Constructing Disability Care Across Traditional and Biomedical Sectors in the Pluralistic Health System of Sierra Leone

Abstract

Pluralistic health systems, in which biomedical and traditional providers coexist, shape how care for persons with disabilities is organised in low-income settings. In Sierra Leone, little is known about how providers from different sectors conceptualise care for persons with disabilities. This study examines how providers describe their professional roles, conceptualise disability care, and position themselves in relation to other providers. It draws on semi-structured interviews with ten healthcare providers in Freetown, Sierra Leone (five biomedical, five traditional), analysed using qualitative content analysis. Providers understand their roles through distinct professional trajectories. Traditional healers explain disability through spiritual, social and functional causes; biomedical providers primarily through clinical frameworks. Both sectors combine treatment, rehabilitation and everyday support in their practice. Referral between sectors is asymmetrical: traditional healers refer to hospitals and within their own networks, while biomedical providers refer exclusively within the formal sector. Among the ten participants in this exploratory study, disability care was described within a pluralistic but hierarchically structured health system, with providers working with overlapping populations but occupying unequal positions of authority. The findings point to unacknowledged interdependencies between sectors and suggest implications for more equitable and coordinated disability care in similar settings that merit further investigation.

1. Introduction

Countries in sub-Saharan Africa (SSA) have a high proportion of persons with disabilities and chronic illnesses, and Sierra Leone is no exception [1,2]. Disability serves as an umbrella term that encompasses physical, sensory, intellectual and psychosocial impairments and chronic conditions that differ in onset, trajectory, visibility, support needs and the social responses they elicit [3]. The elevated prevalence of disabilities in SSA is linked to continued exposure to communicable diseases, maternal and neonatal complications, injuries (including road-traffic and war-related injuries), and unsafe living and working conditions such as poor housing, limited access to safe water and sanitation, and food insecurity [4,5]. As many of the resulting impairments are lifelong and frequently co-occur with other chronic conditions, persons with disabilities typically have greater and more continuous care needs than the general population, including treatment of underlying conditions, prevention and management of secondary complications, ongoing rehabilitation, counselling and psychosocial support, and the use of assistive devices [6,7,8]. Hence, in this article, we use ‘disability care’ or ‘care’ as broad terms for provider-delivered support related to disability, encompassing healthcare and rehabilitation as well as emotional, social and practical support where these form part of providers’ roles. Despite the high prevalence of disability in SSA, empirical research on care provision for persons with disabilities remains largely concentrated in high-income countries, resulting in limited evidence on how providers in other settings perceive, organise, and deliver care [9,10,11].

To understand how the care needs of persons with disabilities are (not) met, it is necessary to consider how care is organised in Sierra Leone. Like many countries in SSA, Sierra Leone’s health system is pluralistic. Pluralistic health systems have been defined as settings in which regulated, state-recognised services coexist with a range of other providers and practices that populations draw on for everyday (health)care [12,13,14]. In this article, biomedical providers refer to state-licensed health professionals and facilities that deliver care based on biomedically defined diagnostic categories and treatment protocols (e.g., public and private clinics and hospitals, doctors, nurses and other allied health workers). Traditional providers refer to healers whose practice is grounded in locally embedded pharmacological, spiritual and ritual repertoires, including herbalists, religious and spiritual healers, and traditional birth attendants, who may or may not be formally registered [15,16,17]. Studies from low- and middle-income countries show that such traditional care constitutes an important share of all healthcare contacts and often functions as first points of care, particularly where formal services are geographically distant, financially inaccessible or socially mistrusted, and where treatment resonates more strongly with local explanatory models of illness and healing [13,18,19].

Despite their longstanding coexistence, the relationship between biomedical and traditional providers is not neutral. In policy documents, international health metrics and much academic work, ‘health-related care’ is still mostly used as shorthand for modern, biomedical, evidence-based services. This lens privileges biomedical ways of knowing and caring while sidelining others [20,21]. Colonial and postcolonial histories are central to this asymmetry, as allopathic biomedicine entered many African settings through missionary and colonial administrations and was progressively institutionalised through medical education, regulatory frameworks and funding streams as the authoritative model of care, while traditional practitioners were marginalised or only selectively integrated [12]. Contemporary debates on epistemic injustice in global health continue to show how Eurocentric biomedical knowledge shapes which practices are eligible within global and national health governance [22].

These dynamics are particularly relevant in the context of disability care, as research (or rather its absence) from Sierra Leone and other SSA settings shows that little is known about how different healthcare providers themselves understand disability care in this pluralistic context [18,23,24]: how they come to occupy provider roles, how they describe the care they offer to persons with disabilities, and how they position themselves vis-à-vis other providers in a system shaped by colonial legacies and contemporary inequalities. This article addresses this gap by drawing on qualitative interviews with biomedical and traditional providers in Sierra Leone to examine how they understand disability care.

2. Conceptual Background

Understanding provider perspectives in this pluralistic setting requires a conceptual lens that captures how (1) roles and professional expertise, (2) disability frameworks and types of care and (3) provider relationships are organised and made sense of.

2.1. Roles and Professional Expertise in Pluralistic Health Systems

Health systems research from low- and middle-income countries shows that authoritative claims to health expertise extend well beyond formally regulated professions. Alongside doctors, nurses and allied health workers, a wide range of community-based and traditional providers deliver care, often acting as first points of contact in settings where biomedical services are scarce, distant or mistrusted [13,25]. Studies of community health workers, traditional healers and faith-based practitioners demonstrate that their authority is grounded in forms of legitimacy that are only partially captured by formal qualification frameworks and more by community recognition, i.e., that someone can do something about a specific illness, misfortune or spiritual threat [18,26,27].

