WHO BENCHMARKS FOR THE TRAINING OF TUINA Department of Integrated Health Services World Health Organization (WHO) Avenue Appia 20 – CH-1211 Geneva 27 – Switzerland
WHO BENCHMARKS FOR THE TRAINING OF TUINA WHO benchmarks for the training of tuina ISBN 978-92-4-001798-6 (electronic version) ISBN 978-92-4-001799-3 (print version) © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Design and layout by Inis Communication Contents Foreword iv Preface v Acknowledgements vi Glossary vii Executive summary viii 1. Introduction 1 2. Categories of training 3 2.1 Training for people without a medical background 3 2.2 Training for people with a traditional medical background 3 2.3 Training for people with a conventional medical background 3 3. Levels of training 5 3.1 Basic requirements 5 3.2 Advanced requirements 5 4. Learning modules for full training 7 4.1 Basic requirements 7 4.2 Advanced requirements 8 5. Learning modules for adapted training 9 5.1 Adapted training for people with a traditional medical background 9 5.2 Adapted training for people with a conventional medical background 9 References 10 Annex 1. Suggested subjects and learning hours for full training at basic and advanced levels 11 Annex 2. Working group meeting 12 Annex 3. Online consultation 14 iii Foreword The World Health Organization (WHO) is currently implementing its 13th General Programme of Work (GPW13) to support countries in reaching all health-related Sustainable Development Goals (SDGs). GPW13 is structured around three interconnected strategic priorities: achieving universal health coverage; addressing health emergencies; and promoting healthier populations. These strategic priorities are supported by three strategic shifts: stepping up leadership; driving public health impacts in every country; and focusing global public goods on impact. Traditional medicine has always had a role in this collective endeavour. The Declaration of Astana, renewed from the Declaration of Alma-Ata towards universal health coverage and the SDGs, reaffirms the role of traditional medicine in strengthening primary health care, a cornerstone of health systems, in pursuit of health for all. This has also been reflected in the WHO global report on traditional and complementary medicine 2019, in which 88% of WHO Member States acknowledge the use of traditional and complementary medicine in health care. Taking note of the growing importance of traditional medicine in the provision of health care nationally and globally, WHO and its Member States have strived to explore ways to integrate, as appropriate, safe and evidence-based traditional and complementary medicine services within national or subnational health systems, as committed to in the Political Declaration of the High-level Meeting on Universal Health Coverage. WHO aims to provide policy and technical guidance to Member States; promote the safe and effective use of traditional and complementary medicine through appropriate regulation of products, practices and practitioners; and support Member States in harnessing the contribution of traditional and complementary medicine to people-centred health care in implementing the WHO Traditional Medicine Strategy 2014–2023. Setting norms and standards is a unique function of WHO. The normative work is driven by needs and could be translated into real impact in relevant countries through appropriate policy options. This series of benchmarks, covering various systems and interventions of traditional, complementary and integrative medicine, aims to provide a reference point to which actual practice and practitioners can be evaluated. I am very pleased to introduce this series to policy-makers, health workers and the general public, and I firmly believe it will serve its purpose. Zsuzsanna Jakab Deputy Director-General World Health Organization iv Preface Integrated health services are essential for the World Health Organization (WHO) in the implementation of its 13th General Programme of Work, which aims to support countries in achieving universal health coverage and the health-related Sustainable Development Goals. The overarching mission for the Department of Integrated Health Services is to accelerate equitable access to quality health services that are integrated and people-centred, and that can be monitored and evaluated. WHO is unique in its mandate to provide independent normative guidance. Its normative products encompass a wide range of global public health goods, including norms and standards. It is therefore the primary role of the Department of Integrated Health Services to generate and produce relevant global goods. Key to improving its work in this area is ensuring global public health goods are driven by country needs and can deliver tangible impacts at the country level. As of 2018, when 88% of WHO Member