Effectiveness of Integrated Health Systems in Africa: A Systematic Review

Background and objective: Traditional medicine (TM) was integrated into health systems in Africa due to its importance within the health delivery setup in fostering increased health care accessibility through safe practices. However, the quality of integrated health systems in Africa has not been assessed since its implementation. The objective of this paper was to extensively and systematically review the effectiveness of integrated health systems in Africa. Materials and Methods: A systematic literature search was conducted from October, 2019 to March, 2020 using Ovid Medline, Scopus, Emcare, Web of Science, Cumulative Index to Nursing and Allied Health (CINAHL), and Google Scholar, in order to retrieve original articles evaluating the integration of TM into health systems in Africa. A quality assessment of relevant articles was also carried out using the Quality Assessment Tool for Studies with Diverse Designs (QATDSS) critical appraisal tool. Results: The results indicated that the formulation and execution of health policies were the main measures taken to integrate TM into health systems in Africa. The review also highlighted relatively low levels of awareness, usage, satisfaction, and acceptance of integrated health systems among the populace. Knowledge about the existence of an integrated system varied among study participants, while satisfaction and acceptance were low among orthodox medicine practitioners. Health service users’ satisfaction and acceptance of the practice of an integrated health system were high in the countries assessed. Conclusion: The review concluded that existing health policies in Africa are not working, so the integration of TM has not been successful. It is critical to uncover the barriers in the health system by exploring the perceptions and experiences of stakeholders, in order to develop solutions for better integration of the two health systems.


Introduction
Traditional medicine (TM) refers to the sum total of all explicable knowledge and practices used in the diagnosis, prevention, and elimination of physical, mental, and social imbalance. TM exclusively relies on practical experience and observations handed down verbally or in writing from generation to generation [1]. TM's use is increasing in both developed and developing countries. For example, the proportion of residents who have patronised TM at least once in developed countries is 38% in Belgium, 42% in the United States of America, 48% in Australia, 70% in Canada, and 75% in France [2]. TM use is reported to be more popular in Africa, Asia, and Latin America, since 80% of the population continue to depend on TM for their primary health care needs [2,3]. The high

Defining the 'Integration of TM'
In this systematic review, TM integration refers to any research that has focused on the incorporation of herbal/indigenous medicines, including bonesetters, into health systems. Integrated health systems also include partnership between orthodox and traditional health service providers. The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines were adapted for this review [19]. A literature search was performed from October, 2019 to March, 2020 using Ovid Medline, Scopus, Emcare, Cumulative Index to Nursing and Allied Health (CINAHL), Web of Science, and Google Scholar to retrieve original articles on the integration of TM into health systems in Africa. Various keywords or synonyms were used in the search strategy to expand the search term because a number of terms have been used in the literature to refer to the same concept. Although the review is focused on the effectiveness of integrated health systems in Africa, the words 'effective' and 'Africa' were not included in the search terms to avoid restrictions of the search. Africa was precluded from the search term to avoid excluding articles reporting research conducted in Africa, but without the word 'Africa' in their titles. Minor differences existed in the search terms, depending on the type of database and search engine (Supplementary Table S1).

Eligibility Criteria
There were no restrictions for the time and type of study, but the study setting was limited to Africa. Articles included in this systematic review are primary studies published in peer-reviewed journals reporting on measures taken to aid TM integration into health systems and the effectiveness of such integrated systems. Studies which referred to TM as herbal/indigenous medicine were selected for the review. The review excluded the following: Systematic reviews, theses, non-English articles, and other articles with animals as the target population.

Selection and Extraction of Data
I.G.A identified relevant articles and T.I.E replicated the search to confirm the search strategy. Uncertainties regarding the included studies were resolved by discussion, until a consensus was reached. The characteristics obtained from included studies were the target population, type of study, methodology, measures taken to integrate TM, summary of findings/results, and effectiveness of TM integration. However, interventions implemented to integrate TM into formal health systems were the key inclusion criteria.

