Stakeholder attitudes to the regulation of traditional and complementary medicine professions: a systematic review

Health care systems are coming under increasing pressure from challenges posed by the growing burden of non-communicable diseases [1, 2], the health care needs of ageing populations [3], the accelerating incidence of epidemics and pandemics [4], burgeoning health care costs [5], and the prospect of health care workforce shortages [6]. Changing needs, shifting priorities and the increasingly consumer-led nature of health care systems have resulted in significant changes in the contemporary health care workforce. This includes the evolution or growth of new professions and changes in scope of existing professions. According to the World Health Organization (WHO) there are now over 150 occupations in the health workforce sector [7], although one commentator considers this number closer to 350 [8].

One area of the health workforce in which there has been considerable growth and evolution is traditional and complementary medicine (T&CM). T&CM refers to a broad set of health care practices and beliefs indigenous to a culture and place (traditional medicine), and practices that are neither indigenous nor part of the predominant health system of a country (complementary) [9, 10]. T&CM designations are therefore jurisdictionally defined [9]. Although some T&CM practices have ancient roots, the worldwide growth in consumer use and recognition of T&CM commenced in the latter part of the twentieth century, in part due to the Declaration of Alma-Ata [11] and later the release of WHO traditional medicine strategies [9, 12]. The rise in T&CM use has proved to be a global phenomenon, evident in both developing and developed nations [13‐20]. Commensurate with this rise in use there has been a substantial increase in the number of T&CM practitioners over the past 20 years [21‐23]. Indeed in some jurisdictions the T&CM cadre is estimated to outnumber general practitioners (GPs) [23], making this cohort a significant part of the health care workforce globally.

Regulation of health practitioners is generally defined as the actions taken by public authorities to control activities and standards relating to health practice [24‐26]. While models of health workforce regulation vary across jurisdictions [27, 28], one schema classifies six categories of occupational licensing: no regulation, self-regulation, state sanctioned self-regulation, statutory self-regulation, co-regulation and statutory regulation [29]. In many jurisdictions the regulation of health professions appears to be moving away from non-government regulatory models towards nationally based regulatory approaches [30], and greater regulatory partnerships between the public, professions, and regulators [27]. Further, the WHO has identified regulation as a key milestone of their global health workforce strategy [6], and regulation of the T&CM workforce specifically as one of three strategic objectives of the WHO T&CM strategy [9]. Despite these strategic priorities, there is considerable variation worldwide in the way in which T&CM occupations are regulated, as well as the form of regulation applied. Regulatory developments for T&CM practices are argued to be lagging behind their growth in use [31], and not all T&CM occupations operate within adequate accountability-based, public interest regulatory frameworks [9, 10]. For instance, some T&CM professions are statutorily regulated in certain countries, others reside outside statutory frameworks but occupy a state-recognised place in health provision, and some T&CM practices are neither statutorily regulated nor acknowledged by the state, but continue to operate within their jurisdictions, sometimes informally [10].

There is a public health imperative for governments to establish mechanisms for recognising and monitoring T&CM practices and practitioners, and promote their appropriate integration or restriction within health care systems [10]. Establishing suitable regulatory frameworks may ensure appropriate and consistent minimum standards of education and practice [10, 32], and facilitate workforce mobility across country borders [9], potentially alleviating forecast health care workforce shortages [6], and contributing to the WHO’s mission of promoting health for all [33]. WHO, through its traditional medicine strategy, has noted the lack of action in progressing T&CM regulation and encourages member states to engage more actively with this policy to facilitate the appropriate regulation of T&CM within their jurisdictions [9]. By taking a global perspective the development of insights regarding potential enablers and barriers of regulation across a range of jurisdictions is facilitated, which can inform future application of regulatory policy in a number of different settings.