States acknowledged the use of traditional and complementary medicine, WHO’s support in evaluating the safety, quality and effectiveness of traditional and complementary medicine has continuously ranked in the top areas of need, according to the WHO global report on traditional and complementary medicine 2019. WHO prioritizes normative products based on an assessment of demands. To address increasing needs and to drive impact in countries, this series of benchmarks captures the main systems and interventions of traditional, complementary and integrative medicine by setting up required norms and standards on training and practice. WHO’s guiding principles and quality assurance procedures have been strictly followed in designing and formulating these benchmarks. WHO will not only assess the quality of these normative products but also streamline systems and plans for monitoring and evaluation. I am pleased to present this series of benchmarks and invite you to join us in measuring and documenting their impact. Edward Kelley Director Department of Integrated Health Services World Health Organization v Acknowledgements The World Health Organization (WHO) acknowledges the technical support of the National Administration of Traditional Chinese Medicine, China, without which the production of this document would not have been possible. Thanks are due to the China Association of Acupuncture-Moxibustion and Changchun University of Chinese Medicine, China, which kindly provided logistic support to the WHO working group meeting on this document. Special thanks go to Zhihong Wang, Mingjun Liu, Xin Zhang and Nicola Robinson, who have actively and diligently contributed to the drafting and editing of this document. WHO is indebted to all experts who have provided their inputs to the WHO working group meeting and the peer review process. Qi Zhang and Qin Liu undertook revision work under the guidance of Edward Kelley. Colleagues within the WHO headquarters team for traditional, complementary and integrative medicine provided secretarial support. vi Glossary Basic requirements The fundamental level of knowledge and skills needed for people with various backgrounds who are aiming to provide a limited tuina service, which will be combined as part of their treatment options. Advanced requirements The higher level of knowledge and skills (in addition to that under the basic requirements) needed for people with various backgrounds who are aiming to provide a comprehensive tuina service, which will enable them to become a specialized tuina practitioner. Full training The tuina training programme designed for people without a previous medical background. It includes complete learning modules for tuina, traditional Chinese medicine, conventional medical knowledge and other relevant areas to satisfy both basic and advanced requirements. Adapted training The tuina training programme designed for people with a traditional or conventional medical background. It includes adjusted learning modules for tuina, traditional Chinese medicine, conventional medical knowledge and other relevant areas to satisfy both basic and advanced requirements. vii Executive summary Why this benchmark? In 2010, the World Health Organization (WHO) published the Benchmarks for training in tuina. This presented what professional experts and health regulators considered to be appropriate training programmes for tuina practitioners.1 Various backgrounds of tuina service providers were addressed inadequately in this document, however, and there is a lack of a defined career pathway for tuina providers. Based on the needs of Member States, the updated benchmarks aim to reduce the gaps by setting up required leaning modules for each category of tuina service providers at different levels, so that individual practices and practitioners can be compared, evaluated and accredited. This document will join the benchmarks for the practice of tuina to form an integral part of the serial benchmarks, targeting key modalities of traditional medicine intervention and contributing to the establishment of a reference toolkit for countries. How was this benchmark prepared? Three drafts were prepared during the development of this benchmark document, with intensive technical support from an expert group based in China. A WHO working group meeting and an online consultation were organized to facilitate the production of these drafts. The process has collectively involved dozens of experts in relevant areas worldwide. In line with WHO established principles and processes for benchmark development, the WHO Secretariat made the planning proposal and clarified the scope of work. The first draft was prepared by selected leading experts based on the framework provided by WHO. This draft was presented to the working group meeting for discussion. Twenty-nine experts from 12 countries across the WHO regions joined the working group meeting. After two days of intensive discussion on the scope, structure and content of the draft document, the meeting was concluded with consensus and advice on further improvement, which guided production of the second draft. This draft was then ready for online consultation. Eleven experts from six countries across the WHO regions joined the consultation, reviewed the progress made since the last working group meeting, and contributed to the development of the third daft. This draft marked the conclusion of the consulting process and became the last technical version of the benchmark before formatting and printing. 