Medical pluralism can potentially help achieve universal health coverage
Global formulas for assessing human healthcare resources don’t count traditional medicine practitioners. Photo: iStock The World Health Organization (WHO) prescribes a doctor-patient ratio of 1:1,000. The figure was arrived at after careful consideration and is a critical requirement to meet the Sustainable Development Goals set by the United Nations.
India’s population is set to surpasse China’s, with 1.428 billion people as against 1.425 billion, according to the latest United Nations Population Fund estimates. The existing healthcare system should struggle to meet the demands.
But in July last year, the Union Minister of State for Health and Family Welfare Bharati Pravin Pawar proclaimed in the Parliament that the country’s doctor patient-ratio has surpassed the gold standard set by WHO.
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“There are 1.3 million allopathic doctors registered with the State Medical Councils and the National Medical Commission (NMC) as of June 2022. Assuming 80 per cent availability of registered allopathic doctors and 565,000 AYUSH (Ayurveda, Siddha, Unani, Naturopathy, Homeopathy and Sowa Rigpa) doctors, the doctor-population ratio in the country is 1:834, which is better than the WHO standard of 1:1000,” Pawar argued in a written reply to a Rajya Sabha question.
However, a 2021 WHO report arrived at a different conclusion. FactChecker, a fact-checking initiative, parsed through the country-wise data by the WHO’s South-East Asia Region. It found that until 2018, India was below the 44.5:10,000 ratio set by the global strategy on human resources for health in 2016 and just above the 2006 standard of 22.8 healthcare workers per 10,000 population.
This dissonance partly exists because global formulas for assessing human healthcare resources don’t count traditional medicine practitioners.
Assuming an 80 per cent availability of the 1.3 million allopathic doctors for 1.24 billion people (according to the 2011 census), the doctor-patient ratio would translate to 1:1,194, online newspaper The Print reported, lower than what has been set by the WHO.
A closer assessment of the data shared by Pawar reveals how the 564,000 AYUSH doctors — a majority of whom practise Ayurveda — are tipping the scales in India’s favour. The importance of traditional medicine in provisioning universal health coverage has been recognised by the WHO, which has advocated for these systems to be “included in the provision of essential health services” in its 2019 Global Report on Traditional and Complementary Medicine (T&CM).
The global health body further argued: “Improving equitable access to safe, quality and effective T&CM services can potentially meet communities’ needs and build sustainable and culturally sensitive primary health care. The Declaration of Astana, adopted at the Global Conference on Primary Health Care in October 2018, made clear that the success of primary healthcare will be driven by applying scientific as well as traditional knowledge and extending access to a range of healthcare services, which include traditional medicines.”
This kind of global focus on bringing traditional medicines to the forefront of healthcare delivery is not happening in isolation. Until 2014, AYUSH was a department under the Union Ministry of Health and Family Welfare after which it became a ministry of its own.
Since then, the sector has received unprecedented attention, catapulted by the COVID-19 pandemic. This has also raised the importance of practising Ayurveda — and other indigenous systems of medicine — like never before.
But some academics and scholars in the field have their reservations about the reality of practising Ayurveda. GL Krishna — an Ayurveda physician, Homi Bhabha fellow and visiting scholar at Indian Institute of Science, Bengaluru — argued in an editorial for the English daily The Hindu how practising is not a “feasible career for most Ayurveda graduates” given the “trust deficit in these systems.”
Muneer Kutty graduated with a Bachelor of Ayurvedic Medicine and Surgery (BAMS) from Amrita Vishwa Vidyapeeth — a teaching and research institute in Kerala — in 2013. “I really did not anticipate what was in store for me. BAMS is a different world in itself,” he said in a conversation with Down To Earth (DTE).
A dichotomy overshadowed his undergraduate experience; what students are taught in 11th and 12th class science and modern subjects during BAMS often don’t align with what is taught in Ayurvedic scriptures.
“Our professors engage in a lot of verbal gymnastics to prove what was written in traditional texts centuries ago is correct even today,” Kutty said, adding that this incoherence eventually led to a feeling of insecurity.
After graduating in 2013, Kutty practised Ayurveda at a small clinic in his hometown in Kerala for six-seven months. But this experience was marred with a feeling of incompetence.
“I did not feel confident enough to diagnose a patient, prescribe them the appropriate treatment or even believe that these medicines would work. For a BAMS graduate, neither are you proficient enough in what the Ayurvedic scriptures are saying or modern medicine subjects and diagnostics,” he said.
Symptoms of these hurdles in the clinical practices of Ayurveda can be spotted when one takes a close look at the education system itself. There, issues range from a lacking clinical exposure, the need to update an age-old syllabus, improper teaching of modern medicine and the mushrooming of sub-standard colleges, DTE had earlier reported.
Focusing on the latter, PS Pandey, an Ayurveda practitioner based in Uttar Pradesh’s Benaras, said, “A drawback of our system of medicine and its education is that we cannot teach our students Ayurveda properly. This is closely linked to the eruption of poor-quality institutes. It’s only natural that this will translate into clinical practice also.”
