Table 1 Perceptions by themes and respondents The content of the table underlines the great variety in how different study participants see the phenomenon of integration of herbal medicine with biomedical services

Patients generally used herbal medicine alongside biomedicine for various reasons:

-“some diseases do require herbal medicine or a combination of both” (female, food seller, 41 year)

- when biomedicine is not effective enough or does not entirely solve the problem, herbal medicine may be used” (P5, female, dressmaker. 29 years)

Patients also mentioned concerns about herbal medicine in general:

- “they are good especially when you get good herbal medicines with the correct prescription. The fear is that most of them are without prescription, sometimes bad people also prepare unsafe herbal medicines” (P5, female, dressmaker. 29 years)

- “the dosage is not always accurately dispensed” (P1, male, retired chief inspector, 72)

Patient mentioned their interest in seeing biomedical technology to the practice of herbal medicine:

“if you can use machines to detect the level of cure or treatment of diseases with the herbal clinic, we would appreciate it” (P1, male, retired chief inspector, 72 years)

One patient was an herbal medicine provider and said:

“Yes, I am an ardent user of herbal medicine. God gives me visions and I give them certain medicines to treat their illness. Some patients came to me suffering from fibroid and I gave them herbal medicines for treatment. I personally use it too and because of my constant usage I don’t fall sick a lot”(P2, female, farmer, old woman not certain of her age)

The majority of the nurses acknowledged the important role that herbal medicine plays in patients’ treatment choice

The providers also shared their own interest in using herbal medicine. A staff nurse said: “Herbal medicines are good. I used herbal medicines when I was not [yet] a health professional. I will recommend herbal medicines to other patients”

The tendency of some herbal medicine practitioners to claim that one remedy could cure several illnesses was found to be dishonest

Nurses applauded that scientific methods were increasing applied in testing and prescriptions of herbal remedies.

It was noted that it is better that herbal remedies be prescribed within the hospital setting than outside:

“Herbal medicine in the hospital now goes through research before it is administered. Also people now accept it because it is in the hospital and prepared under hygienic conditions” (female nurse, interview)

“It motivates patients to come to the hospital because herbal medicine is easily accessible” (male, anesthetist, FGD).

Doctors were generally skeptical towards herbal medicine but thought it safer when provided from the hospital

I think it would be better to come to the herbal clinic for medicines than go to any place for medicines” (female, doctor 1)

“I sometimes refer patients to herbal clinic especially patients who are not financially sound to purchase their drug, provided there is an herbal medicine option” (female, biomedical doctor 2).

“There have been proliferation of herbal medicines and structures have been built for that purpose. People are trained to cater the needs of patients. I have used herbal medicines for food poisoning.

The medical herbalists all appeared enthusiastic about Positive towards the concept

“We respect each other but how integrated the system is, is dependent on individual’s perspective.”

(Medical herbalist, 2.)

“When patient’s condition requires surgical operation, the case is referred to the main hospital.

(medical herbalist 1)

Key informants all expressed positive sentiments about herbal medicine in the sense that they supported the integration in theory:

“Ghana has started some kind of integration of herbal treatments into the health system. Currently, it is parallel”. (Ministry of Health)

“The system has not been fully integrated”. There is sometimes cross referral”.

(hospital management)

“Sometimes, we become confused with collaboration and integration. It is not fully integrated” (GHAFTRAM).

Patients we encountered in the out-patients’ department were not always aware that there was a herbal clinic on the compound

Some patient saw the integration as a way of authorizing the use of herbal medicine.

“As you can see, this means herbal medicines are good. Some diseases require the use of herbal medicines so people will come here for treatment.” (P4, female, 41 year, biomedical)

“Not aware of existence of herbal clinic. Some disease require herbal medicine” (P2, old female, not sure of age, biomedical) Patients were positive towards the concept, they felt it was safer.

“It is a good initiative. The herbal medicines will complement the biomedical medicines” (P6, male, 36 years, biomedical)

“It very good. because when visited, the main hospital and herbal clinic and combined, both really worked well” (P16, male, 51 year; P20, female 60 year, herbal)

Nurses did not perceive service to be integrated.

“we are not integrated or working together” (female, nurse 1)

“Not really integrated. It is seen as another unit. It is the patient's choice” (female, nurse, FGD)

Did not see integration but parallel collaboration

“not for see any integration anytime soon,

“It has not really worked, I think it is more parallel” (female biomedical doctor 1)

Perceived a strong integration

“we work hand in hand with biomedical unit” (medical herbalist 2)

Positive towards integration

“We decided to assign some general nurses to the herbal clinic when it started with one medical herbalist”. We did this on our own.” (Hospital mgt.)

“I don’t have a problem with either it being integrated or parallel. The main focus is to make the patient satisfied. The second is to make sure it is of high quality”(association of medical herbalists)

Patients used the same laboratory

“At the herbal clinic, they let you go for laboratory tests before you are treated. I think they help”. (P20, female, 60 year, herbal)

“I first went to the hospital for my folder because I had used the biomedicine and it did not help me.” (P17, female, 21 year, herbal)

Some nurses saw the out-patient department as the only point of integration

“Patients go straight to the herbal center when they have their folders from the OPD and most people like herbal medicine” (female, nurse, FGD)

“We have not admitted any patient who uses herbal medicines and biomedical medicines. I don’t think it is integrated, because we are not working together with them”. (female, nurse, interview)

Doctors’ experiences concerning integration-related practices varied greatly. Some did not see any integration:

It has not really worked. You are in between two choices. It is the patients’ choice to choose between biomedical medicines and herbal medicines. It is not really integration.

(female, senior medical officer)

“There is no information flow between us. But they sometimes have presentations on herbal medicine in Ghana”. (female, senior medical officer 1)

Another doctor saw it differently: The information flow is very good. We have the prescribers meeting. They decide what is to be done. They make presentations on what has happened (female, senior medical officer 2)

Yes, we do transfer some of the patients to the herbal clinic especially the men who suffer from ED. The herbalist is my friend. The biomedical drugs are expensive

(Female, senior medical officer)

Medical herbalists perceived the out-patient department and the laboratory as points of integration.

“The integration system is very strong. There are sometimes intra referrals from herbal to biomedical and vice versa”.

“Patient goes to OPD, then to herbal clinic, we check vital stats, then patient will be examined during consultation and referred to the lab if necessary. We ensure continuity for review” (medical herbalist 1).

Key informants perceived referrals as ways of integration.

“In case there is a challenge, we confer with them. We do cross referrals. If we realize that a patient needs the biomedical medicines, then we refer them to the main stream hospital. On the other hand, we get cases if a patient has been on biomedical medication and still it is not working”. (association of medical herbalist)