Online Program

Barriers and facilitators of integration of tcam (Traditional, Complementary and Alternative Medical) providers for essential health service delivery in three Indian states

Tuesday, November 5, 2013 : 10:50 a.m. - 11:10 a.m.

Devaki Nambiar, PhD, Public Health Foundation of India, Gurgaon, India
Jk Lakshmi, PhD, Indian Institute of Public Health, Hyderabad, Hyderabad, India
Kabir Sheikh, PhD, Governance Hub, Public Health Foundation of India, Delhi, India
John Porter, MBBS MD MPH FRCP FFPH, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
TN Sathyanarayana, MBBS MPH, Indian Institute of Public Health, Hyderabad, Hyderabad, India
Venkatesh Narayan, MPH, Governance Hub, Public Health Foundation of India, Dehi, India
Efforts to engage TCAM practitioners in the public health workforce have growing relevance in India as part of its agenda to achieve universal health coverage. As part of a larger mixed methods implementation research study, we undertook in-depth interviews with policymakers, administrators, TCAM and allopathic practitioners, traditional healers, health workers and community representatives in three diverse Indian states: Kerala, where a number of systems have strong historical and systemic roots (N=63), Meghalaya, where local health traditions hold sway (N=59), and Delhi, where national, state, and municipal jurisdictions interface with multiple systems of medicine (N=61).

Barriers to integration included limited formal communication across systems of medicine, diverse levels of collegiality, and dissonance between expectations of practitioners and design of service delivery. For example, certain disease conditions are widely considered appropriate for TCAM care, yet patients with those conditions may be precluded from access (eg. Chronic arthritis patient must climb to third floor to consult an Ayurvedic doctor). Facilitators of integration included high-level political will and/or individual access to top decision-makers, personal interaction between practitioners of various systems, and the exercise of patient choice, both in rhetoric and in experience. Patients themselves drive inter-system referral; in rarer cases, doctors refer to known peers from other systems.

Larger operational questions of inter-system coherence exist, but have also been overcome, albeit in ad hoc ways, through the exercise of personal or political influence. For integration to succeed, the rationale of patient choice could guide institutionalization of opportunities for routine interaction across systems of medicine.

Learning Areas:

Other professions or practice related to public health
Provision of health care to the public

Learning Objectives:
Demonstrate three case studies of health systems integration of systems of medicine for essential health services delivery in a Middle Income Country context Identify common barriers to integration emerging across Indian states where a single TCAM dominates, where a non-recognized systems dominate, and where multiple systems have proliferated Describe facilitators of integration across the aforementioned variable settings Formulate strategies that may be applied in diverse health system settings to achieve integration of systems of medicine

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I was involved with the conceptualization of the study, in the collection and analysis of data.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.