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| ONE NATION, ONE HEALTH SYSTEM - SPECIAL ISSUE |
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| Year : 2023 | Volume
: 7
| Issue : 1 | Page : 6-12 |
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One Nation One Healthcare system: Esoteric idea or essential act?
Bhushan Patwardhan1, Rajeshwari Singh2
1 Savitribai Phule Pune University, Pune, Maharashtra, India
2 Ministry of Ayush, Government of India, New Delhi, India
| Date of Submission | 06-Nov-2022 |
| Date of Acceptance | 14-Nov-2022 |
| Date of Web Publication | 08-Dec-2022 |
Correspondence Address:
Dr. Bhushan Patwardhan
Savitribai Phule Pune University, Pune, Maharashtra
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jras.jras_170_22
The importance of the pluralistic healthcare approach and evidence-based integration of medical systems is well recognized in various reports and policies. There is a need to bring synergy in the context of public health, medical and health education, research, clinical practice, and health administration. There is a growing consensus in favor of transforming the pathy-centric fragmented healthcare system to a people-centric integrative healthcare system in a stepwise manner near future. One Health concept is more about zoonotic and environmental considerations. We propose a One Nation One Healthcare (ONOH) system concept that tries to build on the idea that One Health prioritizes people’s basic healthcare needs and brings the best from scientific experimental research and traditional experiential practices as consolidated evidence-based medicine. ONOH does not mean mixopathy or monopoly of any one system. Whether this is a utopian esoteric idea or an essential act in the best interest of people and nation for moving toward universal health coverage requires a serious dialog and action. Keywords: Ayush, health, integration, public health, traditional medicine
How to cite this article:
Patwardhan B, Singh R. One Nation One Healthcare system: Esoteric idea or essential act?. J Res Ayurvedic Sci 2023;7:6-12 |
| Background | |  |
The World Health Organization visualizes “One Health” as an integrated, unifying approach to balance and optimize the health of people, animals, and the environment. The approach mobilizes multiple sectors, disciplines, and communities at varying levels of society to work together. However, the One Health approach is particularly relevant for controlling zoonoses, food and water safety, nutrition, pollution management, and combatting antimicrobial resistance. The One Nation One Healthcare (ONOH) system tries to build on the “One Health” concept and extend it to evidence-based health care, bringing the best from the plural systems of medicine, including allopathy, traditional, complementary, and integrative medicine, in the best interest of people and nations.
India officially recognizes multiple healthcare systems and has adopted a pluralistic model concerning education, research, clinical practice, and healthcare administration. Traditionally and culturally, our communities have considered holistic health involving body, mind, and spirit stemming from the principles of prevention. The concept of health in Ayurveda is Swasthya, meaning the ultimate bliss at the level of body, mind, and spirit. The value of Swasthavrita, Dinacharya, and Ritucharya to attain Swasthya requires individual efforts. The natural power of the body and mind to heal is also important. Although doctors are needed to treat diseases, health needs active efforts and participation of individuals and communities to take our health into our hands.[1]
In India, Ministry of Family and Health Welfare and the Ministry of Ayush (MoA) are responsible for the conventional modern medicine (allopathy) and traditional healthcare systems (Ayush), respectively, with widespread infrastructure in the country.[2],[3] Allopathy and Ayush systems are well-regulated healthcare systems in the country under specific legislation. Both allopathic and Ayush systems are placed almost parallelly with a minimal provision for official interaction and exchanges concerning education, research, clinical practice, and public health delivery structure.[4] Sometimes, this has resulted in mutual distrust and unhealthy competition among the various streams of healthcare experts, ignoring the actual ground-level problems of the general population.
