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StatuS and Role of ayuShand

local health tRaditionSundeR the national RuRal health MiSSion


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StatuS and Role of ayuSh

andlocal health tRaditionSundeR the national RuRal health MiSSion

Ritu Priya and Shweta A.S.

National Health Systems Resource Centre

National Rural Health MissionMinistry of Health & Family Welfare

Government of IndiaNew Delhi


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NHSRC, 2010

ISBN 978-81-908725-4-6

Published by the National Health Systems Resource Centre. NHSRC has been setup as an autonomous registered society under the National Rural Health Mission to

provide technical support and capacity building or strengthening the public health

system in India.Designed and Produced by Matrix Publishers 3, Akarshan Bhawan, 4754/23 Ansari Road, New Delhi 110002

www.matrixpublishers.org


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akwgms

Te National Health Systems Resource Centre (NHSRC) grateully acknowledgesthe constant support and guidance provided by Smt. S. Jalaja (ex-Secretary, Dept. oAYUSH), Shri Shiv Basant (ex-Jt. Secy., Dept. o AYUSH), Shri Verghese Samuel(ex-Jt. Secy., Dept. o AYUSH), Shri Amarjeet Sinha (ex-Jt. Secy., NRHM), Dr. G.S.Lavekar (Retd. Director CCRAS*) and Dr. A. Raghu (Assistant / Deputy Advisor,Dept. o AYUSH), Dr. Rama Jayasundar (Associate Proessor, AIIMS).

We thank the current Secretary AYUSH Shri Anil Kumar and the senior ocers o

his department or organising a detailed presentation and discussion on this reportin their oce and the valuable comments received, as also or their eorts to use thisreport or taking their programme orward.

We are also grateul to Dr. Arun Srivastava and Dr. V. Suhasini o the Society orEconomic Development and Environmental Management (SEDEM) or collaborative

preparation o tools or data collection.

We are indebted to members o the Programme Advisory Committee or theirguidance and support.

Te specic inputs in various phases o the study and the consistent support bymembers o the Public Health Planning team as well as Health Financing and HMISdivisions o NHSRC made the study possible.

We are thankul or:

Field Data Collection: Dr. S.N. Pandey, SOM-GOU and 10 State Investigatoreams

Data Entry Team: apan Banerjee and team (Data Solutions)

Validation Team: Dr. N. Srikanth, Dr. K. Prameela Devi, Dr. Shruti, Dr. B.Venkateshwara

* CCRAS Central Council or Research in Ayurveda & Siddha SOM-GOU School o Oriental Medicine -Te Global Open University


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Dr. Gurucharan Bhuyan and Dr. S. Selvaraju, Dr. Anil Khurana and Dr. Divya aneja,Research Ocers rom CCRAS, CCRHs, CCRUMp, and Dr. H.S. Dwivedi.

Report Writing: For writing the individual state reports, we thank Dr. Ramamani

Sundar or inputs in the amil Nadu report, Ms. Kriti Singh or as many as 9 states,Ms. Kamalini Mukherjee and Ms. Swati Das or some states. Support rom Dr. KumarAtanu and Mr. Ranvir Singh along with the AYUSH interns at NHSRC, Dr. VinodMishra and Dr. Bushra Naz is also acknowledged.

Conceptualisation, Coordination and Analysis:

Dr. Ritu Priya, Advisor - Public Health Planning (NHSRC), conceptualised the studyrom a health systems perspective, led the NHSRC team in development o tools andramework o analysis, as well as in report writing.

Dr. Shweta A.S., Consultant AYUSH, Public Health Planning (NHSRC),coordinated with the collaborating partners and contributed in analysis and

writing o the report. She led the validation exercise or knowledge and practice oproviders and the community rom the AYUSH perspective and developing relatedrecommendations.

Ms Ashi Karke or secretarial assistance and support and Shri Padam Khanna orcoordinating the publication o this study.

T. SundararamanExecutive Director, NHSRC

s CCRH Central Council or Research in Homeopathyp CCRUM Central Council or Research in Unani Medicine


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BRANCH NAME DESIGNATION

Ayureda 1. Dr. G.S. Lavekar Director, Central Council for Research in

Ayurveda & Siddha (New Delhi)2. Dr. N. Srikanth Asstt. Director, Central Council for Research in

Ayurveda & Siddha (New Delhi)

3. Dr. K.D. Sharma Retd. Dy. Director, Central Council for Research

in Ayurveda & Siddha (New Delhi)

4. Dr. Rammanohar Director, AVT Institute of Advanced Research,

Arya Vaidya Pharmacy (Coimbatore)

5. Dr. Raghu Asstt. Advisor, Dept. of AYUSH (New Delhi)

Yoga 6. Dr. I.V. Basavaraddi Director, Morarji Desai National Institute of Yoga

(New Delhi)

Unani 7. Dr. M. Khalid Siddiqui Director, Central Council for Research in Unani

Medicine (New Delhi)Naturopathy 8. Dr. B.T.C. Murthy Central Council for Research in Yoga &

Naturopathy (New Delhi)

9. Dr. S.N. Pandey Prof. & Head, School of Oriental Medicine, The

Global Open University (Nagaland)

Siddha 10. Dr. M.A. Kumar Dy. Advisor, Siddha, Dept. of AYUSH (New Delhi)

Homeopathy 11. Dr. S.R. Islam Director, Homeopathic Medical College, Bharti

Vidyapeeth University (Pune)

12. Dr. Anil Khurana Asstt. Director, Central Council for Research in

Homeopathy (New Delhi)

Allopathy 13. Dr. S.N. Deshpande HoD, Psychiatry, Dr. Ram Manohar Lohia Hospital

(New Delhi)

14. Dr. K.P. Singh Medicine Dept., Guru Teg Bahadur Hospital

(New Delhi)

LHT 15. Mr. G. Hari Ram

Murthy

Foundation for Revitalisation of Local Health

Traditions (Bangalore)

16. Smt. Bhanwar Dhabai Rashtriya Guni Manch (Udaipur)

Social Science 17. Prof. Madhulika

Banerjee

Associate Prof., Political Science, Delhi University

(New Delhi)

18. Prof. V. Sujatha Associate Prof., Centre for the Study of Social

Systems, Jawaharlal Nehru University (New Delhi)

NMPB 19. Shri B.S. Sajwan/T.U.

Haqqi

CEO, National Medicinal Plants Board (New Delhi)

Amchi/Sowa-Rigpa/Tibetan Medicine

20. Dr. Khangkar Dolkar Head, Dolkar Herbals (New Delhi)

Epidemiologist 21. Dr. Atul Kotwal Epidemiologist and Specialist in Community Health,

Armed Forces Medical College (Pune)

PROGRAMME ADvISORY COMMITTEE MEMBERS


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Inestigator

Teams

Name & Qualications of

Team Leader

Team

Associates

Central Team atDelhi, SOM

Dr. S.N. PandeyProf. and Head

School of Oriental Medicine

The Global Open University (Nagaland)

(Retd. Sr. Research Ofcer, CCRYN)

Mrs. Dhannya Pramod, M.Sc. (IT)Mrs. Richa Pandey, M.A. (Eco.)

Mrs. Bindu, B.A., Computer

Mr. Ashish Rawat

Dr. Manish Sharma, BAMS

Dr. M.P. Gandhi, MBBS

State Teams

Andhra Pradesh1. Dr. Jitendra Prasad Dr. P.N. Shivaraj

Assam2. Dr. Raj Kumar, N.D. Mrs. Renu Devi, M.A.

Bihar3. Dr. Awadhesh Kumar Mishra, BNYS Mr. Siddharth Saran, BA., PGDM

Dr. Chandra Sekhar Dwivedi,

BAMS

Delhi4. Brig. Subhas Chander Manocha Dr. Manish Sharma

Haryana5. Mrs. Hemlata Sharma,

N.D., M.A. (Yoga), M.Phil.

Mr. Vikas Dahiya, M.A.

Mr. Subhas Ghosh

Jammu & Kashmir6. Dr. H.N. Patwari, BAMS -

Jharkhand7. Dr. Awadhesh Kumar Mishra, BNYS Mr. Doob Raj Mehto, Dip. Acu.

Mr. Shiv Kar Purti (Retd. US, GOI)

Karnataka8. Dr. Nagendra Dr. Hema

Kerala9. Dr. Muruli Naik Mr. M.V. Joy

Manipur10. Dr. Raj Kumar, N.D. Dr. Rajeshwar Singh, BHMS

Mr. Ajit SinghNagaland11. Dr. Raj Kumar, N.D. Ms. Kevilhuninuo Nagi,

Anthropologist

Orissa12. Dr. S.K. Raut Ray, BSAM Dr. Kamal Mahapatra, BSAM

Punjab13. Mrs. Hemlata Sharma,

N.D., M.A. (Yoga), M.Phil.