The World Health Organisation’s strategies on traditional, complementary and integrative medicine [28], as well as its 2025 Global traditional medicine strategy [14] reflect growing formal recognition of these providers. While such moves to institute traditional medicine reshape their identity and legitimacy in global health, studies show that traditional healers remain affected by marginalisation, contested recognition and tensions with biomedical practitioners [17,27]. Sierra Leone offers a concrete example of this ambivalent institutionalisation. The National Health Promotion Strategy for Sierra Leone (2017–2021) [29] explicitly lists traditional healers, traditional birth attendants and other informal structures as part of the country’s health promotion landscape and identifies them as important actors for reaching communities. At the same time, they are primarily positioned as channels for behaviour-change messaging rather than as healthcare providers, even though they occupy positions that differ markedly from biomedical professionals in terms of regulation, resources and reach. Hence, we ask:

• RQ1. How do different healthcare providers in Sierra Leone construct their roles in disability care provision?

2.2. Disability Frameworks and Types of Care

Frameworks for conceptualising disability shape how its causes are understood, what is considered amenable to intervention, and who is seen as responsible for providing disability care. In a biomedical framing, disability is linked to underlying health conditions that affect body functions and structures, for instance through disease, injury or complications during pregnancy and birth [30]. Care is oriented towards diagnosing and treating conditions, preventing secondary complications and supporting functioning through rehabilitation and assistive devices, with responsibility located primarily in health and rehabilitation services and in the actions of individuals and families [1].

The social model, developed largely in disability activism and scholarship in Europe and North America, shifts attention to the social, economic and environmental barriers that restrict societal participation of persons with disabilities [30,31]. In this perspective, the main targets of change are inaccessible infrastructure, exclusionary institutions and discriminatory practices. Care extends beyond clinical intervention to include measures that promote access, safety and participation, and is closely linked to rights-based and capability approaches to disability [32,33].

In many low- and middle-income settings, including Sierra Leone, these frameworks further intersect with spiritual and cosmological explanations of disability. Empirical work shows that persons with disabilities and their families may attribute some conditions to biomedical causes and others to witchcraft or spiritual beings [23,24,34]. As these different frameworks have direct implications for how care for persons with disabilities is envisaged and enacted, we ask:

• RQ2. How do different healthcare providers conceptualise and enact disability care?

2.3. Provider Relationships in Disability Care

In pluralistic health systems, relationships between different provider groups are central to how care is organised. Studies from several African and Asian contexts describe settings in which traditional and biomedical providers work with overlapping populations but relate to one another through a mix of pragmatic coexistence, competition, and selective collaboration, often marked by asymmetries in regulation, resources and formal authority [18,35,36,37]. These studies have examined these relationships in specific clinical domains such as mental health, maternal health or infectious diseases. In the context of disability, relational dynamics take on particular significance as disability care is often long-term and may be interpreted through overlapping biomedical, social and spiritual frameworks. Hence, our third research question asks:

• RQ3. How do traditional and biomedical providers relate to each other in disability care?

3. Materials and Methods

3.1. Study Design

As part of a larger research project on care for persons with disabilities in Sierra Leone [23], we conducted an exploratory qualitative study based on semi-structured interviews. Its purpose was to generate preliminary insights into how different healthcare providers conceptualise and enact disability care. The study was carried out in collaboration between an academic research team, the non-governmental organisation Enable the Children (ETC) under World Hope International that provides therapeutic and psychosocial support for children with disabilities and their families in Freetown, and two independent Sierra Leonean researchers who were recruited as local interviewers for this study.

3.2. Recruitment and Sampling

We conducted ten semi-structured interviews, five with biomedical providers and five with traditional providers (see Table 1 for participant demographics). Sampling was purposive and aimed to include providers with experience in disability care and diversity in training, professional roles and understandings of care. Biomedical providers were recruited from five formal health facilities in Freetown with different roles in the biomedical healthcare system. Three were approached via existing ETC collaborations, and two were identified through the networks of the local interviewers. Traditional providers were community-based; two were accessed through ETC contacts and three independently by the interviewers. Traditional healers with different trajectories and specialities of services were included to ensure diversity. The local interviewers presented themselves and the study to participants as a university research project and did not mention the NGO connection to avoid social desirability.

Table 1. Participant demographics.

No	Provider Type	Self-Described Specialty/Position	Years in Practice
1	Traditional healer	Traditional and spiritual healer	33
2	Traditional healer	Native doctor	36
3	Traditional healer	Traditional medical healer	32
4	Traditional healer	Traditional healer	18
5	Traditional healer	Traditional and spiritual healer	20
6	Biomedical provider	Rehabilitation therapist	12
7	Biomedical provider	Physiotherapist	14
8	Biomedical provider	Head nurse	13
9	Biomedical provider	Senior nurse on a children’s ward	15
10	Biomedical provider	Paediatrician	20

Note. Traditional healers reported longer periods in practice than biomedical providers. This reflects entry into practice in youth or childhood through apprenticeship alongside a relative or close family friend, compared with entry after the completion of school certificates and a health-related degree among biomedical providers.