The health system has experienced tremendous pressure over the years to meet the increasing healthcare needs of the population.[5] According to 2013 civil registration data, over 27% of deaths in India result from inadequate medical care, primarily related to hospital accessibility and expensive healthcare costs.[6] Equal access to quality healthcare is another critical issue that has been neglected in the current healthcare structure in the country.[7] This has been of extreme concern in rural set-ups. According to Census Data 2011, qualified medical professionals, irrespective of their streams, are reluctant to render their services in remote rural areas and tend to migrate toward townships and cities.[8] In addition to the fact that unqualified medical professionals flourish in these rural areas for a variety of reasons, the rising burden of chronic illnesses and the emergence of pandemics such as COVID-19 have accelerated healthcare disparities and exposed a long-ignored need for a robust and well-coordinated health system equipped with skilled human resources that can adapt to provide both medical and public health administrative support to the country.[9]
The COVID-19 outbreak has shown how vulnerable the healthcare systems could be around the globe. Even countries with a good healthcare infrastructure have shown how easily the system could get overburdened.[10] We have also seen how evidence-based medicine can become prone to overwhelming unsubstantiated claims with almost no evidence. This circumstance has also demonstrated how Ayurveda and other traditional systems may significantly solve public health issues in several Indian states.[11] Hence, there is a need to relook at the status of healthcare delivery in India.
This article encompasses a process of critical enquiry and provides some options for future action for the development of a better health ecosystem that blends the principles of modern medicine and Ayush within their identity in the domains of education, research, clinical care, and societal relevance to transform the thinking, working, and the actual delivery of health by ensuring an optimal blend of mutually acceptable principles and theories, thereby resulting in a healthier society and Swasth Bharat.
| Existing Enabling Provisions for Integrative Health Policy | | |
During the Nagpur session of the Indian National Congress in 1920, the concept of integration emerged, which recommended the “Integrated System of Medicine and Research, which should be a combination of both our Ayurveda, Unani, Tibba, Siddha, and Modern medicine system choosing the best out of all and thus supporting one system by another to serve mankind to its best.” Bhore Committee 1946 tactfully preferred to underplay most other committees from independent India, including Sokhey Committee 1948, Chopra Committee 1948, Pandit Committee 1949, Dave Committee 1956, Udupa Committee 1958, Mudaliyar Committee 1959, Srivastava Committee 1975, Bajaj Committee 1986, followed by the 11th and 12th plans reiterated the idea of pluralism and integrative approach.[12],[13]
Furthermore, the Indian Council of Social Sciences Research and the Indian Council of Medical Research (ICMR) recommended an alternate model of healthcare that focused on bringing together the best of traditional and modern science into an integrated preventive, promotive, curative, democratic, decentralized participatory, community-rooted, economical, and equitable model of health care.
The National Health Policy (NHP) of 1983 recognized the long history of medical and health sciences. It recommended the phased integration of indigenous and modern systems and the involvement of Indian System of Medicine and Homoeopathy (ISM&H) in healthcare delivery programs. In 1999, the Central Council of Health and Family Welfare recommended posting at least one ISM&H physician in the primary health care (PHC).[14]
NHP 2002 advocated the untapped potential of ISM&H. It focused on evidence-based research to determine their efficiency, safety, and dosage. It also encouraged certification and quality marking of products to enable a widespread acceptance of these systems of medicine. The issue of equity has been raised at every level, including between states, rural–urban areas, and other underserved areas. NHP 2002 also advocates the enforcement of mandatory two year rural posting before awarding of the graduate degree and further public health training to all categories of health workers, including the paramedics of allopathic disciplines.[15]
A distinct NHP 2002 for ISM&H briefly discussed education, research, medicinal plants, drug standardization, ancient medical manuscripts, revitalization of local health traditions, veterinary medicine, and operational use of ISM&H in Reproductive and Child Health Care (RCH) and Maternal and Child Health (MCH) and also the integration ISM&H of medicine with allopathic services, so as to ensure a significant role in the public healthcare system.[16]
