The Honorable Prime Minister's vision for ‘New India’ endeavoring to empower youth, women and poor is indeed laudable. The ‘New India’ also needs to be a ‘Healthy India’ where its own traditional systems can play a significant role. Ayurveda, Yoga, Naturopathy, Unani, Siddha, Sowa Rigpa, Homoeopathy collectively covered under the Ministry of AYUSH, represent a pluralistic and integrative scheme of health services. AYUSH can play an important role in realizing the dream of ‘New India’ by providing quality healthcare and medical care for its citizens. At present we are witnessing a highly receptive environment where the value of AYUSH systems in healthcare is widely recognized. Many reforms in administration, research strategies, nature of practice and education are already underway at the Ministry of AYUSH.
The National Health Policy (NHP) 2017 has strongly advocated mainstreaming the potential of AYUSH within a pluralistic system of Integrative healthcare. The NHP 2017 uses a new language of ‘medical pluralism’ and re-emphasizes the need for integrating AYUSH in the National Health Mission, research and education. Indeed, the NHP 2017 is the most powerful policy expression of integrative healthcare since independence for which the Ministry of Health and Family Welfare must be congratulated.
The scope of NHP 2017 in the context of AYUSH is very extensive. It generally recognizes medical pluralism as reality in India with an amplified role for AYUSH. It suggests a three dimensional mainstreaming of AYUSH services. NHP 2017 highlights strategies to meet national health goals through protocol driven integrative practices. It highlights importance of scientific evidence for safety and efficacy of AYUSH medicines and practices, and indicates the necessity of capacity building, and critical mass of competent professionals through quality education and training at national and international levels. It is crucial at this time for AYUSH stakeholders to develop a clear roadmap and strategy for effective implementation of NHP 2017.
1. Medical pluralism
It is important for policy makers to clearly understand the fuller implications of medical pluralism in the current environment. Historically, the Indian society has been accommodating of diverse and even foreign knowledge systems and pluralistic in its choices and practice of healthcare. However, post-independence even though the Indian Government legally recognizes seven different systems of healthcare, the health governance and regulatory system is fractured. We, have not designed effective administrative framework in education, research or health services to revitalize the pluralism heritage of India. Right from the Bhore Committee in 1946, national policies have been advocating integrative approaches. However, in reality, a ‘fragmented’ policy of medical pluralism has prevailed. The fragmentation is evident from the fact that seven systems – Allopathy, Ayurveda, Yoga, Naturopathy, Unani, Siddha, Sowa Rigpa and Homoeopathy (AAYUSH) function in silos under different Ministries, Departments, and Councils both under the Central and State Governments. The fragmentation is reflected in the fact that today, there are different medical councils for various recognized systems of healthcare without any synergy or common regulatory arrangements. Developing effective interfaces between medical councils could be an important strategy for promoting pluralism. The Inter Departmental Committee (IDC) constituted by the Department of Health Research (DHR), Ministry of Health and Family Welfare for identifying viable new medical systems/therapies may be very useful for this purpose. This high power IDC chaired by Dr V M Katoch, former Secretary of DHR, includes Secretaries from AYUSH, Health, Medical Education, Legal Affairs, NITI Aayog, Drug Control General, University Grants Commission, Medical Council of India, among few others. It is possible that IDC may encourage collaborations of different Ministries, Departments and Councils to work simultaneously and harmoniously for holistic development.
The idea of pluralism must begin with educational reforms. A long-term strategy involving radical changes in medical education, research, clinical practice, public health and the legal and regulatory framework is needed, to innovate India's public health system and make it both integrative and participatory [1]. This will require systematic efforts to re-design professional medical education by offering a single common undergraduate medical degree in AYUSH by giving minimum required allopathic medical education on par with present curriculum. Additionally, foundation courses on medical pluralism; core courses focused on AYUSH systems may be included, together with electives designed to encourage building bridges between the plural systems. Such common undergraduate degree in will be a hugely innovative solution to develop the required number of doctors in family medicine and public health. Inter and intra disciplinary specializations, and super-specialization could be offered only at the post-graduate levels. This can be a revolutionary change to ensure dignity of AYUSH systems on par with Allopathy as also to bring the required harmony and equity amongst plural systems.
The idea of pluralism suggests the need to develop a common, strategic and focused health research agenda aligned to emerging national needs. Today, five separate research councils develop independent and unrelated research agendas for India's health needs. Health services are the most visible public space for demonstration of pluralism. The current design, structure and functioning of medical services are antithetical to a pluralistic paradigm. Allopathic services have a separate Ministry, much larger budget and administrative machinery. AYUSH health services have an independent Ministry, a miniscule budget and much smaller administrative machinery; yet their numbers of trained medical personnel are comparable. These two ministries and their administration must have common objectives, and a formal interface. Despite the legal status of AYUSH healthcare systems, the insurance sector does not provide adequate coverage for AYUSH systems. The NHP 2017 advises documentation of community based health practices, scientific re-validation of home remedies and their dissemination on digital platforms. In fact, this can serve as the fourth non-institutionalized tier of health services and can reduce the present burden on primary, secondary and tertiary levels of healthcare.
The challenge for both the Ministry of Health and Ministry of AYUSH is to develop an implementation framework to operationalize the NHP 2017. The DHR, ICMR and AYUSH research councils need to have core agenda aligned to NHP 2017. India can take scientific leadership in healthcare only when modern and traditional knowledge systems work together accepting and mutually respecting their respective strengths.
