A situational analysis of health tourism for appropriation of indigenous herbal sexual stimulants and fertility enhancers in Zimbabwe: A situational analysis paper

Abstract In Zimbabwe, health tourism for the sake of gaining access to herbal substances for sexual and fertility enhancement remains both undocumented and shrouded in myths. The significance of indigenous herbal medicine practice in stimulating medical tourism growth has remained understudied, undervalued and unappreciated. Seemingly, research has paid very little attention to this branch of health tourism based on traditional medical practice. The pharmacological properties of the various indigenous herbal medicine prescribed, dispensed and consumed under health tourism remains scientifically unassessed and not much is known about the nature of the tourist traffic whose main purpose of travel is the consumption of these indigenous herbal substances for sexual stimulation and/or fertility enhancement. As a result the commercial potential of indigenous sexual stimulants and fertility enhancement herbs remains uncharted both for health tourism and the health sector in general in Zimbabwe. This situational analysis paper sought to clarify the knowledge on the medical tourism market place concerning indigenous herbal medicine for sexual stimulants and/or fertility enhancers. The paper also maps out what has been achieved within the herbal medical tourism industry. Specifically the paper explores the medical tourism entrepreneurial potential and highlights the knowledge gap concerning herbal medicine and health tourism development based on these traditional herbal medicines and highlight areas for further research.

ABOUT THE AUTHORS Chipungu Odmell is a Masters in Philosophy student at Chinhoyi University of Technology, Zimbabwe. My research topic includes Tourism policy issues and health tourism. My MPhil thesis being prepared with the assistance of my two supervisors Dr Patrick Walter Mamimine and Dr Kudakwashe Chitindingu is about the potential of using traditional herbal medicine for health tourism development. The originality of the thesis is the evaluation of the nature of tourist traffic whose main purpose of travel is the consumption of indigenous herbal substances for sexual stimulation and fertility enhancement and its potential for anchoring health tourism development and subsequent drug development. Traditional herbal medicines are a cheaper form of treatment and have been used since time immemorial as the first line of defence against various ailments. This paper will stir research interest in traditional herbal medicines and health tourism development.

PUBLIC INTEREST STATEMENT
The potential of using traditional herbal medicine for sexual stimulation and fertility enhancement has remained understudied. This is despite the fact that globally 80% of the world's population still depends on traditional medicine for their primary health care needs. Traditional medicine over the ages has continued to play a pivotal role in healthcare. Globally a number of people travel long distances in search of these indigenous medicines. However, this form of tourism has remained understudied and uncharted for health tourism development and the health sector in general. Understanding this form of travel and the herbal medicines used as sexual stimulants and fertility enhancement can lead to health tourism development and new drug discovery. Exploration of the dynamics of this consumption of herbal medicine can lead to the integration of traditional herbal medicine into mainstream medicine practice and subsequent health tourism development.

