Supplement
WHO Country Cooperation Strategy 2006-2011 India Supplement
© World Health Organization Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. For rights of reproduction or translation, in part or in toto, of publications issued by the WHO Regional Office for South-East Asia, application should be made to the Regional Office for SouthEast Asia, World Health House, Indraprastha Estate, New Delhi 110002, India. The designations employed and the presentation of material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. August 2007
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Contents 1. Background on traditional medicine: global and India-specific.................... 1 2. Infrastructure of AYUSH ............................................................................. 3 3. Issues and challenges .................................................................................. 4 4. Mainstreaming AYUSH within the National Rural Health Mission ................ 6 5. WHO global and regional policy directions ................................................ 7 6. Channels of collaboration ........................................................................... 8 7. Strategic Agenda: Ongoing and future directions and priorities for cooperation ............................................................................ 9 Annexes 1. Summary of infrastructural facilities under Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homeopathy (AYUSH) ............... 11 2. Statewise number of registered AYUSH practitioners as on 1.1.2005 ......................................................... 12 3. Statewise/Systemwise number of AYUSH Hospitals with their Bed Strength in the country ...................................................................... 13
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Background Global background
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Traditional medicine (TM) refers to health practices, approaches, knowledge and beliefs incorporating plant, animal and mineral-based medicines, spiritual therapies, manual techniques and exercises, applied singularly or in combination to treat, diagnose and prevent illnesses or maintain well-being. Nearly 25% of modern medicines are derived from plants first used in traditional medicine. The global market for herbal medicines currently stands at over US$60 billion annually and is growing. Countries in Africa, Asia and Latin America use TM to help meet some of their primary health care needs. In Africa, up to 80% of the population uses traditional medicine for primary health care. In industralized countries, adaptations of traditional medicine are termed “Complementary”or “Alternative” (CAM). Traditional Medicine can also have an impact on infectious diseases. For example, the medicinal herb, Artemisia annua, used in China for almost 2000 years has been found to be effective against resistant malaria and could create a breakthrough in preventing almost one million deaths annually, most of them among children, due to severe malaria. Over one-third of the population in developing countries lack access to essential medicines. The provision of safe and effective TM/CAM therapies could become an important tool to increase access to health care.
India-specific background The Indian Systems of Medicine and Homoeopathy (Ayurvedic, Yoga & Naturopathy, Unani, Siddha and Homeopathy (AYUSH)) cover both the systems which originated in India and abroad, but which got adopted and adapted in India in the course of time. In the past decade, there has been renewed attention and interest in the use of traditional medicine in India and globally. It is estimated that 65% of the population in rural India use Ayurveda and medicinal plants to help meet primary health care needs1. India has 15 agro-climatic zones, 47,000 plant species and 15,000 medicinal plants that include 7,000 plants used in Ayurveda, 700 in Unani medicine, 600 in Siddha medicine and 30 in modern medicine. This makes India one among 12 mega bio-diverse countries 1
WHO Secretariat report on Traditional Medicine: Fifty-sixth World Health Assembly: Provisional agenda item 14.10
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of the world. The Indian systems of medicine have identified 1,500 medicinal plants, of which 500 species are mostly used in preparation of drugs. More than 150 plant species have been categorized as endangered. Many consumers use traditional medicine for self-care because of a wide perception that ‘natural’ means ‘safe’. Because of limited quality control and or improper use by consumers, misuse of herbal preparations has been reported. While traditional medicine has long been used, there is negligible documented evidence regarding its safety and effectiveness. The lack of evaluation has, in turn, slowed down the development of regulations and legislation. The rational use of traditional medicine is also hampered by the lack of appropriate training for providers and their ability to follow their stream of practice. In order to augment the use of traditional systems of medicine, the Government of India formulated a National Policy on Indian Systems of Medicine & Homeopathy in the year 2002.
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Infrastructure of AYUSH (please refer to pages 9 and 14 of the CCS document and organization of health sector)
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The department of AYUSH, established as an integral part of the Ministry of Health and Family Welfare in March 1995, addresses key issues relating to upgradation of the educational standards, strengthening the existing research institutions and ensuring a time-bound research programme on identified diseases, drawing up schemes for promotion, cultivation and regeneration of medicinal plants and evolving pharmacopoeia standards. Annexes 1 - 3 provide the infrastructure2 details.
