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AFRICA Angola Regulatory situation Although there is a registry of traditional health practitioners, there are no official legislative or regulatory texts governing the practice of traditional medicine, no licensing procedures for traditional medicine practitioners, no system for the official approval of traditional medical practices and remedies, and no local or national councils in charge of reviewing any problems concerning traditional medicine. Traditional medicine practitioners are not involved in Angola's primary health care programme at the local or national level. Education and training Angola does not have any official training facilities or programmes for traditional medicine. Benin Background information Widespread reliance on traditional medicines can be partially attributed to the high cost of allopathic pharmaceuticals, particularly after the devaluation of the Central African franc. Numerous persons from other countries use Beninese traditional medicine. Statistics Eighty per cent of the population relies on traditional medicine. In the Regular Budget 1998-1999, US$ 14 000 was allocated to traditional medicine. Regulatory situation There is a licensing process and a registry of traditional medicine practitioners in Benin. Local officials are allowed to authorize the practice of traditional medicine in their administrative and/or health subdivisions. Some traditional medicine practitioners are involved in the primary health care programme in Benin. There are national as well as provincial intersectoral councils and groups in charge of reviewing problems concerning traditional medicine. Section 3 of Code 3.4, Quality of Health Care and Health Technology, relates to traditional medicine. One objective under this section is the promotion of traditional pharmacopoeia through the following: updating and distributing a national list of traditional medicine practitioners by field of speciality - US$ 5000 is set aside for this task; developing and distributing a guide for the rational use of traditional pharmacopoeia - US$ 9000 is allocated for this task. The Ministry of Health perceives obstacles to the promotion of traditional medicine in Benin to include the following : lack of means to evaluate the quality, safety, and efficacy of traditional medicine products; lack of training in proper sanitation techniques for practitioners of traditional medicine, leading to unfavourable conditions in the practice of traditional medicine. In consideration of these obstacles and in order to protect consumers, the Government has prioritized the following projects: a census of non-governmental organizations operating in the field of traditional medicine; a census of practitioners of traditional medicine; evaluation of the possibilities of integrating traditional medicine into the national health care system, particularly into health centres at the sub-prefecture level; training traditional medicine practitioners to refer serious cases of certain illnesses, such as malaria and HIV/AIDS, to allopathic health centres. The Government envisions many opportunities for traditional medicine in Benin; these projects are just the first steps in a long process. Botswana Background information Practitioners of traditional medicine provided the only health care services available in most of Botswana until the first part of the decade following independence in 1966. The recent introduction of allopathic services throughout the country appears to have reduced the influence and activities of traditional medicine practitioners, but only to a limited extent and mainly with respect to younger and more formally educated population groups. Traditional health practitioners are well respected and influential in rural areas and remain central figures in the everyday lives of the majority of the rural population. Statistics There are about 3100 traditional health practitioners in Botswana, approximately 95% of whom reside in rural areas. Regulatory situation The first reference to the official acceptance of traditional medicine practitioners in Botswana appears in Section 14.86 of the National Development Plan of 1976-1981: Although not part of the modern health care system the traditional healer (ngaka) performs a significant role in Botswana, especially in the rural areas... The policy of the Ministry is to evaluate further the contribution of traditional healers to the health care system of the country and possibly then to seek ways of closer cooperation and consultation. Similarly, Section 13.28 of Chapter 13 of the National Development Plan of 1979-1984 reads: There are a large number of traditional practitioners of various types who are frequently consulted on health and personal matters. The Ministry of Health will continue its policy of gradually strengthening links with traditional practitioners - both diviners, herbalists, and faith healers. The emphasis will be put on improving mutual understanding, especially about the practices and techniques of the traditional practitioners. No full-scale integration is envisaged, but referrals between modern health care services and traditional practitioners will be encouraged where appropriate. The Medical, Dental, and Pharmacy (Amendment) Act of 1987 outlines registration requirements for chiropractors, osteopaths, naturopaths, acupuncturists, and other complementary / alternative medical professionals in Botswana. Burkina Faso Background information Under colonialism, traditional medical practices were outlawed as harmful and dangerous. Only after independence did the Government promote traditional medicine and begin to restore esteem to traditional medical practices. However, due to a lack of political initiative and significant mistrust between allopathic practitioners and traditional medicine practitioners, it was not until the 1980s that noticeable efforts were made. In 1983, the Government encouraged the formation of associations of traditional medicine practitioners as well as pharmacopoeia units within decentralized sanitary structures of the health system. According to the Burkina Faso Government, traditional medicine will always remain an important source of health care for the majority of the population since traditional medicine is part of African sociocultural foundations. Statistics More than 80% of the population in Burkina Faso use traditional medicine. Regulatory situation The Natural Substances Research Institute and a Health Ministry service were created in 1978 to promote traditional medicine and pharmacopoeia. In 1979, traditional medicine practitioners were officially recognized in Burkina Faso. Title IV of the Public Health Code of 28 December 1970 pertains to traditional medicine. Section 49 states: The practice of traditional medicine by persons of known repute shall be provisionally tolerated; such persons shall remain responsible, under civil and penal law, for the acts which they perform. Subsequent items of legislation shall define the practice of this form of medicine and the status of persons engaged therein. A medical and scientific commission appointed by the Minister responsible for Public Health shall conduct a study of the practice of traditional medicine and shall undertake investigations, notably in respect to traditional therapeutics, in order to identify the mode of action and posology of the drugs involved. The Practice and Organization of Traditional Medicine, Chapter IV of Law 23/94/ADP of 19 May 1994, promulgates the Public Health Code. This chapter defines traditional medicine and traditional medicine practitioners and reiterates their official recognition in Burkina Faso. In July 1996, the Government approved the National Pharmaceutical Policy. In 1997, the National Pharmaceutical Directive Plan was adopted to define the global objectives of the National Pharmaceutical Policy in concrete terms. One of the aims, as designated by the Ministry of Health, was the development and promotion of traditional medicine and traditional pharmacopoeia within the official Burkina Faso health care system in order to improve the health care delivered to the population. The Plan will be taken into consideration in the development of the National Sanitary Policies, which will cover the years 2001-2010. Decrees on the following issues are currently being elaborated: the modalities of private practice of traditional medicine, the creation of and assignments to the National Commission of Traditional Medicine and Traditional Pharmacopoeia, and an inventory of improved traditional medications. In an effort to balance conservation of natural resources and the development of traditional medicines, the Government is also in the process of developing regulations on the exploitation of traditional pharmacopoeia products with the collaboration of national and international partners, such as the World Health Organization. Burkina Faso has local and national intersectoral councils in charge of reviewing problems related to traditional medicine. Local officials in Burkina Faso are allowed to authorize the practice of traditional medicine in their administrative and/or health subdivisions. Some practitioners of traditional medicine are involved in the primary health care programme. Education and training There is no official recognition for the qualifications of traditional health practitioners. However, there is a formal training programme in traditional medicine. Burundi Regulatory situation There are no procedures for the official approval of traditional medical practices or remedies. Traditional health practitioners are not licenced, and local officials are not allowed to authorize the practice of traditional medicine in their administrative and/or health subdivisions, nor are traditional medicine practitioners involved in primary health care programmes at the local or national level in Burundi. Burundi does not have any official or legislative texts regulating traditional medicine. However, in Burundi's Public Health Code of 1982, which limits medical licences to those persons with formal training in tropical medicine, it is stated that practitioners currently treating patients by means of traditional medicine may continue to practice under the conditions and in accordance with the detailed regulations laid down by the Minister responsible for public health. Education and training Burundi does not have any official training facilities or programmes for traditional medicine. Cameroon Regulatory situation Law 81/12 of 27 November 1981 approved the Fifth Five-Year Social, Economic, and Political Development Plan (1981-1986) of Cameroon. Section 16-1.3.1.5 states the following: During the Fifth Plan, measures will be taken to lay down a joint strategy and method to effectively integrate traditional medicine into the national health plan by implementing a program on traditional medicine in conjunction with some of our neighbouring countries. Under this plan, Cameroon created the Traditional Medicine Service within the Unit of Community Medicine in the Yaounde Central Hospital and set up the Office of Traditional Medicine in the Ministry of Public Health. A number of research projects on traditional medicine and training programmes for traditional medicine practitioners have also taken place. Local officials are allowed to authorize the practice of traditional medicine in their administrative and/or health subdivisions, and some traditional medicine practitioners are involved in Cameroon's primary health care programme. Cape Verde Regulatory situation Cape Verde does not have any official legislative or regulatory texts governing the practice of traditional medicine. There are no licensing procedures for traditional medicine practitioners, nor are there any procedures for the official approval of traditional medical practices and remedies. Traditional medicine practitioners are not involved in Cape Verde's primary health care programme at either the local or national level. Education and training Cape Verde does not have any official training facilities or programmes for traditional medicine. Central African Republic Regulatory situation The Central African Republic has local intersectoral councils for traditional medicine and a registry of traditional health practitioners. However, there are no official legislative or regulatory texts governing the practice of traditional medicine. There are no licensing procedures for traditional medicine practitioners, nor are there any procedures for the official approval of traditional medical practices and remedies. Traditional medicine practitioners are not involved in the Central African Republic's primary health care programme at the local or national level. Education and training The Central African Republic does not have official training facilities or programmes for traditional medicine. Chad Regulatory situation Although traditional medicine practitioners are involved in Chad's primary health care programme, Chad does not have any official legislative or regulatory texts governing the practice of traditional medicine. There is no licensing process for traditional medicine practitioners, nor are there procedures for the official approval of traditional medical practices and remedies. Education and training Chad has no official training facilities or programmes for traditional medicine. Comoros Regulatory situation Comoros does not have official legislative or regulatory texts governing the practice of traditional medicine. There is no licensing process for traditional health practitioners, nor are there procedures for the official approval of traditional medical practices and remedies. Traditional medicine practitioners are not involved in the primary health care programme in Comoros at either the local or national level. Education and training Comoros does not have official training facilities or programmes for traditional medicine. Congo Background information In rural areas, herbalists and spiritualists are the two most common practitioners of traditional medicine. In urban areas, acupuncturists and natural medicine providers - medical practitioners who treat with mineral and animal products - are more common. Through scientific analysis, independent researchers have confirmed the efficacy of a number of Congolese traditional medical products - such as manadiar, antougine, meyamium, and diazostimul - leading to their distribution throughout Africa. Statistics For the treatment of pathologies of the reproductive system, 59.9% of Congolese women use traditional medicine. Of these women, 38.2% report having experienced complications or side effects after using these medicines. Regulatory situation The traditional medicine branch of the Ministry of Health and Social Affairs was created in 1974 to develop a national herbarium and determine the number of traditional medicine practitioners in the country. In 1980, the National Union of Traditional Therapists of Congo was founded. In 1982, the traditional medicine branch was expanded, becoming the Traditional Medicine Service. The Service, led by a pharmacist, was charged with conducting research, enriching the national herbarium, gathering medicinal formulas, popularizing traditional medicine, and integrating traditional and allopathic medicine. In 1987, the National Centre of Traditional Medicine was established to promote research, manufacture traditional medical products, exchange information with other traditional medicine institutions, train allopathic doctors and students in traditional medicine, and teach techniques for the aseptic preparation of medicines to practitioners of traditional medicine. Failure to collaborate with traditional medicine practitioners and a poor relationship between traditional medicine practitioners and allopathic practitioners proved to be obstacles to the Centre's work. Congo has official legislative/regulatory texts governing the practice of traditional medicine. It also has local and national intersectoral councils for traditional medicine. Local officials in Congo are allowed to authorize the practice of traditional medicine in their administrative and/or health subdivisions. Some traditional medicine practitioners are also involved in the primary health care programme of Congo; however, in certain centres this integration is very weak. There is a licensing process, a national association, and a registry of traditional health practitioners. The Management of Health Services of the Ministry of Health, the National Union of Traditional Therapists, and other professional traditional medicine associations review the qualifications of traditional medicine practitioners, although there are no set criteria for these qualifications. Traditional medicine practitioners are recognized by the Government and are well tolerated. In 1996, legislation on the recognition of traditional medicine and complementary/alternative medicine was drafted, but it has not yet been finalized because of the 1997-1999 armed conflict. Under current regulations, only herbalists are permitted to practice in the official health care system. Education and training No training in traditional medicine is integrated into the university medical curriculum. Insurance coverage An attempt has been made to standardize the fees of traditional medicine practitioners in Congo, although no patient reimbursement exists for such fees. Cτte d'Ivoire Regulatory situation Cote d'Ivoire has neither official legislative nor regulatory texts governing traditional medicine. There is no licensing process for traditional health practitioners, nor are there procedures for the official approval of traditional practices or remedies. Traditional medicine practitioners are not involved with primary health care in Cote d'Ivoire on either the local or national level. Education and training Cote d'Ivoire does not have official training facilities or programmes for traditional medicine. Democratic Republic of the Congo Regulatory situation The Democratic Republic of the Congo retains health care legislation from the colonial era, including the Decree of 19 March 1952 on the practice of medicine, as amended. The Decree grants exemplary status for traditional medicine practitioners, but also places limitations on their practice. Section 15 states the following: The provisions of this Decree shall not be applicable to nationals of the Belgian Congo or of neighbouring African territories who, in population groups where such customs prevail, carry out treatments and administer drugs in accordance with the usage custom provided they do not constitute a breach of public order. The Second Ordinary Congress of the Popular Revolutionary Movement in Zaire adopted a resolution in November 1977 encouraging research into the rehabilitation and recognition of traditional medicine as a complement to allopathic medicine and urging the establishment of a division dedicated to traditional medicine within the Department of Health. Equatorial Guinea Regulatory situation Equatorial Guinea has official legislative/regulatory texts governing the practice of traditional medicine. There is a licensing process and a registry of traditional health practitioners. However, Equatorial Guinea does not have procedures for the official approval of traditional medical practices or remedies. Local officials in Equatorial Guinea are not allowed to authorize the practice of traditional medicine in their administrative and/or health subdivisions. Traditional medicine practitioners are not involved in Equatorial Guinea's primary health care programme. Education and training Equatorial Guinea has training facilities and programmes in traditional medicine for both health providers and lay persons. Insurance coverage An attempt has been made to standardize the fees of traditional medicine practitioners in Equatorial Guinea, although no patient reimbursement exists for such fees. Ethiopia Background information Traditional medicine in Ethiopia includes medicinal preparations from plant, animal, and mineral substances, as well as spiritual healing, traditional midwifery, hydrotherapy, massage, cupping, counter-irritation, surgery, and bonesetting. Traditional medical practices and remedies are recorded in oral tradition and in early medico-religious manuscripts and traditional pharmacopoeias, which, according to the estimates of some historians, date back to the 15th century AD. Traditional medicine is largely practiced by traditional medicine practitioners, although, particularly for certain common health problems, it is also practiced at home by the elderly and by mothers. The Ethiopian Traditional Healers Association was organized to review the qualifications of practitioners where no regulations exist. Statistics Over 80% of the Ethiopian population rely on traditional medicine. This represents the majority of the rural population and sectors of the urban population where there is little or no access to allopathic health care. In 1986, over 6000 practitioners of traditional medicine were registered with the Ethiopian Ministry of Health. Regulatory situation Proclamation 100 of 1948, Penal Code 512/1957, and Civil Code 8/1987 all state conditions for the practice of traditional medicine and the importance of the development and use of traditional remedies. The 1974 change of government in Ethiopia was followed by official attention to the promotion and development of traditional medicine, particularly after the adoption of the Primary Health Care Strategy in 1978. In November 1979, the Office for the Coordination of Traditional Medicine (21, 23), which is now a full-fledged department directly under the Vice-Minister of Health, was established to organize, train, and register traditional medicine practitioners, and to identify, describe, and register those traditional medicines with actual or potential efficacy. The Ministry of Health also incorporated traditional medicine into the National Ten-Year Perspective Plan 1984-1994, which called for the organization, training, and supervised use of traditional medicine practitioners in strengthening and expanding primary health care services. The Health Policy and the Drug Policy of 1993 both emphasize the need to develop the beneficial aspects of traditional medicine through research and through its use in the official health delivery services. Proclamation 1999 was issued based on the National Drug Policy. In Article 6, Sub-Article 8 of the Proclamation, it is stated that the Drug Administration and Control Authority shall prepare standards of safety, efficacy, and quality of traditional medicines and shall evaluate laboratory and clinical studies in order to ensure that these standards are met. The Authority shall also issue licences for the use of traditional medicines in the official health services. Education and training No officially recognized education is provided in traditional or complementary / alternative medicine. Insurance coverage There is no national health care insurance or private insurance covering traditional medicine. Gabon Regulatory situation Practitioners of traditional medicine in Gabon are involved in the country's primary health care programme. However, Gabon does not have official legislative or regulatory texts governing the practice of traditional medicine. There are no licensing procedures for traditional health practitioners, nor are there procedures for the official approval of traditional medical practices and remedies. Education and training Gabon does not have any official training facilities or programmes for traditional medicine. Gambia Regulatory situation Gambia has official legislative/regulatory texts governing the practice of traditional medicine. There is a licensing process for traditional health practitioners and some traditional medicine practitioners are involved in Gambia's primary health care programme. Education and training Gambia has a training programme in traditional medicine for health workers. Ghana Background information Missionaries introduced allopathic medicine to Ghana during the colonial period. After independence in 1957, the Government initiated a number of medical projects, promoting allopathic medicine as Ghana's official medical system. However, successive governments have recognized both traditional and complementary / alternative medicine, including acupuncture, homeopathy, naturopathy, osteopathy, and hydropathy. Traditional medicine practitioners use herbs, spiritual beliefs, and local wisdom in providing health care. There are a number of associations of traditional medicine practitioners, including the Ghana Psychic and Traditional Medicine Practitioners' Association, which was formed in 1961. In 1999, the Government brought all the traditional medicine associations together under one umbrella organization, the Ghana Federation of Traditional Medicine Practitioners' Associations. Statistics In Ghana, about 70% of the population depend exclusively on traditional medicine for their health care. There is approximately one traditional medicine practitioner for every 400 people, compared to one allopathic doctor for every 12 000 people. With over 100 000 traditional medicine practitioners uniformly distributed nationally, they are not only more accessible to the public, but also the backbone of the health care delivery system. Regulatory situation Restrictions contained in the Poisons Order 1952 limit the use of the substances listed in the Order to registered medical practitioners. The Medical and Dental Decree of 1972 and the Nurses and Midwives Decree of 1972 allow indigenous inhabitants of Ghana to practice traditional medicine, provided they do not practice life-endangering procedures. The Centre for Scientific Research into Plant Medicine was established in 1975. In addition to its research capacity, the Centre operates a hospital providing both traditional and allopathic medicine. Until the passage of the Traditional Medicine Practice Act, the Government worked with the Ghana Psychic and Traditional Medicine Practitioners' Association to license and register traditional medicine practitioners and to ensure a standard of care (29, 30). The Traditional Medicine Practice Act 595 was drafted by traditional medical practitioners, placed before the Parliament in 1999. and passed on 23 February 2000. The Act establishes a council to regulate the practice of traditional medicine, register practitioners and license them to practice and to regulate the preparation and sale of herbal medicines. The Act defines traditional medicine as "practice based on beliefs and ideas recognized by the community to provide health care by using herbs and other naturally occurring substances" and herbal medicines as "any finished labelled medicinal products that contain as active ingredients aerial or underground parts of plants or other plant materials or the combination of them whether in crude state or plant preparation". The Act is divided into four parts. Part I concerns the Traditional Medicine Practice Council, including its establishment; function; membership; tenure of members; meetings; the appointment of committees such as Finance, General Purposes, Research, Training, Ethics, and Professional Standards; granting of allowances to members; and the establishment of regional and district offices. Part II covers the registration of traditional medical practitioners. Clause 9 states that no person shall operate or own a practice or produce herbal medicines for sale unless registered under this act. The qualifications for registration are given in Clause 10. Clause 11 provides for the temporary registration of foreigners who have a work permit, satisfy the requirements for registration under this act, and have a good working knowledge of English or a Ghanaian language. The rest of Part II deals with matters concerning renewal of the certificate of registration, suspension of registration of practitioners, cancellation of registration, and representation to the Council. In Clause 13, it is provided that the Minister of Health, on the recommendation of the Council in consultation with recognized associations of traditional medicine practitioners, may regulate the titles used by traditional medicine practitioners based on the types of services rendered and the qualifications of the practitioners. Part III covers matters concerning the licensing of practices: mandatory licensing; method of application and conditions for licensing; issuance and renewal of licences; acquisition and display of licences; ownership and operation of a practice by a foreign practitioner; revocation, suspension, and refusal to renew a licence and representations to the Council by aggrieved persons; powers of entry and inspection by an authorized inspector; and notification of death to a coroner. Part IV concerns staff for the Traditional Medicine Practice Council as well as financial and miscellaneous provisions, such as the appointment of a registrar, the provision of the Register of Traditional Medicine Practitioners, offences, and regulations. Clause 41 states categorically that the Act shall not derogate from the provisions of the Food and Drugs Board Law PNDCL 305B. The Traditional Medicine Unit (26, 31) under Ghana's Ministry of Health was created in 1991. In 1999, this was upgraded to the status of a directorate. The Ministry, in collaboration with the Ghana Federation of Traditional Medicine Practitioners' Associations and other stakeholders, has developed a five-year strategic plan for traditional medicine, which outlines activities to be carried out from 2000 to 2004. It proposes, among other things, the development of a comprehensive training programme in traditional medicine from basic to tertiary levels. Volume 1 of the Ghana Herbal Pharmacopoeia contains scientific information on 50 medicinal plants. A second volume is currently in preparation. Efforts are being made to integrate traditional medicine into the official public health system. It is expected that by the year 2004, certified efficacious herbal medicines will be prescribed and dispensed in hospitals and pharmacies. Local officials are allowed to authorize the practice of traditional medicine in their administrative and/or health subdivisions. The Government of Ghana has set aside the third week of March every year as Traditional Medicine Week, starting from the year 2000. Education and training Training by apprenticeship is required, accepted, and promoted for practitioners of traditional medicine. The Ministry of Health is working towards including traditional medicine in the curricula of allopathic medical schools and towards the introduction of a diploma course in traditional medicine at the postgraduate level. As a step in this direction, in the year 2000, the Ministry is planning to assess the training needs for traditional medicine practitioners. There are official training programmes for traditional birth attendants. Guinea Regulatory situation In Guinea, Ordinance 189 PRG of 18 September 1984 states that the profession of physician can only be practiced by persons with a Guinean diploma of Doctor of Medicine, a foreign diploma granting equivalent status, or a foreign diploma that entitles its holder to practice medicine in his or her country of origin. Various activities that constitute the unlawful practice of medicine are set out in Section 9. However, traditional medicine seems relatively unaffected by this ordinance. Guinea has official, applied, legislative/regulatory texts governing the practice of traditional medicine. There is a licensing process and a registry of traditional health practitioners as well as local and national intersectoral councils for traditional medicine. Local officials are allowed to authorize the practice of traditional medicine in their administrative and/or health subdivisions, and some traditional medicine practitioners are involved in Guinea's primary health care programme. Guinea-Bissau Regulatory situation Guinea-Bissau has local and national intersectoral councils for traditional medicine. However, Guinea-Bissau does not have any official legislative or regulatory texts governing the practice of traditional medicine and there is no licensing process for traditional health practitioners. Local officials are not allowed to authorize the practice of traditional medicine in their administrative and/or health subdivisions and traditional medicine practitioners are not involved with Guinea-Bissau's primary health care programme. Kenya Statistics Traditional birth attendants deliver most of the babies born in Kenya - up to 75% in some regions. Regulatory situation Traditional medicine started being incorporated into Kenya's national health policy framework in the late 1970s. Kenya's Development Plan 1989-1993 recognized traditional medicine and made a commitment to promoting the welfare of traditional medicine practitioners. The Ministry of Health and provincial authorities require the registration of traditional medicine practitioners. In 1999, Kenya's patent law was revised to include protection for traditional medicines.
Education and training Traditional birth attendants participate in official training programmes in some districts. Lesotho Regulatory situation Lesotho has two statutes that regulate the practice of traditional medicine and limit it to registered practitioners. Section 2 of the Natural Therapeutic Practitioners Act of 1976 defines natural therapeutics as the provision of services for the purpose of preventing, healing, or alleviating sickness or disease or alleviating, preventing, or curing pain "by any means other than those normally recognized by the medical profession". Natural therapeutics includes methods commonly employed by homeopaths, naturopaths, osteopaths, chiropractors, and acupuncturists. Section 3 prohibits non-registered persons from practicing as natural therapeutic practitioners. Applicants for registration must be at least 21 years of age, citizens of Lesotho, and recommended as qualified by the Natural Therapeutic Practitioners Association of Lesotho. The Registrar of the register of natural therapeutics must be satisfied that it is in the public interest to permit the applicant to practice. Persons who were practicing prior to the date of commencement of the Act are deemed to be qualified. Authorised persons under the Act are prohibited from carrying out certain procedures, including performing operations or administering injections, practicing midwifery, withdrawing blood, treating or offering to treat cancer, performing internal examinations, or claiming to be or leading people to infer that the individual is an allopathic physician. The Act also prohibits preventing any person from being treated by an allopathic physician or improperly influencing any person to abstain from such treatment. The Lesotho Universal Medicinemen and Herbalists Council Act of 1978 followed the Act of 1976. It provides for the establishment of the Universal Medicinemen and Herbalists Council. Section 5 states the objectives of the Council: to promote and control the activities of traditional medicine practitioners, to provide facilities for the improvement of skills of traditional medicine practitioners, and to bring together all traditional medicine practitioners into one associated group. The Council is required to do all that is necessary to attain these objectives and to ensure that every traditional medicine practitioner has a valid licence to practice as such. The Council must also keep a register of all its members. Membership is open to every traditional medicine practitioner who pays the prescribed fee. It is an offence to form or encourage the formation of any other association of traditional medicine practitioners. Education and training Lesotho has a training programme in traditional medicine for health workers.
Liberia Regulatory situation Liberia has official legislative/regulatory texts governing the practice of traditional medicine. There is a registry of traditional health practitioners and there are local and national councils for traditional medicine. Local officials are allowed to authorize the practice of traditional medicine in their administrative and/or health subdivisions, and some traditional medicine practitioners are involved in Liberia's primary health care programme. However, Liberia does not have licensing procedures for traditional health practitioners or procedures for the official approval of traditional medical practices and remedies. Education and training Liberia has a training programme in traditional medicine for health workers. Madagascar Background information The National Centre of Applied Pharmaceutical Research (NCAPR), founded in 1976, is composed of five technical departments: ethnobotanical and botanical, chemistry, pharmacodynamics, galenic pharmacy, and experimental clinics. NCAPR has the capacity to analyse herbal medicines from their ethnobotanical form to their manufactured form. NCAPR received financial support from the United Nations Development Programme in 1984 to undertake several projects. In 1985, NCAPR and the World Health Organization agreed to a four-year collaborative project on research into traditional medicines. The main objectives were to establish an inventory of medicinal plants and their indications, investigate the therapeutic and toxic effects of the registered plants, and undertake research standardizing and improving the presentation of traditional medicines. In 1995, NCAPR began reviewing the practice of traditional medicine as a whole by analysing the role of traditional medicine practitioners in the primary health care system. The National Tradi-Therapist Association of Madagascar was formed in 1997. Statistics Serving a population of 12.3 million, there are 4500 allopathic physicians, 220 pharmacists, 360 dentists, 1635 midwives, 3124 nurses, 1282 sanitary aides, and more than 10 000 practitioners of traditional medicine.
Regulatory situation Traditional medicine practitioners are involved in Madagascar's primary health care programme. In 1992, Madagascar had no legislative/regulatory texts governing the practice of traditional medicine, no licensing process for traditional health practitioners, and no procedures for the official approval of traditional medical practices or remedies. In 1996, a commission was created to study the legal aspects of traditional medicine with the intention of regulating its practice. In 1998, a project to grant official legal recognition to traditional medical practice was launched. In the same year, a census of traditional medicine practitioners was conducted, and, in addition, a project in the eastern and northern parts of Madagascar began integrating traditional medicine practitioners into the official health system. In 1999, regulations for herbal medicines were drafted. These were approved by Parliament in 2000. Education and training Madagascar does not have any official training facilities or programmes for traditional medicine for either health workers or lay persons. Malawi Regulatory situation The Malawi Medical Practitioners and Dentists Act of 1987 makes detailed provisions for the registration, licensing, and training of allopathic physicians and dentists. Regarding traditional medicine practitioners, Section 61 reads: Nothing contained in this act will be construed to prohibit or prevent the practice of any African system of therapeutics by such persons in Malawi, provided that nothing in this section shall be construed to authorize performance by a person practicing any African system of therapeutics of any act which is dangerous to life. Some traditional medicine practitioners are involved in Malawi's primary health care programme. Education and training Malawi has a training programme in traditional medicine for health workers. Mali Statistics Seventy-five per cent of the population of Mali uses traditional medicine. There is approximately one traditional medicine practitioner for every 500 inhabitants. Around 180 Herbalist Cards, 200 Therapist Cards, and 1000 Collaboration with the Traditional Medicine Department Certificates have been issued. There are 32 associations for practitioners of traditional medicine in the country. Regulatory situation The Department of Traditional Medicine and the National Research Institute of Medicine and Traditional Medicine were created in 1973. They were designated to demonstrate the value of traditional medicine resources through scientific research and to differentiate the roles of herbalists from those of other traditional medicine practitioners, which included defining their respective status, regulations, and code of ethics. The Department of Traditional Medicine is mandated to inventory medicinal plants and their indications, verify the therapeutic and toxic effects of the recorded plants, undertake studies to improve and standardize the forms of presentation of traditional medicines, train researchers in the fields of traditional medicine and traditional pharmacopoeia, involve traditional medicine practitioners in the politics of primary health care, write technical notices related to traditional medicine, and set up expert advisory missions for national and international institutions interested in traditional medicine in Mali. In order to fulfill this mandate, the Department has planned the following: a census of traditional medical practitioners; an umbrella association to bring together the 32 traditional medicine practitioner associations; the production of improved traditional medicines, some of which have status as essential medicine in Mali and are indexed in the National Therapeutic List; the set up of phytochemical analyses as well as pharmacological and clinical tests of medicinal plants; the training of national and foreign researchers; and participation in symposiums, seminars, and workshops. An order issued by the Minister of Public Health and Social Affairs on 16 May 1980 (38, 39) established a Scientific and Technical Committee to work in conjunction with the National Research Institute of Medicine and Traditional Medicine. The Committee, whose functions are defined in relation to the overall health care needs of the country, has drawn up draft regulations on the practice of traditional medicine. By Decree 94/282/P-RM of 15 August 1994, the Government of Mali regulated the opening of private consultation clinics for traditional medicine, medicinal herbs stores, and improved production units for traditional medicine. According to the Decree, private consultation clinics for traditional medicine are establishments that provide traditional medical care to patients. Medicinal herbs stores are airy and clean premises, which possess shelves and a counter and are run by a chartered person. The only purpose of the stores is to sell medicinal plants or medicines made from plants. However, conventional pharmacists are also allowed to sell herbs. Improved production units for traditional medicine are semi-industrial or industrial units that transform raw materials into herbal preparations and herbal products. Decree 95/1319/MSS-PA/SG of 22 June 1995 establishes organizational and functional rules for the private consultation clinics, medicinal herbs stores, and improved production units. Under this decree, membership in a registered and recognized traditional health practitioner association facilitates one's ability to obtain a certificate of notoriety and morality. Chartered traditional medical practitioners, medical staff, and retired traditional medicine paramedical staff may open private traditional medicine consultation clinics. Chartered medicinal plant sellers, graduates from the Katibougou Rural Polytechnic Institute (which specializes in water and forests) or its equivalent, and graduates from the Superior Normal School (which specializes in biology) or its equivalent are allowed to open medicinal herbs stores. Industrial exploitation of medicinal plants is authorized only when it involves herbs, leaves, sterns, barks, and/or fruits and is permitted only when the plants are cultivated. Collection of wild plants for industrial exploitation is not permitted. Improved traditional medicine production units must be supervised by a pharmacist, and a pharmacist, chemical engineer, or biologist must monitor the control procedures. Article 8 of Decree 95/009/P-RM of January 1995, establishing permits for pharmaceutical products, outlines special rules for requests involving traditional medicines made from plants. These requests should include the name and address of the person in charge of putting the product on the market, and if the latter is not the manufacturer, the name and address of the manufacturer: a summary of the product's characteristics (name, form, pharmacological properties, therapeutic indications, posologies, and administration); chemical and pharmaceutical files; toxicological and pharmacological files; a clinical file; 10 samples of the product; and a receipt for the registration fee. Local officials are allowed to authorize the practice of traditional medicine in their administrative and/or health subdivisions. Some traditional medicine practitioners are involved in Mali's primary health care programme. Education and training Created in 1996, the Faculty of Medicine, Pharmacy, and Odonto-Stomatology of the University of Mali is responsible for training allopathic physicians and pharmacists. Among the requirements for students and researchers are courses directly related to traditional medicine and traditional pharmacopoeia, such as Botany, Pharmacognosy, Vegetal Substances, Chemistry, Pharmaceutical Legislation, and Public Health. Other schools, faculties, and institutes that collaborate with the Department of Traditional Medicine on training and research in traditional medicine include the Rural Polytechnic Institute, the Superior School of Health, the Central School of Commerce and Industry, the Rural Economy School, the Faculty of Science and Technology, and the Faculty of Arts, Languages, and Human Sciences. Universities, organizations, and international and foreign research centres - such as universities in Burkina Faso, Cote d'Ivoire, France, Italy, Norway, and Senegal; the Centers for Disease Control and the National Institutes of Health, both in the United States; and ACCT, GAMES, and the World Health Organization - collaborate together on postgraduate training, research, thesis supervision, and examination boards. Periodic meetings, seminars, and workshops have been organized with traditional medicine practitioners, sometimes through their associations. The main points of national health programmes on AIDS, mental health, and family health have been presented with the intention that traditional medicine practitioners act as intermediaries, informing the public, and in recognition of the fact that traditional medicine practitioners are involved in patient care. The Department of Traditional Medicine organizes and supervises exploratory meetings and missions between associations of traditional medicine practitioners and their foreign partners. Each year the Department of Traditional Medicine organizes open houses on health information, education, and communication in traditional medicine. Radio and television programmes on traditional medicine with independent traditional medicine practitioners, representatives of associations, or persons in charge of technical services are regularly transmitted on public and private stations. Insurance coverage National health insurance covers allopathic medical care for only 500 000 to 1 000 000 of Mali's 11 000 000 inhabitants. It does not cover traditional or complementary / alternative medical care. Mauritania Regulatory situation Adopted in 1981, Decision 1831 established a working group to examine problems concerning traditional medicine and traditional pharmacopoeia. Section 2 of the Decision reads: The task of the working group shall be to determine the situation of traditional medicine and the traditional pharmacopoeia in Mauritania and, in particular: To examine the most appropriate and realistic ways and means of establishing an honest dialogue between the official health services and traditional practitioners in the spirit of the objective of health for all by the year 2000 through primary health care; and To propose the most appropriate mechanisms for identifying traditional practitioners who are amenable to such dialogue in order to determine and acknowledge the part that they can play in the system of comprehensive health care (health promotion, prevention of disease and disability, diagnosis and early treatment of disease, and rehabilitation). Section 56 of Ordinance 83-136 on the practice of medical professions states that the Ordinance does not apply to traditional medicine and traditional pharmacopoeia, as they are to be covered by separate legislation. However, as of 1992, Mauritania did not have official legislative/regulatory texts governing the practice of traditional medicine, any licensing process for traditional practitioners, or procedures for the official approval of traditional medical practices and remedies. Traditional medicine practitioners are not involved in Mauritania's primary health care programme. Education and training Mauritania does not have any official training facilities or programmes for traditional medicine.
