Naturopathic Workforce: A Global Resource Toward the Declaration of Astana Goals

Abstract

Introduction:

The World Health Organization identified health to be the most important social goal and the 1978 Declaration of Alma Ata placed primary health care central to its attainment and the UN Sustainable Development Goals (SDGs) as the template. The Astana Declaration called on a change of focus in primary care, from treatment of specific diseases to the prevention and inclusion of both scientific and traditional knowledge. Such objectives require public–private partnerships in providing health care, including traditional and complementary medicine systems such as naturopathy that align. However, there is limited understanding of global regulatory frameworks and officially recognized training for naturopathy.

Materials and Methods:

This descriptive study employs an adapted mixed-methods explanatory framework to examine naturopathy regulation and education. Analysis merges data arising from a descriptive policy analysis of regulation from 36 countries and survey analysis from 65 naturopathic organizations from 29 countries.

Results:

Four types of workforce regulation were identified within 107 countries where naturopathy was practiced—statutory registration or occupational licensing, coregulation, negative licensing, and voluntary certification. No form of naturopathic regulation was most common. Higher graduate/postgraduate education and access to a broader range of practices were more frequently reported in countries where naturopathy is statutory regulated. Government audits were more frequently reported where naturopathy was statutory regulated or coregulated.

Discussion:

Naturopathic philosophy and practice align with primary health care goals outlined in the Declaration of Astana. The naturopathic workforce represents an untapped health care resource with a demonstrated track record of translating these aspirational goals into practice. However, naturopathy remains inconsistently regulated globally, serving as a significant barrier to partnering with other health system actors to attain the health-related SDGs. Workforce regulation for the naturopathic profession offers increased standards, reduced risks, integrative health workforce planning, and assistance to countries toward achieving the promise of the Declaration of Astana.

Introduction

Health was declared a human right by the World Health Organization (WHO) in 1948 and the 1978 Declaration of Alma Ata placed primary health care central to achieving this social goal by national health systems.¹ The Sustainable Development Goals (SDGs) were adopted in 2015,² providing WHO Member States with the blueprint for global development, all of which are to be achieved by 2030.³ Although progress has been made toward improvements in global health, the 2018 “WHO Global Conference on Primary Health Care” held in Astana, Kazakhstan, was a watershed event that culminated in the formal launch of the Declaration of Astana.

The World Naturopathic Federation (WNF) was one of only two traditional, complementary and integrative health (TCIH) representative groups present at the conference. The conference delegates acknowledged that health systems had focused excessively on treating specific diseases at the expense of prevention, and that there were major challenges in terms of the global rate of noncommunicable diseases (NCDs), aging, and mental health.⁴ The Declaration of Astana—the WHO's guiding document for primary health care for the coming decades—reaffirmed commitment toward meeting primary health care goals including both scientific and traditional knowledge as integral to strengthening public health care services—respecting a person's rights, needs, dignity, and autonomy,⁴ which was part of a broader recommendation of inclusion of TCIH compared with the Alma-Ata Declaration.

However, challenges associated with harnessing TCIH have been highlighted³ potentially impacting partnering with other health system providers in the delivery of the SDGs and for integrative health workforce planning.⁵ TCIH providers may not be formally recognized by a country's regulatory and legal framework, and may not have officially recognized training standards,⁶ despite being widely used by the public in the private sector.

Naturopathy a partner in addressing the Declaration of Astana goals

Naturopathy is a philosophically defined, distinct, and global TCIH system based on traditional European medicine and North American eclecticism^7,8 and recognized by the WHO.^9,10 Naturopathy is well-placed to support achievement of the Declaration of Astana to promote primary health care for all and universal health coverage.¹¹ Naturopaths already provide primary contact care in many settings in accordance with globally accepted naturopathic principles: first do no harm (primum non nocere); healing power of nature (vis medicatrix naturae); treat the cause (tolle causam); treat the whole person (tolle totum); doctor as teacher (docere); disease prevention and health promotion; and wellness.¹²