Background
Globalisation has been instrumental in cultivating a culture of consumerism which has become a mantra of today's health conscious generation. Today's generation travels across the globe to consume a variety of health alternatives that ensure satisfaction and a healthy living. The onset of globalisation has paved way for the phenomenal growth of medical tourism which has been predicted to grow at an average rate of between 30 and 35 (Charity, Walter, Forbes, Kumbirai, & Margaret, 2013;Deloitte, 2009). Health tourism globally has become big business, raking in billions of dollars annually. The industry is predicted to generate revenue in the range between US $ 38-60 billion annually (Cleland et al., 2014;Hunink et al., 2014;Lunt, Smith, & Exworthy, 2011). The statistics clearly show the economic potential that this industry has and unsurprisingly countries like China and India have made it a priority as a new tourism niche market. However, despite this naked potential and with over fifty developed countries having embraced health tourism as a strategic product in tourism, very little is being done in 3rd world countries with Zimbabwe included concerning health tourism development (Charity et al., 2013;Tomka, 2011). Regionally in Africa, the failure to capitalise on this phenomena's potential as a new tourism niche market remains the continent's greatest un-doing.
Health tourism is defined by Carrera and Bridges (2006) as organized travel outside one's healthcare jurisdiction with the aim of health restoration and enhancement through medical intervention. However, in this paper the term health tourism is going to be stretched to include health tourism based on the consumption of indigenous herbal medicines. Traditional herbal medicine in third world countries continue to play a pivotal role as the first line of defence against various illnesses. Countries like China and India have made considerable financial gains trough the exploitation of their indigenous herbal medicines which have continued to enjoy global acceptance.
The idea of people travelling to consume health care is a custom as old as medicine itself. Universal cultures narrate of its existence since time immemorial. Medical tourism has existed in different forms over centuries, and only globalisation and industrialization has served to intensify its frequency in today's world (Chauhan, Sharma, Dixit, & Thakur, 2014;Hancock, 2006;Hishe, Asfaw, & Giday, 2016;Rupande & Bukaliya, 2013). For long, universal cultures have manipulated their knowledge of medieval herbs and their properties for use as the first line of defence against various human ailments (Asase, Akwetey, & Achel, 2010;Au et al., 2008;Maroyi, 2011Maroyi, , 2013. Throughout the ages across the world, herbal plants have traditionally been manipulated for the treatment of human disease (Hancock, 2006).
Traditional herbal medicine has through the passage of time largely remained untapped both for its health tourism potential and medical properties development even though it has continued to play a pivotal role in healthcare. Today, as much as 80% of the world's population still depends on traditional medicine for their primary health care needs (Chauhan et al., 2014;Folashade, Omoregie, & Ochogu, 2012;Hishe et al., 2016;Maroyi, 2013;Shetty, 2010). Maroyi (2013) asserts that Zimbabwe continues to experience an upsurge in demand for herbal medicines yet the traditional remedies remain untapped for their economic potential both at domestic and national level. Nkatazo (2010) asserts that about 80% of Zimbabweans still depend on herbal medicine. Herbal medicines are said to be affordable for economically poor countries like Zimbabwe (Mafuva & Marima-Matarira, 2014).
In Zimbabwe, a number of people travel long distances in search of indigenous herbal medicine for disease treatment. Sexual dysfunction has been the main motivator that has forced people to travel globally in search of a remedy. Even in Zimbabwe, the desire to consume traditional herbal medicines as alternatives have forced people to travel to seek these herbal remedies for sexual stimulation and fertility enhancement. Despite the absence of clear statistics to prove the magnitude of traditional herbal consumers in Zimbabwe, Maroyi (2013) asserts that previous research clearly indicates a widespread use of traditional medicine in Zimbabwe by both urban and rural communities. Nkatazo (2010) asserts that 80% of Zimbabweans still depend on traditional medicine. Nkatazo (2010) positively asserts that even today many patients still remain pluralistic consumers committed to the consumption of both African traditional medicine and modern allopathic medicine. However, even though ethno-medicine has gained a lot of recognition especially in post-independent Zimbabwe Sewani-Rusike (2010) posits that very little research has been done undertaken on health tourism based on these traditional herbal remedies. This failure to exploit the potential posed by traditional herbal medicine comes despite the fact that other countries like India and China are already enjoying the appreciation of their traditional medicines across the globe.
There remains a lack of systematic information on the prevalence, efficacy and safety of herbal plants used as an intervention for problems of sexual dysfunction. Ghazeeri, Awwad, Alameddine, Younes, and Naja (2012) and the volume of medical tourists who travel for its consumption remains unknown and uncharted. The ethno-medicines have not been documented and scientifically validated for efficacy, safety and future drug discovery and development (Maroyi, 2013). Health tourism specifically to obtain access to herbal substances for the purpose of sexual stimulation and fertility enhancement faces problems in that herbalists provide substances whose pharmacological properties are not scientifically investigated (Ameh et al., 2013;Bodeker, Carter, Burford, & Dvorak-Little, 2006;Chauhan et al., 2014;Folashade et al., 2012;Mafuva & Marima-Matarira, 2014;Muweh, 2011;Ojekale, Lawal, Jewo, Oguntola, & Abdul, 2015). However, in the absence of such clinical efficacy and safety data on these herbal medicine people remain sceptical to use them, hampering the promotion of this branch of medicine for health tourism and integration into mainstream allopathic medicine.
This situational analysis paper exposes the underlying potential that lies in developing indigenous herbal sexual stimulants and fertility enhancers both for health tourism and health development in general. The paper exposes the current knowledge that exists on the knowledge market place concerning health tourism appropriation and indigenous herbal sexual stimulants and fertility enhancers.

Problem statement
In Zimbabwe, health tourism for the sake of gaining access to herbal substances for sexual and fertility enhancement remains both undocumented and shrouded in myths (Muweh, 2011). Seemingly, research has paid very little attention to this branch of health tourism (Maunganidze, 2016). The pharmacological properties of the various indigenous herbal medicine consumed under health tourism remains scientifically unassessed for efficacy and safety (Chauhan et al., 2014;Folashade et al., 2012;Ghazeeri et al., 2012;Hishe et al., 2016;Maroyi, 2013;Shetty, 2010) and not much is known about the nature of the tourist traffic whose main purpose of travel is the consumption of these indigenous herbal substances for sexual stimulation and/or fertility enhancement. As a result the commercial potential of indigenous sexual stimulants and fertility enhancement herbs remains uncharted both for health tourism and the health sector in general in Zimbabwe.
Using qualitative content analysis methodology this situational analysis paper sought to highlight the knowledge gap on the medical tourism knowledge market place concerning indigenous herbal medicine for sexual stimulants and/or fertility enhancers. Specifically the analysis paper explores and highlights the global significance to humanity of traditional herbal medicine. The analysis paper extends the frontiers of knowledge in as far as understanding the dynamics of health/herbal tourism and the analysis findings can be used by tourism policy makers to encourage research further researches on traditional herbal medicines in Zimbabwe.

