|ONE NATION, ONE HEALTH SYSTEM - SPECIAL ISSUE
|Year : 2023 | Volume
| Issue : 1 | Page : 35-41
“Integrative Health System” beyond “Integrative Medicine”: A health system research perspective for “One Nation, One Health System”
Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi, India
|Date of Submission||29-Sep-2022|
|Date of Acceptance||14-Nov-2022|
|Date of Web Publication||08-Dec-2022|
Prof. Ritu Priya
Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi
Source of Support: None, Conflict of Interest: None
One Nation, One Health System has many dimensions, and an inclusive Integrative Health System is one of the overarching and cross-cutting approaches to attain it. This paper discusses the imperatives for creating an Integrative Health System that incorporates AYUSH and Allopathic knowledge traditions. Since Integrative Health System is a term diversely understood and used, the need to conceptualize it and come to a shared understanding is highlighted. The paper brings insights and tools from a Health Systems perspective to suggest conceptualizing an Integrative Health System framework. It proposes that the IHS has three components— Integrative Medicine, Integrative Public Health, and an Integrative Health Care System. After discussing these components, the paper moves on to the Health Systems Research required for designing an Integrative Health Care System. The Complex Adaptive Systems approach is considered appropriate and explained. An illustration is provided from a study conducted to study the role and status of Ayush services and Local Health Traditions in the Public health system. Inferring conclusions from the study mentioned above and similar studies undertaken by the author, few illustrative inputs regarding Integrative Health Systems are provided, which would adequately support an ecosystem that allows interaction and dialogue between systems. It is postulated that this requires a shift in thinking from the dominant positivist paradigm to a critical holist paradigm.
Keywords: Integrative health care system, integrative health system framework, integrative medicine, integrative public health
|How to cite this article:|
Priya R. “Integrative Health System” beyond “Integrative Medicine”: A health system research perspective for “One Nation, One Health System”. J Res Ayurvedic Sci 2023;7:35-41
|How to cite this URL:|
Priya R. “Integrative Health System” beyond “Integrative Medicine”: A health system research perspective for “One Nation, One Health System”. J Res Ayurvedic Sci [serial online] 2023 [cited 2023 Mar 27];7:35-41. Available from: http://www.jrasccras.com/text.asp?2023/7/1/35/362938
| Introduction|| |
An inclusive and integrative health system is imperative for One Nation, One Health System. How we envisage and operationalize this goal will shape the Indian health system in the coming years. This paper attempts to spell out the challenges and suggest some directions for how we could think about it in the Indian context.
With all the prevailing social diversity and variations in health status and health care of different sections of the Indian people, One Nation, One Health System evokes a sense of purpose in decreasing the inequalities in health status across regional, rural-urban, caste, class, and gender diversity. It implies equal access to resources of all kinds that are determinants of health from the material conditions of food, water, sanitation, and other environmental dimensions. This is to avail other necessary aspects of life, such as ensuring education, health, nutritional supplementation, and social security, to dignified livelihoods and adequate income; and finally, access to safe and effective health care when required. In global health discourse, One health is a term being used for combined considerations of the health of human and animal populations. In India, the One Nation, One Health System is also being used for a system that combines the knowledge traditions under the acronym of AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha, Sowa Rigpa and Homeopathy) with the dominant conventional biomedicine.
As we attempt to move towards these various dimensions of the One Nation, One Health System, not merely allocation of adequate funding will be sufficient, but also appropriate design of systems that allow crossing of existing boundaries of sectors, disciplines, and knowledge traditions will be crucial. Restricting the scope of this paper to integrative health care,i.e., a pluralist health system, reference will be made to other sectors and dimensions wherever relevant.
There has been much discussion and debate in India about the integration of ‘traditional medicine’ with ‘modern medicine’ for over a century. However, the debate among diverse understandings about what this means and how this is to be operationalized continues to this day. We propose that there is a need for some clarity on the various dimensions of ‘integration’ and, thereby, appropriate use of terminology that could build shared understandings about an ‘Integrative Health System.’ A Health Systems Framework can help resolve some confusion and outline the many dimensions that need to be addressed to build an Integrative Health System.
