Lessons on integration from the developing world's experience

British Medical Journal, Jan 20, 2001 by Gerard Bodeker

It is now recognised that about half the population of industrialised countries regularly use complementary medicine. Higher education, higher income, and poor health are predictors of its use.[1] This growth in consumer demand and availability of services for complementary medicine has outpaced the development of policy by governments and health professions.

As Western governments grapple with policy issues entailed in integrating complementary medicine into national health services, many developing countries have long since addressed these issues. Their experience constitutes a valuable, although largely unexplored, pool of policy data.

Traditional medicine

Almost 20 years ago the World Health Organization estimated that "In many countries, 80% or more of the population living in rural areas are cared for by traditional practitioners and birth attendants."[2]

The WHO has since backed away from the 80% estimate, settling for the safer position that most of the population of most developing countries regularly use traditional medicine. Whereas most people use traditional medicine in developing countries, only a minority have regular access to reliable modern medical services. Hence the formalisation of the traditional sector has implications for equity, coverage of primary health care, and financing.

Key policy issues in integration have been outlined by Commonwealth health ministers.[3] Ministers established the Commonwealth Working Group on Traditional and Complementary Health Systems to promote and integrate traditional health systems and complementary medicine into national health care, giving consideration to several areas (box). Although it is not within the scope of this article to address all of these areas, several can be addressed by considering consumer trends, response from governments, and cost issues.

Consumers

Medical pluralism--the use of multiple forms of health care--is widespread. Consumers practise integrated health care irrespective of whether integration is officially present. In Taiwan, 60% of the public use multiple healing systems, including modern Western medicine, Chinese medicine, and religious healing.[4] A survey in two village health clinics in China's Zheijang province showed that children with upper respiratory tract infections were being prescribed an average of four separate drugs, always a combination of Western and Chinese medicine.[5] The challenge of integrated health care is to generate evidence on which illnesses are best treated through which approach. The Zheijang study found that simultaneous use of both types of treatment was so commonplace that their individual contributions were difficult to assess.

Integration

Asia has seen the most progress in incorporating its traditional health systems into national policy. Most of this began 30-40 years ago and has accelerated in the past 10 years. In some Asian countries such as China the development has been a response to mobilising all healthcare resources in meeting national objectives for primary health care. In other countries, such as India and South Korea, change has come through politicisation of the traditional health sector and a resultant change in national policy.

Two basic policy models have been followed: an integrated approach, where modern and traditional medicine are integrated through medical education and practice (for example, China, Vietnam) and a parallel approach, where modern and traditional medicine are separate within the national health system (for example, India, South Korea).

China

In China, the integration of traditional Chinese medicine into the national healthcare system began in the late 1950s. This was in response to national planning needs to provide comprehensive healthcare services. Previously, traditional Chinese medicine had been viewed as part of an imperial legacy to be replaced by a secular healthcare system. Integration was guided by health officials trained in modern medicine; harmonisation with modern medicine was the goal. This was accomplished by a science based approach to the education of traditional Chinese medicine and an emphasis on research. Both were supported by a substantial organisational infrastructure. To many observers, modern medical control over the terms and process of integration has resulted in the loss of important aspects of traditional theory and practice, issues seemingly unimportant to modern medicine. Fewer acupuncture points are taught than in the classic system, and aspects of the theory of traditional Chinese medicine have been de-emphasised. The effect of "modernisation" resulting in a lesser system has also occurred with traditional medical education in India.

The state administration of traditional Chinese medicine now comprises nine departments and manages the entire sector, ranging from legislation, regulation, and policy through to hospital administration, drug control, and international economic and academic cooperation. Hospitals practising traditional Chinese medicine treat 200 million outpatients and almost three million inpatients annually. Overall, 95% of general hospitals in China have traditional medicine departments, which treat about 20% of outpatients daily.[6]