3.3. Data Collection

Data were collected in April and May 2024. Biomedical providers were interviewed at their workplaces (e.g., offices or consultation rooms), while traditional providers were interviewed in their homes or usual practice locations, according to their preference.

Interviews were conducted face-to-face by the two local interviewers in Krio or English, guided by a semi-structured interview guide. The guide covered providers’ professional trajectories, understandings of disability and its causes, types of care offered to persons with disabilities, and relationships with other providers (see Supplementary File S1). The guide was jointly developed by the academic team, ETC staff and the interviewers, pre-tested in two interviews and refined prior to data collection.

All participants received an information sheet and had the opportunity to ask questions before providing written informed consent. Interviews were audio-recorded with permission, lasted between 37 and 59 min, and were transcribed by the interviewers. Interviews conducted in Krio were transcribed directly into English by the interviewer who had conducted the interview. Personal identifiers were removed and pseudonyms assigned. Participants received compensation equivalent to approximately 10 Euros.

3.4. Data Analysis

Data were analysed using qualitative content analysis [38], supported by MAXQDA 2024 (VERBI GmbH, Berlin, Germany). The analytical process proceeded in three stages. First, prior to coding, the first author (HLL), who speaks Krio, listened to the original audio recordings and checked the English transcripts against the recordings for translation accuracy. She conducted a joint review of all transcripts together with the local interviewers (FB and PM) in person to clarify linguistic ambiguities arising from the translation from Krio. Second, HLL developed an initial deductive coding frame structured broadly around the three research questions. Within these categories, subcategories (e.g., becoming a provider) were developed inductively through close reading of the material. This initial frame was applied to a purposive subsample of four transcripts (two biomedical, two traditional), and the resulting coded segments, together with illustrative quotations, were then presented to and discussed with all co-authors in a research workshop via videoconference. This discussion led to consolidation of overlapping codes and minor revisions to category definitions. Third, the revised coding frame was applied to all ten transcripts by HLL. Coded material was compared within and across provider groups to identify convergences and divergences. An additional presentation of the coding structure to a group of qualitative researchers working with ethnographic and descriptive methods provided external perspective and contributed to further analytical refinement. Upon completion of the full coding, HLL presented the final structure to all co-authors for discussion and validation, with particular attention to whether the interpretations were plausible within the Sierra Leonean sociocultural and professional context.

AI (Claude Opus 4.8, Anthropic, San Francisco, CA, USA) was used for language editing and manuscript revision.

3.5. Positionality

The study team combined European academic, NGO and Sierra Leonean research perspectives. HLL and HY (academia) and AV (NGO) all have longstanding collaborations in Sierra Leone in public health, disability care and rehabilitation and have each lived in Sierra Leone for several years. The two local interviewers (FB and PM), both Sierra Leonean women with experience in qualitative research, conducted all interviews and contributed to the design of the study and interpretation of findings. Their linguistic and contextual knowledge was crucial for building rapport and for understanding locally specific meanings. This research collaboration predates this study, and this is not the first joint publication to emerge from these partnerships. The established working relationships facilitated trust and open communication. Nonetheless, the composition of the team reflects power asymmetries common in Global South-North research partnerships, including differential access to resources, publishing platforms and institutional authority. While the team engaged in ongoing reflexive discussion and worked to involve all members at key analytical decision points, including formulation of research questions and interpretation of findings, the division of analytical work and write-up of the manuscript remained uneven.

None of the authors themselves has disabilities. Despite critical reflections, this may shape how disability and care are interpreted.

4. Results

Results are presented in line with the research questions. An overview of the coding structure and comparative themes across provider groups can be found in Table 2.

Table 2. Overview of the coding structure and comparative themes.

Category	Codes	Traditional Healers	Biomedical Providers
Roles in disability care provision (RQ1)	(a) Becoming a provider	inherited role, fate or calling long informal apprenticeship learning through observation and practice translocal learning through travel occasional short formal trainings (government/NGOs)	deliberate educational and career decision formal training programmes and examinations progression through institutional career ladders ongoing professional training (NGOs, expatriate staff)
	(b) Self-descriptions of provider role	polyvalent community figures combined clinical, social and spiritual responsibilities broader life problem-solving internal distinctions between healer types	institutionally defined roles formal titles and specific clinical or managerial responsibilities structured patient management
		● advocacy and emotional or social support as part of care
	(c) Sources of knowledge and expertise	spiritual authority knowledge grounded in long-term practice familiarity with plants and preparation methods limited written documentation knowledge kept within trained circles links between herbal and pharmaceutical medicine	formal education and credentials reliance on written protocols and guidelines legitimacy tied to documentation and standardisation
Conceptualising and enacting disability care (RQ2)	(a) Understandings of disability	understood through functional loss and social experience (especially stigma)	defined through diagnoses and functional loss
		● intersection of functional and social dimensions acknowledged
	(b) Distinctions between different types of disability	differentiation based on visible function, perceived causes and treatability	differentiation based on diagnostic labels and service pathways
		● boundaries of what can and cannot be treated
	(c) Causes and explanations of disability	multiple, sometimes intersecting explanations (biomedical, social, spiritual) recognition of irreversible conditions	pathophysiological explanations social aspects recognised
	(d) Diagnostics	diagnosis based on experience, observation and spiritual insight rarely explicit criteria	based on examination, observation, and available tests constrained by limited equipment, knowledge and available services
	(e) Treatment and care	herbal and manual techniques and spiritual practices emotional and social support continuous engagement	basic care, medication, physiotherapy, rehabilitation and monitoring of conditions referral for specialised treatment
		● care understood as long-term and multifaceted
Relationships between traditional and biomedical providers (RQ3)	(a) Referrals	frequent referrals within traditional networks regular referrals to biomedical services referral framed as responsibility perception of informal back referrals from biomedical providers	referrals within biomedical system traditional treatment framed as risky and no official referrals to traditional providers
		● referrals seen as part of good practice
	(b) Hierarchies in pluralistic healthcare	ideal of complementary work between traditional and biomedical care experience of being treated as less acknowledged or excluded	strict institutional boundaries biomedical care positioned as primary and legitimate site of treatment
		● parallel systems acknowledged but uneven authority

Note. Entries spanning both columns describe themes shared by traditional healers and biomedical providers.

