Traditional, complementary and integrative healthcare: global stakeholder perspective on WHO’s current and future strategy

Findings

Countries report that the most common challenge with regard to implementing the WHO TM Strategy was insufficient research data.5 Seventy-five countries acknowledged having national research centres for TCIH and 12 reported providing public funding to TCIH research.5 In a major development, WHO and the government of India launched a new WHO Global Centre for Traditional Medicine in June 2022. The centre is still being set up in Jamnagar, India and will have a focus on evidence and learning; data and analytics; sustainability and equity; innovation and technology.10

Discussion

Research and evidence to support healthcare decisions is critical.

While there is a growing body of research on TCIH as indicated by over 26 000 clinical trials on complementary therapies in the Cochrane Central database (MeSH term search on 13 September 2023) and 975 Cochrane complementary medicine-related reviews,11 the scope of the available data is not commensurate with the widespread TCIH use, nor its complexity and diversity.

There is a striking contradiction in the sense that various countries that emphasise the need for more research, fail to invest in the required research.

Another challenge is research methodology. Most TCIH practices are complex systems of theory and practice with a long history of established use.12 While the number of therapies, products and indications to study in TCIH can be daunting—with each TCIH system (eg, anthroposophic medicine, Ayurveda or Naturopathy) potentially including a wide variety and number of therapies and products13—choosing a research design that accurately reflects the specific TCIH practice can be challenging. Research on acupuncture, as an example, require consideration of various issues—many of which are not factored into standard research protocols14:

• Complexity and variability of the intervention, for example, different acupuncture location methods, needle manipulation techniques, number of treatment sessions.

• Individualised nature of treatment prescription, and use as part of combination of treatments

• Importance of practitioner expertise.

• Contextual factors such as the patient–practitioner interaction and patient expectations.

• Adequate controls, that is, sham acupuncture as a placebo can itself have therapeutic effects.

Guidance has been developed to address these challenges for acupuncture trials15 and efforts are made in identifying research designs adapted to the specific nature of TCIH.16

Proposed actions

Increasing the evidence base for TCIH and making results widely available will require the prioritisation and funding in national and global research policies and programmes. Such prioritisation is needed to inform policy and the implementation of safe and effective TCIH interventions. WHO guidance on research designs is needed, reflecting the complexity and diversity of practices and products.

Findings

TCIH is widely used around the world with 170 of the 194 WHO member states acknowledging its use. Yet as of 2018 (no newer information available), only 78 countries indicated that they regulate T&CM practitioners.5 Categories of practitioners most commonly regulated are from indigenous, traditional medicine; acupuncture; and chiropractic. WHO’s support for regulation includes the publication of eight benchmarks for training and seven benchmarks for practice since 2014 (see table 1).

Discussion

Regulation of health practitioners and practices is recognised as an important basis for ensuring quality, safety and effectiveness of health services.17 Regulation ensures accountability, which generates trust and legitimacy. This is also important in contexts where the position of TCIH is threatened within the predominant biomedical healthcare system.18

The above figures on the number of countries regulating TCIH practitioners may be an underestimation: for example, only eight member states reported regulating Naturopathy,5 while the World Naturopathic Federation’s more focused methodology identified 34,19 suggesting that in addition to countries, professional organisations and other relevant stakeholders should also be surveyed for such reports.

Regulation of TCIH practitioners can also have unintended consequences. It has been argued that regulation subjugates TCIH to the dominant biomedical system in which these practices will always be considered as inferior.18 Standardisation of training and practices may threaten the essence of indigenous practices that are passed on informally from generation to generation and that are living and dynamic in character.18

The way forward needs to be nuanced. First, policy-makers, consumers and TCIH practitioners generally support regulation, even if some TCIH practitioners consider self-regulation to be adequate, a view not shared by consumers.17 WHO benchmarking documents thus continue to be of interest for more formalised TCIH practices. As already the case, compiling benchmarking documents for TCIH training and practices should be a collaborative process between the concerned practitioner organisations, educational institutions and the WHO/regulator. Practitioners can provide insight into education outcomes necessary for the profession, help collating the safety, effectiveness, economics data and play a significant role in regulating practices.19

Second, regulation should be part of a broader policy framework for TCIH that also defines and protects indigenous practices. This may include, among others, the protection of indigenous practices, including from unfair use and misappropriation; safety that includes active negotiation of paradigm-specific risk conceptions20; appropriate promotion of practice; and sustainable use of plant and animal species.