| The Complex Health Systems Framework|| |
The WHO’s Building Blocks framework for any health service system provides a valid and commonly understood basis for thinking about the various sub-systems included in a ‘health service system.’ This includes(i) service delivery, (ii) health workforce, (iii) information, (iv) medical products, vaccines, and technologies, (v) financing, and (vi) leadership/governance. In addition, designing an inclusive and people-centered system requires a bottom-up approach. Recognizing that a health system is not only a technical entity but also a social institution shaped by societal conditions, complexity theory is applied to health systems design to relate health systems development to the real-life societal processes that influence the actual implementation of the various sub-systems. What gets implemented is often not the design that is put down on paper in a technical plan document but what is societally acceptable as the logical trajectory following the historical development of health care in the population (called ‘path dependency’ in the language of complexity theory). It depends on how healthcare providers understand and operationalize the plan (from administrators and program directors to the prescribing physicians, nurses, paramedical workers, and community health workers to the community and the patients/their relatives). Each one may modify the implementation steps at their level as they think best under their circumstances. For instance, the patient may go to one or the other system provider based on their experience, even though the educational material gives different guidance. The prescribing doctor may find from experience that patients in their area expect a certain kind of treatment. If they do not get it, they go to another provider and modify their prescription accordingly. Or they may refer a patient to a higher level institution even though, as per system design, they are meant to deal with it themselves. The nurse, ANM, or other care providers may advise some home remedies as adjuvants to the prescribed medicine. The patient may add other adjuvants or take multiple prescriptions from different healthcare providers. All these make the actual measures taken different from what had been envisaged in the program design, bringing complexity to the service delivery process and its outcomes (‘emergent behavior’). If insurance systems are involved, they add another layer of complexity to the treatment process. Economic and social compulsions may lead to non-compliance with prescribed behavior; for instance, informal sector manual workers may not be able to take the prescribed rest, poor women may not get the prescribed diet, and neither may be able to continue treatment for long periods. Healthcare providers may compromise patient care quality due to institutional pressures. For example, suppose a facility lacks the necessary equipment for prescribed tests or has insufficient drug supplies. In that case, they may send patients outside for testing and purchase of medications, even though the institution is supposed to offer free diagnostics and medications to all patients. Community networks that function informally may facilitate the use of services by the public if a respected community member advocates for it, and the impact may become wider through a ripple effect if they fulfill a socially felt need and provide the experience of effectiveness (scale-free networks). Some drastic events may cause a major shift in the health system, such as a significant increase in the use of telephonic consultations and telemedicine brought about by the COVID pandemic (phase transition). These are all healthcare processes influenced by developments in the formal health system and its interaction with informal dimensions of healthcare that exist in all societies and have been described concerning conventional biomedical healthcare alone. Different health system patterns thereby emerge according to the particular context.
Introducing a pluralistic approach adopting biomedicine and Ayush medicine itself is very complex, whereas nurturing multiple networks within the 06 systems of Ayush levels up the complexity even further. Therefore designing and implementing an inclusive and integrative healthcare system requires systematic research, reflection, and theory generation to synthesize the findings and incorporate all such possibilities while envisaging the establishment of One Health, One Nation System.
| ‘Integrative Medicine’, ‘Integrative Public Health’ and ‘An Integrative Health System’|| |
The term Integrative Health System is understood and operationalized in many ways, thereby needing appropriate terminology. The commonest approach is to adopt medical pluralism in clinical care, wherein practice or knowledge of different systems of medicine are effectively adopted for diagnosis, prevention, and management of diseases, drawing from more than one knowledge tradition for a particular disease or health condition for their complementary roles. Here, ‘system’ refers to the knowledge content of the diagnostic methods, preventive and therapeutic regimens, and their ‘integration’ in clinical practice. For instance, Ayurvedic formulations being commonly prescribed by allopathic physicians and modern diagnostics by Ayurvedic physicians. Another is to have practitioners of different knowledge systems sitting under one roof and adopting Cross referral strategies aligning with the strengths and limitations of each system. Since the focus is primarily on individual patient care, this is better termed “Integrative Medicine.”