The Declaration of Astana's recommendation to build sustainable health care aligns with naturopathic care, which focuses on primary prevention, health determinants, and patient-centered health care that is educative in nature and which promotes personal autonomy, self-responsibility, and environmental sustainability.¹¹ The “therapeutic order”—a key naturopathic theory that guides practice—is prevention focused and emphasizes the need to address modifiable lifestyle factors as an initial step to tackling chronic conditions such as NCDs.¹¹ The alignment between naturopathy and public health have been discussed previously.¹³ The naturopathic profession has also demonstrated leadership in areas aligned with the Declaration of Astana, such as global initiatives on NCDs and antimicrobial resistance,⁴ and global community outreach efforts.¹⁴

The naturopathic workforce is an untapped health care resource

Increasing health care workforce shortages¹⁵ particularly in rural areas where recruitment and retention challenges exist¹⁶ and from the COVID-19 pandemic¹⁷ lend support to the integration of naturopathy to achieve the SDGs. Where regulatory frameworks are in operation, the naturopathy workforce has the potential to support neglected sectors of public health,¹⁷ particularly household management of COVID-19, long-COVID,¹⁸ and supportive prevention and management of NCDs.¹¹ Increasingly, collaboration and cooperation between the public and private health care sectors are harnessing multidisciplinary teams⁶ in provision of cost effective integrative health care,¹⁹ although weak regulatory systems that do not support multisectoral engagement are a threat to achieving the SDGs.^2,3

Workforce regulation—a support or threat to achieving SDGs

The main purpose of workforce regulation is to protect the public by strengthening health systems to ensure quality health services that provide acceptable standards of training and care.²⁰ However, some forms of regulation do not fully achieve this goal and may consequently hinder health strategy implementation (see Table 1). Methods of workforce regulation, reported by Carlton,²¹ have been categorized in four ways: voluntary certification, coregulation, negative licensing, and statutory registration or occupational licensing, and form the basis for analysis of the qualitative study component.

Table 1.

Comparison of Occupational Regulation Types Against Key Parameters

Parameters	Type of occupational regulation
Parameters	Voluntary certification	Coregulation	Negative licensing	Statutory registration/occupational licensing
Statutory basis	No	May be	Yes	Yes
Enforceable minimum qualifications for entry to practice	No	No	No	Yes
Probity checking of persons before entry to practice	No	No	No	Yes
Accreditation of qualifying programs for entry to practice	Yes	May be	No	Yes
Enforceable minimum standards of practice	No	No	Yes	Yes
Mandatory continuing professional development	Yes (for members)	May be	No	Yes
Obligation to report professional misconduct by fellow practitioners	No	No	Yes	Yes
Powers to monitor practitioner compliance with practice standards	No	No	No	Yes
Powers to impose conditions on a practitioner's practice	No	No	Yes	Yes
Practice guidelines/codes issued	Yes	No	No	Yes
Complaints and disciplinary powers	Yes (for members only)	May be	Yes	Yes
Powers to remove unfit practitioners from practice	No	No	Yes	Yes
Offenses and penalties for unauthorized use of professional titles	No	No	No	Yes
A publicly accessible register of qualified practitioners	May be	May be	No	Yes
A publicly accessible register of disqualified or barred practitioners	No	No	Yes	Yes
Publication of disciplinary decisions	No	No	Yes	Yes
Protection from civil liability for board members discharging regulatory functions	No	No	Yes	Yes

Reprinted by permission from: Lloyd et al. (2021);¹¹ Adapted from Carlton.²¹

Voluntary certification provided by a professional association through established bylaws, membership entry standards, a code of ethics, and complaints procedure²¹ is subject to the skill set of those in elected positions. Where multiple professional associations exist, membership entry criteria, maintenance of ethical standards, and investigation of complaints have been found to be inconsistently applied.²² In Australia²³ and the United Kingdom,²⁴ professional associations have been found insufficient in this role, and voluntary registers have been largely ineffective^25,26 as associations lack legal mandate to remove expelled members from practice.²⁷ Lack of certainty of training standards serves as a significant barrier to partnering with other health system actors to attain the health-related SDGs.

