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Dissociated reality vis-a-vis integrative planning of AYUSH in Maternal Health Program: A situational analysis in Jaleswar block of Balasore district of Odisha, India
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Publication date (Electronic):
20 July 2016
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Abstract
Mainstreaming of AYUSH and revitalization of local health traditions is one of the innovative components of the National Rural Health Mission (NRHM) in the state of Odisha, India. In this study, an attempt was made to assess the potential of collocating AYUSH to improve maternal health services in tribal dominated Jaleswar block of the Balasore district. In addition, the study aimed at unearthing the underlying challenges and constraints in mainstreaming AYUSH and linking it with the Maternal Health Program.
Review of the policy documents and guidelines, both central and state government, was made to assess the implementation of AYUSH in Odisha. Primary data were collected through interviews with AYUSH doctors, district and block level health administrators, and tribal women.
The study revealed the inadequacy of basic amenities, infrastructure, drugs, and consumables in the health centers for integrating AYUSH in the delivery of maternal health services. Analysis of the job chart and work pattern of AYUSH doctors showed underutilization of their specialized knowledge to treat patients. Lack of continued medical education, standard operating procedures for treatment and spatial marginalization made suboptimal utilization of AYUSH services. This is unfortunate given the fact that such regions are economically underdeveloped and already have a distinct orientation toward indigenous health systems. AYUSH, on account of its holistic approach and proven cost-effectiveness, could be a viable option for improving maternal health in the region.
The study concluded that although there is huge scope for integrating AYUSH in Maternal Health Program under the ongoing NRHM, the full potential is yet to be exploited.
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Most cited references13
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Mainstreaming of Ayurveda, Yoga, Naturopathy, Unani, Siddha, and Homeopathy with the health care delivery system in India
India has a population of 1.21 billion people and there is a high degree of socio-cultural, linguistic, and demographic heterogeneity. There is a limited number of health care professionals, especially doctors, per head of population. The National Rural Health Mission has decided to mainstream the Ayurveda, Yoga, Naturopathy, Unani, Siddha, and Homeopathy (AYUSH) system of indigenous medicine to help meet the challenge of this shortage of health care professionals and to strengthen the delivery system of the health care service. Multiple interventions have been implemented to ensure a systematic merger; however, the anticipated results have not been achieved as a result of multiple challenges and barriers. To ensure the accessibility and availability of health care services to all, policy-makers need to implement strategies to facilitate the mainstreaming of the AYUSH system and to support this system with stringent monitoring mechanisms.
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Status of Indian medicine and folk healing: With a focus on integration of AYUSH medical systems in healthcare delivery
Shailaja Chandra (2012)
Summary Ministry of Health and Family Welfare, Government of India commissioned a former Union Secretary of Department of AYUSH, Shailaja Chandra, to give a status report on Indian medicine and folk healing. Part I of the report was submitted to the Government in September 2011. It covered generic issues relating to the status of Research, Education, Practice, Medicinal Plants, and Drugs specifically relating to the functioning of the Ayurveda, Siddha, and Unani systems of medicine. The focus of the report was on the benefits that the public had received through the systems. Part II of the report was submitted to the Government in February 2013. This report described in this summary focuses on the health seeking behavior of consumers, the prevailing government policy on the integration of several legally recognized medical systems and the widespread use of Ayurveda and Unani medicine as adjuvant therapy. At the center is the current status of integration of these medical systems into health-care delivery as envisaged by Government policy, particularly enunciated under the National Rural Health Mission (NRHM). The report describes visits to central institutions, colleges, and health facilities in five states in the country along with detailed observations on positive developments as well as visible gaps that require to be filled. There are separate chapters on the status of post-graduate education, AYUSH state pharmacies and the regulatory frame-work and legal status of cross practice by AYUSH practitioners. The efforts made to document the current folk healing practices in the North-East states and to provide limited enrolment and recognition to local