By Michael Smith, BPharm, NDa,b, Andrea Burton, MAc, and Torkel Falkenberg, PhDd,ea Michael J Smith & Assoc. Ltd, Stratford, Ontario, Canadab Samueli Institute, Alexandria, VAc Monkeytree Creative, Vancouver, British Columbia, Canadad I C - The Integrative Care Science Center, Jarna, Swedene Karolinska Institutet, Department of Neurobiology, Care Sciences and Society, Division of Nursing, Research Unit for Studies of Integrative Health Care, Huddinge, Sweden
In late October of 2013, the World Health Organization (WHO) launched the WHO Traditional Medicine Strategy 2014-20231 as a follow up to the WHO Traditional Medicine Strategy 2002-2005, published in 2001.2 This updated document builds on work the WHO has undertaken over the past decade to identify further and strategize on the future of traditional medicines (TM) around the world.
After the first strategy proved to have a strong influence on how countries undertook regulation and oversight of TM, the 2008 WHO Congress on Traditional Medicine in Beijing — attended by government representatives from more than 70 countries — identified the need for WHO to take a leading role in updating and expanding the original strategy. Participants who represented every WHO region identified several priorities, collectively known as the “Beijing Declaration,” and endorsed the development of a new global strategy that would build on the successes of the previous strategy and reflect the international situation in 2013.3 The key priorities were as follows:
- The knowledge of traditional medicines, treatments and practices should be respected, preserved, promoted and communicated widely and appropriately based on the circumstances in each country;
- Governments have a responsibility for the health of their people and should formulate national policies, regulations and standards, as part of comprehensive national health systems to ensure appropriate, safe and effective use of traditional medicine;
- Recognizing the progress of many governments to date in integrating traditional medicine into their national health system, we call on those who have not yet done so to take action;
- Traditional medicine should be further developed based on research and innovation in line with the “Global Strategy and Plan of Action on Public Health, Innovation and Intellectual Property” adopted at the 61st World Health Assembly in 2008.
- Governments, international organisations and other stakeholders should collaborate in implementing the global strategy and plan of action;
- Governments should establish systems for the qualification, accreditation or licensing of traditional medicine practitioners. Traditional medicine practitioners should upgrade their knowledge and skills based on national requirements; and
- The communication between conventional and traditional medicine providers should be strengthened and appropriate training programmes be established for health professionals, medical students and relevant researchers.
This endorsement was strengthened in a 2009 World Health Assembly resolution (WHA62.13).4
As with all WHO strategies, the primary audience of the WHO Global Strategy for Traditional Medicine 2014-2023 is WHO member states. The aim of the strategy is to help member states “harness the potential contribution of TM to health, wellness and people-centered health care” and “promote the safe and effective use of TM by regulating, researching and integrating TM products, practitioners and practice into health systems, where appropriate.”3
The purpose of this article is not to critique the strategy itself but to provide context and background that will help readers gain a better insight into the global development work underpinning it.
Development of the Strategy
To ensure that the new strategy presented a global perspective, WHO developed an iterative process that welcomed input and feedback from international representatives. WHO hosted four international working group meetings of government representatives, academics, and international experts to help craft the strategy. To ensure the strategy was current and reflected the needs of the community at large, comments were sought from organizations with official observer status with WHO, the WHO Expert Advisory Panel on Traditional Medicine, as well as more than 20 Collaborating Centers in Traditional Medicine.
One of the more challenging aspects of developing this type of strategy, and an important note for readers, is that it must address countries and regions with very different needs and experiences. As a result, the new strategy takes into account the experience of countries with rich, indigenous TM strongly represented in their national healthcare systems, such as India and China, as well as countries in Africa and the developing world where TM often is the primary form of healthcare available. Additionally, the strategy pertains to countries where forms of complementary medicine such as chiropractic and Traditional and Complementary Medicine (T&CM) products such as herbal medicines are used in conjunction with mainstream healthcare.