Mauritius Regulatory situation The Ayurvedic and Other Traditional Medicines Act of 1989 governs traditional medicine in Mauritius. In this Act. traditional medicine is defined as "the practice of systems of therapeutics according to homeopathy, Ayurvedic, and Chinese methods". The central provisions of the legislation include the establishment of a regulatory body, the Traditional Medicine Board, and a registration system that requires practitioners to obtain a diploma in traditional medicine. The Traditional Medicine Board, established in Section 3 of the Act, is composed of Government officials, medical practitioners, persons knowledgeable in traditional medicine, and laypersons. The Board's functions, set out in Section 8, include disciplinary responsibilities, publication of a code of practice governing standards of professional conduct and ethics, and compilation of an annual list of traditional medicine practitioners. The registration system for traditional Chinese medicine practitioners requires applicants to hold a diploma in traditional medicine. Under Section 24, non-registered persons are not entitled to practice any act of traditional medicine for gain, unless exempted from registration. However, no exemptions are listed in the Act. Unregistered persons are also prohibited from presenting themselves as registered practitioners. The Minister responsible for health has the power to make regulations, set out the basic qualifications required for studying traditional medicine, and establish the terms and conditions under which it may be practiced. The Minister also has the power to impose restrictions on the practice of any aspect of traditional medicine. Local officials are allowed to authorize the practice of traditional medicine in their administrative and/or health subdivisions in Mauritius. There is no chiropractic law. Mozambique Regulatory situation Mozambique does not have official legislative/regulatory texts governing the practice of traditional medicine, any licensing process for traditional health practitioners, or procedures for the official approval of traditional medical practices and remedies. However, in 1991, a proposal was put forward for a three-year programme to establish a foundation for collaboration between the National Health Service and the practitioners of traditional medicine in Mozambique. The proposal suggested that traditional medicine practitioners constitute a separate, parallel, and self-regulating health service that collaborates with the Mozambique Government in the realization of specific public health goals. In this regard, the three-year programme would do the following: establish workshops to train traditional medicine practitioners in the treatment of priority diseases; establish a research-derived information base about traditional beliefs and practices; educate Government health workers at all levels in traditional beliefs and practices; coordinate research in traditional medicines, although, due to a tight budget, this research would not be funded by the Government itself. Collaborative programmes with traditional medicine practitioners also take place under the umbrella of the Department of Health. In addition, there are a number of programmes sponsored by non-governmental organizations, most of which collaborate with either district or provincial health authorities. Namibia Background information Before independence, health services were fragmented along racial lines, and traditional medicine was outlawed. After Namibia's independence in 1990, traditional medicine was legalised. Since then, the Ministry of Health and Social Services has adopted the primary health care approach to the delivery of health services, and major restructuring has been undertaken. The Namibia Eagle Traditional Healers Association was created in 1990. Statistics According to the 1994 Lumpkin Report, there is at least one traditional medicine practitioner per 500 people in the Kavango and Owambo regions. In the Caprivi region, there is about one traditional medicine practitioner per 300 people. In Windhoek (Katutura), the ratio is one traditional medicine practitioner per 1000 people. There are three chiropractors practicing in Namibia. A joint study by the Ministry of Health and Social Services and World Health Organization in 1997 reported that traditional medicine practitioners in Namibia can be classified as herbalists, faith-herbalists, diviner-herbalists, diviners, faith healers, and traditional birth attendants. Regulatory situation The Official National Primary Health Care/Community-based Health Care Guidelines were launched in 1992. In 1994, Lumpkin carried out a preliminary survey on the use of traditional medicine in the country. The resulting report, Traditional Healers and Community Use of Traditional Medicine in Namibia, was submitted to the Ministry of Health and Social Services. Also in 1994, the Namibian Parliament passed an act requiring all health workers, including traditional medicine practitioners, to become legally registered. The act delegated each professional group to elect a board to facilitate the registration process. In 1996, the Namibian Traditional Medical Practitioners Board was created. In 1997, the Ministry of Health and Social Services and the World Health Organization jointly undertook a study entitled Scientific Evaluation, Standardization, and Regulation of Traditional Medical Practices in Namibia. The findings of this study guided the development of the 1998 draft Traditional Healers Bill. They were also used to prioritize activities and to inform the planning process for the 2000-2002 programme on the regulation and integration of traditional medicine. The Traditional Healers Bill will establish the Traditional Healers Council to oversee the registration and regulation of the practice of traditional medicine providers. The Council will be given the task of supervising and controlling the practice of traditional medicine practitioners, fostering research into traditional medicines, and making loans or grants available to traditional health practitioners. Traditional medicine practitioners in Namibia, many of whom come from other African countries, are not currently registered and operate without any guidelines from the Ministry of Health and Social Services. The aim of the Bill is to protect the public from dangerous and opportunistic practices as well as to promote acceptable aspects of traditional medicine in Namibia. Once legislation is in place, the Government intends to include traditional medicine practitioners in community-based health care programmes and incorporate the traditional medical system into the country's official health services referral system. The Allied Health Service Professions Act of 1993 permits the relevant Minister to create a professional board to regulate the chiropractic profession. The objectives of the board, stated in Section 2, shall be to assist in promoting health, oversee professional training, and control the practice of chiropractic. Education and training According to the joint study by the Ministry of Health and Social Services and World Health Organization in 1997, all traditional medicine practitioners, except traditional birth attendants, undergo apprenticeships ranging from one to three years. Niger Regulatory situation In Niger, candidates for the licence to practice traditional medicine are assigned to the National Hospital in Niamey, where they practice under the supervision of the Chief Physician. Once satisfied with the skills of the traditional medicine practitioner, the Chief Physician then recommends that the Ministry of Public Health and Social Affairs issue a licence. A 1989 order established the Committee for Studies on Traditional Medicine and Traditional Pharmacopoeia. The Committee's tasks include formulating the basic premises for a national policy on traditional medicine, preparing statutes for a national institution to be responsible for improving and developing the regulation of traditional medicine, and drafting legislation governing the practice of traditional medicine. Nigeria Background information There has been a rapid expansion of allopathic health care in Nigeria over the last three decades, including an increase in the number of allopathic health care providers. At the same time, because the majority of Nigerians use traditional medicine, the Government of Nigeria has shown appreciation for the importance of traditional medicine in the delivery of health care. Regulatory situation Though informal interaction between the Government and traditional medicine practitioners can be traced back to the 19th century, formal legislation promoting traditional medicine dates to 1966 when the Ministry of Health authorized the University of Ibadan to conduct research into the medicinal properties of local herbs. Efforts to promote traditional medicine continued throughout the 1970s in the form of conferences and training programmes. In the 1980s, policies were established to accredit and register traditional medicine practitioners and regulate the practice of traditional medicine. In 1984, the Federal Ministry of Health established the National Investigative Committee on Traditional and Alternative Medicine. A committee to research and develop traditional and complementary/alternative medicine was formed by the Federal Ministry of Science and Technology in 1988. The Nigerian Medical and Dental Practitioners Act of 1988 forbids the practice of medicine or dentistry by unregistered practitioners, specifically the issuance of death certificates, performance of post-mortems, or certification of leprosy or mental disability. However, traditional medical activities are protected by a provision in Section 17.6, which reads as follows: Where any person is acknowledged by the members generally of the community to which he belongs as having been trained in a system of therapeutics traditionally in use in that community, nothing in [the provisions of the Act dealing with offences] shall be construed as making it an offence for that person to practice or hold himself out to practice that system; but the exemption conferred by this subsection shall not extend to any activity (other than circumcision) involving an incision in human tissue or to administering, supplying, or recommending the use of any dangerous drug within the meaning of Part V of the Dangerous Drugs Act. Registration requirements for chiropractors and osteopaths are outlined in the Medical Rehabilitation Therapists (Registration, etc.) Decree of 1988. A 1992 decree created the National Primary Health Care Development Agency with a broad mandate concerning health matters, including the endorsement of traditional birth attendants. Among other things, the Agency is responsible for supporting village health care systems by paying special attention to and providing maximum support for the training, development, logistic support, and supervision of village health workers and traditional birth assistants, along with the relationship between those workers and their communities and the mechanisms that link those workers to other levels of the health system; paying special attention to the involvement of women and grassroots organization of women in the village health system. In 1994, all state health ministries were mandated to set up boards of traditional medicine in order to enhance the contribution of traditional medicine to the nation's official health care delivery system. The National Traditional Medicine Development Programme was established in 1997. Since then, the Federal Ministry of Health has been instituting measures to formally recognize and enhance the practice of traditional medicine. These measures include the constitution and inauguration of the National Technical Working Group on Traditional Medicine; development of policy documents on traditional medicine, including the National Policy on Traditional Medicine, National Code of Ethics for the Practice of Traditional Medicine, the Federal Traditional Medicine Board Decree, and Minimum Standards for Traditional Medicine Practice in Nigeria; and advocacy for traditional medicine at all levels and in relevant forums, such as the National Council on Health (since 1997), Consultative Meetings of the Honourable Minister of Health with State Commissioners for Health and Local Government Chairmen (in 1999), and the Presidential Think Tank Forum (in 1999). In 2000, the Traditional Medicine Council of Nigeria Act was proposed. The functions of the Council include facilitating the practice and development of traditional medicine; establishing guidelines for the regulation of traditional medical practice to protect the population from quackery, fraud, and incompetence; liaising with state boards of traditional medicine to ensure adherence to the policies and guidelines outlined in the Federal Traditional Medicine Board Act; establishing model traditional medicine clinics, herbal farms, botanical gardens, and traditional medicine manufacturing units in the geopolitical zones of the country; and collaborating with organizations with similar objectives within and outside Nigeria. The Nigeria Medical Council is contemplating integrating homeopathy into the country's health care delivery system. Rwanda Regulatory situation Rwanda has local and national intersectoral councils for traditional medicine and a registry of traditional health practitioners. However, Rwanda does not have official legislative/regulatory texts governing the practice of traditional medicine, a licensing process for traditional health practitioners, or procedures for the official approval of traditional medical practices and remedies. Education and training Rwanda has traditional medicine training facilities for lay persons.
Sao Tome and Principe Regulatory situation Sao Tome and Principe has local and national intersectoral councils for traditional medicine. However, there are no official legislative / regulatory texts governing the practice of traditional medicine, no licensing process for traditional health practitioners, and no procedures for the official approval of traditional medical practices or remedies. Traditional medicine practitioners are not involved in Sao Tome and Principe's primary health care programme. Education and training Sao Tome and Principe does not have any official training facilities or programmes for traditional medicine. Senegal Background information Despite repressive laws against the practice of traditional medicine during the colonial period, almost every village in Senegal has a traditional medicine practitioner. The Experimental Centre for Traditional Medicine was established in Senegal in 1987. It now has an active patient roster of over 30 000 persons and is made up of a professional staff of both allopathic and traditional medicine practitioners. Whether or not spiritualists should be considered as traditional medicine practitioners is currently being debated in Senegal. Regulatory situation Traditional medicine was officially recognized by the Government of Senegal in 1985. Senegal has a registry of traditional health practitioners. The Health Ministry advocates the promotion and rehabilitation of traditional medicine and traditional pharmacopoeia. There are official strategies and activities to encourage collaboration between traditional and allopathic medical practitioners. Education and training Senegal has traditional medicine training facilities for lay persons. Seychelles Regulatory situation Seychelles does not have official legislative/regulatory texts governing the practice of traditional medicine, a licensing process for traditional health practitioners, or procedures for the official approval of traditional medical practices and remedies. Practitioners of traditional medicine are not involved in Seychelles' primary health care programme. Education and training Seychelles has no official training facilities or programmes in traditional medicine. Sierra Leone Regulatory situation In Sierra Leone, the Medical and Dental Surgeons Act of 1966 states that nothing in the Act is to be construed as prohibiting or preventing the practice of "customary systems of therapeutics", provided that such systems are not dangerous to life or health. The Medical Practitioners and Dental Surgeons Decree of 1994 repeals the Medical and Dental Surgeons Act of 1966. However, it retains exemptions for traditional medical practitioners. Section 43 reads as follows: Nothing in this Decree shall be construed to prohibit or prevent the practice of customary systems of therapeutics or the practice of druggists authorized by any law; but nothing in this Decree shall be construed to authorize the practice of any customary system of therapeutics which is dangerous to life or health. In Sierra Leone, some traditional medicine practitioners are involved with the primary health care programme. The Traditional Medicine Act of 1996 regulates the profession of traditional medicine and controls the supply, manufacture, storage, and transportation of herbal medicines. The Act establishes the Scientific and Technical Board on Traditional Medicine and two committees under it: the Disciplinary Committee to advise the Board on matters relating to the professional conduct of traditional medicine practitioners and the Drugs Committee to advise the Board on the classification and standardization of traditional medicines. The Scientific and Technical Board is charged with securing the highest practicable standards in the provision of traditional medicine in Sierra Leone by promoting the proper training and examination of students of traditional medicine, controlling the registration of traditional health practitioners, and regulating the premises where traditional medicine is practiced. It is provided in the Traditional Medicine Act that the Board shall have a registrar who shall make and keep the Register of Traditional Medical Practitioners. Anyone whose name is entered in this Register shall be regarded as a member of the Sierra Leone Traditional Healers Association. Cancellation and suspension of registration, annual publication of the list of registered traditional medicine practitioners, restriction on use of the title "Traditional Medical Practitioner", and the provision of medical aid by traditional medicine practitioners are also covered by the law. Part IV of the Act contains a list of the diseases for which traditional medical providers may not advertise treatments. Education and training Sierra Leone has no official training facilities or programmes in traditional medicine. South Africa Background information Traditional healers - in South Africa known as inyangas, sangomas, and witchdoctors - have a crucial role in providing health care to the majority of South Africans. They are deeply interwoven into the fabric of cultural and spiritual life. In 1980, the Traditional Healers' Organization was created. The National Department of Arts, Culture, Science, and Technology funds consortium research projects into traditional medicines. Statistics Traditional healers are present in almost every community. They are the first health providers to be consulted in up to 80% of cases, especially in rural areas. There are over 200 000 traditional healers in South Africa and only 27000 allopathic medical practitioners. The Traditional Healers' Organization currently represents more than 180 000 traditional healers from South Africa and a number of neighbouring countries, including Swaziland, Zambia, and Zimbabwe. There are approximately 200 chiropractors practicing in South Africa. Every year 1500 tons of traditional medicines are sold in medicine markets in Durban alone. The traditional medicine industry is worth up to 2300000 South African rand per year. Regulatory situation South Africa regulates general traditional healers, herbalists, chiropractors, homeopaths, osteopaths, and naturopaths under the Associated Health Service Professions Act of 1982, as amended. This Act sets up a registration and licensing scheme for various professions. Registration entitles medical providers to practice for gain and call themselves members of that profession. Practice for gain by a non- registered person is an offence punishable by a fine and/or imprisonment of up to one year. To qualify as a traditional healer, one has to serve an apprenticeship of between one and five years and must be well known within the community one serves and amongst other traditional healers. Qualified traditional healers register with the Traditional Healers' Organization and are given a book to certify that they are qualified healers. The qualifications are valid in Africa, Asia, Latin America, Europe, and Australia. However, Section 41 of the Associated Health Service Professions Act of 1982 states that the provisions of the Act shall not be read to "derogate from the right which a medicine man or herbalist contemplated in the Code of Zulu Law may have to practice his profession". The South African law also imposes restrictions on the professional nomenclature that can be adopted by traditional healers. Use of the title "Medical Practitioner", or a title suggesting that its holder is qualified as an allopathic medical practitioner, is prohibited. Applicants for registration as chiropractors must show they hold a degree, diploma, or certificate demonstrating sufficient proficiency in chiropractic. Such qualifications are not, in contrast, required for the registration of an osteopath or naturopath. The Associated Health Service Professions Board may, on an individual basis, impose restrictions on the kind of work that can be carried out by chiropractors or require applicants for registration to obtain further practical experience, on terms stipulated by the Board. Chiropractors and osteopaths are prohibited from performing operations, administering injections (other than intramuscular or hypodermic injections), practicing obstetrics, and taking or analysing blood samples. Additionally, chiropractors and osteopaths may not "treat or offer to treat cancer or prescribe a remedy for cancer or pretend that any article, apparatus, or substance will or may be of value for the alleviation of the effects or for the curing or treatment of cancer". There is also a prohibition against preventing or improperly discouraging a person from obtaining treatment by an allopathic physician or health care professional. Osteopaths are subject to further restrictions, which, among other things, bar them from performing internal examinations or reading or interpreting Roentgen plates as part of a clinical diagnostic procedure. In August 1998, the South African Parliament decided to enlist the help of traditional healers in achieving major goals in primary health care. However, whether traditional healers should become part of the Department of Health itself or belong to their own association in affiliation with the Department of Health remains controversial. The National Department of Agriculture governs traditional medicines via the National Plant Genetic Resource Committee, of which a traditional healer is a member. The National Department of Health produced the National Drug Policy. For the purpose of implementing the National Drug Policy with respect to traditional medicines, the National Department of Health established the National Reference Centre for Traditional Medicines. Traditional medicines are included in the Drug Policy section of the Government's Reconstruction and Development Programme. The goals of the Traditional Medicines Programme of the Department of Pharmacology, University of Cape Town (62, 63), are to promote the use of safe, effective, and high-quality essential traditional medicines; to promote the documentation and scientific; validation of traditional medicines; to contribute to primary health care by providing appropriate information to traditional healers and other health professionals; to support industrial development in this sector; and to contribute to the training of traditional healers. In 1994, the Programme participated in formulating an outline proposal on the registration and control of traditional medicines. In 1998, the Parliament passed Act 132, the South African Medicines and Medical Devices Regulatory Authority Bill, covering the registration and regulation of traditional medicines and changing the regulation of medicines in the country. The Bill establishes the South African Medicines and Medical Devices Regulatory Authority to replace the Medicines Control Council, which was set up in 1965. The Medicines Control Council held allopathic, traditional, and complementary/alternative medicines to the same set of standards and procedures. The South African Medicines and Medical Devices Regulatory Authority Bill, in contrast, makes provisions for different procedures to be applied when registering allopathic medicines and traditional and complementary/alternative medicines. This is done by establishing separate expert committees for the two major types of medicine. In the case of traditional medicines, issues of safety and quality take precedence over demonstrations of efficacy. The aim is to regulate and not to prevent access to what many people use in preference to allopathic medicines. Education and training In the 1960s, due to pressure from the South African Medical Council, non-allopathic medical colleges were closed. Those practicing at the time were 'grandfathered' into a closed register. Allopathic medical doctors retained the right to practice homeopathy regardless of their level of homeopathic education. The Homeopathic Association of South Africa is currently working to gain recognition for homeopathic education as a pre-graduate and postgraduate university subject. The long-term vision is a chair of homeopathy at one of the universities. As a first step, there are overtures to the South African College of Medicine for accreditation and application for registration of a South African Faculty of Homeopathy. There are two institutions offering six-year chiropractic programmes leading to a Master's Degree. Swaziland Regulatory situation In Swaziland, the Control of Natural Therapeutic Practitioners Regulations of 1978 limits the definition of "natural therapeutic practitioner" to persons practicing chiropractic, homeopathy, naturopathy, or electropathy. The prohibitions on professional practice are similar to those in force in Lesotho. Some traditional medicine practitioners are involved with Swaziland's primary health care programme. Education and training Swaziland has no official training facilities or programmes in traditional medicine. Togo Regulatory situation Togo's law on health practitioners holds exemptions in favour of providers of traditional medicine. In the first paragraph of Section 68 of the Criminal Code of 1980, the definition of the illegal practice of medicine very closely reflects Article L 372 of the French Code of Public Health. However, the second paragraph of Section 68, states the following: "The above provisions do not apply to medical practitioners who practice according to traditional methods." Togo has a registry of traditional health practitioners. Some traditional medicine practitioners are involved with Togo's primary health care programme. Uganda Background information Practitioners of traditional medicine vastly outnumber allopathic doctors in Uganda. The National Traditional Healers and Herbalists Association has recently put forth a proposal to establish a hospital in Mengo, Kampala, where traditional health care will be offered. This proposed 20-bed hospital would operate with facilities worth US$ 8.9 million. Traditional and Modern Health Practitioners Together against AIDS and other diseases (THETA) is an indigenous non-governmental organization dedicated to improving mutually respectful collaboration between traditional and allopathic health practitioners in Uganda. THETA is working with traditional medicine practitioners in education, counselling, and improved clinical care for people with sexually transmitted diseases, including HIV/AIDS. Regulatory situation The Medical Practitioners and Dental Surgeons Act 10 of 1968 prohibits unlicensed persons from practicing medicine, dentistry, or surgery. However, Section 36 allows the practice of any system of therapeutics by persons recognized to be duly trained in such practice by the community to which they belong, provided the practice is limited to that person and that community. In Uganda, the Ministry of Health presides over allopathic practitioners, while the Ministry of Women in Development, Culture, and Youth presides over traditional medicine practitioners. The Government of Uganda has expressed interest in recognizing traditional health systems and has set up, under the Ministry of Health, the Natural Chemotherapeutics Research Laboratory to study the therapeutic potential of natural products. The intention is eventually to include in the National Health Service those products deemed efficacious. Research is conducted jointly with traditional medicine practitioners. The Government of Uganda is in the process of developing a health policy emphasizing primary health care. The Health Review Commission recommended that the Ministry of Health work closely with traditional medicine practitioners to achieve the objectives of health for all by the year 2000. The Commission specifically recommended including traditional health practitioners as members of community health teams and welcoming them to participate in primary health care. Education and training THETA organizes training programmes for traditional medicine practitioners and is establishing and managing a resource and training centre to facilitate the collection and dissemination of information on traditional medicine. United Republic of Tanzania Background information Traditional medicine has been practiced separately from allopathic medicine since the colonial period. The practice of traditional medicine is threatened by a lack of written documentation on traditional medical practices, which has made its promotion difficult, and by a decline in biodiversity, including traditional medicinal resources, in certain localities. There has also been a decline in the number of practitioners of traditional medicine. Beginning in the 1990s, complementary/alternative systems of health care have emerged in Tanzania. These new medical options include magnetic therapy, homeopathic medicine, massage, and traditional Chinese, Korean, and Indian medicines. Regulatory situation The Medical Practitioners and Dentists Ordinance, which was constituted before Tanzania's independence and is still in operation, holds exemplary status for traditional practitioners. Chapter 92.20 states the following: Nothing contained in this ordinance shall be construed to prohibit or prevent the practice of systems of therapeutics according to native methods by persons recognized by the community to which they belong to be duly trained in such practice. Provided that nothing in this section shall be construed to authorize any person to practice native systems of therapeutics except amongst the community to which he belongs, or the performance of an act on the part of any persons practicing any such system which is dangerous to life. In an effort to promote and standardize traditional medicine, the Government established the Traditional Medicine Research Unit in 1974 as part of the University of Dar es Salaam and the Muhimbili Medical Centre. In 1985, the Government of Tanzania was in the process of developing a law to register and license traditional practitioners. In 1989, governance of traditional health services was shifted from the ministry responsible for culture to the Ministry of Health, which has established a Traditional Health Services Unit. This Unit is working to unify traditional health practitioners and mobilize them to form their own association. The Unit is also involved in the formation of a traditional medicine policy, the overall goal of which is to improve the health status of the people through the use of effective and safe elements of traditional health care. Traditional health services are officially recognized in the National Health Policy of 1990. Education and training There has been no attempt to introduce or incorporate traditional medicine into the training curricula of allopathic medical students. Zambia Background information During the colonial period, traditional medicine was denigrated. After independence in 1964, the Zambian Government did not enact legislation to regulate traditional medicine, nor was a clear policy on the practice of traditional medicine postulated. Nevertheless, traditional medicine continued to be practiced and was tolerated by the authorities. Currently, herbal medicine, naturopathy, traditional Chinese medicine, reflexology, spiritualism, and other forms of medicine are practiced in Zambia. Both Zambians and foreign nationals practice traditional and complementary/alternative medicine. Statistics At least 70% of Zambians use traditional medicine. Traditional and complementary / alternative medicine is used and accepted by a great majority of the population, regardless of ethnic, religious, or social background. There are more than 35 000 members of the Traditional Health Practitioners' Association of Zambia, founded in 1978, and thousands of non-members. Regulatory situation The Government recognizes traditional and complementary/alternative medicine and there are national policies on traditional and complementary/alternative medicine. The Traditional Health Practitioners' Association reviews and registers traditional practitioners for licensing. Although there are no official regulatory measures for recognizing the qualifications of practitioners, plans are under way to develop such regulations. Traditional medicine and complementary/alternative medicine are neither integrated with allopathic medicine nor into the national health system. However, Traditional Birth Attendants and Community Health Care Workers practice at the level of primary health care. The National Drug Policy has a chapter on traditional medicines, which discusses the materia medica but not the practice of traditional medicine. Education and training There is no formal training in traditional or complementary/alternative medicine at any allopathic training institutions. Insurance coverage Traditional and complementary/alternative medicine are not covered by insurance in Zambia. Zimbabwe Background information During the colonial period, although huge amounts of funds were allocated to the allopathic medical sector, no budgetary provisions were made for the traditional medical sector. Zimbabwe's independence in 1980 marked a turning point in the long antagonistic relationship between allopathic and traditional medicine. The Zimbabwe National Traditional Healers Association (ZINATHA) was formed the same year (76, 77), having been proposed at a meeting of 100 prominent traditional medical practitioners and Government officials organized by the then Minister of Health, Dr H. Ushewokunze. The goals of ZINATHA are to promote traditional medicine and practice, promote research into traditional medicine and methods of healing, promote training in the art of herbal and spiritual healing, supervise the practice of traditional medicine and prevent abuse and quackery, and cooperate with the Ministry of Health to establish better working relations between traditional and allopathic practitioners. Statistics In 1994, there were 11 000 workers in the allopathic health system in Zimbabwe. At the same time, ZINATHA had 24 000 qualified members. There are now over 55 000 traditional medicine practitioners registered with ZINATHA. There are four chiropractors practicing in Zimbabwe. Regulatory situation In Zimbabwe, the Minister of Health presides over both allopathic and traditional health sectors. In 1981, two significant statutes on the practice of traditional medicine were enacted in Zimbabwe. The comprehensive scope of these acts provides a sharp contrast to the general legalisation on the practice of traditional medicine adopted in other jurisdictions. The Natural Therapists Act of 1981 regulates the organization and registration of natural therapists, a term that includes homeopaths, naturopaths, and osteopaths. It is an offence for an unregistered person to engage in the practice of these professions for gain or to claim to be a registered natural therapist. Licensing legislation regulates the educational standards and practice of chiropractic. The Traditional Medical Practitioners Council Act of 1981 is one of the most comprehensive pieces of legislation on the practice of traditional medicine that has been enacted anywhere in the world. Under the terms of the Act, the practice of traditional medicine includes every act the object of which is to treat, identify, analyse, or diagnose, without the application of operative surgery, any illness of the body or mind by traditional methods. The Traditional Medical Practitioners Council Act recognizes ZINATHA as the association for traditional medicine practitioners in Zimbabwe. This legislation also created the Traditional Medical Practitioners Council. The objectives of the Traditional Medical Practitioners Council are to supervise the control and practice of traditional medical practitioners, promote the practice of traditional medical practitioners, foster research into traditional medical practice, develop knowledge of traditional medical practice, hold inquiries for the purpose of the Traditional Medical Practitioners Council Act, and make grants or loans to associations or persons where the Council considers this necessary or desirable for, or incidental to, the attainment of the purposes of the Council. The Minister of Health is to appoint a registrar to establish a register of traditional medicine practitioners. The Traditional Medical Practitioners Council is to grant an application for registration if it is satisfied that the applicant possesses sufficient skill and ability to practice traditional medicine and is of good character. Where appropriate, the Council may grant the applicant a qualification as a spirit medium. The Minister of Health may also grant registration as an honorary traditional medical practitioner, with or without qualification as a spirit medium, to traditional practitioners of special standing. Registered practitioners may use the title "Registered Traditional Medical Practitioner" or "Registered Spirit Medium". An unregistered person commits an offence punishable by up to two years imprisonment and/or a fine if he or she practices or carries on business for gain as a traditional medical practitioner, whether or not purporting to be registered; pretends, or by any means whatsoever holds himself or herself out to be a registered traditional medical practitioner; or uses the title "Registered Traditional Medical Practitioner" or any name, title, description, or symbol indicating or calculated to lead persons to infer that he or she is registered as a traditional medical practitioner. Falsely claiming to be a registered spirit medium constitutes a similar offence. The Council has the authority to make by-laws to define "improper and disgraceful conduct" in the case of registered traditional medical practitioners. A registered practitioner who is found guilty of such conduct or who is grossly incompetent is liable to disciplinary measures, which include cancellation or temporary suspension of registration. The Americas
Argentina Statistics In Argentina, an estimated 3000 physicians and 500 pharmacists practice homeopathic medicine. There are three practicing chiropractors. Some kinesiologists are also members of the chiropractic association. Regulatory situation Traditional medicine is regulated by Article 75-17 of the Constitution, Ley 23.302, Decreto 1269-96, and Resolution 83-94. Only professionally qualified doctors who have graduated from recognized medical schools may legally practice homeopathy. In November 1997, the Chamber of Deputies of Cordoba Province regulated the prescription of homeopathic medications. There is no chiropractic law. Education and training There are seven homeopathic schools offering regular three-year degree programmes as well as intensive programmes. A chiropractic college is being established.
Bolivia Background information The principal specialities of traditional medicine practitioners are coca qawiri, midwifery, aysiri, materos, qulliri, milluris, qaquidores, paqos, layqiri, and rezadores. Statistics In Bolivia, where 50.5% of the population is indigenous, the proportion of the population with access to allopathic medicine ranges from 11% to 70%. depending on the region. There is a strong preference for traditional medicine. In southern Cochabamba, over 55% of the population prefer to use traditional medicine. There are an estimated 5000 practicing traditional health providers. There is one practicing chiropractor. Regulatory situation In 1985, the practice of traditional medicine was legally recognized. Laws governing traditional medicine in Bolivia include Traditional Medicine Practice Regulation 198771-1984, Resoluciσn Suprema 198771-84, and Personerνa Juridica de la Sociedad Boliviana de Medicina Tradicional. In order to practice traditional medicine in Bolivia, it is necessary to have an official licence granted by the Ministry of Human Development. However, only an estimated 500 traditional medicine practitioners have this permit. Revalidation of one's Doctor of Chiropractic degree is required to practice chiropractic. The National Division of Maternal and Child Health was established in 1982 with regulations on the conduct of family health activities. This division is authorized to regulate traditional birth attendants. There is no official programme linking traditional medicine with allopathic medicine. There is no formal registry of traditional medicine practitioners. In 1982, the Ministry of Health established regulations on herbal medicines, and as of January 2001, all homeopathic medicines must be registered. Education and training In 1982, the Ministry of Health set up a training programme for traditional practitioners at allopathic medical schools. KUSKA (a civil organization devoted to multi-disciplinary research in health, education, agriculture, ecology, and eco-tourism) has two schools of traditional medicine: INKARI in Cochabamba and the Kallawaya Institute in La Paz. At these schools, experienced traditional health practitioners offer seminars, workshops, lectures, meetings, and trimester courses, as well as opportunities for students to observe and practice consultations and treatments. Formal courses, workshops, and seminars in traditional medicine are also available through the official health sector. Workshops, principally sponsored by the Catholic Church, are offered for nurses and health promoters. Traditional medical knowledge may also be acquired through personal revelations and inspiration. In Rahay Pampa, traditional medicine is frequently taught to successive generations within a family. Brazil Statistics In Brazil, there are an estimated 12 000 homeopathic physicians, 200 homeopathic veterinarians, 100 homeopathic dentists, 1300 homeopathic pharmacists, and six homeopathic laboratories. There is a chiropractic association in Brazil. Regulatory situation Regulations governing traditional medicine in Brazil include La Polνtica de Atenciσn Integral a la Salud Indνgena de FUNASA, which promotes respect for the traditional systems of health of indigenous communities. In 1980, the Brazilian Medical Association recognized homeopathy as a medical speciality. In 1988, the Government recognized homeopathy and included it in the National Health System. Since 1995, the Federal Council of Pharmacy has recognized and standardized the title of "Specialist in Homeopathic Pharmacy". Education and training As of 1991, physicians seeking homeopathic specialization must complete a 1200-hour course: 450 hours of theory, 450 hours of practice, and 300 hours of monographs. The Feevale Central University and University of Anhembi Morumbi offer chiropractic programmes recognized by the World Federation of Chiropractic. Canada Background information In Canada, complementary/alternative and traditional medicines are known as natural health products and are subject to food and drug regulations. Natural health products include herbal medicines; traditional Chinese, ayurvedic, and native North American medicines; homeopathic preparations; and vitamin and mineral supplements. There are a number of associations of complementary/alternative medical practitioners. In 1983, the Chinese Medicine and Acupuncture Association of Canada (CMAAC) was established as a national organization. CMAAC works to unite practitioners and to lobby the Government for the regulation of traditional Chinese medicine and acupuncture. In 1987, the World Federation of Acupuncture and Moxibustion Societies was formed with the support of the World Health Organization. In 1996, allopathic physicians interested in traditional and complementary/alternative medicine in Canada created the Canadian Complementary Medical Association. Statistics Several reports from the late 1990s found that between 15% and 70% of the Canadian population had used complementary/alternative medicine in the proceeding six to 12 months (89, 90, 91). A 1999 study, for example, reported 70% of Canadians had used one or more natural health products in the preceding six months, but only 24% consulted one or more complementary/alternative health practitioners. The use of complementary/alternative medicine is increasing in Canada (92, 93). The following chart represents findings of the 1999 Berger Monitor survey on the six-month use of complementary/alternative health practitioners in 1993 and 1999. According to a study by the Fraser Institute, of the Canadians who have used complementary / alternative medicine, 36% have consulted a chiropractor, 23% have used relaxation techniques, 23% massage. 21% prayer, 17% herbal therapies, 12% special diet, 12% folk remedies, 12% acupuncture, 10% yoga, 8% self-help groups, 8% lifestyle diets, and 8% homeopathy.
A significant proportion of Canadians report spending 30 Canadian dollars or more per month on complementary/alternative health services or natural health products. From 1996 to 1997, a total of 3.8 billion Canadian dollars was spent on complementary / alternative health care in Canada. The amount spent on vitamins and food supplements is rising by 20% a year. In general, the use of complementary/alternative health care in Canada is higher at younger ages, among women, among people with higher formal education and higher incomes, and in the West. Canadian users of complementary/alternative medicine have more good health habits and better overall health. However, these differences are partly minimized when adjusted for age, education, and household income. Users of complementary/alternative medicine make fewer visits than non-users to both allopathic general practitioners and specialists. The most common reasons for which patients consult complementary/alternative practitioners are problems of the musculoskeletal system and connective tissue. These complaints account for 56% of consultations. Other problems include respiratory diseases, injuries, poisonings, ill-defined conditions, and special investigations. Complementary/alternative practitioners provide most complementary/alternative treatments. However, allopathic physicians are increasingly involved in the provision of complementary/alternative medicine. There are approximately 4500 chiropractors practicing in Canada. Regulatory situation Canadian physicians choosing to provide alternative treatments must comply with guidelines set by the relevant province's College of Physicians and Surgeons. The Federal Food and Drug Act does not recognize traditional Chinese doctors, naturopaths, homeopaths, or herbalists. However, the recent Federal Report (supra) noted that access to quality health care is tied to the education, training, and licensing of practitioners and products. As such, it seems likely that Canada will soon give formal recognition to more complementary/alternative practitioners. Most of the health care legislation, such as the Canada Health Act, focuses on allopathic medical practitioners. However, the regulation of professionals is a provincial matter, and many provinces have become tolerant of non-allopathic health care providers. Ontario's Regulated Health Professions Act, S.O. 1991, c.18 is an example of the more inclusive legislation adopted by a number of provinces. On 26 March 1999, the Federal Government accepted all 53 recommendations made by the Standing Committee on Health in their report, Natural Health Products: A New Vision. While the Health Minister's formal acceptance of these recommendations will not immediately change the status of natural health products in Canada, the policy direction has been set. A transition team was created and it is now working to implement these recommendations. One of the recommendations led to the creation of the Office of Natural Health Products, which regulates the safety, quality, and proper labelling of these products. It is also responsible for supporting epidemiological and social science research and for the dissemination of information to Canadian consumers to enable them to make informed self-care decisions. Beginning in the spring of 2000, the Office of Natural Health Products invited comments and suggestions from a wide range of interested Canadians - including manufacturers, distributors, and retailers of natural health products - on the formation of a regulatory framework for natural health products, covering their production, import, sale, and use in Canada. In March 2001, the Proposed Regulatory Framework for Natural Health Products was drafted. The Framework contains provisions for natural products sold in Canada, including licensing of products and sites, good manufacturing practices, labelling and packaging, and reporting of adverse reactions. The intent is to address consumers' concerns for safety and product quality without being unduly restrictive of the natural health product industry. The Expert Advisory Committee on Complementary Medicines was recently formed to provide scientific advice to the Therapeutic Products Programme of Health Canada on issues regarding the safety, quality, and efficacy of natural health products.