Mr. Rajesh Kumar

Ms. Shilpa Gupta

Sikkim14. Dr. Sarju, BNYS Dr. Neelam, BNYS

Tamil Nadu15. Dr. Shivakumar, BSMS, MD Dr. Pasupathy

Tripura16. Dr. Debasis Bakshi, MBBS Shri T.N. Brahmachari

Uttarakhand17. Dr. K.K. Thakral/

Dr. Awadhesh Kumar Mishra

Dr. Sheel Shaurabh, BHMS

Dr. Padamen Singh Rawat, BNYSWest Bengal18. Dr. Debasis Bakshi, MBBS (Advisory support by

Dr. Krishna Soman, Ph.D.)

MEMBERS OF INvESTIGATOR TEAMS


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ixMessage

MESSAGE

Te National Rural Health Mission adopted a strategy o Mainstreamingo AYUSH and Revitalizing Local Health raditions. Te objective

was to co-locate AYUSH doctors at PHC and CHC and utilize theirservices to expand the basket o choices or the patients to chooserom.

Under NRHM most o the States are recruiting AYUSH doctors on contractualbasis and placing them at CHC and PHC. It has been observed that the use o localhealth traditions has shown an increase and an enabling environment has been created

wherein convergence with AYUSH has improved.

Te study undertaken by NHSRC in 18 States on Status and Role o AYUSH

and Local Health raditions under NRHM, provide valuable inormation andhighlights various aspects that need to be considered rom health system perspective.Te study comprehensively deals with the issues o coverage, quality and utilization oAYUSH services in public health system.

I am sure that the study will serve as a valuable guide or the planners both at Stateand national level to urther strengthen the initiative or Mainstreaming o AYUSHand Revitalizing Local Health raditions.

(P.K. Pradhan)


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xiMessage

MESSAGE

Te mainstreaming o Ayurveda, Yoga & Naturopathy, Unani, Siddhaand Homoeopathy (AYUSH) systems and revitalizing local healthtraditions are some o core strategies under National Rural HealthMission (NRHM). Under the NRHM, a large number o AYUSHacilities have been set up in PHCs, CHCs and District hospital withnancial support rom the Central Government. In addition, the

scope o this strategy is widened by introducing new components viz. upgradation

o AYUSH hospitals and dispensaries in the existing Central Sponsored Scheme orDevelopment o AYUSH Hospitals and Dispensaries.

Te National Health Systems Resource Centre (NHSRC) has been supporting themainstreaming o AYUSH through publication and organizing workshops or capacitybuilding. I place on record my appreciation or the eorts put in by the NHSRC inbringing out the publication regarding Status and Role o AYUSH and Local Healthraditions under the National Rural Health Mission.

(D. D. Sharma)


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xiiiContents

cs

Foreword xv

List of Abbreviations and Acronms xvii

Exective Smmar xix

List of Tables xxxix

List of Figres xli

Chapter I Introduction and Research Methodology 1

Chapter II Prole of AYUSH Health Services 25in the States

Section 1 Service Delivery Institutions Across States

Section 2 Facility Prole and Quality of Stand-alone and Co-located

AYUSH Services

Section 3 Status and Role of AYUSH Doctors

Section 4 Utilisation of AYUSH Facilities

Section 5 Pattern of AYUSH Services Development Across States

Chapter III Knowledge, Practices and Perceptions 113of the Health Service Providers and theCommunity

Section 1 Health Service Providers: Practices and Perceptions

Regarding AYUSH and LHT

Section 2 The Communitys Knowledge and Practice

Section 3 Validation of Provider and Community Knowledge &

Practices by AYUSH Principles and References

Chapter IV Discussion and Recommendations for 175Policy and Planning


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Annexures 223

1. Tools Used for Data Collection

(Schedules and Checklists; Group Discussion)

2. Validation Sample of Two States: Tamil Nadu and Orissa

3. Data on Private Institutions (Kerala Tamil, Nadu and Uttarakhand)4. Allopathic Prescriptions (Case Study in Tamil Nadu)

References and Resource Material 303


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xvForeword

Te National Rural Health Mission (NRHM) has renewed the emphasis onstrengthening Indian Public Health Systems in order to achieve the national goalo health or all. Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homeopathy(AYUSH) systems have been part o the Indian health care system much beore they

were integrated with NRHM. However, under NRHMs strategy o MainstreamingAYUSH and Revitalising Local Health raditions, these systems have now beengiven greater attention.

Tere have been several contractual appointments o AYUSH doctors across thecountry under the co-location strategy o NRHM. However, many questions havearisen about the coverage, quality, and demand or AYUSH services; about the role oco-location in improving coverage, and about the objectives o AYUSH providers andLH in strengthening the health systems.

Tis study was undertaken by the National Health Systems Resource Centre (NHSRC)in order to assess the Status and Role o AYUSH and LH and to analyse NRHMsstrategy o Mainstreaming AYUSH in terms o coverage and quality o services.

Te study, which covered 18 states in India, examined the status o stand-aloneAYUSH services in the public system and the co-located services under NRHM.A comparative analysis across the states revealed a wide variation o coverage, inquality o services, and actors that inuenced the development o AYUSH services.AYUSH and Allopathic services have been compared with reerence to some o the

parameters. Te study also assessed (a) the utilisation o services, (b) the perceptionso the providers based on exit interviews, and (c) perceptions o community throughhousehold interviews.

A comprehensive exercise using the principles and texts o AYUSH systems was

undertaken to veriy the conormance o community knowledge o LH and AYUSHproviders prescriptions with reerence to available standard protocols.

frwr


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Tis study is a pioneering eort to project the considerable public investment inAYUSH services. Further, it provides recommendations on how to strengthen it as

part o an integrated approach to administering comprehensive primary health careservices.

A number o questions or additional research have emerged; we hope this surveyreport will spur urther work on AYUSH services as part o Public Health Systems.

Dr. T. SundararamanExecutive Director

NHSRC, New Delhi


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xviiList of Abbreviations and Acronms

LIST OF ABBREvIATIONS AND ACRONYMS

AFI - Ayurvedic Formulary of India

ANC - Antenatal Care

ANM - Auxiliary Nurse Midwife

AOP/f/d - Average Outdoor Patients/facility/day

API - Ayurvedic Pharmacopoeia of India

ASHA - Accredited Social Health Activist

AYUSH - Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homeopathy

BEmOC - Basic Emergency Obstetric Care

BHW - Basic Health Worker

BPL - Below Poverty Line

CAM - Complementary and Alternative Medicine

CCRAS - Central Council for Research in Ayurveda & Siddha

CCRH - Central Council for Research in Homeopathy

CCRUM - Central Council for Research in Unani Medicine

CCRYN - Central Council for Research in Yoga & Naturopathy

CHC - Community Health Centre

CSS - Centrally Sponsored Schemes

DH - District Hospital

DHS - District Health Society

FH - Faith Healer

FoH - Folk Healer

GDMO - General Duty Medical OfcerGH - Government Hospital

HMIS - Health Management Information System

IMNCI - Integrated Management of Neonatal and Childhood Illness

IPHS - Indian Public Health Standards

ISM&H - Indian Systems of Medicine & Homeopathy

JPHN - Junior Public Health Nurse

LHT - Local Health Traditions

MAAS - Maharashtra Association of Anthropological Studies

MCD - Municipal Corporation of Delhi

MCH - Maternal & Child Health

MO - Medical Ofcer

MPHA - Multi-Purpose Health Assistant

NA - Not Available


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NCAER - National Council of Applied Economic Research

NCDs - Non-Communicable Diseases

NFHS - National Family Health Survey

NGO - Non Government Organisation

NHP - National Health Programmes

NHSRC - National Health Systems Resource Centre

NRHM - National Rural Health Mission

NSSO - National Sample Survey Organisation

OPD - Out Patient Department

ORS - Oral Rehydration Solution

PHC - Primary Health Centre

PNC - Post-natal Care

RCH - Reproductive & Child Health

RH - Rural Hospital

SBA - Skilled Birth Attendant

SC - Sub-Centre

SEDEM - Society for Economic Development and Environmental Management

SFI - Siddha Formulary of India

SGDP - State Gross Domestic Product

SHRC - State Health Resource Centre

SHS - State Health Society

SHSRC - State Health System Resource Centre

SIHFW - State Institute of Health & Family Welfare

SMPB - State Medicinal Plants Board

SPI - Siddha Pharmacopoeia of India

ST - Scheduled Tribes

TBA - Traditional Birth Attendants

TCAM - Traditional Complementary and Alternative Medicine

THP - Traditional Health Practitioners

TM - Traditional Medicine

UFI - Unani Formulary of India

UPI - Unani Pharmacopoeia of India

VHN - Village Health Nurse

VHSC - Village Health & Sanitation Committee

WHO - World Health Organization


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Exective Smmar xix

EXECUTIvE SUMMARY

AYUSH*

services have been viewed as one way o ensuring access to some orm ohealth care to the rural and poor population groups who are underserved by thedominant system. However, with the dominance o modern medicine over the pastcentury, there has been a drastic decline in the legitimacy and services o the othersystems. Now, with the enhanced recognition o their complementary strengths, thereis resurgence o utilisation o raditional, Complementary and Alternative Medicine(CAM), by the well-o o developed as well as the better-o o the developingcountries. With concerns o equity and access in health care, a serious questionarises about the availability and access o quality AYUSH services and Local Healthraditions (LH) or all.