An ‘Integrative Health System’ would organize the requirements that facilitate the practice of ‘Integrative Medicine’ and ‘Integrative Public Health’ through an ‘Integrative Health Care System.’ Integrative Public Health takes knowledge and practice to population lene, Integrative Health Care System provides organisational supports. A ‘health system,’ referred to in mainstream health systems research and health systems development policy is constituted of many other components that are meant to facilitate the practice of preventive, promotive, curative, palliative, and rehabilitative health and medical care. Within the WHO’s framework, the six building blocks are to be designed to ensure the principles of equity in access, universal coverage, adequate quality, and safety and to meet the objectives of the system that are spelled out as improved health, responsiveness, improved efficiency, social and financial risk protection. So far, this framework and its application are premised on applying one knowledge system, the conventional modern bio-medicine. How would the inclusive Integrative Health System be different, other than for its clinical content? One way is to fit all organizational dimensions into the modern medical mode: for instance, hospitals and health centers as service delivery institutions, health workforce of graduate practitioners and specialists, nurses and clinical as well as community paramedics; conversion of medicines into suitable modern dosage forms as pharmaceutical products; commercialize all services; give leadership to administrators/managers rather than the system experts. The other is to examine the various knowledge traditions for their organizational systems to see if some ideas and principles can be of value in re-envisioning the health system for the present and future.
Thus, a health systems perspective on One Nation, One Health System tells us that including more than one knowledge system in a planned way for the organization of health care requires much more research than mere evidence of the efficacy of medicines and procedures of the various knowledge traditions. If Ayurveda is to be practiced in integration with Allopathy, RCTs of the formulations proposed to be included in the regimen must have evidence of efficacy and safety. In addition, evidence should also be generated on how the measures of the different systems interact to enhance efficacy or complementarity and their safety. The regimens and studies must be designed keeping the principles of each system in consideration so as not to violate them in any way. This requires the review of the literature with an understanding of the principles of both systems and laboratory and clinical research with experts of both systems interacting to create optimal regimens. Such regimens that integrate principles and components of more than one knowledge tradition with sufficient evidence of efficacy and safety behind the integrative regimen could then be incorporated into developing Integrated Standard Treatment Guidelines for practitioners and lay persons. ‘Evidence-based practice’ and ‘practice-based evidence’ could be considered for efficacy depending on the specific data and its logical rationale. This forms the interface of Integrative Medicine and Integrative Public Health. Integrative Public Health brings Integrative Medicine to a population level. Health Systems Research component of public health contributes to designing the Integrative Health Care System.
Such creative interactions between systems would also be relevant for preventive measures, including diet, lifestyle practices, supplements, and therapeutic interventions (including medicine/practice/therapy). Traditional local knowledge and practices, popular practices combining measures from allopathy and others, need to be documented and assessed based on principles of the commonly used knowledge lineages as the first step in understanding the health care resources available in society. Then, additional inputs could be given to strengthening health care at the primary level in homes and communities. From a holistic public health perspective, knowledge of each individual’s own ‘Prakriti’ and its implications for personalizing preventive, promotive, and therapeutic measures could be a significant systemic intervention at the population level. Validated tools to assess the Prakriti would need to be applied at the population scale, and then data generated to understand its various implications in the real-life context of different population groups and communities. This would provide a large area of research and empower individuals to understand their bodies, promote their health and well-being, and counter ill health.
This should further be supported by institutions of health care that offer a choice of knowledge traditions as well as the articulation of professional ethics that encourages recognizing the limitations of one’s knowledge tradition and thereby makes the cross-referral by practitioners a legitimate and desirable practice. A combined plural practice by physicians of each knowledge tradition at primary, secondary, and tertiary levels should similarly be facilitated. There are also sub-lineages within each particular tradition, such as Ayurveda or Yoga, with different schools of thought. An institutional design should be evolved after examining the experience of integrative initiatives in our country by state governments and civil society organizations as well as various other countries for their positive and negative consequences, such as in China, Korea, Thailand, Cuba, Brazil and USA,, for how classical textual lineages have attempted to be brought into integrative systems. On the other hand are the attempts of several African and Latin American countries, as well as indigenous medicine in the US, Canada, Australia, and New Zealand, to incorporate the knowledge and practices of non-textual community healers in integrative systems.
| An Integrative Health Care System|| |
Any knowledge tradition has its roots in some organizational ontology and epistemology that includes its modes of new knowledge generation, of passing on of the knowledge system to the next generations, interactions of service providers with the community and with patients, the nature of medicines and their production and distribution, methods for regulation of the quality of services of providers and quality of products, definitions of quality and principles of ethics of health care providers and institutions, ensuring the collection/production and supply of required medicines and other products, financing of the services, and so on, as is the case with Ayurveda.,, These constitute the organizational features of the health system, the institutional structure, and technical, social, and cultural processes. And these, in turn, influence the knowledge base and its practice in the long term.