1 See: https://apps.who.int/iris/bitstream/handle/10665/44358/9789241599689_eng.pdf viii What does this benchmark cover? This document is structured in five parts: Introduction: gives a short briefing on the background and objectives of the document. Categories of training: provides training options applicable for a wide range of tuina service providers. Levels of training: defines general expertise and possible career pathways for tuina service providers. Components and requirements for full training: presents learning modules at different levels for people without a medical background. Components and requirements for adapted training: presents principles of adaptation in terms of learning modules for people with a traditional or conventional medical background. These five parts constitute a complete set of benchmarks for the training of tuina. Who is this benchmark for? By setting norms and standards, this document helps to address the issues related to minimum training requirements for quality tuina services. It offers a useful reference point to evaluate tuina service providers, which will benefit policy-makers, health workers, education providers and the public in general. Qi Zhang Head Unit of Traditional, Complementary and Integrative Medicine Department of Integrated Health Services World Health Organization ix x Tuina is a manual therapy aimed at treating various disorders and enhancing health. It remains one of the most commonly used modalities of traditional medicine practice. With the growing popularity of tuina worldwide, there has been a need for more countries to regulate its practice and practitioners for appropriate integration into health systems. In 2010, the World Health Organization (WHO) published the Benchmarks for training in tuina (1). These benchmarks presented what professional experts and health regulators considered to be appropriate training programmes for tuina practitioners, as well as physicians and primary health personnel who wish to provide tuina treatment. Various backgrounds of tuina service providers were inadequately addressed in this document, however, and there is a lack of defined career pathways for tuina providers. Based on this, these updated benchmarks try to reduce the gaps by setting up required leaning modules for each category of tuina service providers at different levels, so that individual practices and practitioners can be compared, evaluated and accredited. In addition to the introduction, this document incorporates four essential components – categories of training, levels of training, components and requirements for full training, and components and requirements for adapted training – to constitute a complete set of benchmarks for the training of tuina. 1 Introduction 1 2 2 Categories of training 2.1 Training for people without a medical background The training programme designed for people with little or no previous medical education or experience, who have completed secondary education, and who wish to qualify as tuina service providers subject to the recognition and accreditation imposed by local authorities, is referred to as full training in terms of basic or advanced requirements for complete learning modules, consisting of tuina, traditional Chinese medicine, conventional medical knowledge and other relevant areas. 2.2 Training for people with a traditional medical background The training programme designed for people with previous traditional medicine education, who have already gained experience in providing certain forms of traditional medicine practice, and who wish to include tuina in their treatment options or improve their knowledge and skills of tuina, is referred to as adapted training in terms of basic or advanced requirements for adjusted learning modules according to their actual situation, consisting of tuina, traditional Chinese medicine, conventional medical knowledge and other relevant areas. 