4.1. Roles in Disability Care Provision (RQ1)

The analysis of providers’ accounts generated three interrelated codes that captured how they understood their roles in care provision: (a) becoming a provider, (b) self-description of role, and (c) sources of knowledge and expertise.

(a)

Becoming a provider

Participants in both groups portrayed entry into healthcare work as a gradual process. Traditional healers commonly located their entry within family and spiritual lineages. All described having grown up alongside a practising relative or close family friend, e.g., a parent or grandparent, whom they accompanied during healing activities.

“I inherited it. … It was my grandmother, it was her with whom I went.”

(Traditional healer, P2)

Others described healing as something they had not initially envisaged as a career but eventually accepted as a fate, gift or calling, sometimes after starting other forms of education or personal experience of a prolonged illness. In these accounts, becoming a healthcare provider was described as the continuation of an inherited responsibility or following a calling. All traditional healers described long periods of informal apprenticeship (up to ten years) in which they learned from persons by observing and assisting more experienced practitioners in everyday work. At the same time, healers’ trajectories did not remain confined to the setting they grew up in. Several healers reported deepening their practice abroad and, in some cases, acquiring formal certificates.

“I started to learn this job in Guinea, Conakry and I went to Mali, and I came back to Sierra Leone.”

(Traditional healer, P3)

Several traditional healers noted they had also undergone shorter, formal trainings by the government or NGOs in relation to infectious disease prevention and disability in recent years.

Biomedical providers, by contrast, tended to describe entry into care as the outcome of deliberate educational and career decisions. They recounted how they applied to nursing schools, study or NGO training programmes, passed competitive entrance examinations, and progressed through multi-year courses. They often listed subsequent postings and promotions, such as moving from staff nurse to senior nurse as professional milestones, and their participation in ongoing trainings by NGOs or visiting expatriate healthcare staff. In their accounts, becoming a healthcare worker resulted from successfully navigating an educational system, formal career ladders and on-the-job learning.

(b)

Self-descriptions of provider role

When describing their roles, all providers positioned themselves as central to the wellbeing of persons (those with and without disability), but they articulated different scopes of responsibility. Traditional healers tended to present themselves as polyvalent community figures whose work spanned clinical, social and spiritual domains. They described curing sickness alongside mediating conflicts, supporting people with personal or economic difficulties, providing fertility and pregnancy care, and protecting clients from spiritual harm.

“I can cure sickness, and I believe that to make peace is also part of healthcare services. We make peace between people, we help people to travel, and we also help people that have challenges in what they’re doing.”

(Traditional healer, P1)

Two healers distinguished between types of healers and referred to themselves as doctors, distinguishing their work from others:

“You have those who only cure sickness, and you have those who are there to catch thief, and you have those who are working with demons.”

(Traditional healer, P3)

Biomedical providers grounded their self-descriptions in bounded, institutionally defined roles and used formal titles such as head nurse, paediatrician, or physiotherapist, and delineated responsibilities including clinical assessment and treatment, supervision of junior staff, coordination of services and management of specific patient groups. Their descriptions of their work foregrounded clinical and managerial tasks.

Both groups depicted their roles as extending beyond clinical tasks: traditional healers through social and spiritual support, biomedical providers through advocacy and system navigation.

(c)

Sources of knowledge and expertise

Participants grounded their expertise in different knowledge traditions. Traditional healers located their expertise in inherited spiritual authority, apprenticeship and embodied familiarity with leaves and roots. Knowledge was described as learned through immersion, e.g., observing elders, handling plants, and participating in spiritual work rather than through formal curricula. One healer described a structured, practice-based apprenticeship in which herbal knowledge was taught and then demonstrated through plant processing:

“They teach us about some signs and symptoms, and after that they take us in the forest to learn how to process the leaf for medication. You have to also consider hygiene and preservation of the medicine.”

(Traditional healer, P4)

Healers also spoke of plant and spiritual knowledge as something that could not simply be written down or made public. A healer who had learned his trade abroad stressed that much of what he had learned about herbal medicine was deliberately kept off social media so that untrained people would not copy practices they did not understand. Others linked their knowledge to broader claims about the relationship between herbal and pharmaceutical medicine, arguing that biomedical drugs ultimately derived from plants:

“Many drugs are coming from Africa, and even if it is not coming from Africa, it is a leaf that the white people will use and make tablet, syrup or use it to make any kind of drugs.”