Despite widespread consumer utilisation of T&CM, the broadening reach of these practices, and the increasing tendency to regulate T&CM professions, what remains unknown and requires greater understanding are the attitudes and perceptions towards regulation of T&CM across the health care stakeholder landscape. In the broadest sense, stakeholder attitudes are important considerations in many contexts and settings [34]. Within the health care context, understanding stakeholder attitudes is important to ensure that regulation is sustainable, responsive, and appropriate, and serves the public interest in a manner that is reflective of societal norms, expectations, and practices. Attitudes are shaped by self-interest, social identification, and personal values through which opinions are formed [35]. Attitudes and opinions have a bearing on policy by influencing regulatory and policy agendas [35‐37]. Disregarding the attitudes of key stakeholders risks privileging the views of certain groups at the expense of others [36, 37] and may result in regulatory developments that are not responsive to changing health workforce requirements. To date there has been no systematic examination of stakeholder opinions regarding regulated and unregulated T&CM occupations, a deficiency this systematic review aims to address. Consistent with regulatory trends, this review takes an expansive view across a range of stakeholder groups and jurisdictions to investigate, describe, and analyse attitudes towards the regulation of T&CM professions.

The database, Google Scholar and manual searches yielded 3132 non-duplicated records. Following screening, a total of 54 published and unpublished papers met the inclusion criteria and were selected for review. The reasons for study exclusion are detailed in Fig. 1.

This review provides the first known systematic examination of the contemporary empirical literature regarding stakeholder attitudes to the regulation of T&CM professions.

Of the 60 identified studies, six sought opinions from professional associations in Australia, Canada, and UK, two studies from Australia and Canada investigated education providers, and only two, both from Canada, canvassed the perceptions of policy-makers. The largely positive views of these stakeholders are tempered by the limited available research. The lack of research from many countries where T&CM is practised also limits the international generalisability of the findings. In particular, the views of policy-makers outside of Canada are yet to be determined and, consistent with other jurisdictional differences, may well be dissimilar to that seen in the present review. Scholars and commentators have long recognised the crucial role of policy-makers and policymaking in formally recognising T&CM professions. Policy-makers reported their priority of upholding the public interest while outlining a roadmap for regulation and integration. These were considered inducements in exchange for practice restrictions, which some T&CM practitioners and professional associations considered unacceptable. Further research focussed explicitly on these stakeholder groups, particularly those of policy-makers, is clearly needed to inform decisions regarding implementation of the WHO Traditional Medicine Strategy recommendations [9].

Another key finding from the review is that, consistent with regulatory policy provisions, the main focus of stakeholders outside of T&CM professions was on public protection and raising inadequate training and practice standards. While these views were dominant among T&CM practitioners as well, attention was also directed towards the professional benefits and disbenefits of regulation, suggesting that better communication regarding the purpose of regulation is needed. Previous research examining the impact of Chinese medicine regulation in the Australian state of Victoria supports the position that regulation enhances public safeguards with significant improvements in the management of consumer complaints and enforcement of professional standards after its inclusion in the statutory regulation scheme [106]. In addition, comparative examination of T&CM and non-T&CM professions in Australia’s National Registration and Accreditation Scheme has been shown to work at least as well as conventional medical practitioner regulation [107, 108].

Our review found that some T&CM practitioners perceived that professional associations adequately monitored and upheld professional standards obviating the need for regulation, a view contrary to stated consumer concerns. Examination of regulated and unregulated Australian T&CM professions indicates that self-regulatory mechanisms are not as effective for improving public protection when using T&CM services [109]. Furthermore, research on health care workforce regulatory frameworks and reforms emphasise the growing global focus on the public interest, a move away from self-regulatory governance models, and increased independence of complaints handling and oversight of disciplinary proceedings [27, 110].

As increasing T&CM use is a largely consumer-driven phenomenon (given T&CM is rarely integrated into public health systems), it is interesting that most consumers in this review stressed the need to regulate T&CM practices, a finding consistent with research conducted in 1996 (prior to the date inclusion of this review) [111]. This temporal consistency of consumer opinion suggests a long-standing public preference for the independent governance of health practitioners, including T&CM practitioners, who in this review were considered to require the same regulation as that governing conventional health practices. This is notable for two reasons. Firstly because consumer opinion regarding regulation persists despite the diversity of jurisdictions and T&CM professions examined, and secondly because these results run counter to research identifying temporal considerations of stakeholder analysis as potentially limited [112].

Although a common critique of T&CM regulation by some stakeholders is that regulation may grant these professions undue legitimacy, this view was not widely expressed in the identified studies. This finding, in addition to the worldwide reported rates of consumer use of [13‐16], and trust in [113, 114] T&CM practices suggests that the issue of professional legitimacy may be immaterial to a significant proportion of consumers and health professionals who may already view these practices as legitimate regardless of regulatory status [115]. Additionally, the relevance of established accountabilities and minimum standards of a profession for reasons of public safety and debates about professional legitimacy should be viewed as separate and divorced issues.