Coregulation is somewhat similar to voluntary certification, but includes joint responsibility between a government and the association that often acts as a certifying body.²¹ Government recognizes or delegates some functions, for example, exemption from value added tax (VAT), in exchange for the certification body meeting specified governance requirements, certification standards and processes. Membership benefits arising from certification provide membership incentive to comply with self-regulatory standards. However, when the certifying body is not independent to the professional association, and when there is a lack of accountability measures attached to government support, standards have been known to vary.²⁸ The UK Law Commission identified deficiencies in the national voluntary registration scheme administered via a coregulatory framework that was established in 2008 and proposed that voluntary registers be viewed as a stepping stone to compulsory regulation.²⁹

Negative licensing is a mechanism that has been used to regulate statutory unregistered practitioners.³⁰ Negative licensing has limitations in that there is no legal barrier to entry for an unregistered profession; anyone can practice irrespective of the level of training. However, there are mechanisms in place to prohibit a practitioner from practicing where they have breached professional standards determined by a complaints process and code of conduct, or have committed an offence.^21,30 Rather than a replacement for statutory registration, Wardle et al.³¹ have argued that negative licensing does not provide the same protective role, and as such should be supplementary to statutory registration for all health professions.²⁵

Mechanisms for enforcing minimum qualification, probity standards for entry to practice, and regulatory powers to actively monitor compliance with standards are limited to statutory registration or occupational licensing. Lack of regulation for naturopathy has previously been shown to result in variability in training and practice standards.²² Statutory regulation underpinned by law and governance mechanisms not only results in uniform educational standards, the delivery of safe and effective services for consumers²² that are potentially cost-effective and cost-saving,¹⁹ it facilitates transdisciplinary referral mechanisms and policies for reporting adverse reactions.²² An Australian state review of regulatory requirements for naturopathy and Western herbal medicine recommended statutory registration of the workforce based on risk due to scope of practice and a practice context comparable with other regulated health professions,²³ a finding found elsewhere.³²

Furthermore, statutory regulation incentivizes and provides support for public–private sector collaborations and actions, between educational institutions, private and community clinics, encourages practitioners to align with the health needs of the community,² and supports integrative health workforce planning⁵ and policy development. This study investigates the relationship between naturopathic education, practice, and workforce regulation to provide understanding of the complexities impacting integration into health systems. Understanding regulatory complexities and challenges associated with TCIH integration requires examination to meet the goals of universal health coverage for all.

Materials and Methods

Design

The researchers used a sequential, hybrid explanatory mixed-methods design³³ with an embedded study to examine the relationship between naturopathic education and regulation. The mixed-methods research (MMR) case study consists of four phases—a cross-sectional survey,³⁴ document analysis of naturopathic organizational documents, embedded regulatory policy analysis, and lastly semistructured interviews of global naturopathic leaders. This article represents findings from the embedded study; analysis merges data arising from a descriptive policy analysis of regulation from 36 countries and descriptive survey analysis from 65 naturopathic organizations from 29 countries.³⁴

Sample

Cross-sectional survey: Purposive sampling was used to recruit leaders of global naturopathic organizations (educational institutions, professional associations, and regulators of naturopathy) to participate in an online cross-sectional survey. A list of global naturopathic organizations was provided by the WNF and complemented by additional internet searches. Invitations were e-mailed to 228 organizations from 46 countries. Leaders of naturopathic organizations or regulators of naturopathy were invited to participate where the organization primarily focused on naturopathy, education, representation, or regulation (NOT single natural medicine therapies); met or exceeded the WHO training guidelines (a minimum of 2 years, no less than 1500 h, a minimum of 400 h of clinical training) OR provided the highest national education standards for the country as identified by the WNF; and the qualification was obtained through attendance or both attendance and online/distance education. Recruitment and data collection occurred between November 2016 and August 2019.

Policy analysis: In the qualitative strand of this study, conducted between April and June 2021, the WHO 2019 T&CM report¹⁰ was used to create a list of countries that potentially have regulation in place for naturopathy as reported to the WHO by member-states. The CAMbrella report³⁵ was used to locate additional European countries with established regulation that includes naturopathy. Findings from previous WNF surveys^8,36 provided an additional reliability cross-check for countries selected. Regulations found from previous WNF searches and legislation collected from member organizations were included. Fifty-six countries with potential for naturopathy legislation were identified.