NHP 2017 recommends mainstreaming the various health systems in order to leverage the pluralistic healthcare legacy. As defined in NHP 2017, pluralism is reproduced here: 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. NHP 2017 rightly uses the term “integrative” that denotes an evolving approach against “integrated,” which seems static. Integrated medicine refers to combining allopathic and traditional/complementary treatments, which may be mistaken as mixopathy. As against this, integrative medicine is an approach to holistic health care. NHP 2017 also entails increasing the validation, evidence, and research of various healthcare systems as a part of a shared pool of knowledge. It would also entail providing patients with access and informed choice, creating an enabling environment for the practice of various medical systems, establishing an enabling regulatory framework, and encouraging crossreferrals across these systems. The policy recommends a matching human resource development strategy, an effective logistics support system, and referral backup to provide comprehensive care. The policy recommends mainstreaming the different health systems. This would involve increasing the validation, evidence, and research of the different healthcare systems as a part of the shared pool of knowledge. It would also involve providing access and informed choice to the patients, enabling the practice of different systems of medicine, enabling regulatory framework, and encouraging crossreferrals across these. The policy recommends that health centers be established on geographical norms apart from population norms. This would also necessitate the upgradation of the existing subcenters and reorienting PHCs to provide a comprehensive set of preventive, promotive, curative, and rehabilitative services. It would entail providing access to assured Ayush healthcare services and supporting documentation and validation of local home- and community-based practices. The policy also advocates for research and validation of tribal medicines: “The policy further supports the integration of Ayush systems at the level of knowledge systems, by validating processes of health care promotion and cure. The policy recognizes the need for integrated courses for Indian System of Medicine, Modern Science and Ayurgenomics. It puts focus on sensitizing practitioners of each system to the strengths of the others. Further developing sustainable livelihood systems through involving local communities and establishing forward and backward market linkages in processing medicinal plants will also be supported by this policy. The policy seeks to strengthen steps for farming of herbal plants. Developing mechanisms for certification of traditional community health care providers and engaging them in conserving and generating the raw materials required, as well as creating opportunities for enhancing their skills are part of this policy.”[17]
National Education Policy, 2020, advocates that “Healthcare education needs to be re-envisioned so that the duration, structure, and design of the educational programmes match the role requirements that graduates will play.” Students will be assessed on well-defined parameters at regular intervals to work in primary care and secondary hospitals. Given that people make pluralistic choices in health care, our healthcare education system must be integrative, which means that all students of allopathic medical education must have a basic understanding of Ayush systems and vice versa. There shall also be a much greater emphasis on preventive healthcare and community medicine in all forms of healthcare education.[18]
It is to be noted that during these deliberations, the consecutive 5-year plans supported the development of Traditional and Complementary Medicine (T&CM) education, research, and strengthening of infrastructure of teaching institutions through financial allocation. Initiating with the 9th Plan and especially the 11th year Plan[19] (2007–12), Task Force suggested the colocation of Ayush doctors and paramedics in the PHCs, community health centers (CHCs), and District Hospital (DH) centers. Taking the vision forward, in the 12th 5-year plan,[20] India conceived the National AYUSH Mission in 2011 for advancing health for all. The mission aimed to achieve the intended coherence, which was in line with the international recommendations by the High-Level Expert Group meeting on universal health coverage held in 2011. This creative mission was expected to move health policy in the country seriously toward a truly National Integrative Health Scenario by around 2020.
Despite these developments, ambiguity still exists in the integration of Ayush systems, as the system is currently pluralistic and parallel, with parallel education and research. One of the essential missing pieces of data to inform the need for integration of Ayush systems into the national health service in India is missing. Despite the best intentions, the consumer has a choice for going to any system, and sometimes he is taking services of both systems without informing each other or self-medicating Ayush systems. Still, there is an existence of barriers between the two health systems, which unknowingly disturb consumers and service providers. Removing barriers and openness for cross-learning may be a key point for real integration as shown in [Figure 1].
| Supportive Strategies for Integrative Health Policy | | |
Knowing about each other’s system and having faith in each system could be the first step toward integration. A parallel integration in education, clinical practice, research, and public health can build an integrated health framework in the country. There is a need to develop an interface where both systems come together and have trust with each other and systems, within their identity in the domains of education, research, clinical care, and public health to transform the thinking, working, and actual delivery of health by ensuring mutually acceptable principles and theories as proposed in [Table 1]. The four pillars of the integrative health framework comprise medical education, research, clinical practice, and public health as shown in [Figure 2].