India is one o the ew countries that have developed services o traditional medicinethrough the ocial planning process o the health service system. In 2005, the launch othe National Rural Health Mission (NRHM) included the strategy o mainstreamingo AYUSH and revitalisation o LH. Te NRHM is mandated to strengthen the

public system o health services with architectural correction so as to ensure accesso all to quality care, with special ocus on the marginalised sections. Te strategy omainstreaming AYUSH provides or co-location o AYUSH doctors and paramedicsat the Primary Health Centres (PHCs), Community Health Centres (CHCs) andDistrict Hospitals (DHs). Tere are diverse views regarding the primary objectives othis strategy even within the NRHM, where it is viewed either as a way o obtaininghealth care providers or the rural areas where Allopathic doctors are unwilling tobe posted, or as a way o increasing access to and strengthening the services o theAYUSH systems, i.e., mainstreaming o the AYUSH providers or mainstreaming o the AYUSH systems. Keeping both objectives in mind, it was considered important toassess the quality and extent o roll-out o the strategy, so that mid-course correctionscan be undertaken. Tere is little literature available on the AYUSH services in the

* Te acronym AYUSH (Ayurveda, Yoga & Naturopathy, Unani, Siddha & Homeopathy) represents thetradition o systematised, textual health knowledge systems other than the modern.

Local Health raditions (LH ) represent the practices and knowledge o the common people andolk practitioners who ollow an oral tradition o learning and passing on o the knowledge throughpractice.


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public system prior to NRHM, and almost none afer its implementation has begun.Hence, NHSRC undertook this study.

Objectives of the Study

o delineate the implications o the NRHM strategy o mainstreaming AYUSH interms o coverage and quality o services as assessed by public health managementcriteria, by AYUSH criteria, and by the demand or services.

Research Questions

WhatisthecoverageandqualityofAYUSHservices?

HowdopeopleperceivethesesystemsandLHT?

WhatisthedemandforservicesofAYUSHandthefeltneedforLHT?

Isitbeingmet/takenintoconsideration?

Isco-locationimprovingcoverage?Isco-locationprovidingqualityservices?

WhatistheprovidersperceptionofthevalueofAYUSHsystems?

Whatistheproviderspotentialroleinstand-aloneandco-locatedservicesandwhatneedstobedonetoensuretheyfullthatpotential?

WhatisthepotentialroleofLHTandwhatistheroleitisplayingatpresent?Whatneedstobedonetoachievethatpotential?

METHODOLOGY

Te study covers 18 states o India, with data collected in 2008 and 2009. In eachstate it ocused on the coverage and quality o stand-alone AYUSH services existing

prior to NRHM and the co-located services largely initiated under the NRHM inthe public system (except in amil Nadu and West Bengal where it was signicanteven earlier). Comparative analysis across the states has allowed an examination o theactors that inuence the development o AYUSH services in the public system. Some

parameters, such as o institutional coverage, number o doctors in the public systemand the rationality o their prescriptions as well as practice o cross-reerral, have alsobeen compared between the AYUSH and Allopathic services.

High Focus states Jammu & Kashmir, Uttarakhand, Orissa, Bihar and Jharkhand.

High Focus North East states Assam, Manipur, Nagaland, Sikkim and ripura.

Non-High Focus states Andhra Pradesh, Haryana, Punjab, West Bengal, Karnataka, amil Nadu,Kerala and Delhi.


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Exective Smmar xxi

Te demand or AYUSH services has been assessed by triangulation o the perceptionso patients through exit interviews, community through household interviews, andinterviews o Allopathic and AYUSH providers at the stand-alone and co-locatedinstitutions. Data on utilisation o AYUSH services as well as the LH provides

concrete representation o the demand. Respondents o the exit and householdinterviews included dierent socio-economic groups, both sexes and the young,middle-aged and elderly age groups.

Knowledge o the LH and rationality o AYUSH providers prescriptions was validated against the principles and texts o the our systems AUSH. Issues ointegration and interaction across the systems, as perceived and practiced by the healthcare providers and the community, have been explored as well.

MAJOR FINDINGS

Level of Utilisation of AYUSH Services

State and institutional level OPD (Out Patient Department) attendance data showsthat the stand-alone services were better utilised than the co-located in most states.

OPD Attendance at Stand-alone Services

1. Tere is a highly variable utilisation across the states, rom an average o 8 patientsper acility per day (AOP//d) to 78 patients.

2. Nagaland, Jammu & Kashmir, Jharkhand, Haryana and Karnataka had an averageo less than 20 patients AOP//d. However, data collected rom the acilitiesthemselves was 20 patients or more, in these states as well.

3. Uttarakhand, Manipur and West Bengal got 20-40 AOP//d.

4. Orissa, Andhra Pradesh and Kerala showed a state level average between 40 and60 AOP//d.

5. amil Nadu received the highest number o AOP//d, 78 was the state levelgure and 43 the district level.

6. At the acility level in the study districts, AYUSH dispensaries reported providing

services rom 20-127 AOP//d. Te relative ranking o states, however, remainedsimilar to the aggregate data, with minor variations, e.g., Kerala moved up overamil Nadu.


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OPD Attendance at Co-located Services

1. OPD attendance ranged rom 1-4 AOP//d in 8 states, 5-9 in 2, 10-14 in 1, over45 in 1 and over 75 in the exceptional case o amil Nadu.

2. Te co-located services in amil Nadu and Andhra Pradesh had an OPDattendance similar to that o the stand-alone. West Bengal had an even higherattendance at the co-located than the stand-alone acilities.

3. Te attendance at Allopathic acilities ranges rom similar gures as the AYUSHstand-alone acility in Orissa, Manipur and Andhra Pradesh, to about 5 timesthat o AYUSH (as in West Bengal).

4. It is important to note that amil Nadu and West Bengal had initiated co-location oservices well beore the others in the pre-NRHM phase. It can, thereore, be hopedthat the attendance will pick up in the other states as the co-location stabilises.

Tus, while there were some poorly and some well utilised acilities in each state, theocial records o the AYUSH institutions and the state directorates data on OPDattendance showed a airly good level o average acility utilisation or AYUSH stand-alone services in most states. Te OPD attendance data rom the acilities includedin this study, as also observed by the investigators, showed an even higher utilisationthan the state and district aggregated data, thereby giving condence that theaggregated state data was reecting the lower end o the reality and not over-statingit. Indoor services were also in use where they were made available, e.g., in the states oUttarakhand, amil Nadu and Kerala.

Te co-located services were well utilised where they have been in place and wellunctioning or several years. In most states, however, they were still to nd wideusage, though marked variations were ound, as expected, across acilities and districtseven within a state.

Utilisation Reported by Households

Household reporting o use o AYUSH services in the last three months alsocorroborated the high utilisation in most states, ranging rom 20% to over 90%. One-third states had up to 30% reporting utilisation, another one-third had 30-60%, and

the rest one-third states, 60-98% reported utilisation in the last three months.

Tis gure o utilisation o AYUSH OPD services may be higher than in other partso the state, since the design criterion was selection o a good AYUSH services district


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Exective Smmar xxiii

and the households were rom villages where an AYUSH public service acility wassituated. In most states, the household responses included both public and privateservice utilisation. However, it does reect the widespread popularity o AYUSH.

Level of Utilisation of LHT

In 14 o the 18 states, 80-100% o the households reported use o LH. Tey aremost commonly used in the poorest regions which also have the poorest services inthe public and private sectors. In the Non-High Focus states with relatively goodhealth services, i.e., amil Nadu, Kerala, Haryana and Karnataka (those with higheraverage state per capita income and better-developed general health services in the

public and private sectors) too, the use o LH was still in the range o 50-75%.In the exit interiews 2-73% o patients reported use o home remedies or their presenting

illness, and 18-80% were continuing them together with AYUSH and Allopathictreatment, respectiely. Tis corroborates the household reporting o high use o homeremedies.

Te high utilisation o AYUSH serices and LH in states such as amil Nadu and Kerala reutes the argument equently made, that people resort to them because o inaccessible or unaordable general modern health serices. Tese are the states with thebest unctioning public systems o ee health care and high utilisation o Allopathic publicand priate serices. It indicates the community elt need or serices other than that othe modern system. Te pluralistic health seeking behaiour reects the inherent strengths

and limitations o the arious systems, thereby indicating a demand or AYUSH sericesthat remains unullled in the other states due to poor quality o serices and/or poorcoverage.

Pattern of Usage of AYUSH and LHT

Tere is a clear distinction made by the community members between the conditionsor which LH, AYUSH or Allopathy is considered more useul. An importantnding is that AYUSH and LH are in use or both acute and chronic conditions.Broadly, only the serious emergency conditions are excluded or resorting to AYUSHservices.

LH were being used or the early stages o any disease, and in chronic conditions.Tey were largely also continued when taking Allopathic treatment.