Methodology
Globally, the significance of indigenous herbal medicine practice in stimulating health tourism travel and growth of the health tourism industry in general has remained undervalued and understudied. Health tourists consume indigenous herbal medical portions to acquire posterity. However, there remains a lack of systematic information on the prevalence, efficacy and safety of herbal plants used as an intervention in fertility issues (Ghazeeri et al., 2012). Studies to determine the dynamics of indigenous herbal consumption are very scanty, especially in Zimbabwe. Using qualitative content analysis of several published empirical information on the matter of health tourism and traditional herbal medicine for sexual stimulation and fertility enhancement, this paper sought to highlight the global significance to humanity of herbal medicine, its potential to anchor health tourism development and growth and the knowledge gap on the medical tourism knowledge market place concerning indigenous herbal medicine for sexual stimulants and fertility enhancers. Hsieh and Shannon (2005) defines qualitative content analysis as a research method for the subjective interpretation of the content of a text data through the systematic classification process of coding and identifying themes or patterns. Patton (2002) asserts that qualitative content analysis refers to any qualitative data reduction and sense making effort that takes a volume of qualitative material and attempts to identify core consistencies and meanings.
This type of design is usually appropriate when existing theory or research literature on a phenomenon is limited. Mayring (2000) asserts that content analysis uncovers patterns, themes and categories important to social reality. The method analyzes social phenomena in a non-invasive way, in contrast to simulating social experiences or collecting survey answers. Data for the study was prepared from Journals, books, papers, and other relevant sources (covering health tourism and traditional herbal medicines specifically for sexual stimulation and fertility enhancement) which were reviewed. The researchers reviewed an unlimited number of materials on the topic with the majority of the material being from as recent as 2010 to 2016. Classical literature was also analysed, especially on the section of authenticity. The researcher used themes as a unity of analysis. Themes such as the demographic characteristics of consumers of traditional herbal medicine, the value chain involved, health tourists conceptualization of authenticity in traditional herbal medicine consumption, psychosocial impacts and considerations of probable side effects appropriation were used as themes. The results and discussion of the findings based on the defined unit of analysis (themes) are presented below.