2.3 Training for people with a conventional medical background The training programme designed for people with previous conventional medical education, who have already gained experience in their role as a physician or other health personnel, and who wish to include tuina in their clinical practice, is referred to as adapted training in terms of basic or advanced requirements for adjusted learning modules according to their actual situation, consisting of tuina, traditional Chinese medicine, conventional medical knowledge and other relevant areas. 3 4 3 Levels of training 3.1 Basic requirements With reference to the learning modules for providing a tuina service, the basic requirements are as follows: Brief history of tuina; understanding of selected meridians and commonly used acupoints (1); basic techniques of tuina manipulations; ability to conduct specialized examinations and give tuina treatment. Fundamental theory of traditional Chinese medicine; main methods of diagnosis. Essentials of anatomy, physiology and biochemistry of the human body; basic knowledge of diagnostic procedures, their uses and limitations from a conventional medical perspective; principles of hygiene and patient safety (2,3). Laws and regulations related to tuina practice, ethical considerations and professionalism. 3.2 Advanced requirements In addition to the basic requirements, the advanced requirements can be further elaborated in terms of learning modules as follows: Trends in tuina development; in-depth understanding of the whole meridian system and related acupoints; comprehensive techniques of tuina manipulations; ability to make and apply well-informed decisions of tuina treatment based on a comprehensive analysis of a patient’s condition. Knowledge of aetiology and pathology of traditional Chinese medicine; ability to establish a therapeutic principle based on the pattern differentiation. Knowledge of aetiology and pathology from a conventional medical perspective; knowledge of conditions that require urgent treatment or referral. Knowledge of best practice and research of tuina. 5 6 4 Learning modules for full training 4.1 Basic requirements 4.1.1 Learning module for tuina Briefing on tuina: history of tuina; origin and development of tuina. Theory of meridians and acupoints: distribution, functions and relative disorders of the 14 meridians, the eight extraordinary meridians and the 15 collaterals; names, codes, locations and indications of commonly used acupoints for tuina (1). Skills and techniques of safe tuina practice (4): name, classification and indications of tuina manipulations; key elements of basic tuina manipulations; procedures of tuina treatment; settings and facilities required for tuina treatment; precautions and contraindications of tuina treatment; infection prevention and control during tuina treatment; incident management during tuina treatment. Clinical application of tuina: ability to determine disorders that can be treated by tuina; ability to conduct specialized examination and establish therapeutic principles for tuina treatment; ability to locate treatment regions and apply basic tuina manipulations; ability to combine other traditional medicine approaches as appropriate; ability to recognize the limitations of tuina and refer to other health-care professionals as appropriate. 4.1.2 Learning module for traditional Chinese medicine (5) Concept of Yin/Yang and the Five Elements. Individual function and interactive relationship of Qi, Blood, Essence and Fluid. Physiological functions of the Organ systems and their interrelationships. Basic four methods of diagnosis, including inspection, auscultation and olfaction, enquiry, palpation and pulse-taking. 4.1.3 Learning module for conventional medical knowledge Essentials of anatomy (including anatomical location of acupoints), physiology and biochemistry. Ability to collect and integrate the patient’s clinical manifestations, physical examinations, laboratory findings and diagnostic imaging from a conventional medical perspective. Principles of hygiene and patient safety (2,3). 7 4.1.4 Other learning modules Ability to recognize and comply with laws and regulations related to a tuina service. Ability to recognize and comply with principles of medical ethics and professionalism. 4.2 Advanced requirements 4.2.1 Learning module for tuina Briefing on tuina: current trends of tuina practice; current trends of tuina research. Theory of meridians and acupoints: distribution, functions and relative disorders of the extended meridian system, including the 12 meridian divergences, the 12 cutaneous regions and the 12 meridian sinews; names, codes, locations and indications of extended acupoints for tuina. Skills and techniques of safe tuina practice: key elements of comprehensive tuina manipulations; knowledge of systemic tuina, including but not limited to tuina in the abdomen and tuina on the feet; knowledge of special tuina techniques, including but not limited to tuina for paediatrics and tuina for cosmetics. Clinical application of tuina: ability to make an informed decision on tuina treatment based on comprehensive analysis of the patient’s condition; ability to perform comprehensive tuina manipulations; ability to perform systemic tuina and special tuina techniques; ability to conduct self-training exercises for ongoing professional improvement; ability to instruct patients to perform appropriate functional exercises after treatment. 