Policy mandates for Ayush in National Health Policy-2017: Achievements, impediments, and future prospects

ABSTRACT

The Ayush sector has seen multidimensional growth in the last 10 years, especially since its inception as the Ministry of Ayush in 2014 from the earlier Department of Ayush. This expansion is evident across various facets of the sector, notably reflected in the allocation within the union budget, the surge in exports of herbal medicines, the proliferation of educational institutions, the establishment of integrated Ayush hospitals, and the integration into the broader public healthcare system. The National Health Policy 2017 (NHP-2017) is the cornerstone guiding document for all health-related matters, including Ayush systems. It advocates for transitioning from a standalone to a comprehensive three-dimensional mainstreaming of Ayush services, emphasising the intricate integration of Ayush into the public healthcare system and adopting Ayush-based promotive and preventive strategies for fostering healthy lifestyles. Significant strides have been undertaken in recent years to realise the mandates outlined in NHP-2017. Noteworthy initiatives include the approval of 12,500 Ayushman Arogya Mandirs - Ayush (erstwhile Health and Wellness Centres), the establishment of co-located Ayush facilities across three tiers of public healthcare, the provision for Ayush academic departments in all new and forthcoming AIIMS establishments, and, more recently, the publication of guidelines related to Indian Public Health Standards for Ayush. However, several challenges persist, such as the skewed distribution of Ayush facilities, the non-inclusion of Ayush packages from the Pradhan Mantri Jan Arogya Yojana (PM-JAY), and logistical issues about the supply chain of medicines in co-located facilities. Addressing these challenges is imperative for achieving a seamless integration of Ayush systems into the mainstream public healthcare framework and fulfilling the policy mandate designated to Ayush. Such integration holds promise for contributing to realising universal health coverage, national health objectives, and the overarching goal of health for all. This paper delves into the policy imperatives for Ayush within the public health domain as stipulated by NHP-2017, examining its progress, identifying challenges, and proposing potential solutions.

Introduction

Ayush systems comprise Ayurveda, Yoga and Naturopathy, Unani, Siddha, Sowa-Rigpa, and Homoeopathy. These systems of medicine are well-regulated in India. The Department of Indian Systems of Medicine and Homoeopathy (ISM and H) was established in 1995 under the Ministry of Health and Family Welfare, which was later rechristened as the Department of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy (Ayush) in 2003, which further got the status of Ministry of Ayush (MoA) on 09 November 2014. The sector has seen multidimensional growth in various areas in recent years. India’s total Ayush and herbal medicines exports have increased from US$ 1.09 billion in 2014 to US$ 1.54 billion in 2020, registering a robust growth rate of 5.9 per cent annually.[1] The turnover of the Indian Ayush industry is US$ 18.1 billion as of 17 December 2022, and the market size of the Indian Ayush industry, as a whole, has grown by 17 per cent during 2014–2020. The budget allocation to the Ayush Ministry has risen five times from 691 Cr to Rs 3647 Cr in the last 10 years.[2,3]

The National Health Policy (NHP)-2017 is the guiding policy document of the Government of India for all health-related matters covering both modern system and Ayush systems. NHP 2017 primarily aims to inform, clarify, strengthen, and prioritise the role of the Government in shaping health systems in all its dimensions in terms of investments in health, organisation of healthcare services, disease prevention, and health promotion through cross-sectoral actions, access to technologies, developing human resources, encouraging medical pluralism, building the knowledge base, developing better financial protection strategies, strengthening regulation and health assurance. To systematically understand the progress of the Ayush sector in public health, including primary care, as per India’s Health policy, i.e. the NHP-2017 mandate, it is vital to see the mandates assigned to Ayush in the policy, the progress made so far, and existing challenges. This paper aims to highlight the policy mandate for Ayush assigned in NHP-2017 in public health and the current status of progress made so far. The article also highlights the existing challenges and possible solutions for addressing them.

NHP-2017 has given a specific policy mandate for a more inclusive role of Ayush in public health [Table 1].

Table 1.

