It was estimated by the World Health Organisation that during the eighties, “in many countries, 80 per cent or more of the population living in rural areas (were) cared for by traditional practitioners and birth attendants.” The decades that followed saw an unprecedented expansion of biomedicine/western/modern medicine (often called “Allopathy”), and the proportion of the population in rural areas of low and middle income countries cared for by Traditional, Complementary and Alternative Medicine (TCAM) came down significantly. Yet, in large countries like India and China, TCAM still wields considerable policy influence.
In 2015, TCAM in China accounted for 16 per cent of total medical care, up from 14 per cent in 2011, as The Economist observes. In India, TCAM accounts for a much lower proportion of overall medical care — data from National Sample Survey in 2014 indicates that only 6.9 per cent of patients seeking outpatient care opted for TCAM. In the case of hospitalised care, the proportion less than one per cent. Both Indian and Chinese health systems privilege biomedicine over TCAM, but the latter is recognised by the state and receives sizable state support.
In addition, its low penetration within the Indian population has not prevented TCAM — AYUSH (covering Ayurveda, Yoga and Naturopathy, Unani, Siddha, Sowa Rigpa and Homoeopathy) as it is known in India- getting a separate central ministry in India in 2014. The AYUSH Ministry is responsible for policy formulation, development and implementation of programmes for the growth, development and propagation of TCAM medicine and treatment.
The first National Health Policy of India (1983) had observed that planned efforts should be made to dovetail the functioning of the practitioners and integrate services across different systems of medicine in the overall health care delivery system, especially with regard to the preventive, and public health objectives. It also noted that well-considered steps need to be taken to move towards a meaningful phased integration of the TCAM and the modern medicine systems. However, at a functional level, such integration did not happen in India, culminating in a separate ministry for TCAM, thus formalising the creation of a parallel structure in an already fund-starved sector.
The Chinese experience
Indian and Chinese health systems have interesting parallels — as Roemer (1991) observed, one of the first steps India took after independence in 1947 was to develop, with foreign advice, its own plants for producing drugs. Interestingly, China also did the exact same thing after the social revolution in 1949. Policy influence of TCAM is another striking similarity. However, what China strived to achieve through its health policies over decades was to integrate TCAM seamlessly within the overall health care delivery infrastructure.
Raffel (1984) shows that China’s health policy has been unique in the developing world as it tried to organise its health system around four basic principles in delivering health care services to its people:
- Put prevention first,
- Combine western and traditional medicine,
- Combine health with mass movements, and,
- Concentrate on rural areas.
Within these guiding principles, China proceeded to find solutions to the severest problem facing the health system: the shortage and disproportionate distribution of medical human power. The Chinese strategy was to distribute the scarce resources as widely as possible and to substitute less skilled labour for capital and skills that are more advanced. While a component of this Chinese approach, which considerably expanded access to health care featuring “barefoot doctors” is still widely talked about, the equally important TCAM component is often overlooked.
The TCAM physician in the Chinese case, served as a complement to physicians trained in modern medicine. Along with separate hospitals and clinics for TCAM (Figure 1), special wards within existing facilities were created, which helped increase health care utilisation.
Figure 1: Development of TCAM hospitals in China
China’s integration of TCAM into the national healthcare system was driven by the national planning need to provide comprehensive healthcare services to the general population. Traditional medicine was also viewed as part of an imperial legacy to be replaced by a secular healthcare system where TCAM was harmonised with modern medicine. Officials trained in modern medicine guided this process of integration. They followed a science-based approach to the education of traditional Chinese medicine, placing an emphasis on research.
Indian initiatives towards integration
While co-location of TCAM facilities within government hospitals practicing modern medicine is quite common in many Indian states, it was only as late as 2005 that India formally tried“mainstreaming of AYUSH and revitalisation of local health traditions” as part of the National Rural Health Mission (NRHM). However, apart from their role in implementation of national health programmes, the TCAM and modern medicine systems have not been harmonised, and the “choice of treatment system” was left to the patient.