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Department of AYUSH, Annual Report 2005-2006
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Issues and challenges
Over the centuries, India has used its rich knowledge of traditional medicine to prevent and treat diseases. This knowledge has generally been passed down by word of mouth from generation to generation, described in ancient classical and other literature, often inaccessible to the common man. Documentation of this existing knowledge has become imperative to safeguard the sovereignty of this knowledge and to protect it from being misused. Although traditional systems of medicine are recognized, their integration and mainstreaming in health care delivery systems, including in national programmes, remains a challenge. AYUSH manpower needs to be developed at the primary health care level on one side, and at specialty centres and referral AYUSH hospitals on the other. This would contribute towards improving access to basic health services as traditional medicine should find its proper place in national health care systems. There is a need to develop and strengthen complementarity between the two systems. There are opportunities for allowing the use of identified modern medicine drugs by AYUSH practitioners and updating the list of essential medicines for ayurveda, siddha and homeopathy. There is an advantage in appropriately training and orienting personnel from both systems to further strengthen complementarity. In order to use traditional medicines effectively, various therapeutic claims need to be assessed carefully. Standardization of formularies and drugs is a major challenge. The safety, acceptability and efficacy of various drugs and formularies need to be documented before they can be promoted for human consumption. At the same time, there is a need to promote the rational use of plant-based drugs. This need seems to be related to a global phenomenon. Researchers in the USA have shown that roughly 50% of adults who use herbal supplements in the USA do not use them in accordance with evidence-based indications. Though 70 countries have national regulations on herbal medicines, the legislative control of medicinal plants has not evolved around a structured model. This is because medicinal products or herbs are defined differently in different countries and diverse approaches have been adopted with regard to licensing, dispensing, manufacturing and trading.
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In addition to patient safety issues, there is the risk that a growing herbal market and its great commercial benefit might pose a threat to biodiversity through overharvesting of the raw material for herbal medicines and other natural health care products. These practices, if not controlled, may lead to the extinction of endangered species and the destruction of natural habitats and resources. Another related issue is that, at present, the requirements for protection provided under international standards for patent law and by most national conventional patent laws are inadequate to protect traditional knowledge and biodiversity.
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Mainstreaming AYUSH within the National Rural Health Mission (NRHM) (please refer to page 15 of CCS document)
Mainstreaming of AYUSH is a core strategy envisaged under the National Rural Health Mission with an objective to improve outreach and the quality of health delivery in rural areas. The objective of the integration of AYUSH in the health care infrastructure is to reinforce the existing public health care delivery system, with the use of natural and safe remedies, which are time-tested, accessible and affordable3. A functional integration between the AYUSH dispensaries/ hospitals and the health care facilities under the allopathic system is proposed so that the entire spectrum of treatments is made available to the rural poor at affordable cost. In this direction, AYUSH practitioners are being placed at health care facilities. For example, in Himachal Pradesh, more than 600 government ayurvedic dispensaries have been identified for ayurvedic doctors and 80 ayurvedic doctors are already posted in Primary Health Centres (PHCs). Similarly, states like Chattisgarh, Madhya Pradesh, Tamilnadu, and Uttarakhand, have posted ayurvedic doctors in PHCs4. Specialized clinics, one each in Ayurveda, Unani and Homoeopathy render services in the OPD of the two Central Government Hospitals in Delhi. Seven Ayurvedic and five Unani drugs have been supplied to nine States and four cities as part of the ongoing National Reproductive Child Health (RCH) Programme. The Department of AYUSH has identified these drugs keeping in view their utility for treatment of common ailments of pregnant women and children. The nine States covered under this programme are Chhatisgarh, Himachal Pradesh, Karnataka, Kerala, Madhya Pradesh, Rajasthan, Tamilnadu, Uttarakhand and Uttar Pradesh. AYUSH components have been incorporated in the training modules for Accredited Social Health Activists (ASHAs) with department officials contributing to their training on an ongoing basis. Guidelines have been issued to mobilize AYUSH practitioners in the NRHM at all levels, including State Health Mission, District Mission, and Rogi Kalyan Samitis. Indian Public Health Standards for AYUSH facilities in Sub-centres, PHCs and Community Health Centres have been finalized and forwarded to the Department of Health and Family Welfare for incorporation in the relevant documents. There are ongoing efforts to support the integration initiative of the States to establish AYUSH facilities in allopathic set-ups. Department of AYUSH, Annual report, 2005-06 National Policy & Programmes on Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homeopathy (AYUSH), Ministry of Health & FW, GoI, 2002 3 4
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WHO global and regional policy directions
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The World Health Organization launched a comprehensive traditional medicine strategy in 2002. The strategy is designed to assist countries to: • • • • • Develop national policies on the evaluation and regulation of TM/CAM practices; Create a stronger evidence base on the safety, efficacy and quality of the TAM/ CAM products and practices; Ensure availability and affordability of TM/CAM including essential herbal medicines; Promote therapeutically sound use of TM/CAM by providers and consumers; and Document traditional medicines and remedies.