Survey instruments and procedures

Ethics approval was gained from the University of Technology Sydney, Human Research Ethics Committee before commencement [ETH16-0327 updated ETH16-0865]. Participants were provided with a research information sheet and formal invitation to participate together with a link to the survey. Participants provided consent by prereading the research information sheet before commencing the survey. The survey and documentation provided were in the English language. Data were collected using the SurveyGizmo platform between November 2016 and August 2019. An extended survey time frame was necessary as new organizations emerged. The online survey took ∼60 min to complete. Thirty follow-up invitation e-mails were sent to participants over a 34-month period. Participants were requested to collaborate with an English-speaking colleague or to contact the researcher for translation assistance where English skills impacted the ability to complete the survey. No translation assistance was requested.

The survey instrument was developed in conjunction with members of the WNF Professional Mapping Committee and consisted of 59 items relating to 6 domains— (1) organization demographics, (2) education characteristics, (3) organizational influence on education, (4) regulatory characteristics, (5) perception of regulation, and (6) consultation reimbursement characteristics. Definitions were provided for key terms. Survey logic was used to customize questions by organizational and regulation type. The survey instrument (see Supplementary File 1) was piloted on a convenience sample of organizations from five countries and minor changes were made based on feedback. Most survey items were multiple choice (69%), 12% provided seven-point rating scales and 42% provided comments. Items providing open-form answers accounted for 19% of the survey instrument.

Policy analysis instruments and procedures

Publicly available legislative documents were sourced and collected through legal databases and government websites searched between April and June 2021 (see Supplementary File 6—search strategy). An updated search was conducted in December 2022 for countries on the list where legislation had not been previously located (see Supplementary File 2).

An a priori framework was employed to develop tables using four categories of regulation reported by Carlton.²¹ Directed content analysis using deductive logic³⁷ was conducted by two people and cross-checked. Findings were triangulated with the data set from the 2016–2019 survey and foundational data obtained from previous WNF searches and surveys,^8,36 to establish the presence of occupational regulation and a naturopathic workforce in countries (see Tables 2 and 3; Supplementary File 3).

Table 2.

Countries by World Health Organization Region with a Naturopathic Workforce and Statutory Regulation

WHO region	Countries with a naturopathic workforce	Countries with statutory regulation
African Region	Angola, Botswana, Democratic Republic of the Congo, Ghana, Kenya, Mauritius, Namibia, Nigeria, South Africa, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe	Botswana, Democratic Republic of the Congo, Ghana, Namibia, Nigeria, South Africa, Swaziland, Tanzania, Uganda, Zimbabwe
Region of the Americas	Antigua and Barbuda, Argentina, Bahamas, Barbados, Belize, Bermuda, Bolivia, Brazil, British Virgin Islands, Canada, Chile, Colombia, Costa Rica, Cuba, Dominica Republic, Ecuador, El Salvador, Guatemala, Guyana, Haiti, Honduras, Jamaica, Mexico, Nicaragua, Panama, Paraguay, Peru, Puerto Rico, Saint Lucia, Saint Martin, Trinidad and Tobago, United States of America, Uruguay, Venezuela, Virgin Islands	Canada, Chile, Colombia, Cuba, Ecuador, Peru, Puerto Rico, Saint Lucia, United States of America
Eastern Mediterranean Region	Bahrain, Egypt, Iran, Kuwait, Morocco, Qatar, Saudi Arabia, United Arab Emirates	Bahrain, Saudi Arabia, United Arab Emirates
European Region	Albania, Austria, Belgium, Bosnia and Herzegovina, Cyprus, Czech Republic, Denmark, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Liechtenstein, Luxembourg, Netherlands, Norway, Portugal, Romania, Russia, Slovakia, Slovenia, Spain, Sweden, Switzerland, Ukraine, United Kingdom	Albania, Cyprus, Germany, Hungary, Iceland, Liechtenstein, Portugal, Romania, Switzerland
Southeast Asia Region	India, Indonesia, Nepal, Sri Lanka, Thailand	India, Nepal
Western Pacific Region	Australia, Cambodia, China, Cooks Island, Fiji, Hong Kong, Japan, Malaysia, New Zealand, Philippines, Republic of Korea, Samoa, Singapore, Vanuatu, Viet Nam	Cook Islands, Malaysia, Samoa

Adapted from Lloyd et al. (2021).¹¹

WHO, World Health Organization.