Indigenous sexual stimulants and fertility enhancers
Literature indicates that so much remains unknown concerning indigenous sexual stimulants and fertility enhancement. The search for medical intervention to stimulate sexual prowess and fertility is an old custom as old as humanity itself. Universal culture narrates the existence of traditional herbal medicine since time immemorial (Chauhan et al., 2014;Hancock, 2006;Hishe et al., 2016;Rupande & Bukaliya, 2013). This clearly shows that traditional medicine has been in use for years but has remained unexploited commercially for health tourism development and drug development in general. Erectile dysfunction has resulted in health tourists travelling across the globe for the purpose of accessing medical intervention. Traditional herbal medicines have been used to enhance fertility and sexual stimulation. Chauhan et al. (2014) clearly asserts that a variety of indigenous herbs have been used as sexual stimulants and for treatment of infertility by different traditional cultures. This clearly indicates that though the travel by health tourists specifically to consume traditional herbal medicine and sexual stimulants and fertility enhancers has remained uncharted, it remains relevant and pronounced.
These herbal medicines throughout the ages have been manipulated for their properties as the first line of defence against various diseases (Asase et al., 2010;Au et al., 2008;Maroyi, 2011Maroyi, , 2013. Thus observations made in the practice of traditional medicine have been instrumental in the growth of mainstream medicine. However, very little is known concerning the herbal medicine used for sexual stimulation, the dosage, the frequency of uptake, the plant chemical properties and shelf life, despite studies by such scholars as (Ojekale et al., 2015;Maroyi, 2011Maroyi, , 2013. This assertion simply serves to show that a lot remains unknown concerning the consumption of traditional herbal medicine. Thus one may conclude that traditional herbal medicines have the potential to anchor health tourism development and growth even though a lot still remains unknown about health tourism based on the sole consumption of indigenous sexual stimulants and fertility enhancers. There remains a lack of systematic information on the prevalence, efficacy and safety of herbal plants used as an intervention for problems of infertility (Ghazeeri et al., 2012). This assertion calls for further studies to be conducted to increase the knowledge concerning traditional herbal medicine and health tourism on the knowledge market. Thus not much is known concerning indigenous herbal medicines. The volume of medical tourists who visit for the consumption of herbal plants remains unknown and unexplored. In-depth systematic studies to discover and authenticate the ethno medicinal pharmacological compounds of interest are imperative in order to improve the primary healthcare of local communities (Maroyi & Cheikhyoussef, 2015). Thus literature clearly shows that a lot remains to be done in the field of traditional medicine before they become accepted in mainstream medical practice. These studies may provide the break-through in the discovery of novel drugs. Only a few studies have been carried out in a systematic manner (Maroyi, 2013). This is the reason why Maunganidze (2016) suggest that indigenous traditional medicines have been neglected by research at the expense of western based health research.
However, the scholar does not highlight why it is imperative to give traditional medicine such prominence in studies. Thus one can conclude that though studies have been done, only a few have concerned themselves with sexual stimulants and fertility in Zimbabwe, and of those few none has looked at the potential of developing health tourism nor novel drugs based on these traditional herbal remedies. From the analysis of literature, it can be argued that traditional medicine have great potential in terms of anchoring health tourism development and drug development. To emphasise the potential such traditional herbal remedies have, Maroyi (2013) further posits that significant levels of global pharmaceutical knowledge such as the discovery of drugs like quinine came as a result of observations made on traditional medical practices. However, in the absence of any scientific proof of their effectiveness, the validity of these remedies remains questionable. In the absence of scientific validation, people remain sceptical to consume these traditional herbal remedies. Thus it can be said that there is still need to conduct studies to increase the knowledge concerning traditional medicine specifically that of traditional herbal sexual stimulants and fertility enhancers so that communities globally can benefit immensely from this unexplored resource. There is need to have studies that give prominence to both the economic value of traditional medicine and their potential to anchor health tourism development and increase the knowledge on the knowledge market.
Literature clearly indicates some of the grey areas concerning traditional herbal medicines for sexual stimulation and fertility enhancement. Health tourism specifically to obtain access to herbal substances for the purpose of sexual stimulation and fertility enhancement faces problems in that herbalists provide substances whose properties have not been scientifically validated for efficacy and safety (Ameh et al., 2013;Bodeker et al., 2006;Chauhan et al., 2014;Folashade et al., 2012;Mafuva & Marima-Matarira, 2014;Muweh, 2011;Ojekale et al., 2015). This shows the imperative need to validate traditional medicines scientifically so that they become accepted in mainstream allopathic medicine. Maroyi (2013) asserts that validating ethno-botanical medicines still remains an imperative task for future research. The lack of scientific validation and the fact that so little is known about the traditional medical practitioners and their medical practice might be working against the inclusion of traditional medicine into mainstream modern medicine and the development of health tourism based on traditional herbal medicine in Zimbabwe and the world at large.
Traditional medical practice has through the passage of time largely remained untapped both for its health tourism potential and medical properties development. Literature strongly indicates that traditional medicine over the ages has continued to play a pivotal role in healthcare. Today, as much as 80% of the world's population still depends on traditional medicine for their primary health care needs (Chauhan et al., 2014;Folashade et al., 2012;Hishe et al., 2016;Maroyi, 2013;Shetty, 2010). Thus it can be argued that African traditional herbal medicines still in today's world perform an essential role in satisfying basic health care of traditional communities. Maroyi (2013) asserts that Zimbabwe continues to experience an upsurge in demand for herbal medicines. This asserts the position of traditional medicine at the forefront of disease control especially in third world countries were synthetic drugs are expensive and beyond the reach of many. Herbal medicine is cost effective for poor resource countries such as Zimbabwe (Mafuva & Marima-Matarira, 2014). Thus, this is evidence that drug development from traditional medicine can pay a pivotal role in elevating the livelihoods of many poorer communities globally by providing affordable drugs. Escalating livelihood problems worsened by recurrent droughts, crumbling economy, joblessness and a poor health delivery system have all connived to prompt people to travel and consume traditional herbal medicine in Zimbabwe.
In Zimbabwe, a number of people travel long distances in search of indigenous sexual stimulants and fertility enhancers. However, the dearth of literature due to the paucity of relevant studies in this area and the absence of central ethno-botanical records and statistics further renders the popularity and usage of traditional medicine mysterious. Despite the absence of statistics, previous research Maroyi (2013) clearly indicates a widespread use of traditional medicine in Zimbabwe by both urban and rural communities as the scholar goes on to say that even today many patients are still remain committed to the consumption of African traditional herbal medicine. Thus it can be said that traditional medicine has remained the most affordable and easily accessible source of treatment for many poor communities in Zimbabwe. Evidence presented in literature asserts that many Africans remain pluralistic consumers (consuming both traditional medicine and western medicine) as western medicine has not replaced traditional medicine. However, even though ethno-medicine has gained a lot of recognition especially in post-independent Zimbabwe as pointed out by Sewani-Rusike (2010), very little research has been done undertaken on health tourism. Other countries like India and china are already enjoying the appreciation of their traditional medicines across the globe. The potential for the development of health tourism and the health sector in general as a whole both locally and internationally based on indigenous herbals for sexual stimulants and fertility enhancers is enormous.
However, in the absence of such clinical efficacy and safety data on these herbal medicine people remain sceptical to use them. This lack of clinical assays of the traditional herbal medicine for sexual and fertility enhancement continues to hinder the full exploitation of this branch of medicine for health tourism development and medical development as people remains sceptical to consume them. Thus medical tourism for the sake of accessing herbal medicine for sexual stimulation and fertility enhancement has been alive yet its manipulation for health tourism has remained on the peripheries of government policies. The major reason for this failure to fully exploit the potential benefits of traditional herbal medicine specifically for sexual stimulation and fertility enhancement for the development of health tourism is a lack of adequate knowledge concerning these traditional medicines. Literature clearly indicates that there is need for further studies.
One of the importance carrying a systematic review of traditional medicine as indicated by the analysis of literature is that it leads to new drug development. The systematic review of traditional medicine provides a useful route employed in the search for novel drugs (Amusan, Sukati, Dlamini, & Sibanze, 2010). The development of novel drugs would positively benefit global communities' health wise especially in the developing world were a host of diseases outbreaks are rampant. Amusan et al. (2010) cited in Chitemerere and Mukanganyama (2011) clearly assets that through biospecting of the indigenous herbal plants used as remedies in disease control by local societies provides a potential for the discovery of more therapeutic drugs. Thus this clearly calls for further studies in the field of traditional medicine practice as very little remains known. This is true basing on the fact that only a few indigenous herbal plants have been clinically assayed to validate their claims to efficacy. Thus there remains very limited knowledge on the knowledge market concerning traditional medicine specifically for sexual stimulation and fertility enhancement. Thus there is a need for further studies to stimulate health tourism anchored by this traditional medicine and health sector in general.
It is strongly suggested in literature that some herbal plants exploited for their therapeutic properties traditionally can be developed into new drugs. In the face of traditional claims of efficaciousness by indigenous medical plants in the treatment of sexual dysfunction, it is imperative to undertake more clinical and pharmacological studies to assay this unexploited potential of traditional knowledge. Kamatenesi-Mugisha and Oryem-Origa (2005), asserts that further research into the efficacy and safety of herbal remedies for male sexual disorders is imperative. The area of indigenous herbal medicines for sexual dysfunction is characterized by a dearth of systematic review of scientific literature on experimental evidence generated for medicinal plants useful in erectile dysfunction and there is need for in-depth pharmacological survey (Chauhan et al., 2014). Maroyi (2011), admits that there need to standardize the traditional forms of herbal preparations, dosage, and routes of administration to allay any health tourist consumer fears. Thus it can be said that knowledge concerning herbal medicine remains very limited hampering its potential to benefit mankind.
Thus it can be interpreted from the analysis of literature that there is need to have systematic studies that demystifies health tourism based on traditional medicine for sexual stimulants and fertility enhancers, studies that assay the herbal medicines for claims of efficacy, safety, future drug discovery and record statistics of the magnitude of the patients who consume these herbs. Literature currently on the knowledge market clearly indicates that health tourism for the sake of gaining access to indigenous herbal substances to solve problems of sexual dysfunction. Not much is known about the nature of the tourist traffic whose purpose of travel is the consumption of indigenous herbal substances for sexual stimulation and fertility enhancement. The pharmacological properties of the various herbs prescribed and dispensed by traditional healers and others have not been scientifically assessed and not much is known about the pharmacological properties.