(Traditional healer, P5)

Biomedical providers anchored their expertise in formal education and clinical guidelines. Their authority was described as credentialed, cumulative and tied to institutional pathways. In their accounts, knowledge was legitimate because it was documented, standardised and backed by written protocols, even if everyday work required continuous adaptation to scarce equipment and fragile infrastructures. Traditional healers, by contrast, positioned “paper” as something they largely lacked and associated biomedical staff with, while insisting that their own authority rested on long practice, spiritual sanction and knowledge of patients’ bodies.

Across both groups, however, expertise was described as bounded. Traditional and biomedical providers alike emphasised that there were conditions they could not treat and converged in presenting good care as knowing both what one can do and when someone else is better equipped to act.

4.2. Conceptualising and Enacting Disability Care (RQ2)

The analysis of providers’ accounts generated five interrelated codes of how disability care was understood and practised: (a) understandings of disability, (b) distinctions between different types of disability, (c) causes and explanations of disability, (d) diagnostics, e) treatment and care.

(a)

Understandings of disability

Across both groups, disability was primarily framed in functional terms, but with different emphases. Several traditional healers perceived persons with disabilities as a distinct social group with specific emotional and relational needs. They were described as “not like the normal person” (Traditional healer, P1), easily affected by mockery and exclusion, and in need of encouragement and recognition. Their accounts consistently linked disability to how a person is seen, treated and affected in social encounters, rather than to a clearly defined medical condition.

Biomedical providers employed a more technical and standardised medical language in defining disability. They consistently used terms such as ‘person with disability’ and tied these to specific diagnoses (e.g., clubfoot, epilepsy or genetic conditions). At the same time, they also highlighted the emotional dimension of disability, particularly the experience of marginalisation. A rehabilitation worker described how he addressed these feelings when working with patients:

“Persons with disability in Sierra Leone, they are very marginalised, are being provoked in society. Whenever they come to our hospital, or we see them in the community, we show love to them, we encourage them, we also explain to them why they have this disability.”

(Biomedical provider, P6)

(b)

Distinctions between different types of disability

Both traditional and biomedical providers distinguished between different forms of disability and drew relatively clear boundaries around which types they did and did not address. Traditional healers, for instance, differentiated pragmatically between transient injuries and long-term functional limitations, as the following quote illustrates:

“Some children, when they go to play football, and someone scraps them, I can treat that one. I can dress the wound, but when a child is cripple, when the child cannot walk for long, I cannot provide a cure for such children. I tell the parents that one is not my field.”

(Traditional healer, P5)

In the same interview, the healer also differentiated between various head-related conditions: she felt able to treat a “split head” (understood as an acute lesion), but distanced herself from cases involving a “very big head,” which she associated with severe or congenital conditions beyond her competence. Other healers categorised disability less anatomically and more in terms of visible functional status and social markers, referring, for instance, to “those who use crutch” or children who “just sit in one place” (Traditional healer, P3). Importantly, several noted that persons with disabilities might visit them for normal, everyday sicknesses like malaria or spiritual queries but that their underlying disability was not the target of treatment.

Biomedical providers organised disability systematically around types of functional loss, diagnostic labels and service pathways. These distinctions then shaped case management:

“Let’s say if this child has clubfoot, we are not surgeons; we are not able to do this. So, we refer to [children’s hospital] or to other centres. If the child has epilepsy, then after doing our assessment, we refer to any hospital that has that facility.”

(Biomedical provider, P6)

Thus, traditional healers tended to distinguish disability types in pragmatic and often visual terms, emphasising which cases they could or could not treat, while biomedical providers categorised disability through formal diagnoses and linked these categories to defined referral and treatment pathways.

(c)

Causes and explanations of disability

Across interviews, disability was explained through multiple causal frameworks. Traditional healers combined biomedical, spiritual and social explanations, often as overlapping ways of making sense of different cases. Several healers challenged community attributions of disability to “devil” causes, pointing to physical causes such as infection or poor nutrition during pregnancy:

“Some of them [pregnant women] have an infection they don’t know and which affect the child. … That is the reason why some children will have problems with their head, some their eyes, and that is why they say these types of children are devil, but they are not devil. It is because of these problems during pregnancy.”

(Traditional healer, P2)

Other healers mentioned witchcraft, spiritual or demonic influence, but often alongside biomedical causes. Interviewers’ probes (“how do you know?”, “how do you tell the difference?”) revealed that explicit criteria for distinguishing spiritual from biomedical cases were rarely articulated. Several healers acknowledged that disabilities could have physical and spiritual origins yet remained vague about where exactly these boundaries lay. If a body was understood as fundamentally altered by God, neither biomedical nor traditional treatment could restore it:

“Anything that God disfunctions in the body, no doctor can do it, and no herbalist can do it… If God has changed that part, you cannot cure it.”

(Traditional healer, P1)

Biomedical providers explained disability mainly through pathophysiological mechanisms, again with pregnancy and early childhood appearing as critical periods, as well as infections and untreated healthcare conditions leading to chronic illnesses and disabilities. While biomedical staff stayed within biomedical models, they recognised that spiritual interpretations of the causes of disability shaped community behaviour and care-seeking.

“Some of them believe it’s a spiritual thing. So, when they come, we explain to them that this is not spiritual; it is the illness that caused this disability.”

(Biomedical provider, P9)

(d)

Diagnostics

Diagnostic work differed in tools and framing across both groups, yet both groups emphasised the importance of recognising the limits of one’s competence. As described in (c), traditional healers said they distinguished between spiritual and medical cases, but rarely articulated explicit criteria, which was also notable in their diagnostic approach:

“When their parents come with them, I take a look at them, but some of them, you will know that this is not a spiritual job; it is a medical job. I will just call the parents and tell them you need to take the patient to the hospital so that they can check the person.”