Table 3.

Type of Occupational Licensing by World Health Organization Region

WHO region	Countries with naturopathic workforce (n = 107)	Statutory regulation (n = 36)	Coregulation/negative licensing (n = 4)/(n = 1)	Voluntary certification (with no other type of regulation) (n = 15)	No occupational regulation (n = 52)
	n (%)	n (%)	n (%)	n (%)	n (%)
African Region	14 (13.1)	10 (27.8)	0	0	4 (7.7)
Region of the Americas	35 (32.7)	9 (25.0)	1 (25.0)^a	2 (13.3)	23(44.2)
Eastern Mediterranean Region	8 (7.5)	3 (8.3)	0	0	5 (9.6)
European Region	30 (28.0)	9 (25.0)	2 (50.0)^a	11 (73.3)	8 (15.4)
Southeast Asia Region	5 (4.7)	2 (5.6)	0	0	3 (5.8)
Western Pacific Region	15 (14.0)	3 (8.3)	1 (25.0)/1 (100.0)^b	2 (13.3%)	9 (17.3)
Total	107 (100.0%)	36 (33.6%)	4 (3.7%)/1 (0.9%)^b	15 (14.0%)	52 (48.6)

Brazil, Norway, and the United Kingdom included under coregulation.

Australia has both coregulation and negative licensing regulatory mechanisms in operation.

Inclusion and exclusion criteria were applied to documents collected before data extraction commenced (see Supplementary File 4).

Data analysis and integration

In accordance with the explanatory MMR design, priority was placed on the initial quantitative phase and subsequent qualitative components are used to explain the quantitative results.³³ Before survey analysis, raw data were screened for incomplete responses or duplicates. Disqualified and partially completed responses were removed from analysis. Descriptive statistics were tabulated as frequencies and percentages using IBM SPSS Statistics Standard edition Version 25, and cross-tabulations were calculated by regulation type and country. Medians were calculated for rating scales.

Survey results informed requirements for policy analysis. Policy analysis examined the type of workforce regulation used for naturopathy and how it was applied, and was compared with survey data, specifically educational frameworks and practices of a range of potentially restricted acts and regulation type reported by survey participants (i.e., “no regulation,” “title protection,” “defined scope of practice,” and “other” regulation types).

Results

The findings presented demonstrate types of regulation of the naturopathic workforce and the interface with education frameworks and naturopathic practices.

Professional regulation frameworks

Four types of naturopathic workforce regulation were identified within countries in this study (n = 107)—statutory registration also referred to as occupational licensing (33.6%, n = 36), coregulation (3.7%, n = 4), negative licensing (0.9%, n = 1), and voluntary certification (14.0%, n = 15). In almost half of the countries (48.6%, n = 52), no form of naturopathic workforce regulation was identified (see Table 3; Supplementary File 3).

Thirty-six countries were found to have some form of naturopathic workforce statute-based regulation (see Tables 2 and 3). Relative to the presence of a naturopathic workforce, the region of Africa had the highest proportion of countries with a statutory registered naturopathic workforce (71.4%) (n = 10). In other regions ∼20%–40% of countries had statutory registration or occupational licensing for the naturopathic workforce—S.E. Asia (40%), E. Mediterranean (37.5%), the Americas (25.7%) (n = 9), Europe (30.0%) (n = 9), and the Western Pacific (20.0%) (n = 3).

Some countries, namely Canada and the United States, have occupational licensing laws specific to the naturopathic profession (i.e., a “Naturopathy Act”) in many jurisdictions. In most countries (80.6%, n = 29), the legislative mechanism used is an umbrella law. The umbrella law may be a generic “health professions law” with regulations enacted for each participating profession, for example, in the Canadian provinces of Alberta and British Columbia. In others, the naturopathy profession is regulated alongside other disciplines of traditional medicine, or allied health professions, for example, in South Africa and Samoa.