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For Treating Chronic Conditions

More cases o chronic illness were ound among the patients taking AYUSH treatment,as compared to those taking Allopathic treatment. Joint pain, skin problems andrespiratory disorders are amongst the most commonly mentioned health problems or

which AYUSH is sought or, as mentioned both by the users (exit interviews) and thecommunity (household interviews). High blood pressure, heart disease and diabetes,are also among the top ve mentioned by community members in several states.

For Treating Acute Illness

However, it is important to note that among the users o AYUSH services, the largestnumber was or acute everyday problems such as cold & cough, ever, diarrhoea anddiculty in breathing or all age groups. Jaundice and Chikungunya have also beenamong the top ve mentioned in some states.

For Promotive and Preventive Functions

Specic usage o the Siddha acility or increasing childrens immunity is a specialnding in amil Nadu. However, their use or promoting health o the mother during

pregnancy as well as or the babys health is extremely widespread. Tey are popularor recuperation in conditions such as malnutrition and convalescence.

Communitys Perceived Reasons for

Utilisation of AYUSH and LHTReasons o valuing AYUSH are those that are commonly accepted in health literature:

previous experience o getting cured, belie in the traditional system, side eectso the allopathic medicine, perceived eectiveness in chronic diseases, easy to use(community can well relate to) and no other option o health acility available.

Eective, cheap, easily available, easy to use and no side eects were the commonlycited reasons why the LH were ound useul.

Level of Awareness in the Communityregarding AYUSH and LHT

Across the states, awareness regarding medicinal plants was ound to exist in 47-100%households, and about ood items having medicinal properties was ound to exist in


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Exective Smmar xxv

54-100% households. Kerala and Karnataka had the lowest responses, while in allother states responses were about 90% or more.

Validity of Community Knowledge and Practice

Te communitys knowledge o medicinal plants and medicinal value o oods wasvalidated in all 18 states.

More than 75% o home remedies used or diarrhoeal disease, anaemia and diabetes,as well as in convalescence and maternal and child health (MCH) conditions, were

validated across the states.

Tis is generally indicatie o the strength o peoples knowledge and its links with theindigenous systems suggesting that it should be the base to build upon as a positie resource

rather than being neglected or een denigraded, as ofen implied in the general Inormation,Education and Communication (IEC) messages and health providers communications.Tis also implies that the peoples knowledge can urther be strengthened and updatedas per AYUSH scientic episteme or larger prophylactic and therapeutic use. It can alsocontribute to the strengthening o content o the AYUSH systems.

Perceptions and Practices among HealthCare Proiders Related to AYUSH and LHT

70% o the Allopathic doctors were o the view that AYUSH systems are not

redundant and suggested ways o strengthening their services. Tey also mentionedhome remedies as useul. 55% o them advised home remedies in combination withAllopathic treatment to their patients.

Te AYUSH as well as the Allopathic doctors expressed the need or researchand documentation o some common health practices and illustratively quoteda ew.

Te ASHAs across the states [and Village Health Nurses (VHNs) in amil Nadu]had good knowledge about local medicinal plants and advised herbal remedies to

people in the community. However, their level o responses was lower than rom thehousehold interviews in the community. Tis was relatively low in Kerala, Punjab andHaryana.


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Stats and Role of AyuSh and Local healt Traditions nder te NRhMxxvi

Practice of Combination Treatment and Cross-Referral

between Different Systems

Both the Allopathic and AYUSH doctors have listed several conditions or whichtreatment o dierent systems is combined. Tey also list conditions where AYUSH

providers reer to Allopaths, and others where Allopaths reer to AYUSH. However,the cross-reerral was done verbally and in an inormal way, thereby not beingdocumented or ormally recognised.

Te conditions or which combination or reerrals were listed by the doctors tendto tally very well with the peoples perceptions and use. Tis triangulation is a strongbasis or urther examination and inclusion o those ound cost-eective, sae andeasily accessible into multi-pathy Standard Guidelines or reatment.

POPULATION COvERAGE OF AYUSH SERvICES

Number and Type of Facilities Stand-aloneand Co-located

Tere is a wide network o stand-alone AYUSH acilities in the public system in moststates, ranging rom 1 institution per 17 thousand persons in Uttarakhand to a lowo 1 or over 1 lakh in Jharkhand and Bihar. With co-location, the ratio o serviceinstitutions to population improved to 1:12 thousand in Uttarakhand (rom 1:17thousand), and 1:14 thousand in Orissa (rom 1:33 thousand) to 1:60 thousand in

Andhra Pradesh (rom 1:76 thousand).

In the states o West Bengal and amil Nadu, where large-scale co-location existed evenbeore NRHM, the result o the NRHM strategy has been addition o co-locationacilities at the Primary Health Centre and Community Health Centre levels. Earlier,the ocus was on District and Sub-district Hospitals.

Relative to Allopathic acilities [excluding Sub-Centres (SCs) which are not meant tohave doctors providing services], the total AYUSH services still remained low in moststates even afer co-location. Te exceptions were Kerala, ripura and West Bengal,

where the AYUSH service institutions were more in number than the Allopathic evenprior to NRHM. In Orissa, the number o AYUSH service institutions became morethan that o Allopathy afer co-location under NRHM, as has the ratio o doctors inthe same proportion.


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Exective Smmar xxvii

Among the High Focus states, the hill states, i.e., the North East (NE) states (exceptripura and Assam), Jammu & Kashmir and Uttarakhand had the best coverage byAllopathic institutions, the Government o India having set lower population norms inthese areas with dicult terrain. However, they have very varied coverage by AYUSH

services; Uttarakhand, ripura and Jammu & Kashmir, having good coverage, andManipur, Assam, Nagaland and Sikkim having poor coverage. Bihar and Jharkhandhave poor coverage o both Allopathic and AYUSH services. Orissa is the exception

with good coverage o both.

Among the Non-High Focus states, Punjab and amil Nadu have good coverage oAllopathic services, but amil Nadu lags in coverage o AYUSH services. All othershave low institutional coverage o Allopathy, and even lower o AYUSH services.Kerala is the exception with the highest coverage o Allopathy and AYUSH services.

QUALITY OF AYUSH SERvICES

Te quality o AYUSH services was assessed based on a set o parameters coveringinrastructure, human resources, supplies, record-keeping and other inputs. Whilethe quality varied across states, in almost all, the quality o inrastructure, presence ohuman resources, supply o medicines, and records were ound to be unsatisactory.Combining indicators or all these parameters a qualitative grade was composed orthe quality o acilities in each state.

Among the stand-alone acilities, in 8 states they were graded air, in 2 good and in

3 very good. Among the co-located, 7 were graded poor, 6 air and 2 good. Tus,the quality o services was ound to be better in the stand-alone than the co-located,the gradient across states being similar.

Infrastructure and Logistics

Among the stand-alone institutions, the hospitals generally had good buildings withreasonable maintenance; however, the dispensaries were in comparatively poorershape in all states, some still running rom semi-pucca or kaccha buildings even in

the Non-High Focus states. Cleanliness was generally ound to be lacking in mostinstitutions, especially in the toilets and the vacant space in the compound. Watersupply and electricity were generally erratic, with no back-up o tanks or generators.

Vacant space around the compound was generally ound in the acilities covered


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Stats and Role of AyuSh and Local healt Traditions nder te NRhMxxviii

across states, except Delhi, though it lay unutilised or herbal gardens or quarters orthe sta.

Among the co-located acilities, the District Hospitals had separate space or the

AYUSH OPD in all states, the CHCs had separate space only in Orissa, Manipurand Sikkim, and in no state in the PHCs. Signages were generally not adequate. Whilewater supply and electricity were generally erratic, there was back-up o tanks andgenerators or the whole institution that beneted the AYUSH services as well. Mosthad some vacant compound but no herbal gardens.

Tus, on an average, all the states could just qualiy marginally or marks on theparameter o inrastructure.

Drug Supply

Te supply o AYUSH medicines was stated to be inadequate by the providers andusers, and the packaging and drug dispensing has been reported as inconvenient tothe patients.

Supplies were generally better at the stand-alone than the co-located services. TePHCs in particular had poor supply; a large number o those studied not yet havingbegun to get AYUSH medicines.

Diagnostics

Diagnostic acilities are available at the co-located institutions, but only at very ewstand-alone AYUSH hospitals, and none at the stand-alone dispensaries.

Human Resources

Te ratio o number o AYUSH doctors to AYUSH institutions reveals the positiono vacant posts and lack o doctors and paramedics in the public system in atleast5 states Bihar, Jharkhand, Manipur, ripura and Punjab. With co-location, underNRHM, the doctor : population ratio has improved considerably. Jammu & Kashmirand Orissa have among the best AYUSH doctors in the public system: populationratio afer co-location, at approximately 1:15 thousand. Bihar, with no co-location,has the worst at over 1:4 lakh.


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Exective Smmar xxix

However, across states, despite co-location, the AYUSH doctors continue to be 2 to15 times less than the Allopaths. Orissa is an exception since it now has more AYUSHdoctors than Allopaths in the public system.