Data Synthesis
The included studies were evaluated based on interventions implemented to integrate TM into formal health systems and key findings in relation to the effectiveness of the integrated health system. It is worth mentioning that the effectiveness was inferred from the findings and conclusions of various studies. This is because the effectiveness of integrated health systems was described, rather than explicitly stated, in the findings. Inference was conducted by evaluating the level of awareness, usage, satisfaction, and acceptance of the integration of TM among target populations. Awareness was inferred based on self-reported knowledge of the introduction of TM into the health system, while usage was deduced from the interactions between stakeholder groups (orthodox and TM practitioners, and health service users). Satisfaction was deduced on the basis of the fulfillment that participants derived from the system and acceptance was gleaned based on the value that participants placed on their role and the role of other stakeholders in the integration agenda. With quantitative studies, percentage scores correlating to inferred knowledge, usage, satisfaction, and acceptance which were less than or equal to 39% were deemed low [20], while values of 40% and above were assumed to be moderate/positive indicators [17]. Similar inferences were conducted for qualitative studies and representative quotes were used to support the inferences drawn.

Quality of Methods Assessment
The Quality Assessment Tool for Studies with Diverse Designs (QATSDD) developed by Sirriyeh et al., was used to evaluate the quality of included studies [21]. The tool was adopted because it was applicable in all instances, since the review identified and included all types of studies. The tool is made up of 16 criteria and all the criteria were applicable to the mixed methods study, while qualitative and quantitative studies were assessed using fourteen 14 of these criteria. Each criterion on the list was allotted a score of zero to three, where 0 represents 'criterion not mentioned at all', 1 represents 'very slightly mentioned', 2 represents 'criterion moderately stated', and 3 represents a 'vivid explanation' of the criterion. In view of this, the highest mark for the mixed methods study was 48 (16 × 3) and 42 (14 × 3) was the highest mark for the qualitative and quantitative studies, respectively. The total scores of included studies were further converted to percentages. For example, a mixed methods study with a score 48 out of 48 equates to 100% (48/48 × 100 = 100). The percentage scores were further categorised into three groups such that an article was considered excellent if the percentage score was 80 and above, good if scores ranged between 50% and 79%, and low if the score was below 50%.

Results
In total, 6995 articles were identified from five databases and the Google Scholar search. However, 2744 duplicates were removed, leaving 4251 articles. A total of 93 articles were retained after title and abstract screening. Thirteen out of the 93 articles met all of the inclusion criteria after full text screening (see Figure 1).

Distribution of Reviewed Articles
Thirteen articles were included in the review. Five (38.5%) of the articles originated from Ghana [12,17,[22][23][24]. Three studies (23.1%) were conducted in South Africa [25][26][27]. The remaining five studies were carried out in Burundi [28], Botswana [20], Cameroon [29], Nigeria [30], and Zambia [31]. The reviewed studies were conducted over a period of thirteen years. The earliest study [31] was conducted in 2006, while the latest studies were carried out in 2019 [24,27]. Figure 2 shows the number of included studies from different countries in Africa.

Characteristics of Reviewed Articles
Of the 13 included studies (Figure 1), seven were qualitative and five were quantitative studies. Only one was a mixed methods study. Two of the qualitative studies used a phenomenology approach (qualitative research which emphasizes similarities in lived experiences within a specific group of people) to achieve the study objectives [22,27], while one study [12] used an inductive reduction approach. Ethnography (qualitative research in which the researcher defines and interprets common and learnt forms of behavior, values, beliefs, and language of a culture-sharing group) was employed as research design for the qualitative aspect of the mixed methods study [28]. However, three of the qualitative studies did not state the research design used [23,25,26]. All quantitative studies used a cross-sectional design in achieving the study objectives [17,20,[29][30][31].
As shown in Table 1, four studies targeted health practitioners and patients as study participants [12,22,25,28]. Two studies only focused on health practitioners [24,31]. Two other studies solely targeted TM practitioners [27,30], while another two focused on orthodox medicine practitioners (OMPs) [20,26]. One study assessed both TM practitioners and community members [29]. Another study also considered people interested in TM research as the target population [23]. The last reviewed article only targeted patients [17]. More focus was placed on TM practitioners, as nine of the included studies sampled TM health providers as study participants [12,22,24,25,[27][28][29][30][31]. Only one study included key informants, consisting of the Faculty of Pharmacy (FOP), Ghana Federation of Traditional Medicine Practitioners (GFTMP), Medical Herbalist Association (MHA), Hospital Management (HM), and Pharmaceutical Directorate of Ministry of Health (PDMH), as part of the study group [22].
The sample size of quantitative articles ranged from 60 [20] to 6690 [28] participants. The most common sampling technique employed by quantitative studies was the convenient sampling procedure [20,29]. Other techniques used were systematic [17] and stratified sampling [28]. Two studies [30,31] failed to state the sampling techniques employed in choosing participants for the study. For qualitative studies, it ranged from 27 [27] to 37 participants [25]. The purposive sampling technique was widely used among qualitative studies [22,23,25,26]. Another sampling approach used was snowballing [12,28]. However, one study combined both snowballing and purposive sampling techniques in participant selection [24]. One qualitative study failed to mention the type of sampling technique employed in choosing participants for the study [27]. Generally, all reviewed articles assessed the perception, knowledge, acceptability, and satisfaction of study participants in relation to TM integration. The review inferred the effectiveness of integrated health systems on the premise of participants' awareness, usage, satisfaction, and acceptability of TM integration into formal health systems. Twelve of the studies disclosed that integrated health systems in Africa were not effective [12,20,[22][23][24][25][26][27][28][29][30][31]. Ineffective TM integration was appraised on the basis of a low level of participants' knowledge about TM integration into health systems, minimal interaction among stakeholders within the integrated system, inadequate satisfaction derived from accessing or practicing in the system, and power imbalance within the integrated systems. Only a single study reported moderate/good indicators for the integrated health system among study participants [17]. The practice of an integrated health system was reported to be feasible as the satisfaction and acceptance levels among participants were high.
Ahenkan et al. [24] Ghana: Wenchi municipality 35 orthodox and TMPs Qualitative Relational analysis Aimed to bridge the existing information and knowledge gaps on the integration of two districts and competing health systems.