Conceptualisation of authenticity in health/herbal tourism experiences
Authenticity though a complex concept, remains central in tourism studies (Carter, 2008;Rickly-Boyd, 2012). The analysis of literature proved that authenticity in health tourism based on traditional medicine is not well articulated, it still remains a grey area to be researched upon. It remains a "fuzzy" concept to use Cohen's (1974, p. 528) term. The majority of studies in existence such as ones by (Bazzano, 2010;Belhassen & Caton, 2006;Ivanovic, 2011) deal with the issue of authenticity based on cultural/heritage tourism and not of experience health tourism based on traditional sexual stimulants and fertility enhancers. The different conceptualization of authenticity presented in literature presents authenticity as a vague term, one prone to mean different things to different people. Cohen (1988) asserts conceptualization of the term authenticity is fluid across people, time and places. The subjective nature of the concept renders it difficult to define as the term embraces different perspectives and tastes of a multiplicity of tourists typologies (Cohen, 1979), tourism styles (Bruner, 1991, Cohen, 19721979), tourist travel careers (Pearce & Moscardo, 1985), age and gender. Thus, one may argue basing from the analysis of literature that the concept of authenticity remains an elusive one in health/herbal tourism. Kolar and Zabkar (2010) emphasize the centrality of authenticity to tourism studies by saying that comprehending authenticity aids a better understanding of the behaviour of tourists, their experience and is pivotal in determining the marketing success of a tourism product. Thus this clearly indicates the limited knowledge that exists on the knowledge market of how health tourists conceptualize the concept of authenticity health tourism based upon the consumption of traditional medicine specifically for sexual stimulation and fertility enhancement. Much of the definitions awash in literature denote authenticity from the perspective of primitiveness, pristine and natural not yet touched by modernity or western influence (MacCannell, 1976, p. 160 cited in Mamimine, 1998. Mamimine (1998) argues that these definitions have a major weakness of adopting a static perception of authenticity and overlooking the constructed nature of the phenomena. Thus from the analysis of literature it can be argued that there is need to understand how health tourists conceptualize the term authenticity in the conceptualization of indigenous sexual stimulation and fertility enhancement. This is a clear indication that the knowledge on health tourism based on the consumption of traditional medicine is very limited, there remains a need to carry further studies.
Tourists are motivated by desires for authentic experiences (Gilmore & Pine, 2007;Ivanovic, 2011). Literature strongly asserts that the quest for authentic experiences is central to modern societies. Authenticity is seen to provide the competitive edge for different tourism product. However, other scholars such as (Bruner, 1991;Cohen, 1988) argue authenticity is not every tourist's concern. This school of thought argues that although authenticity is of significant importance in tourism, it is not of concern to every tourist. Thus there is a need for studies to understand how health/herbal tourists conceptualize the authenticity as a concept. However it remains a mystery how health tourists perceive issues of authenticity in health/herbal tourism based on indigenous sexual stimulants and fertility enhancers. Hence as a concept, a position is yet to be researched on what authenticity means for tourists who participate in medical tourism for the purpose of gaining access to herbal substances for sexual stimulation and fertility enhancers, how they conceptualise the authenticity of the herbal medicines they consume under health/herbal tourism.

Value chain
There is a lack of clarity on the value chain involved in the consumption of indigenous herbal medicine for sexual stimulation and fertility enhancement. From the analysis of existing literature, it is clear that this is one area that remains on the peripherals of modern research. The value chain concept is defined as all the activities that are done to bring a product from the conception stage to the market (Chopra & Meindl, 2004;McCormick & Schmitz, 2001). Thus this implies that there a exist a gap in knowledge on the activities involved from conception to the final consumer of traditional herbal medicines, further cementing the need for further studies to bridge such knowledge gaps on the knowledge market. However value chains are complex and tend to include so many linkages and relationships in the chain making it complex to capture all the activities in a definition. The present value chain in most developing countries is characterized by herbalists and traditional healers who are also the gatherers and collectors of the herbal plants and mostly dispense it in its crude form (Hishe et al., 2016;Shinwari & Qaiser, 2011).
The value chain concept in traditional herbal medicine in Zimbabwe remains unknown, the players involved, market size and characteristic remain as mysteries to be resolved with researches. Literature remains silent on the value chain concept in traditional herbal medicine in Zimbabwe. The herbal practice remains traditional, secretive, unorganized and unregulated. The value chain for the herbal medicine industry in Zimbabwe is characterized by an absence of data of the nature and volume of the trade, pricing, actors involved and the statistics remain elusive. Thus basing on the analysis of existing literature on traditional medicine consumption there remains a need to identify the main actors in the supply chain of herbal medicine in Zimbabwe, the value addition and pricing at each stage of the value chain.
Findings from the analysis of literature, clearly indicates that questions still remain unanswered on the levels of knowledge possessed by these actors concerning their products. This scenario is further amplified by the lack of a guiding policy and enforced monitoring. The absence of a data base of all herbal medicinal plants traded means that there is no way of verifying trade names with botanical names thus rendering the regulation of the herbal industry in Zimbabwe difficult. This https://doi.org/10.1080/23311886.2018.1440498 therefore means that there is limited knowledge on how those in the value chain of traditional medical practice package, price and market their products. Packaging plays a pivotal role as an extrinsic factor in shaping perception and attitude (Ampuero & Vila, 2006;Grunert, Bredahl, & Brunsø, 2004). However, even though literature emphasises the pivotal role of packaging, it remains to be known how packaging and pricing shapes and influence the perceptions and attitude of the health tourists who consume these herbal substances in Zimbabwe. Thus there is need to intensify research efforts on ethno-medicines value chains in Zimbabwe.