Coregulation was identified in Australia, Brazil, Norway, and the United Kingdom. The only country that had negative licensing (where unregistered practitioners could be removed from practice) was Australia. Regulation of the European naturopathic workforce was found to differ between countries (n = 30) (see Table 2; Supplementary File 3) with voluntary certification (36.7%, n = 11), statutory regulation (30.0%, n = 9), and “no occupational regulation” (26.7%, n = 8) reported. “No occupational regulation” was also common in the Region of the Americas and Western Pacific (see Supplementary File 3). Subnational regulation of the naturopathic workforce was found in Canada, Switzerland, and the United States, where provinces, cantons, or states apply their own rules and regulations.

Quality education frameworks

In the survey 2016–2019, 65 organizations responded (29% response rate) from 29 countries (63% country response rate) (see Supplementary File 5). All six WHO world regions were represented. Respondents primarily represented professional associations (53.8%, n = 35), followed by educational institutions (38.5%, n = 25) and regulatory boards (7.7%, n = 5).

The regulatory status most frequently reported was “no regulation” (43.1%, n = 28), followed by “defined scope of practice” (41.5%, n = 27), “title protection” (27.7%, n = 18), and “other” regulation type (10.8%, n = 7).

More than half of the naturopathic educational institutions in this study reported delivery of higher education programs (60%, n = 15) and delivery via an official national qualification or education accreditation framework (68%, n = 17). Delivery of undergraduate degrees in naturopathy were reported in Australia, Brazil, and New Zealand, countries in which the naturopathic workforces did not have statutory registration, although some form of coregulation was present in Australia and Brazil (see Supplementary File 3). Graduate/postgraduate naturopathic education was reported in Canada, Puerto Rico, South Africa, and the United States where the naturopathic workforces have statutory registration.

Most educational institutions (76%, n = 19) (n = 25) from 11 countries reported some type of external audit by multiple organizations as part of quality assurance mechanisms (see Supplementary File 6). Program audits by professional associations (33.3%, n = 12) were more commonly reported where naturopathy was not regulated, and by an external agency or accreditation body (30.6%, n = 11) or by government audits (30.6%, n = 11) more commonly where the profession was regulated (see Table 4). Regardless of regulatory status, government audits were reported where programs were delivered via a national qualifications or accreditation framework. The most frequent type of audits reported were for course content, delivery, and assessment, followed by a clinical process (see Table 4; Supplementary File 6).

Table 4.

Characteristics of Global Naturopathic Education Frameworks

Characteristics of naturopathic educational programs (n = 25)^a	N	%
Program and qualification type
Vocational (diploma or unspecified qualification level)^b	10	40.0
Undergraduate bachelor's degree (Australia, Brazil, New Zealand)	6	24.0
Postgraduate qualification (Canada, Puerto Rico, South Africa, United Kingdom, United States)	9	36.0
Qualification delivered by national qualifications' framework
Yes^c	17	68.0
No	8	32.0
Characteristics of program audits (n = 25)
Schools reporting some type of external audit
Yes	19	76.0
No	6	24.0
Organizations responsible for external audits^d
Government	11	30.6
Private	0	0.0
Professional association	12	33.3
Accrediting body	11	30.6
Other	2	5.6
External audit type^e
Governance/quality assurance	18	19.8
Course content, delivery, and assessment	27	29.7
Clinical processes	20	22.0
Financial	17	18.7
Other	9	9.9

Adapted from Dunn et al. (2001).³⁴

In 2018, World Naturopathic Federation identified 131 naturopathic programs that meet the minimum WHO benchmarks for training in naturopathy—1500 h including 400 h of clinical practice, and highest standard in the country.

Belgium, Czech Republic, France, Italy, Nepal, Slovenia, Uruguay, Venezuela (n = 10 respondents, n = 8 countries).

Included Italy based on UNI ISO standard.

n = 19 [36 responses].

n = 24 [91 responses].

In setting standards, when naturopathy was regulated with legislated “title protection” (77.7%, n = 14) (n = 18) and/or a “defined scope of practice” (74.0%, n = 20) (n = 27), regulatory boards were reported to have the most influence. Where naturopathy was unregulated (75.0%, n = 21) (n = 28) or when other nonstatutory types of regulation existed (85.7%, n = 6) (n = 7), national professional associations were more frequently reported to undertake this role.