Salary Structure

Tere is parity in salary structure between the AYUSH and Allopathic doctors in onlya ew states; among the doctors in regular service in Kerala, amil Nadu and Jammu& Kashmir, and among the contractual doctors in co-located acilities o Jammu &Kashmir, Bihar, Manipur and ripura. In all others, it is much lower than that o theAllopaths.

Designation

In Haryana and amil Nadu, the AYUSH doctors are designated as Assistant MOs(Medical Ocers) irrespective o their level o seniority. Tey do not become in chargeo acilities i an Allopath is also posted at the same acility.

In all other states, the designation is MO, but the charge remains with the Allopaths.

Roles and Responsibilities of AYUSH Doctors

Primarily OPD services seem to be the major activity o AYUSH doctors. Where thereis no other doctor, they practice both Allopathy and AYUSH. Tis is specially markedat the PHC level in most states. In CHCs and District Hospitals, they practice theirown system o medicine most o the time. In some states, such as Manipur and Orissa,they also conduct deliveries at PHCs where there is no Allopathic MO. Tere is nooutreach activity and no clear role denition in implementing the National HealthProgrammes (NHPs). In some states there are a ew mobile clinics and health melas

where the AYUSH doctors participate. Tey may also be involved in some trainingactivity or Reproductive and Child Health (RCH) care and AYUSH componento the Auxiliary Nurse Midwives (ANMs) and Accredited Social Health Activists(ASHAs).

Validation of the Prescriptions of AYUSH Doctors

Over 75% o the AYUSH doctors prescriptions were validated by AYUSH textreerences and principles in all the states where prescriptions were recorded, i.e.,


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11 o 18 states surveyed. About 25% were outside the texts, Kerala ndings showingonly 5% outside. Jammu & Kashmir showed a 100% outside because all AYUSHdoctors practiced Allopathy since no AYUSH medicines were being supplied, andthe expectation in the service was that they practice only Allopathy.

Record-Keeping of AYUSH Services

Te acilities proled in the study had records o OPD attendance, but did not have wellmaintained utilisation data by age, sex as well as the prole o presenting complaints.Tere was also a mix o terminologies o diseases quoted rom both the AYUSHsystem as well as modern medicine diagnostic terms, e.g., arthritis is also mentionedas vata vyadhi. Inormation about reerral o patients was not covered anywhere,

whether o cross-reerral within a co-located institution or to other institutions. Te

services provided by these institutions in National Health Programmes (NHPs),especially National Vector Borne Disease Control Programme (NVBDCP) (e.g.,Chikungunya), are not properly recorded. Where recorded, the reporting mechanismstill needs to be put in place.

However, a comparison o the acility level OPD utilisation data with the statelevel aggregated data showed that the state records had lower gures and, thereore,

were denitely not inated, though there was likelihood o under-reporting due toincomplete/irregular reporting by acilities and districts.

Te web-based Health Management Inormation System (HMIS) o the generalhealth services, provides data on the co-located services only. Tere, too, data isavailable or state and district levels, providing only the OPD attendance. In manystates, it was obvious that the aggregated data was based on incomplete reports withonly some districts and acilities sending in their data.


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Exective Smmar xxxi

IMPLICATIONS OF THE FINDINGS FOR HEALTH SERvICESDEvELOPMENT POLICY

Recommendations to Strengthen and Mainstream

the AYUSH Serices and Reitalise LHT

Financial Allocation

1. Given the appreciation and high utilisation o AYUSH services in most states,the unmet elt need must be recognised and catered to.

2. A higher nancial allocation needs to be made or the AYUSH services. Amere 3% o the total budget is grossly inadequate and, with the large number oinstitutions, can only ensure poor quality o services in them. China gives over40% o its health budget to raditional Medicine (M) services, research and

production o pharmaceuticals and equipment.

Improing Coerage

3. More acilities are required in districts and blocks where they are lacking, andmore personnel including doctors may be sanctioned at acilities where the loadis high. Setting guidelines or norms by population coverage and accessibility

would be useul. Tis is clearly required in Bihar, Jharkhand, all the North Eaststates except ripura and Manipur, and in all the Non-High Focus states exceptKerala, Punjab and West Bengal.

4. Even in states such as amil Nadu and Kerala where the unctioning o existingservices is high, the coverage requires to be increased i wider access is to beensured. At present, a larger segment o the population has to resort to the privatesector to ull its demand or AYUSH services.

5. As state comparisons show, administrative and technical supervision are bothnecessary or better coverage and quality o services. Te cultural and political

will behind the development health services in general and the M services inparticular, are equally crucial ingredients. Tereby, all our must be strengthenedi better AYUSH services are to be made available in any state.

Improing Quality

From an equity perspective, it is clear that there is unequal access to qualityAYUSH services between the states and across socio-economic sections. Te


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Stats and Role of AyuSh and Local healt Traditions nder te NRhMxxxii

populations in states with low average state per capita income tend to have access topoorer quality AYUSH services in the public system, even when institutional coverageis higher.

Co-located Services6. Te co-location o AYUSH services (pre and post NRHM) within the Allopathic

institutions is proving useul since it is providing a wider coverage o AYUSHservices. However, at the time o this study, in all states the co-located services

were ound to be o poorer quality than the stand-alone. Teir utilisation wasalso lower, except in amil Nadu, West Bengal and Delhi, where the co-locationhad been in operation or some years, initiated well beore NRHM. As the morerecent co-located services stabilise, it can be expected that their quality willalso improve. How ar it improves is likely to depend on a policy environment

avouring the potential o peoples knowledge and the AYUSH systems, as well asthe quality o the health services as a whole.

7. An even wider coverage at the primary level o health care would be useul, giventhe pattern o conditions or which AYUSH services are most commonly used,i.e., at the PHCs and SCs (Sub-Centres). Teir role in MCH care, treatment oacute conditions such as diarrhoea and Acute Respiratory Inections (ARI), as

well as non-communicable diseases (NCDs) is well documented and validated.Te outreach services o the ANMs and ASHAs must make ull use o the

potential o AYUSH and LH in primary care or the above.

8. Utilisation o AYUSH in certain epidemic diseases, e.g., Chikungunya, wasreported in some states. Tus, their role in treating, especially including the NCDsand chronic diseases, must also be utilised in specic public health interventions,

with its process and outcomes to be documented or analysis o useulness andwider application.

9. Te AYUSH systems and LH must be viewed as complementary and supportiveto each other, and thereby dealt with as a composite whole. Te LH were still

very much a part o peoples knowledge and practice. Peoples knowledge omedicinal plants and oods was largely validated by the science o AYUSH.

Strengthening Management

10. Supervision, monitoring and planning should be integrated or the stand-aloneand co-located services at the district level. Te District AYUSH/Ayurveda/Homeopathy Ocers should have active charge o the technical dimensions o


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Exective Smmar xxxiii

co-located services as well. Tey should receive support rom the state level interms o adequate unds, sta, transport and training.

11. Tere also needs to be better coordination with the NRHM administrativelyand o the support structures. An AYUSH unit at the State Health Resource

Centre (SHRC/SIHFW) could greatly acilitate this process o strengtheningand change.

12. A Rogi Kalyan Samiti should be constituted at each stand-alone institution anduntied unds made available to them.

13. Te AYUSH wings o co-located institutions should also get the benet o untiedunds.

Infrastructure

14. While creating the separate space or AYUSH services should be the responsibilityo the NRHM and/or the state, i.e., the source or construction and extension othe rest o the building o the PHC, CHC or DH.

15. Clear signages should be placed outside the institution to announce the availabilityo AYUSH services at the co-located institution along with visible and easy accessto the services inside the building.

Trainings

16. Te AYUSH doctors need in-service training on their systems or re-orientationin the changing environment or building greater accountability and condence.

raining in Basic Obstetric Care and in National Health Programmes are neededor AYUSH doctors perorming the tasks o conducting normal deliveries andimplementing the NHPs, respectively as required at the co-located institutions.

17. AYUSH colleges must be involved in the planning where they have acultycapacity and strengthened where they do not. Educational curriculum must bestrengthened in both, public health and administrative dimensions as well as the

principles-based practice o the system.

18. Te Allopathic doctors, nurses and para-medics should be given in-serviceorientation to the value and uses o the AYUSH systems and LH. Tose amongthem who are interested may be given urther training. Tose practicing cross-reerral should be involved in the institutional level planning or AYUSH servicesand LH.


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Stats and Role of AyuSh and Local healt Traditions nder te NRhMxxxiv

19. Local Non Government Organisations (NGOs) and AYUSH colleges doinggood work on LH and AYUSH should be involved in the SHRC or providinginnovative practices and support or training o various in-service cadres.

Drug Supply20. Te drug supply needs to be augmented beyond what is already being made

available. Systems must be developed to ensure transparency in procurement oAYUSH medicines. Tey must be supplied as per need o the institution basedon its patient load and the morbidity prole. Te packaging also needs to be moreuser riendly.