Proposed actions

WHO might develop model policies for the regulation of TCIH practitioners and practices, taking into account the distinct nature of formal and informal practices. Countries are encouraged to evaluate and recognise WHO benchmark documents as minimum standards, as relevant for their national context.

Findings

WHO has so far focused on herbal medicines by establishing forums for regulators such as the International Regulatory Cooperation on Herbal Medicine, and developing guidelines on herbal processing, quality control and production, notably the preparation of an international herbal pharmacopoeia (see table 1). Thirty-five countries reported having specific regulatory pathways for herbal products (the most widely regulated form of TCIH products); this could be an under-reporting as some countries may have specific provisions for TCIH products under the same regulation.5

Discussion

The regulation of TCIH health products plays an important role as they are extensively used, including as a form of ‘over-the-counter’ self-health care without practitioner oversight and this can therefore impart both significant benefits as well as potential risks.

WHO has so far addressed herbal products and has hardly addressed regulation of other types of TCIH products, such as those of mineral or animal origin,1 nor has it provided guidance on specific registration approaches for TCIH products.

A specific, risk-based approach seems well suited for TCIH products, tailoring regulatory requirements to the intended use and history of use, safety and effectiveness, ensuring rigorous assessment for high-risk products as well as indication claims, while always ensuring quality. Recognising the longstanding history of use and safety profile of many TCIH products, countries such as Switzerland, Germany, Canada and Australia provide specific pathways for TCIH products, ensuring quality, safety and access.21–23

From the perspective of planetary health, TCIH products have potential advantages and disadvantages. Shifting even modestly the prescribing of biomedical pharmaceuticals to TCIH products could reduce carbon emission and pollution from biomedical pharmaceuticals.24 However, unless produced sustainably and in full respect of the Convention on Biological Diversity, including the Convention’s Nagoya Protocol on Access to Genetic Resources and the Fair and Equitable Sharing of Benefits,25 TCIH products can be a threat to endangered plants and wild animals.26

Proposed actions

WHO should address regulatory issues for all types of TCIH products, not only herbal products. Risk-based regulatory pathways for the full-range of TCIH products should be encouraged in all countries. WHO can provide relevant policy guidance on how to establish such regulations, taking into account the specific efficacy, safety and accessibility considerations of TCIH products.

Findings

Despite their potential and sometimes risks, WHO has not yet issued specific reviews or guidance as to where TCIH interventions may be most useful and how to integrate evidence-based TCIH interventions in disease prevention and management—this was simply not part of the current TM strategy. A notable exception was COVID-19, where WHO and some member countries reacted to the high interest and use of TCIH.27 WHO issued a report on traditional Chinese medicine (TCM) in COVID-19 and in China, for example, national guidelines for TCM in COVID-19 were issued and several herbal products approved for use in COVID-19.

Discussion

The potential of TCIH to help address global health challenges such as non-communicable diseases (NCDs), cancer and antimicrobial resistance (AMR) need to be actively considered and existing evidence and experience taken into account. Lifestyle management and developing self-health care literacy and capacity form a central focus of many TCIH systems (eg, Ayurveda, Yoga and Naturopathy).19 28 29 An emerging research base supports greater inclusion of TCIH, with numerous studies illustrating the role of TCIH approaches in addressing NCDs—for example, the benefit of acupuncture and moxibustion for smoking cessation.30

Integrative oncology, that is, using TCIH practices alongside conventional cancer treatments optimises health, and improves quality of life, and clinical outcomes.31 32 This may involve integrating a specific therapy based on its evidence; integrating practices based on the patients’ health belief models and cultural-religious background33; or integrating a whole TCIH system, such as anthroposophic medicine, into cancer care.34

TCIH practitioners have also been active in addressing the global AMR challenge by reducing reliance on antibiotics. It has been shown that physicians with additional training in TCIH prescribe fewer antibiotics—largely due to encouraging more self-health care practices and TCIH practices—for uncomplicated infections for similar populations than their conventionally practising colleagues, without adversely affecting outcomes.35 36 On the other hand, patient preferences for traditional medicine can be a contributing element to delaying or avoiding adequate treatment for tuberculosis37 and malaria,38 illustrating the need for effective integration of, and collaboration between, the different approaches.

