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TRADITIONAL AND COMPLEMENTARY MEDICINE IN PRIMARY HEALTH CARE

TRADITIONAL AND COMPLEMENTARY MEDICINE IN PRIMARY HEALTH CARE

Acknowledgements

This document was produced as part of the Technical Series on Primary Health Care on the occasion of the Global Conference on Primary Health Care, under the overall direction of the conference coordination team. Technical direction was provided by Zhang Qi, Shannon Barkley and Ed Kelley in the department of Service Delivery and Safety, WHO headquarters, Geneva, Switzerland.

The writing team consisted of Sangyoung Ahn, Liu Qin and Aditi Bana, WHO headquarters, Geneva, Switzerland.

Valuable comments and suggestions to the first draft were made by Ghazanfar Khan (Consultant, WHO headquarters).

The views expressed in this document do not necessarily represent the opinions of the individuals mentioned here or their affiliated institutions.

WHO/HIS/SDS/2018.37

© World Health Organization 2018. Some rights reserved. This work is available under the “https://creativecommons.org/licenses/by-nc-sa/3.0/igo” CC BY-NC-SA 3.0 IGO licence.

The role of traditional and complementary medicine in primary health care Traditional and complementary medicine (T&CM) is a health practice with strong historical and cultural roots, which has global acceptability and applicability (1). The health practices included under the umbrella term of T&CM can vary from country to country and from region to region. T&CM (2) is an important primary health care resource to many populations, and has been recognized as a component of achieving “health for all” since the Declaration of Alma-Ata in1978 (3).

WHO acknowledges the contribution of T&CM to health, wellness, people-centred health care and universal health coverage and seeks to bring traditional medicine “into the mainstream of health care, appropriately, effectively, and above all, safely” (1, 4, 5).

Since the 1970s, the integration of ‘proven’ traditional practices with national health systems has been advocated to improve primary care access and health outcomes through increasing the availability of services as an additional point of contact (6, 7, 8, 9). This acknowledges that, in some areas, traditional practitioners are the first contact and sometimes the only health providers available, and traditional herbal remedies are used for primary health care (10).

The role of T&CM practitioners in educating individuals, families, and communities on health promotion, disease prevention, public health issues, and appropriate care-seeking can also be capitalized on in the search for having healthier populations (11,12,13).

The importance of traditional practices in self-care is also highlighted in the UN General Assembly’s resolution on adopting 21 June as the International Day of Yoga which acknowledges yoga’s significance in “building better individual lifestyle” and for “the health of the world population”(14).

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Traditional medicine — Traditional medicine has a long history. It is the sum total of the knowledge, skill and practices based on the theories, beliefs and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health, as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness.

Complementary medicine — The terms “complementary medicine” or “alternative medicine” refer to a broad set of health care practices that are not part of that country’s own tradition or conventional medicine and are not fully integrated into the dominant health care system. They are used interchangeably with traditional medicine in some countries (1).

Situation analysisThe interim data in the WHO Global Report on Traditional and Complementary Medicine shows that 87% of all WHO Member States formally acknowledge use of T&CM; 100 Member States have a national policy on T&CM; and 124 Member States have national regulation of herbal medicines. This shows a consistent upward trend in the number of Member States formally engaging with T&CM.

Almost half the population in many industrialized countries now regularly uses some form of T&CM (Unites States, 42%; Australia, 48%; France, 49%; Canada, 70%), and considerable use of some form of T&CM exists in many developing countries also (Chile, 71%; Colombia, 40%; up to 80% in African countries) (15). In the 2007 United States National Health Interview Survey, respondents reported using T&CM for wellness and disease prevention (16).

The National Health Insurance Service of the Republic of Korea demonstrates that the most frequent reason for visiting Korean health facilities is for musculoskeletal-related diseases,with 138 million visits in 2012 (17).

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Successful models of integrationPrimary care, with its emphasis on comprehensive, person-centred care and family and community orientation, has a central role in integrating care along the continuum of care.In many countries, primary care is a natural hub for integration with T&CM (18). If traditional and conventional medicine are to work effectively side by side in the health care system and if traditional and complementary medicine are to realize their potential in primary health care and health equity, an evidence-based approach is an important step (19). This evidence can guide decisions around effective modalities of traditional medicine as well as the best methods for integration.

In China, traditional medicine practitioners are allowed to practice both in public and private clinics and hospitals. The public or patients are free to choose traditional medicine or conventional medicine for health care services, or their doctors can provide advice on which therapies may be better suited to their particular health condition. The number of visits to traditional medicine health facilities in China was 907 million in 2009.

In India, all seven traditional systems or modalities of medicine with official recognition (ayurveda, yoga, naturopathy, unani medicine, siddha, sowa rigpa and homeopathy) have institutionalized education systems and research councils. Traditional medicine is also offered as a choice to people seeking health care at primary, secondary and tertiary levels. Services such as education on home remedies, locally available medicinal plants and yoga practice are included in the school health programme for preventive and health promotive care. The current National Health Policy 2017 also prioritizes including traditional medicine personnel to cater to the primary health care needs of urban populations (20, 21, 22).

