Summary of Major Findings and Recommendations I. Status of Integration Health Seeking Behaviour and Medical Pluralism Need for Independent Surveys on the Utilization patterns of the AYUSH Systems Many claims about the large-scale use of traditional medicine are based on surveys which are open-ended and generally restricted to localized studies. (The Report has given a broad idea of various studies and their findings show large variation depending on the settings and sample size.) There is therefore a need to understand the dimension and circumstances under which traditional medical therapies and drugs are being opted for by different communities both in urban as well as rural settings. Such findings if based on a representative sample can form the basis for the overall management of AYUSH services within the health system. This is also needed because several pressure groups alternately embrace or decry the traditional systems, which calls for an objective and professional approach to analyzing what is actually happening in terms of consumer preference and utilization. The NSSO survey results may be the first nationwide survey, the results of which would be available only in June 2013. While this is a good step the recommendation is to repeat the surveys at regular intervals. Congruence of Traditional and Modern Medicine The concept of mainstreaming AYUSH and encouraging integration of different medical
systems was given a big thrust from 2005 onwards after the NRHM programme was introduced. In pursuance of Government policy the two Departments of the Ministry– Department of Health and the Department of AYUSH made a joint effort to promote integration. Their policy letters to all State Governments underscore the need for convergence. In physical terms that means positioning of AYUSH manpower where much has been achieved; but in terms of convergence from the patients’ point of view much more could be achieved. The recommendations highlight the barriers which need to be removed if the public is to benefit from the policy of integration. Need to Convince Government Professionals about AYUSH Systems
The AYUSH alternative does not appear to have permeated into the work culture of the medical fraternity in most government health facilities. Despite policy level instructions and the physical posting of contractual AYUSH doctors, the State heath machinery under the State Directors of Health Services and the NRHM hierarchy–particularly those responsible for the supervision of the primary and secondary health infrastructure (PHCs, CHCs and the district hospitals)–require special orientation to overcome barriers which are still deep-rooted. Some government doctors from the modern medicine stream have yet to overcome suspicion about the traditional medicine systems. Senior health administrators need to implement government policy which has expressly provided AYUSH services in government facilities. This should not be difficult as the extra support that has become available through the posting of
Summary of Major Findings and Recommendations xxxv
AYUSH doctors has been accepted by them and even welcomed. Formulation of Standard Responses and Guidelines Both at the national level and the state level, there remains a paucity of guidelines and operating practices to promote integration of AYUSH medical systems (drugs and therapies) into the health care system. A group of experts needs to prepare such guidelines which should include standard responses to guide and counsel patients that wish to use different systems in tandem. Determining the Relationship between NRHM and non-NRHM AYUSH doctors For several decades long before NRHM started, the AYUSH infrastructure was already widespread in many States. After NRHM came into existence, there is a need to spell out the extent to which AYUSH stand-alone facilities should work independent of the AYUSH initiatives under NRHM. The NRHM set-up at the state level does not appear to have sufficient expertise to supervise the AYUSH systems and AYUSH work done in the PHCs and CHCs. Mere physical location of contractual doctors will not achieve the desired results. Since it will be cost-ineffective to establish another supervisory set-up only for the AYUSH component of NRHM, the existing State AYUSH Department's staff ought to be used for supervision. (The advantages of doing this have been covered in the Report in the sections describing the field visits.) Need to Facilitate Referrals for AYUSH Treatment There is a need to have guidelines and standard operating practices laid down for making referrals for specialized treatment. Ultimately, the patient loses out on the benefits
xxxviâ€ƒ Status of Indian Medicine and Folk Healing
of integration when doctors â€“ particularly the modern medicine doctors show ignorance when patients seek advice on trying AYUSH therapies in parallel. For certain medical conditions cross-reference can be made if the patient so demands, and three examples are for availing of panchakarma treatment in government facilities, for undergoing Ksharasutra procedures for piles and fistula and for the treatment of liver and skin diseases. Need for Standard Promotional Literature on AYUSH Standard literature on the availability of AYUSH treatment as well as for preventive health needs to be supplied by all co-located facilities and district hospitals indicating where more information can be accessed. Signage at the Government health facilities needs to be designed professionally and given to the State Governments to get translated into regional languages as the present efforts were found to be haphazard and perfunctory at many places. Measuring the Contribution of Contractual AYUSH Doctors Although the physical presence of the AYUSH doctor has been accepted in the co-located facilities as an additional hand, his presence has yet to become an advantage for patients. The output of the AYUSH doctor needs to be measured by a different set of yardsticks when AYUSH drugs are available and when there is insufficient or no supply of AYUSH drugs as both situations exist. There is also a need to measure the output of AYUSH doctors separately for doing AYUSH work and doing modern medicine work. (The Report has shown how the mechanical collection of data provides little information about the progress of mainstreaming AYUSH.)
Need for Supervision of AYUSH Drug Supply Since AYUSH work has a direct relationship with drug availability, the supply made to the PHCs/CHCs needs to be overseen regularly from the State level. When not even the names of the medicines are known to the supervisory level NRHM staff, it is necessary to involve the Director ISM of the State and the District AYUSH officers in supervising the AYUSH component of NRHM. A monthly meeting of the Director of AYUSH/Ayurveda/ISM with the District CMOs and the District Programme Manager of NRHM would be useful as the contractual AYUSH doctors have been engaged primarily for performing AYUSH related functions. They are increasingly being treated as additional hands to supplement or substitute the work of the regular PHC doctors, which was never the consideration when hundreds of AYUSH doctors were appointed to mainstream AYUSH services under NRHM. Need for Training AYUSH Doctors Appointed under NRHM to Use Emergency Medicine Having said this, it must also be recognized that several PHCs and CHCs are using AYUSH doctors to perform duties as the sole “in charge” of the facility. This has the approval of the State Health Departments. These contractual AYUSH doctors are regularly put on night duty as the single doctor on duty which amounts to being on emergency duty. The instructions must visualize all the situations that are likely to arise at night, with a view to safeguard patient safety. The AYUSH doctors are anyhow prescribing allopathic drugs available in the dispensary. There is a need to orient all NRHM contractual AYUSH doctors about the administration of all drugs, including injections and parenterals which are stocked in the PHC/CHC. (The training possibly does not take care of emergency
situations when life-saving measures may require to be taken.) Patients are not expected to know the difference in competencies of single doctors on duty. In the National List of Essential Medicines (NLEM) notified for government facilities there are three categories of drugs: Primary (P), Secondary (S) and Tertiary (T). Under NLEM 2011 there are 348 drugs listed. Of these : • 181 fall under the category of P, S and T to be used by all facilities; • 106 medicines fall under the category of S and T and • 61 drugs are categorized as T only. The pharmacology of the 181 drugs which fall under the category of P, S and T should be taught to all AYUSH doctors recruited under NRHM as they are functioning as the single doctors in charge of the PHC. Eventually this knowledge should be imparted by making appropriate additions to the curriculum. Observations of Fifth CRM (Common Review Mission) related to AYUSH i. The Fifth CRM had reported that AYUSH doctors’ posts have been utilized for positioning allopathic doctors. ii. It has been also pointed out that work of the AYUSH doctors goes unnoticed. iii. Non-availability and inadequacy of AYUSH drugs was found rampant in almost all PHCs. iv. The MIS for AYUSH stand-alone and co-located facilities ought to be incorporated into the overall Health MIS that is prepared for the District and the State as a whole.