Proposed actions

WHO should identify and review the potential of TCIH for health promotion, prevention and disease management, and encourage member states to do the same.

Findings

The 37 countries of the WHO Western Pacific Region have agreed to define and enshrine in national health policies the role of T&CM in the achievement of well-being and health, and then incrementally establish or strengthen other key components such as ensuring quality, safety and effectiveness of health-care services, increasing coverage and equitable access to services, and enhancing research, evidence generation and innovation over time’.39 The addition of a chapter on TM in the International Classification of Diseases (ICD-11) now allows TCIH data collection as part of routine health information systems.

Discussion

A positive health framework is needed to harness the contribution of TCIH to achieve UHC. India presents an example of a country proactively working towards integration of biomedical and TCIH practices (referred to in India as Ayush-Ayurveda, Yoga and Naturopathy, Unani, Siddha, Sowa-Rig-pa and Homeopathy) in UHC. The Ayush system includes its own ministry which is responsible for standards and guidelines for regulation of educators, research facilities, products and health services for each recognised system. Historically, each Ayush system and biomedicine worked largely in silos, with encouragement of integration now seen as a national policy priority—the Indian National Health Policy 2017 explicitly calls for mainstreaming the potential of Ayush systems in all aspects of life as part of promotion of good health.40 Despite a policy of revitalisation of local health traditions and appropriate inclusion within Ayush, local, indigenous practices are in reality often not included and risk being side-lined.18 41

Although the WHO TM Strategy calls for increased consideration of TCIH integration, some countries are becoming more restrictive. The Spanish Ministry of Health and Ministry of Science, for example, published a ‘plan for the protection of health against the pseudo-therapies’ (Plan para la protección de la salud frente a las pseudoterapias) in 2018 and have since listed 73 therapies as pseudo-therapies, while 67 are under evaluation, including acupuncture and Ayurveda.42

In this context of variable support, approaches and mechanisms for integration, guidance on models of appropriate TCIH integration into health systems, as under preparation by WHO, will be useful in the coming years. Such guidance could help countries with achieving an integration that ensures safety and effectiveness for the public, avoiding the possible extremes of banning or permitting all TCIH practices.

Access issues should also be considered. Traditional medicine has long been considered a ‘gap filler’ for UHC in low-income countries where it is widely available and accessible and biomedical care is scarce.43 However, a review of TCIH use in sub-Saharan Africa suggests that demand for TCIH increases rather than decreases as access to biomedical care improves, suggesting preferences that go beyond availability and affordability.44 Many higher-income countries do not include TCIH in their health coverage; in these settings, health seeking for TCIH appears to be associated with higher education but not higher income, suggesting that people seek TCIH against significant economic and other barriers.45 Including TCIH into health coverage is important to ensure equitable access and counterbalance the risk of unfair commercialisation in this sector.46

As part of a positive policy framework, a positive health and well-being model that extends beyond the absence of disease model is also important, because factors such as resilience, sense of purpose, meaningfulness and self-management are increasingly recognised as central aspects of health.47 TCIH can contribute to a shift from disease-oriented to person- and community-oriented healthcare39 because traditional and complementary systems typically conceptualise health positively as the ability to balance and actively restore wholeness.12 48

Proposed actions

The TCIH policy framework from the Western Pacific region39 may provide a potential blueprint for integration and for collaboration among all healthcare professions. WHO guidance on TCIH integration into health systems will help countries identify their own preferred model of integration. The inclusion of evidence-based TCIH interventions into health coverage is needed to ensure equitable access. And maybe most importantly, a reorientation of healthcare systems from a disease—to a person-centred model can rely on TCIH approaches as a key component in this reorientation.49