4.2.2 Learning module for traditional Chinese medicine (5) Pattern differentiation according to the theory of Eight principles, the theory of Qi, Blood, Eessence and Fluid, the theory of Organ system, and the theory of meridians and collaterals. Ability to analyse and synthesize clinical data to determine appropriate pattern differentiation and establish therapeutic principles accordingly. 4.2.3 Learning module for conventional medical knowledge Ability to achieve an appropriate diagnosis and a reasonable assessment from a conventional medical perspective. Ability to recognize a serious condition and administer first aid or refer to other health-care professionals as appropriate in emergency situations. 4.2.4 Other learning modules Ability to interpret the best evidence of tuina practice. Ability to apply the current knowledge of tuina research. 8 5 Learning modules for adapted training 5.1 Adapted training for people with a traditional medical background 5.1.1 Basic requirements adapted requirements for 4.1.1 according to actual situation; adapted requirements for 4.1.2 according to actual situation; full requirements for 4.1.3; full requirements for 4.1.4. 5.1.2 Advanced requirements adapted requirements for 4.2.1 according to actual situation; adapted requirements for 4.2.2 according to actual situation; full requirements for 4.2.3; full requirements for 4.2.4. 5.2 Adapted training for people with a conventional medical background 5.2.1 Basic requirements full requirements for 4.1.1; full requirements for 4.1.2; adapted requirements for 4.1.3 according to actual situation; adapted requirements for 4.1.4 according to actual situation. 5.2.2 Advanced requirements full requirements for 4.2.1; full requirements for 4.2.2; adapted requirements for 4.2.3 according to actual situation; adapted requirements for 4.2.4 according to actual situation. 9 References 1. Benchmarks for training in tuina. Geneva: World Health Organization; 2010 (https://apps.who.int/ iris/bitstream/handle/10665/44358/9789241599689_eng.pdf, accessed 28 July 2020). 2. Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. Geneva: World Health Organization; 2016 (https://apps.who.int/iris/ bitstream/handle/10665/251730/9789241549929-eng.pdf, accessed 28 July 2020). 3. Patient safety curriculum guide. Geneva: World Health Organization; 2011 (https://apps.who.int/iris/ bitstream/handle/10665/44641/9789241501958_eng.pdf, accessed 28 July 2020). 4. WHO benchmarks for the practice of tuina. Geneva: World Health Organization; 2020 (https://apps. who.int/iris/bitstream/handle/10665/340839/9789240016903-eng.pdf, accessed 17 May 2021). 5. International classification of diseases, 11th revision. Geneva: World Health Organization; 2018 (https://icd.who.int/dev11/l-m/en, accessed 28 July 2020). 10 Annex 1. Suggested subjects and learning hours for full training at basic and advanced levels Key subjects for each learning module are suggested below with corresponding numbers of learning hours to reflect the components and requirements for full training at basic and advanced levels. It is recognized that training should be competency-based, and adaptation will be applied in consideration of the trainee’s individual background and previous knowledge and skills. Learning modules Key subjects Basic level (hours) Advanced level (hours) Tuina Introduction to tuina 16 30 Meridians and acupoints 128 144 Tuina manipulations 80 96 Tuina treatment 96 128 Exercises for tuina 48 64 Acupuncture 48 128 Paediatric tuina – 64 Foot tuina – 48 Cosmetic tuina – 64 Subtotal 416 766 Traditional Chinese medicine Basic theory of traditional Chinese medicine 96 128 Traditional Chinese medicine diagnostics 96 128 Clinical essentials of traditional Chinese medicine – 176 Subtotal 192 432 Conventional medical knowledge Anatomy 128 128 Physiology 64 64 Pathology 64 64 Biochemistry 64 64 Diagnostics 96 96 Clinical essentials – 64 First aid – 32 Subtotal 416 512 Other relevant areas Medical laws and regulations 48 48 Medical ethics 32 32 Evidence-based medicine – 32 Research methodology – 32 Subtotal 80 144 Supervised clinical practice 400 500 Total 1504 2354 11 Annex 2. Working group meeting Participants WHO African Region Samuel Osei Kwarteng, Ghana Health Service/Ghana Police Hospital, Ghana Anastasia Michaelina Yirenkyi, Acting Director, Traditional and Alternative Medicine, Ministry of Health, Ghana WHO Region