Summary of Major Findings and Recommendations xxxvii
Status of Adjuvant Use of Ayurveda and Unani Medicine India is the only country in the world which officially recognizes multiple systems of medicine. The fact that patients use different systems of medicine simultaneously is well known but the advantages, disadvantages, risks and benefits of combined use do not appear to have been studied in depth. In preparing Part II, the experience relating to the adjuvant use of AYUSH along with modern medicine was studied through a survey of 2000 patients to get an idea of what was happening. Consultations were also held with a cross-section of practitioners both in the government and private sector working in a wide range of facilities. Based on the results of these initiatives the following recommendations have been made: Need for Clarity on Adjuvant Use of AYUSH Medication A Task Force should be set up to address the ground realities relating to patients’ combined use of modern medicine and AYUSH drugs and therapies. Only the Government can set up an expert group which can examine whether cases of adverse drug reaction or contraindications call for a cautionary to be issued. The group should have on it pharmacologists who have been working with the AYUSH sector as well as practitioners from Ayurveda and Unani medicine, who can describe the constituents of the drugs. A beginning should be made in respect of conditions where the combined use of drugs from different systems is widely prevalent. A well-considered approach on the adjuvant use of AYUSH drugs particularly in sensitive areas such as lowering blood sugar and hypertension is needed. The expert group needs to draw up a list of precautions, do’s and don’ts about the adjuvant use of AYUSH drugs.
xxxviii Status of Indian Medicine and Folk Healing
In due course it would be necessary to design guidelines for the secondary and tertiary level hospitals too as that would help patients that have long-term medical problems and who resort to adjuvant therapy for a variety of reasons. The example of the Medanta conglomerate which has provided integrated treatment to over 2000 patients in multi-specialty settings can work as a model, to start with. A detailed report on the strategies followed at Medanta has been given in the main chapter while describing the corporate initiative. Need for Guidelines for Patient Counseling Guidelines need to be drawn in consultation with experts from all drug based AYUSH systems to guide patients about the benefits and strengths available under each system of medicine. This initiative will save the patient from a lot of confusion, loss of time and unnecessary expenditure on the basis of lay recommendations. For example, a patient suffering from Piles (hemorrhoids) or Fistula-in-ano may be ignorant about a noninvasive Ayurvedic treatment procedure called Ksharasutra. Similarly, there have been ample instances wherein patients slated for surgery for Chronic Tonsillitis, Uterine fibroids, PCOD, sinus-related interventions, Urinary calculus, have benefited by opting for AYUSH treatment. Unani medicine is being accessed for the treatment of Vitiligo and Siddha treatment is well known in the South for the treatment of Psoriasis. Information on treatment options available under AYUSH in respect of specific diseases should be published with the names of the places where such treatment is available in the public sector facilities. When allopathic drugs are used alongside for other conditions like diabetes, hypertension, thyroid etc. which cannot be stopped while ASU treatment is in progress, the guidelines should indicate the precautions to be taken including the timings of drug use.
Need for Basic Information on ASU Services to Be Also Given to non-AYUSH Doctors in Government Health Facilities Modern medicine doctors in the Government health facilities also need to be provided with standard literature so that patients can gain basic information about options available without the doctor himself having to get involved. They need only have a list of government facilities in each district of the State where the related AYUSH treatment is available and provide this information to the patient if requested. This would enable the patient to select an appropriate treatment option based upon his special circumstances. This should include the need to seek advice on adjuvant use of drugs from different systems. Need for Interaction Between Modern medicine & AYUSH Doctors in the Interest of Patient Care Presently, there is no forum for regular interaction between the medical professionals belonging to different streams during the course of medical education or during practice. This has in fact given rise to “mutual misgivings” regarding the strengths and weaknesses of the alternatives available. Since it is impractical to stop a practice which is patient driven, there is a need to introduce ASU modules in the MBBS curriculum which give an overview of commonly practiced ASU interventions. Essential information regarding herb-drug/food-drug/ drug-drug interactions related to commonly used herbs/drugs/dietary compounds ought to be a part of the module.The module may be introduced either during the final MBBS or during the period of internship. As a long-term measure, a 10-year integrated MBBS/MD/PhD in integrative medicine needs to be introduced, wherein the essentials of all major healthcare systems can be incorporated. If this is linked with openings for research, it would generate much greater interest in the AYUSH systems.
Need for Sensitization of Para-medical Staff Apart from the doctors, the nursing and pharmacy staff working at the primary and secondary hospitals also need to be exposed to the strengths of the AYUSH systems. The introduction of short orientation modules on AYUSH in the nursing and pharmacy courses needs to be facilitated by Department of AYUSH by holding discussions with the Nursing and Pharmacy Councils and degree/ diploma granting bodies. This should be done through the Para-medical Services Division in the Ministry of Health to see that the strategy is followed systematically. Interaction within the AYUSH Systems The research staff of the Councils work in isolation and there is virtually no interaction intra-the systems which militates against taking up joint projects and co-authorship. All ASU research staff and physicians need to be encouraged through a policy directive issued by the Department of AYUSH to the Research Councils to participate in seminars, workshops and conferences organized on a common subject by a sister Council. This would provide a forum to share knowledge and experience. In all such conferences, there should be proper representation from the relevant research staff from the other system up to at least 25 percent of the total participation. Likewise at least 10percent of the participants in scientific seminars and conferences should be from the research division of private sector companies from among those who have already published papers in good journals. More specifically: i.
A joint ICMR-AYUSH decision making body with representation of all research councils should be constituted for promoting interdisciplinary research. This was dealt with extensively in the Chapter on Research in Part I of the Status Report. Summary of Major Findings and Recommendations xxxix
Both CCRAS and CCRUM have units running through the length and breadth of the country but there is virtually no interface between the research personnel intra-AYUSH. The senior research staff working in different units of CCRAS and CCRUM are quite often unable to provide guidance to pursue rigorous research. Ideally, there should be a common platform where the outcomes of research studies in similar areas are discussed and repetitive projects discouraged.
An effort to cross-reference common medicinal plants in the Ayurvedic and Unani Pharmacopoeias could serve as a bridge between the two systems. Independent advice of a group of scientists involved in pharmacopoeial work needs to be taken.
Posting postgraduate doctors from the Ayurvedic and Unani systems jointly on hospital duty needs to be attempted so that they can learn from each other and a better working relationship grows. The younger research and clinical staff would welcome this strategy but the official system will resist the move, which calls for intervention at a central level. It appears that the research officers of the Councils have been permitted to publish the outcomes of their research in national and international journals. It was reported that most papers are only going into the in-house journals which have no “impact” factor. There should be an editorial policy and an editorial Board set up with experts having a track record of publishing. An emphasis on publication in national and international journals should receive encouragement and recognition because most of the research staff do not appear to be interested in publishing. There are several repetitive functions
xl Status of Indian Medicine and Folk Healing
which are undertaken by both the Councils. These areas relate to statistical functions, maintenance of herbal gardens and publishing work. It would make for greater efficiency if such facilities and staff are operated in common and the satellite centres of the Ayurveda, Siddha and Unani Research Councils, made accessible to all research staff as a matter of policy. In the absence of this, too many small units are operating on a tiny scale, which is very inefficient. Suggestions of the Steering Committee on AYUSH The Steering Committee on Health/ AYUSH set up for preparing the 12th Plan had made several useful recommendations which need to be implemented. These are indicated below : i.
Cross-disciplinary learning between Allopathic and AYUSH systems at postgraduate levels should be encouraged.
ii. AYUSH chairs should be established in medical colleges, which would provide the necessary technical expertise to jointly take up research, teaching and patient care. Once cross-disciplinary education is allowed, there would be a new class of professionals who would be able to leverage the strengths of each system to develop the most appropriate and effective treatment regimes. iii. Department of AYUSH should develop standards for facilities at primary, secondary and tertiary levels, standard treatment guidelines and model drugs list for the community health workers. iv. All primary, secondary and tertiary care institutions under the MOHFW, state health departments and other Ministries should have facilities to provide AYUSH services of appropriate standard.
Contemporary Ayurveda and Ethical Marketing of Ayurvedic Drugs Recognizing Private Sector Initiatives It is evident that the market has already decided how Ayurvedic drugs can become acceptable to a new clientele. The sale of Ayurvedic drugs has expanded with doctors of the dominant medical system willing to prescribe the same for their patients. The phenomenon has to be taken note of as it is a great step forwards towards integration of medical systems for public benefit. This is despite the reservations that many modern medicine doctors still harbour which is what makes it noteworthy. The strategies employed by Himalaya Drug Company (HDC) one of the leading Ayurvedic drug manufacturers in bringing about integration have led to a worldwide understanding of the strength of Ayurvedic Medicine. HDC's strategies include: i.
Collection and presentation of scientific and empirical data while talking to modern medicine doctors.
Documentation of the data collected during clinical trials to prove the efficacy and safety of the drugs.
Selecting a convincing research design and publishing outcomes in good journals
Providing information on the adjuvant use of Ayurvedic drugs supported by scientific/medical data.
Providing information about dosage of the drugs when used alone and in combination with allopathic treatment.
It is necessary to learn from such strategies
as modern medicine doctors have to be convinced and the resistance will not break down until special efforts are made to allay their fears which are understandable.
II. AYUSH in Selected Statesâ€“Findings from Field Visits**1 Odisha Suggestions for better coordination i.
Under NRHM the integration and mainstreaming of AYUSH was a part of government policy and has been accepted right from the year 2006. It is necessary that awareness about the availability of AYUSH doctors and medicines is built up. At all places visited it was clear that the two year delay in supply of medicine had lowered public expectations.