(Traditional healer, P1)

They referred to experience, their methods or spiritual insight without specifying observable markers for diagnosis. At the same time, they articulated diagnostic boundaries very clearly, e.g., one healer repeatedly answered that they did not know about certain disabilities (Traditional healer, P5) and would not treat due to this uncertainty.

Biomedical healthcare providers, by contrast, described diagnosis in terms of physical examination, observing symptom progression and, where available, tests, followed by referrals to other entities for confirmation when needed. They repeatedly stressed that diagnostic work was constrained by structural limitations and referred to missing equipment, lack of specialised services and gaps in training for working with persons with disabilities, noting that this restricted what kinds of diagnostics could realistically be done.

(e)

Treatment and care

Across accounts, providers described treatment and care for persons with disabilities as a long-term approach. Traditional healers combined herbal, manual and spiritual techniques. They portrayed their herbal interventions as grounded in deep knowledge of leaves and roots, often described as medicine in its own right.

“We use the leaves and the roots for the sickness. I know the leaves that can cure some problems and the roots that can cure others. The medicine we give them is from the bush; we prepare it, we boil it, we soak it, we pound it.”

(Traditional healer, P4)

Herbal work was combined with manual treatments such as massages and bone-setting. At the same time, healers saw emotional and social support as central elements of care, talking with clients about stigma, eating and drinking with them together to counter fears of contagion, or reassuring clients when their disability made them feel isolated. Rituals and ceremonies were carried out when a case was seen as having a spiritual dimension, sometimes in parallel with biomedical care.

Biomedical providers described an equally broad spectrum of actions, but organised within specific professional roles. Rehabilitation and physiotherapy staff focused on physiotherapy and occupational therapy, often over longer periods, and emphasised referral pathways, e.g., for surgery, neurology or pharmacological treatment. Clinical staff (paediatrician and nurses) highlighted their clinical work (i.e., medication, monitoring, prevention of complications) as well as foundational caregiving: food, hygiene, dressing, mobility support and accompaniment when patients were hospitalised. Biomedical staff also described how structural constraints shaped the forms of care they were able to provide. They pointed to everyday resource gaps that limited the scope of treatment and required continual improvisation: medications not covered by the free health package, insufficient assistive devices, and wards that could not accommodate the needs of children with complex disabilities.

4.3. Relationships Between Traditional and Biomedical Providers (RQ3)

The analysis of providers’ accounts generated two interrelated codes concerning how traditional and biomedical actors relate to each other in disability care: (a) referral practices within and across sectors, and (b) hierarchies in pluralistic healthcare.

(a)

Referrals

Across interviews, providers described referral as a central part of good practice, but the direction, density and visibility of these referrals differed by sector. Traditional healers talked most extensively about referring both within their own networks and across to biomedical services. Within the traditional sector, referrals were portrayed as routine and tied to specialisation. Healers described a networked division of labour in which cases are moved on to colleagues who are known for a particular skill, such as bone setting or spiritual work:

“That is why we are working in collaboration with other colleagues; it does not mean that by all means you should be able to provide all the cure for the patients.”

(Traditional healer, P3)

Several healers framed this internal referral culture as an ethical obligation. Holding on to a patient without being able to help was described as risking problems if something went wrong. Cross-sector referrals from traditional healers to hospitals or NGO services were equally prominent. Three healers repeatedly emphasised that certain conditions, including many disabilities, were not their field and should be sent to biomedical services:

“If a person with disability meet me at home and they ask me to treat that person and I can’t, I will refer them to the hospital because that is what we were told.”

(Traditional healer, P5)

Another participant described how post-Ebola regulations had formalised such cross-referrals. In this, traditional healers present themselves as the first point of contact and as active referees to formal services.

Biomedical providers also described referrals as integral, but almost exclusively within the formal sector. They spoke of sending patients with specific conditions to other hospitals or to specialist services as part of standard care pathways. By contrast, referrals from biomedical to traditional providers were entirely absent from the interviews with biomedical participants. Moreover, biomedical providers were explicit about not making referrals, as traditional healing could cause harm:

“They [traditional healers] are causing a lot of problems and giving us a lot of persons with disabilities. When somebody has a fractured leg and goes to a herbalist, the herbalist will try all his treatments until the wounds become septic and finally the patient foot will be amputated, and he becomes disabled. I have a case on my ward right now. They are contributing to disability.”

(Biomedical provider, P10)

“If the patient decided to go the native ways, country medicines, we sign that on your chart. You went against medical for traditional healing.”

(Biomedical provider, P8)

Biomedical providers described encounters with traditional healers, yet only in areas of educating and sensitising them about making referrals and limiting their care. Traditional healers, however, offered a more complex picture that hints at informal, unacknowledged back-referrals. One healer argued that when hospital staff reached the limits of their own resources, they would refer patients to traditional care, even if this was not articulated as formal referrals:

“It is not easy for the doctor to refer a patient to a traditional healer. They will tell them [patients] that we have done everything, but we did not see any sickness, or we can’t treat you, but if you have understanding, you will know what to do and seek traditional treatment.”