In Malaysia,T&CM services are integrated in to public health care centres across the country.

In the Republic of Korea, doctors of Korean medicine can serve as public health physicians in a public health centre or sub-centre in a rural village, remote islands, and mountainous area for three years instead of doing the mandatory military service.

The wide utilization of T&CM in primary health care offers new possibilities in dealing with complex emergencies. In 2002, 58.3% of the total severe acute respiratory syndrome (SARS) patients received traditional Chinese medicine treatments (23); and during the great eastern Japan earthquake in 2011, kampo treatments were effective for treating both physical and mental distress, where modern medical facilities had been destroyed (24). A feasibility study was also carried out to evaluate the provision of acupuncture in a Japanese emergency department to patients presenting with pain and/or nausea (25).

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An evidence-based approach towards integrationEvery country in the world needs to be concerned about the sustainability of its health services. As a contribution to achieving sustainable services, T&CM has found global applications for the drivers of demand in many countries – in the prevention and management of chronic diseases, in symptom management, and in meeting the health care needs of ageing populations. Countries are seeking to expand coverage with essential services at a time when consumer expectations for care are rising, costs are soaring, and most budgets are either stagnant or actually being reduced. Given the unique health challenges of the 21st century, interest in T&CM is undergoing a revival because it is available, accessible, affordable and acceptable to the local population. This revival reinforces the need for countries to educate the consumer about the safety and quality aspects of T&CM to facilitate informed decision-making (26).

The concept of essential medicines has been accepted worldwide as a powerful tool to promote health equity and its impact is remarkable as one of the most cost-effective elements in health care. A total of 34 Member States reported that herbal medicines are included in their national essential drug list. The inclusion of herbal medicines in the list is evidence/risk-based, using the same criteria for selection as other medicines.

In Mongolia (27), in order to facilitate the safe and effective use of herbal medicines in primary health care, the Nippon Foundation, in collaboration with the Ministry of Health, developed family medical kits containing traditional medicines. Traditional medicines included in the kits had to be recognized by the Mongolian Ministry of Health and be in compliance with national policies. In Myanmar (28), household traditional medicine kits have been distributed to rural villages to provide access to common traditional medicines suitable for acute conditions.

A number of countries, for example, Cambodia, The Lao People’s Democratic Republic, Viet Nam and Thailand have established “medicinal gardens”at the community, village and home levels. To help support community involvement in the programmes, a range of medicinal plants that have been used traditionally, are culturally acceptable and are suitable for self-medication, are selected by the respective governments. An advantage of this cost-effective way of providing access to medicines is that as new evidence becomes available to support cultivation and the safety and effectiveness of herbal medicines, the gardens can be supplemented with plants to better target current and local health needs.

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Some traditional systems of medicine are highly developed and well documented. National governments systematically record and monitor the use of T&CM services, and 45 countries reported the coverage of T&CM by health insurance. WHO has devoted an entire chapter to traditional medicine in the International Classification of Diseases 11th Revision (ICD-11). This constitutes a significant step towards the integration of traditional medicine into the classification used in the conventional medicine ICD. It will enable easier counting of traditional medicine health services and measuring their type, frequency, effectiveness, safety, quality, outcomes and cost, both nationally and internationally.It will also allow the conduction of health systems research to count episodes in primary health care and better understand its health outcomes (29).

However, there are still many challenges faced by Member States in relation to T&CM. Seventy-four percent of the respondent Member States quoted a lack of research data as their top challenge, followed by a lack of financial support for research on T&CM, lack of mechanisms to monitor safety of T&CM practices and also a lack of education and training for T&CM providers. There are also cultural barriers (beliefs and attitudes), and a lack of support from central governments and institutions that decelerate the integration of T&CM within national health systems, particularly in primary care settings.

Mindful of the traditions and customs of peoples and communities, governments should consider how T&CM, including self-care, might support disease prevention or treatment, health maintenance and health promotion in primary health care, in line with patient choices and expectations, while remaining consistent with evidence on quality, safety and effectiveness (30, 31).

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A new era of primary health careTC&M will continue to represent a key component of primary health care in the modern era of demographic change, especially with ageing populations, and the significant epidemiological transitions to chronic diseases and multi-morbidity. It contributes to empowering people and communities and provides important modalities for prevention, promotion, treatment, rehabilitation and palliation in primary care. The generation, synthesis and dissemination of knowledge and information on T&CM will be an important part of a successful integration of T&CM in primary health care implementation. Active research on acupuncture (32), frailty in locomotor disease (33) and infectious diseases management using T&CM (34), among others, will contribute to this transition.

WHO will continue to provide policy guidance and leadership in bringing the best features of each system of medicine together within the context of primary health care, and will closely monitor the impact that T&CM can have when used alongside conventional medicine.

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