Unless there is full understanding about government policy at the level of senior health administrators (medical and public health) the fruit of deploying AYUSH health manpower will not be realized.
Considering the volume of the work and the time taken in follow-up, there is a need to assign a competent senior officer with direct access to the Secretary of the Health Department to oversee the integration aspects at the NRHM facilities and to give a sense of ownership to the concept of pluralistic medical and health care. Most persons in the AYUSH hierarchy do not appear to be able to demand sufficient attention to glaring gaps in implementation. Unless a solution is found locally, the tendency for working in strictly divided compartments
**1 There may be repetition in respect of some recommendations made after the State visits. The recommendations have not been clubbed at one place only to give a State-specific picture for further use. However, the general recommendations made for one State are generally applicable to all States.
Summary of Major Findings and Recommendationsâ€ƒ xli
responsibility is first accepted at the top. Joint sensitization along with the AYUSH doctors needs to be organized where a list of nearby facilities, names of persons to be contacted and phone numbers are made available to patients.
will continue and the public for whom all this is being done will not benefit. Only the PHCs will get additional hands to help with day-to-day work which was not the aim of the NRHM strategy. iv.
The Department of AYUSH Manual and joint instructions issued by the Union Secretaries for Health and AYUSH on mainstreaming AYUSH had emphasized that an important aspect of NRHM was “to know about the strengths of the AYUSH systems” and to promote “a culture of cross-referrals”. Therefore apart from the infrastructural aspects, the coordination and healthcare delivery aspects in government facilities require to be monitored under the fulltime guidance of a Director for Indian Systems of Medicine/ AYUSH. Apparently the position had been vacant for some time.
Better signage is necessary at the CHCs and PHCs particularly indicating how the public can benefit from the AYUSH systems and the specific areas where the systems have strength. There is a need to have standard instructions available for the guidance of patients. Likewise, there is a need for basic operational guidelines to be given to the contractual AYUSH doctors so that there is uniformity in following a regimen for the usual conditions (even as treatments may vary at times depending on the “constitution” or “prakriti” of different patients).
The treating allopathic doctors need to be made capable of advising the patient where to go (within the government facilities), in cases a patient asks for information on AYUSH facilities. This will not happen unless there is complete understanding at the highest levels of the health hierarchy and the
xlii Status of Indian Medicine and Folk Healing
vii. There was a suggestion made by AYUSH officials in Odisha that there should be an Advisory Board or Standing Committee which can give regular inputs to the Health Department about gaps that exist and how better coordination can be built up. This was mentioned by the PI during the meeting with the Odisha Health Secretary. Ideally, the Advisory Committee should be headed by a serving officer of the Department of Health who can translate the suggestions into practical strategies and obtain the orders of the Secretary quickly. viii. The engagement of part-time allopathic lecturers to impart modern medical education on specific subjects should be followed through soon. As this requirement to take classes has been given officially to the modern medicine doctors, it needs to be implemented without excuses. If honorarium and transportation charges are not being paid, it is unlikely that any member of the allopathic faculty would agree to give lectures in an Ayurvedic institution. The prescribed rate for outside lecturers appears to be Rs. 450 per lecture but even so the modern medicine doctors were not attending as required. Perhaps an arrangement could be worked out with the Kalinga Institute of Medical Sciences (KIMS) or some other professional institute which is qualified to undertake the responsibility on a continuous basis. ix.
Several positions of medical officers both
to which they belong. However, it is for policymakers to take an overall view because if the organization is not headed by a sufficiently articulate and resourceful officer, it would not be possible to infuse any dynamism into AYUSH service delivery.
Unani and Ayurveda appeared to be lying vacant. This needs to be reviewed. x.
An awareness programme needs to be built up on the State television channels where doctors and administrators with good communication skills speak about how the integration of the systems under NRHM can benefit the patients.
In States like Himachal Pradesh, Kerala, Karnataka, Gujarat, Rajasthan, Jammu & Kashmir and Odisha, there is a common Principal Secretary in charge of all aspects including Health, medical education and AYUSH. However, in the States of Maharashtra, Uttar Pradesh, Jharkhand and some others, AYUSH is combined under the Principal Secretary (Medical Education), and NRHM is handled by another Principal Secretary who is in charge of policy matters, the national programmes, government hospitals and rural health facilities.
That is one more reason to position a supervisory officer of a sufficiently high level as the Commissioner for AYUSH in Uttar Pradesh as functional linkages need to be established between the regular AYUSH and the NRHM AYUSH infrastructure and related matters like drug procurement and supply.
There is a critical need for improving and expanding the utilization of the Lucknow State pharmacy which is preparing Ayurvedic and Unani medicines and has a huge infrastructure available. If more medicines are supplied directly by the State pharmacy it would improve the availability of drugs round the year. Between Lucknow and Pilibhit pharmacies, a substantial part of the requirements of all Government facilities can be met. This would require enhancement of raw material supply and budgets for operational activities.
Uttar Pradesh i.
The State being very large, it is well known that there is huge diversity within regions, districts and communities. At the organizational level, it was apparent that with the absence of a senior unifying force to look after both Ayurveda and Unani systems, the hierarchy of each medical system was working independent of the other and with little collaboration.
There is a need to have a focal point which can act as a bridge between the professional people belonging to both the systems, to be able to plan, make overall recommendations and follow them up with the Health Department. A position of Commissioner (AYUSH) which could be filled from the Indian Administrative Service (IAS) or from the Indian Forest Service (IFS) (as was the prevailing practice in Andhra Pradesh) would provide much-needed leadership. The Andhra Pradesh example of having a generalist officer as the Commissioner would work better as the gaps to be filled are purely organizational and administrative in nature and not technical. This would avoid an intersystem tussle too. It is possible that there would be both criticism and resistance against such a move as all technical officers understandably have aspirations to reach the top of the organization
Summary of Major Findings and Recommendationsâ€ƒ xliii
As far as traditional skills like bone setting are concerned, the practice is very popular and widely acknowledged as being the mainstay in rural areas. Even in a Government Medical College in Kerala, and in a few well-appointed nursing homes in that State, the practice of bone setting is being resorted to routinely and happens to be the first preference of numerous patients. Even educated patients interviewed by the PI in Kerala had told her that when bone setting is done by a skilled person, it reduces immobility and the attendant problems of shortening and stiffness of the limb, which accompany conventional fracture treatment. More importantly, surgery can be avoided if the patient has other health problems. It is necessary in a large State like Uttar Pradesh to make systematic efforts to get the AYUSH medical colleges to consider mainstreaming of such skills (not the bone setters) into Ayurvedic and Unani practice as Kerala has done.
At the time the PI visited the State, the colocation of AYUSH doctors under NRHM was still to take off. Eventually, the State would be recruiting a very large number of doctors when the NRHM policy and strategies on AYUSH are adopted fully. An understanding needs to be reached on how integration is to be brought about between modern medicine and AYUSH doctors working in the same facility. There is a need to address the issue of the use of modern medicine by AYUSH doctors, which is not permitted in UP (Chapter on legal issues has brought this out).
Andhra Pradesh i.
The State has a post of Commissioner of AYUSH where an IAS officer is generally
xlivâ€ƒ Status of Indian Medicine and Folk Healing
posted. When the PI visited the State an Indian Forest Service Officer (IFS) was looking after the work of Commissioner of AYUSH. It is understood that this arrangement has since been made into a regular one. IFS officers already have a strong knowledge of plants and can get into AYUSH-related issues quite easily, particularly those relating to medicinal plants and drugs. IAS officers at the level of Commissioner get transferred frequently and the initiatives taken often loose momentum with each transfer. An IFS officer is more likely to stay for a longer duration. The position of Commissioner (AYUSH) seems to be unique to Andhra Pradesh and Tamil Nadu States. Having the position of Commissioner (AYUSH) helps because it provides leadership and continuity within the AYUSH sector. A senior generalist officer can apply strong negotiating skills to get the attention of the State Health Secretary and the health hierarchy including the modern medicine doctors. In Andhra Pradesh, the posting of a Commissioner appears to have helped to raise the level of acceptance of AYUSH and is a good model for other States to follow. ii.
The PI had requested for a brainstorming with modern medicine doctors also present to discuss approaches to integration which was not in much evidence in the facilities visited. However, during discussion there was opposition to any concept like integration beyond physical co-location. This negates the government policy on integration of AYUSH under NRHM. Unless it is understood and accepted by key people like the Directors of Health Services and Medical Education, the message may not translate into implementation.