The Fifty-sixth session of the WHO Regional Committee for South-East Asia in 2003 adopted a resolution, SEA/RC56/R6, with a view to share evidence-based information and country experiences on traditional systems of medicine in the Region as well as experiences from other regions; to assist Member States in strengthening national policies, strategies and plans of action; to establish a regional task force on traditional medicine for reviewing and facilitating the development of strategies and policies on traditional systems of medicine; and to advocate for the establishment of a “Global alliance on traditional medicine”.
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Channels of collaboration
The main CCS document elucidates the collaborative programme and the proportion of resources utilized at the national and state levels. Technical assistance in AYUSH follows the same approach as depicted in the diagram below, and amounts to US$300,000 in the current biennium 2006-07. The WHO Country Office works with the central and state research councils and educational institutions. Figure: Collaborative Programme of WHO India and the Department of AYUSH Main Channels of Collaboration
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Strategic Agenda: Ongoing and future directions and priorities for cooperation (please refer to page 33 of the CCS document)
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As articulated in the main CCS document, four high priority areas have been identified for WHO support. The first three areas concern communicable diseases; family and community health; as well as noncommunicable diseases and mental health. The fourth priority relates to the strengthening of health systems within the national and global environment, with a focus on human resources. This includes technical support from the WHO Country Offices (WCO) in the field of traditional medicine. The following are the specific areas where technical support has been initiated and would be pursued during the CCS period 2006-2011:
Policy Policy development is focused on strengthening legislation and the regulatory framework in the context of globalization, patent and intellectual property rights. Initiatives are being taken to address the need to review existing laws, strengthen regulatory capacity, and work with the states to amend the acts governing the practice of modern medicine by AYUSH practitioners as has been done in the states of UP , MP , HP , Gujarat, and Maharashtra.
Safety, efficacy and quality This includes research and development, notably safety, acceptability and efficacy of formularies. The WHO Country Office would also support operational research and documentation of health information for evidence-based decisions.
Documentation and preservation of practices As per the national ISM policy of protecting the country’s traditional medicinal knowledge, WCO extends support for translating and printing rare and old manuscripts of traditional systems. Currently the digitalization of libraries in the Unani Council and in the Yoga Institute are being supported. Work on the Traditional Knowledge Digital Library (TKDL) on Unani Medicine is progressing and is linked with the digitalization of the library. The transcription of the targeted 77,000 formulations which are in Urdu, Arabic and Persian from 42 Unani books is being carried out in the patent application format. It is intended to continue this support.
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Capacity building Institutional development is focused on strengthening laboratories and institutions for quality assurance and drug standardization; laboratory testing; quality control in manufacturing; international quality standards certifications (GLP, GMP); and strengthening legislation, regulatory framework, patent and intellectual property rights. WCO is supporting the Department of AYUSH to review its guidelines and protocols.
Promoting rational use In order to promote rational use, capacities of the providers need to be enhanced to enable them to properly use products of assured quality; facilitate good communication between TM/CAM providers, allopathic medicine practitioners and patients. It is important to increase the capacities of consumers to make informed decisions for the proper use of products of assured quality as this can contribute significantly in reducing the risks associated with TM/CAM products such as herbal medicines. WCO would continue to support the development of training guidelines for commonly used TM therapies and to strengthen the capacities of professional associations and academic institutions in this regard.
Access and partnerships There is a need to forge alliances and partnerships with the private sector to further improve access. However, access to services is contingent upon the ability to pay. WCO will attempt to facilitate such partnerships, analyse and disseminate strengths and weaknesses, stimulate discussions on the acceptability of strategies, and provide assistance for piloting such initiatives.