Health Management Information System

21. Record-keeping, as well as ow o inormation o the services provided at AYUSH

institutions, needs immediate rening. For instance, the OPD attendance orAYUSH services must record and report the diagnosis/presenting complaints. omainstream the system, it is very important to record what the system is cateringto.

22. Te merging o HMIS, at least or the co-located acilities, requires that somecommon terminologies be developed or the diagnosis o conditions, and theircategorisation. However, this must keep intact the epistemological bases o thesystems.

23. Moreover, there is a need to record the reerral data at these institutions. Indicators

or the initiatives o mainstreaming AYUSH and revitalising LH should bedeveloped and incorporated in the monitoring tools or NRHM and the healthservices as a whole.

Building Blocks o a Decentralised, Locally Rooted, Aordable and EcologicallySustainable Health Care System: Enabling a Bottom-up Health Services Development.

24. Reerral linkages o LH (particularly home remedies) to AYUSH services atthe stand-alone and co-located AYUSH acilities at the primary and secondarylevels, need to be established or catering to scientic use o AYUSH by thecommunity. Te strengths and limitations o LH and AYUSH at every levelneed to be analysed and strengthened in terms o both resources and servicesoered (medicinal herbs and plants, drugs, specialised equipment, humanresources, etc.).


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Exective Smmar xxxv

25. Te Indian Public Health Standards (IPHS) prescription o cultivating localmedicinal plants and herbs in the compound o the PHCs and SCs needs to beimplemented. While being useul in strengthening the LH in the community,this could also be useul in strengthening linkages between the AYUSH

practitioners at the co-located acilities and LH. Tis is a prerequisite torevitalise the traditional medical knowledge and also nurture the mainstreaming.Tis activity should be coordinated with the State Medicinal Plants Board(SMPB) on one hand, and the local community organisations, Village Health &Sanitation Committees (VHSCs), raditional Healers Associations, etc., on theother.

26. Massive documentation and validation o the local heath practices by the AYUSHcontext specic epistemology and the linkage between the two to be undertakenby the district and state level bodies or promotion and use.

27. Tere is a need to create an enabling environment within the ormal systemor interaction between the co-located doctors o dierent systems and

promotion o cross-reerral between them. Tere is clearly an appreciation o thecomplementarity o the other systems o medicine among both Allopathic doctorsand AYUSH doctors in the public services. Tey are also advising patients at aninormal level, to use them. However, at the ormal level there is no cross-reerral,as was seen rom the prescriptions at the acilities.

28. One mechanism could be to develop Standard Guidelines or reatment thatcombine measures rom home remedies to primary care o the AYUSH and

Allopathic systems, and urther on to their specialised services when required atsecondary and tertiary levels.

AYUSH in National Sureys on Health CareUtilisation & Futuristic Bridging Research

29. Te existing National health surveys, such as the National Family Health Survey(NFHS) and the National Sample Survey Organisation (NSSO) rounds thatocus on health, reveal a decided inability or methodological limitation orcollecting and analysing data related to AYUSH or home remedies. It is strongly

recommended that in the uture rounds their data collection tools and analyticalrame must be designed to capture the role being played by these systems in termso peoples use o them in dierent social strata.


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Stats and Role of AyuSh and Local healt Traditions nder te NRhMxxxvi

30. AYUSH research should be streamlined so as to get quality output o scienticevidence based on principles o AYUSH or each district so that local ecology,cultural and social context are given due consideration. Practice-based evidencegeneration is more valid than laboratory-based evidence o biomedicine or

a logical raming o interventions or acilitating mainstreaming AYUSHand working on the above recommendations. Epistemologically sensitiveepidemiological methods should be evolved such that the complementarity o allorms o research may be worked out and the community and laboratory researchbrought together into an integral whole.

31. NRHM should initiate institutionalisation o such creative uturistic research incollaboration with the Department o AYUSH. Tis is where the uture o healthcare development lies i it is to be aordable and ecologically sustainable.

32. A paradigm shif is required or planning o health care development i all the

above recommendations are to be operational. A possible ramework is presentedin the box below. Its implementation requires a readiness to reorm the governance

paradigm and give people the centre-stage or health care planning.

The Planning Paradigm for Health Care Development

I decentralised planning and implementation with community involvementis to be achieved in accordance with the spirit o NRHM, community needsin terms o AYUSH and LH are required to be incorporated in planning. Inact, i the bottom-up paradigm o planning is to be adopted, then these have tobe the starting point or consideration o peoples health care, and architecturalcorrection o the health care system as a whole should be designed with this

perspective. A ramework or such an approach is outlined below:

i. Each district must plan beginning rom its epidemiological data onmorbidity and mortality, and rom inormation about the prevailing healthseeking behaviours o all sections o the local people, including use o LH,AYUSH and Allopathy. Documentation and validation o these should bean ongoing task at the district and state levels.

ii. Te documentation o health seeking behaviours should be an activityrequired o the AYUSH doctor at the PHC and CHC. Te local traditionalpractitioners, the panchayat and the VHSC should be associated with theactivity.


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Exective Smmar xxxvii

iii. Te documentation could be collated at district leel as community knowledge,the traditional practitioners practices being certied by the panchayat aslocally benecial knowledge.

iv. Te documentation should be ollowed by validation, based on the locally prevalent systematised traditional medicine by the AYUSH doctors atdistrict level and then promoted or use by the community as well as put touse at the health centres. Tis would not only revitalise the LH but alsocontribute to strengthening the knowledge base o AYUSH and promote itsnon-commercial practice using local herbs.

v. Te IPHS requirement o a herbal garden in each SC and PHC provides theopportunity to acilitate linkage between the cultivation o medicinal herbsand plants and their local use, involving the local traditional practitioners

or this activity and linking it with the AYUSH doctor o the co-locatedacility. Tis is recommended as one o the community-linked processes thatthe NRHM must operationalise. Te panchayat and the VHSC should beassociated with this activity as well.

vi. Use o the LH and AYUSH or MCH, NCDs and any other conditionsound suitable must be identied and promoted or sel-care, home-basedcare and institutional care, as appropriate. Each state should generate multi-

pathy Standard Guidelines or reatment or all health care providers(including the doctors o Allopathy and AYUSH, ANMs and ASHAs),

stating the role o AYUSH and LH in primary care and the points o cross-reerral. Tis requires assessment o cost-eectiveness o optional regimensrom home remedies to AYUSH to Allopathy at primary, secondary andtertiary levels.

vii. Campaigns initiated by the Department o AYUSH, such as or MCH inHomeopathy, Geriatric services and theKshaar Sutra or ano-rectal disorderscurrently being undertaken by selected stand-alone Ayurveda institutions,should be taken up at the co-located services as well.

viii. Te AYUSH graduates who receive clinical training in conducting normal

deliveries could provide MCH services (including deliveries) in the stand-alone institutions. Tey could involve the local dais as support in thedeliveries, as well as or ANC and PNC.


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Stats and Role of AyuSh and Local healt Traditions nder te NRhMxxxviii

ix. Te use o AYUSH and LH in epidemic situations (as already undertakenor Chikungunya and dengue in some states) needs to be studied andincorporated into public health practice in other states.

x. Tese steps would give the mainstreaming o AYUSH strategy its content sothat it does not merely become the mainstreaming o AYUSH providers.

xi. Use o the HMIS or regular monitoring o implementation o plans andquality o services, identiying gaps and thereby strengthening inputs wouldthen improve quality as well.

Factoring in the health care needs that can thus be provided by LH and AYUSHwould reduce the load on Allopathic services as well. As it becomes eective, thiswould also decrease the need or secondary and tertiary care, thereby creatingthe possibility o sustainable and comprehensive health care services. Further

planning o services should then optimise the workload and role o the HRo both Allopathy and AYUSH, and thereby plan or increase in coverage byinstitutions as well as the HR recruitments in the institutions. Tis would be themost cost-eective and accessible primary level care.