The Department of AYUSH should get a suitable organization in the Health Sector like NIHFW, PHFI or NHSRC to partner with an AYUSH institution to hold sensitization programmes for senior State level medical functionaries. State institutions can also be enrolled to undertake similar exposure-cumorientation programmes as acceptance of the policy of integration at higher professional levels, is low.
explanation about the properties of the herbs along with service of a fresh decoction made on the spot would help propagate the benefits available from specific medicinal plants.
There seems to be immense scope for teaming up with universities and colleges to organize lectures and hands-on display on the cultivation and use of medicinal plants especially for those pursuing general courses on botany, pharmacology and Ayurvedic Dravyaguna.
The Institute offers an excellent location for meetings of the State Medicinal Plant Boards. Even if the temperate climate available at Joginder Nagar is unique only to Himachal Pradesh and other mountain States, it should be possible to engage stakeholders from Uttrakhand, Sikkim and some North-Eastern States in an exchange of experiences. This would facilitate interaction between cultivators, collectors and tribal people andÂ Â give greater visibility to the Institute. The Department of AYUSH/ NMPB should consider setting up a group of experts both from the field of botany, medicinal plant cultivation as well as tourism to use the potential of this institution to benefit a wider group of stakeholders. The NMPB should designate this as a resource centre too.
Pharmacy, Joginder Nagar
There is considerable scope for upgrading this pharmacy but what is needed even more is vibrant leadership. According to the figures given to the PI, the annual production capacity was 300 quintals. Both in terms of land availability and the proximity to the Joginder Nagar herbal garden, and the Ayurvedic Pharmacy College
Himachal Pradesh i.
The network of government-run Ayurvedic hospitals and health centres are actively engaged in providing Ayurvedic treatment but paucity of medicine and irregularity in the supply of drugs was found to be a recurring problem everywhere. This was taking away from the dedicated contribution of many District Ayurveda Officers as also from the continuity of treatment. There is every need to step up internal production in the State pharmacies to cater to the growing demand for AYUSH drugs instead of depending so much on purchased drugs which do not seem to be ordered or to reach in time.
Herbal Garden, Joginder Nagar (HP Government)
Since the specimens available in the garden as well as stocked in the herbarium are so plentiful, it would be worthwhile to place this institute on the tourist map of Himachal Pradesh as has been recommended in the case of Jammu & Kashmir also. The display of exotic medicinal plants, their properties, followed by a live demonstration of how decoctions are prepared could become an interesting and educative visit for tourists from other states. An
Summary of Major Findings and Recommendationsâ€ƒ xlv
located next door, there is potential for increasing production. Human resources, plant material and space are readily available. With more investment and better coordination it would be possible to expand production.
With planned investment and professionally supervised production and supply it would be possible for the State pharmacy to meet 80percent of the basic drug requirement of the state dispensaries. Owing to problems of leakage, seepage, fungus which are common in hilly places, it is unlikely that medicines procured from other States would remain in good condition even if the vagaries of tendering and supply can be overcome. It would be far better to augment the supply from within the State and to see that at least 30 highquality medicines produced by the State pharmacies are collected by the District Ayurveda Officers every quarter. Steady availability of medicines would give a huge impetus to the propagation of Ayurveda for which there is high public demand as well as support at a policy level.
to come. Two Medical Colleges one each for Kashmir and Jammu division are under construction which may in due course take care of this problem to some extent.
The AYUSH doctors appointed under NRHM had not received in-service training in respect of their own system without which it would be difficult for them to become conversant with what is expected of them. The NHSRC report2 has pointed out that the NRHM appointees are only doing allopathic work which should be restricted.
Awareness & Publicity:
During the PI’s visit to the State, it was pointed out that there was huge expenditure on propagating general health benefits under NRHM but no funds had been made available for conducting training or issuing advertisements for the propagation and promotion of AYUSH systems. The Director (ISM) felt that a separate budget provision was needed to conduct seminars at the tehsil/block/ district levels and for publishing best practices and the beneficial effects of Ayurvedic and Unani systems for preventive and promotive healthcare.
Jammu & Kashmir i.
Medical Manpower Needs
The state does not have any government college for Ayurveda and Unani medicine in the public sector, there being only three private colleges in the State, one in Jammu division and two in Kashmir division. Without educational institutions, the production of doctors for manning public sector facilities would become a problem in the years
While the receptivity at higher levels including at the level of the Secretary and Special Secretary for Health, the DHS and the Director NRHM was comparatively high compared to what the PI found in any other State, this had not permeated to the health facility level. Steps need to be taken to overcome the resistance of allopathic doctors to writing
Ritu Priya and Shweta A.S. Status and role of AYUSH and Local Health Traditions under the National Rural Health Mission – Report of a study, National Health Systems Resource Centre (NHSRC), National Rural Health Mission, Ministry of Health & Family Welfare, Government of India, New Delhi, 2010.
xlvi Status of Indian Medicine and Folk Healing
even a simple referral which does not constitute a recommendation to use any particular therapy but atleast facilitates a patient to go to an AU facility within the same complex instead of starting from scratch. iv.
Supervision and Reporting systems
The Director (ISM) and his hierarchy of AYUSH doctors do not have any role to play in the NRHM organizational structure and reporting systems. It has to be recognized that only the AYUSH doctors can suggest correctives when it comes to the AYUSH component of work done by the contractual AYUSH doctors recruited under NRHM. Hence, the Director (ISM) ought to be given official legitimacy and authority to check on the AYUSH work done in the public health facilities under NRHM, and his advice should be heard when the AYUSH activities under NRMH are reviewed.
Practice of Modern Medicine by AYUSH (NRHM) Appointees
The tendency to do only allopathic work as backup support for the Primary Health Centres seems to be growing. The objective of positioning AYUSH doctors will not be met, particularly if the supply of drugs also remains nonexistent. Therefore, there is every need to strengthen coordination and reporting systems in which the Director (ISM) has a specific role to play in the State Health Society and the district AYUSH officers in the ISM Department coordinate and report on the AYUSH component of the work being done by the contractual appointees in the co-located facilities. Otherwise the contractual doctors will increasingly be used only as “additional hands”. That could not help the cause
of popularizing AYUSH in the State. vi.
Harmonization and integration
There is a need to sensitize the modern medicine doctors as well as the paramedics about the strengths of the AYUSH systems. Unless this is done, the tendency to look upon the introduction of AYUSH merely as a symbolic strategy will persist. The patients would ultimately lose out and the money being spent on so many contractual AYUSH doctors would not benefit the patients.
vii. Shalimar Garden and Herbal Garden at Nehru Memorial Botanical Garden (NMBG), Chasmashahi
The ancient Hammam (Turkish bath) which had been excavated at the Shalimar Gardens in Srinagar is being restored so that visitors and tourists could see the traditional Baths in their original form. It might be useful to link this with Unani concepts if research supports it, as the baths will be visited by thousands tourists once the restoration is done.
There is immense scope to develop herbal tourism and to heighten interest among visitors and tourists in the preparation and use of fresh decoctions. It appears that funds that have been given by the ISM Department to the Directorate of Horticulture under Medicinal Plants Mission had not been utilized. This was brought to the notice of the Secretary Health.
viii. PHC Gulmarg
If the single doctor on night duty is expected to attend to the administration of parenterals and to use emergency life-saving drugs, he should be trained for this and his competence should be tested also as the public cannot
Summary of Major Findings and Recommendations xlvii
distinguish between AYUSH doctors.
Legal Empowerment Needed for AYUSH Doctors to Practice Modern Medicine
Since the AYUSH doctors are being regularly placed as the single doctor on night duty at the PHC, the health system should be clear whether such doctors should be administering injections and using life saving drugs and IV fluids. If that is the expectation, the doctors require hands-on training in hospital settings and the State should then notify the AYUSH doctors as competent to practise modern medicine under the D&C Act, 1940 which would give the doctors protection against court cases also. If they are not to perform certain functions it should be clear as to which staff member is authorized to perform the functions particular on night duty. As per Supreme Court directives, everything depends on what the State notifies.
The availability of treatment facilities needs to be notified along with timings and possible payments to be made by paying patients. This is because some skin conditions like vitiligo carry immense stigma and people are in search of treatment. People who use the internet would feel encouraged if all loose ends could be tied up before coming to a new city for treatment.
Arya Vaidya Shala (AVS) Kottakal attracts a large number of patients from India and many other countries too. Most of the clientele coming from outside Kerala come through the Internet. AVS although it is relatively far away from the airport and quite inaccessible manages to give full confidence to visiting patients from abroad and from within India. The strategies they have used ought to be studied and utilized to make things simpler for outstation patients.