Traditional Native North American medicine In the Yukon Territory, the Health Act of 1990 endorses traditional native North American medical practices. Section 5 includes provisions to secure "aboriginal control over traditional aboriginal nutritional and healing practices and to protect these healing practices as a viable alternative for seekers of health and healing services". The Minister of Health also "promote(s) mutual understanding, knowledge, and respect between providers of health and social services offered within the health and social service system and the providers of aboriginal nutrition and healing". In Ontario, traditional birth attendants providing midwifery services to aboriginal persons or members of an aboriginal community are exempt from the general rule that restricts "managing labour or conducting the delivery of a baby" to allopathic physicians, nurses, and midwives. Traditional birth attendants can adopt the title "Aboriginal Midwife" as a professional designation and portray themselves as qualified to practice in Ontario. Manipulative therapy In at least nine Canadian provinces, special statutes restrict the practice of manipulative therapy to persons who fulfil specific requirements and have been registered and/or licensed. All provinces have laws regulating the practice of chiropractic. In Ontario, manipulative therapy is regulated under the Regulated Health Professions Act of 1991 and the Chiropractic Act of 1991. The Health Professions Act states that it is an offence for a person to "move the joints of the spine beyond the individual's usual physiological range of motion using a fast, low-amplitude thrust" unless the person is authorized by one of the listed health profession acts, such as the Chiropractic Act. The Chiropractic Act limits the practice of chiropractic to members of the College of Chiropractors. The legislation permits the use of the title "Doctor" by members of the College of Chiropractors of Ontario. No offence is committed under the Health Professions Act when an otherwise impermissible joint movement is performed in the course of "treating a person by prayer or spiritual means in accordance with the tenets of the religion of the person giving the treatment" or where the treatment is performed by an aboriginal medical practitioner providing traditional medicine services to aboriginal persons or members of an aboriginal community. Chiropractors have professional status in Alberta. In 1994, Alberta introduced requirements for the continuing education of licensed chiropractors. Practitioners must acquire 75 hours of continuing education every three years as a condition for renewal of their annual licence. Full credit is given for participation in programmes accredited with listed professional bodies. Credit may also be given for other educational activities with an emphasis in chiropractic, such as research or university studies. In Saskatchewan, the Chiropractic Act of 1994 repeals the 1978 Act on the same subject and prohibits anyone other than a member of the Chiropractors' Association from using the titles "Chiropractor", "Doctor of Chiropractic", or "any word, title or designation, abbreviated or otherwise, to imply that the person is engaged in or qualified to engage in the practice of chiropractic." Section 22 of the Act lays out the restrictions on and exemptions to the practice of chiropractic in Saskatchewan: 1. No person other than a practicing member shall engage, for fee or reward, in the practice of chiropractic. 2. Subsection 1 does not apply to a person providing first aid or temporary assistance in cases of emergency. 3. Nothing in this Act extends to or interferes with the privileges conferred on any person who practices a profession, trade or calling that the person is licensed or authorized to practice pursuant to any other Act. Traditional Chinese medicine and acupuncture Health Canada, through the Therapeutic Products Programme, is actively pursuing the National Initiative on Traditional Chinese Medicine. British Columbia, Alberta, and Quebec include acupuncture among their regulated health professions. Saskatchewan and the Yukon Territory have guidelines on the practice of acupuncture. A 1993 report by the British Columbia Health Professions Council recommended the designation of acupuncture as a health profession with three limitations: acupuncture should not be used in the treatment of serious illnesses, such as cancer; acupuncture should not be used as anaesthesia during surgery, unless supervised by a physician or dentist; and the patient must be told to consult an allopathic physician, dentist, or naturopath if acupuncture fails to improve the patient's condition within two months. The Ministry of Health in British Columbia has agreed that traditional Chinese medicine and acupuncture should be regulated. In April 1998, the British Columbia Health Professions Council recommended designating "the profession of traditional Chinese medicine as a health profession under the Health Professions Act." The Council also recommended that a college be established to govern both practitioners of acupuncture and practitioners of traditional Chinese medicine. This college will ensure that practitioners complete adequate training based on Government standards. The Health Disciplines Act of 1980 sets out a framework for the recognition and regulation of health disciplines in Alberta. Acupuncture is governed by the accompanying Acupuncture Regulation. In order to be registered as a member of the acupuncture health profession, an applicant, who need not be an allopathic physician, must complete both an approved programme of study and an examination. Competence in English must also be demonstrated. However, this requirement may be waived where the applicant practices under the supervision of an English-speaking acupuncturist. Before acupuncture treatment is administered in Alberta, the patient must have consulted with an allopathic physician or dentist and informed the acupuncturist of this. Acupuncturists are prohibited from implying to patients that acupuncture cures diseases or advising patients to discontinue treatment recommended by an allopathic physician or dentist. If an improvement in the patient's condition does not occur within six months, the patient must be referred to an allopathic physician or dentist. In Alberta, permissible technical modes of practice are restricted to needle acupuncture, electro-acupuncture, moxibustion, cupping, and acupressure. Only non-invasive measuring equipment may be used in patient examinations. The Acupuncture Regulation also lists a number of procedures that cannot be delegated to non-acupuncturists, including taking patients' medical histories, using diagnostic instruments or therapeutic devices on patients, and inserting or removing acupuncture needles. The Quebec Medical Act of 1973 required the Bureau of the Ordre des Mιdecins to enact rules for the training, practice, and annual registration of allopathic physicians practicing acupuncture. Rules were also introduced concerning the practice of acupuncture by non-physicians. Non-physician practitioners must hold a recognized college diploma and pass an acupuncture exam set by the Quebec medical regulatory body. Detailed patient records must be kept covering matters such as diagnoses made, treatments rendered, and details of patient consultations with other medical professionals, including allopathic physicians. Under Section 44 of the Medical Act of Quebec, no person can claim to be an acupuncturist unless he or she is a registered non-physician or allopathic physician who has undergone the required training in acupuncture. Moreover, non-physician practitioners are precluded from using the title "Doctor" or any title that may infer that status unless they have a doctorate in acupuncture, in which case they may use the title "Doctor of Acupuncture". A number of medical professional regulatory bodies in Canada have published guidelines relating to acupuncture. In Saskatchewan, such guidelines were drawn up by the College of Physicians and Surgeons. These permit the practice of acupuncture by allopathic physicians who hold a recognized diploma. The guidelines do not mention the practice of acupuncture by non-physicians. Guidelines issued by the Yukon Medical Council, however, state that acupuncture is a medical procedure that should only be performed by allopathic physicians or dentists with an appropriate level of training. The guidelines do not permit physicians to delegate acupuncture procedures to others, such as physiotherapists, "except in an approved institutional setting such as a public hospital". The reasoning behind this is that the Yukon guidelines acknowledge that acupuncture has a "valid role" in patient management but warn that, based on current knowledge, "it does not have a curative effect on the fundamental disease process". The guidelines strongly endorse two training programmes recognized by the College of Physicians and Surgeons in British Columbia, but stop short of requiring completion of a programme of study. Naturopathy Naturopathy is regulated in Alberta, Manitoba, and Saskatchewan. In each of these three provinces, naturopaths must meet specified educational requirements and be registered in order to practice naturopathy or use the title of "Naturopath". Educational requirements include the completion of a four-year college programme. Manitoba and Saskatchewan also require an examination in anatomy, physiology, chemistry, general diagnosis, and the principles of naturopathy. In all provinces, naturopaths are prohibited from performing certain health care activities, such as the prescription and administration of allopathic drugs, obstetrical practice, and surgery. In Alberta, two corresponding provisions in the Chiropractic Profession Act of 1984 forbid dual registration as a naturopath and chiropractor. One states that registered chiropractors cannot practice naturopathy and the other that practicing naturopaths cannot be registered as chiropractors. Education and training Complementary/alternative training programmes are provided by private institutes, universities, and community colleges, but there is no universal system of accrediting and validating programmes. Though there is no standardized complementary / alternative component in allopathic curricula, most medical schools offer some form of training in complementary / alternative medicine to their students of allopathic medicine, but this usually takes the form of a two-hour to four-hour lecture. The 1998 Standing Committee Report states that there is increasing interest in having more training programmes and more standardized training curricula in complementary / alternative medicine for both complementary/alternative and allopathic providers. In 1985, the Institute of Chinese Medicine and Acupuncture was established to promote the training standards of the Chinese Medicine and Acupuncture Association of Canada. Students interested in entering the four-year programme offered by the Institute are required to have first completed three years of coursework in the sciences at a recognized university. There are two chiropractic colleges in Canada recognized by the World Federation of Chiropractic. Insurance coverage Coverage of complementary / alternative therapies by provincial health insurance plans and workers' compensation boards is selective and minimal. Some provincial health insurance plans cover chiropractic (Alberta, British Columbia, Manitoba, Ontario, Saskatchewan, and New Brunswick only for seniors who purchase extended coverage), and one covers naturopathy (British Columbia). Osteopathy is covered in Alberta. Workers' compensation boards cover chiropractic in all provinces and territories. Workers' compensation boards in British Columbia, Newfoundland, Ontario, Prince Edward Island, Quebec, and the Yukon Territory cover acupuncture on a case-by-case basis or on prescription by an allopathic physician (92, 116). The Alberta Health Care Insurance Plan discontinued its coverage of acupuncture on 1 March 1994. Patients are now solely responsible for the cost of acupuncture treatment. About 96% of the private health insurance coverage in Canada is group policies purchased primarily by employers. This insurance is a non-taxable benefit so long as, among other things, reimbursement is only provided for qualified medical practitioners, which include chiropractors, osteopaths, naturopaths, therapists, acupuncturists, and dieticians. Chile Background information The Mapuche Community Hospital offers traditional and allopathic treatment options. Practicing at the hospital are traditional medical providers, bonesetters, and two allopathic doctors. The hospital is affiliated with Mapuche University. Both the hospital and the university receive financial support from the Ministry of Health. Statistics In Chile, 10% to 12% of the population is indigenous. Seventy-one per cent of the population uses complementary / alternative medicine. There are between 2000 and 10 000 traditional health practitioners in Chile. Principal traditional medical specialities are herbalism, spiritualism, traditional birth attendance, aromatherapy, bach flowers, acupuncture, bonesetting, and chiropractic. Regulatory situation National policies emphasize equal treatment for traditional and allopathic medicine. Homeopathy and the Homeopathic Pharmacopoeia are legally recognized. The Public Health Institute recognizes homeopathic remedies. Traditional and complementary / alternative medicine are regulated by Ley 19.253 of October 1993, which takes into consideration their role in public health. The Ministry of Health oversees the Unit of Traditional Medicine, which also governs complementary/alternative medicine, and the Unit of Indigenous Community Health. The Unit of Traditional Medicine was established in August 1992. Its objectives are to set standards for the safety and efficacy of traditional medicines and to encourage the use of proven traditional medicines, including incorporating them into allopathic health programmes. The Unit of Indigenous Community Health develops the primary health care system at the community level. The Health Ministry issues licences for the practice of traditional medicine, but very few traditional medicine practitioners are licensed. Unlicensed traditional health practitioners risk fines or the closure of their offices. There is no official registry of traditional medicine practitioners. Education and training Mapuche University offers programmes in traditional knowledge leading to Bachelor's, Master's, and Doctorate degrees. Students of these programmes may choose to specialize in traditional medicine. The university also cultivates medicinal plants and conducts research on traditional medicine. Most students of traditional medicine learn through apprenticeships with experienced providers. In some cases, these are family members. Some practitioners receive medical insight through personal revelations. Traditional medical training for official allopathic health personnel is not very extensive and consists of occasional informative events that may or may not be included in official training programmes. The Government has recognized homeopathy as a medical system, but there are no officially recognized training programmes or examinations. A chiropractic college is being established. Colombia Background information Traditional medicine is widely practiced in Colombia. Statistics Forty per cent of the population has used complementary/alternative medicine. There are six chiropractors practicing in Colombia. Regulatory situation The Congress of Deputies officially recognized homeopathy as a system of medicine in 1905. In 1914, the Government standardized training requirements for homeopathic doctors and established a system of title protection. Only allopathic physicians may practice homeopathy. The Institute of Medicaments and Food regulates the manufacturing of homeopathic remedies. Integration of homeopathy into the Public Health Services is planned. Chiropractors are not permitted to use X-ray equipment. However, chiropractors may request radiologists to provide X-ray services for their patients. Education and training Homeopathy is taught in three schools authorized by the Ministry of Education. The regular three-year courses are limited to licensed allopathic physicians. Costa Rica Background information There are no associations of traditional medicine practitioners in Costa Rica. Women do not practice traditional medicine. Statistics There are at least 19 practitioners practicing indigenous traditional medicine. There are two chiropractors practicing in Costa Rica. Regulatory situation Though the production of traditional medications is regulated, the practice of traditional medicine is ignored in official health laws. There is no registry of traditional health practitioners in Costa Rica. Traditional medicine practitioners are not licensed, nor are they sanctioned for practicing medicine. This may soon change, however, as the Legislative Assembly is currently considering a bill that would regulate traditional medicine. There are no official programmes linking traditional medicine with allopathic medicine. The College of Physicians and Surgeons recognized homeopathy as a medical speciality in 1994. By a pronouncement of the Sala de Jurisdicciσn Constitucional of the Supreme Court on 9 January 1998, allopathic medical doctors can be accredited postgraduate homeopathic studies under the Medical Speciality Regulations. Homeopathy is thereby treated as a branch of allopathic medicine and governed by the same regulations as other allopathic specialities. A chiropractic law is pending. In 1996, a multidisciplinary committee composed of representatives from the Ministry of Health and colleges of pharmacy in Costa Rican universities convened to formulate regulations on herbal medicines. In 1998, the committee published Decree 26782S regulating the industrialization, registration, commercialization, and publication of herbal preparations and herbal products. Education and training There are no institutions officially responsible for teaching traditional medicine. Postgraduate homeopathic studies are available through an institution recognized by the College of Physicians and Surgeons. Cuba Statistics Sixty per cent of the population use traditional or complementary/alternative medicine. Sixty per cent of allopathic physicians are trained in traditional or complementary / alternative medicine. There are 579 registered herbal products made in Cuba. An additional 295 registered herbal products are imported. Regulatory situation Following the 1959 revolution, Cuban health authorities forbade the practice of traditional medicine by anyone except traditional birth attendants. Traditional birth attendants were slowly integrated into Cuba's health services as ancillary staff. The 1983 Cuban Public Health Law puts forth strict requirements for the qualification of health care workers. Traditional medicine practitioners are not granted exemplary status. Section 90 states the following: Medical, dental, and pharmaceutical activities and other health professions shall be practiced by persons who have followed special courses and hold a qualification conferred by a centre of higher education in Cuba (or an equivalent foreign qualification); the activities of health technicians, qualified staff, and other health workers shall be practiced by persons who have followed special courses and hold a qualification granted by an institute, school, polytechnic, or centre for technical training in health. A 1988 decree, which contains regulations for the implementation of the Public Health Law, prohibits the practice of medicine by persons who do not meet these qualification criteria. In 1992, the Ministry of Health officially recognized homeopathy. National and international homeopathic congresses were scheduled during 1997 and 1998, and there are an increasing number of physicians using homeopathic remedies. Homeopathic dispensaries are spread all over the country. A standard good manufacturing practice for the manufacture of homeopathic remedies has been accepted. In 1992, acupuncture was integrated into the Cuban health care system. In 1995, the Traditional Medicine Programme was instituted, prioritizing the cultivation of medicinal plants, the education of practitioners, research into traditional medicine, and the integration of traditional medicine into the national health care system. Education and training Courses on introductory and advanced homeopathy are given at the medical and pharmaceutical schools. Dominican Republic Background information The principal traditional medical specialities are vodun, ensalmadorismo, and herbalism. Statistics There are between 2000 and 3000 practitioners practicing traditional health in the Dominican Republic. Regulatory situation Although there is an official programme linking traditional medicine with allopathic medicine, there is no official registry of traditional health practitioners, and traditional medicine practitioners are not licensed in the Dominican Republic. Education and training The Ministry of Health and Social Welfare offers training programmes for traditional birth attendants in hospitals and health centres throughout the Dominican Republic. The Pan American Health Organization assisted in revising these programmes in 1973 (120, 126). There are no other institutions that teach traditional medicine. Instead, traditional medicine is taught through apprenticeships with experienced practitioners. Traditional medical knowledge may also be transmitted through dreams and personal revelations. There are no official training programmes in traditional medicine for allopathic health personnel. Ecuador Background information In Ecuador, there are associations of traditional medicine practitioners that work at regional and local levels. Some of these associations were created by indigenous organizations and others by state initiatives. Statistics There are nine chiropractors practicing in Ecuador. Regulatory situation Section 174 of the Ecuadorian Health Code of 1971 limited the practice of physicians, pharmacists, dentists, midwives, and other health practitioners to persons holding qualifications "granted or validated by the University of Ecuador". Under Section 179, health authorities were responsible for the detection and suppression of the illegal practice of medicine and allied professions "without prejudice to normal judicial proceedings". By Section 180, "It shall be automatically assumed that a person is illegally practicing [medicine]... if, without holding a legally conferred qualification, diploma, or certificate, he possesses equipment or materials for such practice." In the beginning of 1998, indigenous peoples proposed a bill to regulate traditional medicine. This bill was passed in June and came into force in August 1998. Based on this bill, the Constitutional Assembly included two articles in the Constitution that stipulate principles on which the practice of traditional medicine must be based. Chapter 4, Section 4, Article 44 reads as follows: The State will formulate national health policy and will monitor its application. It will control the operation of the entities of this sector. It will acknowledge, respect and promote the development of traditional and alternative medicine, the practice of which will be regulated by law and will promote scientific and technological advancement in the health area subject to bio-ethical principles. The Constitution of the Republic, Chapter 5, Article 84, Numeral 12 establishes collective rights: to the systems, knowledge and practice of Traditional Medicine, including the right to the protection of ritual and sacred places, plants, animals, minerals and ecosystems of interest to the State from the point of view of traditional medicine. There is no registry of traditional medicine practitioners in Ecuador and no licensing procedure for practitioners of traditional medicine. There is no official institution in charge of regulating traditional medical practice. There is, however, the National Division of Indigenous Health, which was created by a ministerial resolution to promote the development of traditional medicine. In Ecuador, there are no specific programmes linking traditional medicine with allopathic medicine. But, with increasing interest in traditional medicine, particularly Quichua medicine, the State is focusing more attention on official linkages. Some efforts have been made to coordinate with institutions and organizations affiliated with traditional medicine in Ecuador. In 1983, the Government recognized homeopathy as a medical practice. The Ecuadorian Medical Federation began officially recognizing homeopathy as a medical speciality in 1988. It is also recognized in the Constitution of the National Assembly. There is no chiropractic law. Education and training Universidad Andina Simσn Bolνvar, a private Andean university in the city of Quito, is responsible for teaching traditional medicine in Ecuador. Offerings include certificate programmes, seminars, workshops, and meetings. The Ministry of Public Health established training courses for traditional birth attendants in 1974 with the aim of incorporating them into the health services of rural areas. There is no official training in traditional medicine offered to allopathic health personnel. Guatemala Background information The principal traditional medicine specialists in Guatemala are traditional birth attendants, bonesetters, herbalists, spiritualists, chupadores, massage therapists, and practitioners who specialize in muscle tears. A 1977 order established the Guatemalan Association of Acupuncture. The Association promotes the knowledge and the study of acupuncture and facilitates professional contacts with acupuncturists in other countries. Membership in this association does not license individuals to practice acupuncture. The University of San Carlos is undertaking research on medicinal plants. Statistics There are approximately three traditional health practitioners per municipality. About 250 traditional health practitioners are registered with the TOTO-Integrado Association. Regulatory situation The laws regulating traditional medicine in Guatemala include Acuerdos de Paz, the Political Constitution, the Health Code, and Regulations for the Quality Control of Herbal Products (82, 129). The Health Code defines, classifies, and outlines registration and licensing requirements for all medicines. The Regulations for the Quality Control of Herbal Products classifies herbal products and registration procedures for them. Although there is no official licence to practice traditional medicine, 10% of traditional medicine practitioners have a permit to practice. These permits are issued upon completion of a training course organized by the Public Health Ministry and local health centres. The permits are not available throughout the country. Traditional medicine practitioners without permits may practice within their own communities, but they are rejected by institutions and risk being sued for malpractice. A registry of traditional health practitioners is currently being developed. The programme of the Integral Healthcare System links traditional and allopathic medicine. Education and training Courses in traditional medicine are available through the Public Health Ministry. Additionally, CDRO in Totonicapan, Barefoot Doctors in Chinique, and Quiche Guatemala offer technical studies, seminars, informal presentations, and workshops that include instruction in traditional medicine. Traditional medicine is also learned through apprenticeships, which may include practice, observation, readings, workshops, and videos. How to treat a particular illness is sometimes learned as a result of having suffered from it oneself. Personnel in the official health services do not receive training in traditional medicine. Honduras Regulatory situation Section 130 of the Honduran Health Code of 1966 States the following: The practice of naturopathy, homeopathy, empiricism, and other occupations considered to be harmful or useless by the Secretariat for Public Health and Social Welfare shall be prohibited in the country. Practitioners of traditional medicine are not granted exemplary status. There is no chiropractic law. Jamaica Statistics More than 8000 medicinal products, including 610 vitamins, 90 minerals, and 60 herbal remedies, were registered and licensed in Jamaica between 1975 and 2000. Of the 403 medicinal products registered in 1999, 9.5% were of herbal origin. Herbal products are a multi-million dollar industry in Jamaica. Regulatory situation In 2000, the Parliament considered revisions to the Food and Drugs Act of 1964 and the Food and Drugs Regulations of 1974. The revisions were aimed at ensuring the safety, efficacy, and quality control of herbal products. In 2001, the Parliament approved the revisions, under which the following applied: Products are subject to approval, requirements for which are similar to, but not as elaborate as, those for pharmaceuticals. The onus is on manufacturers to substantiate quality, efficacy, and safety. Products containing vitamins and minerals in less than three times the recommended daily amount are classified as foods and do not require formal registration. Vitamins containing more than three times the recommended daily amount are classified as drugs. Herbal products require registration if they contain substances used for conditions that normally need medical intervention. Herbal products containing substances used for self-limiting conditions that do not normally require medical intervention do not require registration. Registered products, like drugs, require a permit for importation. Products that are not registered do not require a permit for importation; however, proof of quality is required annually or such other time, as deemed necessary. The revisions define an herbal medicine as "a medicinal product consisting of a substance produced by subjecting a plant or plants to drying, crushing, or any other process or of a mixture whose sole ingredients are two or more substances so produced or of a mixture whose sole ingredients are one or more substances so produced and water or some other inert substance". This definition is adapted from Section 132 of the United Kingdom's Medicines-Act of 1968. There is no chiropractic law. Chiropractors are recognized as medical practitioners but prohibited from providing physical therapy services and from using the title of "Doctor". Mexico Background information The principal traditional medical specialists are traditional birth attendants, herbalists, bonesetters, curanderos, snake culebreros, shamans, spiritualists, and sobadores. Statistics Traditional birth attendants preside over more than two-thirds of childbirths in Mexico. There are 55 to 60 chiropractors practicing in Mexico. There are about 3000 homeopathic physicians. Regulatory situation In 1980, the Mexican Institute of Social Security created a unit to study traditional medicine and medicinal plants. Later, a programme was introduced to foster the integration of traditional and allopathic systems of medicine. The programme was designed to involve traditional practitioners in the health activities of 3500 rural medical units within the Social Security System. The Mexican Institute of Social Security is also working with the national plan for depressed zones and marginalized groups (Coplamar) to integrate allopathic and traditional medicine. Mexico's registry of traditional medicine practitioners is kept by the National Indigenous Institute and the Mexican Institute of Social Security. Traditional medicine forms an integral part of the health care delivery system. Although there is no official licence for the practice of traditional medicine, other than for traditional birth attendants, the authorities are currently working on creating such a licence. Proposals for a bill to regulate traditional medical practice, aside from that of traditional birth attendants, have been made since 1989. The Regulations of 20 October 1976 established a distinct sector of the health field for qualified traditional birth attendants. Section 2 of the Regulations define qualified traditional birth attendants as persons who have been attending deliveries without training and are licensed and qualified under the Regulations. Licences are issued by health centres following the completion of a training course. Section 9 states that entry to the course is restricted to persons who have attained majority, are literate, and are recognized by the communities in which they work as carrying out obstetric activities. Section 13 specifies that traditional birth attendants may attend women in their community during normal pregnancy, delivery, and the puerperium provided that they notify a health centre. They may also prescribe appropriate medications in accordance with the instructions of the Secretariat for Health and Welfare. There is a proposal to add provisions to the General Health Law that would regulate the quality control of medical activities, establishments, products, and services. Chapter 4 of these proposed changes covers herbal medicines. Homeopathy has been accepted and integrated into the national health system in Mexico. In 1895, a presidential decree was issued to establish a national homeopathic school; to regulate training requirements for homeopathic doctors, including title protection; and to establish a national homeopathic hospital. In 1996, the Government recognized homeopathy as a medical speciality. Licensing legislation regulates chiropractic educational standards and practice. Chiropractors have been licensed since 1988. Credentials must be periodically revalidated. Education and training The National Indigenous Institute has a unit dedicated to the organization, coordination, and instruction of traditional medicine. In some states, the Institute coordinates with associations of traditional medicine practitioners to provide workshops, courses, and other activities where practitioners can gather and share their knowledge. Traditional medicine is taught through apprentice programmes, including practice, observation, and workshops. In some cases, families are known for a particular speciality. The Mexican Institute of Social Security offers informal presentations and workshops on traditional medicine, medical anthropology, and community work techniques to personnel working in the official health services. There are several schools and hospitals teaching homeopathy. Homeopatia de Mexico, an association for homeopathic practitioners, obtained official recognition for its postgraduate school in 1996. A chiropractic college is presently being established. Nicaragua Statistics There are 2500 persons registered in the registry of traditional medical practitioners. The principal traditional medical specialities are traditional birth attendance, herbalism, spiritualism, and massage. Regulatory situation The Department of Traditional and Popular Medicine of the Ministry of Health regulates traditional medicine in Nicaragua. No licence is required to practice traditional medicine. While there are no restrictions or legal barriers that limit its practice, the Nicaraguan Academy of Homeopathic Medicine is working towards gaining official status for homeopathy. The National Council of Universities supports homeopathy and accepts its practice by allopathic doctors. A regulation on the use of plant medicines is currently being developed and will eventually be under the responsibility of the Department of Drugstores of the Ministry of Health according to the General Law of Medication and Drugstores. Education and training In 1989, the Ministry of Health established the National Centre of Popular and Traditional Medicine with the objective of training health promoters and allopathic medical and paramedical persons in these fields. In 1991, courses in traditional medicine were introduced into allopathic nursing schools, and allopathic nurses began being trained in basic plant therapy and medical anthropology. After the change of government in the same year, the Centre became a non-profit foundation independent from the Ministry of Health. Along with the National Autonomous University of Nicaragua and several institutions under the leadership of the Ministry of Health, the Centre forms a part of the National Commission for Essential Investigation. Cecalli, Soynica, the School of Agriculture, UNAN, Real Nicaraguense de Sistemas Traditionales, and MINSA also offer training in traditional medicine. Though allopathic health personnel may follow these courses, training in traditional medicine is not offered through the official health services. Panama Background information The Government of Panama has made considerable efforts to register and train traditional birth attendants and to integrate them into the country's health care system. Statistics Although there is only one chiropractor practicing in Panama, both the United States and Canada have been sending chiropractic missions to Panama since 1997. Regulatory situation Law 4376 of August 1999 created the Area of Traditional Medicine under the National Directorate of Health Promotion. The Area is charged with developing a strategy of action for the incorporation of traditional medicine into primary health care, including research on medicinal plants. The Carta Organica Administrativa de la Comarca, following Executive Decree 194 of 26 August 1999, governs traditional medicine in the Ngφbe-Buglι region. Article 258 of the Carta classifies traditional medical specialities, the services they offer, and their legal status regarding diagnosing ailments and dispensing medicines. This same article recommends that traditional and allopathic medical practitioners cooperate and collaborate together. Article 257 creates the Special Medical and Technical Commission to bring together traditional medicine and allopathic medicine. Articles 261 and 262 refer to the organization of botanical gardens for the scientific study of medicinal plants and propose the publication of texts and health manuals. Article 266 defines the functions of the Special Medical and Technical Commission, including the following: coordinating with the national health system: certifying traditional health practitioners; organizing the methodology for a study of traditional medical practice; educating the public about scientific investigations into the methods, uses, and effects of traditional medicine; preparing a health infrastructure plan for the community; studying the medical history of the Ngφbe-Buglι. In recognition of the existence, contribution, and importance of traditional medicine to the health of indigenous communities, Article 3 of Law 36 of 3 October 2000, a nationally applicable law, created an autonomous institute of indigenous traditional medicine. The institute recognizes, protects, and promotes traditional knowledge related to the medicinal properties of plants, access to genetic resources in indigenous regions, and the return and distribution of benefits from the commercial application of this knowledge. In Article 4 of Law 36, it is stated that at the institute there will be one representative of each indigenous community, one representative of traditional medicine practitioners, the Minister of Health or designate, and one representative of the Panamanian Medical Association. Article 7 establishes traditional medicine as the patrimony of the communities from which it comes and advances the conservation and promotion of traditional medicine in indigenous areas. It also states that allopathic medicine should not be forced upon these communities. Article 8 recognizes traditional health systems in indigenous communities. Article 10 mandates indigenous authorities to mount a campaign of protection, promotion, and conservation of traditional medical practices. Article 21 orders the establishment of a Faculty of Medicine and a Faculty of Pharmacy of indigenous materia medica and their use in the treatment of sickness. The rest of the articles of Law 36 refer to access to resources, benefit sharing, intellectual property, and the commercialization of medicinal plants. Licensing legislation regulates chiropractic educational standards and practice. A chiropractic law was adopted in 1967, permitting chiropractors to "examine, analyse and diagnose the human body by way of any method physical, chemical, electrical, or the use of x-ray" and provides for "the adjusting, manipulation and treating of the human body". Peru Background information The principal traditional medical specialities are herbalism, traditional birth attendance, and bonesetting. The National Institute of Traditional Medicine has 17 branches throughout the country. It disseminates information and conducts research on traditional medicine. In particular, the Institute is responsible for a research programme in traditional medicine known as the General Direction of Research and Technology. This programme is responsible for carrying out clinical research, conducting medical anthropological research, gathering demographic statistics, and facilitating the integration of traditional and allopathic medicine. It is also charged with promoting the protection, control, and cultivation of medicinal plants. Regulatory situation Traditional medicine was officially prohibited in Peru in 1969, but the prohibition was not enforced. The National Institute of Traditional Medicine is the official institution working on the regulation of traditional medicine. The Congress of the Republic is discussing potential laws and statutes for the regulation of traditional medicine. A bill on traditional medicine was proposed in 1999, but has not yet been passed. Although there is no official licence in Peru for the practice of traditional medicine, the Ministry of Health issues practice permits. A registry of traditional medicine practitioners is currently being developed in Peru. The Ministerial Decree for the Creation of Rural and Urban Peripheral Health Services places priority on the investigation and preservation of traditional medicine. Section 4 of the Supreme Decree 010-97-SA of 1997 regulates plant medicines and natural resources of medicinal value. It defines and classifies plant medicines and natural resources of medicinal value, outlines procedures and requirements for their registration, and details the requirements that must be met for the manufacture and sale of plant medicines. Education and training Students of traditional medicine learn via apprenticeships involving practice, observation, and videos as well as from personal experiences, revelations, and dreams. In some cases, medical skills are passed down within families. The National Institute of Traditional Medicine provides official training programmes in traditional medicine. In addition, some universities and non-governmental organizations registered with the Ministry of Health offer programmes in traditional medicine for traditional medicine practitioners. Some universities offer seminars, workshops, meetings, and conferences in traditional medicine for students studying allopathic medicine. Courses, workshops, and informal presentations are also offered to official health personnel. United States of America Background information Complementary/alternative medicine has a substantial presence in the United States health care system. Both public and professional interest in these therapies is increasing. The College of Physicians and Surgeons at Columbia University and the Falk Institute of Pittsburgh University have research projects devoted to assigning an integrative role in the health care system to complementary/alternative therapies. In 1991, Congress established the Office of Alternative Medicine within the National Institutes of Health to encourage scientific research in the field. The National Institutes of Health Revitalization Act of June 1993 was a landmark. It expanded the Office of Alternative Medicine within the National Institutes of Health from a staff of six to a staff of 12. The Office's objectives include the facilitation and evaluation of "alternative medical treatment modalities, including acupuncture and Oriental medicine, homeopathic medicine, and physical manipulative therapies". The Office is mandated to set up an advisory council, establish an information clearinghouse to exchange information on traditional medicine, support research and training, and provide biennial reports on the Office's activities to the Director of the National Institutes of Health. These reports are then included in biennial reports to the President and Congress. Statistics A 1997 national survey estimated that in the previous year 42.1% of the adult population in the United States had used at least one of the complementary/alternative therapies included in the survey. This is an increase from 33.8% in 1990. The therapies included in the survey were relaxation techniques, herbal medicines, massage, chiropractic, spiritual healing by others, megavitamins, self-help groups, imagery, commercial diets, folk remedies, lifestyle diets, energy healing, homeopathy, hypnosis, biofeedback, and acupuncture. Rates of use of complementary/alternative therapies in 1997 ranged from 32% to 54% in the socio-demographic groups examined. The therapies with the greatest increases in use included herbal medicines, massage, megavitamins, self-help groups, folk remedies, energy healing, and homeopathy. Visits to chiropractors and massage therapists accounted for nearly half of all visits to complementary/alternative medical practitioners in 1997. The probability of patients visiting a complementary/alternative medical practitioner increased from 36.3% to 46.3% between 1990 and 1997. The total number of visits to complementary/alternative medicine practitioners increased from 427 million in 1990 to 629 million in 1997, thereby exceeding total visits to all primary care allopathic physicians. Estimated expenditures for professional complementary/alternative medical services increased 45.2% between 1990 and 1997. For 1997, these expenditures are conservatively estimated at $21.2 billion with at least $12.2 billion of this paid out-of-pocket. Total 1997 out-of-pocket expenditures relating to complementary/alternative therapies are conservatively estimated at $27 billion, which is comparable with the projected 1997 out-of-pocket expenditures for all physician services. Just over half of patients (64% in 1990 and 58.3% in 1997) of complementary/alternative medical practitioners pay entirely out-of-pocket for the services. Approximately 3000 allopathic physicians and other health care practitioners currently use homeopathy. In 1993, more than 45 000 licensed chiropractors and 32 000 Doctors of Osteopathy were practicing in the United States. More than 60% of osteopathic physicians are involved in primary care. The profession is responsible for approximately 10% of the total health care delivered in the United States. Chiropractors currently see 10% to 15% of the population of the United States. There are about 6000 acupuncture practitioners in the United States. An estimated 3000 allopathic physicians have taken courses in acupuncture with the intention of incorporating it into their medical practices. There are over 1000 licensed naturopathic doctors in the United States. There are approximately 50 000 biofield practitioners providing 18 million sessions annually. There are approximately 50 000 qualified massage therapists in the United States, providing 45 million one-hour massage sessions per year. There are 10 ayurvedic clinics in North America, including one hospital-based clinic that served 25 000 patients between 1985 and 1994. Regulatory situation In the United States, regulatory controls surrounding complementary/alternative medicine involve six related areas of law: licensing, scope of practice, malpractice, professional discipline, third-party reimbursement, and access to treatments. State laws dominate the first five areas. Federal laws, particularly food and drug laws, largely control the sixth. In each of these areas, legal rules aim to safeguard consumers against fraud and to ensure patient protection against dangerous practices and practitioners. Because allopathic medicine has historically dominated licensing, accreditation, reimbursement, and other regulatory structures, however, existing legal rules governing complementary/alternative therapies and providers arguably favour allopathic medicine and paternalism at the expense of concerns for patient choice and autonomy. Licensing laws in each state provide that the unlicensed practice of medicine is a crime, with medicine being broadly defined to include such matters as diagnosis and treatment of disease or any human condition. Both non-licensed providers of complementary/alternative care (such as non-allopathic physician homeopaths, herbalists, iridologists, nutritionists, and spiritualists not practicing within the tenets of a specific recognized religion) and licensed complementary/alternative care providers (such as chiropractors and, in many states, acupuncturists, massage therapists, and naturopaths) who exceed their legislatively authorized scope of practice risk prosecution for unlicensed medical practice. Under malpractice rules, practitioners are liable when their professional practices deviate from standards of care applicable to their locale and speciality and when patient injury results. This is problematic since complementary/alternative care by definition deviates from allopathic standards of care. Professional disciplinary cases are frequently brought against allopathic providers integrating complementary/alternative practices, often in tandem with civil malpractice lawsuits. Third-party reimbursement is regularly denied to patients receiving such treatments because the third parties consider the treatments to be experimental and/or not medically necessary. Patients find access to complementary/alternative treatments restricted further on the grounds that the medicinal substances used to diagnose, cure, or mitigate disease are classified under federal law as new drugs and are thus subject to extensive premarketing approval to show safety and efficacy before they may be used. Although more and more complementary/alternative medical providers are being licensed in the United States, legal rules must continue to evolve to accommodate widespread consumer and provider use of therapies that have historically fallen outside the scope of allopathic medicine. Traditional Native North American medicine Traditional Native North American medicine in the United States is regulated under the Self-Determination Act. Homeopathy Arizona, Connecticut, and Nevada have specific licensing boards for homeopathic physicians. The market for homeopathic medicine in the United States is a multi-million dollar industry. Homeopathic remedies are recognized and regulated by the Food and Drug Administration and are manufactured by pharmaceutical companies under strict guidelines. Manipulative therapy Statutes regulating the practice of manipulative therapy exist in every state of the United States. Practice is restricted to persons who fulfil certain requirements and have been registered and/or licensed. In many cases, practicing without a licence is an offence. Licensing legislation regulates chiropractic educational standards. An example of such legislation is found in Sections 6551-6556 of Book 16 of the Consolidated Laws of New York. The New York statute states that chiropractors may not treat specified diseases; perform operations; reduce fractures or dislocations; or prescribe, administer, dispense, or otherwise use medicines or medicaments in their practice. Only licensed persons may practice chiropractic and use the title of "Chiropractor". To be eligible for a professional licence, an applicant must have completed two years of pre-professional college study and a four-year chiropractic resident programme as well as obtaining satisfactory experience and passing the licensing examinations. In the United States, practitioners of manipulative therapy are sometimes considered on the same professional level as allopathic physicians. Part 59 of Title 57 of the United States Code of Federal Regulations includes osteopathic general practice in the definition of allopathic family medicine. However, with the exceptions of South Carolina and Arizona, all states require chiropractors to add an accompanying qualifying reference to chiropractic following the use of the title "Doctor" or "Physician". Acupuncture Section 355 of the Federal Food, Drug, and Cosmetic Act covers the labelling of medicines and devices, including acupuncture needles and equipment. In 1973, acupuncture was declared by the Food and Drug Administration to be a method of treatment for investigational use by licensed practitioners only until "substantial scientific evidence is obtained by valid research studies supporting the safety and therapeutic usefulness of acupuncture devices". The Food and Drug Administration at that time published a notice calling for labeling requirements for such devices, including the following warning: "Caution: experimental device limited to investigational use by or under the direct supervision of a medical or dental practitioner." States have an array of provisions regarding the practice of acupuncture. In New York, legislation was passed in 1974 on the recommendation of the State Commission on Acupuncture. The legislation allowed state boards responsible for medicine and dentistry to formulate rules and regulations governing the provision of acupuncture and to establish licensing procedures for its practice in New York. The main prerequisites for a licence were that the applicant had practiced acupuncture for at least 10 years and had a licence as "a doctor of acupuncture, herb physician, or doctor of traditional Chinese medicine duly issued by the licensing board of any foreign country". A 1991 statute altered the above position by substituting licensing rules; creating a board of acupuncture made up of acupuncturists, licensed allopathic physicians, and members of the public; and obliging licensed acupuncturists to advise patients about the importance of consulting a licensed allopathic physician concerning their prognosis, and keep a record of the dispensation of this advice. To qualify for a licence to practice acupuncture, applicants must satisfy a pre-professional education requirement of at least 60 hours in an approved university or college, including a minimum of nine hours in the biosciences. They must then complete a professional programme, lasting a minimum of 450 hours, which involves classroom instruction in the biosciences and acupuncture and supervised clinical acupuncture experience. Applicants must pass a licensing exam set by the National Commission for the Certification of Acupuncturists or other approved body. Finally, applicants must be at least 21 years of age. Section 8216 permits the enactment of rules for the certification of allopathic physicians and dentists as acupuncturists. Limited permits for applicants who meet the requirements for admission to the licensing exam can be issued. However, practice under a limited permit must be under the supervision of a licensed acupuncturist. During the 1970s, the legislatures of several other states established conditions for the licensing of acupuncturists who were not allopathic physicians. As of 1981, non-allopathic physicians have been permitted to practice acupuncture under various conditions in at least 15 states. Under a 1978 act in Rhode Island : [No treatment by acupuncture] shall be performed unless within a period of 12 months preceding the treatment the patient shall have undergone a diagnostic examination by a duly licensed and registered physician with regard to his illness or malady. The doctor of acupuncture [as defined in the act] or the licensed acupuncture assistant [likewise defined] shall first... be familiar with the results of the said diagnostic examination. The act provides for the establishment of the State Board of Acupuncture and also defines the conditions under which the Board may issue licences to practice acupuncture or to perform as an acupuncture assistant. The conditions for the issue of a licence in Rhode Island are as follows: the applicant must have successfully completed a course of study of 36 months in acupuncture at a college in the Hong Kong Special Administrative Region of China or have qualifications considered equivalent by the State Board of Acupuncture, the applicant must have practiced acupuncture for 10 years, and the applicant must have passed examinations set by the Board. In Florida, only persons certified by the Department of Professional Regulation may practice acupuncture. Some of the conditions for certification are that the applicant must be at least 18 years of age, have undertaken two years of education in acupuncture at a school or college approved by the Department (experience may be substituted for a part of this training), and pass an examination. It is a misdemeanour to practice acupuncture without a valid certificate in Florida. California's Business and Professions Code lays down an extensive set of provisions regulating the acupuncture profession. California has appointed an Acupuncture Board, which consists of nine members. By law, four of these members must be acupuncturists with at least five years of experience who are not also allopathic surgeons or physicians, one must be an allopathic physician or surgeon with two years of experience in acupuncture, the remaining four must be members of the public who are neither acupuncturists nor allopathic physicians or surgeons. In California, in order to receive a licence to practice, applicants must be at least 18 years of age, have completed an approved course in acupuncture or a tutorial programme in the practice of acupuncture, passed an examination administered by the appropriate Board, and completed a clinical internship programme of up to nine months. The length of the internship depends on the applicant's examination results and prior clinical training. Internship requirements are waived for applicants who have previously completed 800 hours of clinical training. Practicing acupuncture without a licence is a misdemeanour. A previous requirement that acupuncture treatments cannot be performed on a patient without a prior diagnosis or referral from a licensed physician, surgeon, dentist, podiatrist, or chiropractor has been removed from the legislation. The completion of 30 hours of continuing education every two years is required for renewal of the annual practicing licence. Naturopathy Naturopathy remains relatively marginalized in the United States. Few states license naturopaths. Although legislation on naturopathy varies between states, a number of general regulations do exist. Under state licensing procedures, naturopaths have a limited range of treatment options. The use of electricity, heat, water, vibration, and muscular articulation are permitted as therapeutic modalities, but the general practice of medicine and surgery are prohibited. The administration of toxic drugs is similarly prohibited. Hypnosis Treatment involving the use of hypnosis is characterized as the practice of medicine and surgery and is therefore subject to licensing requirements. Biofield therapy No state has licensing requirements for biofield practitioners. Since legal constraints in many states restrict the use of the terms "patient" and "treatment", most biofield practitioners use the terms "receiver" and "session" in describing their work. Education and training The majority of allopathic medical schools in the United States now offer courses on complementary/alternative medicine. Beginning in 1997, primary care allopathic physicians have been able to take courses designed to introduce them to homeopathy and to encourage them to incorporate homeopathy in their practices. The United States has the largest number of chiropractic colleges of any country. Sixteen colleges are recognized by the World Federation of Chiropractic and accredited by the Council on Chiropractic Education, the United States accrediting agency for the chiropractic profession. The Council on Chiropractic Education establishes minimum standards and assesses institutional compliance with these standards as well as overall effectiveness. With only a few states licensing naturopaths, all except two naturopathic colleges have closed. Entry to these colleges is conditional on two years of pre-professional coursework. The programmes are four years in length. Insurance coverage Complementary/alternative therapies are infrequently included in benefit packages, although the number of insurers and managed care organizations offering coverage is increasing. When complementary/alternative therapies are covered, they tend to have high deductibles and co-payments that are subject to stringent limits on the number of visits or total dollar coverage. Chiropractic care is the exception. In many states, chiropractic is covered in full or in part by Medicaid, Medicare, and other Social Security programmes as well as private health insurance. The cost of chiropractic treatment can also be reclaimed under workers' compensation legislation designed to reimburse, at least in part, medical expenses incurred by injured workers. Venezuela Statistics The Liga Medicorum Homeopathica Internationalis has 41 members in Venezuela. There are approximately 10 chiropractors practicing in Venezuela. Regulatory situation In Venezuela, health care is restricted to formally educated medical professionals. Section 13 of the 1975 Venezuelan law on the practice of medicine states that persons who perform any act that is restricted to medical practitioners, without having fulfilled the requirements of the law, are deemed to be practicing medicine illegally. Only traditional birth attendants who have received a ministerial permit are exempted. Allopathic physicians may practice homeopathic medicine after completing specialized postgraduate studies. There is no chiropractic law, although the practice of chiropractic is permitted under common law by officially recognized health care providers. Education and training The School of Homeopathic Medicine of the Venezuelan Homeopathic Medical Association is responsible for training allopathic physicians specializing in homeopathy. Algeria Regulatory situation The Algerian Public Health Code of 23 October 1976 rendered the practice of medicine without a licence an offence. Apart from Section 364 on the practice of herbalists, no exceptions were made for the practice of traditional medicine. Section 47 explicitly prohibited medical auxiliaries from using "secret or occult procedures". This monopoly on the practice of medicine was retained and fortified in Law 85-05 of 16 February 1985 relating to health protection and promotion, which repealed the 1976 Code, among other things. Under Section 197, in order to practice as an allopathic physician or dentist, a person must be licensed and hold an Algerian diploma of Doctor of Medicine or Dentistry or a recognized foreign equivalent. The exclusion of traditional medicine is underscored by the broad language of provisions contained in Section 214 that define the activities constituting the illegal practice of medicine or dentistry. These include acting as a physician or dentist without a licence and further circumscribe the activities of Persons who habitually take part, whether for consideration or not, even in the presence of a physician or dentist, in making a diagnosis or in treating diseases or surgical or dental conditions, congenital or acquired, real or supposed, by personal acts, oral or written advice, or by any other means whatsoever, without fulfilling the conditions prescribed in Sections 197 or 198 [governing the mandatory qualifications for medical and dental specialists]. Section 225 includes provisions prohibiting medical auxiliaries from "announcing or applying technical procedures other than those that are taught in national training programs". Despite these restrictions, traditional medicine practitioners seem to be tolerated. Cyprus Background information Written records, especially from monasteries, record different types of traditional medicine and herbal preparations that were practiced from the Middle Ages through the 19th century in Cyprus. Most traditional forms of medicine involve mixing herbs and abiding by certain behavioural rules promoting healthy diets and habits. Since British colonization, allopathic doctors have provided health services. Statistics Although most patients use allopathic medicine, some consult homeopaths and other complementary/alternative medical practitioners. Only a few allopathic doctors practice homeopathy, acupuncture, or other forms of complementary/alternative medicine. There are fewer than 10 complementary/alternative medical practitioners who are not also allopathic doctors. These practitioners offer curative courses focused on using relaxation techniques or herbs to alleviate stress or stop smoking. Regulatory situation Only allopathic doctors can provide medical treatment in Cyprus. It is a criminal offence for others to practice medicine or give medications. There is no official recognition of any kind of traditional or complementary/alternative medicine other than chiropractic. Again except for chiropractic, there are no national policies regulating traditional or complementary / alternative medicine, nor have traditional or complementary / alternative medicine been integrated with allopathic medicine. A compulsory registration scheme for chiropractors was introduced in Cyprus in 1991. Registration is limited to persons holding a recognized degree, diploma, or certificate. It is a criminal offence to practice chiropractic without being registered. Education and training There are no official training courses in traditional or complementary/alternative medicine. Insurance coverage No national or private health care insurance covers traditional or complementary / alternative medicine. Traditional medicine is not included in the proposed National Health Insurance Scheme. Djibouti Background information Traditional medicine practitioners include cheiks, medical providers who use the Koran or other Islamic scriptures to treat patients, and herbalists. Some practitioners combine both methods. Regulatory situation With the exception of traditional birth attendants, the Government tolerates, but does not officially recognize, traditional medicine. Lacking legal status in Djibouti, no clear regulations control its practice. A 1999 law advocating the necessity to legislate traditional medicine may lead to changes in this regard. Only one category of traditional health practitioner has been integrated into the public health system: traditional birth attendants. Traditional birth attendants work under the supervision of public health staff in the rural structure of the primary health care system. Egypt Statistics The practice of traditional medicine in Egypt is limited to a very few traditional medical providers. There is one chiropractor practicing in Egypt. Regulatory situation The National Drug Policy was promulgated at the beginning of 1999 as an essential part of the National Health Policy. Within the framework of the National Drug Policy, reforms have been carried out in the following five areas: rational use of drugs, issues related to the drug industry, quality assurance and quality control, management of drug supplies, and human resource development. In Egypt, all herbal preparations and herbal products must meet the same standards as manufactured chemical preparations, according to the law on practicing pharmacy. Herbal preparations and herbal products must be manufactured in a licensed pharmaceutical plant according to local and international good manufacturing practices. They must also be registered with the Central Administration of Pharmaceutical Affairs. The National Organization for Drug Control and Research analyses medicinal plants and inspects herbal preparations and herbal products to ensure their safety. Herbal preparations and herbal products are priced according to the law and are distributed only to pharmacies. There is no chiropractic law. Islamic Republic of Iran Background information Traditional medicine and Islamic medicine are practiced in Iran through hokama who have small shops where they not only recommend medicines, but also prepare and sell them. With the expansion of allopathic medicine and services, however, the number of hokama has diminished greatly. The Shaheed Beheshti University of Medical Sciences has done a lot of research on medicinal plants. It has also organized an international congress on traditional medicine and materia medica. Most of the research done on medicinal plants has been pre-clinical. In Iran, there is no specific hospital for conducting clinical trials of herbal medicines. Statistics Over the last 10 years, the Government has undertaken an inventory of medicinal plants. So far, 2500 flora of Iran's 8000 medicinal plants have been inventoried and recorded in 20 volumes of 125 herbs each. One hundred fifty certificates for herbal medicine have been issued. Eighty-four herbal products have undergone clinical trials and been licensed. These are included in Iran's list of essential drugs. By the end of 2004, the Government intends to have issued licences for 300 herbal products. Seven faculties of pharmacy are conducting research on medicinal plants in seven provinces. There are 30 pharmaceutical companies producing herbal medicines, 20 of which produce herbal products and 10 produce herbal preparations. There are also many small herbal shops that supply herbal materials and spices for medicinal use. There are 14 chiropractors practicing in Iran. Regulatory situation Traditional medicine practitioners are neither supported nor banned by the Government, provided patients are not harmed. A chiropractic law is pending. Currently, chiropractors may practice in conjunction with allopathic physicians. The Government of Iran is very interested in traditional medicines and has initiated a number of programmes related to them. Since 1991, the Food and Drug Control Agency has been working in the field of herbal medicines. In 1991, the National Academy of Traditional Medicine in Iran and Islam was established. It is mandated to support research on herbal medicines; to study the history of Iranian traditional medicine; to preserve Iranian traditional medicine; to investigate education in traditional medicine and recommend an education plan to the Ministry of Health and Medical Education, including the incorporation of traditional medicine training and research into allopathic medical programmes; to educate the public on the rational use of traditional medicine; and to republish famous Iranian books on traditional medicine. In 2001, the Academy recommended that the Ministry of Health and Medical Education officially begin training allopathic medical students in Iranian traditional medicine. In 1996, the Ministry of Health and Medical Education established the Council Committee of Medicinal Herbs and Products. The Committee consists of a panel of experts charged with evaluating the safety and efficacy of herbs and herbal products and issuing rules and regulations for the packaging of herbal medicines. In order to make allopathic drugs affordable, the Government subsidizes the pharmaceutical industry's importation of raw materials. As the Government does not subsidize herbal products or locally produced herbal raw materials, herbal products are often more expensive than generic drugs. There is no national patent office and no national patent law in Iran. In 2000, a draft patent law was submitted to the Parliament, but it has not yet been approved. Education and training All pharmacy students must study pharmacognosy. In the Universities of Tehran and Isfahan, pharmacy students are required to write a thesis on research related to a medicinal plant. Insurance coverage The Government health insurance covers 90% of the Iranian population, but only a few registered herbal products are covered by the insurance. Jordan Background information Traditional medicine is deeply rooted in the history and culture of Jordan. Traditional medical practitioners and remedies ensure equitable access to primary health care, particularly where a large portion of the population relies on it. Over the last decade, there has been a growing interest in traditional and complementary/alternative medicine, including Chinese traditional medicine, acupuncture, phytotherapy, homeopathy, and chiropractic. Traditional medicine is practiced by herbalists, practitioners of traditional medicine, and allopathic doctors and other health professionals. Statistics There is one chiropractor practicing in Jordan. Regulatory situation There are no national policies recognizing traditional or complementary/alternative medicine. Traditional and complementary/alternative medicine are not integrated into allopathic medicine or into the national health system. However, some traditional and complementary/alternative medicine doctors and health professionals have been approved to practice in primary health care. A chiropractic law is pending. Kuwait Regulatory situation Laws in Kuwait prohibit traditional medicine providers from practicing medicine. However, herbal medicines are not banned. The use of medicinal plants in the official health sector began in 1978. Supplementing a ministerial resolution on the registration of all drugs, a document and guidelines were issued on the safety and quality assurance of herbal medicines. This document describes the main principles that should be observed when registering herbal medicines, particularly in regard to safety, efficacy, and consistency. This document categorizes medicinal plants into three groups: plants used on a daily basis, plants subject to large-scale scientific studies and registered in pharmacopoeias, and new plants that need to be studied. For each of these plant types, there are specific registration requirements intended to encourage people to use plants that do not cause adverse reactions or require allopathic medical advice, as well as to protect people from plants with toxic elements and about which there are no published studies. Following the document and guidelines, the Minister of Health issued a ministerial resolution organizing the handling and registration of herbal medicines in Kuwait. A ministerial decree, based on World Health Organization recommendations, established the Centre for Islamic Medicine to undertake the registration of herbal medicines and to introduce the use of medicinal plants in the treatment of some diseases. Among its various tasks, the Centre provides therapeutic services; undertakes the registration of herbal medicines imported into Kuwait, as decreed by the relevant ministerial decision; analyses and tests the efficacy and suitability of all medicinal plants that enter into the country for human consumption; undertakes the importation of medicinal plants necessary for the preparation of drugs used in the treatment of some diseases; studies and evaluates the best pharmaceutical rendering of each herbal preparation and herbal product; carries out various studies on each plant, preparation, and product so as to identify the stability, efficacy, and safety of the active substances therein. In 1986, together with the Islamic Organization for Medical Sciences and the World Health Organization Eastern Mediterranean Regional Office, Kuwait worked to establish regional standards for herbal medicines. Kuwait's registration policy was reviewed and endorsed by the Ministers of Health of the World Health Organization Eastern Mediterranean Region Member States and has become a reference and basis for the registration of herbal medicines throughout the region. The Council of Arab Ministers of Health and the Council of Health Ministers of the Gulf also endorsed the registration policy. Pakistan Background information Pakistan's traditional unani and ayurvedic systems of medicine came to the United India via Arab physicians. However, the unani medicine currently practiced in Pakistan is vastly different from its Greek roots. Most Pakistanis rely on unani medicine, finding it efficacious, safe, and cost effective. The use of herbal medicines and homeopathy is also widespread. The National Institute for Health has established a section on traditional medicine (tibb). Statistics Unani medicine is widely used throughout the country. About 70% of the population, particularly in rural areas, use traditional and complementary/alternative medicine. Approximately 52 600 registered unani medical practitioners serve the nation through both the public and private sectors in urban and rural areas. About 360 tibb dispensaries and clinics provide free medication to the public under the control of the health departments of provincial governments. About 95 dispensaries have been established under provincial departments of Local Bodies and Rural Development, and one tibb clinic is working under the Provincial Department of Auqaf. A separate Directorate of Hakims has also been established under the Federal Ministry of Population Welfare Programme, and 16 000 diploma-holding unani physicians of traditional medicine have been involved in the National Population Welfare Programme. About 40 000 homeopathic physicians are registered with the National Council for Homeopathy. Regulatory situation Unani, tibb, ayurveda, and homeopathy have been accepted and integrated into the national health system in Pakistan. Ordinance 65 of 7 June 1962 was issued "to prevent the misuse of the allopathic system". It provided that only registered medical practitioners were entitled to use the title "Doctor", to perform surgery, or to prescribe any specially listed antibiotics or dangerous drugs. These prohibitions were also applicable to practitioners of traditional medicine, it being prescribed that "no person practicing the allopathic, homeopathic, ayurvedic, etc., system of medicine may use the title of 'doctor', unless he is a registered practitioner". Subsequently, the Unani, Ayurvedic and Homeopathic Practitioners Act of 1965 was passed to regulate qualifications and to provide for the registration of practitioners of the unani and ayurvedic systems of medicine. The Act applied to tabibs, practitioners of unani medicine, and to voids, practitioners of ayurvedic medicine, both being prohibited from using the title "Doctor". Under the Act, the Board of Unani and Ayurvedic Systems of Medicine was established in order to arrange for the registration of qualified persons, to maintain adequate standards at recognized institutions, to conduct research, and to perform other activities. Requirements for the registration of practitioners were laid down, and training at recognized institutions was fixed at four years. The Act established that the following persons might apply for registration: persons passing the qualifying examinations for the award of a diploma in the unani and ayurvedic systems; any tabib or void with not less than seven years of practice; any tabib or void with five to seven years of practice, who either satisfied the Board as to his or her knowledge or skill or passed, within a specified period, an approved test in the theory and practice of the unani and ayurvedic systems; and any person who passed a written and practical examination in the subject of the "old system" of medicine. The Government thereafter issued the Unani, Ayurvedic and Homeopathic Systems of Medicine Rules of 1965, which included implementing provisions on the registration of practitioners, elections to the boards, and recognition of teaching institutions. The Act introduced the title of "Homeopathic Doctor" for registered homeopaths, although the use of analogous titles was forbidden to practitioners of ayurvedic and unani medicine. Under this Act, courses in homeopathy provided by recognized institutions must be four years in duration, culminating in a qualifying examination. Persons who have passed this examination, persons holding qualifications from an approved homeopathic institution, and certain practitioners of long standing, "possessing the requisite knowledge and skill", are eligible for registration as homeopathic doctors. The Board of Homeopathic Systems of Medicine was established in order, inter alia, to maintain adequate standards in recognized institutions and to make arrangements for the registration of duly qualified persons. The legislation referred to above was also applicable in what was then known as East Pakistan, now Bangladesh. The Ministry of Health, through the National Council for Tibb oversees the qualifications of practitioners. After successful completion of tibb qualifications, candidates are registered with the National Council for Tibb, allowing them to practice traditional medicine lawfully. Education and training Tibbia colleges, Pakistan's unani teaching institutions, are recognized by the Government and are under the direct control of the National Council for Tibb, Ministry of Health, which is responsible for maintaining standards of education in recognized teaching institutions, revising/modifying curricula and syllabuses, and holding annual examinations. Twenty-six colleges in the private sector and one college in the public sector offer four-year diploma courses in Pakistani traditional unani and ayurvedic systems of medicine that follow the prescribed curriculum and conditions laid down in the regulations. Hamdard University has recently introduced a five-year programme to follow intermediate (FSc) training. About 5000 students are enrolled in its Faculty of Unani Medicine. Annually about 950 persons graduate from the programme. Seventy-six colleges of homeopathic medicine offer officially recognized programmes for the four-year Diploma of Homeopathic Medical Science. Several hospitals, outpatient clinics, and dispensaries are attached to the homeopathic medical colleges. Saudi Arabia Background information Traditional medicine in Saudi Arabia is based on herbal remedies and spiritual healing. There is hardly a city or village in the country where traditional medicines are not used or sold. They are also commonly used in home remedies for certain ailments. In 1940, allopathic medicine began being used in large cities. Since then, the health authorities have taken all possible measures to develop highly sophisticated allopathic hospitals. The population of Saudi Arabia today enjoys very good health facilities. There was official resistance to complementary/alternative medicine until the 1990s when more Saudi Arabians demanded access to complementary/alternative medicine, and some professionals who had been trained abroad began to practice. The most popular therapies are acupuncture; herbal, nutritional, and health food products; and homeopathy. Regulatory situation A scientific research project on the merits and demerits of Saudi Arabian traditional medicines was undertaken as a precursor to drafting a regulatory framework and statutory provisions for the practice of Saudi Arabian traditional medicine and the sale and manufacture of the medicines used in it. An act governing the practice of pharmacy and trade in medicines and medical products was issued by Royal Decree M/18 dated 18/3/1398 H (equivalent to 26 February 1978). Articles 44 and 50 of this act prohibit the handling of locally produced or imported products prior to their registration with the Ministry of Health. Paragraph 13A of the special provisions on registration regulations for pharmaceutical companies and their products, which was amended through Ministerial Resolution 1214/20 dated 17/6/1409 H (equivalent to 25 January 1989), requires the registration of medicines and all products having medical claims, including herbal preparations containing active ingredients that possess medicinal effects. The License Committee established under the Ministry of Health is responsible for approving or disapproving, mainly on the basis of safety and efficacy, the marketing and use of herbal preparations and herbal products, health food products, and natural health products, including items for cosmetic use. The Ministry of Health has approved guidelines restricting licences to practice acupuncture to those persons who have at least 200 hours of training, are anaesthetists, rheumatologists, or orthopaedists, and who comply with hygienic standards. Licensing legislation also regulates chiropractic educational standards and practice. Education and training No formal education exists in traditional or complementary/alternative medicine in Saudi Arabia; interested allopathic physicians go abroad to receive such training. Insurance coverage Traditional medicine is not covered by the health insurance system; however, some traditional medicine practitioners, especially spiritualists, practice free of charge. Sudan Background information Traditional medicine in Sudan has roots in Islamic and West African medicine. People in many areas of the country depend on herbal medicines, which are an integral part of the health care system. There is wide experience with the use of herbs in medical treatment. Many families specialize in herbal medicines and this knowledge is passed on from one generation to another. Patients travel from the capital to rural regions to consult herbalists, especially for difficult diseases. The Medicinal and Aromatic Herbs Research Institute was created 25 years ago and has trained a considerable number of specialists in different fields required for research in medicinal plants. Statistics The Sudan Atlas of Medicinal Plants records the scientific name of more than 2000 medicinal herbs collected from different parts of the country, many native to Sudan. All of these herbs are in current use in traditional medicine. Regulatory situation There is legislation for the registration of herbal preparations and herbal products. Syrian Arab Republic Regulatory situation No licences are issued to providers of herbal medicine; such practices are limited to specialists. In 1997, the Ministry of Health issued decisions on the technical prerequisites necessary for the establishment of laboratories for herbal medicine. In 1998, the Ministry issued decisions on the manufacture and distribution of herbal medicines and on a system of controls. The manufacture of herbal medicines has been included in the national drug policy. Both public and private laboratories have been active in processing medicinal herbs, and the Ministry of Health has given preliminary approval for the establishment of laboratories that would manufacture herbal medicines. A file concerning the manufacturing of herbal medicines has been developed in preparation for their registration. Three draft laws covering herbal medicine have been prepared. One concerns herbal medicines that would be used in primary health care. Education and training A syllabus on treatment with herbal medicines has been recommended for inclusion in the curricula of faculties of medicine. A syllabus on medicinal plants and herbal medicines has been introduced into the curricula of pharmacy faculties and at health institutes for technical assistant pharmacists. United Arab Emirates Background information In 1989, the Ministry of Health's Zayed Centre for Herbal Research and Traditional Medicine was established in Abu Dhabi to conduct research on medicinal plants and traditional medicine practitioners. Similar research is conducted by the Desert Section of the Desert Marine Environment Research Centre, the Department of Pharmacology at the Faculty of Medicine of the University of Al-Ain, the Society of National Culture, and the History and Culture Centre. There is high consumer demand for herbal preparations and herbal products in the United Arab Emirates. Regulatory situation Section 1 of Federal Law 7 of 1975 put in place licensing and registration requirements for the practice of medicine. Only an allopathic physician who holds a medical degree may apply for a licence to practice medicine. Under Section 2, non-citizens who seek to practice as general practitioners must complete an additional two years of post-internship medical practice. In the United Arab Emirates, birth attendants are designated as medical professionals by Federal Law 5/1984, the practice of which is open to physicians, pharmacists, and other licensed individuals. By Section 3, the Minister of Health is to publish licensing qualifications and outline the powers and duties of licensees. In order to provide a legal framework to ensure that their benefits could be enjoyed without unnecessary risks, registration criteria for herbal medicines were published in January 1998. These criteria were established by a committee of allopathic physicians and personnel from the Zayed Centre and Emirates University. The registration criteria include the following: documentation, including detailed monographs, for the herb; reference sample of the active ingredient of the herb; laboratory analysis for identity, purity, and quantity. Priority in registration is given to single-ingredient products. Products containing more than one herb must have a logical justification for the combination based on the uses of the finished product. Therapeutic claims beyond traditional uses are not accepted unless scientifically justified. As of April 1999, 27 applications had been received. Seven of the applications were completed and approved, seven had completed the laboratory screening process, and 13 were waiting for laboratory analysis. These 27 applications had come from companies located in a number of countries, including Germany, Switzerland, Austria, India, Indonesia, and China. A 1999 report outlined several problems with the criteria. Companies had difficulty fulfilling the documentary requirements, especially relating to stability data, and many companies wanted to register traditional products with more than 10 active ingredients, such as ayurvedic medicines. Analysis of the active ingredients in the final products proved technically difficult because of both qualitative and quantitative interference in the assays. Enforcing the law has also posed challenges. EUROPE Austria Statistics The chart below lists the distribution of allopathic physicians practicing complementary / alternative medicine in Vienna in 1997.
In 2000, the Liga Medicorum Homeopathica Internationalis had 670 members in Austria. While there are no homeopathic hospitals, homeopathic consultation takes place regularly in five allopathic hospitals in Vienna and in one allopathic hospital in Klagenfurt. Austria has one academy of holistic medicine. Regulatory situation Only legally qualified and authorized medical professionals may practice medicine in Austria. Under Section 1.2 of the Federal Medical Law, medical acts are defined as "all activities based on medico-scientific knowledge carried out directly or indirectly on human beings" performed for the purposes of diagnosis, treatment, and prophylaxis. Under the Law on Physicians of 1984 (173, 174), medical acts that are not provided by authorized medical professionals, such as midwives, medical-technical assistants, and nurses, are reserved for allopathic physicians. Article 184 of the Penal Code states that unskilled persons who practice medical acts or activities reserved for allopathic physicians risk a fine or imprisonment of up to three months. However, the courts have been tolerant with regard to complementary/alternative medical practitioners and charges of charlatanism. In practice, Article 184 is enforced only when practitioners use methods that do not have any scientific support, such as mystic water treatment. According to the Law on Health Services, only scientifically recognized medical care can be provided in hospitals. Acupuncture, neuraltherapy, and chiropractic are recognized, but not homeopathy. However, homeopathy is recognized by the National Committee of Medicals. Nonetheless, and despite the fact that there are neither specific legal or paralegal regulations nor draft regulations on the use of complementary/alternative medicine in the country, allopathic physicians are implicitly permitted to use any medical technique they deem appropriate, provided they obtain the consent of their patients. Under their own responsibility, therefore, allopathic physicians may use complementary/alternative medicine in their treatment regimes. Education and training The Council of the Order of Physicians issues diplomas officially recognized as medical qualifications in acupuncture, homeopathy, manual therapy, and neuraltherapy. Training courses for these diplomas last between two and three years (from 140 to 350 hours). Neuraltherapy and chiropractic are taught in universities. The National Medical Association recognizes the examination and title of "Homeopathic Doctor". A three-year postgraduate homeopathic curriculum is available and leads to a diploma awarded by the official Medical Society of Austria. Advanced training is offered through seminars, lectures, and conferences with Austrian and international scholars. There are activities and associations for students interested in homeopathy at universities in Vienna, Graz, and Innsbruck. As of 1 August 1996, the creation of a new educational institution of complementary / alternative medicine is punishable by imprisonment. Insurance coverage Public insurance funds have the following reimbursement criteria for medical treatments: scientific proof of effectiveness, cost-effectiveness, and appropriateness. Complementary/alternative medicine is generally not covered. Exceptions are made, however, for homeopathy and, for purposes of pain relief, massage, balneotherapy, and electrotherapy. Exceptions are also made when allopathic treatments are unsuccessful and relatively recognized complementary/alternative treatments are the last resort. The Oberφsterreichische Gebietskrankenkasse partially reimburses acupuncture treatments. Some private insurance companies cover complementary/alternative medicine. Belgium Statistics According to a 1998 poll, almost 40% of the Belgian population - women more than men - have used complementary/alternative medicine at least once. Of these persons, 77% were satisfied with their treatment. While the general public is in favour of the Ministry of Health giving official recognition to homeopathy, acupuncture, osteopathy, and chiropractic, allopathic physicians are evenly divided: 43% are in favour and 43% are opposed to such recognition. The most widely consulted complementary/alternative therapies in Belgium are homeopathy, accounting for 81% of complementary/alternative consultations; acupuncture, accounting for 38%; osteopathy, 27%; phytotherapy, 25%; and chiropractic, 21%. One allopathic physician out of four believes that these therapies should be reimbursed. Fifty-nine per cent of patients who use complementary/alternative medicine and 36% of patients who do not use complementary/alternative medicine are willing to pay higher premiums to cover this reimbursement. Most providers of complementary/alternative treatments are allopathic doctors or physiotherapists. One allopathic physician out of four provides complementary / alternative treatments; these are mostly general practitioners. The most commonly practiced forms of complementary/alternative medicine are homeopathy, practiced by 59% of providers of complementary/alternative medicine; acupuncture, practiced by 40%; and phytotherapy, 28%. Thirty-three per cent of manipulative treatments are provided by physiotherapists and 34% by non-allopathic practitioners. There are three homeopathic organizations for allopathic physicians and pharmacists and two for patients. The Union of Acupuncturists Physicians was created in 1981. Regulatory situation A monopoly on the practice of medicine was introduced by the Practice of Medicine Act of 1967. Under this act, the practice of medicine, which includes diagnosis, treatment, prescriptions, surgery, and preventive medicine, was the exclusive domain of legally qualified allopathic physicians. After the intervention of the European Commission with regard to the (non) enforcement of European Directives on homeopathic products, the Government of Belgium asked the Federal Department of Public Health to draft legislation on complementary/alternative medicine. On 29 April 1999, the new law was adopted by the Belgian Parliament. In November 1999, the Government enacted bylaws to ensure enforcement of the law. Article 2 of the new law introduces provisions for homeopathy, chiropractic, osteopathy, and acupuncture and provides for the recognition of other complementary/alternative techniques. Article 3 establishes a commission to advise the Government on the practice of complementary/alternative medicine, particularly registration of practitioners, membership in recognized professional organizations, insurance for professionals, regulation of advertising, and restrictions on medical acts. In order to register, practitioners must demonstrate that they provide high-quality and accessible care that has a positive influence on their patients' health. Article 6, Paragraph 1 requires the commission to be composed of five allopathic practitioners (with at least one being a general practitioner), nominated by faculties of medicine, and five complementary/alternative practitioners, nominated by recognized professional organizations. The commission, in Article 6, Paragraph 2, is also designated to advise the Government on organizing a peer-review system and a code of professional ethics. By Article 8, the practice of a registered complementary/alternative form of medicine is allowed only when the practitioner is licensed for that practice by the Ministry of Social Affairs, Public Health, and Environment. In Article 9, complementary/alternative practitioners are required to maintain medical records for each patient. Complementary/alternative practitioners who are not also allopathic physicians must obtain a recent allopathic physician's diagnosis from their patient prior to commencing treatment. If patients choose not to consult an allopathic physician before seeing a complementary/alternative practitioner, they must put their wishes in writing. Registered complementary/alternative practitioners must take precautions to ensure that patients are not deprived of allopathic treatment. As a result, complementary/alternative practitioners who are not also allopathic physicians must keep allopathic physicians informed of the health of their patients. With patient consent, complementary/alternative practitioners are permitted to seek the advice of other complementary/alternative practitioners who are not allopathic physicians. Infringement of the law - in particular, practicing complementary/alternative medicine without a licence or treating a patient without having obtained an allopathic physician's diagnosis or without having the patient's desire to avoid such diagnosis in writing - risks a fine (under Article 11) or the suspension or withdrawal of the provider's licence to practice (under Article 8). Education and training Complementary/alternative medicine is not taught in Belgian medical schools; however, the Belgian Medical Faculty of Homeopathy offers courses for allopathic physicians, surgeons, dentists, pharmacists, and veterinarians. These courses comply with standards set by the European Committee for Homeopathy. The Belgian Acupuncture Federation is authorized by the Belgian Government to train acupuncturists to practice under the new licensing law. In order to be permitted to practice acupuncture, a provider must be certified as an allopathic medical doctor, dentist, physiotherapist, nurse, or midwife, as well as having completed at least 750 hours of acupuncture training - 250 hours of basic theoretical principles of traditional Chinese medicine, 250 hours of traditional Chinese medicine pathology, and 250 hours of clinical practice - and having written a thesis. There are two associations of acupuncturists offering three-year training programmes; however, most practitioners using acupuncture are trained in East Asia or France. Insurance coverage The Belgian social security system does not officially reimburse complementary / alternative treatments, regardless of whether they are provided by allopathic physicians or not. Practically speaking, however, allopathic physicians using complementary/alternative medicine may assure their patients that at least part of their fees will be reimbursed. Osteopathic treatments are reimbursed so long as physiotherapists use a classic designation to prescribe them. In March 1997, the Socialist Mutual Insurance of Tournai-Ath was the first company to partially reimburse specific complementary/alternative treatments. They reimburse 25% of homeopathic remedies up to a maximum cost of 6000 Belgian francs per year and per beneficiary. They also reimburse 400 Belgian francs for each osteopathic treatment with a maximum of six treatments, but only if they have been provided by an allopathic physician, nurse, or physiotherapist. The list of reimbursed homeopathic remedies is adapted from the European Union Directive on homeopathic products. Reimbursement may soon be extended to other techniques, such as acupuncture and phytotherapy. Private insurance companies reimburse chiropractic care and, partially, acupuncture treatments. Denmark Statistics The complementary/alternative treatments most used by the Danish population are reflexology, acupuncture, massage, natural medicine, homeopathy, natural healing, kinesiology, and chiropractic. A 1994 study reported that 33% of the adult population of Denmark had used complementary/alternative medicine during the previous year, women used it more frequently than men, and the average age of patients of complementary/alternative medicine decreased in the period from 1970 to 1994. The study also found that of those who used complementary/alternative treatments, 77% considered themselves cured, 17% experienced no effect from the therapy, and 1% considered their health problems to have worsened as a result of their treatment. People most often sought complementary/alternative therapies for joint and muscular problems. Approximately 700 physicians are members of the Danish Society for Medical Acupuncture; 116 of these are newly certified. There are 265 chiropractors practicing in Denmark. The Danish Chiropractic Association has 300 members. There are 16 000 allopathic medical doctors in Denmark. There are also several associations of non-allopathic physician providers. Regulatory situation In Denmark, allopathic physicians holding an academic degree in medicine, having taken the Hippocratic oath before a faculty of medicine, and authorized by the National Health Service are not restricted as to the medical techniques they may use. The title of "Physician" is protected and only licensed allopathic physicians may call themselves such. Public-sector medical positions are reserved for authorized doctors. Two laws regulate the practice of complementary/alternative medicine. The Medicine Act legislates the making and marketing of natural remedies and includes criteria for packaging, providing information to patients, and advertising. The Practice of Medicine Act of 1970 permits non-allopathic physicians to practice medicine regardless of their training and without previous authorization. However, non-allopathic physicians are not recognized as official health care providers, their titles are not protected, and they are not integrated into the national health care system. By Articles 23-26 of Order 426 of the Practice of Medicine Act of 1976, issued by the Minister of the Interior on 19 August 1976, non-physicians may not perform specific medical acts that are reserved for licensed allopathic physicians, nor are they permitted to use needles except under the supervision of an allopathic physician. The medical acts reserved for licensed physicians are the following: treating persons for venereal diseases, tuberculosis, or any other infectious disease; performing surgery; administering general or local anaesthetics; providing obstetric aid; applying medicines that may be dispensed only with a physician's prescription; using X-ray or radium treatments; or practicing therapies using electric machines. Violation of this limited monopoly is punishable by up to 12 months in prison. However, non-allopathic practitioners are only prosecuted for selling harmful products, otherwise exposing patients to a provable danger, or causing the serious deterioration or death of their patients. Sentencing is particularly severe in cases where the patient is mentally ill or handicapped, under 18 years of age, or considered incapable of managing his/her own affairs. Ancillary staff, by contrast, may practice complementary/alternative medicine without restriction. Chiropractors are the exception to this law. They are regulated by a 1992 law. Whenever patients consult a chiropractor without an allopathic physician's referral, the chiropractor must inform the patient's practitioner of the diagnosis and treatment, whether the practitioner is an allopathic physician or not. A Danish study on complementary/alternative treatments concluded that current legislation in this field is sufficient and further regulations are not necessary. Education and training The Danish Society for Medical Acupuncture offers a 120-hour diploma course in acupuncture for allopathic physicians. The Danish Chiropractic Association provides training for non-allopathic physicians. Membership in the Danish Chiropractic Association is restricted to those persons trained at a college accredited by the American Council on Chiropractic Education who have completed a six-month apprenticeship with a member of the Association and have passed the Association exam. Insurance coverage The Danish Chiropractic Association is working to obtain official recognition and full social insurance reimbursement for chiropractic treatments. In the meantime, reimbursement is determined by a 1975 agreement between public insurance schemes and chiropractors. Under this agreement, public insurance covers one-third of the costs of up to five chiropractic consultations and one X-ray examination per year, on the condition that these are provided by chiropractors recognized by the Danish Chiropractic Council. When patients are referred by licensed allopathic physicians, some acupuncture and osteopathic treatments are also reimbursed. Finland Background information The Ministry of Social Affairs and Health recognizes the increasing contribution of complementary/alternative therapies to the Finnish Health Care System. Among older rural Finns, massage, bonesetting, and cupping are popular; among younger urban Finns, natural medicine, manipulation, acupuncture, and hypnosis are popular. Statistics About 50% of the adult Finnish population have used complementary/alternative medicine at least once. There are 30 chiropractors practicing in Finland. In 1987, there were 200 local health centres providing acupuncture treatment. Regulatory situation Act 559 of 28 June 1994 regulates the licensing of medical practitioners. By Article 4, the right to practice as an independent allopathic medical doctor can be granted to practitioners who have completed basic medical training and who have additional training in primary health care or special training in an allopathic medical speciality. Professional allopathic medical providers who fulfil the required conditions have a number of rights, including the right to use a protected occupational title. Only allopathic doctors and, by Decree 564/1994, registered chiropractors, naprapaths, and osteopaths are recognized health practitioners and allowed to practice medicine - specifically, to diagnose patients and charge fees. However, according to Act 559, other medical practitioners may treat patients if they do not practice within public services and do not pretend to be health care professionals. As a result, only allopathic doctors and registered chiropractors, naprapaths, and osteopaths are supervised by the medical authorities in practicing complementary/alternative medicine. Other medical practitioners are not supervised, nor is their licensing regulated. While anyone can use an unqualified title, such as "Chiropractor", by Act 559 only registered chiropractors, naprapaths, and osteopaths may use the descriptor "Trained" in describing themselves. Act 559 also confers title protection to allopathic physicians. Articles 34 and 35 of Act 559 relate to the illegal practice of medicine, punishable by fine or up to six months in prison, although prosecution is rare. The objective of these articles is to protect patients and medical professionals working within public services. A licence is necessary to market homeopathic products with a degree of dilution less than one million. Education and training Since 1975, acupuncture has been an accepted part of allopathic medical practice, and training in acupuncture is a component of the medical curriculum of allopathic physicians. Chiropractors, naprapaths, and osteopaths must complete at least four consecutive years of training approved by the National Board of Medico-Legal Affairs. Chiropractors generally train in the United States. Other complementary/alternative therapists often attend schools in Sweden. Insurance coverage When provided by an allopathic physician, acupuncture is covered by the Social Insurance Institution (SII). In general, other complementary/alternative therapies are also reimbursed by the SII, provided they are given by medically qualified allopathic doctors during their normal sessions and provided the doctors do not specify which treatment they used. The SII covers treatments given by recognized chiropractors, naprapaths, and osteopaths when the following conditions are met: Patients can show that they first obtained a diagnosis and statement of required treatment from a licensed allopathic physician. Patients are referred to the complementary/alternative therapist by a licensed allopathic physician. The complementary/alternative therapist works in an institution led by a physiotherapist or an allopathic physician. Complementary/alternative medications, however, are not covered by the SII. In Finland, no private insurance companies reimburse complementary/alternative medicine except in some cases of chiropractic treatment, where reimbursement follows the same criteria used by the SII. France Background information Homeopathic and herbal health care products are very popular in France. The most popular forms of complementary/alternative medicine are, in order of popularity, homeopathy, acupuncture, herbal medicines, water cures, chiropractic, thalasso-therapy, osteopathy, and iridology. Statistics A 1987 survey found that 36% of allopathic doctors, mostly general practitioners, used at least one complementary/alternative technique in their medical practices. Among allopathic physicians using complementary/alternative medicine, 5.4% used it exclusively; 20.7%, often; and 72.8%, occasionally. The social security system qualifies allopathic physicians using complementary/alternative medicines as "doctors with a particular type of practice (MEP)". Any doctor can be so designated. In 1993, physicians who were registered as MEPs represented 6.2% of the whole medical corpus. Thirty per cent of MEPs provide acupuncture treatments. Twenty per cent provide homeopathic therapies. An additional 50 000 non-allopathic practitioners provide complementary/alternative therapy in France. There are approximately 390 chiropractors practicing in France. There are between 2000 and 4000 kinesiotherapists. One survey found 49% of the people questioned - 53% of the women surveyed and 44% of the men - had used complementary/alternative medicine at least once, 16% during the previous year. Complementary/alternative medicine is most popular among people between the ages of 35 and 45,59% of persons in this age group having reported using complementary/alternative medicine. Sixty-eight per cent of executives and academics had used complementary/alternative medicine, compared to 60% of middle managers and intermediate professionals and 40% of farmers, the least likely group to use complementary/alternative medicine. Those surveyed reported using a complementary / alternative medicine for minor diseases (49%), chronic symptoms (54%), serious illnesses (3%), and the prevention of disease and promotion of a healthy lifestyle (17%). Seventy per cent of patients of complementary/alternative medicine considered it effective for minor diseases; 65%, for chronic diseases; and 9%, for serious illnesses. Only 11% of patients considered these therapies ineffective for minor diseases; 15%, for chronic diseases; and 38%, for serious illnesses. France has many organizations for practitioners and patients of complementary / alternative medicine. Regulatory situation Under Articles L 372 through L 376 of the Code of Public Health, persons other than licensed allopathic physicians who habitually or continuously diagnose or treat illnesses, real or supposed, or who perform activities constituting medical procedures are illegally practicing medicine. Persons wishing to obtain a licence to practice medicine must possess a State certificate; hold French, Tunisian, Moroccan, or European Union citizenship; and be registered by the professional society of physicians. Despite prosecution, non-allopathic practitioners - particularly physiotherapists using complementary/alternative methods such as chiropractic and osteopathy - continue to practice, and the number of allopathic physicians using complementary/alternative medicine is increasing. Allopathic physicians providing complementary/alternative treatments either assist persons practicing medicine illegally or practice complementary/alternative medicine themselves. In both cases, they risk being tried for penal and disciplinary infractions. Recent decisions, however, suggest that the courts are becoming more tolerant towards the practice of complementary/alternative medicine. Education and training Teaching complementary/alternative medicine to non-allopathic physicians is permitted. The number of schools and courses in complementary/alternative medicine has recently increased, although they vary widely in quality. Private schools, however, may not issue diplomas to their graduates. According to Article 4 of the Act of 18 March 1880, only the State has this power. Despite the allopathic medical establishment's opposition to the recognition of chiropractic, the Decree of 11 February 1953 provides for the incorporation of chiropractic into medical schools. However, the Decree has not been applied and chiropractic has never been taught in French medical schools. In fact, the practice of chiropractic is illegal in France. Nonetheless, there is a school of chiropractic. The University of Bobigny established the Department of Natural Medicines in 1982. Since then, diplomas have been awarded in acupuncture, homeopathy, phytotherapy, osteopathy, auriculotherapy, naturopathy, oligotherapy, and mesotherapy. In 1990, the University Diploma in Natural Medicines - training leading to an inter-university certification recognized by the French National Order of Physicians - was created for acupuncture and osteopathy. Recognition of a certification in homeopathy is under consideration. Phytotherapy is already incorporated into training in pharmacy. However, these therapies are not considered medical specialities. In order to obtain recognition as a medical speciality, the discipline must be taught according to the criteria followed for an allopathic speciality, i.e., the training should be full-time and include periods of clinical practice. Some non-allopathic practitioners receive their training at foreign schools. For example, kinesiotherapists / physiotherapists who also provide chiropractic treatments are usually trained in the United Kingdom or Germany. Insurance coverage In France, social security and private insurance reimburse some forms of complementary / alternative medicine so long as an allopathic medical practitioner provides them. Social security reimburses homeopathic prescriptions written by authorized physicians and specific medical activities and products, including chiropractic, medical phytotherapy consultations, and complementary/alternative technical sessions with an approved kinesiotherapist. Acupuncture treatments given by MEP physicians are also reimbursed, provided that the physicians observe regulations regarding allopathic consultations. Germany Background information In 1992, the Federal German Ministry of Research and Technology initiated an extensive research programme on complementary/alternative medicine coordinated by the University of Written/Herdecke. Statistics Three-fourths of allopathic physicians use complementary/alternative medicine and 77% of pain clinics provide acupuncture treatments. In 1994, there were between 10 000 and 13 000 practitioners of complementary / alternative medicine, or Heilpraktikers, 8000 of whom were members of professional associations. There are approximately 40 chiropractors practicing in Germany. There were 20 million patient contacts with complementary/alternative medicine in 1992. The most frequently sought complementary/alternative therapies are, in order of popularity, homeopathy (accounting for 27.4% of patient contacts), acupuncture (15.4%), procaine injection therapy, chiropractic, ozone and oxygen therapy, herbal medicines, humoural pathology, massage, and cell therapy. According to a 1992 poll, between 20% and 30% of the population had used complementary/alternative medicine, with 5% to 12% having used it during the previous year. Complementary/alternative therapies are more popular with women than men. Most complementary/alternative patients are between the ages of 18 and 65 and have a relatively high level of education. In most cases, patients have first sought treatment with allopathic medicine. There are many organizations for practitioners and patients of complementary / alternative medicine. Regulatory situation In Germany, there is no legal monopoly on the practice of medicine. Thus, licensed non-allopathic physicians may practice medicine, and all licensed medical practitioners are allowed to use complementary/alternative medicine. There are, however, some restrictions on the performance of particular medical acts. Only allopathic physicians and dentists are allowed to practice dentistry. Only allopathic physicians are allowed to treat sexual diseases, treat communicable and epidemic diseases, deliver specific medications, give or provide anaesthetics and narcotics, practice obstetrics and gynaecology, take X-rays, perform autopsies, and deliver death certificates. Infringement may result in penal punishment. In order to obtain a title as an allopathic physician, a person must have an academic degree in medicine, practical experience, a licence from public authorities, and a medical certificate confirming that there are no indications of physical or mental disability or addiction to drugs. Licensed Heilpraktikers may practice medicine with the exclusion of these specific medical acts. To qualify for a Heilpraktiker's licence, a candidate must be at least 25 years old, have German or European Union citizenship, have completed primary school, have a good reputation in order to guarantee a normal professional practice, have a medical certificate confirming that there are no indications of physical or mental disability or addiction to drugs, and pass an examination before a health commission proving that the candidate has sufficient knowledge and ability to practice as a Heilpraktiker and that the candidate's treatments do not negatively affect public health. The exam verifies the candidate's basic knowledge of anatomy, physiology, hygiene, pathology, sterilization, disinfecting, diagnosis, and health regulations, particularly the epidemic law. However, the questions are required to be basic and understandable. Chiropractors must obtain a Heilpraktiker licence regardless of whether or not they have a degree from an accredited institution. Education and training As part of the standard curriculum, allopathic medical schools are required to test students on their knowledge of complementary/alternative medicine. Students may also select a postgraduate specialization in complementary/alternative medicine. Heilpraktiker candidates do not have to follow standardized training in order to pass the licensing exam, which has resulted in a wide variety of teaching methods as well as variations in the length and quality of training. According to a recent poll, only 10% of Heilpraktikers did not have any form of training, while 88% had from one to four years of training. The German Federal Association of Heilpraktikers organizes training in 29 cities for persons who desire to obtain a Heilpraktiker licence. Some of this training lasts three years or 350 hours. In Germany, the title "Homeopathic Physician" is legally protected. The Medical Chamber bestows this title after a three-year training programme. Advanced obligatory training courses for homeopathic professors are given on a regular basis. Official homeopathic teaching contracts exist with the medical faculties in Berlin, Dusseldorf, Hannover, Heidelberg, and Freiburg. Chiropractors holding a degree from a regionally accredited institution may use the title "Doctor of Chiropractic". Insurance coverage In Germany, public and private insurance provides the same kind of coverage. Both currently reimburse some complementary/alternative treatments and are moving towards broadening this coverage. Even though there is no constitutional right to obtain reimbursement, the following criteria have been established to determine the coverage of complementary/alternative medicine by both social insurance and private insurance: If no allopathic treatment is available to treat a specific illness or to reduce its pain or if the aetiology is unknown - for example, for multiple sclerosis or certain forms of cancer - the use of complementary/alternative medicine is reimbursed provided the treatment has a minimum chance of success whether or not the method of treatment is generally scientifically recognized. If the aetiology is known, but no allopathic treatment is available, the recourse to complementary/alternative medicine is allowed, provided there is a minimum chance of success according to the aetiology. The same allowance is given when a previous allopathic treatment has been unsuccessful. When an allopathic treatment and a complementary/alternative treatment are both available but the allopathic treatment has side effects or risks for the patient, in general or in particular, the use of complementary/alternative medicine is reimbursed. However, in this case, it is necessary to balance the risks and the cost-effectiveness of the treatment. If there are safe allopathic and non-allopathic treatments at a patient's disposal, he/she may choose the less expensive treatment. Anthroposophic, phytotherapeutic, and homeopathic products are reimbursed. By Articles 92 al. 1 and 135 al. 1 Sozialgestezbuch, in order to be reimbursed, experimental treatments have to be recognized, in broad terms, as useful and safe. Some private insurance companies also reimburse treatments not scientifically recognized if they are provided by Heilpraktikers and if their effectiveness is not completely rejected. Hungary Statistics The Hungarian Homeopathic Medical Association has 340 members. There are three practicing chiropractors in Hungary. Regulatory situation Although allopathic physicians are the most common providers of complementary / alternative medicine, non-allopathic physicians and non-allopathic practitioners may provide specific complementary/alternative treatments. In February 1997, the Hungarian legislature passed two pieces of comprehensive legislation on natural medicine: Government Decree 40/1997 (IV 5) Korm. r. on natural medicine and the Decree of the Minister of Welfare 11/1997 (V 28) on some aspects of the practice of natural medicine. These two decrees clearly and officially integrate allopathic and non-allopathic physicians who practice complementary/alternative medicine into the national health care system. The Decrees came into force on 1 July 1997. The Decrees outline precise rules regarding the curriculum of complementary / alternative medical training as well as its practice. Each complementary/alternative discipline has its own training requirements and State exam. Within a legal framework, non-allopathic physicians are allowed to use complementary/alternative medicine once they have passed the exam. Articles 1 through 7 of the Decrees regulate conditions for practicing complementary/alternative medicine. Annexes 1 through 4 list the specific requirements for each form of complementary/alternative medicine. Article 1 identifies three categories of authorized medical practitioners: allopathic physicians, practitioners with a non-academic higher medical qualification, and other non-allopathic practitioners. Natural doctors are authorized practitioners who have passed the required exams and are permitted to use complementary/alternative medicine. Article 1 also contains restrictions on the use of complementary/alternative medicine. Only allopathic physicians may practice homeopathy, Chinese and Tibetan medicine (including acupuncture), biologic dentistry, therapies using oxygenation, neural-therapy, anthroposophy, and magnetic bioresonance. Both allopathic physicians and medical practitioners with a non-academic higher health qualification may provide manual therapies. Practitioners who do not hold a higher health qualification may provide acupressure, massage therapy, lifestyle counselling, reflexotherapy, bio-energy, phytotherapy, and auriculotherapy. Article 2 clarifies the legal framework in which natural doctors are allowed to practice. Paragraph 1 of Article 2 states that allopathic physicians are in charge of diagnosis, therapy planning, and patient follow-up. Other practitioners who have the necessary qualifications may participate in patient care at the request of the patient or through an allopathic physician's referral. Natural doctors who are non-allopathic physicians are allowed either to practice under the supervision of an allopathic physician or, more independently, to provide care after an allopathic physician has made a diagnosis. Consulting allopathic physicians may not oppose a patient's choice to seek treatment from a natural doctor. Article 2 Paragraph 2 delineates medical acts that may not be performed by non-allopathic physicians. If a patient is under the treatment of an allopathic physician, natural doctors must consult the patient's allopathic physician. Article 2 Paragraph 3 stipulates that only qualified psychologists or allopathic physicians with a qualification as psychotherapists are allowed to provide psychotherapeutic care based on natural medicine. By Article 3, natural doctors must submit to the same directives as other medical practitioners, such as respecting obligations, abiding by ethical rules, and keeping patient records. Article 4 permits the use of all regular drugs under the provision of complementary / alternative medicine. Homeopathic products not registered in Hungary can be used if the registration procedure is in process. Article 5 gives the Institute of Health, under the authority of the Ministry of Social Welfare, the responsibility of regulating the training and examination of natural doctors. Under Article 7, allopathic physicians with an academic degree in medicine may ask for a licence to practice as natural doctors without being required to take another exam. They are also allowed to use the title of "Natural Doctor", but to use the title of specialists in particular therapies, they must take the exam. Allopathic physicians are the only practitioners who do not have to pass the exams to practice complementary/alternative medicine. Psychologists with higher health qualifications and other practitioners must take a specific examination in natural medicine before they may use the title of "Natural Doctor". Natural doctors are registered and supervised by a special commission. Annex 1 contains a complete list of authorized complementary/alternative treatments and of the medical practitioners who are allowed to provide them. Annex 2 outlines the information that natural doctors must record, such as patient histories and a description of the current treatment. Annex 4 gives the theoretical and practical requirements for examinations in acupuncture, massage techniques, lifestyle counselling, reflexology, physiotherapy, bioenergy, and auriculotherapy. For each therapy, the Annex lists the definition of the technique, practical and theoretical requirements, rules on ethics, and specific topics for examination. In 1977, the Government recognized homeopathy as a medical method, but there is no officially recognized training programme or examination. Chiropractic is regulated, but not defined, by law. The Ministry of Education recognizes the Doctor of Chiropractic degree. Ireland Statistics There are 55 chiropractors practicing in Ireland. There are numerous associations of professional complementary/alternative practitioners. Regulatory situation As in the United Kingdom, the Medical Council is the statutory body that regulates the medical profession. In order to practice medicine as an allopathic physician, a provider must possess a certificate of qualification from a medical school and be registered with the Medical Council. Although allopathic physicians do not have a legal monopoly on medical practice, registered allopathic practitioners have some exclusive rights. Only those who are registered as doctors are permitted to treat venereal diseases, practice obstetrics, certify death, issue medical certificates for official purposes, prescribe a wide range of controlled drugs, give advice in court on specific issues, supply services to police for alcohol-linked traffic offences, and administer anaesthetics. All medical positions in State services, the army, civil service, or private industry are restricted to registered allopathic medical practitioners. Persons without an allopathic medical degree are tolerated by law to practice complementary/alternative medicine; however, only medical practitioners with a university degree in allopathic medicine are recognized. Under Section 61 of Part V, Fitness to Practice, of the Medical Practitioners Act of 1978, it is an offence for non-registered practitioners to provide medical treatment under the pretence of being a registered practitioner. People who make false declarations for the purpose of obtaining registration are punishable by a fine and/or imprisonment. There is no chiropractic law, although the practice of chiropractic is permitted under common law. Chiropractors may obtain a licence to operate X-ray equipment. Education and training There is no postgraduate training for allopathic physicians in complementary / alternative medicine.