For instance, is it structured as a bottom-up approach that prioritizes individual and contextual variations and subjectivities and empowers lay people, or is it a top-down technocratic structure with centralized, rigid regulatory mechanisms to be universally applied? Is it decentralized and epistemologically varied by local context and individual preference? Does it include self-care as a component of the system design and thereby devise ways to strengthen self-care, or is it primarily focused on health centers and hospitals? Is self-care considered a peripheral issue, or is it central to the system’s practice itself? What mechanisms are instituted in the system to ensure quality and safety in the practice of self-care?,,,
Similar questions can be asked for each system element relevant to a specific context to tease out its complexity. Envisaging and designing an Integrative Health System is, thus, a complex task. It requires a holistic perspective to link a health system’s dimensions to its design. This requires evolving a critical mass of health care providers in each knowledge tradition who can interact with those from other traditions with an open mind and work together to develop inter-disciplinary concepts and their application for integrative promotive, preventive, therapeutic, palliative and rehabilitative measures, in coherence with pluralist principles, contemporary societal values of equity and equality and the prevailing healthcare context. It requires Ayush experts, Allopathic practitioners, and Health systems researchers to think together.
This requires an ethos and an ecosystem that encourages breaking out of the silos of one’s knowledge tradition to dialogue with others, keeping the real-life situation of the context for which the system is being designed. Top-down planning approaches design institutional systems with a focus on what is available and can be strengthened through formal institutions. Bottom-up approaches attempt to optimize the people’s resources and introduce reforms in the institutional structures to make them more accessible to the people, especially the more vulnerable and under-served. However, what is required for effective systems designs is considering the complexity of both the institutional and the widespread practice. What is their prevailing situation? What are the gaps in the optimal functioning of both? How can these gaps be filled? Who benefits from the services, in what way, for which health conditions, and why? How can there be a greater coherence between the institutional and the people’s components of health culture forming a healthy continuum?
| Required Health Systems Research|| |
A study at the National Health Systems Resource Centre undertaken in 2008–09 across 18 Indian states attempted to generate data on health systems dimensions of the services of knowledge other than conventional bio-medicine in the public system. There was, then, little data available on the geographical spread and population coverage of government services of the knowledge traditions other than allopathy (Ayush) despite many colleges, hospitals, and dispensaries in the public system across states and even more in the private sector. There was no literature or data available on their quality and utilization. These basic sets of information are necessary for systematic health systems planning and designing systems. In addition, the study attempted to understand the extent of using other knowledge traditions at the household and community levels. It also studied factors that influenced the growth and development of Ayush services in various states and the factors that influence their utilization. It conducted prescription audits at stand-alone and co-located Ayush facilities on the one hand. On the other, it documented the knowledge and utilization of Ayush services and traditional home remedies in rural households. Knowledge and utilization of local health traditions were also studied. The prescriptions of the Ayush and allopathic doctors and household practices were then validated by the principles and texts of the locally relevant Ayush tradition. Since it was a pioneering study, several conceptual and methodological innovations had to be made. Consultative and collaborative initiatives were taken to develop the innovations and to operationalize the study. This included evolving the validation method with a CCRAS team that was later used by the teams of the Central Council of Siddha, Unani, and Homeopathy.
Among the many salient findings that emerged was one that was eye-opening and provided evidence for the validity of adding a new dimension to the three-tier health service system approach. This was about the lay persons’ household knowledge and practices, which were found to be extensive. With knowledge of over 70% of the items found to be valid by the body of knowledge of Ayush systems, the study recommended that this knowledge resource form the base of an integrative health systems design, thereby, be its first tier. The second tier is the traditional healers and government community health workers (ASHAs and ANMs). The PHC, CHCs, District Hospitals, and medical colleges form the third, fourth, and fifth tiers.
Subsequently, a study conducted in urban populations of Delhi, including samples from the homeless, slum, and middle-class residential areas, found that the informal mechanisms of health care are resorted to more than the formal services for which all planning is being done. A third study corroborated the significant utilization of home remedies during the early phase of the COVID pandemic, wherein 50% of; households of the middle class across ten major cities, covering all regions of the country, had resorted to home remedies for prevention and treatment during that period. Thus, these and other studies provide evidence for individual and household-level self-care and home remedies forming the first tier of health care, with the inclusiveness of this approach across geographical, rural-urban, and socio-economic diversities.