Snowballing/purposive
The integrated health system in Ghana was said to be inefficient because regulatory mechanisms were unknown to health practitioners. This, according to the study, was due to inefficient policy implementation, and the slow pace of executing regulations governing TM practice in Ghana. Sought to advance the debate on the possibility and usefulness of integration within the socio-politically unstable setting of Burundi.

Stratified sampling and snowballing
The nature of the integrated health system was deemed to be weak, though the idea of integration was popular among participants. The weak nature of integration was attributed to skewed power dynamics in the integrated system.
Gyasi et al. [12] Ghana: Sekyere south district and Kumasi metropolis 16 health care users 7 TMPs 6 health professionals Qualitative Inductive reduction approach Explored health care users' and providers' experiences and attitudes towards the implementation of intercultural health care policy in Ghana.

Snowballing
There was a positive attitude towards integration with high awareness level, but inadequate institutional support and regulatory policies were revealed to impede the integration process.

Interventions Implemented to Aid the Integration of TM into Health Systems in Africa
The official practice of TM started in the early 1980's [29]. This means that the practice of an integrated health system in Africa has been in operation for approximately 39 years (Table 2). All reviewed articles acknowledged that TM integration was initiated through the formulation and execution of health policies [12,17,20,[22][23][24][25][26][27][28][29][30][31]. Countries such as Burundi, Ghana, and South Africa went a step further by implementing other measures to facilitate the integration process. For example, in Burundi, the association of TM practitioners was formed and an integrative medicine unit was created in the Ministry of Health [28]. In Ghana, the government instituted the Traditional Medicine Practice Council (TMPC), established a TM directorate in the Ministry of Health, and introduced TM into the tertiary education system [12,17,23]. In South Africa, a council was created to oversee the activities of TM practitioners [27].

Awareness as a Measure of an Effective Integrated Health System in Africa
Varying levels of awareness were observed among review articles. Seven studies reported a low level of awareness about the existence of integrated health systems in their countries [20,22,24,26,[29][30][31]. For example, Kaboru, Falkenberg [31] recounted that a lower proportion (24%) of study participants claimed knowledge of the practice of an integrated health system in Zambia. A similar result was observed in the work of Madiba [20], where only 18.6% of participants knew of the integrated health system in Botswana. The knowledge gap was more profound in the area of availability of TM policy which regulates the activities of practitioners. However, six studies reported a moderate level of awareness among study participants [12,17,23,25,27,28]. For instance, a study conducted in Ghana reported that 42.2% of participants knew about the presence of TM units in the study sites [17] and 91% of orthodox medicine practitioners in Burundi were also aware of the integrated health system [28]. Participants attributed their source of knowledge to the interaction between traditional and orthodox health practitioners, but also admitted that integration was weak ( Table 2).