Details about Unani treatment, herbs and other ingredients used in the treatment should be listed with full details and links on the website. The website can be developed using the IT services of a specialized institute like National Institute of Indian Medical Heritage (also located at Hyderabad) so that interested users can see the ingredients used in Unani drugs and their properties.
The CRIUM can become a flagship Institute for the treatment of skin diseases, but the physicians should be trained in handling questions, and ideally the treating physician should not be changed mid-stream during treatment.
Central institutions visited by the PI Central Research Institute of Unani Medicine (CRIUM), Hyderabad i.
The Institute is doing useful work particularly in the area of treating cases of vitiligo. However, for people coming from all over the country it may not be possible to stay at the Instituteâ€™s hospital continuously. It is necessary to build awareness about the facilities available for vitiligo treatment and patient care. The website should answer questions on the probable duration of treatment and of intermittent stay in Hyderabad. Paying guest/hotel arrangements need to be identified and listed on the website to give guidance and confidence to outstation patients who can then make their own arrangements.
xlviiiâ€ƒ Status of Indian Medicine and Folk Healing
Ayurveda Regional Research Institute (ARRI), Mandi (HP) The PI was shown a good location where a new building is to come up but being on a steep
hillside, it is questionable how many people would take the trouble of reaching the spot which would need four-wheeled transportation for the most part. It was observed that the annual OPD of this Institute even when it is located in the heart of the marketplace at Mandi was just over 18,000 persons. The subjects selected for research studies are far fewer. The number would reduce substantially by moving to another location higher up on a hillside seen from the point of view of getting sufficient patients. This needs to be looked into. Regional Research Institute of Unani Medicine (RRIUM), Bhabrak (Odisha) The new building is well located and impressive but a dispute about a piece of land required to be sorted out with the State revenue authorities to avoid infructuous expenditure on a very large building, which from present indications was not going to be occupied in the near future because of a tussle with local users. The local RRIUM officers need to be supported by the CCRUM Headquarters. Herbal Garden at the Central Research Institute of Unani Medicine (CRIUM), Lucknow i.
There was no flexibility available with the in charge of the Institute for investment in gardening equipment, or for promoting water conservation and nets for preventing destruction of plants by monkeys. There appears to be a need to devolve greater financial authority on the local officers and to leave it to audit to check on the prudence of incurring expenditure. Centralizing all authority curbs initiative and the utility to the public remains a question mark. There also appears to be a need to involve students of both Ayurveda and Unani to visit the herbal garden and to play a more pro-active role in the
management of the garden to increase their understanding of the properties of various plants. iii.
Keeping this herbal garden as another small unit of CCRUM with no sustainable linkages with botanists, faculty members both from Unani and Ayurvedic side and university faculty and students, produces limited benefit. Such units need to be judged by their linkages and outreach performance and not merely by day-today, routine activities. The benchmarks need revision as the research output was not evident.
III. Postgraduate Education in Ayurvedaâ€“Filling the Gaps Undoubtedly the Central Sector scheme for the development of AYUSH Institutions which provided Grant-in-aid for infrastructural development of AYUSH Colleges has made a substantial difference to some institutions. But the overall production of postgraduates to pursue initiatives related to teaching, research and speciality treatment remains grossly insufficient. The extent of the problem has been recounted in detail in the chapter. The recommendations inter-alia include the following suggestions: Manpower Study A manpower Needs Assessment Study needs to be undertaken to take stock of the gaps that remains after making a notional assessment of the annual out turn of postgraduates and their placement. Since the gap is already very large and is likely to grow, some emergent measures need to be taken to augment the number of seats available for post-graduation. That in turn would depend upon the availability of teachers to take PG classes. Therefore short-term and medium-
Summary of Major Findings and Recommendationsâ€ƒ xlix
term plan for expanding PG education needs to be evolved. Increasing PG Seats in Under-represented Speciality Areas There are about 2421 Ayurvedic hospitals and about 15017 Ayurvedic dispensaries throughout the country (as on 1.4.2012). If at least one postgraduate is considered essential for each clinical branch of Ayurveda (Kaya Chikitsa, Bal Roga, Shalya, Shalakya and Prasuti), hundreds of postgraduates would be needed in each discipline to meet the health care needs within hospital settings as well as provide private practitioners who also draw a huge clientele. Increasing PG seats is a necessity if specialization is to be promoted. Purely as a short-term measure, it may be considered whether qualified experts from the Research Councils for Ayurveda (as well as Unani and Siddha systems, if they face a similar paucity of teachers and postgraduates) could be inducted to take on teaching responsibilities for postgraduates with the approval of affiliating Universities. If that is allowed, the identified research institutes of CCRAS (also CCRUM if required) could register students for MD and PhD degrees after obtaining affiliation from the nearest university. A twinning programme could be arranged with the faculty of nearby Ayurveda colleges so that the CCRAS research units can conduct PG education and research together. The CCRAS scientists could be authorized to guide selected MDs and PhDs in addition to their core research work which would be beneficial for both, as it would bring much needed dynamism and productivity into the research institutes. The research staff of the Council could be given short-term reorientation and training to equip them to undertake teaching.
lâ€ƒ Status of Indian Medicine and Folk Healing
Minimum Standard Requirements (MSR) of Ayurveda Colleges & Attached Hospitals Regulation, 2012 Need for Accreditation System for AYUSH Colleges It is recommended that an accreditation system for AYUSH colleges may be considered to evaluate the adherence to standards instead of a once-in-five-years inspection. Regular evaluation needs to be undertaken by an accreditation agency as was envisaged for the National Council for Human Resources in Health (NCHRH) as the general feeling is that most institutions would not take matters seriously, knowing that there would be no oversight for several years. Engagement of Retired Faculty The introduction of video-taped interviews should be introduced before engaging retired faculty members after the age of 65 years (which has been made permissible under the new regulations.) This is necessary because some of the older faculty members are unable to keep the interest of the students alive and it is better not to re-appoint them mechanically, regardless of competence and teaching ability. Revamping the Syllabus and Curriculum The structural changes will only have an impact when the syllabus and curriculum also undergoes a change and keeps pace with contemporary demands. In order to make the postgraduates more research oriented, they need to be encouraged and recognized if they publish in high impact journals. They also need to improve their language and internet skills. This had been dealt with in detail in Part I of Status Report. It is essential that research techniques and computer skills, which are essential tools to gain entry into the field of high quality
publication, are taught to the students as soon as possible. These aspects need to be included in the syllabus, and qualified parttime teachers need to be engaged for giving this exposure on a continuous basis. Some of the funding that is made available under the Central scheme should be earmarked for giving exposure training in research institutions like AIIMS, PGI Chandigarh, the GB Pant Hospital at Delhi, the CMC Vellore among others. Even by sending batches of two or three students to a research institute in the medical field to observe and learn from the rigours of independent research, the present tendency to gloss over the need for conducting scientific research with rigour may be better understood. Such initiatives would need to be taken centrally by having a steering committee with members from ICMR and the Directors of AIIMS, PGI Chandigarh among others. The Committee’s role would be to design research exposure programme for AYUSH doctors so that they get sufficient knowledge of how independent research is conducted.
IV. Building Credibility for Panchakarma Years ago, only skilled people performed Panchakarma therapies which form the backbone of Ayurvedic therpeutics. Nowadays the procedures are practised lasting for vastly differing length of time. Owing to the absence of standardization of Panchakarma procedures, patients face a dilemma about whether the procedures were executed fully. Specific protocols for each procedure have been recounted in the ancient texts but unless there is oversight the tendency to cut corners does arise. Despite Panchakarma’s immense potential both as a direct as well as a supportive therapy, it is not widely accepted as effective and trustworthy. The main recommendation is therefore to do everything possible to
position Panchakarma at par with Chinese Accupuncture which has a proper licensing procedure. The following suggestions may be considered: Effectiveness Studies There is a need to build substantial evidence to show the benefits of Panchakarma as a therapeutic intervention. Several observational studies are required to justify what today are mere claims. The efficacy of Rasayana (rejuvenation) drugs need scientific endorsement and by simultaneously setting up two similar groups of patients - one which undergoes Panchakarma and another which does not, outcomes can be evaluated in comparative terms. Unless such evidence is documented following an acceptable protocol and the co-researchers on the team are from related disciplines, the outcomes, even if they are very positive and claims about effectiveness may not be trusted. Evaluation Studies on Patient Responses There are no prescribed end points in terms of primary and secondary outcomes. As such there is a need to atleast evaluate the patient’s perception of his expectations and experiences which would help identify the gaps between the “perceived” and the “practised” standard of Panchakarma procedures at different facilities. Evaluation of Panchakarma
Research has shown that trainees (who generally administer the procedures) tend to offer procedural explanations to the patients but owing to their limited experience and over enthusiasm, there is a possibility of over-projection of expected benefits. The non-involvement of senior consultants in the process of explaining the processes to the patients has been viewed as a deficiency.