Policy mandate (clauses) related to Public health for Ayush in NHP-2017

Policy mandate for Public health for Ayush in NHP-2017
Pluralism	The policy recommends pluralism, defined as “Patients who so choose and when appropriate, would have access to Ayush care providers based on documented and validated local, home and community based practices. These systems, inter alia, would also have Government support in research and supervision to develop and enrich their contribution to meeting the national health goals and objectives through integrative practices.”.
Healthy living and prevention	It promotes healthy living and prevention strategies from Ayush systems and Yoga in the workplace, schools, and communities.
Mainstreaming of Ayush	The policy proposes seven fundamental policy shifts in organising health care services including stand-alone to a three-dimensional mainstreaming of Ayush services. It recommends mainstreaming the potential of Ayush by ensuring access to Ayush remedies through co-location in public facilities and a more comprehensive introduction of Yoga in schools and workplaces.
Comprehensive Primary Healthcare services	The policy recognises the establishment of Health and Wellness Centers. It includes upgrading the existing Sub-Centres and reorienting PHCs to provide a comprehensive set of preventive, promotive, curative, and rehabilitative services. It mandates access to assured Ayush healthcare services and supports documentation and validation of local home—and community-based practices.
Ayush in urban health	The policy prioritises the utilisation of Ayush personnel in urban health care.
Integrated medical care	The policy recognises the need to halt and reverse the growing incidence of chronic diseases. For Ayush, it emphasises developing the protocol for mainstreaming Ayush as an integrated medical care. This has enormous potential for effective prevention and therapy that is safe and cost-effective.
Linkage with ASHA and community platforms	Policy talks about linking Ayush systems with ASHAs and VHSNCs.
Leveraging Digital tools	Policy advocates leveraging Digital Tools for Ayush in terms of utilisation for the generation and sharing of information about Ayush services and Ayush practitioners, for traditional community-level healthcare providers and household-level preventive, promotive, and curative practices.

Achievements made in public health related mandate

• (a) Major public health-related programs/schemes under the MoA:

  • National Ayush Mission (NAM): NAM is a flagship scheme (Centrally Sponsored Scheme) launched in 2014 to strengthen Ayush-based services through increased accessibility and availability in the States.[4]

The budget allocation of NAM has been increased from Rs. 400 crores (2016–2017) to Rs. 1200 crores (2023–2024 Budget Estimates) to ensure effective implementation and fulfilment of its mandate related to cost-effective Ayush services, upgradation of Ayush institutions, and others. Achievements of NAM as of 31 March 2022 are placed in Figure 1.

Figure 1.

Achievements of the National Ayush Mission

To mark 75 years of Independence, the Ayush Ministry initiated a series of lectures for students from over 75,000 Schools and Colleges on popularising the benefits of the Ayush system among Youth.[5] Various target groups related programs have been launched under the NAM like Ayurvidya (school children), Vayomitra (elderly care), etc., [Figure 2]. The provisions in these programs also emphasize primary prevention and primary care for specific diseases and target populations.

Figure 2.

08 programmes recently added under the National Ayush Mission

• Ayushman Bharat Ayush Health and Wellness Centres (HWC): Ayushman Bharat HWC Programme was launched in 2018 to provide a comprehensive range of primary healthcare services with a selective approach to healthcare. It was envisaged that 1,50,000 Ayushman Arogya Mandirs (AAM) (erstwhile Health and Wellness Centres) would be operated by upgrading existing Subcentres (SCs) and Primary Health Centres (PHCs) by December 2022, and the target was achieved within the set time limit. The Union Cabinet, on 20 March 2020, also approved the operationalisation of 12,500 Ayush HWCs by upgrading existing Ayush Dispensaries/Health Subcentre through State/UT Governments under the broad umbrella of NAM in a phased manner with a financial outlay of Rs. 3399.35 Crore for a period of 5 years up to 2023–2024. A total of 11771 Ayush AAMs are functional nationwide as of 14 July 2024. The objectives of this initiative include providing comprehensive primary healthcare through Ayush using a team-based approach and establishing a holistic wellness model based on Ayush principles and practices with a particular focus on preventive, promotive, curative, and rehabilitative healthcare services.[6]

• Ayuswasthya Yojana and Champion Service Sector Scheme: The Ministry is also running Central Sector schemes like Ayuswasthya Yojana with components of Ayush and Public Health, Ayush in sports medicine and up-gradation of facilities to Centre of Excellence and Champion Service Sector Scheme for the Establishment of Ayush Super Specialty Hospitals/Day Care Centres for Medical Tourism (recently discontinued).