Insurance coverage When a registered allopathic doctor provides complementary/alternative treatment, it is not distinguished from other medical care and is covered by the General Medical Services. Italy Background information The private sector ensures the availability of complementary/alternative medicine. The Societa Italiana di Omeopatia, founded in 1947, links the different societies and schools of homeopathy. Statistics Of Italy's 250 000 allopathic physicians, 5000 use complementary/alternative techniques. Of those using complementary / alternative techniques, around 1300 practice acupuncture. There are approximately 200 chiropractors practicing in Italy. Twenty-four per cent of adults have used complementary/alternative medicine at least once. Women, particularly those between 25 and 50 years of age, are the most likely to use complementary / alternative medicine. In order of popularity, homeopathy, acupuncture, herbal remedies, prana therapy, anthroposophic medicine, and chiropractic are the most popular complementary / alternative therapies. More than three million people, 5.25% of the population, use homeopathy. Ninety-two per cent of these patients are female, 79% are adults, and 69% are middle class. There are about 5000 homeopathic doctors, 7000 pharmacies selling homeopathic products, and 20 companies that produce or distribute homeopathic medicines. The market for homeopathic products in Italy grew from 10 billion lira in 1982 to 120 billion lira in 1994. In September 1996, a petition enclosing 300 000 signatures of patients of homeopathic medicine asked the Italian Parliament to give official recognition to homeopathy. Regulatory situation In order to practice as an allopathic physician, a person must have a degree in medicine or surgery, must have passed the corresponding State exam, and must be registered in a professional register. Paramedics are specifically excluded from practicing complementary/alternative medicine. According to a decision by the Criminal Supreme Court of Appeals in Perugia, only registered allopathic physicians may practice complementary/alternative medicine. Allopathic physicians using complementary / alternative, rather than allopathic, techniques are responsible for any consequences to their patients. Allopathic physicians are not permitted to aid or cooperate with non-allopathic practitioners to illegally provide medical care of any kind. However, the courts have also ruled that chiropractic is a profession, even though it is not licensed. Chiropractors are considered medical auxiliaries rather than medical specialists and must work under the supervision of an allopathic doctor. Complementary / alternative practitioners who are not also allopathic physicians can be prosecuted under Article 348 of the Italian Penal Code, although this rarely occurs. Indeed, the Criminal Supreme Court of Appeals in Perugia's decision noted that even if acupuncture is taught in Italian universities, only physicians and surgeons are allowed to practice it. The Court considers medical and/or surgical expertise necessary to establish an exact diagnosis and avoid prejudicial consequences to patients. Law 175 of 5 February 1992 expressly prohibits the use of titles that are not recognized by the State. No forms of complementary/alternative medicine are recognized as medical specialities under this law. Specific regulations on complementary/alternative medicine currently cover only homeopathy and anthroposophic medicine. Homeopathy has a long history in Italy; attempts to regulate it began in the middle of the nineteenth century. On 17 March 1995, legislative Decree 185 was adopted, executing Directive 92/73/CEE, which regulates the marketing and registration of homeopathic and anthroposophic products. Education and training Acupuncture training is available for both allopathic physicians and non-allopathic physicians. Some anaesthesiology programmes include specialities in acupuncture. The University of Catania, Sicily, offers a postgraduate programme in acupuncture. The Society of Italian Acupuncturists and the Paracelse Institute also offer training. The latter is a member of the World Federation of Acupuncturists and Moxibustion Society. However, training programmes in complementary/alternative medicine, even when offered at the university level, are not legally recognized. Insurance coverage Each Italian region has its own regulations on the reimbursement of health care. In Lombardy, for example, there is a co-payment of 70 000 Italian lira for complementary/alternative medicine. The National Health Service pays the remainder. When provided by an allopathic doctor holding a university medical degree, acupuncture, hypnosis, antalgic lasertherapy, pressing massotherapy, lymphatic drainage, reflexive massotherapy, biofeedback, and vertebral manipulation and other articulation massage are reimbursed. Since the Italian Government is working to reduce National Health Service expenses, this information is likely to change soon. Not all private insurance programmes reimburse complementary/alternative medicine services. Those that do vary in the amount they reimburse and they generally require treatments to be provided by allopathic physicians, except in the case of articulation manipulation. Insurance premiums vary according to the age, sex, and health status of the patient. They are approximately 500 000 Italian lira annually for a child and 1 500 000 Italian lira annually for an adult. Latvia Background information Several methods of complementary/alternative medicine are integrated into the social welfare system of Latvia. Statistics Homeopathy and acupuncture are the most popular types of complementary/alternative medicine. Most complementary/alternative practitioners are allopathic physicians. There are several complementary/alternative medical associations. Regulatory situation The Council of Ministers of the Republic of Latvia has delegated the power to regulate and supervise all medical specialities to the Medical Society of the Republic of Latvia. The Cabinet of Ministers' Regulations on the Certification of Health Professionals of 1995 provides procedures for licensing medical professionals. In order to practice legally as a recognized physician, a candidate must have graduated from a local medical academy or from any other medical college delivering a recognized diploma. Candidates must also obtain authorization according to local legislation. Before allopathic physicians can legally practice complementary/alternative medicine, they must complete the requisite course and exam for the State licence, which is valid for five years. In order to renew a licence, a practitioner must complete a new course and examination. Allopathic physicians providing complementary/alternative treatments - such as acupuncture, homeopathy, auriculotherapy, iridology, magnetotherapy, osteoreflexotherapy, phytotherapy, naturopathy, laser-therapy, biofeedback, Ci-Gun, and Su-Jok - are supervised by a commission of experts that includes members of medical associations and the Medical Society of the Republic of Latvia. Acupuncture and homeopathy have the same clinical speciality status as allopathic specialities. Local laws regulate complementary/alternative medicine. The Administrative Codex prohibits non-allopathic practitioners from practicing medicine of any kind. However, patient lawsuits are uncommon except in cases of serious harm to their health. Education and training Since 1990, over 300 physicians from the Scandinavian and Baltic States of Latvia, Estonia, and Lithuania have completed training in acupuncture and traditional Chinese medicine. There are a few special programmes for non-allopathic physicians intended to give them basic medical knowledge. These programmes consist of between one and two years of medical courses at a medical school. Qualification courses in the Reiki method and medical astrology are also offered.
Insurance coverage Complementary/alternative treatments are generally not covered by the compulsory health insurance. Acupuncture and homeopathy are exceptions: in 1994 they were included in the list of medical specialities reimbursable by social insurance. In September 1998, two insurance companies, Balta and Parex, began coverage of legally provided complementary/alternative medicine. They cover two-thirds of expenses for consultations and treatments by acupuncture, homeopathy, Dr R. Voll electropuncture, iridodiagnosis, and bioresonance when are provided by authorized allopathic physicians. Treatments given by non-physicians are not covered. Liechtenstein Statistics There are three chiropractors practicing in Liechtenstein. Regulatory situation According to Order I and Article 49 of the Health Law, to practice medicine in Liechtenstein, a candidate must be a citizen of Liechtenstein; live in Liechtenstein; be a graduate of a Swiss, German, or Austrian school of medicine; have the necessary capacity, reputation, and hygienic knowledge; respect the duties of a general physician; and obtain a licence to practice. The right to work as an independent allopathic general practitioner and the right to use a specialist title require postgraduate studies followed by an internship. According to Article 22 of the Health Law, chiropractors are considered medical professionals. The practice of complementary/alternative medicine by allopathic physicians is not regulated. Allopathic physicians may use complementary/alternative therapies without having to pass a supplementary exam. However, Article 9 of Order I states that "physicians have to practice only in their speciality and according to their knowledge, with the exception of emergencies". Paramedics are also permitted to provide complementary/alternative medicine. By Article 24 Paragraph A Lit. I of the Health Law of 18 December 1985 (178, 179, 180), complementary/alternative practitioners may provide health care so long as they refrain from those acts reserved for allopathic physicians. Although there are no court rulings on this point, none of the medical acts included in Article 24 Paragraph A Lit. I are considered to be reserved for allopathic physicians (in particular those related to natural medicine). Therefore complementary/alternative providers only need a business licence to provide treatment legally, even though they are not allowed to provide care in the national health care system. A new medical department is in charge of issuing licences and controlling conditions of practice. Although complementary/alternative practitioners have yet to be subject to prosecution, Article 184 of the Penal Code specifies that an unqualified person who performs medical acts that are legally reserved for allopathic physicians - such as surgery, treatment of infectious diseases, or prescription of controlled medications - can be punished with a fine or a prison sentence of up to three months. The State health authorities perceive a contradiction between Article 24 Paragraph A Lit. I of the Health Law and Article 184 of the Penal Code. They are considering two ways of resolving it: either introducing a law to cover practitioners of natural medicine or abolishing Article 24 Lit. I of the Health Law. There is currently a controversial draft Law on Natural Medicine that, if passed, would resolve the contradiction by loosening the restrictions on the right to perform medical acts. Education and training Complementary/alternative practitioners are generally trained in foreign countries. Insurance coverage Complementary/alternative treatments are not covered by compulsory social insurance. To obtain reimbursement for such services, it is necessary to have complementary/alternative medical insurance. Coverage under this insurance is limited to 500-1500 Swiss francs per year. Luxembourg Regulatory situation In order to practice medicine as a physician, a candidate must hold a university certificate, obtain authorization from the Minister of Health, and have the consent of the Medical College. Treatment, diagnosis, and prevention of disease are restricted to members of the allopathic medical corpus. Article 7 of the Law of 29 April 1983 stipulates that persons without the required qualifications who practice or participate in the diagnosis or treatment of real or supposed pathological disorders through personal acts, verbal or written consultations, or other methods, can be prosecuted. Non-allopathic practitioners using complementary/alternative medicine are regularly prosecuted. Though not legally binding, the Code of Professional Ethics states that it is unethical for allopathic physicians to recommend, to either their patients or acquaintances, therapies that are based on illusory methods or which are not scientifically proven. The Medical College is unequivocally opposed to the practice of complementary / alternative medicine in Luxembourg. It considers practitioners of complementary / alternative medicine to be quacks and crooks. Nevertheless, members of Parliament are in favour of granting official recognition to complementary/alternative practitioners and techniques. Education and training There is no officially recognized complementary/alternative medical training in Luxembourg. Insurance coverage Reimbursed at 80% of fees, homeopathy is the only officially covered complementary / alternative practice. In the case of other complementary/alternative therapies, there is no specific reimbursement rate in the list of publicly covered medical acts and services, meaning that theoretically, they are not covered by public health insurance. However, when they are legally provided by a recognized allopathic health care professional, complementary/alternative treatments are unofficially reimbursed in the context of a normal consultation. Approved allopathic physicians are thereby free to choose the treatment they provide. There are no private insurance companies offering coverage for complementary / alternative medicine. Malta Background information Traditional Chinese medicine, chiropractic, and osteopathy are widely practiced. Statistics There are no established professional organizations or self-regulating bodies for complementary/alternative practitioners in Malta. Regulatory situation The medical professions are regulated by Part II of the Medical and Kindred Professions Ordinance (Chapter 31 of the Laws of Malta) and Part IV of the Department of Health Ordinance (Chapter 94 of the Laws of Malta). Only registered allopathic medical professionals are allowed to practice medicine. In order to practice, a candidate must have a licence issued by the President of Malta and be registered in the Medical Register. To obtain this licence, the candidate must have successfully completed a university programme leading to a degree as an allopathic medical doctor or the equivalent. Allopathic physicians may practice complementary/alternative medicine. Non-allopathic practitioners are not legally recognized in Malta, and at present, there is no registration system for such practitioners. As stipulated in Chapter 31 of the Laws of Malta, non-allopathic practitioners are not allowed to perform procedures reserved for recognized allopathic medical professionals such as physiotherapists, physicians, and pharmacists. However, they are not prohibited from practicing medicine. Although there are no legal sanctions on complementary/alternative practitioners themselves, a breach of the regulations outlined in Chapter 31 usually constitutes a criminal offence and is punishable by a fine, imprisonment, or both, according to the specific article breached. There are also restrictions on advertising treatments and clinics. The court exercises its discretion when determining appropriate punishment. By Section 98 of Chapter 31 of the Laws of Malta, the only forms of complementary / alternative medicine licensed by the Ministry of Health are acupuncture, moxibustion, and traditional Chinese medicine. Conditions of licensing are imposed by the Ministry of Health as deemed fit. Article 3 of the provisions requires clinics for traditional Chinese medicine to provide only traditional Chinese medicine. It further stipulates that patients diagnosed with an infectious disease must be referred to a registered allopathic medical practitioner for treatment and that no treatment for infectious diseases can be given at the clinics. Article 6 of the provisions outlines hygienic standards for the clinics, and Article 7 states that all persons treated by traditional Chinese medicine, including acupuncture, must be referred by an allopathic doctor registered to practice in Malta. The Public Health Department must be informed of the name and qualifications of every person employed under licence. The Department is also responsible for carrying out inspections. Acupuncture is not registered as a profession in Malta. Acupuncture licences are conditional upon proof of adequate training and experience. The licensee must renew the licence annually via a written application. Acupuncturists employed by the Mediterranean Centre for Traditional Chinese Medicine are usually qualified allopathic doctors as well as acupuncturists. Malta is considering allowing specific complementary/alternative providers, particularly chiropractors and osteopaths, to be registered by the local Board of Professions Supplementary to Medicine alongside allopathic professions. Education and training Bonesetters are usually taught through family training. Some chiropractors and osteopaths are certified by overseas teaching institutions. As there is no local registration of these practitioners, there are no standardized qualifications to practice. Insurance coverage The State runs acupuncture clinics within the public health services. Treatment at these clinics is provided free of charge. Private acupuncture clinics provide their treatment on a fee-for-service basis. The costs of acupuncture and other complementary / alternative medical services obtained privately are not reimbursed. Private insurance does not cover complementary/alternative care. Netherlands Background information The Dutch Association of Homeopathic Doctors was established in 1898. Statistics According to a 1985 study, 18% of the population has used complementary/alternative medicine at least once - 6% to 7% during the previous 12 months. In 1990, over 900 000 people consulted a complementary / alternative practitioner other than their own allopathic general practitioner. More women than men use complementary/alternative medicine, especially those between the ages of 35 to 50. Most patients treated with herbal medicines and by paranormal healing have little formal education; most patients of other forms of complementary/alternative medicine are executives and professionals. The 1985 survey reported more than 4000 complementary/alternative practitioners in the Netherlands: 735 naturopaths, 300 paranormal healers, 220 homeopaths, 475 anthroposophical professionals (either allopathic doctors or other professionals, such as anthroposophical nurses), 945 acupuncturists, and 1450 manual therapists. There are 125 chiropractors practicing in the Netherlands. In addition to these providers, according to a 1992 survey, almost half of Dutch general practitioners have provided complementary/alternative treatment at least once - 40% have used homeopathy, 9% manipulative medicine, 4% acupuncture, and 4% naturopathy. The most popular forms of complementary/alternative medicine are, in order of popularity: homeopathy, herbal medicine, manual therapies, paranormal healing, acupuncture, diet therapy, naturopathy, and anthroposophical medicine. The most common conditions presented to complementary/alternative practitioners are musculoskeletal pain and complaints of nervous origin. Patients most often report that they use complementary/alternative therapy because allopathic methods are ineffective for their chronic disorders. Only 14% of patients seek complementary/alternative care without having first consulted an allopathic practitioner. In one survey of patients treated with complementary/alternative medicine, 56% said that their health condition improved quite a lot, 22% felt that some improvement had occurred, and 22% saw no improvement at all. According to a consumer survey, about 80% of the Dutch population would like to have complete freedom of choice over their medical treatments; specifically, they would like health insurance schemes to recognize complementary/alternative medicine. Sixty per cent of the Dutch population is ready to pay higher insurance premiums in order to have this choice. Regulatory situation Since 1993, when the Medical Practice Act of 1865 was replaced by the Individual Health Care Professionals Act, non-allopathic providers have been allowed to practice medicine in the Netherlands. The new act came into force on 1 December 1997, bringing the legal status of non-allopathic practitioners in line with that of allopathic paramedics: they may practice medicine provided they do not perform specific medical acts reserved for allopathic physicians, except under the orders of an allopathic physician. Violation of this limited monopoly can be prosecuted. The medical acts reserved for physicians are surgical procedures, obstetric procedures, catheterizations and endoscopies, punctures and injections, general anaesthesia, procedures involving the use of radioactive substances and ionizing radiation, cardioversion, defibrillation, electroconvulsive therapy, lithotripsy, and artificial insemination. The Individual Health Care Professions Act also introduces a system to protect the titles of a limited number of professional groups, with the possibility of creating new medical specialities under specific conditions. It also defines the training requirements necessary for registration as one of these medical professionals. The eight professions regulated are allopathic medical doctor, dentist, pharmaceutical chemist, health care psychologist, psychotherapist, physiotherapist, midwife, and nurse. While non-allopathic practitioners are not allowed to use these titles or to work in the national health services, procedures are now in place for them to obtain recognition for their speciality, including a protected title. There are also legal registers in which qualified medical practitioners of homeopathy, herbal medicine, manual therapies (such as chiropractic and osteopathy), paranormal healing, acupuncture, diet therapy, naturopathy, and anthroposophical medicine are entitled to be registered once they satisfy specific legal requirements. This registration gives them the right to practice under a protected title, with the aim of insuring they are qualified in a specific field of health care. Education and training According to the Dutch Health Council, complementary/alternative medical institutions have organized a number of training courses, taken steps to develop standards of training and professionalism, and established national registration systems. About 60% of the members of complementary/alternative professional organizations have undergone training in a field of allopathic medicine, often as a physician, physical therapist, or nurse. Introductory courses on complementary/alternative medicine are included in the curriculum of several Dutch medical schools. Allopathic doctors wishing to be trained in anthroposophical medicine, acupuncture, homeopathy, or manipulative therapy can attend part-time courses for one to four years. There are also postgraduate programmes for physical therapists, most of whom study acupuncture or manipulative therapy. Without allopathic medical or paramedical training, individuals may register in one of the three academies for naturopathy offering full-time courses of three to four years. Students completing the three-year basic course in homeopathy earn the designation "Homeopathic Physician". Registration must be renewed every five years, based on proof of participation in compulsory continuing-education courses. A disciplinary committee monitors and penalizes homeopathic malpractice. Insurance coverage Officially, only homeopathic and anthroposophic medicines are reimbursed by social insurance. However, private health insurance reimburses all care given by allopathic general practitioners, whether allopathic or complementary/alternative. Two-thirds of the population have private health insurance. In 1988, all large private insurance companies began covering homeopathy, acupuncture, and manipulative therapy as part of their standard or supplementary packages. In addition to the legally defined standard package, which is the same for all 45 health insurance funds, the funds also offer a supplementary package to which their clients can voluntarily subscribe. Under the supplementary coverage, 26 of the 45 health insurance funds reimburse some kinds of complementary/alternative medicine if provided by an allopathic physician or a physiotherapist, usually homeopathy, acupuncture, and anthroposophical treatments. In many cases, reimbursement was given only when care was provided by allopathic physicians or physical therapists who were members of a professional organization. In 1991, in response to consumer demand, many packages were expanded to cover more types of complementary/alternative medicine and to cover care provided by non-allopathic practitioners. As of 1998, 47 private insurance companies cover between 25% and 100% of complementary/alternative treatments provided by allopathic physicians or members of professional organizations - to a maximum of 300 to 2500 Dutch florins per year. This coverage generally includes homeopathy, anthroposophy, acupuncture, manual therapies, chiropractic, naturopathy, and neuraltherapy. Norway Background information Although some authorised allopathic doctors and other health personnel in Norway have integrated acupuncture and/or homeopathy into their practice, most usually do not use complementary/alternative therapies. Some persons with authorization to practice as health personnel, such as nurses, have complementary/alternative medicine practices. Statistics A 1994 poll reported that 23% of men and 30% of women had used complementary / alternative medicine at least once. Most respondents in this group were middle-aged persons living in towns. The most popular therapies are acupuncture, accounting for 35% of consultations for complementary/alternative treatments; homeopathy, accounting for 33%; reflexology, 29%; natural medicine, 29%; chiropractic, 16%; kinesiology, 7%; natural healing, 3%; and iridology, 3%. The Norwegian Association of Chiropractors has about 100 members. Regulatory situation In principle, everyone in Norway is allowed to treat patients, regardless of training or profession. However, only allopathic physicians, and to some extent dentists and persons assisting physicians and under the guidance of a physician, are allowed to use the title "Doctor of Medicine", use a title indicating a speciality in a specific illness, or advertise - although anyone can place an announcement in the press that contains only a name, address, consultation hours, and general information on services provided. Specific medical acts are similarly restricted. These include the use of controlled medications in treatment, surgical procedures, injections, general or local anaesthesia, diagnostic or therapeutic methods restricted to physicians, treatment of cancer, diabetes, dangerous anaemia, struma/goitre with sticky forms, and some contagious/infectious diseases mentioned in Act 55 of 5 August 1994 on contagious/infectious diseases (such as venereal diseases, tuberculosis, infectious hepatitis, HIV, poliomyelitis, and infectious meningitis), as well as practicing in an itinerant way. To receive authorization to practice as an allopathic medical doctor, a candidate must possess a medical degree from a Norwegian or other recognized university and have undergone an 18-month internship. Norway has the oldest regulations in Europe on the practice of medicine by non-allopathic physicians. The first legislation of this kind in Norway dates back to 1619. A new law was adopted in 1871. The Act of 1871 was to some extent less restrictive than the current Act 9 of 19 June 1936 on the limitations of the right of persons who are not allopathic physicians or dentists to undertake treatment of ill persons. Act 9 was used as a model for legislation in Sweden and Denmark. Aside from allopathic physicians or dentists, anyone who wants to practice complementary/alternative medicine is subject to Act 9 of 19 June 1936. Under the law, non-physicians and non-dentists who treat patients are subject to a jail sentence of up to three months if the patient's life or health is exposed to serious danger either by the treatment or because the patient did not seek a health care provider who could have prevented the danger. Anyone sentenced to prison for such violations can no longer practice medicine. Except in the most serious cases, criminal sanctions are rarely used. Allopathic practitioners are restricted from using complementary/alternative therapies unless the therapies are considered to be responsible practice within the practitioner's profession, the patient is informed about the method and its status, and the patient agrees to the treatment. The insertion of acupuncture needles is considered a surgical intervention and can only be performed by allopathic physicians, dentists, or persons delegated by physicians. Since 1990, chiropractors have been officially recognized as health care professionals. Only licensed chiropractors are permitted to use the title of "Chiropractor". To be licensed, a candidate must have completed a training programme and passed examinations at an approved institution; undertaken additional training in Norwegian health law and chiropractic disciplines; completed one year of practical training; and not be in a position that would lead to withdrawal of the authorization - for instance, the candidate must not be found unsuitable for practicing chiropractic due to old age, illness, alcohol/drug abuse, or other circumstances. To become a member of the Norwegian Association of Chiropractors, chiropractors must have completed a course approved by the American Council on Chiropractic Education and undergone three months of clinical training. With some exceptions, homeopathic medicines may only be sold from pharmacies. A licence is necessary to market homeopathic products when the degree of dilution is less than one million. In June 1995, the Storting (parliament) examined the place of complementary / alternative medicine in the Norwegian health service. Among other things, the Storting decided to consider introducing certification of the various types of training and education available for complementary/alternative medical professions. In 1997, with the intention of revising the 1936 law, the Ministry of Health appointed a committee to write a report on complementary/alternative medicine. The report was delivered to the Ministry in December 1998. It describes the situation of complementary/alternative medicine in Norway and includes a discussion of the clinical effects of treatments, possible legal measures, and means of communicating research results and other information to the public. The Government has not yet decided how to follow up on the report. In Beijing on 6 April 1999, the Ministers of Health of Norway and China signed a memorandum of understanding on Chinese/Norwegian cooperation in the field of health to increase the knowledge and understanding of traditional Chinese medicine among Norwegian health personnel. Education and training The 1990 chiropractic law regulates the training of chiropractors; however, there are no recognized schools of chiropractic in the country. There are two schools of homeopathy in Norway. One offers courses to all persons with some education in allopathic medicine. Beginning with the basics, it is a five-year programme with classes taught one weekend each month. The other school only offers courses to persons who have the minimum qualifications to practice allopathic nursing. Insurance coverage Public reimbursement is not available for what is regarded in Norway as complementary/alternative medicine. Coverage for homeopathic treatments, for example, is not included under the official health care system. However, by the regulations governing the national insurance scheme, partial reimbursement is available for chiropractic treatment provided the chiropractor is authorized as a health care professional (although not necessarily a member of the Norwegian Association on Chiropractic) and the patient was referred to the chiropractor by an allopathic physician. This coverage is limited to a maximum of between 10 and 14 consultations per year. In Norway, Norsk Helseforsikring, which is connected to International Health Insurance Denmark AS, is the only private insurance company offering partial reimbursement for complementary/alternative medicine. The insurance covers chiropractic and, when performed by a licensed allopathic physician as part of medical treatment, acupuncture. Russian Federation Statistics There are one or two chiropractors practicing in the Russian Federation.