Summary of Major Findings and Recommendations li
Hence the following recommendations are made:
by all State Government Ayurvedic Hospitals that provide Panchakarma treatment.
The delay caused by “waiting for turn” should be reduced without compromising on the quality of services. The Model followed by AVS Kottakal and some other centers should become the benchmark for the duration of procedures as well as essential equipment and consumables that would need to be used. AVS Kottakal has checklists for each procedure which can be seen by the patient also.
Privacy for women should be assured as it affects their receptivity to undergoing treatment.
It is also necessary to encourage reputed Panchakarma centres in the private sector to acquire accreditation as there is a low level of hygiene and general upkeep in many facilities. Accreditation will provide minimum benchmarks for hygiene and give users more confidence about the facility. Department of AYUSH could also give a bridge loan to reputed private facilities to get NABH accreditation on the condition that they treat an agreed number of referred cases sent by the Government facilities.
Patients need to feel comfortable during the process of preparation and during the actual treatment. Uncertainty leads to stress which impacts negatively on the outcomes. Cancelling or refusing Panchakarma services due to breakdown of equipment or absenteeism of staff should be monitored to bring in more professionalism. A thorough recordkeeping of the equipment and regular supply of all consumables is necessary to improve efficiency.
Standard Operating Procedures Accreditation for Panchakarma Centres
Standard Operating Procedures (SOPs) for Panchakarma needs to be introduced for all centres whether in the government or private sector. The National Accreditation Board for Hospitals and Healthcare Providers (NABH) has brought AYUSH hospitals and wellness centres under its ambit. It has issued detailed guidelines on services to be maintained by AYUSH hospitals aspiring for certification. There is a need to introduce a Central Scheme to support the acquisition of NABH Certification
lii Status of Indian Medicine and Folk Healing
Need of Guidelines for Ayurvedic Panchakarma Massage Parlours There has been a phenomenal increase in the demand for specific Panchakarma procedures to enhance beauty and provide relaxation. Most five star hotels and high-end tourist resorts provide some form of Panchakarma limited to massage and Shirodhara. Since the name of Ayurveda is being used, there should be a requirement for such procedures to be performed only by qualified staff. Care has to be taken that the fair name of Ayurveda or Panchakarma does not fall into disrepute. By involving the Tourism Departments of the states through the Ministry of Tourism it would possible to bring uniformity in the services provided, when the service is claimed to be a part of Ayurveda. If they are merely offering massage services, it needs no intervention. However, the use of the term Ayurvedic massage or Panchakarma should have attendant requirements that have to be fulfilled on the lines of the green leaf strategy of Kerala State. Establishing a ‘Centre for Scientific Research in Panchakarma In the long term there is a need to plan for a Centre where the related validation
studies can be undertaken or alternatively to fund research which can be undertaken in leading medical research institutes which can permit the use of their equipment to test the change in markers and physical parameters of the patient after undergoing different procedures. A group of scientists from Ayurveda as well as related modern medicine research fields including biophysicists needs to be set up to agree on measurement devices and markers that can evaluate different parameters to establish the efficacy of each intervention separately. That is a long-term measure. In the short-term since most of the subprocedures of Panchakarma seem to be a part of physical medicine as seen from a contemporary perspective, a Panchakarma unit should be started at the All India Institute of Physical Medicine and Rehabilitation (AIIPMR), Mumbai. Collaborative studies can be undertaken with AIIPMR which would be a simple way of determining the effectiveness of Panchakarma procedures. There is likely to be no resistance as that Institute is generally interested in pursuing procedures that help the rehabilitation of physically challenged patients. There is no doubt that Panchakarma has a strength in the areas of restoration and rehabilitation. AIIPMR receives the kind of patients that would benefit from such treatment. The Institute comes under the Ministry of Health/Directorate General of Health Services.
Manesar, Haryana (Deemed University under Department of Biotechnology, Government of India) if Department of AYUSH approaches them and also funds the project. ICMR should be involved in identifying the most appropriate scientific centres run by different agencies.
Research Study on Shirodhara - A Model to Follow
Need for a policy on the revival of State Pharmacies
A study which has been referred to in the main chapter had described the efficacy of Shirodhara when it is undertaken in a standardized reproducible manner. This study can be a model for similar studies to be undertaken on the efficacy of Shirodhara once a centre is established. Studies could also be undertaken in collaboration with the National Brain Research Centre (NBRC),
A policy on the revival of State pharmacies needs to be made as the provisioning of drugs has to go hand-in-hand with the appointment of hundreds of contractual doctors under NRHM. Even if funding for drugs is provided for the NRHM facilities, efforts would need to be made to compress the time taken for the drugs to actually reach the facilities. The procurement process is ridden with
Promotion of Panchakarma on the lines of Chinese Acupuncture Despite its popularity, Panchkarma is underutilized at a global level as compared to Acupressure and Acupuncture. Clinics for such procedures are available in abundance, particularly in the US. Chinese acupuncture is available with full certification of therapists and technicians. In the US such staff is not only of Chinese origin but can belong to any nationality. There is a need to gain similar foothold for Panchakarma services by offering courses for students in the US, leading to the grant of a licence. Initially such courses can be started with the approval of any US State authority which is prepared to allow such courses to be run in that State. Ayurveda and Panchakarma do not need endorsement from the US. However that is one of the most effective ways of marketing authentic and effective Panchakarma services. The recommendation should be seen in that spirit. V.
A Study of Selected State Pharmacies
Summary of Major Findings and Recommendationsâ€ƒ liii
procedural problems. If the ultimate goal is to see that AYUSH is mainstreamed, out-of-theway measures would need to be taken to run the State pharmacies in a cost-effective and efficient way. It must be recognized that total reliance on budgetary support and supplies made under NRHM or Department of AYUSH would never be able to meet the requirements of the hospitals and stand-alone facilities, which are completely a State responsibility. Recommendations Based on the Outcome of a Visit to six Randomly-selected State Pharmacies i.
All State pharmacies should be able to prepare and supply at least 30percent of the demand of medicines required by the government-run hospitals and dispensaries to avoid large scale shortage of drugs which exists at most facilities. Instead of giving small grants to the States as a part of an overall scheme, central funding should be related to improvement in production in specific identified pharmacies.
Quality control is an important aspect of GMP. State Government Pharmacies should adopt proper quality control processes. This needs to be reviewed periodically by engaging an independent agency before funds are released for specific pharmacies (and not in bulk) so that improvements can be evaluated.
The utilization and upkeep of equipment needs to be monitored by the State AYUSH Department. Compliance certificates should be obtained annually from each pharmacy and periodic external checks should be instituted to verify the status.
Pest control procedures should be prescribed and a certificate of compliance obtained annually.
livâ€ƒ Status of Indian Medicine and Folk Healing
Waste disposal guidelines should be issued and a compliance certificate obtained annually.
The staff strength should be suggested by Department of AYUSH on normative lines and should be related to capacity utilization and production.
vii. Plentiful space that is available at most State pharmacies should be utilized properly. The demand and supply of drugs needs to be planned properly at the State level and a fixed percentage of the drugs required to be supplied only by the State pharmacies. viii. The revival of such pharmacies may require changing the terms of engagement of the staff, and moving to a higher standard of financial management and production. This would also require that rules applicable to industrial units would need to apply as working only during government working hours is inefficient. State pharmacies working on commercial lines are functioning quite successfully if the examples of TAMPCOL in Tamil Nadu and Oushadi in Kerala are considered. In the interest of using the capacity nearer home so that the uncertainties of transportation and storage are minimized, there is a need to follow the examples of Tamil Nadu and Kerala. Even if a couple of States set up a joint sector undertaking, it would be a great beginning.