• Tertiary care Ayush facilities: The MoA recently established many new and satellite national-level institutions to provide quality education and healthcare services. These institutes have been established in different locations, i.e. Delhi, Shillong, Pasighat, Leh, Goa, Panchkula, and Ghaziabad.

• Indian Public Health Standards for Ayush: The MoA recently published these standards for Ayush dispensaries/AAM and hospitals to define the requirements of Ayush public health facilities as per population norms and service delivery standards.

• (b)Integration of Ayush in the mainstream public healthcare system:

  Integration of Ayush in National Health Programs: Mainstreaming of Ayush is one of the core strategies of the National Rural Health Mission, which seeks to provide accessible, affordable, and quality health care to the rural population. Currently, 7032 PHCs, 2793 Community Health Centres (CHCs), and 484 District Hospitals (DHs) colocated with Ayush facilities out of the total 25937 PHCs, 6349 CHCs and 761 DHs across the country are functional to provide choice to patients for different systems of medicine.[7] Similarly, programs like the National Programme for Health Care of the Elderly (NPHCE) also have the mandate of mainstreaming Ayush – revitalising local health traditions and converging with the Ministry of Social Justice and Empowerment. The MoA, along with the Directorate General of Health Services (DGHS), implemented NPCDCS (National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke) for health promotion, prevention, and management of Noncommunicable diseases or Lifestyle disorders in few selected districts of the country as a pilot project.[8]

• Ayushman Bharat-Ayushman Arogya Mandir program: Under the ambit of this program, one of the key principles is enabling the integration of Yoga and Ayush as appropriate to people’s needs. Yoga is integral to all AAMs. 161831 AAMs are functional as of 14 July 2024. There is a mandate of 10 monthly Yoga/wellness sessions at the AAM. Further, one of the interventions under this program is the weekly (once) conduction of Ayurveda Clinics at AAM, which should be mainly aimed at providing helpful diet counselling, management of chronic aches and pains, elderly care, etc.[9]

• Posting of Ayush Doctors as Community Health Officers (CHOs) at AAM-SCs: Ayush doctors are posted at many AAM-SCs in various States/UTs as CHO. These CHOs have an important role in delivering comprehensive primary healthcare service packages and dispensing modern medicine. However, they were initially not allowed to prescribe Ayush medicines per the AB HWC guidelines. Recently, the Ministry of Health and Family Welfare has also decided to allow the prescription of Ayush medicines by these CHOs and the supply of these medicines through NAM.

• Integration of Ayush healthcare services in health institutions of different Ministries: MoA has signed MoUs with the Ministry of Defence to integrate Ayurveda in the health establishments under the Directorate General of Armed Forces Medical Services (DGAFMS) and Directorate General Defence Estates (DGDE), which has resulted in the establishment of Ayurveda OPDs at 12 AFMS (Armed Force Medical Services) Hospitals and 37 Cantonment Board Hospitals.[10] Apart from these, Ayush services are also available in many Railway, Labour Ministries and Army hospitals.[11] All newly established AIIMS are mandated to undertake Ayush-based clinical activities like OPD and IPD services in these institutions, collaborate with other departments to develop integrative protocols, undertake collaborative research, etc.

• Department of Integrative Medicine at Central Government Tertiary Care Hospitals: The Government of India is establishing the Integrative Medicine Department at Central Government Tertiary Care Hospitals to provide comprehensive and holistic services. Many such departments are already functional, such as the Department of Integrative Medicine at Safdarjung Hospital, New Delhi, AIIMS, New Delhi, NIMHANS, Bangalore, and so on.[12]

• Pradhan Mantri Bhartiya Janaushadhi Pariyojana (PMBJP): Ayurveda medicines have been included in the PMBJP to ensure access to quality Ayurveda medicines for all sections of the population.