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xxxixList of Tables

LIST OF TABLES

TABLE NAME PAGE

1. Details of the Study Sample: Institutions And Respondents 11

2. Parameters and Grading Pattern for Quality of AYUSH Services 18

3. Validation Methodology: Ayurveda 20

4. Validation Methodology: Siddha 21

5. Validation Methodology: Unani 21

6. Validation Methodology: Homeopathy 21

7. Comparative Structures of Allopathic and AYUSH Health Service

Delivery Institutions

33

8. AYUSH Service Delivery Institutions in the Study District 35

9. System-wise Services of AYUSH in the States: Stand-alone and

Co-located

37

10. Satewise Number of AYUSH & Allopathic Doctors in Stand-alone and

Co-located Institutions by Population

46

11. Total Number of AYUSH Doctors and Institutions in the Public

System of Study Districts

49

12. Status of Human Resources in the AYUSH Facilities surveyed:

Stand-alone and Co-located

57

13. Grading for Quality of AYUSH Facilities Across States 58

14. Institutional Status of AYUSH Doctors Relative to Allopathic

Doctors

74

15. OPD Attendance at AYUSH and Allopathic Services Across States 82

16. System-wise OPD Utilisation of AYUSH Across States 85

17. System-wise Utilisation of AYUSH Indoor Services by Number of

AYUSH Beds Across the States

86

18. Institutional Support Structure for AYUSH Services Across States 103

19. Injections and Treatment of Diarrhoea: Pattern of AYUSH and

Allopathic Prescriptions in OPD

119

20. Perception of the Providers on AYUSH & LHT 123


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Stats and Role of AyuSh and Local healt Traditions nder te NRhMxl

21. Self Reported Reasons for Choosing AYUSH by the Patients (Exit

Interviews) and Households

132

22. Five most Common Conditions for which AYUSH is Used by

Community in the Study District

133

23. Pattern of Resort to AYUSH Treatment by Duration of Illness (Exit

Interviews)

137

24. Pattern of Resort to Allopathic Treatment by Duration of Illness (Exit

Interviews)

138

25. Limitations of AYUSH as Perceived by Households in the Study

District

139

26. Advantages of Using Home Remedies as Perceived by Households in

the Study District

152

27. Validation of the Prescriptions of AYUSH Doctors and the Community

Knowledge of Local Health Traditions in the Study District

166

28. IIth Plan Allocations (2007-12) 180


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xliList of Figres

LIST OF FIGURES

FIGURE NAME PAGE

Study Design 101. Average Population Coverage per Allopathic & AYUSH Institutions across

States

32

2. Average Population Coverage per AYUSH & Allopathic Institution: High

Focus States (Non NE)

39

3. Average Population coverage per Institution AYUSH & Allopathic: High

Focus NE states

40

4. Average Population coverage per Institution AYUSH and Allopathic:

Non High Focus States

41

5. Number of AYUSH Institutions and Doctors Across States (Stand-alone

& Co-located)

52

6. Number of Educational Institutions: AYUSH and Allopathic Across

States

54

7. Average Population Coverage Per AYUSH Service Institution by

Allopathic Institution Coverage, Average State Per Capita Income and

Vacancy Position of Allopathic Doctors in PHCs

89

8. Quality Grading of AYUSH Services with Population Coverage Per

Institution AYUSH & Allopathic by Economic Status: Non High Focus

States

91


Institution (AYUSH and Allopathic) by Economic Status: High Focus NE

states

92


Institution (AYUSH & Allopathic) by Economic Status: Non High Focus

States

94

11. Average OPD Attendance as Patients Per Facility Per Day by the Quality

of AYUSH Services, Coverage of AYUSH and Allopathic Services and %

BPL in the State

97

12. Average Population Coverage Per Institution in States with Independent

Commissioner /Secretary for the Directorate of AYUSH

99

13. Average Population Coverage Per Institution with States having No

Separate Directorate for AYUSH

100

14. Average Population Coverage Per Institution with States having SeparateDirectorate for AYUSH

102

15. Percentage of Households Reporting Utilization of AYUSH Services in

the Last Three months in the Study District

130


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Stats and Role of AyuSh and Local healt Traditions nder te NRhMxlii

16. Duration of suffering from the Presenting Health Problem of Patients

Seeking AYUSH Treatment in the Study District

135

17. Duration of Suffering from the Presenting Health Problem of Patients

Seeking Allopathic Treatment in the Study District (% Responses)

136

18. Self reported use of Home Remedies by the Patients at Exit Interview inthe Study Districts 141

19. Percentage of Households and ASHA /ANMs in the Study District with

Awareness regarding Medicinal Plants

144

20. Percentage of Households Reporting Use of Food items with Perceived

Medicinal Properties in the Study District

145

21. Percentage of Households Reporting Use of Home Remedies in the

Study Districts

146

22. Percentage of Households Reporting Use of Traditional Health

Practitioners in the Study Districts

147

23. Percentage of Households Reporting Use of Folk Healers by the

Households in the Study District

148

24. Percentage of Households Reporting Use of Faith Healers by the

Households in the Study District

148

25. Percentage of Households Reporting Use of Home Remedies for 20

Specied Conditions

149

26. Percentage of Households Reporting Use of Home Remedies for

Healthy Pregnancy in the Study District

151

27. Percentage of Households Reporting Use of Home Remedies for Safe

Delivery in the Study District

153

28. Percentage of Households Reporting Use of Home Remedies for

Healthy Lactation in the Study District

153

29. Percentage of Households Reporting Use of Home remedies for Babys

health in the Study Districts

154

30. Percentage of Households Reporting Use of Traditional Birth Attendants

for Deliveries in the Study District

155


for Health Problems During Ante Natal Period in the Study District

156


for Health Problems During the Post Natal Period in the Study District

156


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Introduction

and ResearchMethodology

I


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Introdction and Researc Metodolog 3

INTRODUCTION

Te acronym AYUSH (Ayurveda, Yoga & Naturopathy, Unani, Siddha &Homeopathy) represents the tradition o codied, textual health knowledge systems

other than the modern, while Local Health raditions (LH) represent the practicesand knowledge o the common people and olk practitioners who ollow an oraltradition o learning and passing on o the knowledge. Planned development o healthservices in the public system began in India aer Independence, based primarily onmodern medical science (Bhore Committee Report, 1946). However, services osystems o health knowledge, other than the modern Allopathic, have been parto the public system o health care in the country. Te number o service deliveryinstitutions has grown to being close to those o Allopathy. Yet, they have been a blindspot or mainstream public health; almost non-existent in public health literature,health systems research or teachings. Pluralistic health culture and the role o other

systems o medicine has been recognised and the inclusion o their large manpowerin rural areas in public health programmes has been recommended repeatedly, but

with no attention to the services existing within the public system. Ocially labelledIndian Systems o Medicine & Homeopathy (ISM&H), the impressionistic view othese services among health bureaucrats/administrators has been that o decrepit,

poorly unctioning and poorly utilised institutions that are inconsequential anduseless, existing only because o political compulsions.

On the other hand, there is a growing recognition, nationally and internationally, othe need or incorporating the contributions o these systems o health knowledgeinto the dominant one to meet the limitations o modern medicine. Te relevanceo traditional medicine is seen in the context o promoting ecologically sensitivelie patterns and technologies conducive to local natural conditions, and because

peoples preerences and use o M show the impact its various orms have on their well-being. Te Planning Commission expert groups have responded since the9th Five Year Plan by recommending strengthening o the ISM&H services (nowcalled AYUSH since 2003). Attention o planners has been drawn with even moreurgency due to the increasing demand and market potential or herbal medicinesand pharmaceutical ormulations o these systems. Te research that has rapidly

increased in ISM&H in the past decade has been almost entirely on the medicinal products o these systems with an eye on their value to economic growth o thecountry.


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Stats and Role of AyuSh and Local healt Traditions nder te NRhM4

Te NRHM, initiated in 2005, adopted Mainstreaming o AYUSH and Revitalisationo LH as one o its strategies to strengthen the public services. Te NationalHealth Policy on ISM&H (2002) had emphasised the need or strengthening themor playing a major role in the public health care system and also integrating them

with the Allopathic services. Te 11th year Plan (2007-12) ask Force suggestedthe co-location o AYUSH doctors and paramedics in the PHCs, CHCs and DHs.Human resources being a major constraint in reaching the service delivery goals, the

public health system has been introducing Community Health Workers (CHWs),ASHAs and now the 3-year rural doctors without paying much attention to thealready existing human resources o AYUSH, both ormal and inormal, includingcommunity-based olk and traditional health practitioners. Te role they can play isto cater to health needs o the community with their own knowledge base, and notonly by acting as a substitute human resource. Tus, the NRHM strategy or AYUSH

and LH is meant to cater to both needs, or trained health human resources and orpromoting the use o systems other than Allopathy. Te NRHM budget provides orsalaries o contractual AYUSH doctors as per IPHS norms or PHCs, CHs and DHs.Te inrastructure and drugs are to be provided by the Department o AYUSH underthe CSS.

Most states have some AYUSH services in the public system; many o them airlyelaborate networks providing wide coverage through stand-alone AYUSH institutions(except a ew states where there were co-located AYUSH services at the Allopathiccentres and hospitals even prior to NRHM). However, no serious eorts have been

made to survey the ground realities with regard to acceptance and usage o the existingservices by the public, status o integration o these systems in health care delivery atdierent levels; their quality o unctioning; practical diculties aced by institutionsand health care personnel in health care delivery; and those aced by the general publicin availing the services. Te status o co-located services under NRHM that startedaer its initiation in 2005 needs to be studied in this context.

Te limited international literature on traditional medicine and public health alsoreveals the need or studying strengths and limitations o the services in India. Weare one o the 25 countries that has given ocial support to traditional medicine and

developed services in the public system. Analysts o the available inormation whilepreparing the global atlas o traditional medicine, observed that what is lacking is adetailed understanding o the diering patterns o use according to disease, income,gender, age, geography and culture. Other research questions include: What are the


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emerging trends o raditional, Complementary and Alternative Medicine (CAM)use? What is the quality o services being oered to the public? What models existor partnering the best o CAM along with the best o conventional medicine to

provide eective and aordable health care? (Bodeker and Burord, 2007, reprint

2009).