Regulatory situation The Russian Federation provides a striking example of a change in policy towards complementary/alternative medicine that may be followed in other former socialist countries. Section 34 of the Fundamental Principles of the Health Legislation of the Union of the Soviet Socialist Republics and of the Union Republics required physicians to use only those diagnostic, prophylactic, and therapeutic methods and pharmaceutical products authorized by the Ministry of Health. Neither homeopathy nor homeopathic medicines were authorized. By contrast, the right to practice the art of healing by "popular" medicine is protected by Section 57 of the Russian Federation legislation governing health care. It remains to be seen how this provision will be interpreted, but its general open-ended language suggests that it is likely that complementary/alternative practitioners will have wide powers to practice. A 1995 decree refers to homeopathy in the Russian Federation. It permits the use of homeopathy in every clinic and hospital, giving it official recognition. There is no law specifically regulating chiropractic, although some chiropractors have been permitted to practice. Education and training The State Scientific and Practical Centre of Traditional Medicine and Homeopathy of the Ministry of Public Health of the Russian Federation was created in 1999. The Centre's goals include organizing and conducting scientific research and coordinating and realizing educational activities in complementary/alternative medicine. A standard Government education programme in homeopathy has been developed by the Committee for Homeopathy of Russia and approved by the Ministry of Health. Homeopathy has also been introduced at the Russian Medical Academy as a postgraduate speciality. Spain Background information Homeopathy was introduced into Spain in the beginning of the 19th century. The first Spanish homeopathic hospital, the Fundacion Instituto Homeopatico y Hospital de San Jose in Madrid, was founded in 1878. The Academia Medico Homeopatica de Barcelona was founded in 1890. There is an outpatient homeopathic clinic at the Hospital del Nen Deu of Barcelona. The Spanish Society of Homeopathic Medicine was founded in 1996. It represents all homeopathic associations. In addition to homeopathy, popular complementary/alternative therapies include acupuncture, auriculotherapy, neuraltherapy, and biological medicine. However, until 1987, complementary/alternative medicine (with the exception of homeopathy) had only a minor role in the Spanish health care system. There are several associations linked to complementary/alternative medicine in Spain. Since 1996, the Spanish Medical Council has supported complementary/alternative medicine, provided it is practiced by licensed physicians. Statistics There are 50 chiropractors practicing in Spain. Regulatory situation In Spain, the practice of medicine is the exclusive right of allopathic doctors. In order to obtain the right to practice medicine, a candidate must hold an academic degree in medicine, have authorization from a medical college, pledge professional secrecy, be current in his or her taxes, and as outlined in the Statutes of the Collegial Medical Organization, respect the Spanish Code of Professional Ethics of 1990. Natural medicine, by the Royal Decree of 27 March 1926, may only be practiced by licensed allopathic physicians. On 16 June 1997, the Code of Medical Professional Ethics was adopted in Catalonia. Article 44 of this code stipulates that doctors using complementary/alternative medicine must inform their patients of the importance of continuing necessary allopathic treatments and of the non-conventional character of the complementary/alternative therapy. Furthermore, doctors must coordinate their supplementary therapy with the allopathic physician in charge of the patient's basic treatment. Article 44 forbids using methods that have not been scientifically validated to make a diagnosis or treat a patient. Royal Decree 127/1984 does not include branches of complementary/alternative medicine as medical specialities. Opposing this, professional associations registered with the Ministry of the Interior are seeking recognition from the Spanish Government for graduate practitioners using complementary/alternative medical techniques. The Council of Medical Colleges of Catalonia wants to make homeopathy, acupuncture, and natural medicine official. Under Article 62 of Royal Decree 3166/1966 of 23 December 1966, licensed paramedics are allowed to perform medical acts only under the supervision of an allopathic physician. The three categories of paramedic professions are practitioners of odontology, psychologists, and university graduates in nursing, which include, for example, physiotherapists. Some paramedics illegally practice complementary / alternative medicine. The illegal practice of medicine is regulated by Article 403 of the Penal Code, approved on 23 November 1995. This article states that if persons without relevant academic certificates practice acts specific to a profession, they risk imprisonment for a period of up to 12 months. This includes all intrusions made by non-allopathic physicians in the field of medicine. State authorities are relatively tolerant with private allopathic doctors and non-allopathic practitioners using complementary/alternative medicine. On 23 January 1984, in response to a case regarding acupuncture and reflexology, the Spanish Supreme Court declared that it is not necessary to have a degree in medicine in order to practice medicine. However, only approved medical professionals may make a diagnosis, give a clinical or medical examination, or decide to apply a specific therapy. On 19 June 1989, in a Supreme Court decision, a non-allopathic practitioner of acupuncture-moxibustion was found not guilty of intrusion into the field of medicine on the basis of two points : first, the practitioner had several foreign certificates and was a member of the Latin American Association of Research on Acupuncture-Moxibustion; second, as complementary/alternative medicine is not taught within Spanish medical faculties and as there is no official certificate authorizing and legitimizing complementary/alternative medical practice, it does not legally exist. Consequently, it does not correspond to any legally determined profession and therefore its practice cannot be the object of intrusion. In January 1993, the Supreme Court released a non-physician acupuncturist. The argument was the same: complementary/alternative medicine is not included within the official list of medical specialities and therefore practicing complementary / alternative medicine is not an intrusion into the field of medicine. Similarly, the Spanish Association of Physiotherapists denounced certain chiropractors for intrusion into the field of medicine. However, in an 18 March 1997 decision, the regional Court of Valencia stated that chiropractors and other practitioners using complementary/alternative medicine are not committing intrusion. Article 54 of the Law on Medicaments 25/1990 of 20 December 1990 and Royal Decree 2208/1994 of 16 November 1994 regulate homeopathic remedies and the commercialization of homeopathic products. Education and training The medical universities of Madrid, Sevilla, Murcia, Zaragoza, Valladolid, Barcelona, and Santiago offer certificate courses in homeopathy, naturist medicine, and acupuncture to allopathic physicians. The universities of Barcelona, Sevilla, Valladolid, and Murcia offer postgraduate training in homeopathy for physicians. For pharmacists and veterinarians, some universities offer basic and advanced homeopathic training programmes as well as other courses and certificates. Sociedad Espaρola Acupunctura and Sociedad Espaρola de Medicos Acupunctores in Madrid offer two-week introductory courses, three 90-day training courses, and a complete three-year training programme. With the sponsorship of the Council of Europe and the World Health Organization, the Teaching Centre of Traditional Chinese Medicine in Spain provides comprehensive training for both physicians and non-physicians in acupuncture with the intention of gaining professional status for acupuncture. Other professional organizations also provide courses in complementary/alternative medicine. Insurance coverage Two public hospitals, Hospital del Nen Deu in Barcelona and Fundacion Instituto Homeopaticoy Hospital de San Jose in Madrid, provide homeopathic care to outpatients on a fee-for-service basis. Under Article 94 of Law 26/1990 of 20 December 1990, there is no justification for homeopathic products to be financed through the State insurance system, INSALUD. Efforts by the Homeopathic Physicians Charter of the State of Spain to gain social security coverage for homeopathic medications have been unsuccessful. In Spain, only a few private insurance companies provide coverage for any complementary / alternative medicines. Sweden Statistics In a 1989 survey, 20% of adults reported having received complementary/alternative medical treatment. Forty per cent of patients of complementary/alternative medicine stated they had chosen these treatments because they were not satisfied with the National Health Service. Seventy per cent stated that through their complementary/alternative treatment their health had improved or they had been cured of their illness; 1% stated their health had deteriorated. Chiropractic is the most commonly consulted complementary/alternative medicine in Sweden. Thirteen per cent of the population has consulted one of the 130 practicing chiropractors at least once. The next most popular form of complementary/alternative medicine is homeopathy, accounting for 4% of consultations, followed by acupuncture, naturopathy, and herbal medicine. Regulatory situation In Sweden, the National Board of Health and Welfare maintains a registry of public health and medical personnel. Practitioners who are not included in the Supervision of Health and Medical Personnel list of medical practitioners (which includes only allopathic doctors, dentists, nurses, midwives, and physiotherapists) may not be registered. Thus, officially only recognized medical practitioners are under public scrutiny. The requirements for practicing medicine are included in the Act on Competence 542 of 1984 and the Medical Care Act 786 of 1996. Although non-registered persons may treat patients, specific medical acts are restricted to allopathic physicians. The specific treatments reserved for physicians are outlined in the Quackery Act - Law 409 of 1960, modified in 1982. Only a physician is allowed to act as a doctor in medicine; practice general or local anaesthesia; provide care with radiological methods; practice in an itinerant way; treat specific contagious diseases; treat cancer, diabetes, epilepsy, or pathological conditions associated with pregnancy or childbirth; treat a child who is younger than eight years old; issue written recommendations or instructions for the treatment of patients who are not personally examined by them; provide acupuncture; and test or supply contact lenses. The violation of these restrictions is an offence and may be prosecuted. Non-allopathic practitioners who damage a person's health by using inappropriate therapies may be charged with charlatanism constituting a danger to health. Practitioners found guilty of this charge are punishable under the penal law and may be prohibited from working in the health care field. In 1989, Sweden granted recognition to chiropractors satisfying the standards of the Council of Chiropractic Education. By Government Bill 1988/89:96, those chiropractors completing studies as doctors of chiropractic have the right to obtain a licence and to be registered under the National Health Service. However, no Swedish training programme has so far been certified as meeting the appropriate standards. Currently, all registered practitioners have been trained abroad. Chiropractors trained at the Scandinavian College of Chiropractic in Stockholm are working to be included among the recognized practitioners. Homeopathic remedies are legal and are manufactured according to good manufacturing practices. In 1994, official recognition was extended to naturopaths. The Swedish Commission on Competence does not intend to amend the rules of authorization for them. Osteopaths remain unrecognised and the Swedish Commission on Competence does not have any proposals regarding osteopathy. The Swedish Commission on Competence was delegated to undertake a comprehensive review of the principles governing authorization and competence and, in the light of this review, to put forward proposals concerning, for example, rules of authorization and competence for various categories of professional medical care, including the Quackery Act. The Swedish Parliament mandated the Commission on Alternative Medicine to examine issues concerning the position of complementary/alternative medicine in Swedish society. The recommendations of the Commission on Alternative Medicine (1989) and the proposals of the Swedish Commission on Competence (1996) can be summarized as follows: create an association of non-allopathic practitioners who have had at least one year of training and are registered by the National Board of Health and Welfare; create a State register of all non-allopathic practitioners who have passed their exams; create professional titles; uphold the law reserving specific medical acts for allopathic physicians; introduce some types of complementary/alternative medicine into the National Health Service and incorporate complementary/alternative practitioners into the National Health Service, provided specific conditions are fulfilled; strictly control the advertising of natural remedies; plan scientific studies on the effectiveness of complementary / alternative medicine. Education and training Most of the increasing numbers of homeopaths working in Sweden today have been educated at private institutions. This education corresponds to that of allopathic physicians in many ways. There are three private schools providing homeopathic training. There is also a four-year basic medicine course taught by professors from the University of Upssala. No Swedish chiropractic training programme is officially recognized. Insurance coverage While non-allopathic practitioners may treat patients in Sweden, their care is not reimbursed by the health care system. Only acupuncture provided by an allopathic physician is reimbursed by social insurance, and then only partially. The Commission on Complementary/Alternative Medicine did not propose the reimbursement of treatments obtained from practitioners of complementary/alternative medicine. Switzerland Background information Patients of complementary/alternative medicine who are ill report that they use complementary/alternative medicine because the therapies do not involve treatment with drugs or chemicals, there are no side effects, and allopathic medicine was unsuccessful in treating their illness. Patients of complementary/alternative medicine who are not ill report that they use complementary/alternative medicine to improve their well-being and to keep from falling ill. Statistics A 1992-1993 study showed that the use of complementary/alternative medicine within the previous 12 months was closely related to whether or not a patient had complementary/alternative health insurance: Of those surveyed who had insurance covering complementary/alternative medicine, 20.7% did not use complementary/alternative medicine; 18.9% used one form of complementary/alternative medicine; 21.5%, two forms; and 39.0%, three or more forms. Those without insurance covering complementary/alternative medicine reported the following: 56.4% did not use complementary/alternative medicine; 20.5% used one form of complementary/alternative medicine; 13.4%, two forms; and 9.7%, three or more forms. Persons living in the German-speaking and French-speaking parts of the country used complementary/alternative medicine more extensively than those living in the Italian-speaking region. Women and persons with higher levels of formal education were more likely to consult a complementary/alternative medical practitioner than were men and persons with lower levels of formal education. The most commonly consulted forms of complementary/alternative medicine are shown in the chart below.
a The percentages are the proportion of respondents who consulted a complementary/alternative practitioner, not the total number of people surveyed. There are approximately 180 chiropractors practicing in Switzerland. Complementary / alternative therapies are provided by allopathic physicians, natural doctors, non-allopathic practitioners, pharmacists, and patients themselves. There are many organizations linked to complementary/alternative medicine in the country. Regulatory situation In Switzerland, cantons (similar to states or provinces) make their own public health regulations, including the regulation of local medical practice. Nonetheless, some degree programmes and professions, such as allopathic physicians or chiropractors, are recognized throughout the country, and the titles of some professions, including "Medical Doctor" and "Chiropractor", are protected. The cantons allowing only allopathic physicians to practice medicine are Appenzell internal Rhodes, Jura, Nidwalden, Uri, and, with the provisions noted, the following: Aargau: a licence is not required to provide care to healthy persons (when treating nervousness, stress, sleeplessness, or phobias, for example). Basel Stadt: authorized physiotherapists and masseurs are permitted to use reflexology. Bern: the practice of acupuncture by non-allopathic practitioners is tolerated when provided under the orders of an allopathic physician. Fribourg: the Department of Health may issue licences to practice complementary/alternative medicine on condition that practitioners do not use methods and techniques restricted to authorized health care professionals. Geneva: recently, the authorities have been relatively tolerant of non-allopathic practitioners. Glarus: reflexology, acupressure, and other similar forms of massage may be freely provided. Schwyz: non-physicians may obtain a licence to practice acupuncture. Solthurn: a draft law would enable the practice of complementary/alternative medicine as a self-employed profession. Vaud: recently, the authorities have been relatively tolerant of non-allopathic practitioners. Zug: under the supervision of the health authority, reflexology, sport massage, acupressure, and health advising may be freely provided. Acupuncture may be provided by persons who have completed three years of training, including comprehensive theoretical and practical courses, and who have passed a cantonal exam. Zurich: magnetism is not considered a form of medicine and, therefore, its practice does not require official authorization. Although the law in these cantons is typically monopolistic, the authorities are relatively tolerant with regard to non-allopathic practitioners. In order to be allowed to practice in German-speaking cantons (Appenzell external Rhodes, Basel Landschaft, Graubόnden, Luzern, Obwalden, St. Gallen, Shaffhausen, and Thurgau), non-allopathic providers must pass the State exam and obtain a licence from State authorities. In most German-speaking cantons, there are specific medical acts that are reserved for physicians. In non-German-speaking cantons, the situation is slightly different. In the canton of Neuchβtel, since the introduction of a 1995 law, non-allopathic practitioners are permitted to provide non-dangerous complementary/alternative therapies. While a licence to practice is not required, complementary/alternative medical providers may not advertise their services. In Valais, the same restrictions apply, with two additional requirements: complementary/alternative providers must clearly inform their patients that they do not have any allopathic education and they must have a licence from the health department. In the canton of Ticino, non-allopathic practitioners may practice medicine without a licence; however, they must clearly inform their patients that they do not have an allopathic education. And, they are not permitted to advertise; use optical, mechanical, electrical, or ionizing equipment; or prescribe medications or drugs. Homeopathy is among the most frequently practiced complementary/alternative therapies in Switzerland. All persons legally providing health care may apply homeopathy according to the standards of good medical practice. In some cantons, those not medically qualified may practice homeopathy as well. In 1998, the National Medical Association recognized homeopathy as a medical sub-speciality. Chiropractic is considered an independent medical profession that is federally regulated and recognized throughout the country. There are several requirements that must be met to be allowed to practice as a chiropractor, including limited competence in medical diagnosis and treatment. To practice chiropractic, a person must have Swiss citizenship, hold a diploma giving access to a university, have studied at least four years in a chiropractic college recognized by the American Council on Chiropractic Education, have passed the American commission exam, have passed the Swiss intercantonal exam, have passed the Swiss federal exam to be allowed to X-ray, and have completed at least a one-year internship with a Swiss-authorized chiropractor. Education and training The universities of Zurich and Bern include an introductory course on complementary/alternative medicine in the standard curriculum for allopathic physicians. In Bern there are also more extensive courses on homeopathy, neuraltherapy, traditional Chinese medicine, phytotherapy, anthroposophic medicine, hydrotherapy, and bio-resonance. The Swiss Medical Association has been aware of the need to establish complementary/alternative medical specialities. In 1999 and 2000, it set up a new training programme for allopathic physicians. Homeopathy, Chinese medicine, acupuncture, anthroposophic medicine, and neural therapy are now granted speciality titles for allopathic physicians. Training for these techniques, as with allopathic specialities such as cardiology or rheumatology, lasts between eight and 10 years. Students who are not allopathic practitioners may study at any one of several private institutions offering training programmes in complementary/alternative medicine, including the following: Swiss Association of Natural Doctors: the programme, which lasts six semesters and is provided on weekends, includes introductions to anatomy, physiology, and biochemistry; seminars in physiology and pathology; and seminars on diagnostic and treatment techniques. School for Natural Medicine in Zurich: two training options are available, both include basic courses in anatomy, physiology, and pathology. Students then specialize either in homeopathy and traditional Chinese medicine or in several forms of complementary/alternative massage. The programme lasts four years. Academy for Natural Medicine in Basel: the school offers a basic common course in anatomy, physiology, pathology, psychiatry, neurology, and physical diagnosis. After completing this common course, students choose from among three specializations: homeopathy, phytotherapy and natural medicine; traditional Chinese medicine; or acupuncture. The programme lasts four years plus a required four-month internship. Swiss School for Osteopathy of Belmont/Lausanne: this school is working to obtain official recognition equivalent to a university faculty. It offers a five-year diploma and a six-year doctorate programme. Although chiropractic is a recognized profession in Switzerland, there are no recognized chiropractic schools in the country. Practitioners must train abroad. Some cantons - Appenzell external Rhodes, Basel Landschaft, Graubόnden, Obwalden, St. Gallen, Shaffhausen, and Thurgau - have specific rules concerning the exam that candidates must pass to be allowed to practice complementary/alternative medicine. Insurance coverage There are several levels of health care protection in Switzerland. Insured persons are free to choose between minimum basic coverage and extensive coverage provided through policies that provide coverage for complementary/alternative health care and medications. Since July 1999, five commonly used complementary/alternative therapies - homeopathy, Chinese medicine, anthroposophic medicine, neural therapy, and phytotherapy - have been reimbursed by compulsory social insurance when they are provided by an allopathic physician with a postgraduate education recognized by the Swiss Medical Association. Treatments provided by non-allopathic physicians are not reimbursed. Except for acupuncture, in order for these therapies to continue to be reimbursable after 2005, their efficacy and cost-effectiveness have to be proven by that year. The complementary/alternative medicine policies of private insurance companies influenced the Swiss Government's decision to cover the most commonly used therapies. Private insurance companies, such as Caisse Vaudoise, generally offer complementary/alternative health care policies covering acupuncture, acupressure, Alexander technique, anthroposophy (when provided by a physician), audiopsycho-phonology, auriculotherapy, lymphatic drainage, etiopathy, curative eurythmy, eutony, homeopathy, postural integration, iridology, colonic irrigation, Kneipp therapy, kinesiology, anthroposophic medicine, mesotherapy, naturopathy, osteopathy, polarity, energetic balancing, reflexology, relaxation, breathing techniques, shiatsu, sophrology, and sympathicotherapy. The supplementary fee for complementary/alternative policies varies between 10 and 20 Swiss francs per month. Reimbursement varies between 30 and 100 Swiss francs per consultation; three to 10 consultations are covered per year. Ukraine Statistics There are no hospitals in Ukraine in which only complementary/alternative therapies are used. Regulatory situation Though allopathic physicians may use allopathic or complementary/alternative therapies, only allopathic physicians and registered non-allopathic practitioners working under physicians are allowed to provide medical treatments. The Ministry of Health authorizes licences for physicians. It requires an authenticated copy of documents attesting to the level of education and necessary qualifications for the practice of medicine, such as a medical diploma or a certificate of specialization, a letter of reference issued by a former employer, and approval from the designated local authority. Complementary/alternative medicine is covered under general regulations. In order to be registered as a legal non-allopathic practitioner, it is necessary to complete a special programme given by the Academy of Physicians Postgraduate Education or by the Ukrainian National Medicine Association, which is under the supervision of the Ukrainian Ministry of Public Health. Some specific branches of complementary/alternative medicine, such as reflexotherapy, have their own code of speciality. Steps are being taken to introduce an official specialization in homeopathy for allopathic physicians. Homeopathic remedies are officially recognized by the Decree on Medicines of the Ministry of Health. Quality control of homeopathic remedies is based on the German Pharmacopoeia. The Ukrainian Ministry of Public Health regulates the production of homeopathic medicines, and the Comission of the Pharmacological Committee on Homeopatic Medicines under the supervision of the Ukrainian Office for Public Health is responsible for delivering licences for their sale. Specialised homeopathic chemist shops exist in Ukraine. People can also buy homeopathic medicines from Germany and Austria. Education and training The Academy of Physicians Postgraduate Education and the Ukrainian National Medicine Association offer special courses for non-allopathic practitioners in homeopathy, iridology, reflexotherapy, aromatherapy, and phytotherapy. Insurance coverage There is no public or private reimbursement of complementary/alternative medicine. Patients seeking complementary / alternative treatment must pay for the care themselves. United Kingdom of Great Britain and Northern Ireland Background information Successive governments have ensured that as long as patients require complementary/alternative treatment, access to it will be guaranteed. As a result, the United Kingdom is the only country in the European Union with public-sector hospitals for complementary/alternative medicine. Indeed, there are National Health Service homeopathic hospitals in London, Glasgow, Liverpool, Bristol, and Tunbridge Wells. At Saint Mary's Hospital, where relaxation, dietetic, yoga, and meditation therapies are available, allopathic physicians work closely with non-physicians. Homeopathy provided by allopathic physicians is included in the National Health Service. Complementary/alternative medications, homeopathic products, and other natural remedies are becoming increasingly popular and are now widely available in health food stores and pharmacies. In response to the increased use of complementary/alternative medicine by the public and the Government's concern over its effectiveness, the British Research Council on Complementary Medicines was formed in 1982. Among other things, it noticed the major role of complementary/alternative medicine in reducing the costs of the health care system. In general, in order to become a member of a professional organization, non-allopathic practitioners must be covered by insurance and adhere to the Code of Professional Ethics. Statistics During the past 20 years, interest in complementary/alternative medicine has increased. Seventy per cent of the public is in favour of complementary/alternative medicine becoming widely available in the National Health Service - particularly osteopathy, acupuncture, chiropractic, and homeopathy. One-eighth of the British population has tried complementary/alternative medicine, and 90% of these people are ready to use it again. Complementary/alternative medicine is most popular with middle-aged, middle-class women. The complementary/alternative therapies most used are herbal medicines, osteopathy, homeopathy, acupuncture, hypnotherapy, and spiritual healing. Much complementary/alternative medical practice centres on treating chronic diseases. Most patients of complementary/alternative medicine are also patients of allopathic medicine. Complementary/alternative practitioners without an academic degree provide the largest proportion of complementary/alternative medicine. In 1987, there were about 2000 non-allopathic medical practitioners. In 1999, there were 50 000 complementary/alternative medical providers. Approximately 10 000 of these are officially registered health professionals. In 1998, up to five million patients consulted a complementary/alternative practitioner. Patients spend about 1.6 billion pounds sterling each year on complementary/alternative medicine. There are approximately 1300 chiropractors practicing in the United Kingdom. There are several professional associations of complementary/alternative practitioners. Regulatory situation Although complementary/alternative medical practitioners without an allopathic medical degree are tolerated by law, only medical providers holding a university degree in allopathic medicine are officially recognized : to practice medicine as a physician, a person must posses a certificate or qualification from the faculty of medicine of a university and complete one year of general clinical training. During the clinical training period, a physician candidate has provisional registration. After satisfactorily completing the training, the candidate may obtain full registration. Being a registered medical practitioner confers privileges and responsibilities, including the right to use the title or describe oneself as a registered practitioner, to be recognized by law as a physician or surgeon, to recover fees for medical attendance or advice in a court of law, to hold specific posts, to provide general medical services in the National Health Service, and to give some statutory certificates. The General Medical Council, a statutory body that regulates the medical profession, maintains the register of qualified allopathic doctors. Although registration, for which specific training is required, provides certain privileges to non-allopathic practitioners as well, the right to practice medicine without formal recognition is established in British Common Law. This right protects an individual's freedom to carry out medical activities not specifically prohibited by an act of Parliament. As a result, given some restrictions and provided they do not breach the Medical Act of 1983, non-allopathic providers can practice medicine regardless of their training. In principle, non-registered persons are even allowed to perform surgical acts with the consent of patients. If such acts result in maltreatment, however, non-allopathic practitioners may be prosecuted under the penal law and the tort-based common law of negligence. And if a patient dies, the practitioner may be prosecuted for involuntary homicide. Registered physicians cannot be so prosecuted. Under the terms of the Venereal Disease Act of 1917 and Section 4 of the Cancer Act of 1939, there are some limitations on the rights of non-allopathic practitioners. Non-allopathic practitioners may not perform certain medical acts, practice specific professions, or use particular titles. Only registered allopathic doctors may treat cancer, diabetes, epilepsy, glaucoma, and tuberculosis; prescribe controlled drugs; perform specific medical acts such as abortion; or treat venereal diseases. Unqualified practitioners may not claim to be or practice as pharmacists, midwives, or dentists, or imply that they are State-registered allopathic practitioners whose legal status is regulated by the Professions Supplementary to Medicine Act of 1960. This Act regulates dieticians, medical laboratory technicians, occupational therapists, physiotherapists, radiographers, and orthopaedists. Further, commercial use of the term "health care centre" in relation to any premises where no allopathic doctors and nurses are employed is prohibited. Allopathic physicians referring patients to non-allopathic practitioners for treatment retain clinical responsibility for their patients. The Medical Act of 1983 does not regulate which forms of therapy may be practiced by registered physicians. Thus, there is no restriction on registered allopathic physicians using complementary/alternative medicine if they have the requisite skills and/or qualifications. Further, the agreement of 1 April 1990 between allopathic general practitioners and the Family Health Service Authorities does not define the staff that may work with an allopathic physician. Thus, a physician's staff may include physiotherapists, chiropractors, and dieticians. In 1950, the Government gave official recognition to homeopathy in the Faculty of Homeopathy Act. The Government regulates osteopathy and chiropractic through the quite similar Osteopath and Chiropractor Acts of 1993 and 1994. While registered practitioners of these two professions have special rights, including title protection, they, like other non-allopathic practitioners, are not recognized as official health care providers and may not work in National Health Service hospitals. Nonetheless, these two acts are considered to be important developments in complementary/alternative medicine. Other practitioners, including acupuncturists, homeopaths, and herbalists, are now pursuing the same level of recognition. The regulation of chiropractors and osteopaths, as with all health care professionals, is based upon a register. The right to use the title of "Chiropractor" or "Osteopath" is restricted to registered chiropractors and osteopaths, and registration depends on having recognized qualifications, although there are transitional provisions for experienced practitioners. The General Chiropractic Council, which includes a significant number of non-chiropractors, is publishing its own Code of Professional Ethics. Under the Osteopath and Chiropractor Acts of 1993 and 1994, the principal criteria for disciplinary action are professional incompetence, conduct that falls short of the standards required of a registered osteopath or chiropractor, conviction of a criminal offence, and serious health impairment affecting the ability to work as an osteopath or chiropractor. Under this Code, practitioners facing disciplinary action from the Committee may be admonished, suspended, or dismissed. The right to practice is initially granted for a period of up to three years, then for periods of two to three years. However, this is not yet in effect. Homeopathic and other natural remedies are sold by many independent pharmacies. The European Directive on Homeopathic Products regulates the making and marketing of homeopathic products in the United Kingdom, The licensing of other medicines is regulated by the Medicines Act of 1968. Applications for drug registration must be accompanied by details of relevant research and clinical trials. Requirements are less stringent if the medicines do not contain a new chemical substance or if they are herbal preparations. The Health Act of 1999 provides two options for achieving statutory regulation for a profession or therapy. The first option allows associations representing a profession to apply for statutory regulation. The second option allows professions to join the Health Professions Council; membership in the Council confers title protection. Education and training The British Medical Association recommends incorporating complementary/alternative medicine into the undergraduate curriculum of medical schools and making accredited postgraduate training available. While most non-allopathic practitioners have good training, the quality of complementary / alternative medical programmes varies. The Institute of Complementary / Alternative Medicines is working with the Training Desk to establish national standards of training acceptable to both the public and the Government. There are 54 professional associations representing complementary/alternative practitioners and offering comprehensive full-time courses in anthroposophy, chiropractic, homeopathy, phytotherapy, naturopathy, and osteopathy, lasting for a minimum of three years. The Faculty of Homeopathy Act empowers the Faculty of Homeopathy to train, examine, and confer diplomas in homeopathy to allopathic physicians and other statutorily recognized health professionals. There are four schools of chiropractic in the United Kingdom. Insurance coverage With some exceptions, fees for complementary/alternative therapies are not reimbursed by the social security system. Exceptions are made for treatments available within National Health Service hospitals, which are provided free of charge, and occasionally for acupuncture, osteopathy, and chiropractic treatments. An allopathic general practitioner may claim reimbursement for a wide range of staff, including physiotherapists, chiropractors, and dieticians; however, the authorities have the freedom to reimburse all, part, or none of these costs. Some private insurance programmes reimburse the five most popular forms of complementary/alternative therapy - homeopathy, osteopathy, herbalism, acupuncture, and naturopathy - when they are provided by allopathic physicians. The services of chiropractors and osteopaths are reimbursed by trade bodies and by several associations, such as industrial and veterans' associations. South-East Asia Bangladesh Background information Ayurvedic medicine is widely practiced in Bangladesh. Regulatory situation When Bangladesh constituted the eastern part of Pakistan, the Pakistani Board of Unani and Ayurvedic Systems of Medicine was operative in the country. Following independence, the Bangladesh Unani and Ayurvedic Practitioners Ordinance of 1972 restructured this body as the Board of Unani and Ayurvedic Systems of Medicine, Bangladesh. The Board is responsible for maintaining educational standards at teaching institutions, arranging for the registration of duly qualified persons (including appointing a registrar), and arranging for the standardization of unani and ayurvedic systems of medicine. A research institute has been functioning under the Board since 1976. The Bangladesh Unani and Ayurvedic Practitioners Ordinance of 1983 prohibits the practice of unani and ayurvedic systems of medicine by unregistered persons. A significant feature of the Ordinance is the deliberate omission of a provision contained in preceding legislation that made it an offence for an ayurvedic or unani practitioner to sign birth, medical, and physical-fitness certificates. Education and training Control over the teaching of unani and ayurvedic medicine rests with the Board of Unani and Ayurvedic Systems of Medicine. There are nine teaching institutions under the Board, five for unani medicine and four for ayurvedic medicine. They offer diplomas upon completion of a four-year programme. The Registrar of the Board also serves as the Controller of Examinations. Bhutan Background information What is now classified as Bhutanese traditional medicine was introduced into Bhutan in the beginning of the 16th century by Lam Shabdrung Ngawang Namgyal. This medical system has roots in Buddhism and Tibetan traditional medicine. During its early practice in Bhutan, providers of traditional medicine were trained in Tibet. In addition to medications, Bhutanese traditional medicine includes acupressure, acupuncture, moxibustion, cupping, cauterization, medicated oil massage, herbal and steam baths, and the application of cold and warm poultices to the body. In 1988, a research unit was established in the Institute of Traditional Medicine Services. This unit conducts research for further quality control of raw materials and finished products for traditional medicines as well as developing new products. It also ensures the sustainability of traditional medicine services and looks for ways to increase the cost-effectiveness of traditional medicine. Statistics There is a hospital for traditional medicine in Thimphy, the capital city of Bhutan. An additional 15 traditional medicine units across the country provide services to about 60% of the country's population. The Government plans to establish more units, to cover all 20 districts in the country. There are more than 2990 different medicinal plants used in Bhutanese traditional medicines. About 130 traditionally used formularies are made from 110 different herbal preparations. About 70% of the raw materials used in these preparations are available in the country, both as wild and cultivated stocks. The remaining 30% are imported from India. There are more than 300 herbal products produced in Bhutan. Most are compound forms, with three to 90 ingredients. Regulatory situation In 1967, in an effort to promote and preserve traditional medicine, it was formally recognized and institutionalized as an integral part of the national health system of Bhutan. In 1979, the Institute of Traditional Medicine Services was founded. It is housed in an allopathic hospital in order to encourage the integration of traditional and allopathic medicine, particularly mutual consultation, treatment, and referrals, and to enable patients to have greater access to a range of health care choices. Bhutan's Institute of Traditional Medicine Services is charged with establishing a traditional medicine system that is scientifically sound and technologically appropriate, and which meets the needs of the population. To fulfil this mandate, the Institute works to provide access to traditional medicine for the entire population; to attain self-reliance in raw materials for the production of traditional medicines, including the conservation, cultivation, rotational collection, and preservation of rare and endangered species of medicinal plants; to improve the quality of traditional medical services through training practitioners; and to increase the production of traditional medicines for export. Profits from exporting traditional medicines are to be used to strengthen traditional medicine within Bhutan. Small-scale mechanised production of traditional medicines started in 1982 with the assistance of the World Health Organization; previously, all medicines had been prepared manually. All herbal products are now produced mechanically following good manufacturing practices, with an emphasis on quality control. Herbal products take the form of pills, tablets, medicated ointments, syrups, and capsules and are purely natural - no artificial chemicals are used. Education and training Officially recognized formal training of traditional medical doctors (drungtsho) began in 1971 with the establishment of a five-year drungtsho programme. In 1978, the training curriculum was standardized. In 1979, the programme became part of the National Institute of Traditional Medicine. The course now consists of five years of institutional training followed by a six-month internship: three months in an allopathic hospital and three months in the traditional medicine hospital and a traditional medicine unit. During the three-month internship in the allopathic hospital, interns are introduced to allopathic medicine and the health sciences. Democratic People's Republic of Korea Regulatory situation In the Democratic People's Republic of Korea, traditional medicine is integrated into the official health care system. This policy of integration is reflected in a number of policy declarations since 1947. It was a prominent feature of the Government's 1967 political programme and was reiterated in a 1980 public health law. Under Article 15 of this law, with a view to preserving national therapeutic traditions, the State is required to combine traditional medical practices with allopathic diagnosis in medical establishments. India Background information For centuries, ayurveda, siddha, and unani systems of medicine have coexisted with yoga, naturopathy, and homeopathy. Siddha is one of the oldest systems of medicine in India. In Tamil, siddha means "perfection" and a siddha was a saintly figure who practiced medicine. Siddha has close similarities to ayurveda, the difference between these two systems being more linguistic - Tamil versus Sanskrit - than doctrinal. In siddha, as in ayurveda, all objects in the universe, including the human body, are composed of the five basic elements: earth, water, fire, air, and sky. Yoga was propounded by Patanjali and is based upon observance of austerity, physical postures, breathing exercises, restraining of sense organs, contemplation, meditation, and samadhi. Naturopathy is a system of drugless treatment and a way of life. It is very close to ayurveda. The introduction of allopathic medicine during the colonial period led to the Government's neglect of traditional medical systems. Now, however, ayurveda, unani, siddha, naturopathy, homeopathy, and yoga are well integrated into the national health care system. There are State hospitals and dispensaries for both traditional medicine and homeopathy; however, traditional medicine and homeopathy are not always well integrated with allopathic medicine, particularly in allopathic hospitals. Statistics Traditional medicine is widely used in India, especially in rural areas where 70% of the Indian population lives. There are 2860 hospitals, with a total of 45 720 beds, providing traditional Indian systems of medicine and homeopathy in India. In 1998, more than 75% of these beds were occupied by patients receiving ayurvedic treatment, which is by far the most commonly practiced form of traditional medicine in India. There are 22 100 dispensaries of traditional medicine. There are 587 536 registered traditional medicine practitioners and homeopaths, who are both institutionally and non-institutionally qualified. Regulatory situation Ayurveda, unani, siddha, naturopathy, homeopathy, and yoga are all recognized by the Government of India. The first step in granting this recognition was the creation of the Central Council of Indian Medicine Act of 1970. The main mandates of the Central Council are as follows: to standardize training by prescribing minimum standards of education in traditional medicine, although not all traditional medicine practitioners and homeopaths need be institutionally trained to practice; to advise the central Government in matters relating to recognition/withdrawal of medical qualifications in traditional medicine in India; to maintain the central register of Indian medicine, revise the register from time to time, prescribe standards of professional conduct and etiquette, and develop a code of ethics to be observed by practitioners of traditional medicine in India. All traditional medicine practitioners and homeopaths must be registered to practice. The Central Council of Homeopathy, constituted in 1973, has the same mandates. The Indian Government created the Department of Indian Systems of Medicine & Homeopathy in March 1995. The primary areas of work for the Department are education, standardization of medicines, enhancement of availability of raw materials, research and development, information dissemination, communication, and the involvement of traditional medicine and homeopathy in national health care. More than 4000 personnel work in these areas. The Indian Government seeks the active and positive use of traditional medicine and homeopathy in national health programmes, family welfare programmes, and primary health care. Education and training Through the Central Council of Indian Medicine and the Central Council of Homeopathy, the Indian Government is working to standardize the training of traditional medicine practitioners and homeopaths. In support of this, seven national institutes are under the control of the Department of Indian Systems of Medicine & Homeopathy: National Institute of Ayurveda: established in 1976, located in Jaοpur, offers a PhD MD in ayurveda; National Institute of Homeopathy: established in 1975, located in Calcutta, offers Bachelor's and MD degrees in homeopathy; National Institute of Naturopathy: established in 1984, located in Pune, offers talks in Hindi and Marathi and programmes for teachers and doctors; National Institute of Unani Medicine: established in 1984, located in Bangalore, offers postgraduate research opportunities in unani; National Institute of Postgraduate Teaching and Research in Ayurveda: located in New Delhi, offers PhD and MD degrees in ayurveda; National Academy of Ayurveda: established in 1988, located in New Delhi, offers a Degree of Membership Certificate in ayurveda; National Institute of Yoga: established in 1976, located in New Delhi, offers a one-year diploma in yoga. An institution for siddha medicine is planned. In addition to these national institutes, there are a number of facilities for medical education under the Department of Indian Systems of Medicine & Homeopathy :