Usage as a Measure of an Effective Integrated Health System in Africa
The usage of an integrated health system was inferred as the interaction between stakeholders (orthodox medicine practitioners, TM practitioners, and health care users) within the health system. A total of ten articles reported a low usage of the health system among study participants [12,20,[22][23][24][26][27][28][29][30]. The usage of an integrated system was particularly low among orthodox practitioners, as only 27% of participants had ever collaborated with TM providers and 10% were willing to refer clients to TM providers [20]. The under-utilization of integrated health systems in Africa was attributed to the absence of protocol to publicize the integrated health system [22], TM products, and services not included in national health cover [23] and an unwillingness of orthodox practitioners to embrace the incorporation of TM practice into formal health systems [20,24]. Generally, inadequate evidence-based research to support TM practice was cited by orthodox practitioners as the reason for their resistance. Nonetheless, three studies reported a moderate usage of integrated health systems [17,25,31]. A Ghanaian study reported that 42.2% of participants patronized health services offered at the TM units in the study settings [17]. However, 13% of the participants stated that usage of the integrated system could increase through positive recommendations from orthodox practitioners. (Table 2). A study conducted in Zambia reported a moderate level of usage, as 53% of TM practitioners interacted with the formal health system by advising clients to access certain biomedical services, such as laboratory services, before they (TM practitioners) commenced treatment [31]. Usage was reported to be moderate in South Africa, as health service users patronized both health systems simultaneously or at different time periods, depending on the efficacy of treatment. For example, a participant stated, "We commenced treatment at orthodox health care, then progressed to TM providers but accessing TM worsened the ailment. So we stopped and returned to orthodox health care" [25].

Satisfaction as a Measure of an Effective Integrated Health System in Africa
Satisfaction was determined by the level of fulfilment that participants derived from integrated health systems. Ten reviewed articles reported a low level of satisfaction among participants [12,20,[23][24][25][26][27][28][29][30]. Satisfaction was recounted to be minimal because 70% of participants were not pleased with TM practice [20]. This low satisfaction was mainly due to the failure of policy makers to enact and implement policies to promulgate the integration process, weak communication within the referral system between health care providers, and lopsided power relations within integrated health systems. However, one study reported that 53% of study participants were satisfied with the integrated health system because their preference for TM had increased due to its operation in health centres [17]. Another study reported varying levels of satisfaction among participants. The variation ranged from 'being satisfied with the system' (e.g.,"The collaboration is very strong. There are sometimes intra referrals from TM units to orthodox and vice versa. Clients go to Out Patients Department, then to TM unit, we check vital statistics, then clients would be examined and recommended to do some laboratory test when necessary. We ensure constancy for the sake of report"-TM practitioner) to 'not satisfied with the system' (e.g., "We have not admitted any client who patronise TM and orthodox medicine. I don't consider it as integration, because we are not working jointly with them"-orthodox medicine practitioner) [22].

Acceptance as a Measure of an Effective Integrated Health System in Africa
Acceptance was closely linked to the satisfaction of participants. While satisfaction evaluated the fulfilment that people derived from the integrated system, acceptance was deduced based on the value that participants placed on their role and the role of other stakeholders in the integration process. Eight of the reviewed pieces of literature indicated that the acceptance of integrated health systems in Africa was low among orthodox medicine practitioners [12,20,22,[24][25][26]28,29]. For example, Falisse et al. [28] found that, although the majority of orthodox medicine practitioners in Burundi (91%) were aware of the integrated system, only 19% supported formal integration [28]. Related results were disclosed by a Ghanaian study, where orthodox medicine practitioners were highly unprepared to refer clients to TM practitioners [12]. Likewise, orthodox practitioners in South Africa frowned at the integration process because they (OMPs) perceived TM practice to be an obstacle to successful management of clients' health [25]. Differing levels of acceptance were observed among TM practitioners. A Nigerian study [30] reported a high level (64%) of acceptance among TM practitioners at Mushin, Lagos, and the findings of Maluleka and Ngoepe [27] identified a contradictory report, as acceptance of the integrated system was low among TM practitioners in South Africa. This was because they (TM practitioners) experienced marginalization in the integrated system. One study found that perceived acceptance was reported to be high among both health practitioners in Ndola and Kabwe, in the Copper belt and Central provinces of Zambia. This was due to the fact that 77% of orthodox health providers and 97% of TM practitioners felt that there was a potential prospect for them to learn from each other in order to work effectively [31]. Overall, the practice of an integrated health system was popular among health service users. Two studies reported a high acceptance of an integrated system among service users in Ghana [12,17]. It also emerged that the practice of an integrated health system was highly favorable among scholars involved in TM research [23].

