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Setshwano Rametse has a problem, a painful and difficult problem, and for years she tackled it in just the way you might expect a sophisticated, well-educated professional would. She battled infertility, consulting a range of medical experts and pursuing a variety of invasive and expensive clinical procedures. But none produced the child she longed for.

And so a couple of years ago, Ms. Rametse, 35, did something that she admitted seemed a little bizarre for a highly educated marketing executive with a six-figure income. She went to see a traditional healer, an older woman who entered a trance-like state and summoned Ms. Rametse's ancestors, and those of her husband, to try to cure their childlessness.

From the healer, Ms. Rametse received a diagnosis dramatically different from any she had gotten in the sophisticated medical centres of Johannesburg. The healer told her that the problem lay with her husband's family. Raised by a single mother, he did not know his ancestors on his father's side, was not in touch with them or respecting them. The very basic step of informing them of his birth and marriage had not been taken. And until this was rectified, "this gift of a child would not be given to us," Ms. Rametse said.

She and her husband, married years ago in a Christian church, will soon recelebrate their marriage in a traditional ceremony in which all of his ancestors will be evoked. "You communicate to your ancestors and they pass the message on to God. They are the nearest thing to God and we have lived with them," she explained. "It's from the traditions of our culture."

Ms. Rametse's view is not unusual: 80 per cent of South Africans - which means nearly the entire black population, including the rapidly expanding middle class - turn to traditional healers, either in place of, or before, the conventional, Western health system, to address their problems.

Ntlomo Koka, a Pretoria sangoma (healer in isiZulu), would like to be part of a national college of traditional healers, would like to make sure standards are maintained, that there is no abuse by quacks claiming to have quick cures for AIDS or cancer. But the process will be terribly complicated, she said: A healer must study, apprentice and wait for dreams and messages from the ancestors to say she or he is ready for formal initiation. How will the government handle that, she wonders?

And how can a medical-insurance company decide which should cost more: the throwing of bones to diagnose a problem, or entering a trance? "What if tonight I have a dream in which I heal a wound with a pear, where I squeeze pear juice into an abscess and then I cover it over with the skin of the pear? Will you list, 'One pear cures X number of wounds?' " Ms. Koka laughed.

"But that pear could be a secret recipe that works for me, that the ancestors gave me. We're of a spiritual nature and talking about regulating this is very complex. You can't."

Jonathan Broomberg has an equally puzzled tone when he discusses this issue. He is the head of strategy and health policy for Discovery Health, the largest medical-insurance company in South Africa. Discovery is taking the industry lead in engaging with traditional health practitioners.

Dr. Broomberg said his firm is keen to be responsive to its customers, but then, given the massive use of the traditional health system here, providing insurance coverage for sangoma and inyanga (herbalist) treatment also offers the potential to recruit a great many more clients for insurance products.

But it's not going to be easy. "The government currently requires that any claim from a health-care provider have [a code]. What do you do with 'the ancestors are angry?' " he asked. "The answer may be that there are some compromises to be made on legal and systems requirements."

But that's not straightforward, either. Any new medical service or technology is vigorously evaluated for clinical and cost effectiveness. "But how do we measure [a traditional herb or bone-throwing session]? I don't think we are going to be able to do it. And that raises a moral dilemma: How can you justify suspending disbelief to all of these treatments and still apply those rigorous standards, the high burden of proof, to all these Western medicines?"

That's an industry challenge, but Anthony Mbewu, head of South Africa's Medical Research Council, who oversees research into many forms of indigenous knowledge, argues that if other non-traditional treatments such as homeopathy, and intangibles such as psychiatry, can be covered by insurance, then there must be a way to include traditional healing, too.

Dr. Broomberg noted that "the government is obviously very keen to see this happen" and indeed, that is one of the major drivers of this process.

President Thabo Mbeki, a passionate champion of the "African renaissance," has long argued that traditional medicine has been dismissed by racist outsiders as witchcraft, when in fact many of the compounds now routinely used in Western medicine have their origins in traditional healing.

Yet many people here appreciate the government's push. "Of the 13,000 pharmaceuticals in use today, probably 1,000 have had clinical trials; the randomized clinical trial was only invented 50 years ago," said Prof. Mbewu, who sits on Mr. Mbeki's task team on traditional and African medicine. "Of the 3,000 African traditional medicines in common use in South Africa, many have been in use for centuries. ... You can't say, 'The fact that your grandmother and your great-grandmother used it is irrelevant.' "

What needs work, he said, is finding a way for Western and traditional practitioners to function together "so that a patient with TB who clearly has AIDS is referred to an orthodox clinic, because we have no evidence that traditional health practitioners can cure that person." Instead, he said, healers who see people with common symptoms of HIV must treat those, but also refer their clients for HIV tests.

Nceba Gqaleni, deputy dean of the Nelson R. Mandela School of Medicine at the University of KwaZulu-Natal and an expert on indigenous health care, said a healer is not much different from a psychiatrist. A patient in his clinic comes with a headache, and he uses that to lead to a diagnosis of stress and high blood pressure and prescribe lifestyle change.

"Well, healers throw the bones to go into a deep conversation about these things," he said. "We need to talk about outcomes, even though the methodology might not be the same. They're all truths, and they're relative."

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A slow process

South Africa's government is working to formalize the practice of traditional medicine. That involves many things: regulating the practice of healers, herbalists and diviners; testing and registering their remedies; and perhaps, most complicated and most significant, making their practice available both through the public-health system and through the private sector, to which a growing number of the country's citizens have access through medical insurance.

That puts South Africa at the forefront of a global effort, launched by the World Health Organization, to formalize the use of traditional medicine, everything from the ancient Ayurvedic system in India to acupuncture in China.

South Africa's parliament adopted a new law last year to make traditional healing a self-regulating profession, similar to medicine and pharmacy. Healers are now in the process of organizing a governing council, adopting standards of training, writing codes of practice and setting up committees to discipline members for abuses. But the process is slow: There are an estimated 200,000 traditional health practitioners of different kinds in the country, and most practise independently.

Stephanie Nolen