(Traditional healer, P4)

(b)

Hierarchies in Pluralistic Healthcare

Accounts of collaboration were shaped by how providers positioned their own and others’ authority within healthcare. Traditional healers articulated an ideal of complementary treatments—herbal/spiritual and biomedical—that should work together on equal footing. At the same time, they described feeling treated as less acknowledged by biomedical actors and excluded from decision-making spaces:

“We should believe that there are two types of curing which is the hospital and the traditional. These two ways need to agree to work together… But they [biomedical] always see the traditional healers as nonentity. They make us feel like we are nobody and they are superior.”

(Traditional healer, P2)

Other traditional healers drew on their international work experience to argue for institutional co-presence, referencing countries where traditional healers are allowed in hospitals and perform ceremonies, e.g., before surgery to address spiritual dimensions of health problems. Biomedical staff, by contrast, made institutional boundaries and professional hierarchies explicit:

“No! It can’t be like that. We are not allowing them [patients and relatives] to call the traditional healer to come and treat a patient in this hospital.”

(Biomedical provider, P8)

Here, the hospital was viewed as the primary and legitimate site of treatment and traditional care was tolerated only outside its walls. Traditional healers described these practices as expressions of professional prejudice and contested them by foregrounding their own centrality in everyday care, especially in the many rural areas of Sierra Leone where biomedical healthcare was largely absent:

“There are places without PHU [peripheral health unit] or where bike [motorbikes for difficult terrain] cannot reach, and there are people in those communities who are sick. Who are these people that provide treatment for them? The traditional healers. So, if you have a traditional healer that is living in that community, they should incorporate us; we can address problems. But unless they include the traditional healers, healthcare will not be complete.”

(Traditional healer, P1)

5. Discussion

This exploratory study examined how ten different healthcare providers in Sierra Leone describe their roles, conceptualise disability, and relate to one another within a pluralistic health system. The findings suggest that authority, knowledge and care practices are organised differently across biomedical and traditional sectors, and point to interdependencies between sectors that participants described as insufficiently acknowledged in policy and research.

For RQ1, the study shows how provider roles are constructed at the intersection of distinct, but interacting, epistemic traditions. Traditional healers in this study presented their trajectories into becoming a healthcare provider as both inheriting a role through family or accepting a spiritual calling as well as pursuing long periods of informal apprenticeship, and, in some cases, training certificates and government or NGO courses. Their trajectories complicate a simple opposition between ‘traditional’ and ‘biomedical’ healthcare [12,13,39] and align them more closely with sociological accounts of professions as groups that actively construct and defend jurisdiction through specific training pathways and claims to expertise [40]. In the Sierra Leonean context, where national strategies nominally recognise traditional healers as part of the health promotion landscape [14,29]. This suggests that healers are pursuing forms of professionalisation within a system in which ‘papers’ and certificates operate as key credentials, even as that knowledge remains only selectively recognised.

In contrast, biomedical providers’ accounts foreground codified language, diagnostic categories and hierarchical training and promotion pathways. These features resonate with global health analyses of how biomedical knowledge is institutionalised and standardised through written curricula, protocols and guidelines [20,21].

The analysis of conceptualising and enacting disability care (RQ2) shows that providers across sectors share plural understandings of disability but connect them to different explanatory models, responsibilities and therapeutic possibilities [23,26,34]. Care practices reflect these different conceptual anchors: traditional healers emphasise emotional and relational aspects of disability, describing stigma, exclusion and the need for reassurance, while biomedical providers emphasise rehabilitation, complication prevention and resource constraints. This reflects the different emphases of biomedical, social and rights-based disability models [30], but the material also shows that providers bridge these models in practice. For example, biomedical staff’s efforts to value patients or address marginalisation resonate with social-model concerns, while healers’ emphasis on functional limitations recognises material conditions alongside spiritual explanations. In line with work arguing that disability care in low- and middle-income countries is shaped by multiple, simultaneously enacted models [24,34,41], these findings illustrate how providers navigate and combine these frameworks in practice.

Within this plurality, decisions about when to intervene and what to offer are organised around clear distinctions between what is seen as open to cure and what is treated as a sphere of care without a curative horizon. Both groups drew lines around conditions beyond possible reversal and reoriented practice accordingly towards long-term support, prevention of deterioration, and accompaniment. The criteria differed—theological limits on what God allows to change, clinical assessments of irreversibility, awareness of structural constraints—but in each case, articulating limits was tied to notions of professional responsibility [30]. Participants’ accounts also reflected the breadth encompassed by the term disability, with differences in functional limitations, perceived causes, treatability and support needs shaping how care was understood and enacted.

Moreover, care for persons with disabilities emerges, in both sectors, as a layered practice. Traditional healers weave together plant-based and manual techniques with efforts to protect clients from spiritual harm and to counter social exclusion, while biomedical providers combine rehabilitation, medication and complication management with basic caregiving and protection of patients who are left without family support. These patterns suggest that both sectors assemble a mix of clinical, social and emotional labour across different situations and settings [13,18].

In terms of relationships between providers (RQ3), the findings show that interactions between traditional and biomedical providers are shaped by asymmetric referral pathways and unequal institutional status. Traditional healers describe both within-sector referrals and regular referrals into hospitals, consistent with evidence that traditional providers often function as first points of contact and triage in settings where biomedical services are constrained [13,18,42,43]. Biomedical providers, however, depict referral almost exclusively as an internal process within the formal health system and frame recourse to traditional care as occurring against medical advice. This is consistent with evidence across SSA that biomedical providers report limited knowledge of specialist disability services and reluctance toward traditional practice [44,45].

