Mainstreaming, co-optation and countervailing powers: the barriers to and Impacts of AYUSH Integration in Odisha, India

Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homeopathy (AYUSH) integration into state primary healthcare centres in India is intended to promote medical pluralism and bridge India’s health workforce deficit. Integration processes have been challenged in other contexts by limited implementation of integration policies. However, how health systems and policy contextual factors influence integration in India, how AYUSH doctors with unique healthcare philosophies practice in biomedical settings, and the implications of integration for primary healthcare and for AYUSH doctors, remain unknown, which this study aimed to explore. The data sources were in-depth interviews (n=37) with AYUSH doctors, administrators, and biomedicine professionals, and observation of primary healthcare centres’ day-to-day functions in three districts of Odisha state. Findings illustrate the complex nature of AYUSH integration, represented by an interdependent process in which the institutional and policy contextual factors influenced not only the functions of AYUSH integration but also the professionals involved in the primary healthcare system. Concurrently, the healthcare professionals involved in the integration process shaped the contextual factors. The most significant hindering factor for AYUSH integration was medical dominance. Biomedical doctors in the primary healthcare centres adopted various strategies, namely, subordination, limitation, exclusion, incorporation and co-optation, to dominate AYUSH doctors and maintain their hegemony. AYUSH doctors were able to exert countervailing power to redress the power imbalances, which appeared to be a facilitating factor for AYUSH integration and meant that they were, to an extent, able to practice their systems of medicines and embed TCAM features – holistic and patient-centred care - into the mainstream public health system. However, the pathways of AYUSH integration were more consistent with AYUSH doctors as assistant physicians than expert AYUSH practitioners, which suggests a process of eventual deprofessionalisation and potential loss of AYUSH knowledge. The structure and governance of AYUSH integration require substantial changes more aligned with medical pluralism, independent AYUSH practices and reduced medical dominance.