Geetha Krishnan, former technical officer of traditional medicine at WHO, argued the feasibility of practising Ayurveda is dictated by public demand, which is very much there.
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“The skillset needs to be reinvented and reintroduced so that students of the current programme can be armed to address the needs of society appropriately. This expertise shouldn’t be developed only for what is required today but what will be required in the coming years,” Krishnan said.
Several scholars have also argued that given the lacunas in their education, practitioners often have to gauge what treatment truly works through a trial-and-error method — a luxury which not many can afford.
“Sifting the usable parts from the obsolete ones requires prior experience, a knowledge of practice trends and robust common sense,” Krishna argued.
But others believe that as a practitioner, you will have some degree of self-learning while practising.
“Given the nature of this system of medicine, an Ayurveda practitioner needs to understand a patient’s clinical symptoms far more subtly and analyse it with more scrutiny than their counterpart to decide the appropriate line of treatment,” Krishnan said.
Ayurveda’s focus on individualised treatment that stresses a customised prescription makes it incomparable to modern medicine, which functions based on standard operating protocols (SOP).
“Customisation is the soul of Ayurveda clinical practice and the demand of the current era is SOPs. This is a major conflict. And that’s why being an Ayurveda clinician is a difficult task,” Prasad Pandkar, an Ayurveda practitioner and teacher at Banaras Hindu University, told DTE.
While Kutty’s experience is singular and not a generalisation of what all students go through, of the 60 people in his batch, only about five or six still practise Ayurveda. A majority of them come from a long line of familial history in traditional medicine. Others sought the academic route by earning either an MS or MD in a specialisation.
“For those who are fortunate enough to get into a college as an assistant professor, the average pay is around Rs 30,000 per month. There is a waiting list for professors to get a job at self-financed colleges; some even demand a security deposit before getting the job. So even after 10 years of toiling, the job security is very poor,” Kutty said.
With limited avenues for clinical practice, many turn to modern medicine. But there is a clear geographical divide in what scholars — and state governments — think of this integration. For instance, Maharashtra, Punjab, Tamil Nadu, Assam, Himachal Pradesh, Gujarat, Bihar and Uttar Pradesh have allowed AYUSH practitioners to prescribe modern medicine.
Ayurveda becomes more insulated the further south one goes. Kerala, Karnataka, Andhra Pradesh and Telangana don’t allow AYUSH practitioners to practise modern medicine. The southern states are very committed to maintaining the purity of Ayurveda. The sector believes it will lose its autonomy if modern medicine is integrated.
“As an Ayurvedic scholar, I would be strongly against using an allopathic medicine or a system which you have not studied,” Krishnan said, but adds that ground realities cannot be ignored where Ayurveda doctors allegedly fill the gaps left by MBBS doctors, particularly in the rural healthcare delivery system.
However, available literature has pointed holes in this argument. Underlining that this integration does not help strengthen the credibility of traditional systems like Ayurveda, a 2018 paper published in the Journal of Ayurveda and Integrative Medicine argued: “Existing state policies that legitimise Allopathic practice by non-Allopathic practitioners do not help the rural poor to access proper medical treatment for acute conditions.”
Urban areas have seen a seven-times higher density of AYUSH practitioners compared to rural areas, with a doctor-patient ratio is 0.2:10,000, according to 2016 estimates based on National Sample Survey data.
“The public sector BAMS doctors are posted as District Ayurveda officers managing AYUSH dispensaries. These dispensaries are highly dispersed and maintained relative to a state’s interest and commitment to providing AYUSH services,” the Journal of Ayurveda and Integrative Medicine paper noted.
Certain policy changes are required if Ayurveda practitioners must be utilised to provide peripheral healthcare services. There is a need to reassess and ascertain the utility of Ayurveda knowledge and its skilling capability according to society’s requirements. This needs to be done regularly, Krishnan said.
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“If Ayurvedic doctors are being utilised to manage healthcare in rural areas, it should be made a point that they use Ayurvedic medicine. Before graduating, students must have more possibilities to learn alongside eminent practitioners who have the capability and skill to identify disease and diagnosis properly and decide what treatment to give at what stage,” he added.
As for Ayurveda practitioners practising modern medicine, it should only be looked at as a short-term solution and even then, they must be given specific training in modern medicine, over and above what they have studied, he added.
Disease burden is changing — more deaths are now recorded due to non-communicable diseases than ever before, up from 37 per cent of total deaths in 1990 to 61 per cent in 2016, according to government data. The opportunity is ripe for India to focus on improving the state of Ayurveda in India and utilising it appropriately.
Medical pluralism can potentially be the route to achieving universal health coverage.
“The strengths of traditional medicine for primary care, disease prevention, health promotion, mental wellbeing and delaying the progression of chronic diseases need to be utilised along with the advances of modern medicine in critical care, treatment of acute conditions and diagnostics,” a December 2022 paper published in The Lancet argued.
A career in Ayurveda practice must be motivated to realise this through robust clinical training, improved pay and clear definitions of their role.
This article was supported by Health Systems Transformation Platform as a part of HSTP – Health Journalism Fellowship 2022.
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