These one-sided referrals may reproduce patterns where traditional providers are positioned outside recognised care pathways despite treating overlapping populations [36]. These patterns are consistent with other analyses of how colonial and postcolonial histories have entrenched biomedical authority and marginalised other epistemologies in many African health systems [12,21]. Importantly, the accounts indicate spaces of unacknowledged interdependence, as a traditional healer described situations in which biomedical services relied on them informally, even where such practices are not recognised in hospital narratives. This resonates with Sierra Leonean evidence [26] that conditions understood as spiritual in origin rarely enter formal care pathways. While the current study cannot assess the broader prevalence or structural determinants of these patterns, the descriptions of participants suggest a gap between policy framings that depict traditional and biomedical sectors as parallel and the more intertwined realities described by providers themselves. For persons with disabilities specifically, the referral asymmetries described by participants point to the possibility of fragmented care trajectories across sectors.

A further dimension concerns how harm is attributed across sectors. Biomedical providers attributed disability-producing harm to some traditional practices, particularly when patients with fractures or acute conditions present to hospital only after complications have advanced. This is consistent with published reports documenting complications of traditional bone setting, including non-union, mal-union, chronic infection, and limb amputation in several African countries [46,47]. At the same time, evidence from other contexts indicates that iatrogenic disability is also produced within biomedical and quasi-biomedical practice, for instance through injection-induced sciatic nerve injury [48,49]. Moreover, informal medicine sellers in Sierra Leone similarly represent influential but weakly supervised sources of pharmaceuticals, with documented risks of inappropriate use and resulting harm [18]. Together, these findings from other studies suggest that risks of harmful practices are distributed across sectors. Within biomedical systems, adverse outcomes are framed as malpractice; comparable accountability frameworks are largely absent for harm occurring outside formal care structures [50]. How harm is attributed across sectors, and what this means for accountability, is a question for further research and cannot be answered by the present study.

Our findings point to several areas that warrant further research and may be explored for policy and practice. Examining collaborations and formalising bidirectional referral protocols could improve care for persons with disabilities. WHO’s global traditional medicine strategy [28] provides a framework for dialogue about the role of traditional, complementary and integrative medicine in health systems. Joint trainings on disability triage and complication risk, as well as the integration of traditional healers into community-based rehabilitation, require further empirical work [13,51]. Policymakers and practitioners could explore the role of traditional healers in providing preventive and social support while developing collaborative supervision mechanisms for safe practices [12].

Limitations and Future Research

This study has limitations that shape how its findings should be interpreted. As a small, exploratory study with ten interviews in and around Freetown, the sample cannot capture the full range of positions within either provider group or support systematic assessment of within-group heterogeneity. The sample size was set a priori for this exploratory component and was not intended to establish saturation or representativeness. The findings should accordingly be understood as reflecting the perspectives of these ten purposively selected participants. Freetown’s comparatively dense health infrastructure and its greater exposure to NGO and international health activities may shape provider perspectives in ways that differ markedly from those of providers in rural or peri-urban areas. Providers practising in more remote areas or within different strands of traditional and faith-based healing may articulate other understandings of disability and other forms of collaboration or conflict. Future studies with broader and more diverse samples, including comparative work across districts or countries, would help clarify how context-specific the patterns identified here are. The sample also included few female providers (gender information removed in relation to participant demographics to protect participant identity), particularly among traditional healers, where only one woman was interviewed. While no systematic gender analysis is possible on this basis, this female participant articulated clearer boundaries regarding the scope of her practice and more frequent referral to other providers, suggesting that gendered positions and roles may shape how care responsibilities and limits are negotiated. Future research could explore whether and how gender intersects with professional authority, boundary-setting, and referral practices across provider groups. Recruitment via an NGO and professional networks further implies that participants are likely to be relatively engaged with disability care and, in some cases, already exposed to cross-sector collaboration. This may have led to an underrepresentation of more conflictual or exclusionary positions, particularly among traditional providers who are not linked to formal structures. It should be noted that although interviewers presented themselves using their academic affiliation, participants recruited through ETC contacts may have articulated more positive accounts of NGOs and inter-sector relationships than would be found in a more randomly recruited sample. Deliberate sampling of providers outside such networks, including more marginal or commercially oriented actors, would allow future research to map a wider spectrum of practices and hierarchies.

6. Conclusions

This qualitative exploratory study suggests that disability care in Sierra Leone’s pluralistic health system cannot be understood as the sum of two parallel sectors, but as a therapeutic landscape in which roles, knowledge and responsibilities are actively negotiated. Traditional and biomedical providers draw on distinct and interacting epistemic traditions: traditional healers acquire authority through lineage, apprenticeship and community recognition; biomedical providers through codified training, credentials and institutional hierarchies. Both assemble layered care practices that combine clinical, social and emotional labour, and operate in a system that formally privileges only one set of practices. Referral patterns, as described by participants, remain asymmetrical: traditional healers described systematic cross-sector referrals, whereas biomedical providers largely excluded traditional practice from recognised pathways. These dynamics call for further research and an exploration of changes to disability care: how traditional healers might be engaged as more than behaviour-change conduits, how accountability mechanisms that span sectors can be built, and how the caregiving and advocacy work that both sectors described could be recognised. Addressing these questions requires further empirical work and locally grounded negotiations about patient safety, legitimacy and shared responsibility. These questions cannot be resolved at a distance from the communities and providers these systems are meant to serve.