Other findings also led to recommendations that contribute to creating an Integrated Health System. Recommendations included Integrated Standard Treatment Guidelines that have been discussed above, setting up of a District Health Resource Centre that would document and validate local health traditions and traditional health care community providers, ensure that their raw material of medicinal plants needed by them be protected and promoted and that their knowledge is also protected and promoted by relating it to the Ayush services in the area. In the present context, this would also include having Health and Wellness Centres with Ayush providers practicing their knowledge traditions and developing links with local traditional healers and home remedies.
The health systems perspective adopted for the NHSRC study and the comprehensiveness of its findings resulted in its being referred to for drafting the Health chapter for the 12th five-year plan of the Government of India. Literature searches reveal that since the NHSRC study was conducted over twelve years ago, no subsequent studies comprehensively cover health systems issues of the Ayush services. But they are certainly needed since the coverage and quality of health services and the people’s utilization of them are constantly changing. For any system’s maintenance, strengthening, and planning, there has to be a continuous cycle of: situational analysis of the system and its sub-systems, prioritization of the health problems to be addressed and choice from among the available interventions, then preparing an optimal design of the delivery system, its monitoring, and evaluation from both technical and social audit perspectives., Services of all knowledge traditions need to conduct this for themselves to progress and remain relevant in contemporary times. Regional coverage and inclusion of all socio-economic sections are increasing now, with institutional development and breaking of gender and caste barriers to becoming practitioners of the various Ayush traditions.
Such systems research is even more essential when an Integrative Health System is being designed. Interaction between researchers of Ayush systems and public health/health systems will facilitate interdisciplinary thinking on the issues involved.,, Current advances in scientific systems research must be drawn upon. Trans-disciplinary research with critical holism as the default theoretical approach is very much at the frontiers of complex systems studies. Science and technology studies that examine the science and society interface and ecological system studies have developed these much more than in Public Health. Since they are examining ways of transforming the dominant knowledge and technological systems away from the techno-centric, environmentally degrading, and inequality-generating development model towards more sustainable development (i.e., socially inclusive, economically viable, and environmentally integral), we would also do well to learn from the theoretical and operational research approaches being developed at the frontiers of these fields.
| Conclusion|| |
We must rethink our paradigm of knowledge/science to effectively develop an Integrative Health System and move towards One Nation, One Health System. We, in India, certainly have the intellectual and institutional resources to engage in dialogue for such a rethinking to move towards a more holistic approach. How far we use our resources to overcome this challenge will shape the present and future health system.
The challenge of achieving One Nation, One Health System is recognizing the complexity involved and framing it in operational and feasible ways without being reductionist. With the prevailing hierarchy between different knowledge traditions, recognizing the legitimacy of diverse ontologies and epistemologies, each with its strengths and limitations, is essential for developing Integrative Medicine. Integrative Public Health research must innovate to the application of Integrative medicine at the population level without violating the epistemic principles of the knowledge tradition from which the intervention draws, either from any one tradition or as Integrated Treatment Guidelines, depending on what evidence shows is of most optimal benefits to the most significant number.
In addition, an Integrative Health System must be designed considering the organizational principles of all the health knowledge traditions, eschewing the negative or outmoded aspects and extracting the positive attributes that should contribute to innovative thinking for an inclusive present and future. It may be most productive to think of an Integrative Health System as one that provides the ecosystem for interaction and dialogue between various health knowledge traditions. This would require a paradigmatic shift from the prevailing dominant positivist paradigm with one singular approach of biomedical science to a paradigm of ‘critical holism’ with multiple approaches that can legitimately co-exist. Without denying the strengths of any available approach, the system must be capable of making the optimal choices from available traditions and operationalizing them in complementary ways. Simultaneously, it must be capacitated to generate innovative ideas and practices through dialogue across the available knowledge traditions for integrative systems. Thus all health knowledge traditions should grow and develop with their principles and genius. The interaction with others would challenge and diffuse new ideas for the benefit of all in their specific context. This dialogic process and innovation must happen at all levels, from individual and family self-care to communities and bio-regions within districts and at the regional, national, and global scales. This will then be a continuously evolving and learning ecosystem that builds on the strengths of all knowledge traditions and, in turn, strengthens each one to benefit the Indian Health System as a whole.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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