Appropriation in health tourism
The analysis of literature on traditional herbal medicine consumption clearly indicates that it still remains to be known what the term appropriation means in health tourism as the majority of studies in existence define it based on cultural tourism. Literature defines appropriation as the taking of a symbol of cultural practice such as cultural dances, folklore, cuisine, traditional medicine and religious symbols out of its original context (Ortega et al., 2013;Scafidi, 2005). Thus it can be concluded that in appropriation cultural elements are copied and taken outside of their original context. Literature clearly indicates that appropriation is a recurrent theme in heritage based studies but remains understudied in medical tourism based on traditional herbal substances for sexual and fertility enhancement. Thus is can be concluded that the meaning of appropriation in health tourism based upon the consumption of traditional herbal medicines is not well articulated in literature. Further enlightenment is needed through further researches.
Literature indicates that International "bio-prospecting" companies have led to bio-piracy robbing local communities of revenues due to them. Literature further asserts that bio-piracy destroys the natural fabric that stitches together the social livelihoods of traditional healers and local communities. This clearly indicates that there is need to carry out researches that exposes bio-piracy, document traditional herbal practice to put traditional knowledge in the public domain for protection and patenting and appeal to the conscious of the government to attach greater importance to traditional herbal medicine and craft policies and regulations that protect the Traditional Knowledge Systems. Such researches would encourage the creation of a national data base with all the inventories of traditional herbal remedies and encourage innovation in traditional medicine practice.

Who are the herbal consumers: Demography and herbal consumption
The analysis of literature proved that the demographic profile of health tourists who travel for the sole purpose of consuming indigenous herbal sexual stimulants and fertility enhancers remains largely unknown. Tschopp, Fröhlich, Keller, and Axhausen (2003) defines demography as the composition (size, distribution, and structure) and development of population. However despite the definition being too broad, different dimensions of the population such as age, gender, levels of education and levels of income and places of residence amongst a host of others come out. There remains no categorization or classification of health tourists who travel specifically for the consumption of indigenous herbals sexual stimulants and fertility enhancers. Kastenholz, Carneiro, and Eusébio (2005) asserts that despite the burgeoning literature on the issue of health tourism and demography, empirical information about the patients (health tourists) is lacking. Their identity, nature of expenditure and treatment types sought remains a mystery (Yeoman, Hsu, Smith, & Watson, 2011). The demographic characteristics of the health tourist who consume these traditional herbal medicines remain largely unknown. Thus it can be interpreted that health tourism based upon the consumption of traditional medicine has remained on the peripherals of modern research. Very little is known about the demographic profiles of its participants.
Elite studies by scholars such as (Kerstetter, Hou, & Lin, 2004;Master & Prideaux, 2000;Silberberg, 1995) on already established tourism products such as heritage and cultural products have been done and the demographic and socio-economic profiles of the tourists who consume the cultural/ heritage tourism products are known. However, no research study on health tourism for the sake of gaining access to indigenous herbal substances for sexual stimulation and fertility enhancement has profiled health/herbal tourists' in Zimbabwe. Also not much is known about the nature of the tourist traffic whose motivation is the consumption of indigenous herbs for sexual and fertility enhancement, the spending habits and the frequency and method with which they make purchases remains unknown. As a result the, the commercial potential of sexual stimulants and fertility enhancement herbs remains uncharted both for health tourism and the health sector in general in Zimbabwe. Demographic studies help in the understanding of tourist present and future behaviour (Gnanapala, 2015;Ivanovic, 2011;Reisinger & Steiner, 2006;Woodside, Hsu, & Marshall, 2011). Profiling health tourists assists in Destination Marketing Organizations in planning for this form of tourism. It is a niche market that has remained unnoticed over the centuries due to it being overlooked by modern research.