Another significant challenge was applying and understanding how different types of governmental systems influence the regulation of T&CM. While some countries have centralized national healthcare systems and can enact sweeping change or new regulations quickly, healthcare in other Western countries (i.e., Canada, Australia, and the United States) is regulated primarily at the state or provincial level. For the latter countries, because T&CM may never be regulated at the national level, it is difficult to measure and compare how far their T&CM sectors have evolved in comparison to other countries where T&CM is nationally regulated.
Given this divergent regulatory environment, the new strategy is broadly intended to meet the needs of a wide range of individuals and governments and must be read in this context.
Contents of the Strategy
The WHO Traditional Medicine Strategy 2014-2023 is divided into five sections, including:
Section 1: An introduction that includes common terminologies, the role of T&CM around the world, information on how WHO supports T&CM, background on development of the strategy, and a description of why this new strategy is important.
Section 2: An outline of the global progress that has taken place in T&CM policy and regulations, practices, education, and research since publication of the WHO Traditional Medicine Strategy 2002-2005.
Section 3: An analysis of the current global picture for T&CM including demand, uses, progress in regulation, importance of universal health coverage, and the integration of T&CM (including opportunities and challenges).
Section 4: A clear description of strategic objectives, strategic directions, and strategic actions. This is the most important section of the document and outlines the future steps recommended by the numerous advisors and experts throughout the course of developing the document. The fourth section is described in more detail below.
Section 5: An overview of the crucial aspects of the strategy and suggestions on how it can be implemented and measured.
The first strategy was built around four key objectives: (1) policy, (2) safety, (3) efficacy, and (4) quality, access, and rational use. The new strategy focuses on three strategic sectors, which are further divided into two strategic directions each. The strategic sectors focus on the need to (1) build the knowledge base around T&CM through appropriate national policies; (2) strengthen quality assurance, safety, proper use, and effectiveness of T&CM by regulating products, practices, and practitioners; and, (3) the promotion of universal health coverage by integrating T&CM services appropriately. The complete three strategic sectors and associated strategic directions can be found in Table 1. In addition, the strategy recommends specific actions to governments and stakeholder groups as to how these objectives can be reached.
What is Different in the New Strategy?
Rather than comparing the 2014-2023 strategy directly with the last, item by item, it is more useful to think of it as a completely unique document, reflecting the reality of T&CM in 2014. It contains many of the same themes as the former strategy — such as the importance of ensuring safety, development of robust policy, and supporting education among consumers — while also addressing the many advances that have occurred in the past decade. One example of advancement is in the area of regulation of T&CM products such as herbal medicines. The current increase in the number of countries regulating these products reflects a new capacity for one of the strategic actions within this new strategy.
As noted, the most critical elements of the strategy and the area that will be most useful to member states are the strategic objectives, directions, and actions contained in Section 4. These are distinct and specific actions that countries can take to strengthen their T&CM sector. The challenge for the responsible persons developing the strategy, and for those tasked with its implementation, is that each country is facing a unique situation in terms of how to view T&CM and what is feasible for them to accomplish within the next 10 years.
There are some specific areas in which the new strategy stands apart from the last one. These include the following:
Stronger recognition of complementary medicine, as well as TM. The title WHO Traditional Medicine Strategy 2014-2023 should not be confusing. This strategy recognizes that many therapies and products considered traditional medicines in one of part of the world are being used internationally as complementary medicines. The strategy recognizes that this sector is now global in scope and also that different countries are facing different challenges in addressing needs and priorities concerning T&CM.
A longer implementation period. While the first WHO TM strategy was designed to cover a four-year period, the implementation of the new strategy is intended to be spread over a full decade. This longer period reflects the time required for changes to occur and for collaborations and partnerships to be developed. Unlike the first strategy, the new strategy identifies the need for ongoing monitoring and adaptations, and provides a reasonable timeframe in which to accomplish this.
Recognition of the importance of self-care. While the first strategy recognized that practitioners were not always involved in consumer use of T&CM products such as herbal medicines, it did not identify the self-care market — or, as it is referred to in the strategy, “self health-care” — as a specific priority. Reflecting the global market for dietary supplements and Natural Health Products (as they are legally called, for example, in Canada), as well as the growth in popularity of such practices as yoga, one of the three strategic directions (4.3) focuses exclusively on self-care. Specifically, this direction notes that consumers must play a central role in determining what products or practices they wish to take.