healers has been recounted. The use of Ayurveda in the veterinary sector has also been covered in an independent chapter. A few promising initiatives, which bring hope of greater recognition have been touched upon. Finally, the transformation needed by focusing on priorities, which can bring rich returns forms the concluding chapter of the report. There are detailed recommendations at the end of each chapter and these deal with measures needed to strengthen integration in a rational and efficient way. The growing tendency seen in a range of patients to resort to the adjuvant use of Ayurvedic and Unani medication for a variety of reasons has been discussed at length with several recommendations that advise the issue of guidelines on using certain drugs in combination, the need for patient counseling and for drawing up protocols for physicians to follow. Several suggestions have also been made for better integration and understanding among medical administrators and professionals. Recognizing the ground realities where AYUSH doctors recruited under NRHM are quite often functioning as the sole in-charge of Primary Health Centres (PHC) particularly in remote areas, the emphasis in the report is on equipping them properly if they are expected to provide primary level acute and emergency care. However, the fact that they have been primarily recruited to provide AYUSH health-care services has also been underscored. The recommendations also include strengthening post-graduate education both quantitatively and qualitatively and to increase a requirement for rigorous and independent research the quality of which needs to be judged by publications in reputed journals-something that continues to be ignored (with a few exceptions). The need for greater refinement in the overall administration of Panchakarma therapies has been commented upon followed by several recommendations on the need to take up effectiveness studies before eventually moving to the establishment of a Center for Scientific Research in Panchakarma (CSRP) to undertake joint research on changes in physical parameters that occur when different procedures are undertaken. Chapter-wise Synopsis of the Report - Part II This report contains 12 chapters. The genesis of each chapter and noteworthy features and key recommendations that stand out are summarized below. Chapter I: Status of integration This chapter has four subchapters dealing with Health seeking behavior and medical pluralism Congruence of traditional and modern medicine Status of adjuvant use of Ayurveda and Unani medicine Contemporary Ayurveda and ethical marketing of Ayurvedic drugs. The first subchapter gives an account of what is known through surveys and reports, which describe public preferences for traditional medical treatment in different settings. It shows how dispersed and sporadic past efforts have been which demands that regular, representative surveys be undertaken to provide an objective analysis of consumer preferences including the widespread adjuvant use of Ayurveda, Unani, and Siddha systems to support allopathic treatment. The second sub-chapter gives an account of the efforts made by the World Health Organization which had recommended harmonization of traditional medicine into the dominant medical systems of each country. The chapter highlights the policy prescriptions of the NRHM and the Department of AYUSH on mainstreaming AYUSH into the delivery of health services. The extents to which the recommendations have been implemented by various states have been commented upon with particular reference to the functioning of co-located facilities and the utilization of contractual doctors appointed under NRHM. The third subchapter contains details of a brainstorming, which was organized by the Principal Investigator (PI) under the aegis of the Central Council for Research in Unani Medicine and supported by the Central Council for Research in Ayurvedic Sciences (CCRAS) to decide upon the priorities for Part II of the status report. The subchapter recounts the outcome of the meeting with Ayurvedic and Unani experts who described their experiences with the adjuvant use of Ayurveda and Unani medicine in different settings – both government and in the private sector. It also describes how the suggestions made at the meeting were taken forward by organizing a special survey comprising of 2000 patients that came to avail of treatment in 6 Ayurveda and 4 Unani hospitals located in different parts of the country. This subchapter also deals with the responses and viewpoints expressed by modern medicine experts as well as numerous physicians working in settings like dispensaries of the Municipal Corporation of Delhi, the Employees' State Insurance (ESI) Corporation, the Ayurvedic and Unani Tibbia College, Delhi, the faculty of a leading Ayurvedic college in Himachal Pradesh together with the views of a modern medical specialist exposed to Ayurvedic therapeutics. It brings out each physician's experience and advice in the form of written responses. The subchapter also presents a detailed interview with an Ayurvedic doctor responsible for providing integrated medical treatment in the super