The health authorities review the qualifications of practitioners through the Central Council of Indian Medicine and the Central Council of Homeopathy, which can both determine whether these colleges and universities may continue to admit students. Insurance coverage Few people besides State employees have medical insurance, although this insurance does cover traditional medicine. Indonesia Background information Indonesian practitioners of traditional medicine may be divided into four groups: herbalists; skilled practitioners, including traditional birth attendants, circumcisers, bonesetters, masseuses, and traditional dentists; spiritualists; and supernaturalists. Statistics The use of traditional medicine is increasing each year. Traditional medicine provides an important resource for self-care within the health services and through traditional medicine practitioners. Forty per cent of Indonesia's population uses traditional medicine, 70% in rural areas. A 1995 Ministry of Health survey reported 281 492 practitioners of traditional medicine practicing in Indonesia, a significant increase over the 112 974 reported in 1990 (189, 190). Of these practitioners, 96.2% use traditional Indonesian methods of treatment. The rest use medical treatments, such as acupuncture, that belong to the traditions of other countries. Among the 281 492 traditional medicine practitioners in Indonesia, 122 944 are traditional birth attendants, 51 383 are general traditional medicine practitioners, 25 077 are masseuses, 18 456 are circumcisers, 18 237 are tukang jamu gendong, 14 000 are herbalists, 12 496 are spiritualists, 10 118 are supernaturalists, and 8781 are bonesetters. Traditional birth attendants are an important feature of Indonesian health care. According to national figures for the period 1983 to 1987, allopathic providers attended only 43% of childbirths. The remainder were either unattended or attended by traditional birth attendants. At least 91 427 traditional birth attendants have completed a training programme offered by the Ministry of Health. At the end of 1999, there were 723 manufacturers of traditional medicines in Indonesia, 92 of which were large-scale industries. These companies produce thousands of registered traditional medicines. Regulatory situation Article 1 of Indonesia's Health Law Act 23-1992 places traditional medicine as an integral part of curative and nursing care. Article 2 emphasizes the need for supervision of traditional medicine to ensure its safety and efficacy. Article 3 supports further development and improvement of forms of traditional medicine deemed safe and efficacious in order to fulfill the goal of optimal health for the community. The Health Law Act classifies traditional medicines (jamu) into two groups: The first group consists of traditional medicines produced by individual persons or by home industries. These medicines need not be registered. They are made by traditional medicine practitioners for use by their own patients. They may not be labelled or marked except with the empirical name. The Minister of Health is responsible for helping the producers of these medicines ensure the quality of their products. To this end, the Ministry permits the use of only 54 species of plants in these medicines. The safety of all 54 species is known through traditional experience. The second group consists of traditional medicines produced and packed on a commercial scale, whether large or small. These medicines must be registered and licensed before they may be sold. In order to be registered, jamu (and traditional medicines not indigenous to Indonesia) must have undergone scientific study, including microbiological testing. These studies are to ensure the safety and efficacy, composition and rationality of the composition, dosage form, and claimed indications for the medicines. For use in formal health services, clinical trials must be carried out. The Ministry of Health of Indonesia has produced a publication, Guidance for Clinical Trial of Traditional Drug, to help manufacturers fulfill these requirements. In accordance with the 1993 General Guidelines, health efforts, including those for traditional medicine, have been strengthened within the framework of the national health care legislation. Traditional birth attendants are permitted to practice without registration or a licence, Allopathic physicians with appropriate training in acupuncture are able to practice acupuncture in public hospitals. Education and training The Centre for Traditional Medicine Research, under the Ministry of Health and Social Welfare, provides training in traditional medicine. The Directorate of Selected Community Health Development, also under the Ministry of Health and Social Welfare, offers training programmes in primary health care for traditional practitioners of acupressure. Myanmar Background information Traditional medicine in Myanmar is based on ayurvedic concepts and influenced by Buddhist philosophy. From 1885, the beginning of the colonial period in Myanmar, until the Second World War, allopathic medicine was promoted over traditional medicine. During the Second World War, however, allopathic medicines were scarce and traditional medicine regained prominence. Statistics The Department of Indigenous Medicine was established in August 1989. It houses more than 4000 ancient palm-leaf and parchment writings and books on traditional Myanmar medicine. Since the promulgation of the Traditional Medicine Law in 1996, a total of 3962 medicinal items have been registered and 632 manufacturers have been issued production licences. Over 8000 practitioners of traditional medicine are registered in Myanmar. There is one 50-bed hospital for traditional medicine in Mandalay, one 25-bed hospital in Yangon, and three 16-bed hospitals in other parts of the country. There are 194 township-level traditional medicine departments, each with its own outpatient clinic. Regulatory situation Prior to the Second World War, several national committees recommended that the Government recognize traditional medicine, but no action resulted. Four years after Myanmar's independence in 1948, the Myanmar Indigenous Medical Committee was formed. The Committee drafted the Indigenous Myanmar Medical Practitioners Board Act 74, which was passed in 1953 and amended in 1955, 1962, and 1987. The Act established the Indigenous Myanmar Medical Practitioners Board, which advises the Government on the revival and development of traditional Myanmar medicine, related research, and the promotion of public health, among other things. Section 11 specifies "suppression of charlatans or quacks who are earning their living by means of indigenous Myanmar medicine" as a particular function of the Board. Subject to the sanction of the Head of State, the Board is also empowered to prescribe topics for examination in traditional Myanmar medicine, register practitioners, and remove practitioners from the register if a defect in character or undesirable conduct is established. Section 24 of the Act prescribes that subject to the provisions of Section 23 of the Myanmar Medical Act, practitioners of traditional medicine must be registered in order to sign medical certificates, which by law must be signed by a medical practitioner. Similarly, unless he or she has obtained the prior sanction of the Head of State, an indigenous medical practitioner who is not registered may not hold certain specified appointments in publicly supported hospitals or other health facilities. Section 7 of the Indigenous Myanmar Medical Practitioners Board Rules of 1955 provides for the registration of traditional medicine practitioners under six categories. The system of classification is essentially based on the division of Myanmar medicine into four branches: dhatu, ayurveda, astrology, and witchcraft. In Section 9 of the Rules, details are given of the knowledge required for registration in each specific category. Provision is made, in Section 10, for authors of works on indigenous medicine to be registered in one of three groups. Section 10 also prohibits the registration of monks as medical practitioners. Under Section 12 of the Rules, the Board is mandated to find ways to consolidate the four branches of medicine currently practiced into a single system. The Board is also mandated to conduct research and advise the authorities on standardizing methods of treatment provided in Government-operated dispensaries. The Indigenous Myanmar Medical Practitioners Board Amendment Act 48 of 1962 introduced Sections 22-A and 28-A empowering the Chairman of the Revolutionary Council of Myanmar to cancel the registration of indigenous medical practitioners, prescribe qualifications for registration, and terminate the services of any or all of the members of the Board and appoint new members in their place. Under these powers, a new Board was appointed to initiate the re-registration of practitioners. In 1996, the Government promulgated the Traditional Medicine Law in order to control the production and sale of traditional medicines. The Ministry of Health has updated and revised the Indigenous Myanmar Medical Practitioners Board Amendment Act and renamed it the Traditional Medical Council Law. It is now in the process of receiving State approval. Education and training The Ministry of Health established an educational institution known as the Institute of Indigenous Medicine in 1976. It offers a three-year training programme followed by a one-year internship. The Institute also conducts a one-year course in primary health care for traditional medicine practitioners who have no certificate or licence to treat patients. Those who are successful in the course receive a licence to practice traditional medicine. Nepal Background information The use of medicinal herbs in Nepal's traditional medical system dates back to at least 500 AD. In Nepal, traditional medicine, although low profile, has been an integral part of the national health system. Parallel to the allopathic system, traditional medicine is encouraged in all spheres because of its efficacy, availability, safety, and affordability when compared to allopathic drugs. Statistics Ayurvedic medicine is widely practiced in Nepal. It is the national medical system. More than 75% of the population use traditional medicine, mainly that based on the ayurvedic system. There are 141 ayurvedic dispensaries, 14 zonal dispensaries, 15 district ayurvedic health centres, and two ayurvedic hospitals. One of these hospitals is centrally located in Naradevi, Kathmandu, and the other is regionally located in Dang. They have 50 and 15 beds, respectively. There are 623 institutionally qualified practitioners of traditional medicine and about 4000 traditionally trained practitioners. Homeopathy has been recently introduced into Nepal. Regulatory situation The policy of the Government, based on five-year plans, involves a system of integrated health services in which both allopathic and ayurvedic medicine are practiced. Ayurvedic clinics are considered to be part of the basic health services, and there is a section responsible for ayurvedic medicine in the Office of the Director General of Health Services. The programmes for health services included in the Fifth Five-Year Plan make provision for four ayurvedic hospitals, one in each of the four development regions. The Ayurvedic Governmental Pharmaceutical Unit works to provide inexpensive medicaments. The Ayurvedic Medical Council was created through legislation passed in 1988. Section 2.1 of this Act gives the Council's mandate as, among other things, steering the ayurvedic medical system efficiently and registering suitably qualified physicians to practice ayurvedic medicine. In Section 4, the legislation sets out highly detailed provisions for registration that classify applicant practitioners into four groups according to their qualifications and experience in ayurvedic science. By Section 5.2.2, membership in a particular group fixes the range of ayurvedic medicines that a practitioner is permitted to prescribe. Registered practitioners enjoy a monopoly over the practice of ayurvedic medicine: direct or indirect practice of ayurvedic medicine by other medical practitioners is forbidden by Section 5.1.1. Section 5 of the Act enables registered ayurvedic practitioners to issue birth and death certificates as well as certificates concerning the ayurvedic medical system and patients' physical and mental fitness. Education and training Formal education in the ayurvedic system is under the supervision of the Institute of Medicine of Tribhuvon University. The Auxiliary Ayurveda Worker training programme is run from the Department of Ayurveda under the Council for Technical Training and Vocational Education. Sri Lanka Background information Traditional medicine forms an integral part of the health care delivery system in Sri Lanka. Traditional and natural medicine founded on the concept of three humours has a long anecdotal history of effective diagnosis and treatment. Unfortunately, there is a lack of scientific research to support this history. Ayurvedic medicine is widely practiced in Sri Lanka. Statistics In Sri Lanka, 60% to 70% of the rural population relies on traditional and natural medicine for their primary health care. Regulatory situation The popularity of traditional medicine led to the promulgation of the Indigenous Medicine Ordinance in 1941. This Ordinance provided for the establishment of the Board of Indigenous Medicine, whose duties include the registration of traditional medicine practitioners, and oversight of the College of Indigenous Medicine and the Hospital of Indigenous Medicine. The establishment of the Department of Ayurveda within the Ministry of Health by Ayurveda Act 31 of 1961 constituted a landmark in the modern history of ayurveda. Ayurveda, as defined in the Act, encompasses all medical systems indigenous to Asia, including siddha and unani. The Act defined the Department's objectives as provision of establishments and services necessary for the treatment of disease and the preservation and promotion of the health of the people through ayurveda; encouraging the study of, and research into, ayurveda via scholarships and other facilities to persons employed, or proposed to be employed, in the Department and by the grant of financial aid and other assistance to institutions providing courses of study or engaging in research into ayurveda; and taking, developing, or encouraging measures for the investigation of disease and the improvement of public health through ayurveda. The Ayurveda Act 31 of 1961 also specified the duties of the Ayurvedic Medical Council, which include registration of ayurvedic practitioners, pharmacists, and nurses and regulation of their professional conduct as well as authority over the Ayurvedic College and Hospital Board and the Ayurvedic Research Committee. The Ayurvedic Physicians Professional Conduct Rules of 1971 were made by the Ayurvedic Medical Council under Section 18 of the 1961 Act and approved by the Ministry of Health. They establish a code of ethics for ayurvedic physicians. Professional misconduct includes procuring or attempting to procure an abortion or miscarriage; issuing any certificate regarding the efficacy of any ayurvedic medicine or any ayurvedic pharmaceutical product containing statements that the practitioner knows to be untrue or misleading; conviction of an offence under the Poisons, Opium and Dangerous Drugs Ordinance that was committed in the practitioner's professional capacity; selling to the public, either directly or indirectly, any ayurvedic pharmaceutical product for which the prior sanction of the Ayurvedic Formulary Committee has not been obtained; and exhibiting or displaying any medical degree or medical diploma that has not been approved by the Ayurvedic Medical Council. In early 1980, the Ministry of Indigenous Medicine was established as a separate department to be led by a senior parliamentarian - who is an ayurvedic practitioner by profession. Responsibility for the Department of Ayurveda was transferred to the Ministry. A central feature of the Ministry's operation has been the establishment of traditional medical dispensaries and hospitals that provide medical care at no cost. The Cabinet Ministry for Indigenous Medicine was established in 1994; there was previously a State Minister for Indigenous Medicine. Research and development activities are undertaken on behalf of these ministerial offices by the Department of Ayurveda and the Bandaranaike Memorial Ayurvedic Research Institute, founded June 1962. The Homeopathy Act of 1970 recognized homeopathy as a system of medicine and established the Homeopathic Council appointed by the Minister of Health in 1979. The Homeopathic Council is responsible for regulating and controlling the practice of homeopathic medicine and maintaining the Homeopathic Medical College. The 1970 Act exempted persons practicing homeopathic medicine, pharmacy, or nursing from the provisions of the Medical Ordinance and empowered the relevant Minister to make regulations for the control of professional conduct and other matters. In particular, the Council is empowered to register and recognize homeopathic medical practitioners; recognize homeopathic teaching institutes, dispensaries, and hospitals; hold examinations and award degrees in homeopathic medicine; and arrange for postgraduate study in homeopathy. The Council also maintains a register of homeopathic practitioners. With some exceptions, qualification following a course of study of not less than four years is a prerequisite for registration. Only registered practitioners may practice homeopathy for gain and use the title "Registered Homeopathic Practitioner". Such practitioners are also entitled to issue certificates or other documents required to be issued by medical practitioners; hold posts as medical officers in public medical institutions; and sign birth or death certificates, medical certificates, and certificates of physical fitness. Education and training A World Health Organization/United Nations Development Programme project for the development of traditional medicine in Sri Lanka (SRL/84/020) was implemented in the 1980s. Phase I began in October 1985 and ended in May 1988. Phase II (SRL/87/029) began in 1989. The importance of human resource development in the traditional and natural medicine sector was highlighted in this project. The project enhanced the teaching capability of eight instructors of traditional medical practice and the professional capability of 1217 general practitioners of traditional medicine to provide advice at the community level on the preventive and promotive aspects of primary health care and treating common ailments. The same project provided incentives to establish the National Institute of Traditional Medicine, which carries out educational and training programmes for traditional and ayurvedic practitioners, school children, and the general public. The Institute does not offer opportunities for advanced training or postgraduate education, so in 1993 the Department of Ayurveda began to provide alternative resources for Ayurvedic Medical Officers to obtain postgraduate qualifications through the Institute of Indigenous Medicine at the University of Colombo, Rajagiriya. Thailand Background information Thai traditional medicine draws from Indian and Chinese systems of traditional medicine. It encompasses a holistic philosophy and is based principally on plants, including the use of herbal saunas, herbal medicines, herbal steam baths, and hot compresses; traditional massage; acupressure; and reflexology. Practitioners of traditional medicine represent an important resource for the Thai health care system. Traditional Thai medicine is also practiced in Cambodia, Lao, and Myanmar. Statistics In 1998, Thailand imported more than 35% of its allopathic medicines and about 30% of its traditional medicines. Regulatory situation Official policy towards traditional medicine in Thailand has a well-recorded history: 1182-1186: 102 hospitals were established, and at least 30 kinds of herbs were used in treatments. 1504: traditional medicine formularies received official endorsement. 1767: Thai traditional medicine and allopathic medicine were separated for the first time since the introduction of allopathic medicine. 1782-1809: herbal medicine formularies were inscribed on the wall of the temple Wat Potharam. 1824-1851: protocols for diagnosis and treatment were inscribed on the wall of the temple. Allopathic medicine was reintroduced by missionaries who used quinine to treat malaria. 1888: the Siriraj Hospital, which combined both allopathic and traditional medicine, was established. 1913: Thai traditional medicine and allopathic medicine were separated for the second time by the discontinuation of formal education in traditional medicine. 1929: a law classifying medical practitioners increased the separation between traditional and allopathic medicine: "Traditional medicine practitioners were defined as those who practice medicine based on their observations and experiences that were passed on by word and in traditional textbooks but were not based on scientific grounds". 1941: the production and sale of 10 traditional medicine formulas by the Government dispensary were stopped. In the last few decades, particularly following the Alma-Ata Declaration and a World Health Organization conference on traditional medicine, Thai traditional medicine has received renewed interest. The National Institute of Thai Traditional Medicine was established on 24 March 1993 as a division of the Department of Medical Services. The Institute is charged with facilitating the integration of Thai traditional medicine into the public health services. In 1987, an amendment to a royal decree enabled the Ministry of Public Health to integrate ayurvedic doctors into the medical work force of both State-run hospitals and private clinics. Ayurvedic doctors and Thai traditional practitioners are allowed to use some basic allopathic medical tools in their practice, such as the thermometer and sphygmomanometer, but are not allowed to prescribe allopathic medicines. The Government is currently working on developing the use of herbal medicines. The goals of the Eighth Public Health Development Plan 1997-2001 are to increase the use of allopathic medicine, increase the use of traditional medicine, curb the use of extravagant medical and pharmaceutical technology, and promote traditional treatments within the national public health care system. Included in this policy is the development of research into medicinal herbs, training of traditional medicine practitioners, and use of medicinal herbs and traditional medicine practitioners in an official capacity. Specific objectives are as follows: support and promote Thai traditional medicine in the national health care system as a means to improve health through self-reliance at the personal, family, community, and national levels; upgrade the standard of Thai traditional medicine for acceptance and integration into the national health system; support the basis of Thai traditional medicine by developing a comprehensive system and strategy for its official use, including academic development, integration of administrative services into the national health care system, production of medicinal herbs and Thai traditional medicines, dissemination of information, and promotion of the use of Thai traditional medicine; support organizations and agencies that deal with Thai traditional medicine in both the Government and private sectors; increase the use of medicinal herbs by supporting the production of plants, developing the pharmacopoeia, and collaborating with traditional medicine practitioners. By 1999, Thai traditional medicine was integrated into the facilities of 1120 health centres. Most of these health centres are health stations at the sub-district level, which represent more than 75% of health facilities. All types of traditional medicine practitioners are registered with the Medical Registration of the Ministry of Public Health. Education and training The first school for Thai traditional medicine was established in 1957 at Wat Po. Since 1962, graduates from such schools have been licensed to practice general traditional medicine. In December 1997, the Ministry of Health's National Institute of Thai Traditional Medicine established the Thai Traditional Medicine Training Centre, where programmes in pharmacy, Thai traditional healing, Thai traditional massage, and reflexology are offered. For people who do not have the opportunity to attend a university, the National Institute of Thai Traditional Medicine, in collaboration with the Department of Non-Formal Education, offers courses in Thai traditional medicine at non-formal education centres at the primary and secondary school levels. An ayurved-vidyalaya college was established in 1982 by the Foundation for the Promotion of Thai Traditional Medicine, a private organization supported by the Government. During its three-year programme, students study not only aspects of Thai traditional medicine, but also basic science and allopathic diagnostics. This later training is intended to facilitate their ability to communicate with other health care professionals. Students of allopathic medicine receive no training in traditional medicine. Act 7 of 30 December 1966, however, enables allopathic physicians, pharmacists, nurses, and midwives who want to practice Thai traditional medicine to do so. To be eligible to practice traditional medicine, allopathic practitioners are required to follow a three-year course of training and instruction with a registered and licensed traditional medicine practitioner and to pass an examination set by the Commission for the Control of the Practice of the Art of Healing. AustraliaBackground information Traditional Chinese medicine has been practiced in Australia since the influx of Chinese migrants to the Australian gold fields in the 19th century. Its popularity is growing, as reflected by the proliferation of traditional Chinese medicine practitioners, training courses, and professional associations during the last decade. Statistics Approximately one billion Australian dollars are spent on complementary/alternative medicine each year. A 1996 study reported that 48% of the population has used complementary/alternative medicine at least once, There are approximately 2500 chiropractors practicing in Australia. In December 1995, the Victorian Department of Human Services commissioned a study on the practice of traditional Chinese medicine. The study found that traditional Chinese medicine accounts for an increasing percentage of total health care services. There are at least 2.8 million consultations each year, representing an annual turnover of over 84 million Australian dollars. In 1995, over 1500 primary practitioners reported their principal health occupation as traditional Chinese medicine. This number was expected to almost double by the year 2000, with the graduation of over 1100 students from qualifying programmes for traditional Chinese medicine. There are 23 professional associations representing different segments of traditional Chinese medicine. Traditional Chinese medicine is provided to patients of all ages, including infants. Two out of three patients are female, 50% have a tertiary education, and over 80% have English as their first language. Although 44% of cases are rheumatological or neurological in origin, traditional Chinese medicine treats a broad range of complaints. Over 75% of patients are treated for a recurrent problem of at least three months' duration. Regulatory situation Seven Australian territories - Capital Territory, Northern Territory, Territory of Christmas Island, Territory of the Cogos (Keeling) Islands, Norfolk Island, South Australia, and Western Australia - grant allopathic physicians an exclusive monopoly on medical care by prohibiting the practice of medicine by unregistered or unqualified persons. No provisions directly govern the practice of traditional Chinese medicine, although practitioners are regulated in part by various state and/or federal regulations and guidelines. In New South Wales, Queensland, Tasmania, and Victoria, there is general freedom to practice medicine or surgery, but it is tempered by a number of restrictions. For instance, unqualified persons may not recover fees or treat venereal diseases. In addition, New South Wales makes it an offence to treat cancer (a similar prohibition exists in Victoria), tuberculosis, poliomyelitis, epilepsy, diabetes, and other specific diseases. In Australia, there is a long history of efforts by associations of chiropractors and osteopaths to obtain statutory recognition for their professions. This is reflected in the laws regulating chiropractic and osteopathy. In certain Australian states, chiropractors are specifically exempted from the allopathic physicians' monopoly to practice medicine. For instance, the Medical Act 1894-1968 of Western Australia prohibits persons other than allopathic medical practitioners from practicing medicine or surgery, "provided that this paragraph shall not apply to a person practicing as a... chiropractor who gives... chiropractic advice or service". Chiropractic and osteopathy are the subject of specific legislation in South Australia, Capital Territory, Victoria, and New South Wales. In Victoria, chiropractors and osteopaths must hold an approved degree or diploma in order to be registered by the territorial board. Although registration is not compulsory, only registered persons and allopathic medical practitioners are permitted to recover fees or charge for their professional services. In 1974, the Australian Parliament set up the Committee of Inquiry into Chiropractic, Osteopathy, Homeopathy, and Naturopathy. The Committee published an extensive report in 1977. In New South Wales, the re-enactment of the Medical Practitioners Act 1938 as the Medical Practice Act 1992 resulted in several amendments to the 1938 text. The growing acceptance of traditional medicine was at the root of changes to a number of prohibitions on the cures and treatments offered of by non-allopathic practitioners. In 1998, the Therapeutic Goods Act was established with the objective of providing a national framework for the regulation of therapeutic goods in Australia, particularly to ensure their quality, safety, efficacy, and timely availability. Most products claiming therapeutic benefit must be registered with the Australian Register of Therapeutic Goods before being sold in Australia. The Therapeutic Goods Administration is responsible for administering the Act. In 2000, the Therapeutic Goods Administration developed the Guidelines for Levels and Kinds of Evidence to Support Claims for Therapeutic Goods. The Complementary Medicines Evaluation Committee recognizes two types of evidence to support claims on therapeutic goods: scientific evidence and traditional use. The extent of required evidence depends on the claims made for the product. For the Committee, traditional use refers to written or orally recorded evidence that a substance has been used for three or more generations for specific health-related or medicinal purposes. Some exceptions to this requirement are made for homeopathy. The regulations include clauses for the use of medicines as one component of a multifaceted treatment, the use of treatments that combine a number of traditions, and the use of treatments that are recent modifications of traditional therapies. Traditional therapies are considered to include traditional Chinese medicine, traditional ayurvedic medicine, traditional European herbal medicine, traditional homeopathic medicine, aromatherapy, and other traditional medicines. Education and training The number of traditional Chinese medicine programmes offered by universities and private colleges is growing. Programmes, some of which lead to diplomas, range from 50 hours to over 300 hours. There are also traditional Chinese medicine programmes available for qualified allopathic practitioners. These range from 50 to 250 hours. The Royal Melbourne Institute of Technology, the University of Technology at Sydney, and the Victoria University of Technology have degree programmes in traditional Chinese medicine. These programmes are offered within the schools of Applied Science or Health Science. Acupuncture was first offered as a formal education programme in Sydney in 1969 with the founding of the privately owned school, Acupuncture Colleges, Australia. This programme subsequently formed the basis of the Diploma of Applied Science (Acupuncture) accredited by the New South Wales Higher Education Board in 1987 and the four-year Bachelor of Applied Science (Acupuncture) accredited by the New South Wales Higher Education Unit in 1992. Following the same programme, the Victoria University of Technology began offering a Bachelor of Health Science (Acupuncture) in 1992. The Royal Melbourne Institute of Technology, the University of Technology at Sydney, and the Victoria University of Technology also offer Master's degrees and graduate diplomas in acupuncture. With growing acceptance of acupuncture by the public and by allopathic practitioners, graduates are able to play a larger part in the public-health sector of the community, working in allopathic hospitals, community health centres, and in areas of specialized health services. The Bachelor of Health Sciences in Acupuncture prepares graduates for this role in general health care. Training in homeopathy has been from the level of the FHom of London. There are two chiropractic colleges recognized by the World Federation of Chiropractic. Naturopathy, European herbalism, homeopathy, and nutrition are taught at the Southern Cross University in New South Wales. Cambodia Background information The Ministry of Health has established the Centre for Traditional Medicine, which is limited to basic work in a few botanical medicines and has little input into pharmaceutical issues. Much of the knowledge available on botanical specimens is based on their use in neighbouring countries. Shops throughout the country sell traditional medicines from around the world. Regulatory situation A law on the organization of traditional therapeutics and traditional pharmacopoeia was enacted in 1964. This law defines traditional therapeutics as treatment and care using traditional methods, excluding surgical and obstetrical procedures, dental surgery, and electrical, chemical, or bacteriological methods of therapy and analysis. To practice, traditional medicine practitioners must be at least 25 years old, have completed a three-year apprenticeship, and possess a licence issued by the Minister of Health. Traditional medicine may not be practiced on the premises of allopathic health care establishments. The National Drug Policy, developed with technical collaboration from the World Health Organization, is intended to increase the importance of traditional medicine and encourage traditional medical practice as a complement to allopathic medicine. The Policy states that fundamental and applied research on traditional remedies will be pursued and diseases that can be treated effectively with traditional medicines will be identified. The Law on the Management of Pharmaceuticals was adopted on 9 May 1996, replacing relevant existing legislation. Following the adoption of this law by the National Assembly, a draft decree pertaining to the manufacture, importation, exportation, and supply of traditional medicines was submitted by the Ministry of Health to the Council of Ministers. Education and training There is no officially recognized curriculum incorporating the use of traditional medicines. China Background information Over the last century, traditional Chinese medicine has co-existed with allopathic medicine. (See the Introduction for a description of traditional Chinese medicine.) Statistics There are 350 000 staff working at more than 2500 hospitals of traditional medicine in China. In addition, 95% of general hospitals have units for traditional medicine and 50% of rural doctors are able to provide both traditional and allopathic medicine. In 1949, there were 276 000 practitioners of traditional medicine in China. The figure increased to 393 000 in 1965 and 525 000 in 1995. Among these traditional medicine practitioners are 257 000 traditional medical doctors who graduated from traditional medical universities with a knowledge of both traditional and allopathic medicine, 10 000 allopathic medical doctors retrained in traditional medicine, 83 000 pharmacists who are specialists in herbal medicines and who have graduated from traditional medicine universities, 72 000 assistant traditional medicine doctors, and 55 000 assistant herbal pharmacists trained in traditional medicine secondary schools. In China, traditional medicines account for 30% to 50% of total consumption. There are 800 manufacturers of herbal products, with a total annual output worth US$ 1800 million. There are over 600 manufacturing bases and 13 000 central farms specialized in the production of materials for traditional medicines. There are 340 000 farmers who cultivate medicinal plants. The total planting area for medicinal herbs is 348 000 acres. There are 170 research institutions across the country with perhaps the most prestigious being the Academy of Traditional Medicine in Beijing. Regulatory situation In China, the integration of traditional medicine into the national health care system and the integrated training of health practitioners are both officially promoted. The Government of China has reinforced its commitment to the integration of traditional and allopathic medicine on a number of occasions. Adopted in 1982, Article 21 of the Constitution of the People's Republic of China promotes both allopathic and traditional Chinese medicine. The Bureau of Traditional Medicine was set up as part of the Central Health Administration in 1984. In 1986, the State Administration of Traditional Chinese Medicine was established. In 1988, the Central Secretariat of the Chinese Communist Party stated the following : Traditional Chinese medicine and Western medicine should be given equal importance. On the one hand, our unique successes in public health and hygiene can be attributed to traditional Chinese medicine. Hence, traditional medicine should not be abandoned. Instead, it is to be well preserved and developed further. On the other hand, traditional Chinese medicine must make full active use of advanced science and technology to ensure its further development. The policy of integration of traditional Chinese medicine and Western medicine should persist. Both systems should cooperate with each other, learning from each other's merit to make up their own shortcomings. Both should strive for the full play of their own predominance. Again in 1997, the Government reiterated that one of its guiding principles in the field of health care is equality in policies related to traditional and allopathic medicine. The integrated nature of the Chinese medical system is underscored by the fact that traditional and allopathic medicine are practiced alongside each other at every level of the health care system : Western-style and traditional Chinese doctors work together at the [township] centre according to the policy of integrating the two systems of medicine. Patients may see either type of doctor. The 1985 Management Stipulations for Physicians and Assistants of Traditional Chinese Medicine requires traditional medicine practitioners to learn and make use of innovations in allopathic medical technology. The criteria for qualification as a traditional Chinese medical physician or assistant are also set out in the Management Stipulations. Qualification as a traditional medical physician can be achieved through a number of routes, typically combining post-secondary academic studies and one to two years of practicing, teaching, or researching traditional medicine. By Article 5 of the Stipulations, the academic component can be undertaken at a university or college devoted to traditional medicine, within a department of traditional medicine at a school of allopathic medicine, or by completion of a State-approved diploma or certificate. Under Article 7, a similar, but less demanding, combination of academic studies and one year of practical involvement in traditional medicine is typically needed for qualification as a traditional medicine assistant. Under a 1985 circular issued by the Chinese Ministry of Public Health's Department of Traditional Chinese Medicine, persons who studied under the former apprenticeship system - in place before the 1960s when formal examinations were not required - may take the formal examinations leading to qualification as a traditional medical physician or assistant. The examinations follow the completion of courses administered by private institutions with Government recognition. The courses may be taken as correspondence courses, night classes, or at workers' universities. Candidates who fail these tests, or persons who decide not to take them, must pass a unified examination offered by the Health Department before their qualifications to practice as traditional Chinese medicine assistants or physicians will be recognized. For assistants, the examination is based on information taught at the secondary school level. There is a more demanding unified exam based on a three-year post-secondary education for those in the apprenticeship system who wish to convert their existing status to the level of pharmacist or physician of traditional medicine. In addition to physicians and assistants, a third tier of health professional exists in traditional Chinese medicine: individuals examined and officially recognized as proficient in a particular branch of traditional medicine. However, the absence of a uniform method of assessment for these practitioners has led to some unqualified individuals being able to obtain official recognition, according to a 1989 circular issued by the State Administration of Traditional Chinese Medicine. Motivated by a desire to protect the integrity of traditional medicine and to safeguard patients' interests, the response of the State Administration has been to introduce annual testing of practitioners in this third tier. Tests are administered by a group of senior traditional medicine practitioners. The annual testing involves both a theoretical component and a clinical examination. Successful completion of the annual testing leads to a certificate, which details the candidate's specific skills and the range of diseases that can be treated. Failing the annual test results in cancellation of the candidate's certificate and right to practice, pending re-examination. Released in 1988, a series of Provisional Management Stipulations regulates private health care offered by traditional Chinese medical physicians within the State-sponsored socialist health-care system. Article 4 of the Stipulations endorses an official policy favouring preventive care and instructs private-sector physicians to undertake primary health care as designated by the local health authority. The right to practice traditional Chinese medicine privately is restricted to those who have passed the unified examination and technical assessment or who have met the Ministry of Public Health's requirements for regulation as a health professional and have practiced medicine in State-owned or collective medical institutions for three years. A licence must be obtained to open a private practice and the licence holder "shall strictly observe the approved practice, place, range of service and business limits to the practice". Under 1989 regulations, traditional Chinese medical assistants are only permitted to open their own practice in rural towns, which include county-level townships and villages. In small towns and cities, they may only serve in private physicians' clinics. Under Article 2, persons with a certified proficiency in a particular branch of traditional Chinese medicine, subject to annual retesting, are only permitted to open a practice at the local county or district level. Prompted by a desire to protect patients from abuse and deception, regulations concerning medical qigong were enacted in China in 1989. Qigong is described in the preamble to the regulations as "a self-cultivation approach to keep fit through dredging meridians, adjusting the mind, and balancing yin, yang, qi, and blood to get rid of diseases". The regulations provide that practitioners of qigong must obtain approval from the local health authority to teach qigong in public places. By Article 1, teaching must be based on scientific approaches. Under Article 2, qigong practitioners working in medical institutions must possess medical qigong skills and be qualified as traditional Chinese medical physicians or assistants under the Management Stipulations described above. According to Article 4, those who intend to treat patients with emitted qi (energy) must have their methodology and the claimed curative effect approved by the city health authority. If the curative effect is shown to be tenable, based on a study of 30 cases of the same type of illness by a designated medical institution, a licence will be issued. Article 6 prohibits non-medical institutions, including the army, from rendering medical treatment. Education and training Traditional Chinese medicine used to be taught through apprenticeships. Now, there are 57 secondary schools teaching traditional Chinese medicine, with an enrolment of 29 000 students. These schools train medical personnel for rural and basic units. There are also 28 universities and colleges of Chinese traditional medicine and pharmacology, with a total enrolment of 46 000 students, including 2800 undergraduates. Together, these universities and colleges provide 14 professional undergraduate programmes along with programmes for Master's and Doctorate degrees. A chiropractic college is presently being established. To qualify as a physician of traditional Chinese medicine, a candidate must typically complete five years of study. Admissions standards to colleges or universities generally require completion of middle school (seven grades), but there is some flexibility: in some colleges, a primary school education (four grades) is sufficient. As mentioned above, medical education is integrated in China. Although there are more allopathic medical schools in China than traditional medical schools, every allopathic medical school contains a department of traditional medicine and every traditional medical school contains a department of allopathic medicine. Between 10% and 20% of the teaching in allopathic medical schools is allocated to traditional medicine. A somewhat greater emphasis is placed on allopathic medicine in colleges of traditional medicine. The Division of Traditional Medicine in the Ministry of Public Health suggests orienting 30% of teaching in these schools to allopathic medicine. Insurance coverage Health insurance covers both allopathic and traditional medicine. Hong Kong Special Administrative Region of China Background information Although traditional Chinese medicine is widely used, allopathic medicine has been the focus of the health care system in the Hong Kong Special Administrative Region of China (Hong Kong SAR). Statistics In a general household survey conducted by the Census and Statistics Department of the Government of Hong Kong SAR in 1996, it was reported that traditional Chinese medicine practitioners provide 10.5% of medical consultations. An earlier survey showed that up to 60% of Hong Kong SAR's population had used traditional Chinese medicine either for treatment of disease or maintenance of health. According to the 1996 survey, there are 6890 traditional Chinese medicine practitioners in Hong Kong SAR, of whom 66% are full-time practitioners. There are 37 chiropractors practicing in Hong Kong SAR. There are approximately 2000 types of Chinese medicinal herbs for sale in Hong Kong SAR. About 3300 brands of proprietary traditional Chinese medicines are available, of which 500 brands are manufactured locally. Information provided by the Government's Census and Statistics Department showed that in 1998, 500 trading organizations were involved in the import/export, wholesale distribution, and retail sales of traditional Chinese medicines. Regulatory situation Until recently, there was no specific legal control or recognition of traditional Chinese medicine in Hong Kong SAR. Regulations fell under the Public Health and Municipal Services Ordinance, which controls the sale of drugs unfit for human consumption, and the Pharmacy and Poisons Ordinance, which prohibits the adulteration of traditional Chinese medicines with allopathic drugs. The Basic Law of Hong Kong SAR provides that the Government shall formulate policies to develop allopathic and traditional Chinese medicine and to improve medical and health services. In 1989, to promote the proper use and good practice of traditional Chinese medicine, the Secretary for Health and Welfare set up the Working Party on Chinese Medicine. The Party was mandated to review the use and practice of traditional Chinese medicine in Hong Kong SAR. In 1995, the Secretary for Health and Welfare appointed the Preparatory Committee on Chinese Medicine. In March 1997 and March 1999, the Committee submitted reports on the regulation and development of traditional Chinese medicine in Hong Kong SAR. In his 1997 policy address, the Chief Executive of Hong Kong SAR announced that for the protection of public health, a statutory framework providing legal recognition to traditional Chinese medicine and appropriate regulation of its practice, use, and trade would be established. The Chinese Medicine Bill was drawn up in 1998 and was introduced in the Legislative Council in February 1999. The Legislative Council passed the Chinese Medicine Ordinance, which is based on self-regulation, in July 1999. The Chinese Medicine Council - a regulatory body comprised of traditional Chinese medicine providers, trade professionals, academics, lay persons, and Government officials - is responsible for implementing the regulatory measures. The Department of Health will provide administrative support and enforce the regulations. A registration system for practitioners of traditional Chinese medicine will be created in 2000. Likewise, a registration and licensing system to regulate the manufacture and trade of traditional Chinese medicines will be set up in phases in 2000. The safety, efficacy, and quality of proprietary traditional Chinese medicines will be assessed before they are registered. The dispensation, storage, and labelling of traditional Chinese medicines will also be regulated. Education and training Educational institutions offer refresher courses for providers and dispensers of traditional Chinese medicine to upgrade their knowledge and skills. Undergraduate courses in traditional Chinese medicine practice and pharmacy have recently been introduced at local universities. Fiji Background information In Fiji, both the traditional medicine of the indigenous population and that of Indo-Fijians who brought with them their own medicinal plants and medicinal plant knowledge are practiced. Rural Fijians are the primary users of traditional medicine, though its popularity in urban areas is increasing. Traditional medicine practitioners are often consulted before allopathic medical providers. Many allopathic providers also practice traditional medicine. Statistics Founded in 1993, the Women's Association for Natural Medicinal Therapy, a non-governmental organization promoting traditional medicine, has begun a survey of over 2000 practicing providers of traditional medicine in 13 of the 14 provinces in Fiji. In two of these provinces, the surveys have been completed. These surveys and conversations with local people indicate great faith in allopathic medicine even though villagers may find traditional medicine to be more effective and cost efficient. The surveys further suggest that many people, including practitioners of allopathic medicine, use traditional medicine but hesitate to call it such because traditional medicine is associated with witchcraft. Between 60% and 80% of the population use traditional medicine. According to Fiji's Biodiversity Strategy and Action Plan, the average Fijian household uses US$ 200 worth of medicinal plants annually. If these traditional medicines were replaced by allopathic medicines, this would amount to a total of US$ 75 million annually. Regulatory situation The Medical and Dental Practitioners Act of 1971 empowers the Minister of Health to issue regulations governing chiropractic, acupuncture, and chiropody. Such regulations were issued in 1976. In 2000, the Cabinet of the Government of Fiji instructed the Minister of Health to develop a national policy on traditional medicine. In Fiji, the lawful practice of acupuncture is subject to registration by the Permanent Secretary for Health. Applicants for registration must prove either that they are licensed as acupuncturists in the United Kingdom, Canada, New Zealand, or any of the states of the United States or that they possess a certificate from the health authorities of China, the Province of Taiwan, Hong Kong Special Administrative Region of China, Singapore, or the Philippines to the effect that they have practiced acupuncture in any of those locations for a period of not less than three years. Education and training Most students of traditional medicine receive their training through oral instruction from established practitioners. No great importance is attached to formal education in either traditional medicine or complementary/alternative medicine at universities or medical schools, although some training is done through primary health care. The Government and medical associations review the qualifications of practitioners, but there is no regulatory measure for recognizing the qualifications. Licensing legislation regulates educational standards for chiropractic. Insurance coverage Practiced outside of the national health care system, traditional medicine is not covered by insurance. Japan Background information In Japan, traditional medicines are classified into two broad groups: kampo medicine and traditional medicine indigenous to Japan. Traditional Chinese medicine, introduced to Japan between the 3rd and 8th centuries, was modified to meet local needs and became known as kampo medicine. For about 10 centuries, from the time of its introduction until it was superseded by allopathic medicine in 1875, kampo medicine was the mainstream Japanese medicine. Following the Meiji Restoration in 1886, the newly established Japanese Government endorsed German allopathic medicine over kampo medicine. After 1885, new doctors were trained only in allopathic medicine, with the result that kampo medicine almost disappeared. By 1920, fewer than 100 doctors were practicing kampo medicine, but after the Second World War, there was a resurgence of public interest in kampo medicine and today it is practiced extensively. Acupuncture, moxibustion, Japanese traditional massage/finger pressure, and judo-therapy are also widely practiced in Japan. Statistics The 1998 production value of kampo medicines in Japan was 97 708 million yen, or 1.7% of total medicine production. Of this, prescription kampo medicines accounted for 83.2%; proprietary medicines, for 15.9%; and household distribution, 0.9%. A nationwide survey conducted in October 2000 found that 72% of registered allopathic doctors currently use kampo medicines in their clinical services. In addition to the 268 611 registered allopathic medical doctors, the number of registered medical practitioners at the end of 1998 included 69 236 acupuncturists, 67 746 moxacauterists, 94 655 massage practitioners, and 29 087 judotherapists. There were also 125 953 registered pharmacists at the end of 1998. Regulatory situation Under the Medical Practitioners Law 201 of 1948, only allopathic physicians may practice medicine, including kampo medicine. However, there are no restrictions on the types of medical procedures allopathic physicians may use in their practice. According to the Pharmacists Law 146 of 1960, a person must be qualified as a pharmacist in order to engage in services related to traditional medicines. The Subcommittee on Kampo Medicines and Products of Animal and Plant Origin of the Central Pharmaceutical Affairs Council has developed regulations governing kampo medicines as proprietary medicines. These regulations also apply, with necessary modifications, to prescription medicines. The Pharmaceutical Affairs Law in Japan does not distinguish between traditional and allopathic medicines; both types of preparations are subject to the same regulations. Kampo medicines are products prepared for use in accordance with kampo medicine formulae, which, according to the principles set out by the Central Pharmaceutical Affairs Council, are formulae described in established books on kampo medicine