Tourist perceptions and authenticity
The analysis of literature indicates that the issue of tourist perceptions has been well articulated in cultural studies but remains a grey area in health tourism. There remains a dearth of literature on how health tourists who travel for the purpose of gaining access to indigenous herbal substances for sexual stimulation and fertility enhancement perceive issues of authenticity in indigenous herbal substances. Perceptions shape attitudes and according to Chaniotakis, Lymperopoulos, and Soureli (2010) attitudes influence purchase intentions hence important to this study. Perception is defined as the way people, select, organize and interpret stimuli into a meaningful and coherent picture (Gnanapala, 2015;Lamb, Hair, & McDaniel, 2015;Reisinger & Steiner, 2006;Robbins & Coulter, 2005). Thus from the above definition one can deduce that perception forms impressions about a product and therefore shapes the purchase decision-making process of the health tourists. Thus it can be interpreted that how health tourists who travel for the sole consumption of traditional herbal medicine specifically for sexual stimulation and fertility enhancement form impressions and make purchase decisions remains unknown.
Thus in health/herbal tourism the perceptions of health tourists on the authenticity of these substances still remains largely unknown. Studies have been done to profile tourists perceptions related to heritage tourism (Chhabra, 2005;Ivanovic, 2011;Waitt, 2000;Yeoman, Brass, & McMahon-Beattie, 2007). Thus in health/herbal tourism in Zimbabwe, questions still linger about the tourists perceptions of authenticity towards these herbal substances for sexual stimulation and fertility enhancement. Palani and Sohrabi (2013) highlights the importance of authenticity by saying that, it is an "evaluative and decision-making criterion that guides consumer choice". The scholars went on to assert that it is important to discover and comprehend from the tourist's viewpoint the perceived characteristics of authenticity. Mkono (2013) posits that "the concept of consumer need for authenticity is relatively under-studied", much has been done on notions of authenticity only. Thus it can be concluded from the analysis of literature that there is lack of a general understanding of perceptions of authenticity of tourists who participate in traditional health/herbal tourism. Thus it is imperative to undertake studies that document how health tourists construct their notions of authenticity in health tourism that is based on indigenous sexual stimulants and fertility enhancers.

Psychosocial impacts of indigenous sexual stimulants and fertility enhancers
The term psychosocial is a combination of two terms psychology and social (Mendizabal, Hearn, Anderson, & Hodgkin, 2011). The term psychosocial emphasizes the close connection that exists between the psychological aspects of an individual's experience such as emotions, thoughts and behaviour and the social environmental experiences such as relationships, culture and traditions. They define psychology as the internal physical elements linked to the mind such as feelings, thoughts and attitudes, and social as an individual's relationship with the external environment such as family, workplace and in the socio-cultural environment (Baxter, Bordoloi, Dragomir, & Timor). From the definitions above the underlying theme is that of an individual's response to stimuli from the environment. This combination of psychological and social factors determines the psychological wellbeing of an individual (Baxter et al.). The objective draws attention to the totality of health tourists' experiences with health/herbal substances for sexual stimulation and fertility enhancement and how the experiences has a bearing in their relations with the wider world. The term psychosocial emphasizes the need to review these issues within an interpersonal context of wider families and communities in which the health tourists and traditional medical practitioners stay. Thus it can be concluded that there is need for further studies to understand the psychosocial impact of the consumption of indigenous herbal sexual stimulants and fertility enhancers. This increase in knowledge would lead to an increased commercial exploitation of the traditional medicines by local communities.
Modern drugs have had varied success and health tourists travel in search of medical intervention against problems of infertility and sexual dysfunction. Through the analysis of literature, the researcher found that infertility and sexual dysfunction leads to reduced sexual desire, loss of libido and lower quality of life, withdrawal and conflicts in relationships with both family and feelings of psychological distance manifest, isolation, reduced sexual activity and withdrawal from society sets in society (Lara et al., 2015;Pakpour et al., 2016;Pakpour, Yekaninejad, Zeidi, & Burri, 2012;Peterson, Pirritano, Christensen, & Schmidt, 2008). Sexual dysfunction is also known to result in disorders of ejaculation, desire, orgasm, erectile dysfunction, depression, anxiety, traumatic sexual experiences and stress (Cimanga Kanyanga et al., 2016;Moshfegh et al., 2016;Salehi, As' adi, Naderan, Shoar, & Saberi, 2016).
However, it remains to be known how the health tourists respond to the herbal substances for sexual stimulation and fertility enhancement. There remains a gap in knowledge on the psychosocial impacts of indigenous herbal sexual stimulants and fertility enhancers on health tourists consuming the indigenous herbal substances for sexual stimulation and fertility enhancers. Thus it can be concluded that there is need to have a study that seeks to find the psychosocial impacts that come with consuming indigenous herbal medicine for sexual stimulation and fertility enhancement. Herbal medicines besides providing sexual satisfaction are vehicles for family and social cohesion. In Zimbabwe, the area of psychosocial impacts as a result of the consumption of indigenous sexual stimulants and fertility enhancers remains understudied and is characterized by an absence of relevant literature. Thus there is need to have studies that empowers knowledge on the consumption of indigenous herbal sexual stimulants and fertility enhancers. Moreira et al. (2014) asserts that improper consumption of traditional herbal medicine poses psychosocial dangers. Generally literature proves that there is a misconception that natural herbal product because they are natural they are not toxic and that they have no side effects. According to (World Health Organization, 2008b) this misconception coupled with the existence of self-styled healers' results in consumers suffering both physical and psychological damages. However, in Zimbabwe statistics of the psychosocial impacts of traditional medicines remain sketchy hence inviting more research in the area. Pakpour et al. (2012) clearly asserts that for males the ability to perform during sexual performances gives both an identity and a sense of worthy (self esteem). How consumers react to these herbal dosages for sexual stimulation and fertility enhancement remains unknown as literature remains silent on traditional herbal consumption impact. Thus it is imperative to undertake studies in traditional herbal medicine as the herbs have assumed greater importance.