VI. Regulatory Framework for ASU Drugs Recommendations Related to AYUSH Drugs Quality Control i.
The new clientele of AYUSH drug users is becoming increasingly discerning and conscious about safety and quality. For
They are not only prescribing allopathic medicines but are being trained to handle different situations that arise in health settings. Their posting as the sole in-charge necessitates them to be conversant with the use of emergency measures. But in that case the States have to use the provision of the D&C Act, 1940 to make appropriate notifications to support such practice. Such notifications cannot then be confined solely to Government appointees. They would apply to all ISM/AYUSH doctors that have graduated after the recognized degree course. The example of States like Maharashtra would then need to be followed to give legal cover to the AYUSH doctors. The most balanced approach would be to allow ASU doctors to practise modern medicine to the extent that is needed at the primary health centre level, while accepting that would need to include immediate response to emergencies, acute illnesses, besides routine illnesses. The contractual AYUSH doctors should be trained to handle such situations through posting in government hospitals before being posted as the sole in-charges of PHCs/ CHCs.
this, the regulatory and enforcement authorities have to show zero tolerance for indifferent quality. The number of statutory and ordinary samples collected and the findings and follow-up action taken needs constant review at the State level. ii.
At least one percent of the drugs in the market should be obtained as survey samples (not statutory samples), tested and the outcomes of laboratory testing publicized. The work of the State licensing and enforcement authorities needs to be monitored constantly. This is a very weak link.
The position of Drugs Controller General for AYUSH needs to be created with the full complement of supporting staff.
Most of the State governments appoint Drug Inspectors (Ayurveda) (Unani) from among Ayurvedic Medical Officers except in States like Delhi and Kerala. Sometimes a member of a college teaching facility is given the responsibility. There ought to be separate qualifications prescribed in the recruitment rules along with previous experience of regulatory work for engagement of AYUSH drug inspectors. This should be adopted on an all India basis which will strengthen quality control.
As far as private practitioners are concerned, the State should notify that ASU doctors using modern medicine need to avail of a training which equips them to handle emergency situations excluding surgery. Against the payment of a fee which the States should prescribe, medical colleges and hospitals may accredited for conducting such training confined to stabilizing the patient who needs emergency intervention, before he can be referred to an appropriate facility.
A certificate of having acquired this training should be issued by a State
Branding of Ayurvedic drugs should not be banned as this prevents investment in R&D and marketing of classical medicines. This was explained at length in Part-I of the Report under the chapter on Drugs.
Recommendations related to Practice of Modern Medicine i.
It is evident that Ayurvedic doctors are managing several health facilities as the sole in-charges of PHCs and CHCs.
Summary of Major Findings and Recommendationsâ€ƒ lv
Board and the display of the certificate made mandatory. Side by side, a list of interventions and drugs that must not be used by ASU practitioners should be listed to remove all ambiguity.
RAV needs to reinvent itself while continuing with its core activities. If this institution is to grow, a person who is conversant with the higher education sector and preferably one who has served as a Vice-Chancellor or a similar position is needed to provide leadership as Chairman of the Governing Body.
The status of this unique institution has been described based upon the findings of a survey which was administered as a part of this study. The extent to which a selection of the Gurus and Shishyas has been done 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. The efforts made by the Institution were found to have led to some positive outcomes though these are limited to one aspect of practical exposure only. 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 been referred to.
RAV can also be made as a functional body to regulate and conduct courses on AYUSH paramedical education (Diploma of two years) or a oneyear certificate course including ASU Pharmacy education, ASU Nursing, Panchakarma technicians’ course. RAV could also organize or run basic Ayurveda Education for Allopaths and selected visitors from abroad. RAV can enter into Memoranda of Understanding with State colleges and State pharmacies to impart AYUSH paramedical education and take on the role of the certifying authority until an independent Council is established to regulate standards.
RAV’s terms of reference, aims and objectives need to be augmented so that the Institute organizes study tours and exposure visits for the college going children of NRIs who are looking for avenues to learn about their roots combined with an exposure to Indian culture which includes Indian Medicine.
Recommendations for Upgrading the Institute for Formal Teaching
VIII. National Institute of Indian Medical Heritage (NIIMH)—A Historical Overview and Major Contributions
Unless the State notifies that the AYUSH doctors can practice modern medicine under the Drugs & Cosmetics Act, 1940, the mere issue of executive instructions could be violative of the Supreme Court's orders and hence the States should be alerted about the need for issuing appropriate notifications.
VII. Guru-Shishya Parampara—A Critique of the Rashtriya Ayurveda Vidyapeeth
Besides conducting the Guru-Shishya courses which are basically to improve exposure and learn skills, there is a need for RAV to move into more structured education also. The suggestions made by two earlier Committees set up by the Government (Reports have been annexed) do not appear to have been acted upon fully.
lvi Status of Indian Medicine and Folk Healing
This is a unique institution under the Central Council of Research in Ayurvedic Sciences. It is one of the earliest institutions set up for studying the history of medicine emanating from the advice of eminent medical historians and others from the renowned Johns Hopkins
University in Baltimore USA. The institution has been working primarily in the area of documenting the result of historical research and is now focusing on providing easy access to all the information and documentation that has been collected. Recommendations Visibility i.
The Institute should hold an Annual Conference in which academics who are working in the History of Medicine field are invited along with publishers who specialize in this area. Linkages should be established with international scholars who are proficient in Ayurveda and Unani medicine or are studying Sanskrit/Arabic/Persian manuscripts so that they know what the Institute can do for them.
The Institute should set up on Advisory Committee with representation from different stakeholders, from multidisciplinary backgrounds like history of medicine, anthropology, political science and also from the world renowned Johns Hopkins University, USA so that new ideas are generated and the institute becomes a gateway for scholars and students of the History of Indian Medicine.
NIIMH should maintain a database of AYUSH PG/PhD theses, copies of good AYUSH journals, including other traditional systems and establish reading halls so that research can be undertaken in comfortable, wellequipped surroundings.
The Institute should be permitted to accept registration fees for seminars and conferences and the funds can be permitted to be used for hiring good facilities for conferencing, boarding
and lodging of out-station participants. However all such functions should be outsourced to a suitable agency as the Institute has no in-house capacity to handle this.
IX. Folk Healing Practices of the North East 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 based upon field surveys conducted by academic and teaching institutions in the North-East. Recommendations for Giving Certification to Folk Healing i.
The efforts which are being made to conserve and revive folklore in the North East and to give it validation and recognition are good initiatives seen on a broad plane. But there is a need to understand the dynamics of accepting the responsibility for the selection of healers considered fit for â€œcertificationâ€?. The aim of such certification needs to be spelt out. If it is to give legitimacy the question of how the standards for inclusion were selected and the credibility of the certifying agency would need to be prescribed. There is also a need for clarity about entitlements which accrue as a result of certification. Sooner or later the aspirations of those who have received certification will grow and demands for parity or some other recognition will start. At that time the basis for selection of healers may arise which should be anticipated from now so that the process is clearly understood.
The efforts to understand and document the folk healing practices are very good. However, it is necessary to have an
Summary of Major Findings and Recommendationsâ€ƒ lvii
overall idea of where this would lead. The Ministry of Environment & Forests and the Ministry of Tribal Affairs have had considerable experience of dealing with allied subjects of rights, entitlements and protection of sui generis knowledge. The NEIFM needs to become a nucleus around which past endeavours in the area of folk healing can be collated at one place for the North East region. The Institute should start by building networks and accessing studies and reports which were undertaken elsewhere. iii.
With the increase in deforestation, forest fires and overexploitation of medicinal plants, there is also a need to sensitize the people about the need to preserve the forest and promote herbal gardens. NEIFM should shoulder this responsibility by networking with an organization in each State which can implement approved strategies. Scientific validation, reverse pharmacological and observational studies are required to understand the healing properties of plants outside the codified systems focusing on those plants which are being used extensively by the healers but are outside the ASU formularies. The outcomes need to be published in botanical journals.
The State-specific recommendations are not being repeated as they are by and large, common.