Agbor and Naidoo [29] Cameroon
In 1981, Cameroon formally recognised and integrated TM into the health system, but the recognition was not controlled by the MOH. In July 1995, a governmental declaration with the registration number (95-040) mandated traditional practitioners in Cameroon to form local and national associations to regulate the practice of TM.

39
Patients perceive the integrated system as an orthodox health system tolerating traditional care. Therefore, knowledge on integration was low.
Usage of the integrated system is low because of inadequate scientific evaluation problems in TM practice.
Perceived satisfaction was high, but actual satisfaction was low, because the level of integration was low.
Low acceptance of practitioners within the system was because 71% had no professional education as most were trained through apprenticeships and only had primary education.

19
Participants were aware of the existence of an integrated system and perceived it to be a step in the right direction, but they reported that administration of the integration procedure needed to be intensified.
Usage of the integrated health system was reported to be low since the national health cover did not embrace TM products and services.
Participants were displeased at the pace of the integration process. Satisfaction was low because participants felt the integrated system should be more efficient than it was at the time of the survey.
Acceptance of the integrated system was high among participants. This was because they recommended that the number of health facilities with TM units should be increased. In 1999, during an ECOWAS special health conference in Abuja Nigeria, the President of the Federal Republic put forth the TM development program and urged for its integration into the formal health system plan.

21
Awareness was low because an intervention put in place to aid collaboration was not well-known among participants.
The lack of regulatory protocol to push the integration agenda has contributed to minimal usage of the system.
Low level of satisfaction due to inadequate support from policy makers. 64% of the participants were willing to succumb to regulations governing the integration process.
This depicted a high acceptance among participants.
Campbell-Hall et al. [25] South Africa Both practitioners knew of the existence of the integrated system. This was evident in the interaction between healers and orthodox practitioners (training and referrals).
Level of usage was low as participants reported of referring clients to hospitals, but they did not receive referrals from hospitals.
Low satisfaction echoed in the views of participants as they claimed that integration was onesided.
Level of acceptance was low as TMPs felt marginalized. Again, orthodox practitioners did not accept the activities of the healers.

Assessment of the Methodological Quality
As indicated in Table 3, the included studies were of a good methodological quality and had QATSDD scores ranging from 57% to 86%. One study scored above 80%, and was thus classified as having an excellent methodological quality. Five studies scored above 70% and none of the studies were below 50%. The average methodological quality score of the included studies was 69%, which equates to an acceptable standard based on the criteria of the QATSDD assessment tool. Overall, the included studies provided detailed information about sampling, data collection methods, data analysis, and the strengths and limitations of the study. Table 3. Quality assessment of included studies using the quality assessment tool for studies with diverse designs (QATSDD).