• Contribution of Ayush in managing the COVID-19 pandemic: The States/UTs substantially used Ayush HR in different identified roles for managing the COVID-19 pandemic outbreak, and around 28,000 Ayush HR were deployed. The States/UTs extensively used Ayush interventions to mitigate and manage COVID-19. The number of Ayush prophylactic medicines beneficiaries was 9,70,46,305 (approx. 9.7 crores) in 15 States/UTs. In addition, Andhra Pradesh and Gujarat have distributed 22.17 crore doses of Ayush prophylactic medicine. States/UTs have also used Ayush intervention to manage COVID-19.[13]

• School Nutrition (Kitchen) Garden: The Department of School Education and Literacy, Ministry of Education issued guidelines on School Nutritional Gardens in 2019. The primary objective was to help address malnutrition and micronutrient deficiencies by consuming freshly grown vegetables and fruits. The guidelines also include details about medicinal plants and their uses. As of September 2022, more than 4 lakh schools were equipped with Nutrition Gardens.[14]

• Saksham Anganwadi and Poshan 2.0: The Ministry of Women and Child Development’s Saksham Anganwadi and Poshan 2.0 scheme focuses on maternal nutrition, infant and young child feeding, treatment of Moderate Acute Malnutrition (MAM) and Severe Acute Malnutrition (SAM), and wellness through Ayush. The scheme integrates traditional knowledge to prevent diseases, promoting wellness through Yoga, cultivating medicinal herbs in Poshan Vatikas, and using Ayush formulations to address conditions like anemia. MoA is responsible for promoting the ‘Yoga at Home, Yoga with Family’ campaign at Anganwadi centers and homes. Under the Supplementary Nutrition Programme, the MoA is mandated to provide technical support, recommend Ayurveda interventions, and help develop Poshan Vatikas with medicinal plants.[15]

• Integrative Medicine: To promote pluralism and integrative health, the Government of India constituted a committee on August 13, 2020, and subsequently, 04 working groups comprising Education, Research, Clinical Practice, and Public Health were also formed under this committee. The committee was mandated to propose a framework of comprehensive integrative health policy to achieve inclusive, affordable, evidence-based health care and also to suggest recommendations for effective implementation of integrative health care through Education, Research, and Clinical Practice. The committee was also tasked to propose a roadmap for disease prevention and health promotion in national programs based on modern and traditional integrative approaches.[16]

• Ayush Grid: The Ayush Grid platform is envisaged as an IT backbone for all functions and services and for allowing integration of all stakeholders related to Ayush Healthcare Care.[17] From a user’s perspective, Ayush Grid is a central IT platform offering multiple IT services for all systems of medicines under the Ayush ecosystem across functional areas, viz., healthcare delivery, education, research, capacity building, drug licensing, standardisation, and media outreach. Ayush Hospital Management Information System (A-HMIS), National AYUSH Morbidity and Standardized Terminologies Electronic Portal (NAMASTE), e-aushadhi portal, Yoga locator application, Ayush Suraksha, WHO m-Yoga app, Traditional Knowledge Digital Library, Ayush Sanjeevani App and Ayush Research Portal are some of the noteworthy IT initiatives.

Barriers

• Inadequate administrative setup in States/UTs like State Programme Management Unit (SPMU) and District Programme Management Unit (DPMU).

• Dual administrative control over co-located Ayush facilities under NHM; wherein, engagement of Ayush Doctors and paramedics; their training is supported by the Department of Health and Family Welfare, while the MoA supports Ayush infrastructure, equipment, furniture, and medicines under NAM. There is also no defined provision for HR recruitment under NAM, resulting in implementation issues.

• No defined National integrated protocols are available for defining clear-cut instructions or referral pathways among practitioners of different systems.

• There are 3801 Ayush hospitals and 36068 Ayush dispensaries across the country, per the National Health Profile-2023 report. There is a considerable disparity in the availability of hospitals/dispensaries in various States/UTs. The population covered by each Ayush hospital in different States/UTs is roughly around 26000 to 3.8 crore. Further, each Ayush dispensary in various States/UTs covers a population of 3777 to 256043, excluding Manipur, which only has 01 Ayush dispensary for a 3165000 population.

• Integration of Ayush in programmes like National Programme for Prevention and Control of Non Communicable Diseases (NP-NCD) was implemented in pilot mode only. There is a need to institutionalise such programmes.

• Projects sanctioned under Ayurswasthya Yojana have not resulted in high-impact publications.

• Uptake of the Champion Service Sector Scheme for establishing Ayush Super Specialty Hospitals/Day Care Centres for Medical Tourism was minimal and the scheme is discontinued recently.

