,43,51,52,53,54,55]. Open ended questions were also employed so as to gather more information on the study thematic categories [43,56]. Table 3 Selected market centres, willing respondents, their sex and ethnic a liation. The number of respondents who refused to be interviewed was also captured. The data collected was entered in Microsoft Excel where descriptive statistics: averages/mean, frequencies and percentage descriptive statistics were conducted [43]. The Chi square statistics was performed on the traditional and modern governance data sets using the STATA software version 13.0 and data presented using tables, bar charts, column graphs and a pie chart [3,18].  Modern Governance Practices Table 5 The Modern Governance Practices of traditional medicine. The number of interviewed respondents from each locality are indicated in brackets.

Modern
Governance Practices The modern governance practices were not signi cantly different in all the market centres surveyed, p (0.080) > 0.05 in the surveyed market centres.
Descriptively, most respondents (100%) perceived that county-by-laws were fully observed by all practicing Traditional Medicine Practitioners in order to be allowed to freely practice in the counties. In addition, the practitioners also observed total compliance (96%) to meeting the market trading fee in order to avoid unnecessary punishment or penalties from the county government authorities. Majority of the respondents (88%) were in favour of regular monitoring and checks in the area of traditional medicine and quality control. However, lack of designated market spaces (23%) and practicing rooms (4%) were notable bottlenecks for the Traditional Medicine Practitioners.
Traditional governance practices Table 6 The Traditional Governance Practices of traditional medicine. The numbers of interviewed respondents from each market location are indicated in brackets. Bars re-harvest of MedPl  1  1  2  0  3  1  1  2  11   Total  33  29  34  19  38  7  10  24  194 Pearson's Chi square (77) = 34.3683, p = 1.000 The Traditional Governance Practices were not signi cantly different in all the market centres surveyed, p (1.000) > 0.05. Descriptively, majority of the Traditional Medicinal Practitioners (Fig. 5) are against re-harvesting of freshly harvested medicinal plants (92%) and backed limited or no disclosure of traditional medicine knowledge (85%) and thus maintain secrecy of the TM practice. The conservative nature of traditional medicine practice bars breastfeeding mothers (19%) and menstruating women (15%) from practice. Some Traditional Medicine Practitioners were guided by environmentally conscious decisions: discouraging uprooting of solitary medicinal plants (35%), care for main roots (62%) and covering of exposed roots with mounds of soil (65%). These traditional governance practices touched on morality, purity and cultural beliefs, for instance, not having sexual intercourse when a traditional medicine practitioner has a patient (50%), not imposing xed treatment charges (58%) to allow patients pay what their spiritual conscience dictates, freedom from curse or crime (69%) and lastly having a close diary in gathering of traditional medicine (69%).
Secrecy/Limited or no disclosure of traditional medicine knowledge Semi-structured interviews, eld observations and photographic collections revealed that few Traditional Medicine Practitioners (15%) in the surveyed market centres were willing to disclose important traditional medicine knowledge.
However, the willing respondents could not divulge a lot of important information, for instance, medicinal plant local name and the collection site, but would rather disclose information about the parts used, the disease treated and the mode of preparation. Most of the medicinal plants displayed in the open air markets (Fig. 6a & 6b) lacked proper identifying traits (morphological and oral taxonomic characters) therefore making it di cult for users/patients and researchers to easily identify the traditional medicine plants traded. This was deemed to retain the traditional medicine knowledge in some families. Preferences and liking for traditional medicine Based on experience and feedback from customers/patients (Fig. 7), most Traditional Medicine Practitioners believe that people prefer traditional medicine to conventional medicine because they are considered better, faster in action and e cient (62%), natural, organic and safe (50%) and some think they are affordable and accessible (46%).

Sources of Traditional Medicine knowledge
Most of the Traditional Medicine Practitioners learnt their traditional medicine knowledge (Fig. 8) from their grandmothers (57%) and some learnt from their fathers (13%), mothers (11%), aunts (8%) and few claimed they learnt by themselves (3%) and others learnt traditional medicine from researchers of traditional medicine (3%).

Major Challenges that affect Traditional Medicine in Kenya
The Professional Experts and TMPs showed divergent opinions based on what a icts traditional medicine sector (Fig. 9).
Most Traditional Medicine Practitioners perceived that lack of market spaces (92%) and suspicion as a result of mistrust (96%) were the main challenges. On the other hand, the Professional Experts perceived that lack of adequate documentation in traditional medicine knowledge (100%), inadequate nancial capital (100%) and existence of incompetent TMPs or quacks (92%) were glaring challenges.