X. Ayurvedic Veterinary Products â€“ Status and Future Prospects The scope for the development and propagation of Ayurvedic veterinary medicine has been brought out and the opportunity that is available for selectively moving from chemical additives to safer alternatives
lviiiâ€ƒ Status of Indian Medicine and Folk Healing
has been described. This is with a view to benefiting the public as consumers of milk, poultry, eggs and meat. Need to Prepare an Ayurvedic Veterinary Pharmacopoeia There is a need to prepare and publish a separate Ayurvedic Veterinary Pharmacopoeia covering the Ayurvedic veterinary products. A separate veterinary Pharmacopoeia has been published in the case of synthetic drugs and pharmaceuticals (Published by Indian Pharmacopoeia Commission). It is understood that the newly formed Pharmacopoeia Commission for Indian Medicines (PCIM) has formed a Veterinary Ayurvedic Committee to initiate this work. However, the availability of resources and other facilities needs to be looked into so that the work is expedited. Separate Wing for ASU Veterinary Sector There is a need to initiate inter-ministerial dialogue/cooperation between the Department of AYUSH, Ministry of Health and Family Welfare and the Department of Animal Husbandry, Ministry of Agriculture and the Veterinary Council relating to the use of Ayurvedic medicine for Veterinary use. Within the Department of AYUSH there should be one technical officer who can focus on specific needs of the veterinary sector and facilitate processing the approval of new regulations needed for this sector. He should visit the factories making Ayurvedic Veterinary medicine to understand the processes etc. Presence on the ASUDTAB The AYUSH veterinary sector should be given greater representation on the ASUDTAB. There are several government notifications which have been issued keeping only the human application of ASU medicines in mind. There is a need to either exempt ASU veterinary medicines from the purview of such notifications or to look
into their applicability for the veterinary sector. Ideally, animal- specific standards need to be prescribed for quality control as well as other aspects like labeling.
can use cheaper alternatives as substitutes. However, unless the regulations envisage and encourage this, the cost-effectiveness issue will not be overcome.
Training Veterinary Manpower about Ayurvedic Medicine for Animals
The Ayurvedic veterinary sector is still small but it has a huge potential given the interest in natural products and the large population of animals and poultry that can be treated for some conditions without resorting to the use of chemical drugs. Greater encouragement to R&D and awareness building through participation in Animal Husbandry camps and schemes would popularize the use of Ayurvedic veterinary products.
The number of veterinary doctors being limited, they generally attend to serious and complicated cases only. A vast majority of the common metabolic disorders (which are generally self limiting and non-life threatening) are attended to by VLIs, VLW’s and AIW’s. Most of the licensed Ayurvedic drugs are meant for common metabolic disorders. The State Departments of Animal Husbandry need to be sensitized about the availability of Ayurvedic products and to start including them in the inventory of stores. There is a need to encourage the paramedical veterinary manpower to understand the benefits of traditional veterinary medicine. Companies engaged in the manufacture of Ayurvedic veterinary products should be encouraged to impart know-how and training to the para workers and to livestock and poultry farmers. This requires official acceptance by the DGHS/NCDC/Department of Animal Husbandry. This further requires the AYUSH sector to assemble these players and oversee that the process starts. Prioritizing ASU Veterinary Sector Ayurvedic veterinary medicines are generally sold based on their relatively lower cost compared to modern medicine. While the Ayurvedic products were once cheaper, since the main ingredients being used are medicinal plants which are becoming costly, the Ayurvedic veterinary medicine is losing out on its major usp–its comparatively lower cost. There is a need to encourage research and simplify regulations so that manufacturers
Need to Create Balya-Poshak/Positive Health Promoter Drug Category There are a large number of animal feed supplements of both synthetic as well as herbal origin. Such herbal feed supplements are often a combination of vitamins and nutrients mixed with herbal powders and/or extracts. This requires that a new category is introduced with separate requirements for animal use. To overcome the apprehension that the Ayurvedic Drug Licensing Authorities may object to the combination of herbal ingredients with synthetic ingredients like vitamins and nutrients there is a need to arrive at an understanding and to declare what is expected. The Food Safety and Standards Authority of India (FSSAI) have apparently yet to prepare guidelines for licensing veterinary products. Therefore, there is a need for Department of AYUSH to take a view on responsibilities for laying standards and for monitoring this sector.
XI. Initiatives with a Difference It is expected that the two initiatives described in the Report viz. the Science Initiative in
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Ayurveda (ASIIA) and the Vaidya-Scientist Fellow Program would open up a new approach to the study of Ayurveda. A wider public should be made aware of such initiatives in order to create hope that if past efforts have not yielded substantial results, one can anticipate better outcomes from such new initiatives which are on the anvil.
XII. Transformation Needed Studying Integration in China Sending Delegation to Study Success of TCM in China An important goal of NRHM and the overall health policy has been to mainstream AYUSH into healthcare delivery. China achieved integration of modern medicine and Traditional Chinese Medicine (TCM) decades ago. Although several delegations have visited China, there is a need to send a cross-section of health system managers namely a Medical Superintendent of a Central Government hospital, and selected State Directors General and Directors of Health Services to visit China to understand how integration of TCM at different levels of health care delivery has taken place. Time needs to be spent on specifically observing how integration takes place at the patientâ€™s level, instead of making general visits to institutions which have been made several times. A team comprising one modern medicine Doctor, an AYUSH physician and a hospital administrator may be asked to prepare a paper on the integration that was observed, particularly how cross referrals were managed after initial registration of the patients. This needs to be studied keeping in mind specific medical conditions so that the operating procedures that are followed when modern medicine and TCM are used together are clear.
lxâ€ƒ Status of Indian Medicine and Folk Healing
Promoting Research under the Aegis of NCCAM Designing and Pursuing Meaningful Grant Proposals It would be useful to select a team of AYUSH doctors who are already publishing papers (the Benaras Hindu University, Department of Ayurveda has several such faculty members) to conduct an up-to-date search of Complementary and Alternative Medicine (CAM) projects that have been funded by the National Centre for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health (NIH) in the US in the last five years. The subject areas and conditions under which research grants have been given to researchers from different countries and institutions need to be gleaned. With the help of ICMR the effort should be to get good research proposals accepted by NCCAM. Also to facilitate foreign researchers interested in conducting research in India to undertake collaborative research. Protocols are already available in the Department of Health and the Ministry of External Affairs and ICMR to approve such collaborative projects. This is necessary to get global recognition. Promoting High Quality Research and Publications It is important to give continuous support to journals because they bring credibility to the research work that is being done which will help raise acceptance of the systems and also the standard of further research and published work. Part I of the Status Report had already indicated the paucity of published research emanating from the AYUSH sector. Apart from the fact that the Research Councils have been unsuccessful in publishing papers of real significance in high-quality journals, even the universities and colleges have not been able to make any impact on the canvas of publications on Complementary and Alternative Medicine. The publication of good journals from India provides a platform and
therefore such journals need to be encouraged and supported with financial support to make them viable. No journal can be published without proper editorial and research staff engaged on a full-time basis and funding has to keep that in mind. Guidelines on Research Proposals The system for screening and approving requests for publication of journals should be independent of any bureaucratic or departmental approvals. Once a high level committee of well respected experts is set up, it should be left to the Committee to finalize the grants within the budeget provided which should be generous. Acting Against Exaggerated Advertisements that make Medical Claims The Drugs and Magic Remedies (Objectionable Advertisements) Act (DMRA), 1954 and the rules thereunder were enacted way back when the production of pharmaceuticals was very small. Under this Act, advertisements related to childbirth, women’s diseases, menstrual disorders, infertility and impotency, treatment of severe infections and certain other diseases like cancer, rheumatism, diabetes, and hypertension are prohibited. The AYUSH sector has unfortunately become notorious for publishing exaggerated claims and cures including the above areas. The labelling provisions make unacceptable claims and many educated patients turn away from using even simple medicine because of such claims. Starting Toll-free Helpline A mechanism should be introduced whereby the departments of AYUSH at the State level warn the public through newspaper advertisements and on television that there are centres as well as manufacturers of medicines that make claims about curing intractable diseases like Cancer and HIV/AIDS and
diabetes. The public should be asked to seek advice from an All-India toll-free number (to be set up by Department of AYUSH) to guide the caller. Standard responses should be available on the monitor for helpline staff to give guidance. These should be prepared by experts but converted into commonly used languages-English and Hindi. A model for this is already available in the Call Centre initiative taken by the Ministry of Health’s Call Centre run by the Jansankhya Sthirata Kosh for reproductive and child health. Cancellation of Licence All Ayurvedic and AYUSH hospitals that advertise claims of curing certain intractable diseases should be sent a notice that the hospitals/ nursing home licence would be cancelled if such claims are made. State governments need to be given a doable set of guidelines as to how they should deal with these situations and at least a couple of cases in a year should be followed up; which can stand as examples for other States to follow with tenacity. Uniform Policy on Reimbursement of AYUSH Treatment The Department of AYUSH should take steps to convince all Ministries and Departments to reimburse medical expenses on AYUSH treatment taken by employees and dependents suffering from specific conditions in recognized facilities. AYUSH treatment should be permissible in any AYUSH facility in the case of an employee requiring rehabilitation after undergoing an accident or injury suffered in the course of performing duty. In the case of non-duty related conditions and in the case of other employees of Central Government and their families, specific package deals should be recognized upto a specified amount to be undertaken in hospitals recognized by Department of AYUSH.
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