specialty corporate hospital conglomerate called Medanta, at Gurgaon. In this interview, a new way of integration has been described through an interview with the Senior Consultant (Ayurveda) and Coordinator in the Department of Integrative Medicine. The interview brings out the manner in which patient preferences have been elicited and taken into account. Furthermore, how the initial negative reactions, which were encountered from modern medicine specialists were overcome. There are many lessons to be learnt from the example, which has successfully prevailed over barriers to integration which exist elsewhere. The fourth subchapter gives an overview of efforts made by the private sector to widen the use of Ayurvedic drugs. The growth in sales of Ayurvedic products with a focus on the modern medicine practitioners has been referred to. Interviews with key professionals working in the Himalaya Drug Company (HDC) have been presented, which gives an idea of how their strategies have successfully broken barriers to integration, which are seen elsewhere. A detailed interview with professionals working in HDC has been recounted by summarizing those strategies that appear to have made the difference. The overall recommendations include the need for independent surveys on the utilization patterns of the AYUSH systems; need to convince Government health and medical administrators about government policy on the integration of AYUSH systems; the need for formulating standard responses and guidelines for treating critical areas where a combination of therapies are used; the need to facilitate referrals for AYUSH treatment; the need to produce standard promotional literature on the benefits of AYUSH and the availability of services. Recommendations on the need for measuring the contribution of contractual AYUSH Doctors when they provide AYUSH services and also perform modern medicine functions (a trend which is quite widespread) has been highlighted so that the output is differentiated and measured. In this context, since there is no domain expertise on the functional requirements of AYUSH available with the NRHM managers there is a recommendation to use the extensive human resource capacity available in the existing non-NRHM facilities to provide oversight for the NRHM related AYUSH work. Likewise, the need for supervision of AYUSH drug supplies which were found to be universally in short supply has been dwelt upon. A contentious issue, which has still to be confronted remains the need for equipping AYUSH doctors appointed under NRHM to perform the functions of the in-charge of government health facilities, which includes the provision of primary level emergency and acute care. This has been commented upon with examples and concrete suggestions on what is feasible and should be implemented within the law that governs such dual practice. The near absence of interaction between modern medicine and AYUSH doctors has been described bringing out what is essentially needed if the patient's welfare is to be kept uppermost in view. Finally, there are several initiatives taken by the private sector in the area of integration and drug production aligned to contemporary Ayurveda. The recommendation is to selectively recognize and build upon such initiatives as they represent consumer choice and market response. Chapter II: AYUSH in selected states – Findings from field visits In this chapter, the observations during the Principal Investigator's visits to the States of Odisha, Uttar Pradesh, Andhra Pradesh, Himachal Pradesh and Jammu and Kashmir have been recounted. The text is supported by photographs, which display interesting facets of the therapeutic work done in different state run as well as small private facilities. There is a detailed account of official meetings with the Principal Secretaries and senior officers of the AYUSH Departments in the States. The focus in this chapter is on the benefits that the public seem to be receiving from the policy of mainstreaming AYUSH. There is also a brief account of States that could not be visited, but which were consulted on the basis of a questionnaire. Different recommendations are made for bringing about greater efficiency and coordination keeping the local situation of each state. Chapter III: Post-graduate education in Ayurveda – Filling the gaps This chapter shows the views of a leading exponent of Ayurveda and his criticism that post-graduate medical education in Ayurveda has not been developed adequately, which is impacting on the future of education, research, and practice. The report gives the status of Post Graduate (PG) education together with suggestions on steps that could be taken to improve the situation in the short term. These include conducting a needs assessment study for projecting the future need for post-graduates, suggestions for increasing PG seats in under-represented specialties, the need for introducing accreditation systems for AYUSH Colleges, overseeing the competencies and contemporary outlook of retired faculty before granting extensions mechanically. Chapter IV: Building credibility for Panchakarma This chapter recounts the manner in which