2. AYUSH research for New India
The Center for Complementary and Integrative Health, Savitribai Phule Pune University had organized a symposium and national consultation to discuss the role of AYUSH research for realizing the dream of ‘New India’. The symposium witnessed a unique confluence of experts from modern as well as traditional knowledge systems. The symposium was attended by over 100 experts with diverse backgrounds representing three generations. Key themes of national consultations included intense discussions on NHP 2017 in context to AYUSH research, priorities, capacity building, public health, integrative research and translation. The Opening Plenary was delivered by two Secretaries, Dr Soumya Swaminathan, Director General, ICMR and Secretary, DHR, Ministry of Health and Family Welfare, and Dr Rajesh Kotecha, Special Secretary, Ministry of AYUSH, who shared their vision and commitment for collaborative research and mainstreaming of AYUSH in public health.
Both the Secretaries emphasized research, capacity building, adoption of newer approaches, need for scientific evidence, appropriate study methods, effective use of information technology and the value of trans-disciplinary approach with partnership between and the Ministry of Health and Family Welfare and AYUSH. The resonance between the thoughts expressed by the authorities of both Ministries is an assuring sign for the vision of ‘New India’.
The consensus of the national consultation at Pune was that implementation of NHP 2017 should be done with an Integrative healthcare framework. The potential of AYUSH systems in this frame should be demonstrated by improved health indicators. An AYUSH interface with science-policy-practice is needed to stimulate innovation. The research priorities and funding mechanisms should be optimized and aligned to NHP 2017. Cross-disciplinary training and human resource development schemes should be aimed at producing a critical mass of clinicians and researchers from biomedical sciences and AYUSH systems. Need for ‘AYUSH Health Observatory’, ‘AYUSH IT Mission’ and ‘Team India’ approach was highlighted. The consensus also indicated need to encourage high quality research, ethical practice and improved public health delivery. A white paper based on the symposium consensus and recommendations will soon be published in J-AIM.
3. NITI Aayog action agenda
As this editorial is being written, the National Institution for Transforming India commonly known as NITI Aayog has released its three-year vision of strategy and action agenda for India. NITI Aayog needs to be complimented for preparing and publishing this document. It is a major task aiming to involve experts from diverse disciplines and distill relevant suggestions in a comprehensive document. In such a consultation process, seeking inputs from Indian thinkers, academicians, reformers and other stakeholders remain crucial. Involvement of international experts, lobbies and advocacy groups in our national vision, strategy and action plan exercise must be carried out with great care. The NITI India Action Agenda preface rightly states that “all ministries and departments must progress simultaneously and harmoniously for holistic development”. However, it is very disappointing to note that this good intent has not been sufficiently captured by NITI in actual action.
The health section of Action Agenda focuses on public and preventive health, assurance of healthcare, reforming fiscal transfers from the Centre to states for better health outcomes, accelerating human resource development and improving access to medicines. However, the hubris of Allopathy or modern medicine is palpable throughout the section.
The NITI India Action Agenda has not sufficiently recognized the importance of mainstreaming AYUSH's potential for holistic health. The AYUSH sector seems to have been marginalized. AYUSH is mentioned in relation to need for increasing co-location of AYUSH services in public health system. A bridge course has been proposed for training nurses/AYUSH practitioners to enable them to prescribe essential medicines. These popular recommendations may compromise the identity of individual systems, and encourage a culture of preferred allopathic practice. In the long run, such an approach may be detrimental to scholarship, research and classical healthcare practices. It is strange that the NITI India Action Agenda did not include the need for AYUSH bridge courses to enable allopathic practitioners to deal with NCDs, where knowledge of nutrition and lifestyle is essential.
Empowering nurses and AYUSH practitioners is certainly important for increasing efficiency in the public health system. However, equating AYUSH practitioners with nurses is highly inappropriate. Such comparison not only denies their real value, dignity and effectiveness of the systems they represent, but endorses the disgraceful misconception that AYUSH practitioners are merely a form of cheap labor. Additionally, to address workforce shortages, the NITI India Action Agenda recommended a new three-year course for primary, community and family medicine. Earlier, the High Level Expert Group had suggested a similar strategy for a mid-level healthcare providers, which was criticized by experts [2]. We feel that the NITI India Action Agenda on health needs to be better aligned to NHP 2017, so that the objective of demonstration of the potential of mainstreaming AYUSH can be effectively implemented in the best interest of all people.
The NHP 2017 concludes with a very realistic note stating ‘a policy is only as good as its implementation’. It envisages an effective implementation framework be put in place to deliver on its policy commitments. The three-year NITI India Action Agenda does not appear to provide a roadmap that would promote pluralism effectively as per the potential of various healthcare knowledge systems. Fortunately, concerned Ministries and Departments of Health are functioning simultaneously and harmoniously in the spirit of holistic development. The increased cooperation between AYUSH, ICMR and DHR is reassuring. NITI as a national think-tank must take serious cognizance of NHP 2017 and take steps to explore potential of mainstreaming AYUSH in public health.
To sum up, AYUSH has a major role in making ‘New India’ healthier. For this purpose, policy makers must align their vision and strategies in line with the Indian knowledge legacy, sociocultural aspirations, availability of talented human resource and national priorities. The dream of healthier ‘New India’ can be achieved only with collaborative efforts that bring the scholarship and actions together. In Charaka's words ‘Nothing is impossible for those who have scholarship, thoughtfulness, wisdom, attentiveness, diligence and action’.
विद्यावितर्कोविज्ञानं स्मृतिः तत्परता क्रिया। यस्यैते षड्गुणास्तस्य नसाध्यमतिवर्तते ॥ - चरकसंहिता
4. Editors' declaration
Both the Editors are members of Inter Departmental Committee.
Authors thank Dr Alex Hankey and Dr Girish Tillu for valuable suggestions and edits.
Footnotes
Peer review under responsibility of Transdisciplinary University, Bangalore.
References
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