• Supply of medicine and shortfall of HR: For a long time, irregular medicine supply has remained a core issue in providing quality services in Ayush public healthcare facilities.[18] Shortfalls of HR also adversely affect the quality of service delivery.

• Linkages of AAMs with Ayush facilities: there is no convergence between AAM-SCs and Ayush facilities regarding referrals and teleconsultation.

• Pradhan Mantri Jan Arogya Yojana (PM-JAY): Ayush packages are not included in the PMJAY, which affects access to secondary/tertiary care services through Ayush systems.

• Linkages of Ayush systems with ASHAs and VHSNCs are not uniform in all States and are minimal.

• There is a negligible interface between the information system of modern and Ayush systems of medicine, resulting in two parallel digital structures working in silos. Mechanisms for seamless integration of the Ayush grid in Ayushman Bharat Digital Mission (ABDM) still need to be built. Initiatives like AHMIS are currently limited to the institutes under the Central Government.

Discussion and Way Forward

The substantial efforts of the Government of India to mainstream Ayush are praiseworthy. These efforts have certainly increased the accessibility of Ayush services. However, much attention is needed to fill the gaps as detailed under the heading ‘Barriers’. There are priority areas wherein specific measures need to be taken to strengthen Ayush’s contribution to public healthcare delivery. A whole-of-government approach needs to be adopted for the mainstreaming of Ayush [Figure 3].

Figure 3.

Way Forward: A whole-of-government approach

Areas for improvement

1. Administrative Setup and Coordination:

   • Strengthening Administrative Units: There is a pressing need to strengthen the administrative setup at the state and district levels, including the well functional SPMU and DPMU with adequate resources. This will ensure better implementation, monitoring, and reporting under Ayush public healthcare programs and services.

   • Streamlined Administrative Control: Address the dual administrative control over co-located Ayush facilities under the NHM. Align the engagement, training, and support of Ayush personnel under a unified administrative structure for more coherent policy implementation.

2. Human Resources (HR) and Capacity Building:

   • Recruitment and Training: There is an urgent need to notify and fill vacant Ayush positions periodically. Establish explicit provisions for ongoing capacity building and skill-based training for Ayush HR to maintain high service delivery standards.

   • Shift the engagement and training component of Ayush doctors and paramedics from NHM to the MoA to improve implementation and monitoring efficiency

3. Medicine Supply and Infrastructure:

   • Uninterrupted Medicine Supply: Ensure a regular supply of Ayush medicines. Develop digital solutions similar to the Drugs and Vaccine Distribution Management System (DVDMS) to streamline the supply chain management of Ayush medicines.

   • Infrastructure Development: Implement the IPHS for Ayush facilities in a time-bound manner, requiring additional funding from the union and state governments. This will create a uniform structure of Ayush public health facilities across states and improve access to quality services.

4. National Integrated Protocols:

   • Development of Protocols: Develop national integrated protocols for diseases of national priority. This will provide clear referral pathways and guidelines for practitioners of different systems of medicine, promoting seamless integration and patient care continuity.

5. Inclusion in National Health Programs/Schemes:

   • Expanded Role in Health Programs: Programs like the NPHCE and the NP-NCD should include a more prominent role for Ayush services. This can enhance the effectiveness of these programs through preventive and promotive health strategies.

   • Ayush Packages in PM-JAY: Include Ayush packages in the PM-JAY to facilitate access to secondary and tertiary care Ayush services, and to reduce out-of-pocket expenditures.

   • PMBJP: Increase the number of Ayush drugs in PMBJP to increase the affordability of these drugs in marginalised populations and reduce out-of-pocket expenditure as, at present, only 07 medicines are available in the portfolio of PMBJP.[19]

6. Digital Integration:

   • Ayush Grid and ABDM Integration: Fully integrate the Ayush Grid with the ABDM. This will facilitate evidence-based policy decisions, seamless cross-referrals, and comprehensive data monitoring and evaluation across health systems.

   • Teleconsultation and Outreach: Utilize digital platforms to expand teleconsultation services and outreach programs, making Ayush healthcare accessible to a broader population, especially in remote areas.