Discussion
In this study, women and more so elderly women dominated the traditional medicine practice. This can be attributed to the silent, informal and yet powerful traditional governance practices that by design excludes younger and inexperienced women. The exclusion of the younger practitioners boosts credibility and con dence among the customers or patients and mitigates safety fears among the consumers of traditional medicine. These traditional governance practices include barring of breastfeeding women and those undergoing menstruation from practicing traditional medicine (Fig. 5, Table 6). In Othman & Farooqui [11], and Peltzer & Pengpid [57] women also dominated the survey. Umair et al. [12] presented a unique gender representation where men were dominant in the survey for religious and cultural reasons that discouraged women from publicly interacting with male strangers. The mean age of practitioners (64 years) with an average experience of 25 years revealed that the sector is driven by experienced and knowledgeable practitioners who have accumulated enormous traditional knowledge in traditional medicine. Most of the Traditional Medicine Practitioners acknowledged growing interest among the younger people in consuming traditional medicine (reproductive age category). Sex, gender and cultural inclinations had a bearing on the overall representation in some market centres, for instance, the Makutano (West Pokot County) and Eldoret (Uasin Gishu County) market centres where all Traditional Medicine Practitioners interviewed were women and in Kitale (Trans Nzoia County) where all Traditional Medicine Practitioners interviewed were men (Table 3).
Most Traditional Medicine Practitioners learnt their traditional medicine knowledge from their grandmothers (57%) than from other family members. This is to ensure a continuous ow of the traditional knowledge in traditional medicine from one generation to another, and more so sustain the practice within the family tree. Suspicion and secrecy seemed to be a common phenomenon with most of the Traditional Medicine Practitioners' refusing to disclose vital traditional medicine knowledge and others (46%) refused to be interviewed. The relationship between professional experts and Traditional Medicine Practices continued to be strained with suspicion and Traditional Medicine Practioners' choose to have limited or no disclosure of traditional medicine knowledge. This suspicion is exacerbated by the fear of losing their hard earned traditional knowledge, inheritance and family livelihood. Laws of Kenya regrettably created more harm than good in the advancement of traditional medicine and sadly enough this act still exists in our laws. In Peltzer & Pengpid [57], two traditional practitioners were excluded from their study for allegedly practicing witchcraft.
The traditional governance practices varied with notable cultural differences seen in the surveyed market centres but were not statistically signi cant. In this study, the traditional governance practices were more pronounced in Arror, Makutano and Eldoret market centres and were less pronounced in Kakamega and Kitale market centres. These differences can be attributed to varying cultures and presence of different ethnic and tribal groupings. The demand for traditional medicine is growing and it is not only utilized by rural population but also in the urban population and also as a last resort for many people when modern medicine fails. Thus underscoring the need to integrate traditional medicine into the general health care and even promote patient referrals [22]. Lack of designated market spaces or practicing rooms for Traditional Medicine Practitioners forces practitioners to practice on the roadsides and face imminent exposure to dusty or wet street spaces and real danger of contamination.

Conclusion
Modern governance practices have continually received a lot of attention as compared to the much traditional governance practices. Traditional governance practices play a big role in traditional medicine as it determines who is eligible to practice, where to practice, what to avoid when practicing, how to practice and any other delicate questions that surrounds traditional medicine. Traditional governance practices are silent but yet powerful system of informal and unwritten rules that forms the backbone of traditional medicine. Traditional governance practices are closely associated with the socio-cultural beliefs of the local communities.
The existence of good laws and policies alone is not enough, there is need for education and awareness campaigns on these regulations taking into consideration of the needs and aspirations of the Traditional Medicine Practitioners. However, despite limited awareness on the current laws and policies, the Traditional Medicine Practitioners showed unwavering compliance on the enforced county-by-laws. Most legal and policy frameworks are general jurisprudence and rarely cover traditional medicine, medicinal plants, processing of herbal products, safety and e cacy.
Lastly, there is need to integrate traditional governance practices into our formal regulatory frameworks and consider harmonizing the traditional and modern governance practices in order to have a vibrant traditional medicine sector. The feeling of exclusion by the traditional medicine practitioners heightens suspicion, mistrust and slows development of the TM sector.
For the improved governance of traditional medicine, I recommend that: Traditional Medicine Practitioners be included in the process of making laws and policies governing the traditional medicine Stringent regulatory procedures and monitoring should be observed to ensure safety and e cacy Integrate traditional medicine in the primary health care and encourage referrals to modern health centres Practicing/trading spaces should be set up for Traditional Medicine Practitioners to prevent contamination of the traditional medicine Practicing Traditional Medicine Practitioners should be thoroughly vetted to rid the market centres of incompetent, unquali ed and unethical practitioners popularly dubbed 'quacks' Traditional governance practices should be integrated in the legal and regulatory frameworks for traditional medicine and be given some importance just like the extra attention given to modern governance practices Declarations Figure 1 A snapshot of a registration or recognition form issued by the Department of Culture to traditional medicine practitioners.

Figure 2
A map showing adjacent counties where selected market centres are located.

Figure 3
Page 24/28 Modern governance practices observed in the sampled market centres.

Figure 4
A sheltered traditional medicine market in Luanda, Vihiga County, Kenya.
Page 25/28 Figure 5 The traditional governance practices that regulate the trade and practice in traditional medicine.  The main challenges a icting traditional medicine sector in Kenya as perceived by both professional experts (regulators) and Traditional Medicine Practitioners (practitioners).

Supplementary Files
This is a list of supplementary les associated with this preprint. Click to download. QUESTIONNAIREGovernanceofTM.docx