While TCAM and modern medicine stay as separate watertight compartments in theory, in practice, things have been quite different. As a system reeling under severe staff shortages (Figure 2), TCAM professionals practicing modern medicine on the frontlines is often unavoidable. However, the significant contributions of TCAM professionals in government hospitals in India are unreported, as they are not supposed to — strictly speaking — practice modern medicine.
Figure 2: Doctor shortages in Indian public hospitals: 2017
Additionally, there is the very real risk of an untrained hand, however experienced she or he may be in practicing and prescribing modern medicine, causing harm to patients. Nevertheless, it occurs and the government acknowledges it. A study conducted under the Ministry of Health and Family Welfare (MoHFW) states: “Where there is no other doctor, they (AYUSH doctors) practice both Allopathy and AYUSH. This is specially marked at the PHC level in most states.”
Government reports often acknowledge that in many hospitals, although the service is provided by a TCAM doctor, data is reported under the name of some other doctor practicing modern medicine “for legal reasons.” Such ‘invisibilisation’ of the significant contribution of TCAM professionals to the health system is deeply problematic and unethical. Modern medicine and TCAM, which represent professionalised and codified medical systems need to be dovetailed, and the practice integrated in a way that will maximise access and clinical outcomes, keeping in mind national health goals. This makes a scientific approach inevitable. The ongoing Double-Blind Placebo-Controlled Clinical Trial under the Central Council for Research in Ayurvedic Sciences (CCRAS) of an Ayurvedic cure for Dengue is a very interesting development in this direction.
Health being a state subject adds an extra layer of complexity to any national level initiative. Indeed, there are states like Maharashtra who have adopted a realistic approach where TCAM professionals are allowed to practice modern medicine and prescribe drugs, after completing a one-year course. There is strong resistance to any such initiative by professional bodies representing modern medicine.
There are states like Maharashtra who have adopted a realistic approach where TCAM professionals are allowed to practice modern medicine and prescribe drugs, after completing a one-year course.
Unfortunately, any effort by the central government to improve health access leveraging TCAM, taking a cue from the experiences such as China’s have been blocked by strong interests. The National Medical Commission Bill, 2017 tried to introduce specific educational modules or programmes for developing bridge courses across various systems of medicine thus promoting medical pluralism, but faced stiff opposition. Soon thereafter, a parliamentary panel on health recommended the government scrap the proposal for the bridge course to allow AYUSH practitioners practice modern medicine citing patient safety.
However, studies prove that for any policy initiative safeguarding patient safety, streamlining the system of modern medicine itself should be the first step. After all, a World Health Organisation (WHO) study using the 2001 Census data discovered in 2016 that in 2001 nearly one-third of the practitioners calling themselves ‘allopathic doctors’ in India were educated up to only secondary school level, and 57.3 per cent of them did not have any medical qualification. In rural areas, only 18.8 per cent of ‘allopathic doctors’ had any medical qualification.
Ayushman Bharat as the way forward
With National Family Health Survey 4 showing that important indicators like full immunisation coverage are improving at a sluggish pace, it is supremely important to have a health workforce that has a shared understanding of national health goals, a common approach and scientifically proven tools. A fragmented system, with a possibility of different sections of workforce working at cross-purposes is a risk that needs addressing.
China successfully achieved universal health insurance coverage (UHC) in 2011, culminating an effort, widely known as “the largest expansion of insurance coverage in human history.” As India strives to reprise it, and achieve UHC through the ambitious Ayushman Bharat initiative, lessons from China’s TCAM approach, which is called “interpenetrative pluralism” by scholars may prove valuable. Like China has demonstrated, integration of TCAM into the national health care system needs to be accompanied by an integrated training of health practitioners, and both need to be officially promoted for optimal impact.
After a scientific process of integration, TCAM could have a considerable role in the proposed Health and Wellness Centres (HWC) across the country in preventing and managing non-communicable diseases. Adding TCAM procedures in the benefit package for the National Health Protection Mission (NHPM) may offer a significant opportunity to harmonise TCAM with modern medicine.