currently and frequently used in Japan. The formulae include standard formulae, added or subtracted formulae, and combined formulae. They include formulae containing vitamins B1, B2, and/or C for nutritional supplementation. The extracts prepared from kampo medicine formulae should be limited to those that have previously been used as decoctions. Any ingredient, efficacy, or indication that is not appropriate for proprietary medicines is not accepted. Standards for medicinal plant materials are included in Japanese Pharmacopoeia, the Japanese Herbal Medicine Codex, and Japanese Standards for Herbal Medicines. Japanese Pharmacopoeia First established in 1886 by the Minister of Health and Welfare, and in accordance with Article 41 of the Pharmaceutical Affairs Law 145 of 1960, the Japanese Pharmacopoeia is an official standard regulating the properties and qualities of medicines. Some herbal medicines are included in the Japanese Pharmacopoeia. The 14th edition is expected in 2001 (239, 241). Japanese Herbal Medicine Codex Standards have been established separately for herbal medicines not included in the Japanese Pharmacopoeia. Herbal medicines in frequent use, which are not in the Japanese Pharmacopoeia, are examined according to specific criteria and made official by inclusion in the Japanese Herbal Medicine Codex. Japanese Standards for Herbal Medicines Published in 1993, Japanese Standards for Herbal Medicines contains 248 articles: 165 from the Japanese Pharmacopoeia (XII) and 83 from the Japanese Herbal Medicine Codex. When using substances listed in Japanese Standards for Herbal Medicines as materials or ingredients of pharmaceutical products to be manufactured in, or imported into, Japan, manufacturers and importers should comply with the provisions in this book. When the Pharmaceutical Affairs Law was amended in April 1993, the Regulations for Manufacturing Control and Quality Control of Drugs were changed from manufacturing requirements for drug companies to a prerequisite for licences to manufacture drugs. The Regulations, including new validation requirements, came into effect in April 1996. Moreover, good manufacturing practices for investigational products were adopted via a notice issued by the Director-General of the Pharmaceutical Affairs Bureau of the Ministry of Health and Welfare in April 1997. The Japan Pharmacists Education Centre issues a certificate for pharmacists specializing in kampo medicines and herbal materials in accordance with its own qualification criteria. Renewal of this certification is required every three years. In 1990, the Society of Japanese Oriental Medicine started a registration system of allopathic physicians specializing in kampo medicine. This system requires all registered specialists to attend authorized meetings of the Society and to present relevant scientific papers and medical journals at the meetings. This registration system requires registration as a specialist in kampo medicine to be renewed every five years, in accordance with the rules set out by the Society. The Practitioners of Massage, Finger Pressure, Acupuncture and Moxibustion, etc. Law 217 of 1947 stipulates in Article 1 that anyone other than an allopathic physician who wishes to practice acupuncture, moxibustion, or massage/finger pressure must pass the relevant national examination and obtain either a licence in massage/finger pressure alone or a combination licence in acupuncture, moxibustion, and massage/finger pressure from the Minister of Health and Welfare. Article 2 outlines the requirements that must be met in order to take the national exams: candidates must be eligible to enter a university according to Article 56 of the School Education Law 26 of 1947; have studied more than three years at a school recognized by the Minister of Education, Science, and Culture or at a training institution recognized by the Minister of Health and Welfare; and have obtained the knowledge and technical skill necessary to be an acupuncturist, moxacauterist, or massage practitioner, including knowledge of anatomy, physiology, pathology, and hygiene. In Article 18.2, an exception to these criteria is made for persons with visual impairment; persons with visual impairment, as defined by a Ministry of Health and Welfare ordinance, may take the exams if they are eligible to enter a high school according to Article 47 of the School Education Law 26 of 1947; have studied at a school recognized by the Minister of Education, Science, and Culture or at a training institution recognized by the Minister of Health and Welfare; and have obtained the knowledge and technical skill necessary to be an acupuncturist, moxacauterist, or massage practitioner, including at least three years of study in anatomy, physiology, pathology, and hygiene for certification as a massage practitioner only or five years of study in anatomy, physiology, pathology, and hygiene for joint certification as an acupuncturist, moxacauterist, and massage practitioner. In 1999, the Japan Society for Acupuncture and Moxibustion began a registration system for allopathic medical doctors specializing in acupuncture and moxibustion. The rules for qualification set out by the Society require registration to be renewed every five years. Judotherapists are regulated under the Judo Therapists Law 19 of 1970. By Article 3, in order to become qualified as a judotherapist, a candidate must pass the national judotherapist examination and obtain a licence from the Minister of Health and Welfare. Under Article 12, candidates must be eligible to enter a university according to Article 56 of the School Education Law 26 of 1947; have studied more than three years at a school recognized by the Minister of Education, Science, and Culture or at a training institution recognized by the Minister of Health and Welfare; and have obtained the knowledge and technical skill necessary to be a judotherapist, including knowledge of anatomy, physiology, pathology, and hygiene. Education and training As of 2000, there are 80 medical schools offering six-year allopathic medical programmes in Japan. Though there is no systematic programme exclusively teaching kampo medicine, the Toyama Medical and Pharmaceutical University offers a four-year postgraduate Doctorate programme in kampo medicine as well as the only officially recognized undergraduate medical curriculum where kampo medicine is taught alongside allopathic medicine. A 1998 national survey reported that 18 medical schools have either an elective or required class on complementary/alternative medicine, mainly kampo medicine and/or acupuncture. Beginning in 1998, each year the Japan Society for Oriental Medicine offers a summer programme in kampo medicine for 60 undergraduate students of allopathic medical schools. Forty-six colleges and universities across Japan provide four-year undergraduate programmes in pharmaceutical sciences with traditional medicines as part of the curriculum, with a new enrolment of 7720 students in these programmes each year. The Research Institute for Natural Medicines, established in 1963 as part of the national Toyama Medical and Pharmaceutical University, is a unique national research institute in the fields of kampo medicine and pharmaceutical sciences. It provides undergraduate, two-year Master's, and four-year Doctorate programmes. In April 2000, the Japan Pharmacists Education Centre launched a special training course on kampo medicine and herbal materials in collaboration with the Japanese Society of Pharmacognosy. Both acupuncturists and moxacauterists must complete a minimum three-year training programme. Twenty-two schools and training institutions offer three-year programmes in acupuncture and moxibustion. One university offers a four-year programme. Eighty-seven schools and training institutions offer joint programmes in acupuncture, moxibustion, and Japanese traditional massage/finger pressure. Seven of these are five-year programmes and 22 are three-year programmes. There are 91 schools and training institutions offering a three-year programme in only Japanese traditional massage/finger pressure. Twenty-five schools and training institutions offer three-year programmes in judotherapy. For visually impaired persons, 31 schools and training institutions offer three-year programmes in Japanese traditional massage/finger pressure alone and seven schools and training institutions offer five-year joint programmes in acupuncture, moxibustion, and Japanese traditional massage/finger pressure. Insurance coverage As of April 2000, the National Health Insurance Reimbursement List included 147 prescription kampo formulae and 192 herbal materials used in prescription kampo formulae. Acupuncture, moxibustion, Japanese traditional massage, and judotherapy are also covered by national health insurance. Kiribati Background information Kiribati traditional medicine includes bonesetting, herbal medicine, massage, traditional birth attendance, and word and wind medicine. Allopathic medicine was introduced to Kiribati during the colonial period in the early 1890s. In the 1940s, traditional medicine was outlawed on the grounds that there was no scientific evidence as to its efficacy. Despite the prohibition, traditional medicine continued to be practiced. Regulatory situation The Medical and Dental Practitioners (Amended) Act of 1981 authorizes some aspects of traditional medicine in Section 37, which states, "Nothing in the Medical and Dental Practitioners Ordinance shall affect the right of anyone of Kiribati to practice in a responsible manner Kiribati traditional healing by means of herbal therapy, bonesetting and massage, and to demand and recover reasonable charges in respect of such practice." Lao People's Democratic Republic Background information The Lao phrase for traditional medicine is ya phurn meung, which translated literally means "medicine from the foundation of the country". Lao traditional medicine dates back to at least the 12th century, when the country was united. With unification, traditional Buddhist and Indian medical systems were integrated into the society, quickly influencing traditional Laotian medicine. Allopathic medicine came to the Lao People's Democratic Republic in 1893 when the French invaded the country. Lao traditional medicine remains an important element in the prevention and treatment of disease. Statistics Thirty to forty per cent of both allopathic and traditional medicines are produced domestically. There are seven factories producing allopathic medicines in Laos. Three factories in the Vientiane municipality produce traditional medicines. There are traditional medicine hospitals at all levels. Regulatory situation The Lao People's Democratic Republic has a national programme on traditional medicine with a five-year work plan. The third in a series of national seminars on traditional medicine was held in February 1993 to review the use of traditional medicine in primary health care at the provincial and district levels. A draft national policy on traditional medicine was discussed at a national workshop on traditional medicine held in December 1995 and thereafter submitted to the Ministry of Health. Education and training In 1996, training courses were held in Sayaboury and Champasack provinces on the use of traditional medicine in communities. The courses were intended to promote the rational use of traditional medicine. Malaysia Background information Traditional medical practices brought by Indian and Chinese traders and migrants complemented, but did not replace, the indigenous medical system in Malaysia. The introduction of Islam by Indians and Arabs, on the other hand, led to major changes in the traditional medical system. Among them was treatment by recitation of verses from the Koran. The diversity in medical systems in Malaysia reflects the diverse population of Malay, Chinese, Indian, and indigenous heritage. In addition to allopathic medicine, the major systems of medicine practiced in Malaysia include ayurveda, siddha, unani, traditional Chinese medicine, and traditional systems of medicine, such as that provided by traditional medicine practitioners, spiritualists, bonesetters, traditional birth attendants, and others who use home remedies. Medical options also include homeopathy, naturopathy, reflexology, aromatherapy, and chiropractic. Traditional Malay medical practices can be traced mainly to Indonesia. These medical practices are especially popular among Malay in rural areas and rely on practical experience and observation handed down orally and in writing from generation to generation. Medical treatment may include reciting incantations over water and giving it to the patient to drink, administering herbs internally or externally, giving amulets, and prescribing special baths, with lime flowers or holy water, for example. More than one of these options may be used and more than one traditional medicine practitioner may be called upon. Chinese traditional medicine is believed to have been introduced into Malaysia by Chinese migrants working in the tin mines. These migrants brought herbal medicines as well as other forms of treatment, including acupuncture. Chinese medical practitioners hold high status and are known as sinseh. Today, traditional Chinese medicine is also used in urban centres. Siddha, ayurveda, and unani - all traditional Indian medical systems - are practiced in Malaysia. The majority of medicines used in these systems are of vegetable, mineral, and animal origin. Herbal preparations and herbal products are imported from India as medical tablets, oils, ointments, metals, mineral concoctions, and herbal powders. Statistics The 1996 National Health & Morbidity Survey II found that 2.3% of the people sampled consulted a traditional or complementary/alternative medical practitioner and 3.8% used both allopathic medicine and traditional Chinese medicine. Although no statistics are available, traditional medicine is mainly practiced by providers of traditional medicine, whereas allopathic medical providers practice complementary/alternative medicine as well as allopathic medicine. In Malaysia, sales of traditional and complementary/alternative medicines are estimated to be 1000 million Malaysian ringgit annually, compared with a market of 900 million Malaysian ringgit for allopathic pharmaceuticals. There are 12 chiropractors practicing in Malaysia. Regulatory situation The official health care system adopted and implemented by the Malaysian Government is an allopathic one. Subsection 1 of Section 34 of the Medical Act of 1971 contains the following broad general exemption : Subject to the provisions of subsection 2 and regulations made under this Act, nothing in this Act shall be deemed to affect the right of any person, not being a person taking or using any name, title, addition or description calculated to induce any person to believe that he is qualified to practice medicine or surgery according to modern scientific methods, to practice systems of therapeutics or surgery according to purely Malay, Chinese, Indian or other native methods, and to demand and recover reasonable charges in respect of such practice. Subsection 2 limits the treatment of eye diseases to practitioners of allopathic medicine. Likewise, the Poisons Ordinance of 1952 restricts the use of certain substances to practitioners of allopathic medicine. The Midwives (Registration) Regulations of 1971 legalize the practice of eligible traditional birth attendants. Subsection 2 of Section 11 of the Regulations permits midwifery to be practiced by the following: Any person untrained in the practice of midwifery, who within four years of the commencement of [the Midwives Act of 1966] satisfies the Registrar that such person has during a period of two years immediately preceding application for registration... attended to women during childbirth. There are no other laws affecting traditional medical practice in Malaysia; however, there are a number of laws that regulate the production and sale of traditional medicines. These are the Poison Act of 1952, Sale of Drug Act of 1952, Advertisement and Sale Act of 1956, and the Control of Drugs and Cosmetics Regulations of 1984. Since 1992, traditional medicine products have been registered. The Drug Control Authority is responsible for product registration, including quality and safety. Every manufacturer of traditional medicine is required to comply with good manufacturing practices, and importers are required to comply with good storage practices. All homeopathic medicines have to be registered with the National Pharmaceutical and Drug Control Board. In the past, the Government has taken a neutral stand on the practice of traditional Chinese medicine. However, in recognition of the current and potential contribution of traditional and complementary/alternative medicine to health care, the Government is now considering bringing traditional Chinese medicine into the official health care system. The Ministry of Health has set up the Steering Committee on Complementary Medicine with a multisectoral membership to advise and assist the Minister in formulating policies and strategies for monitoring the practice of traditional Chinese medicine in the country. A national policy is being drafted on traditional Chinese medicine to encourage established practitioners to form their own self-regulatory bodies. These bodies will enable a system of official recognition of member-practitioners. To ensure that the qualifications of practitioners are recognized and can be accredited for formal registration, the bodies are required to set formal standards, including training, for their own practices. They are also encouraged to update the skills and knowledge of their members. The Unit of Traditional Chinese Medicine has been established at the Primary Health Care Section, Family Health Development Division, Ministry of Health. It will be responsible for monitoring and facilitating the implementation of the Ministry's policies as well as strengthening national and international collaboration. There is no chiropractic law. Education and training Recently, the umbrella body for traditional Chinese medicine has issued a Practice Approval Certificate for practitioners who have taken its courses or courses from a recognized university. This certificate is needed for a Business License Certificate. Homeopathy will be introduced as a discipline at the newly established Faculty of Biomedicine. Insurance coverage Neither national healthcare insurance nor private insurance covers traditional Chinese medicine in Malaysia. Mongolia Background information Traditional Mongolian medicine has a known history of more than 2500 years. Rooted in Tibetan and Indian medicine, traditional Mongolian medicine is part of the broader cultural heritage of the people and reflects their lifestyle as well as geographic and climatic conditions. From the 1930s until the end of the 1980s, traditional medicine was officially ignored. Socio-economic changes in Mongolia during the 1990s led to the development of the national culture, including revival of the traditional medical heritage. Traditional medicine is now more popular and accessible to communities. Acupuncture and moxibustion have gradually been recognized as clinically effective in the treatment of disease and in the promotion of health. In 1991, two non-governmental organizations, the Association of Acupuncture and the Association of Traditional Medicine, were established. Statistics There is one 100-bed hospital for traditional medicine, 15 small traditional medicine hospitals with 10 to 20 beds, 19 outpatient clinics for traditional medicine near Government health centres, and 81 private clinics and units of traditional medicine. There are also five manufacturing units for traditional medicines. Including those who have taken short-term courses in traditional medicine, there are about 600 - from a total of 5875 - allopathic physicians providing traditional medicine, acupuncture, and glass-cupping therapy. Regulatory situation The Government of Mongolia considers traditional medicine to be an important health care resource for the population and is therefore working to incorporate traditional medical remedies into the official health service. In 1991, the Health Minister issued an order to begin developing traditional medicine from 1991 to 1995. This led to the establishment of an official structure for traditional medical care within the overall health system. In 1996, the Ministry of Health and Social Welfare worked out a development plan for traditional medicine for 1997-2000, focusing on training new personnel, standardizing training curricula, improving research, and expanding the manufacture of herbal medicines. A draft policy on the development of Mongolian traditional medicine was discussed at the Conference on National Policy on Traditional Medicine in 1998 and was adopted by the State Great Khural Parliament on 2 July 1999. This document contains plans for developing Mongolian traditional medicine over the next 10 to 15 years and covers 19 areas of work, including the following: developing the structure and organization of hospitals of traditional medicine further; interrelating the activities of training and re-training of traditional medicine personnel; producing safe herbal medicines with naturally extracted herbs, in line with good manufacturing practices; providing support to doctors of traditional medicine and to private health institutions; exploring possibilities of curing critical diseases with traditional methods; applying some methods of traditional medicine to ambulance services as well as primary health care. Education and training Before 1989, there were no formally qualified doctors of traditional medicine. Since then, 24 to 26 students have been admitted and enrolled each year in the Department of Traditional Medicine at the national medical university. Many of the teaching materials, including acupuncture textbooks and facilities, are from neighbouring countries. In both the three-year programme and the six-year programme, many hours are allotted to traditional medicine but only a minimal amount of time is set aside for acupuncture. New Zealand Statistics There are 170 chiropractors practicing in New Zealand. Regulatory situation The Government of New Zealand recognizes homeopathy, osteopathy, and chiropractic. Chiropractic has been regulated by law since 1962, and chiropractors are permitted to use X-ray equipment. Education and training There is one school of chiropractic in New Zealand. Papua New Guinea Background information Traditional medicine is widely accepted and practiced in rural areas where the majority of the population lives. The use of traditional plants for curing common ailments and afflictions in village communities is encouraged by private and non-governmental organizations on the grounds that it is a sensible option in the face of the rising costs of allopathic medicine, transport difficulties, and the poor facilities at aid posts and rural health centres. Regulatory situation Although important for individuals and communities, traditional medicine remains outside the formal health system. It is expected that a policy in support of the rational use of traditional medicine will be developed soon and that a role for traditional medicine will be embodied in the new National Health Plan 2001-2010. Provisions for the introduction of proven traditional medicines have already been made in the recently approved National Drug Policy. Philippines Background information The National Health Care Delivery System in the Philippines is predominantly allopathic. Statistics There are about 250000 practitioners of traditional medicine in the country. Approximately five to eight chiropractors are practicing in the Philippines. There are no privately owned hospitals providing formal traditional or complementary/alternative medical services. As of 1999, only a handful of Government hospitals offered acupuncture services to the general public. Natural medicines are marketed over the counter in dozens of health food stores and in a limited number of pharmacies. Regulatory situation The Department of Health has developed a national programme on traditional medicine together with a six-year plan of work. In 1993, a traditional medicine division was established within the Department of Health to support the integration of traditional medicine into the national health care system as appropriate, with technical support from the World Health Organization. The Traditional and Alternative Medicine Act was signed by the President in December 1997. It states that it is the policy of the Government to improve the quality and delivery of health care services to the Filipino people through the development of traditional and complementary/alternative medicine and its integration into the national health care delivery system. The Act created the Philippine Institute of Traditional and Complementary/Alternative Health Care, which will be established as an autonomous agency of the Department of Health. The Institute's mission is to accelerate the development of traditional and complementary/alternative health care in the Philippines, provide for a development fund for traditional and complementary / alternative health care, and support traditional and complementary/alternative medicine in other ways. Training in traditional medicine for allopathic practitioners is a priority in the country. Collaboration on education and research between institutions in the Philippines and other countries has also been established. In the Philippines, traditional birth attendants may legally work only in areas where physicians or registered midwives are not available. The Board of Medicine Resolution 31 of 2 March 1983 recognizes acupuncture as "a modality of treatment for certain ailments to be practiced only by registered physicians in the Philippines". The Board is mandated to promulgate rules and regulations to govern the practice of acupuncture and to evaluate and assess the annual reports submitted by practitioners "on their experiences and the results of their clinical treatment of cases" to determine if they may continue to practice legally. There is no chiropractic law. Education and training More than 200 Government allopathic physicians have been trained in acupuncture. Republic of Korea Background information In the Republic of Korea, the oldest record of traditional medicine, known as oriental medicine, dates to the Gochosun period, about 4332 years ago. Oriental medicine flourished until 1894 when the Gab-O Reform abolished the law of oriental medicine, leading to its decline in favour of allopathic medicine. In 1945, oriental medicine was revitalised and is very popular today. Intended to represent oriental medical doctors and foster legal order, the Korean Oriental Medical Association (KOMA) was organized on 16 December 1952 to promote health through the development of oriental medical science and by facilitating cooperation among its members. KOMA has 16 branch offices established under the National Medical Treatment Law in 1952. These are located in both cities and provinces. The establishment of the Korea Institute of Oriental Medicine was initiated on 24 March 1994 by National Act 4758. The Institute opened on 10 October 1994. It employs over 30 persons, and in 2000, it had a budget of 5047 million won. Among other things, the Institute focuses on clinical trials of oriental medicine, research on the standardization and development of oriental medicines, investigation and analysis of acupuncture, and research to assist in the development of the oriental medicine industry. Plans for expanding the Institute are expected to make it a major research institute for oriental medicine and a worldwide centre for research and study of traditional and complementary/alternative medicine. Statistics There are 107 oriental medical hospitals and 6590 oriental medical clinics. There are 9914 oriental medical doctors. Public health doctors of oriental medicine work at 69 provincial Government health centres. Oriental medicine doctors have worked for the Surgeon General in the army since 1989. There are about 133 acupuncturists, 41 moxibustion practitioners, and 76 acupuncture/moxibustion clinics. Approximately 30 chiropractors are practicing in the Republic of Korea. The Korean Oriental Medical Association has about 10 000 members. According to national medical insurance records, 13 907 000 persons received oriental medical treatment in 1998. This represents 4.8% of the total number of people receiving medical treatment. Regulatory situation The Civil Medical Treatment Law, brought into force in 1951, established a dual system of medical treatment comprised of oriental and allopathic medicine. In 1969, the Ministry of Public Health and Welfare published a notification permitting pharmaceutical companies to produce herbal preparations whose formula is described in the 11 classic books on traditional Korean and Chinese medicine, without first having to submit clinical or toxicological data. The Medical Affairs Division under the Medical Bureau of the Ministry of Health and Welfare was in charge of the administrative management of oriental medical treatment until 1993, when the Oriental Medicine Division was established. In November 1996, this Division was expanded into the Oriental Medicine Bureau, a major bureau of the Ministry of Health and Welfare, with two of its own divisions. The Oriental Medicine Bureau works on short-term and long-term policy planning, research on oriental medical systems, and the administration of oriental medicine. One project is a programme of cooperation with China involving collaborative scientific research and the exchange of researchers and research information. Another project, intended to promote oriental medicine abroad, offers free medical examinations and treatment by oriental medicine in the World Health Organization Western Pacific Region Member States. Future plans for the Bureau emphasize the importance of quality control in manufacturing and distributing oriental medicines, particularly through licensing. Research will also be carried out to index materials and develop methods of chemical analysis of oriental medicines. In 1993, an advisory council on oriental medical policy was established in the Ministry of Health and Welfare. Oriental medical doctors are allowed to perform medical acts, including acupuncture and moxibustion. However, they do not have the right to order X-rays and pathological tests. To get an oriental medical doctor's licence, one must graduate from an oriental medical college and pass the national examination for oriental medical doctors. Under the Medical Treatment Act, acupuncture can only be practiced by persons holding a certificate of qualification. The policy of cultivating acupuncturists was abolished in 1962 and since then only oriental medicine doctors can practice acupuncture. Under the Pharmacist Law, which became effective on 1 July 1994, pharmacists must pass the national oriental medicine exam in order to practice oriental medicine. There is no chiropractic law. Education and training The education system for oriental medicine in Korea was established in 1964. Oriental medical studies consist of a preparatory two-year programme and a regular four-year programme covering the basic subjects of oriental and allopathic medicine. In 1994, there were 3922 students majoring in oriental medical sciences enrolled in six-year programmes at 11 colleges throughout the country. Every graduate school has a Master's and Doctorate programme in oriental medical sciences. In each case there is an affiliated oriental medicine hospital providing clinical education. In 1996, the Government approved the establishment of oriental pharmacy departments at several universities. Insurance coverage A national medical insurance programme covering oriental medical services has been in effect since 1 February 1987. Included in the coverage are oriental medical diagnosis, acupuncture, moxibustion, and 56 kinds of medicines based on herbal extracts. Total medical insurance payments for oriental medicine treatments in 1998 were 315.55 billion won, or 3% of the total medical insurance payments for medical treatment. Patients treated with unauthorised complementary/alternative medicine are not covered by the medical insurance scheme. Samoa Background information Traditional medical practitioners in Samoa have used medicinal plants and other forms of non-drug treatment for centuries. This knowledge is typically passed down within families. Statistics The exact number of traditional medicine practitioners in Samoa is unknown, but a recent survey concerning primary health care workers estimated that there are about 150 full-time practitioners of traditional medicine. Visiting acupuncturists from the People's Republic of China have been providing acupuncture treatments in the country for about 10 years. Approximately 55 000 patients have been treated. Regulatory situation There is no legislation on traditional medicine in Samoa. Although the Medical Practitioner's Act states that only registered persons can practice medicine, practitioners of traditional medicine are not considered to be breaking the law. The Health Sector Reform has included traditional medicine as a sub-component for institutional strengthening/reform. Singapore Background information Singapore's health services are based on allopathic medicine. However, it is common practice among the various ethnic groups to consult traditional practitioners for general ailments. Chinese, Indian, and Malay traditional therapies all have a part in complementary/alternative health care in Singapore. Statistics About 45% of the population have consulted traditional medicine providers. Traditional Chinese medicine is the most prominent traditional therapy, both in terms of the number of its practitioners and patients and in its far-reaching appeal. A list published by the local traditional Chinese medicine community in 1997 reported 1807 practitioners of traditional Chinese medicine in Singapore, most of whom were more than 40 years old. Half of them practiced traditional Chinese medicine on a full-time basis, one-third practiced part-time, and the remainder were not practicing at the time of the listing. Approximately 10 chiropractors practice in Singapore. Traditional Chinese medical practice is restricted to outpatient services in Singapore. About 10 000 persons visit traditional Chinese medicine clinics each day, compared to 74 000 persons who visit allopathic clinics. Regulatory situation The health authorities recognize the importance of traditional medicine in the provision of health care and have initiated efforts to promote and ensure the safe practice of traditional medicine. A traditional medicine unit was set up in the Ministry of Health in November 1995. Act 34, the Traditional Chinese Medicine Practitioners Act of 2000, was passed by Parliament on 14 November 2000 and assented to by the President on 2 December 2000. The Act provides for the establishment of the Traditional Chinese Medicine Practitioner Board to approve or reject applications for registration and to accredit courses in the practice of traditional Chinese medicine, among other things. This accreditation is intended to facilitate registration. The Register of Traditional Chinese Medicine Practitioners shall be kept by the Registrar appointed by the Board. A registered practitioner who desires to obtain a certificate to practice must make an application to the Board. Unlawful engagement in prescribed practices of traditional Chinese medicine is punishable by a fine, imprisonment, or both. Under the power conferred by the Traditional Chinese Medicine Practitioners Act of 2000, the Minister for Health issued the Traditional Chinese Medicine Practitioners (Registration of Acupuncturists) Regulations of 2001, which came into effect 23 February 2001. The Traditional Chinese Medicine Practitioners Board, with the approval of the Minister for Health, issued the Traditional Chinese Medicine Practitioners (Register and Practicing Certificates) Regulations of 2001, which came into effect on 18 April 2001. There is no chiropractic law. Education and training Schools of traditional Chinese medicine have made valuable contributions to the training of traditional Chinese medicine practitioners in the past. Singapore has adopted a standardized six-year part-time training programme in traditional Chinese medicine. National examinations for both acupuncture and traditional Chinese medicine will soon be required for practitioners. Solomon Islands Background information There is very little documentation on traditional medicine in the Solomon Islands. Traditional medicine practitioners regard the medicines they use as their personal property and conduct their practices under very strict confidence. Many of the natural materials used to make the traditional medicines can only be collected at specific times. Regulatory situation In 1979, the Government officially recognized and accepted the use of traditional medicine as a supplement to allopathic medicine in rural communities where the availability of allopathic drugs is limited. The policy states that traditional medical practice is not to be institutionalized but, rather, is to remain largely in the hands of individual practitioners. Vanuatu Regulatory situation In Vanuatu, under the Health Practitioners Act of 1984, amended in 1985, osteopathy and chiropractic are designated as ancillary allopathic medical professions subject to registration. By Section 5 of the Act, a person is eligible to be registered if, in the opinion of the Health Practitioners Board, he or she has sufficient training, skill, and practical experience. At its discretion, the Board can require applicants who do not meet these criteria to complete a recognized training course. Section 18 makes it an offence for a non-registered person to practice medicine or claim to be registered to practice medicine. Viet Nam Background information In Viet Nam, traditional medicine can be divided into two categories: Vietnamese traditional medicine, which is influenced by Chinese traditional medicine, and oriental medicine. In the countryside and in remote and mountainous areas, Vietnamese traditional medicine is more commonly used. In the delta, lowlands, and cities, patients more commonly use a combination of Vietnamese traditional medicine and oriental medicine. Both Vietnamese traditional medicine and oriental medicine form an integral part of the national health care system in Viet Nam and have an important role in promoting the health of the Vietnamese people, particularly in difficult cases, geriatric diseases, and primary health care at the commune level. Allopathic doctors who have graduated from medical universities and who have been trained in traditional medicine have become some of the most outspoken supporters of traditional medicine. They are actively engaged in promoting the rational use of traditional medicine in their institutes and hospitals. Statistics According to Ministry of Health statistics, about 30% of patients receive treatment with traditional medicine. Treatment is provided by traditional medicine practitioners (who have not received any formal education) and by traditional medical doctors (who have graduated from a department of traditional medicine at one of the medical universities in Hanoi, Ho Chi Minh City, or Haiphong). There are about 1000 traditional medicine practitioners, 5000 traditional medical doctors, 2000 assistant traditional medical doctors, and 209 traditional medicine pharmacists. Additionally, there are approximately 8000 private practitioners of traditional medicine. Of this number, about 1400 are acupuncturists. The Viet Nam Association of Traditional Medicine Practitioners has 24 000 members. Of this number, 461 work in public hospitals. The Viet Nam National Association of Acupuncture has 18 000 members, 4500 of whom work in public hospitals. A Traditional Medicine Hospital of the Ministry of Interior Affairs was inaugurated at the end of 1996. Additionally, there are 286 departments of traditional medicine in general hospitals, 45 provincial hospitals of traditional medicine, and four institutes of traditional medicine in Viet Nam. There are three medical colleges that have a faculty of traditional medicine, two pharmaceutical colleges, two secondary schools of traditional medicine, two State pharmaceutical companies, two State pharmaceutical manufacturers of herbal medicine, and three national research institutes for traditional medicine. An Army Institute of Traditional Medicine was established in 1978, with a staff of 100 doctors and pharmacists. The tasks of the Institute include clinical work, research, training, and the manufacture of herbal products. It serves about 20 000 outpatients and 2500 inpatients each year. The Viet Nam Acupuncture Institute operates under the authority of the Ministry of Health. The Institute is responsible for giving nationwide guidance on acupuncture and other medical therapies that reduce or avoid the use of drugs in treatment. It has 350 beds and serves approximately 2500 inpatients and 8500 outpatients each year. Regulatory situation The Government supports public-sector facilities for traditional medicine and encourages people to mobilize resources for the development of traditional medicine, especially for primary health care. Government programmes include training health workers at the community level in using traditional medical methods to treat common and recently defined diseases and encouraging people to plant medicinal vegetables, ornamental plants, and fruit trees. These three groups of plants are intended for use in treating common diseases in the community as well as improving family incomes. This model has become a countrywide programme. A number of official documents indicate clear support for traditional medicine. There is official recognition for a number of traditional therapies, including medications made from plants and animals, massage, acupuncture, acupressure, moxibustion, vital preservation, cupping, and thread embedding. Article 39 of the Constitution of the Socialist Republic of Viet Nam outlines State undertakings to develop and integrate allopathic and traditional medical and pharmaceutical practices as well as to develop and integrate official health care, traditional medicine, and private medical care. More detailed provisions on traditional medicine can be found in a 1989 public health law and 1991 regulations made under it. Among the objectives of health care, Section 2 of the 1989 law lists the development of official Vietnamese medicine on the basis of traditional medicine and pharmacy and the integration of allopathic and traditional medicine. The promotion of these objectives is the shared responsibility of the Ministry of Health, the Vietnamese Traditional Medicine Association, and the Viet Nam General Union of Medicine and Pharmacy. Under Section 34.1, these organizations are additionally charged with ensuring conditions for the operation of all major hospitals and institutes of traditional medicine. Section 34.2 provides that the medical services and the people's committees at all levels are to consolidate and broaden the health-care network using traditional medicine. Section 35 permits licensed traditional medicine practitioners to practice in any State, collective, or private health care institution. This includes acupuncturists who have been trained, who have attended courses in traditional medicine, or whose knowledge of traditional medicine was passed down to them through their family. Traditional medicine practitioners may examine and treat patients as well as offer preventive advice. However, before new treatment methods can be used, they must be approved by the Ministry of Health or provincial health office and the Traditional Medicine Association. Superstitious practice is forbidden by Section 36. Private practice of traditional medicine is subject to management by the Government and the Ministry of Health. The 1991 regulations specify required qualifications for traditional medicine practitioners as well as the permitted range of procedures practitioners may use. A breach of any of these rules that results in serious harm to life or health of another person is punishable under the Criminal Code by imprisonment. The 1993 Vietnamese Ordinance on Private Medical and Pharmaceutical Practice includes detailed provisions on the private practice of traditional medicine. The Ordinance permits certified practitioners of traditional medicine to privately practice the range of activities for which they are certified, provided they have a permit to do so and subject to State overview. Article 5 lists permitted activities as including practice in a traditional medical hospital or clinic and providing traditional forms of treatment such as acupuncture, massage, acupressure, and herbal saunas. Article 7 requires traditional practitioners to hold a diploma of Doctor of Medicine or Assistant Doctor Specialising in Traditional Medicine and to have practiced traditional medicine for a minimum period that varies between two and five years. A number of measures are included in the Ordinance to further safeguard patients' interests. Under Article 17, practitioners must put up a name board that sets out the activities they are permitted to practice. Private practitioners must obtain the permission of the Ministry of Health to use novel treatment techniques or drugs. Superstitious practices are not permitted according to Article 19. Private practice without a certificate or practice that exceeds the range of permitted activities is subject to administrative, disciplinary, or criminal sanctions under Article 34. The Government entrusts the health service system with issuing licences to traditional practitioners through an assessing committee. Anyone who has 13 certificates issued by an assessing committee and the Ministry of Health can privately practice traditional medicine. In the area of acupuncture, the regulatory qualifications of practitioners include Professor, Associate Professor, PhD, Acupuncture Speciality Doctor Level I, Acupuncture Speciality Doctor Level II, and Acupuncture-Oriented Doctor. The Ministry of Health advocates socialization and diversification of traditional medicine. Education and training There is no college or university of traditional medicine in Viet Nam. Although Hanoi Medical University has a department of traditional medicine, it does not meet the needs of developing traditional medicine in Viet Nam. Two secondary schools are the main seats of learning in traditional medicine. There is strong support for a facility of higher education in traditional medicine, and the Government is planning to create a university of traditional medicine to provide programmes for secondary, undergraduate, and postgraduate study (278, 279). Insurance coverage Health insurance covers costs for both allopathic and traditional medicine ; however, this is not on an equal basis in all areas because of differential access to care. General principles The Treaty on the European Union (EU) came into force 1 November 1993. The Treaty instituting the European Economic Community (EEC) was intended to open a large market zone without borders, enabling the free movement of persons, goods, services, and capital. It is Treaty regulations on the movement of persons and goods, in particular, which affect health services and medications (172, 280, 281). For the purpose of employment or for activities as a self-employed person, citizens of the European Union, under Articles 39 to 55 of the Treaty, have the right to move and take residence freely within the European Union. Some limitations and conditions on this freedom are outlined in Articles 12 and 39 of the Treaty. Moreover, by Directive 65/221/EEC, individual countries can limit the right of free movement on justified grounds of public health. Specific directives ensure the mutual recognition of diplomas of allopathic doctors, dentists, pharmacists, midwives, and nurses. Similarly, directives based on Article 95 of the Treaty regarding Union-wide harmonization of legislation regulate, among other things, pharmaceuticals, blood products, medical devices, foodstuffs, dangerous substances and preparations, cosmetics, safety of products, precursors, tobacco products, personal protective equipment, and the protection of personal medical data. Directives on homeopathic products The first phase of European Union legislative harmonization in homeopathy was the adoption of two European Directives that came into force on 1 January 1994 - one on homeopathic products for humans and one on homeopathic veterinary products. These Directives ensure a single European Market for homeopathic products and outline provisions regulating their manufacture, inspection, marketing, and labelling. They also establish a simplified registration procedure for medications containing less than one part per 10 000 of undiluted tincture or less than 1/100th of the smallest dose used in allopathic medicine. According to the 1995 European Commission report to the Parliament and the Council on the application of Directives 92/73 and 92/74, however, the existing level of legislative harmonization is insufficient. The EEC Directive regulates the marketing of proprietary medicinal products. However, individual countries are free to restrict the licensing of herbal medicines. Germany and the United Kingdom have chosen to restrict such licences in order to protect their populations from the possible carcinogenic effects of pyrolizidine alkaloids, which occur in a number of medicinal herbs. Free movement of patients and practitioners and insurance coverage of complementary/alternative medicine products and treatments Directives on the free movement of patients and practitioners and on insurance coverage of complementary/alternative medicine are more difficult to implement. Although the free movement of persons within the European Union is a cornerstone of the Treaty of Rome, the diversity of national policies severely limits its applicability to practitioners of complementary/alternative medicine. Case 61/89 of the European Court of Justice involved an acupuncturist without allopathic medical qualifications practicing in France. The Court's decision confirmed the right of individual countries to make their own legislation on whether or not to reserve the practice of medicine to allopathic doctors. As social insurance remains the province of national governments rather than an issue for European Union consideration, insurance coverage of complementary/alternative products and treatments is unlikely to become the subject of a European Directive. Nonetheless, in April 1994, European Deputy Paul Lannoye presented a proposal on the status of complementary/alternative medicine to the European Parliament Committee on the Environment, Public Health, and Consumer Protection. He asked for provisions for complementary/alternative medicine within social security systems, the incorporation of complementary/alternative medical systems into the European Pharmacopoeia, an end to prosecutions of non-allopathic practitioners in countries where the practice of medicine is the exclusive domain of allopathic providers, and a pan-European system of recognition and regulation of complementary/alternative medical practitioners along the lines of the British Osteopath and Chiropractor Acts. He also requested a research budget of 10 million Euros per year for five years. At the last moment, the European Parliament cancelled the vote on the proposal. At the end of 1995, the Conference of Presidents of the European Parliament put forward a report intended to engage the European Commission in the process of recognizing complementary/alternative medicine. On 27 February 1997 the Committee on the Environment, Public Health, and Consumer Protection began a study of complementary/alternative medicine. On 29 May 1997 the European Parliament passed a resolution, Calling on the Commission, if the results of the study allow, to start the process for the recognition of non-conventional medicines and, for this purpose, to take the necessary steps to encourage the establishment of appropriate committees; Calling on the Commission to carry out a thorough study on the safety, effectiveness, scope of application and the complementarity and alternative nature of all non-conventional medicines, and to prepare a comparative study of the various national legal models to which non-conventional medical practitioners are subjected; Calling on the Commission, in formulating European legislation on non-conventional forms of medicine, to make a clear distinction between non-conventional medicines which are "complementary" in nature and ones which are "alternative" in the sense that they replace conventional medicine; Calling on the Council, after completion of the preliminary works referred to in paragraph 2 above, to encourage the development of research programmes in the field of non-conventional medicines covering the individual and holistic approach, the preventive role and the specific characteristics of the non-conventional medicine; Calling on the Commission to submit a proposal for a Directive on food supplements which are frequently situated on the boundaries between dietary and medicinal products. Such legislation should help guarantee good manufacturing practices to secure consumer protection without restricting freedom of access or choice and ensure the freedom of all practitioners to recommend such products; Calling on the Commission to remove trade barriers between Member States by giving manufacturers of health products free access to all markets in the EU.... A Resolution of the European Parliament, however, is not a binding act, but a declaration of policy. Nonetheless, the adoption of the resolution has led several countries to consider revising their legislation.
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