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

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.