While the findings suggest support for T&CM regulation across stakeholder groups, this may not necessarily indicate majority support. Support for or opposition to regulation of T&CM providers is highly contextual and based on factors such as integration, marginalisation, perceived professionalisation, competition, as well as the specific type of therapy or practice. For example, support for regulation from conventional health practitioners was clearly not universal. Physiotherapists and manual therapists in the Netherlands were less supportive of regulation of chiropractors. Conventional medicine professionals in Korea were also less supportive of legislative governance of acupuncture, chiropractic, and traditional Chinese medicine. These differences may be partly explained by perceived inter-professional competition, as indicated by policy-makers and conventional medicine associations, and implied by physiotherapists and manual therapists in this review. The above examples suggest a clear competitive tension in terms of similar scopes of practice. Such competitive tensions have also been suggested to exist between conventional medicine and naturopathy in Australian, Canadian, and German studies [116‐118]. One commentator has proposed that the care offered by T&CM practitioners could be used to alleviate conventional care workforce shortages [119], a role which is broadly supported (where appropriate) by the WHO [9]. Competition between medical and non-medical clinicians has also been a long-standing issue with respect to policy development and integration beyond T&CM [120]. However, the degree to which T&CM-specific issues influence standard issues associated with inter-professional competitive tensions, and consequently issues such as views towards regulation and scope of practice of another health profession requires further research before it can be confirmed.

In this review lack of regulation was cited by numerous stakeholders as exposing patients to direct and indirect risks. Yet some GPs indicated that well-trained T&CM practitioners posed no risk of harm, and consumers indicated that T&CM treatments should only be prescribed by qualified providers. The issue of harm, therefore, may be a function of the competence of the practitioner and the quality of T&CM training [121, 122]. Supporting this argument is the uncertainty regarding T&CM practitioner competence and training standards which was frequently reported by stakeholders in this review, including T&CM practitioners. These, together with other non-health risks of T&CM practices, have been extensively reviewed by researchers with many of these risks purported to be exacerbated by lack of regulation [123]. These findings suggest that risks to consumers posed by T&CM practices may be mitigated by appropriate regulatory mechanisms that promote greater public protections via appropriate standards and accountability, while ensuring that consumer choice is protected, and practices can be appropriately integrated where there is evidence of patient benefit. In support of this, naturopathic education standards have been found to vary internationally, with nations that have workforce regulatory frameworks in place reporting higher and more consistent education standards than those without regulation [32].

As distinct from previously mentioned conflicting opinions between T&CM professions and consumers, there was also disagreement within the professions. The contrasting attitudes towards regulation between various T&CM practitioners, and between practitioners and organisational representatives may potentially be driven by professional self-interest. Several studies highlighted the benefits to and concerns of T&CM practitioners regarding regulation, revealing potential motivations of self-interest for attitudinal positions taken. ‘Self-interest’ may also be evident at the institutional level, particularly when organisations have been granted privileged roles within professions (such as through accredited or self-regulatory structures) that may be removed should those professions become statutorily regulated. This is suggested by previous examination, which has drawn attention to the resistance of much T&CM regulation in Australia being led by professional associations with commercial interests in educational institutions that may be adversely affected by the higher educational standards imposed by regulation [52, 124]. This view accords with researchers of T&CM and non-T&CM professions who contend that self-interest of education providers [125] and professional associations [126] are often incompatible with the public interest. As such, while T&CM stakeholder perspectives should be considered important context for development of policy, they should not be elevated above other stakeholder perspectives (particularly consumer expectations), and ultimately regulatory decisions should be guided by public interest arguments, and jurisdictional, health system and professional needs, irrespective of T&CM stakeholder views on regulation.

Despite a comprehensive search strategy, over two-thirds of included studies were conducted in three jurisdictions; Australia, Canada, and New Zealand. Yet these jurisdictions represent only a small part of global T&CM practice. High rates of consumer use of T&CM practices are reported in sub-Saharan Africa [17], South America [18], the Arab states [19], Asia [16], India [20], and other world regions [16] where traditional medicine is integral to many cultural health practices and beliefs. These regions are implementing widespread T&CM practitioner regulation [10] with little or no formal research examining stakeholder support, as evident from the review findings. Greater research focus is required into stakeholder opinions of regulation in these regions to ensure evidence-informed policy implementation efforts, and consistent application of regulatory measures across jurisdictions and practices.