Integration of findings in this mixed-methods study observed that in countries where naturopathy was delivered by graduate/postgraduate higher education, the workforce was more often statutory registered and had access to a broader range of potentially restricted acts, for example, physical examination, which may be required to meet the SDGs (see Supplementary Files 6 and 7). Countries delivering vocational-level training (diploma or unspecified qualification level) more often had workforce voluntary certification and reduced access to a range of restricted acts, except Nepal where naturopathy is statutory regulated (see Supplementary Files 6 and 7). Independent audits were reported by differing methods of regulation, although government audits were more frequently reported when the workforce was statutory regulated and where coregulated.

Discussion

The naturopathic workforce is largely unregulated and is inconsistently regulated in federal jurisdictions. Sometimes regulation actively prevents practitioners from practicing safely and effectively, as when bans are placed on medical examination,^34,38 or access to “tools of trade.”^34,39 Lack of regulation often leads to the setting of practice and education standards for the profession to be outsourced to nongovernment sources, which can work where professional infrastructure is well-developed. However, it can result in conflicts of interest or inconsistencies if multiple groups have competing standards²⁸—and has the potential for co-option of title by unqualified practitioners.²²

Regulatory initiatives have the potential to strengthen accreditation of education programs and institutions to ensure graduate competence for entry to practice, to foster multidisciplinary collaboration and health workforce integration,³² and workforce planning.⁵ Existing high-quality workforce data exist for physicians and classes of nurses, however, are limited for other regulated health professionals, particularly registration status, specialty certifications, education within and outside the profession, shared practices, practice characteristics, and demographics.⁴⁰ Limitations of workforce planning and policy development in the past have contributed to invisibility of the naturopathic profession within the health care workforce²⁷ and to limited development of infrastructures to support integration into mainstream health systems²³ and to meeting the Astana Declaration goals.

Limited TCIH legislative provision for naturopathy directly contrasts with the public role of these professionals in health care delivery and is inconsistent with the broad public support for increased regulation of TCIH practice⁴¹ and clarity deserved by consumers.⁴² Regulation is not keeping pace with the changing developments in the health care workforce.³¹ Increased transparency and public accountability have resulted in lay representation on boards of regulated professions,³⁰ yet the public are not afforded the same consideration for unregulated TCIH services. Furthermore, patients seeking TCIH services across borders in the European Union are faced with different standards of training of identical TCIH providers and different reimbursement systems^35,43 due to variable adoption of risk-based regulation between countries.³⁰ This variability remains a tension to achieving the SDGs.

Lack of legislative provision for the TCIH workforce and concomitant standard mechanisms creates two issues: one, the nonintegration of an untapped safe and effective, valuable, accessible, and trusted resource, and two, public exposure to undue risk associated with using practitioners when standards cannot be assured.¹¹ With respect to naturopathy specifically, studies have shown that integration of naturopathic medicine practitioners is clinically cost-effective in multiple settings,¹⁹ with regulation key to improving standards to ensure that benefits are maximized, while risks are minimized.¹¹

Integration of TCIH into health systems and active naturopathic partnership in achieving the health-related SDGs require consistent national regulation for health professions. The naturopathic profession has demonstrated that it can establish required quality mechanisms when supported by government. Irrespective of what legislative instrument is used, naturopathic expertise is essential in regulatory decision-making—setting entry to practice standards, setting, applying, and assessing accreditation standards for education programs and providers, and monitoring professional practice, complaints, and discipline, which has the propensity to further develop the profession. Mechanisms used in regulation decision-making must be appropriate to the profession necessitating the principles of peer review to safeguard standards, promote trust, and better protect the public.¹¹

Limitations

Findings from this study should be viewed within the context of its limitations. Naturopathic regulation is evolving globally and is increasingly under umbrella law. The search terms used were broad, however, due to some limitations in online access to legislation; inconsistency in regulation of terms used between countries and the possibility that different terminology has been used; that traditional medicine regulation includes naturopathy at an operational level but is not explicit in the regulation; or subnational regulation is in process, legislation included may be incomplete.

