INTRODUCTION a brief description of each of the system

INTRODUCTION {rephrase and add more content}AYUSH: the alternative system of healthcare has been in existence for more than 5000 years. It is the traditional and the most natural way of treating any form of ailment with a long-term healing capacity. Though the Indian sector was swept away by the allopathic system of medicine due to the influence of the West, the Indian System of Medicine (ISM) is finding its way back in the recent years as people are beginning to switch to more natural and organic remedies to their chronic disorders. Their holistic approach is the factor that is luring people from all over the world to this method of treatment. Yoga has in fact become an icon of global health and is being widely accepted by people in their fitness routines. The AYUSH system comprising of Ayurveda, Yoga, Unani, Siddha, Homeopathy and Naturopathy was given a first formal structure when a separate department of Indian System of Medicine & Homeopathy was created in 1995 and renamed as Department of AYUSH in 2003. In 2014, the ministry for AYUSH came into existence and the system became more prominent after the 7th 5-year plan.

A concept called “Mainstreaming of AYUSH and revitalization of local health traditions” (Samal, 2016)materialized in the 11th 5-year plan. Ambitious goals for the development of AYUSH have been laid out in the recent 5-year plan to ensure AYUSH services in almost all Indian districts through NABH (National Accreditation Board of Hospitals) accredited hospitals. Stress has also been made on improving the quality of research in this sector. AYUSH IN BRIEFGiven below is a brief description of each of the system of medicine that make up the AYUSH spectrum:Ayurveda:One of the oldest health systems developed 3000 years ago during the Vedic period in the Indian sub-continent and even today it remains as a powerful mind-body health system. The practitioners extensively and wisely use herbal extracts, mineral compounds, floral oils and specific diets as part of their treatment routines. Lack of expertise may render the treatment ineffective and sometimes harmful.

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The ayurvedic texts have also spoken about advanced treatments such as rhinoplasty, kidney stone extraction, sutures and removal of foreign particles from the body.Yoga:Yoga belongs to the six Hindu philosophical schools (Samkhya; Yoga; Nyaya; Vaisheshika; Purva Mimamsa; Vedanta) that were developed during the period of Indus Valley Civilization over 5000 years ago. Though it is popular in the West as a form of physical exercise, in the Hindu philosophy it is more than exercise: meditative and spiritual practice. Yoga has been declared as an intangible cultural heritage by UNESCO.Unani: It is the traditional medicine system of the Islamic culture brought to India by the Muslim rule in the medieval period.

The treatment in this system is based on four humors of the human body: Balgham (Phlegm); Dam (Blood); ?afr?’ (Yellow bile); Saud?’ (Black bile). Siddha: This system of medicine has its origin in South India (Tamilnadu). The Siddhars who were known to possess the eight supernatural powers are considered as the founders of this form of medication. They have documented their wisdom on palm-leaf manuscripts and the experts prepare medicines according to the need of each patient. This system has proven to be very effective in curing rheumatic, liver, ulcer and dermatological disorders.Homeopathy:Homeopathy has its origin in Germany but got quickly blended with the Indian system as the founding principles were common to both the systems.

The medicines are prepared by repeatedly diluting the chosen compound in alcohol or distilled water. The end medicines are in the form of sugar-coated pills and thus are not difficult to consume as other medicines. Naturopathy:It is considered as a drugless treatment of diseases, non-invasive and self-healing. The ailments are cured using only natural food products such as fruits, vegetables and the like. POTENTIAL FOR MEDICAL TOURISM: {rephrase and modify}In the recent years, people preferring the developing countries such as Thailand, Malaysia, India for treatments that will cost them a fortune in the US and other such developed economies has now become a visible trend. India has been doing well on treating foreign nationals who come on a medical tourism to India for treatments such as cardiovascular ailments, orthopaedic and dermatological problems using allopathic form of medicine.

There has been an exponential development in the infrastructure to provide services of world class quality at affordable costs. In addition, the AYUSH form of medicine is another potential avenue for medical tourists as they can find natural remedies for any type of disorder. It is a holistic approach more concerned about the physical, spiritual as well as the emotional well-being of an individual. It is encouraging to note that AYUSH has indeed given a boost to the Indian medical tourism market. This alternative model of healthcare gives an edge over other competitors in Asia as this is exclusive to India.The advantages of going for such form of treatment is that it is highly cost effective and has minimal side effects as the medicines are made only from natural products using traditional procedures. The treatment requires minimum level of technological input.