of the Americas Boyd R. Buser, Chair, Nominations Committee, Osteopathic International Alliance, United States of America Iva Lloyd, President, World Naturopathic Federation, Canada WHO Eastern Mediterranean Region Amir Hooman Kazemi, Traditional Medicine Faculty, Tehran University of Medical Sciences, Islamic Republic of Iran WHO European Region Mehmet Zafer Kalayci, Head, Traditional and Complementary Medicine Department, Ministry of Health, Turkey Hedwig Luxenburger, President, International Council of Medical Acupuncture and Related Techniques, Germany WHO South-East Asia Region Panita Kasomson, Huachiew Traditional Complementary Medicine Clinic, Thailand Drungtsho Tharpala, Department of Traditional Medicine Services, Ministry of Health, Bhutan WHO Western Pacific Region Yihuang Gu, Dean, Second Clinical Medical College, Nanjing University of Chinese Medicine, China Yi Guo, Dean, College of Clinical Medicine, Tianjin University of Traditional Chinese Medicine, China Longxiang Huang, Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, China Hidenori Ito, Oriental Medicine Research Center, Kitasato University, Japan Yong-Suk Kim, Chief, Department of Acupuncture and Moxibustion, Hospital of Korean Medicine, Kyung Hee University, Republic of Korea Lixing Lao, Director, School of Chinese Medicine, University of Hong Kong, Hong Kong Special Administrative Region, China Yachan Li, Director, WHO Collaborating Centre for Traditional Medicine, Health Bureau, Macao Special Administrative Region, China Zhengyu Li, Director, Tuina Therapeutic Section, School of Acupuncture-Moxibustion and Tuina, Shanghai University of Traditional Chinese Medicine, China 12 Fengxia Liang, Vice Dean, College of Acupuncture and Orthopedics, Hubei University of Chinese Medicine, China Baoyan Liu, President, World Federation of Acupuncture-Moxibustion Societies, China Liu Mingjun, Dean, College of Acupuncture and Moxibustion, Changchun University of Chinese Medicine, China Byung-Cheul Shin, School of Korean Medicine, Pusan National University, Republic of Korea Hua Wang, Former President, Hubei University of Chinese Medicine, China Jingui Wang, Vice President, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, China Zhihong Wang, Former President, Changchun University of Chinese Medicine, China Shan Wu, Director, Department of Tuina, Guangdong Hospital of Traditional Chinese Medicine, China Christopher Zaslawski, Discipline Leader, Chinese Medicine, School of Life Sciences, University of Technology Sydney, Australia Hong Zhao, Vice President, Acupuncture and Moxibustion Hospital, China Academy of Chinese Medical Sciences, China Observers Namwoo Lee, Jaseng Korean Medicine Hospital, Republic of Korea Salih Mollahaliloglu, Ankara Yildirim Beyazit University, Turkey WHO Secretariat Qi Zhang, Coordinator, Traditional, Complementary and Integrative Medicine, Service Delivery and Safety, WHO, Switzerland Qin Liu, Technical Officer, Traditional, Complementary and Integrative Medicine, Service Delivery and Safety, WHO, Switzerland Local Secretariat Xin Zhang, Changchun University of Chinese Medicine, China Jingzhi Wang, Hubei University of Chinese Medicine, China Xuqiang Wei, China Academy of Chinese Medical Sciences, China 13 Annex 3. Online consultation Participants WHO African Region Samuel Osei Kwarteng, Ghana Health Service/Ghana Police Hospital, Ghana WHO Region of the Americas Boyd R. Buser, Chair, Nominations Committee, Osteopathic International Alliance, United States of America WHO South-East Asia Region Drungtsho Tharpala, Department of Traditional Medicine Services, Ministry of Health, Bhutan WHO Western Pacific Region Yihuang Gu, Dean, Second Clinical Medical College, Nanjing University of Chinese Medicine, China Hidenori Ito, Oriental Medicine Research Center, Kitasato University, Japan Zhengyu Li, Director, Tuina Therapeutic Section, School of Acupuncture-Moxibustion and Tuina, Shanghai University of Traditional Chinese Medicine, China Byung-Cheul Shin, School of Korean Medicine, Pusan National University, Republic of Korea Jingui Wang, Vice Presidnet, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, China Zhihong Wang, Former President, Changchun University of Chinese Medicine, China Shan Wu, Director, Department of Tuina, Guangdong Hospital of Traditional Chinese Medicine, China Observer Namwoo Lee, Jaseng Korean Medicine Hospital, Republic of Korea WHO Secretariat Qi Zhang, Coordinator, Traditional, Complementary and Integrative Medicine, Service Delivery and Safety, WHO, Switzerland Qin Liu, Technical Officer, Traditional, Complementary and Integrative Medicine, Service Delivery and Safety, WHO, Switzerland 14
WHO BENCHMARKS FOR THE TRAINING OF TUINA Department of Integrated Health Services World Health Organization (WHO) Avenue Appia 20 – CH-1211 Geneva 27 – Switzerland