Health tourists and considerations of probable side effects of the consumption of traditional herbal sexual stimulants and fertility enhancers
Literature indicates that many people remain sceptical about traditional herbal medicine consumption due to the limited nature of validated knowledge about the herbs. In Zimbabwe health tourism specifically to obtain herbal substances for use as sexual stimulants and fertility enhancers faces problems in that herbalists provide substances whose pharmacological properties are not scientifically isolated (Ameh et al., 2013;Bodeker et al., 2006;Chauhan et al., 2014;Folashade et al., 2012;Mafuva & Marima-Matarira, 2014;Muweh, 2011;Ojekale et al., 2015). Thus, it can be interpreted that very little is known concerning traditional herbal medicines. It remains to be known how much the traditional practitioners know about the herbs they dispense. Their knowledge and technical knowhow of the herbal practitioners is contestable due to the absence of a scientific validation. World Health Organization (2005) asserts that health professionals, policy makers and health tourists at large still harbour reservations and disbelief about the efficacy and safety of herbal medicine. Thus in order to dispel this long harboured doubts and fears there is need to carry extensive researches to validate these traditional herbal medicines and increase the systematic knowledge at the disposal of consumers.
Content analysis of literature indicates that very little is known about the herbal medicines used for sexual stimulation and fertility enhancement. The appropriate dosages, frequency of consumption, appropriate harvesting methods, storage and the necessary conditions, preparation, administration, chemical compositions which raises questions of safety and efficacy and shelf life remains largely unknown. This directly exposes health tourists to possibilities of poisoning. Mafuva and Marima-Matarira (2014) asserts that the practice of using unclassified traditional medicines in Zimbabwe is not without its risks. The practice poses cytotoxic consequences that are detrimental to the health and wellbeing of health tourists (Bodeker et al., 2006;Folashade et al., 2012;Ifeoma & Oluwakanyinsol, 2013;Kumar, Dobos, & Rampp, 2016;Tagwireyi, Ball, & Nhachi, 2002). Thus it can be interpreted that herbal medicines can also negatively affect consumers despite the being natural hence the need to have scientific validation of their safety and claims of efficacy.
Findings from literature analysis indicates that the existence of cytotoxic chemicals in herbal substances, have long been documented (Folashade et al., 2012;Ifeoma & Oluwakanyinsol, 2013;Kumar et al., 2016;Mafuva & Marima-Matarira, 2014;World Health Organization, 2005, 2008a. There is a gap in knowledge on whether the indigenous herbal substances consumed under health tourism for the purpose of sexual stimulation and fertility enhancement leads to any undesirable physical impacts. Undesirable physical impacts results in dissatisfaction with a tourism product. It remains unknown how health/herbal tourists in light of such uncertainties surrounding herbal tourism consider the possibility of probable side effects resulting from the consumption of indigenous herbal substances for sexual stimulation and fertility enhancers. Thus in light of these uncertainties there is need to carry out a study that dispels these fears and shade light on the issues highlighted as well as learn from other successful regions such as India and China were herbal medicine and herbal tourism has been successfully implemented and the billion dollar breakthrough of the global Pfizer Conglomerate in developing novel drugs from observations made in the traditional medicinal practice.

Conclusion
Research findings from the content analysis of literature indicates that health tourism for the sake of gaining access to indigenous herbal substances for sexual stimulation and fertility enhancement remains an uncharted territory. Much remains to be done concerning the practice and consumption of indigenous sexual stimulants and fertility enhancers by health tourists as the area has generally remained on the peripherals of modern research. Not much is known about the nature of the tourist traffic whose purpose of travel is the consumption of indigenous herbal substances for sexual stimulation and fertility enhancement. Literature strongly indicates that very little is known concerning traditional medicine specifically for sexual stimulation and fertility enhancement. The players in the value chain of traditional medicine remains unknown, and also the demographic characteristics of health tourists who travel specifically for the sole consumption of indigenous sexual stimulants and fertility enhancement remains virtually unknown. Health tourist's perception of authenticity of traditional medicines, appropriation of heath tourism and the psychosocial impact of traditional herbal medicine for sexual stimulation and fertility enhancement remains unknown.
The lack of comprehensive knowledge on the traditional herbal medicine knowledge market indicates that there is need to conduct ethno-botanical studies to provide answers to the pending questions and knowledge gap highlighted and map the way forward on how these traditional herbal remedies can successfully be exploited for both health tourism and drug development for the medical industry in general in Zimbabwe. There is need to carry out research studies that facilitate the collection of statistics to ascertain the magnitude of health patients involved in the consumption of indigenous sexual stimulants, fertility enhancers and other herbal remedies in general. Lessons can be drawn from other successful nations such as India and China that have gone down the same road with much success as seen by the fact that their herbal products now enjoys global success. This review paper is expected to also stir interests in other quarters such as the health sector. Several drugs such as quinine were developed from observations made on traditional medicine practice. The findings from this analysis will increase researches in traditional herbal medicine both for the health tourism industry and the health sector in general. The study contextualizes the continuation of studies in health tourism based on the sole consumption of indigenous herbal sexual stimulants and fertility enhancers. It will act as a guiding compass directing studies on the grey areas that needs further enlightening to extend the frontiers of knowledge in as far as health tourism and herbal consumption is concerned.