India enjoys a special advantage in using this centuries-old heritage to cater to the health needs of millions- it is home to two of the biodiversity hotspots of the world and since all these medicines require herbal plants the practitioners can freely explore the rich flora of the Indian subcontinent to get the ingredients they require. On the other hand, there are also certain challenges involved in taking this system to a global level: as it is not so popular in other countries, patients who want to take one of these treatments cannot ask their doctors for advice to get more confident on their choice. People might be reluctant in going for a totally new method of treatment with several questions on their minds- what if it fails? How to go back and get checked up? What if the medicines are adulterated? are some of the questions that need to be answered.

 The statistics from the ministry of AYUSH has shown a positive trend in the number of AYUSH practitioners. The number has increased from 736,538 in 2014 to 771,468 in 2016. The total worth of AYUSH products like herbal extracts, ayurvedic powders, dietary supplements that are being exported has increased from $353 in 2014-15 to $404 in 2016-17.

India has been exporting such products to nearly 100 countries. By declaring June 21 as International Yoga Day and extensively promoting the benefits of it, the ministry had been largely successful in making yoga popular both at national and international levels. Yoga camps and conferences have been attracting large number of people since then. In a first such attempt, the ministry of AYUSH organized a two-day BRICS wellness workshop at Bengaluru, India to share expertise and knowledge about traditional medicine in 2016. This was done with an aim of getting AYUSH and its medicines acknowledged overseas and thus increase the number of tourists coming for AYUSH treatment. Recently, the government has also established 26 AYUSH information centres in 24 countries to spread awareness about this system. LITERATURE REVIEW:In order to achieve over all improvement in the health of about 1.3 billion Indians and also to be the most favoured destination for an alternative system of health care for foreign nationals, the vision of the Indian Ministry for healthcare is to place the AYUSH system as the most preferred way of life to inherently improve the health of people without the extensive use of artificial medicines.

To achieve this, seven distinct activities of AYUSH have been identified under information, channels of communication, educational standards, drug dosages, manpower utilization, research & development, medicinal plants and global partnerships. Several initiatives have been taken up along these lines to bring AYUSH to the spotlight and to integrate it with the mainstream system. The concept of “AYUSH CLUSTERS”  has been developed to ensure global recognition by focusing on ‘safety-efficacy-quality-rational’ & ethical usage of this form of healthcare (Katoch et al., 2017). The World Health Organization (WHO) also has been encouraging and sponsoring studies, researches and developmental programs to integrate the traditional medicines of every country to the conventional allopathic systems. The WHO has positively contributed to Ayurveda by implementing the pharmacovigilance program, preparation of documents and consumer guidelines for the proper and ethical use of Ayurveda medicines to get attention on a global level (Chaudhary & Singh, 2011). One of the studies has found that despite the existence of this system for over 1000 years, its integration has been a tedious process and a never-ending agenda. Since only 60% of the population has the access to the allopathic system mainly due to high cost, the alternative medicine system should be considered seriously as the next option to improve the health of the rural population (Manasi & Raju, 2015).

Public health infrastructure plays a key role in providing AYUSH services to rural masses. Another pilot study found that lower-income households have shown strong inclination for self-medication of AYUSH medicines. Although these medical expenses were only about 6% of the total medical expenses, it was popular among patients with chronic disorders, skin-related issues, muscular  & skeletal problems (Rudra, Kalra, Kumar, & Joe, 2017).

 The primary objective of Universal Health Coverage (UHC) mission in India is to provide basic financial support for all Indian citizens, below the poverty line, seeking health services(Samal & Dehury, 2017). AYUSH can be the tool to achieve UHC in India if there is adequate infrastructure, skilled supporting workforce in the medical sector, affordable and accessible drugs and quality of service.EXISTING HEALTH SYSTEMS ACROSS THE WORLD:1. Health system of Canada: The Canadian system provides a national as well as provincial health insurance plans for all its citizens. Hence, they can avail necessary treatments without paying from their income.