7. Policy and Scheme Implementation:

   • Timely Execution of New Initiatives: Execute new initiatives under the NAM promptly, targeting specific groups such as the elderly, pregnant women, children, and adolescents. Ensure close coordination with state governments for effective implementation. Develop standard packages and modules for service delivery and training of the HR.

   • Feasibility Studies for Schemes: Conduct feasibility studies for schemes like the Champion Service Sector Scheme for Ayush Super Specialty Hospitals/Day Care Centres to modify and revamp them based on practical findings and recommendations.

   • Integrative Health Policy: Once finalised by the Government, the Integrated Health Policy will play an essential role in providing holistic and comprehensive services and ensuring a continuum of care. India can be a role model in the field of Integrative Medicine. However, Health and Ayush Ministries/departments at national and state levels need to work in close collaboration.

     Integrate Ayush in Urban health: The Government is now focusing more on Urban Health along with Rural Health. Ayush can play a vital role in Urban health based on the strengths of these systems. WHO Global Traditional Medicine Centre will play a crucial role in integrating Ayush into the mainstream public healthcare system, which aims to support nations in developing policies and action plans to strengthen the role of traditional medicine as part of their journey to universal health coverage.

8. Intersectoral convergence:

   • Enhanced Collaboration: Improve collaboration between Ayush and modern healthcare facilities, especially in urban areas. Integrate comprehensive Ayush services (preventive, promotive, curative, palliative, and rehabilitative) into Army and Railway hospitals, ensuring the posting of skilled Ayush workforce.

   • The School Nutrition (Kitchen) Garden initiative: It needs to be scaled up to saturation. Schools or local administration may also collaborate with Ayush institutions to improve awareness about the use and benefits of vegetables, fruits, and medicinal plants grown in these gardens and in general.

   • Ayush products under supplementary Nutrition programme: In January 2023, the Union Government issued guidelines to States/UTs regarding using Ayush products in supplementary Nutrition. Accordingly, States/UTs must integrate Ayush products under the supplementary Nutrition program in coordination with the State Ayush Departments.

   • Academic Ayush departments at new AIIMS institutions: Ayush departments are integral to all AIIMS as per PMSSY guidelines, with well-defined objectives related to education, public health, and research. However, it is essential to sanction and fill all the posts required for the proper functioning of the Ayush department. Currently, vacancies related to Medical Officers and Senior Medical Officers (Ayush) have been notified/filled by various AIIMS.

9. Community Engagement and Awareness:

   • Leveraging ASHAs and VHSNCs: Strengthen Ayush’s linkages with Accredited Social Health Activists (ASHAs) and Village Health Sanitation and Nutrition Committees (VHSNCs) to promote preventive and promotional healthcare practices.

   • Educational Programs: Expand activities related to Yoga and Ayurveda lifestyle advocacies in schools, colleges, and workplaces to increase community awareness and engagement with Ayush practices.

10. Monitoring and Evaluation:

    • Real-time Monitoring: Leverage digital technologies for real-time monitoring and transparency of Ayush schemes/programs. Fix specific timelines for all procedures to ensure accountability and timely execution of projects. Identify thematic priority areas and publish generic protocols to facilitate investigators. High-impact Publications: Focus on generating high-impact publications from projects sanctioned under schemes like Ayurswasthya Yojana, contributing to the evidence base and enhancing the credibility of Ayush interventions.

The whole-of-government approach and good coordination between different stakeholders will help establish a holistic healthcare model in our country, which can be a model for the world.

Conclusion

The government’s endeavours towards integrating Ayush into mainstream healthcare are commendable. Significant milestones have been attained in recent times, underscoring the growing role of the Ayush system in bolstering public health. This is evidenced by the concerted endeavours of the MoA and State Ayush Departments in fortifying India’s response to the COVID-19 pandemic. The Government is steadfast in its commitment to fulfilling the mandates outlined in the National Health Policy 2017 concerning Ayush, providing unwavering support. However, specific challenges persist, necessitating attention to the seamless incorporation of Ayush into the broader public healthcare framework. Collaborative efforts between the mainstream public healthcare system and Ayush hold promise in advancing Universal Health Coverage and realising national health objectives.

Disclaimer

The views expressed here are solely of the authors and should not be construed as an endorsement from NITI Aayog, Ministry of Ayush, or any other related organization.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.