Panchakarma treatment is being provided in different facilities with special reference to the important areas that need attention while administering the procedures. The need for research studies, which establish the effectiveness and efficacy of Panchakarma therapies, has been emphasized after which studies to identify how the mechanics of how Panchakarma procedures work can follow eventually. The chapter shows why a beginning needs to be made by first establishing the effectiveness of the therapies arguing that if this is not carried out, the status of Panchakarma will be confined to mere claims and a promising opportunity would be lost. The pragmatic route that needs to be followed has been described in consultation with experts. Important recommendations made include the need for standard operating procedures, encouraging accreditation for Panchakarma Centers, undertaking effectiveness studies in a rehabilitation Institute like the All India Institute of Physical Medicine and Rehabilitation (Mumbai) before aiming for the establishment of a CSRP have been given in the form of a short and long term road map. The promotion of Panchakarma on the lines of Chinese Acupuncture has been recommended with specifics on how this needs to be carried out. Finally, the need for prescribing standard duration and list of procedures for Ayurvedic Panchakarma parlors has been suggested to preserve the fair name of Ayurveda. Chapter V: A study of selected state pharmacies The state pharmacies had been established mainly to be able to provide a continuous supply of AYUSH medicines to the government health facilities (hospitals and dispensaries). Keeping this background in view, the PI took note of the persistent and the large-scale shortage of Ayurvedic and Unani drugs, which was apparent everywhere. She commissioned a quick survey to give an indication of the scope for improving the capacity utilization of the state pharmacies and the feasibility of attempting to upgrade them. The chapter recounts details of a survey conducted in different states where four faculty members from the Department of Rasa Shastra and Bhaishajya Kalpana of the National Institute of Ayurveda visited eight state pharmacies and gave their findings. Suggestions have been made for better capacity utilization and for considering the establishment of more joint sector projects which could bring much-needed efficiency and increased output from the state pharmacies. This would avoid too much dependence on Central supplies or procurement from public and private sector manufacturers who fail to supply the drugs on time. Chapter VI: Regulatory framework for Ayurveda-Siddha-Unani drugs This chapter has three subchapters. Major milestones crossed Improving quality control and enforcement - current developments and future prospects Legal status of cross practice. In the first sub-chapter, the focus is on two aspects, which relate to drug licensing and quality aspects of production of AYUSH drugs. First, the key modifications and amendments that have been made in Drugs and Cosmetics Act, 1940 and the accompanying rules and regulations in respect of Ayurvedic, Unani and Siddha drugs have been tabled at one place. Thereafter, the efforts made to promote quality control and to address safety concerns have been recounted also showing how in the absence of policy guidelines on research protocols the need for producing and publishing well-documented research still remains optional and often disregarded. The manufacture and sale of most drugs has been continuing based on their common usage for thousands of years. Although, this is legally permissible, such an approach continuing over decades has militated against the need for conducting research, which could provide data to show how and to what extent the drugs and therapies are effective. The chapter also gives the position in respect of new categories of drugs which have been introduced through recent measures. In the second subchapter, there is a mention of the five subcommittees set up under the ASUDTAB (Ayurveda Siddha Unani Drugs Technical Advisory Board [under the Drugs and Cosmetics Act 1940]) and their terms of reference. For the first time, safety studies and evidence of effectiveness studies are proposed. The status picture has been referred to and the progress given to the PI has been recounted. The third sub-chapter gives an overview of judgments which have been pronounced on the issue of cross practice by AYUSH practitioners, the orders issued by the state governments and the new thinking that is going on in the state of Maharashtra. There is a reference to whatever documentation could be collected from a different state government showing that there continues to be wide variation between the approaches followed by different states in permitting the practice of modern medicine. This chapter needs to be read in conjunction with Chapter II – AYUSH in selected states - Findings from field visits. Chapter VII: Guru-Shishya Parampara – A critique of the Rashtriya Ayurveda Vidyapeeth In this chapter, the current status of this unique institution has been described based upon the findings of a survey which