One o the NRHMs overall mandates is to carry out necessary architecturalcorrection in the basic health care delivery system (Mission Document, 2005). Terole o the systems o traditional medicine and olk practices has historically been anunresolved issue among policy makers (Priya, 2005). I the NRHM can bring theminto the system through mechanisms that allow them to ull their potential role, it

will have dealt with one o the major dimensions that need architectural correction inthe health service system o the country.

Gaps IN INfORmaTION

Tere is no study available on public services o ISM&H/AYUSH rom a healthsystems perspective, bringing the institutional, provider and users data together intoa logical whole. Since health is largely a state subject, the centres support or statehealth systems needs to be based on each states own articulation o what it needs and

what its vision o development is. Te rollout o NRHM strategies will also dependon the existing level o development o AYUSH services in the state. Hence, withdecentralised planning, implementation o the strategy varies greatly across states but

there is little analysis o these variations. Neither is there a study o LH in India roma systems perspective. Te operationalisation o NRHM strategies too has been eachstates responsibility so that the extent o co-location o AYUSH service providers andthe duties assigned to them dier across the states. Such inormation, analysed rom aholistic systems perspective, could provide evidence on which to base policies and isalso required to plan inputs to optimise the NRHM strategy.

aYUsH Helth service Dt

Tere is little documentation o the services o the AYUSH systems in the public

sector, i.e., the quality, access, availability o inrastructure, human resources, records,MIS, etc., o services already existing in the AYUSH services o the public sector. In2006, the Department o AYUSH had commissioned A.F. Ferguson & Co., to do anevaluation o Centrally Sponsored Schemes (CSS) o the Department o AYUSH.


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Focussed on the gaps in implementation and impact o CSS, its report provides someinteresting insights into the unctioning o the State AYUSH Departments (Ferguson,2007). However, its objective was not to study the services per se, and so we get only

partial glimpses. Status o the additional initiatives under NRHM also need to be

examined or the extent o implementation and the nature and quality o servicesbeing provided by the AYUSH practitioners co-located in the primary health careservices.

Te emphasis o the National Policy on ISM&H (2002) on integration o ISM&H with the Allopathic services also requires that the progress in this direction bestudied, so as to identiy the positive initiatives that can provide lessons or others.Simultaneously, identication o the limitations o the eorts would help in takingcorrective steps or implementation as well as strengthening the conceptualisation othe objectives and activities.

Te strategies o co-location and integration raise several issues that need to beaddressed or optimal eectiveness o the initiative. Tese include role o doctorso dierent systems and other unctionaries in providing health care, administrativeissues arising in absence o doctors o one stream where the other is to perorm dutyspecially in providing essential or emergency services to patients or which one maynot be proessionally competent, or legally one is not authorised. Te legalities ointegrated practice, which dier rom state to state, need serious consideration romthe viewpoint o health systems development.

Ntionl Helth survey & Dt on Utilitiono aYUsH nd LHT

Te Department o AYUSH does not report utilisation data. Te NSSO and NationalCouncil o Applied Economic Research (NCAER) health surveys provide some othe national level data on utilisation o health services. However, the recent roundso NSSO do not consider AYUSH services separately at all, and home remedies areclubbed with no treatment (NSSO). Te NFHS too does not take into considerationthe utilisation o AYUSH services, since in its categorisation o treatment was

sought rom a health acility or provider it excludes pharmacy, shop, and traditionalpractitioner (NFHS). Te NFHS does have some data on home and herbal remediesin relation to diarrhoeal disease in children and on general sources o health care inhouseholds, but its ndings are at marked variance with the large body o literature on


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health seeking behaviours rom research in medical anthropology and internationalhealth systems research, since the NFHS-3 nds that only 8% o children withdiarrhoeal disease received such remedies.

Te data on general sources o health care does not have a category o publicsector AYUSH services, though it does have traditional systems in the private sectorand there it nds utilisation or 0.2-0.5% ailments. Tus, while clearly there is anexclusion o traditional systems and olk orms o treatment in the national surveys,it needs to be examined whether there is actually no or very limited demand orAYUSH services, home and herbal remedies, or is this a methodological limitationo these surveys?

sCOpE Of THE sTUDY

In order to ll these gaps in inormation about AYUSH services and the utilisationo AYUSH and LH, NHSRC undertook to conduct this study on the activitiesundertaken by the states under mainstreaming o AYUSH and revitalising o LH.Te analysis was done in the context o existing AYUSH services in the public system,the role(s) being played by the co-located AYUSH providers, and the unmet demandor M.

Ojective o the study

Te study was aimed at providing an overview o the status o initiatives atmainstreaming AYUSH and revitalisation o LH under NRHM as well as o theother services o the AYUSH systems in the public sector across all states. Tis wouldhelp identiy the areas were NRHM should intervene so as to eectively use AYUSHresources to improve the quality o care and lead to more ully unctional public healthacilities. It should lead to better community level care. It should also be catering tothe communitys elt needs and, thereore, identiying the utilisation practices and

perceptions about AYUSH services and LH would be useul. Given the extensivescope o the study geographically as well as the number o inter-connected dimensionsit was required to examine, it was decided to limit the ground level investigation to

one district in each state. While this would mean that the study ndings would not beable to claim representativeness, they would provide a broad overview o the patterno AYUSH services across states and present the diversity among them. Some generalissues or health services development and or strengthening o AYUSH services in


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particular were expected to emerge rom this investigation, with special signicanceor implementation o the NRHM strategy.

In order to ull the main objectives, the specic objectives included:

i. Documenting the status o unctionality o the existing acilities o AYUSHin the public sector, whether supported by the state or the centrally sponsoredschemes.

ii. Documenting the status o co-location o practitioners o the AYUSH systemsin the primary health care acilities, as well as any other initiatives taken in anystate.

iii. Recording the number o acilities in the district providing AYUSH services at alllevels, along with their nancing and utilisation data.

iv. Recording the quality o inrastructure, human resource position, supply o

medicines and equipment, management structures, monitoring mechanisms,record-keeping and inormation system or a selected sample o acilities. Teirutilisation in terms o the number o outpatients and indoor patients availing othe services, along with the nature o their ailment/diagnosis and the prescribing

pattern, is also to be obtained.

v. Te co-located AYUSH services were studied or the same eatures as in (iv)above.

vi. Examining at community level the use o AYUSH and LH as well as relatedperceptions and knowledge among the community members.

vii. Finally, undertaking an analysis o the strengths and weaknesses o the AYUSHservices, the opportunities they present in improving health services and the threatsto their optimal utilisation so as to identiy points o priority intervention.

sTUDY DEsIGN & mETHODOLOGY

Initially, it was decided to cover all states in the country, but upon nding that theDepartment o AYUSH had already commissioned studies o the public AYUSHservices in 5 states by two other organisations, it was decided to collaborate with themor a minimum common methodology and not duplicate studies in those states, so

that nally we would together have covered the whole country. We were nally ableto take 21 states, leaving out only 3 o the North East states. While the public services

were the main ocus, a ew private acilities were also to be included to refect theirsituation and utilisation pattern.


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In each state, one district was selected or the study. Te district with the best servicesin the state, other than the district in which the state capital is situated, was selected.Te best was identied based on the number and level o existing acilities, as well asin consultation with the state department or its rough evaluation o their quality o

unctioning.

Within the district, 2 blocks were selected one a well developed block and the other abackward block. All stand-alone AYUSH acilities in the block and one CHC, 2 PHCs

with co-location and 4 SCs were studied per block. Community perceptions weresought rom the SC villages and through exit interviews at the selected acilities.

For exit interviews, 8-10 patients were to be included per institution, identied seriallyas they came out aer consultation, etc., was completed. I the institution had lessthan 5 patients/day, all were interviewed.

Any major private or NGO acility reported in the area was also included. At least2 such acilities were to be studied per district. Any olk healer who had good

popularity, as reported by the institutional providers or by the households, was also tobe interviewed.

For the Household interviews, 10 households were selected in each SC village.Identiying the major social groups (by caste, tribe, and religion) and clusters in the

village, an appropriate number o households in each was selected. For instance, i5 clusters were identied, 2 households could be selected per cluster by a process o

random selection.However, this design could not be strictly ollowed in all states due to state and district

variations. For instance:

Keralahasnoco-locatedfacilitiesasapolicydecision.

BiharandJharkhandhadnotstartedco-locationatthetimeofsurvey.

Sikkimhadco-locationonlyattheDistrictHospitallevel.

TamilNaduandWestBengaldidnothaveASHAs.

Institutionswerenotasper theRuralHealthServiceStructureinsomestates,suchasWestBengal,TamilNaduandKerala.

Tus, the number o institutions covered, interviews and group discussions conductedin each state were as shown in able 1.


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State level: Directorates & Ofces AYUSH & Allopathic

Tool ued: State Data Sc

status and role of ayush and local health traditions

Documents