The government has been in the forefront in providing medical services to all its residents (Health Canada, 2014).2. Health system of Brazil:The major reforms in the history of Brazil’s medical system were driven by the civil societies. This is distinct and unique as seldom such societies are instrumental in bring out radical changes to an existing system of a country and ensured the development of a Unified Health System (Paim, Travassos, Almeida, Bahia, & MacInko, 2011).3. Health system of France: The French population is being provided highly satisfying health care with private players providing them a lot of choices. The governmental spending on health is the highest among the European countries and also France has the highest life expectancy in the world for women.

Owing to some unhealthy lifestyle practices, the French government has made public insurance compulsory which is financed by employee-employer contributions and also through taxations. Rising costs and the need for a permanent long term treatments are some of the concerns the country is yet to address (Chevreul, Berg Brigham, Durand-Zaleski, & Hernández-Quevedo, 2015).4.

Health system of Germany:The German government spends around 11.2% GDP on healthcare which is one of the highest in the European Union. More powers are given to self-governing bodies and insurance has been made mandatory to all either through public or private funding. They provide huge benefits and unrestricted access to all facilities.

Their key challenge is to ensure equitable services to people from all walks of life(Busse & Blumel, 2014). 5. Health system of Portugal: The National Health Service (NHS) system of Portugal is financed majorly through the collection of taxes. The Portuguese have been provided with adequate health care with most of the people having multi-layered insurance protection.

Primary care and hospital infrastructure falls under governmental spending while pharmaceutical products, technology and the like falls in the zone of private contribution. Thus, the Portugal system of medicine has a healthy public-private partnership in the area of healthcare(Barros, Machado, & Simoes Jde, 2011). 6. Health system of Bulgaria:The medical setup of Bulgaria is not as stable and standardized as most of its European counterparts. The state plays a limited role and the individuals spend their money on insurance unlike France, Germany and Portugal. The payment system is majorly unorganized and there is a serious problem of underfunding in the development of infrastructure(Dimova et al.

, 2012).7. Health system of Netherlands:A single compulsory health insurance scheme was introduced due to which the citizens where given the liberty to freely choose from a basket of providers based on quality, cost and the benefits. Much efforts have been taken to make this system more transparent to the public in order to make informed decisions.

The system has been giving more attention to strengthen the primary care in order to avoid the more expensive secondary care which is more of a preventive approach(Schäfer et al., 2010).8.

Health system of Malaysia:The Malaysian health care system has a mix of positives and negatives: the positives include universal low-cost health services, comprehensive model of public primary healthcare including the most remote areas, more than three-quarters of the Malaysian hospitals have been highly subsidized in order to be accessible to all. Lack of adequate medical practitioners, difficulty in raising funds for public spending due to the lon term policy of free health services, uncontrolled growth of private sector leading to disparity based on the purchasing power of the individuals are some of the challenges confronting the Malaysian medical system. CHALLENGES OF INDIAN MEDICAL SYSTEM:Population; cost; unequal distribution of wealth, unhygienic living conditions, government hospitals not world class, very less % of GDP spent on health care, in the countries discussed above all the citizens are compulsorily given health insurance by the government mainly using the tax generated. Here not possible. diverse cultural practices. AYUSH can be seen as alternative system as it is: cost effective, natural way of healing, less technological input required, long term healing, overall well-being.  {rephrase} + EXPLAIN THE TABLETable 1 AYUSH ACROSS INDIAN STATES:An exploratory research was carried out in Andhra Pradesh to assess the beliefs and attitude towards self-usage of AYUSH medicines among senior pharmacy students by means of descriptive cross-sectional study. The data analysis showed that male students, hostellers were more favourable in using AYUSH than the other groups under study (Ahmad et al.

, 2015). But it was also found that the state had serious problems in successful implementation of AYUSH system such as vacant positions, unfair compensation, poor infrastructure, unethical interpersonal arrangement and very less support from people belonging to non-AYUSH sectors(Lakshmi, 2012). Such gaps have created a negative impression on this form of treatment, demotivating the existing practitioners.