Increased focus on regulation. Preliminary data from a survey of member states indicates that more countries are regulating the practice of T&CM and use of therapeutic products since the introduction of the first strategy. The term “regulation” is used in the broadest sense, ranging in meaning from licensure in some cases to registration in others. While regulation played an important role in the first strategy, in the new one it is identified as a specific strategic direction and is considered to be a key step in ensuring the quality assurance, safety, proper use, and effectiveness of T&CM practices, products, and practitioners.
Increased attention to practice and integration. One of the great successes of the first strategy and the work accomplished by WHO is the development of guidelines, policies, and protocols dealing with herbal medicines and traditional medicinal products in topics ranging from Good Manufacturing Practices (GMPs) to adverse event reporting. A complete list of these WHO publications can be found in Annex C of the document. Building from this strong base, while T&CM products such as herbal medicines play an important role in the strategy and are included in all of the strategic directions, there is increased attention to how the products and therapies are used. A prime example centers on the importance of integration and how T&CM can be used most effectively, with or without a practitioner’s involvement.
Recognition of the importance of involving all sectors. The fact that this strategy is primarily aimed at member states is one of its strengths and one of its weaknesses. Since WHO is not a governmental agency, it cannot directly address individual sectors such as industry, academia, or individual citizens of member states. Rather, it encourages member states to engage all of the relevant constituents. This new strategy actively identifies collaboration with all groups including industry and consumers as being key to its success.
Many people working in the herbal medicine world may wonder whether this new strategy will impact them. As a non-government organization, WHO cannot legislate change and this is not the aim of the 2014-2023 strategy. What the strategy does do is reflect on the global priorities for T&CM as determined through consultation with stakeholders and governments, and also suggest the steps needed to deliver on these priorities. In essence, the strategy is a roadmap for work on T&CM that may have significant impact when followed properly.
One of the most important ways in which this strategy can be used is by engaging governments, both domestically and internationally. This strategy may prove to be a tool to support funding applications for both government and non-government agencies. Some countries actively support T&CM while others do not, and the use of this document may aid international initiatives and provide a cohesive link to the work of WHO. An excellent example of such an international initiative is the Botanical Adulterants Program sponsored by the American Botanical Council, the American Herbal Pharmacopoeia, and the National Center for Natural Products Research at the University of Mississippi.
Ideally, individuals engaged or interested in T&CM will recognize the significance of WHO’s stake in the field and that it has followed up this interest with a long-term plan to support T&CM around the world. Given WHO’s increased attention to the importance of healthy lifestyles as a means of combatting the global epidemic of non-communicable diseases such as cancer and diabetes, this strategy provides an excellent opportunity for the T&CM sector to play a more central role in addressing this important healthcare priority.
This strategy is the primary document on T&CM that reflects the current global situation. It is a living document with an evaluation planned halfway through its 10-year lifespan. If the publication of WHO Traditional Medicine Strategy 2014-2023 starts a dialogue about how traditional and complementary medicine should evolve globally, then it will have been a success.
[Editor’s Note: The authors of this paper acted as three of the primary drafters for the WHO Traditional Medicine Strategy 2014-2023.]
- WHO Traditional Medicine Strategy 2014-2023. World Health Organization website. Available at: . Accessed February 8, 2014.
- WHO Traditional Medicine Strategy 2002-2005. World Health Organization website. Available at: http://apps.who.int/medicinedocs/en/d/Js2297e/4.2.html. Accessed February 25, 2014.
- WHO Beijing Declaration. World Health Organization website. Available at: www.who.int/medicines/areas/traditional/congress/beijing_declaration/en/. Accessed February 8, 2014.
- EB124.R9 (2009) Traditional Medicine. Executive Board and World Health Assembly Resolutions on Traditional Medicine. World Health Organization website. Available at: www.who.int/medicines/areas/traditional/trm_assembly_doc/en/. Accessed February 8, 2014.