was administered by the PI through questionnaires sent to the Gurus and the Shishyas independently. The extent to which a selection of the Gurus and Shishyas has been carried out objectively and whether the experiment is leading to positive outcomes by way of imbibing practical skills has been commented upon, based upon the responses received. Since there were two earlier committees, which had given reports on this institution, the extent to which their recommendations have been given effect to have also been commented upon. Several recommendations have been made which include the need to open a window for formal recognition of the certificates awarded by the Institute. Different models for reinventing the Institute and augmenting its aims and objectives have been made chiefly to enable it to respond to demands for exposure courses coming from within and outside India. In addition, the scope for RAV to be given the responsibility to act as a functional body to regulate and conduct courses for AYUSH para-medical education has been dwelt upon until such time as a Council for setting standards comes up. Chapter VIII: National Institute of Indian Medical Heritage – A historical overview and major contributions This chapter describes a unique institution under the CCRAS. In the status note the historical background of this institution, which is one of the earliest institutions set up for studying the history of medicine has been given. This emanates from the advice of eminent medical historians and others from the renowned Johns Hopkins University in Baltimore USA. The manner in which the institution has been working primarily in the area of documenting the result of historical research has been brought out along with a summary of publications in different fields. The current work in hand has also been described along with efforts made to provide access to information and documentation through the Internet. Chapter IX: Folk healing practices of the North-East In this chapter, the folk healing practices of eight states in the North East, namely Arunachal Pradesh, Assam, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim and Tripura, have been recounted. The report is based upon field surveys conducted by academic and teaching institutions selected by the North-East Institute for Folk Medicine, which functions under the Department of AYUSH and based upon the requirements given by the PI. The current use of folk healing practices has been described supported by photographs and details of the healers and the conditions they treat. Efforts that have been made to document the knowledge and also to enroll some healers and to give their work initial legitimacy have been described. Chapter X: Ayurvedic veterinary products – Status and future prospects Based upon a paper prepared by a well-known pharmacist and supplemented with published data, the chapter gives an overview of the veterinary sector and the role that Ayurvedic medicine presently plays within that. The chapter brings out the scope for the development and propagation of Ayurvedic veterinary medicine and highlights the role that needs to be played by the AYUSH Drugs Sector and the Department of Animal Husbandry, Ministry of Agriculture. The chapter describes how there is not only commercial scope but an immense opportunity for Ayurveda to fill the growing search for antimicrobials, which do not lead to multi-drug resistance and more importantly do not require the use of synthetic additives, which have a harmful effect upon the quality of milk, poultry, eggs, and meat. Chapter XI: Initiatives with a difference This chapter describes two specific initiatives that are being pursued through the scheme titled “A Science Initiative in Ayurveda” and the “Vaidya-Scientist Fellow Program.” These two initiatives have been selected because for the first time there is a movement away from a 40-year focus on drug discovery, drug development, and standardization, to understanding the fundamental concepts of Ayurveda, seen through the lens of pure science. The two initiatives recounted in the chapter carry a hope that a completely new way of understanding Ayurveda might emerge and may also help bridge the chasm between pure science and Ayurvedic concepts. Chapter XII: Transformation needed In this chapter, five suggestions have been made which it is felt could bring about much needed transformation and also build credibility for AYUSH. Studying Integration in China Although several delegations have visited countries like China as well as the US and South America, the report emphasizes the need to send a delegation of health systems managers to visit China to understand the success of TCM at different levels of health-care delivery; to observe how integration takes place at various levels in the health facilities and to prepare a roadmap, which would be of relevance to the primary and secondary health sectors in India. Promoting Research under the Aegis of National Centre for Complementary and Alternative Medicine A suggestion has been made on the need to undertake a search of projects funded by the NCCAM of the National Institutes of Health in the US to analyze the