Discussion
TM plays a significant role in health delivery, which has led to its integration into health systems of various African countries [33]. The rationale behind the integration of TM is to widen the scope of health delivery and improve health seeking behavior among populations [4]. Published research has shown that integration can only be successful if contextual factors, such as the health system architecture, socio-cultural characteristics, and views of stakeholders, are cautiously considered in the integration process [34]. Other important determinants include those directly related to health practitioners, service users, and the broader socio-political structure within which health systems operate [34]. Studies have also shown that the level of effectiveness of an integrated health system mostly relies on the nature of the relationship that exists between all stakeholders in the health sector [34,35].
This systematic review was therefore conducted to assess the effectiveness of integrated health systems in Africa. The measure of effectiveness was based on the awareness, usage, satisfaction, and acceptance of integrated systems. Reviewed articles reported that integrated health systems in Africa were ineffective. Knowledge about the existence of integrated systems was low in most countries and health service users favored the integration of TM into formal health systems. This result is mirrored in the works of Ben-Arye, Karkabi [36] and Jong, van de Vijver [37], where service users agreed that orthodox practitioners should guide clients to choose appropriate TM and refer them to qualified and experienced TM practitioners when the need arises. However, the review identified that the majority of users were uninformed about the official practice of TM in health centers, accounting for the low usage of integrated systems in Africa. Ignorance of service users was attributed to the absence of explicit protocols/documents clearly describing the concept of integration, as well as sensitizing the people about the integration process [22]. However, whilst health professionals, particularly orthodox medicine practitioners, were conversant with the practice of integrated health, their disposition towards the system was poor [28]. Sewitch, Cepoiu [38] confirmed the finding that doctors have an unfavorable attitude towards TM prescription and the referral of clients to TM practitioners. Shallow knowledge about the practice of integrated systems in Africa might be a factor contributing to the undesirably low patronage integrated health care.
The review established that the patronage of integrated health systems was unimpressive due to ineffective communication as a result of a non-functional referral system, the absence of an official document to promote the integrated system, the non-inclusion of TM products and services in national health cover, and skewed power relations within the integrated system [12,22,23,27,28,30]. The unsuccessful collaboration between the two health systems affected the quality of services offered by the consolidated health delivery unit. Therefore, the performance of integrated systems was reported to be unsatisfactory because health practitioners and service users such as stakeholders expressed dissatisfaction with the state of health systems in Africa.
Satisfaction is said to be achieved when health practitioners, together with service users/clients, derive fulfilment in practicing and accessing health services [39]. Most health systems in Africa have not achieved this goal. The review indicated low satisfaction among stakeholders. The unsatisfactory state of health systems in Africa mainly stems from inadequately trained TM practitioners, the slow rate of progress of the integration process, and incompetent measures aimed at eliminating charlatan practitioners [23,28]. Conversely, Agyei-Baffour, Kudolo [17] reported a rise in the use of TM among service users/clients because of moderate satisfaction derived from the integrated system. Orthodox medicine practitioners were not satisfied with the integration of TM into formal health systems because they deemed TM practice to be an obstacle to achieving a healthy population [25]. The absence of a common professional language between the two practitioners further deepened the displeasing state of integrated systems. This discovery is closely linked to the findings of Hollenberg [40] in Canada, where differences in terminologies created communication barriers between orthodox and TM practitioners and hindered professional collaboration in integrative health care facilities. This notwithstanding, TM practitioners were somewhat pleased with the system and acknowledged that there was hope for better integration of the two health entities. The review further assessed the acceptance of the practice of integrated systems.
Acceptance of the practice of integration was low among health practitioners, particularly orthodox health care providers, but high among health service users. This was mirrored in the findings of Falisse, Masino [28], as a relatively low percentage (19%) of orthodox practitioners supported formal integration, while a significant percentage (93%) of clients preferred integration. Likewise, the results of Maluleka and Ngoepe [27] identified that acceptance within the system was low among TM practitioners due to feelings of ostracization. The feeling of exclusion expressed by TM practitioners was a product of a sense of superiority by orthodox providers in the integration process, as well as exclusion of TM in the educational curriculum. Taken together, this review has unraveled key factors responsible for the non-functionality of health systems in Africa. Clearly, for health systems to be effective, more than mere lip service to policy formulations is required, and such policies should include other extraneous factors or interventions. Good health system research is needed to identify specific factors which impede the effective integration of TM into health systems. Future studies should focus on analysing the perceptions and experiences of stakeholders in relation to the integration process within a wider socio-political context.

Strengths and Limitations
This review relied upon reported experiences from participants to highlight the state and effectiveness of integrated health systems in Africa. To the best of our knowledge, this is the first article to assess the effectiveness of integrated health systems and factors impeding the integration process in Africa. However, the included studies were not evenly distributed as a majority of the studies were from Ghana [12,17,[22][23][24]. The exclusion of grey literature and non-English articles created possible grounds for oversight. Furthermore, the QATSDD appraisal tool largely depends on reviewers' knowledge. Therefore, there is a potential for bias [21]. There is also the possibility of misclassification and recall biases, since participants had to recollect their experiences with the integrated health system.

Conclusions
In Africa, the main step taken by countries to integrate TM into formal health systems is policy formulation and the creation of TM practice councils. Some countries have managed to establish institutions responsible for assessing the efficacy of TM and introduced TM practice into the tertiary educational system. Existing health policies are not working, so the integration of TM has not been successful. It is critical to uncover the bottlenecks in the health systems by exploring the perceptions and experiences of stakeholders, in order to offer solutions for better integration of the two health systems.