In addition, in this study survey,³⁴ respondent participation was limited. Therefore, the examination of educational frameworks and accountability mechanisms may not be complete or representative. The survey's extended time frame and the evolving nature of education mean that data collected earlier may not be directly comparable with that collected later. Notwithstanding, this study offers the most comprehensive global examination of education and regulation frameworks for the naturopathic workforce to date and as such offers policy makers and professional stakeholders valuable insights into regulatory challenges that impact the Declaration of Astana goals.

Conclusions

Naturopathic philosophy and practice significantly align with primary health care goals considering prevention, person-centered health care and education, determinants of health, self-responsibility, and sustainability¹¹ outlined in the Declaration of Astana. The naturopathic workforce represents an untapped health care resource with a demonstrated track record of translating these aspirational goals into practice and potentially more so than other primary care practitioners.¹¹ However, the naturopathic profession remains inconsistently regulated globally, serving as a significant barrier to partnering with other health system actors to attain universal health coverage, health-related SDGs. Development of appropriate workforce regulation for the naturopathic profession not only offers benefits to increase standards and reduce risks but can also help countries' workforce planning⁵ initiatives toward achieving the promise of the Declaration of Astana.

Footnotes

Acknowledgments

The authors thank the World Naturopathic Federation (WNF), the participants of these surveys, the global naturopathic community, and the WNF Professional Mapping Committee, particularly Nick DeGroot, Tina Hausser for support provided in aspects of this initiative.

Authors' Contributions

J.D.: Conceptualization (equal); data curation (equal); formal analysis (equal); investigation (equal); methodology (equal); project administration (supporting); writing original draft (lead); and review and editing (equal). I.L.: Conceptualization (equal); data curation (equal); formal analysis (equal); investigation (equal); methodology (equal); project administration (lead); and review and editing (equal). A.S.: Conceptualization (supporting); formal analysis (supporting); methodology (supporting); supervision (supporting); and review and editing (equal). J.A.: Conceptualization (supporting); methodology (supporting); supervision (supporting); and review and editing (equal). J.W.: Conceptualization (equal); formal analysis (supporting); methodology (supporting); supervision (lead); and review and editing (equal).

Availability of Data and Materials

Legislation used in this analysis can be found in the public domain. The survey data set generated during the current study is not publicly available due to potentially identifying information, but is available from the corresponding author on reasonable request.

Author Disclosure Statement

The lead authors have no conflict of interest, although J.D. has affiliation with Naturopaths and Medical Herbalists of New Zealand, Inc. and has been Chair of the World Naturopathic Federation (WNF) Professional Mapping Committee; I.L. is President of the WNF; J.W. and A.S. have affiliations with the Australian Register of Naturopaths and Herbalists (ARONAH) and the WNF. All organizations above support regulation and recognition of naturopaths.

Funding Information

This study is part of a higher degree by a research project undertaken by J.D. through the Australian Research Centre in Complementary and Integrative Medicine (ARCCIM), University of Technology, Sydney (UTS). J.D.'s PhD study has been financially supported by an Australian Government Research Training Program Scholarship and a UTS Research Excellence Scholarship. These funding bodies have had no influence on the study design, data collection, analysis, and interpretation, or the article.

Supplementary Material

Supplementary File 1

Supplementary File 2

Supplementary File 3

Supplementary File 4

Supplementary File 5

Supplementary File 6

Supplementary File 7

References

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Naturopathic Workforce: A Global Resource Toward the Declaration of Astana Goals—A Multimethods Study

Abstract

Introduction:

Materials and Methods:

Results:

Discussion:

Introduction

Naturopathy a partner in addressing the Declaration of Astana goals

The naturopathic workforce is an untapped health care resource

Workforce regulation—a support or threat to achieving SDGs

Materials and Methods

Design

Sample

Survey instruments and procedures

Policy analysis instruments and procedures

Data analysis and integration

Results

Professional regulation frameworks

Quality education frameworks

Discussion

Limitations

Conclusions

Footnotes

Acknowledgments

Authors' Contributions

Availability of Data and Materials

Author Disclosure Statement

Funding Information

Supplementary Material

References

Supplementary Material