subject areas and the conditions under which researchers from other countries have availed of research grants. The need for involvement of ICMR to be able to prepare an acceptable standard of research proposals has been emphasized. It has also been suggested that under the existing regulations that are available for conducting collaborative medical research with foreign research institutions, a few projects that fall within the contours of the standing policy administered by the Ministry of Health and the Ministry of External Affairs need to be taken up. Promoting High Quality Research and Publications The chapter alludes to the main weakness of the AYUSH system, which is the lack of high quality published research. It bring out immense scope for collaborative research to be done and the need for proactively encouraging institutions and researchers outside the government system by facilitating collaborative projects in allopathic and other institutions. Likewise, the need for giving sustained financial support to high quality journals has been emphasized. Acting against Exaggerated Advertisements that make Medical Claims The report brings out the failure of state governments to take deterrent action against the large-scale use of the unacceptable medical claims about cures that are being spread through websites, social network sites and in the print media. The fact that institutions and individuals are making claims, which are prohibited by law, has been brought out. Suggestions have been made as to how this can be tackled so that at least the public has an avenue and an opportunity to check on the reliability of what they read about. More specifically suggestions have been made to establish a toll-free number to provide correct information and for involving the Press Council of India when transgressions in advertising norms are observed. Uniform Policy on Reimbursement of AYUSH Treatment A recent case of an injured and incapacitated NSG commando who was paralyzed and received Ayurvedic treatment but could not get reimbursement for the expenses incurred has been described. A case has been argued for following a uniform policy by treating cases of rehabilitation of government employees who suffer injury while performing duty and to treat them as a separate category and to entitle them to avail of Ayurvedic treatment in a facility of choice. On a general note, the need for the Department of AYUSH to convince all Ministries and Departments to reimburse medical expenses on AYUSH treatment of employees in respect of specific conditions has also been put forth. Note: The report is available on following link: http://reporttraditionalindianmedicine.blogspot.in/p/blog-page.html
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Less equal than others? Experiences of AYUSH medical officers in primary health centres in Andhra Pradesh.
J Lakshmi (2016)
The National Rural Health Mission (NRHM) includes, inter alia, the establishment of an AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy) component (practitioner, trained assistants, drugs and equipment) in every primary health centre (PHC). However, five years following the launch of the NRHM, the AYUSH mainstreaming scenario is below expectations, riddled with ethical and governance issues. Accounts from AYUSH practitioners at PHCs in various regions of the state of Andhra Pradesh reveal enormous lacunae in implementation: unfilled positions, inequitable emoluments, inadequate or absent infrastructure, assistance and supplies, unethical interpersonal arrangements, and limited support from non-AYUSH personnel. The widespread negative impact of these conditions undermines the value of AYUSH, demotivating both practitioners and patients, and failing to provide the intended support to the public health system.
Author and article information
Contributors
Ranjit Kumar Dehury
Journal
Journal ID (nlm-ta): J Ayurveda Integr Med
Journal ID (iso-abbrev): J Ayurveda Integr Med
Title:
Journal of Ayurveda and Integrative Medicine
Publisher:
Elsevier
ISSN
(Print):
0975-9476
ISSN
(Electronic):
0976-2809
Publication date PMC-release: 20
July
2016
Publication date
(Print):
Apr-Jun 2016
Publication date
(Electronic):
20
July
2016
Volume: 7
Issue: 2
Pages: 124-131
Affiliations
Author notes
[∗
]Corresponding author. Department of Health Care Management, Goa Institute of Management,
Panaji, Ribander Campus, 403 006, Goa, India.Department of Health Care ManagementGoa
Institute of ManagementRibander CampusPanajiGoa403 006India
ranjit@
123456gim.ac.in
Article
Publisher ID: S0975-9476(16)30133-4DOI: 10.1016/j.jaim.2015.11.003
PMC ID: 4969268
PubMed ID: 27450758
SO-VID: 0908988a-9d7e-40b7-92a1-20e121469dd4
Copyright © © 2016 Transdisciplinary University, Bangalore and World Ayurveda Foundation. Publishing
Services by Elsevier B.V.
License:
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
History
Date
received
: 24
August
2015
Date
revision received
: 15
October
2015
Date
accepted
: 14
November
2015
Categories
Subject:
General Article
ScienceOpen disciplines: Complementary & Alternative medicine
Data availability:
ScienceOpen disciplines: Complementary & Alternative medicine