Although most research on stakeholder attitudes and perceptions of T&CM regulation has been conducted in Australia, Canada, and New Zealand, this appears to have had limited impact as these jurisdictions have been amongst the most hesitant to implement consistent workforce regulation policies across T&CM professions [10, 31]. A striking example comes from Australia where herbal medicine and naturopathy has consistent stakeholder support for regulation, as well as having regulation recommended by every Commonwealth and State government review of the issue since 2000. Yet these professions remain self-regulated almost 50 years after the first government review recommending they be statutorily regulated [127]. Australia, like many countries, has placed much of its T&CM regulatory emphasis on product regulation, which the WHO considers is only part of the regulatory requirements it recommends to national governments [10]. This political inertia, described by some WHO member states as lack of ‘political will’ [10], also defies T&CM evidence of efficacy and demonstrable public health arguments for regulation of T&CM [9]. In addition to an increased global need for evidence to better inform regulatory decisions when implementing T&CM regulation, governments should also be accountable for ensuring that evidence, where it exists, is used to inform appropriate T&CM policy development. The most appropriate form of regulation for each health system, population, profession, and jurisdiction requires consideration based on evidence, and needs to be explored more explicitly. Our review indicates that regulation of TC&M is not being conducted in an evidence-informed manner. The juxtaposition of jurisdictions generating stakeholder research which has not translated into regulatory policy with jurisdictions implementing regulation without corresponding stakeholder evidence may have significant policy implications and requires careful consideration from the research community engaging with this topic.

This comprehensive review of the state of the current literature on the regulation of T&CM professions comes with several limitations which should be considered when interpreting the findings. Firstly, one-third of studies was identified through hand and grey literature searching. This was likely due to varying definitions, terms and practices used across jurisdictions making a systematic search more difficult. The lack of consensus on T&CM definitions resulted in considerable heterogeneity that was compounded by differences in jurisdictional definitions of conventional medicine versus T&CM practices, and inconsistencies regarding regulation across stakeholder groups. The use of collective T&CM terminology in some studies meant profession-specific data was not available. However, it is worth noting that T&CM is, by definition, a subjective term defined by the health system in which care is offered and as such this variability is understandable. Critical appraisal of qualitative studies was also problematic because there was no identified fit-for-purpose tool for the predominantly descriptive nature of these studies. The included papers cover an extensive time period and variation in attitudinal perspectives due to increasing use of T&CM practices may be expected over that time. However, temporal trends were generally not considered due to high heterogeneity across stakeholder groups as well as being considered of limited value in stakeholder analysis [112]. The results do not report on attitudes to the regulation of professions outside of T&CM such as conventional providers or hospital staff. Nor do the results report the impact of regulation on institutional stakeholders such as health insurers, accreditors, and product manufacturers, or on the health care system generally. Due to these factors, we can only make claims about attitudinal responses to specific professions for a select group of included studies during a specific time period, with a call for greater research into health care workforce regulation in order to explicate these factors. Notwithstanding these limitations, this work provides the most extensive review of this topic to date and may be useful for researchers and policy-makers seeking to examine or implement appropriate T&CM regulation in line with WHO recommendations.

This systematic review identifies widespread consumer and practitioner support for the regulation of T&CM professions. Significantly, consumers and practitioners from all branches of health care are calling for greater independent governance of, and accountably for unregulated T&CM health care professions. The support for regulation derives from a need to safeguard the public by promoting practitioner competence through the establishment of professional and practice standards. Consumers, T&CM practitioners, and conventional medicine practitioners comprised the vast majority of identified studies and their opinions regarding regulation are well represented in the literature. However, there is little research on the views of professional associations, education providers and policy-makers, and no published research on institutional stakeholders such as health insurers and accreditors. The available empirical evidence suggests stakeholders largely support regulation, with policy-makers expecting certain professional commutations which may not be acceptable to T&CM practitioners. In order to corroborate the conclusions of this review, further research is required from a broader range of jurisdictions using rigorous research methods. Determining attitudes across the breadth of health care stakeholders is a critical first step in offering insights into the barriers and enablers of regulation, developing relevant policy and practice recommendations, and informing appropriate policy change regarding T&CM professional regulation.