In north-eastern states, tribal medicines are widely recognised and accepted and AYUSH is least known. But promotion of this form of medicine has led to significant increase in the number of hospitals and practitioners over the recent years(Albert, Nongrum, Webb, Porter, & Kharkongor, 2015). This emphasizes on the need to integrate health policies with the local culture and actively promote the benefits of AYUSH in a way that is understandable to people from various cultural and linguistic backgrounds. In places like Chandigarh, implementation of AYUSH has been a success and majority of the people who were using allopathic medicines and those who were suffering from chronic disorders were found to have migrated to AYUSH form of treatment especially women. However this seems to be a bone of contention for the non-AYUSH practitioners as they viewed this as being unscientific(Jeet & Aggarwal, 2012). On the other hand, a study carried out in places like Kerala and Delhi revealed that there have been elements of mistrust, ambiguity of roles and power imbalances between the allopathic doctors and AYUSH practitioners which is obstructing the integration of both these systems(Josyula et al., 2016).

 AYUSH health camps were conducted at Chhattisgarh. It was found that the camp was effective in treating asthma patients who reported minimal recurrence post treatment. The importance of framing guidelines for conducting AYUSH health camps was highlighted by this camp and the need for a more proactive role of the government in this regard was also stressed(Madhu, 2011). In a research on the infrastructure of AYUSH health units in Uttarakhand, only ayurvedic and homeopathic units were known and the other forms of treatment under AYUSH were least known.

Even for those known systems, only about 80% of the units had separate doctor’s room, only about 60% had pharmacy-cum-storage room and just 25% had colour-coded dustbins for waste segregation and management(Shivdasani, Chanana, Datta, & Das, 2012). This shows that it is high time, transformational reforms are brought in if this sector is to survive in the long run. CHALLENGES OF MAINSTREAMING AYUSH:One study has revealed that only about 5-7% of the Indian population opts for alternative system of healthcare such as AYUSH(Hussain, 2015). The recent survey conducted by the National Sample Survey Organization (NSSO), New Delhi also has indicated that only about 30% of the Indian household or less make use of the traditional medicine(Srinivasan & Sugumar, 2015). This might be attributed to several factors. In a research done on medical pluralism in India, the authors have clearly brought forward the fact the integration has been done only at the infrastructural level but the real integration should be happening at the social and psychological level.

 Table 2 Table 3                EXPLAIN THE TABLEThere is a need for mutual respect and cross-referral for special treatment and expert opinions between AYUSH doctors and MBBS doctors(Ruhil, 2015). Other issues that came up during the course of this research was the uninterrupted supply of drugs, commercial manufacturing of AYUSH drugs with stringent laws for ethical processes and most importantly it should be sown in the minds of people that AYUSH is not secondary to Allopathic form but an alternative and independent system of healthcare. Other issues include scarce supply of AYUSH medicines due to which practitioners are forced to prescribe allopathic medicines due to increasing footfall of patients. Sometimes they are even posted in rural PHCs and are expected to give allopathic prescriptions(Aivalli, 2015).This requires AYUSH practitioners to undergo a short bridge course to understand and handle basic allopathic medicines. From an ethical dimension, lack of proper public accountability and transparency, lack of social justice and unhealthy practices are also some of the concerns to addressed in the process of integrating AYUSH to the mainstream(Gopichandran & Kumar, 2012). The road ahead for AYUSH is to formalize this form of medicine by overhauling the existing structure and developing a new framework. Establishing AYUSH  clinical Trials Accreditation Council (ACTAC); a separate drugs Act for AYUSH; separate AYUSH Trial registry (AYUSHTRI) to scrutinize clinical trial protocols(Dua & Dua, 2013).

These are some of the measures to have a control on unethical practices. In a pilot study, an attempt was made to train the AYUSH practitioners to treat non-communicable diseases(Kumar, Raina, Bhardwaj, & Chander, 2012). The training course had interactive lectures, practical exercises, field visits and some research activities. At the end of the study, the improvement in the knowledge level was significant (p=0.

00). This showed that a proper training was mandatory. WAY AHEAD:Reforms: {use it later in the paper}• Upgrading existing AYUSH infrastructure;• AYUSH practitioners to be actively involved in spreading awareness about this form of medicine• Encourage cross-referral between various streams of healthcare and ensure harmony among them. • Combining AYUSH with various groups workers like ASHA (Accredited Social Health Activists) • Ensure availability of AYUSH drugs at all levels and at all times.

 • Stringent quality measures to avoid unethical practices in the manufacturing of drugs • Building and maintaining herbariums to grow herbal plants in a hygienic environment