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Annex 1 Summary of infrastructural facilities under Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homeopathy (AYUSH) S. No. 1. 2. 3. 4. Beds Dispensaries Registered Practitioners (i) I Qualified (ii) Non IQ 5. (i) Colleges (U.G.) (ii) Admission Capacity (U.G.) 6. (i) Colleges (P.G.) (ii) Admission Capacity (P.G.) 7. Manufacturing Units Facilities Hospitals Ayurveda 753 35182 15193 438721 339233 99488 219 9865 57 905 7997 Unani 74 3774 1153 43578 22241 21337 37 1525 8 73 391 Siddha 276 2386 444 17560 4963 12597 6 320 3 110 446 Yoga 7 105 70 0 – – – – – – – Naturopathy 21 622 55 541 492 49 10 385 – – – Homeopathy 223 11205 5634 217460 150267 67193 178 12785 31 1040 659 Total 1355* 53296* 22635** 717860 517196 200664 450 24880 99 2128 9493
*Includes 1 Hospital of Amchi system with 22 Beds **Includes 86 Amchi Dispensaries
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Annex 2
Statewise number of registered AYUSH practitioners as on 1.1.2005 S. No. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. States /Union territories Andhra Pradesh Arunachal Pradesh Assam Bihar Chattisgarh Delhi Goa Gujarat Haryana Himachal Pradesh Jammu & Kashmir Jharkhand Karnataka Kerala Madhya Pradesh Maharashtra Manipur Meghalaya Mizoram Nagaland Orissa Punjab Rajasthan Sikkim Tamil Nadu Tripura Uttar Pradesh Uttaranchal West Bengal Andaman & Nicobar Islands Chandigarh Dadar & Nagar Haveli Daman & Diu Lakshadweep Pondicherry Total 438721 43578 17560 217460 541 717860 0 0 0 297 297 2923 4934 0 37423 45280 59569 13666 0 27017 100252 3542 980 16192 16902 49 37665 0 4448 20379 23744 0 17 5611 1607 0 0 0 0 1997 3106 7573 4383 1997 7571 33563 29734 0 0 0 230 230 14828 14945 47602 52372 938 63 609 2884 2 1366 0 0 7372 8871 8781 38407 2 116 23256 25245 56994 93663 18029 19629 7111 343 248 1663 456 162 0 0 0 0 7517 5714 1099 0 25794 27006 8666 505 Ayurveda 15231 0 250 131121 391 2264 0 3665 4 1049 Unani 5022 Siddha 0 0 0 0 0 0 Homeopathy 9422 74 624 27597 139 2915 Naturopathy 374 Total 30049 74 874 162383 534 6228
Source: State Governments
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Annex 3
Statewise/Systemwise number of AYUSH Hospitals with their Bed Strength in the country S. No. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. States /Union territories Andhra Pradesh Arunachal Pradesh Assam Bihar Chattisgarh Delhi Goa Gujarat Haryana Himachal Pradesh Jammu & Kashmir Jharkhand Karnataka Kerala Madhya Pradesh Maharashtra Manipur ** Meghalaya Mizoram Orissa Punjab Rajasthan Sikkim Tamil Nadu Tripura Uttar Pradesh Uttaranchal West Bengal Andaman & Nicobar Islands Chandigarh Dadar & Nagar Haveli Daman & Diu Lakshadweep Pondicherry Central Government Health Scheme CCRAS Ministry of Railways Ministry of Labour Ministry of Coal Total Ayurveda 8 (464) 1 (10) 1 (100) 11 (1090) 8 (420) 10 (643) 1 (40) 48 (1850) 8 (835) 24 (420) 2 (100) 1 (160) 122 (8147) 120 (3432) 32 (1345) 51 (7673) – – – 8 (488) 15 (1181) 84 (834) 1 (10) 7 (630) 1 (10) 151 (3727) 7 (319) 5 (509) – 1 (120) – – – – 1 (25) 24 (600) – – – 753 (35182) – – – – – 12 (280) – – – 74 (3774) 17 (875) 2 (8) 1 (60) – 1 (54) 13 (402) 0 3 (250) 5 (635) – – – 0 0 3 (30) Unani 6 (310) – – 4 (459) 1 (90) 2 (111) – – 1 (10) 0 3 (200) 2 (98) 20 (896) 35 (1300) 21 (1221) 44 (3080) 1 (10) 1 (10) 0 6 (175) 5 (195) 7 (250) 0 9 (535) 1 (10) 8 (345) 1 (50) 12 (630) – 1 (25) – – – – – 6 (85) – – – 223 (11205) 1 (25) Homeopathy 6 (300) 1 (50) 3 (105) 11 (510) 4 (130) 2 (150) 1 (50) 14 (970) Siddha – – – – – – – – – – – – 1 (10) 2 (170) – – – – – – – – – 271 (2121) – – – – – – – – – – – 2 (85) – – – 276 (2386) – – – – – – – – – – – – – – – – – – – – – – – – – 7 (105) Yoga – – 1 (25) – – 2 (65) – 1 (–) – – – – 3 (15) 5 (276) 1 (40) – – 2 (65) – 1 (14) – – 2 (22) – – – – – – – – – – – – – – – – – 21 (622) 1 (50) 4 (25) – 3 (–) – 1 (10) – Naturopathy 1 (120) – 0
Figures are provisional. Note: – Nil information. Figures within bracket indicate the bed-strength. India
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