A critical review of the curriculum for Bachelor of Medicine, Bachelor of Surgery[21] (MBBS) and Ayush (BAMS/BUMS/BHMS/BSMS/BNYS)[22],[23] indicates that these curricula are not sufficiently enriched to address current problems in public health and family medicine. For instance, Ayush graduates often may not be well-trained in emergency medicine, advanced surgery, national health programs, epidemiology, public health, etc. In contrast, MBBS graduates are not sufficiently trained in lifestyle, behavior, nutrition, and management of noncommunicable, chronic, and lifestyle diseases such as diabetes as well as simple home remedies and the use of commonly available local medicinal plants. Similarly, the provision for the involvement of biomedical experts in Ayush education is lacking even though there is a lot of biomedicine content in Ayush curricula. On the other hand, however, there is zero Ayush content in MBBS curricula. Almost all MBBS graduates intend to go for super-specialization, but there is a dearth of family physicians. This is making health care more and more expensive and out of reach for a commoner. This is also rendering the “family physician” a nonexisting entity, whereas, in reality, there is a dire need to empower physicians in performing their roles as family physicians.[24] Healthcare research in India at present is either compartmentalized as Department of Health Research or distributed among Department of Science and Technology, Department of Biotechnology, ICMR, Council of Scientific and Industrial Research, Central Council for Research in Ayurvedic Sciences under MoA, etc., operating mutually exclusively on most occasions.[25] The effective preventive strategies in these cited cases would be more rewarding than therapeutic strategies. These strategies should be based on credible evidence in the form of long-term observational and other studies involving preventive strategies through Ayush healthcare systems. Evidence suggests that healthcare-seeking behavior of the Indian population opts for pluralistic healthcare. For example, in states such as Kerala, patients are often aware of the common clinical conditions that need Ayurveda interventions and those that need Allopathic interventions. Hence, they seek either Ayurveda or allopathy based on their discretion. However, this integration is mostly driven by patients themselves. Such awareness is lacking in most parts of India because of multiple factors. Integration at the clinical level is mostly not practiced because of a lack of awareness, training, and missing crosstalk between modern medical clinicians and practitioners of traditional systems. The separate regulations for practice do not consider the needs of the people and the national health goals. Watertight compartments of clinical practice also resist the development of evidence-based medicine and the rational use of advancing medical research. The COVID-19 pandemic has highlighted the role of family and community-centric health care. In addition, the world has realized the strengths of “home-based prevention” and the limitations of curative services during this pandemic.[26] Strengthening the foundation of the health of the people by encouraging a participatory approach may reduce the burden on the secondary and tertiary care.[27] Ayush systems and local health traditions can play an important role in this and must be involved in formal public health initiatives.
Allopathic services have a separate ministry, a relatively large budget (1.4% of Gross Domestic Product [GDP]) and administrative machinery in the center, states, and up to district and subdistrict levels. Similarly, Ayush health services have an independent ministry, but a minuscule budget (3% of the allopathic outlay) and much smaller administrative machinery in the center, states, and up to the subdistrict.[28],[29] To resolve this disparity, common objectives and a formal interface are required to be developed at the administrative levels of Ministry of Health and Family Welfare and the MoA.
| Way Forward | | |
Global health indicators have evolved over time to show a significant shift from medical care to health care, which includes preventive health promotion, rehabilitation, and therapeutic management and cure. Despite recommendations by policies and expert committee reports for decades, an evidence-based integrative healthcare approach has remained elusive in the context of medical education, health research, health services, and administration. ONOH system incorporating modern medical advances stemming from our own knowledge systems, culture, traditions, and experiences may be an advisable approach for Atmanirbhar Bharat.
The ONOH is aimed at bringing synergy in the context of public health, medical and health education, research, clinical practice, and health administration in India as shown in [Figure 2.] The role of the person-centric approach in addressing multifactorial noncommunicable diseases and promoting a lifestyle that effectively prevents them is the core of Ayurveda and Yoga. Traditional health systems based on personalized curative treatment are interwoven in our population’s cultural and social fabric; their full and effective utilization of these systems receives their due attention from a policy standpoint. The formal healthcare delivery system and government agencies cannot bear the entire national healthcare burden. As a result, people must be encouraged to accept responsibility for their health, particularly in preventive domains. This can happen with the education of the masses through initiatives such as the “Fit India” movement and many more of this sort. Our Health in Our Hands and My Health Is My Responsibility should become the motto, and an atmosphere of social reinforcement to keep individuals motivated to achieve their health aims needs to be evolved. This can happen when plural systems of healthcare join hands with each other with the objective of bringing benefit to the society and public good.
In sum, ONOH system envisions transforming from a pathy-centric fragmented healthcare system to a people-centric integrative healthcare system in a stepwise manner near future. ONOH system does not even remotely mean mixopathy or monopoly of any one system. Whether this is a utopian esoteric idea or an essential act in the best interest of people and nation for moving toward universal health coverage requires a serious dialog and action.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1]
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