Characterizing Therapeutic Pluralism Policies in Latin America: A Qualitative Content Analysis

Abstract

Introduction:

The 1978 Alma Ata Declaration initiated international recognition of non-biomedical healing systems and their relevance for primary health. World Health Assembly (WHA) resolutions have called for the study and inclusion of traditional and complementary medicine (T&CM) into national health systems through policy development. The increased public, political, and scholarly attention given to T&CM has focused on clinical efficacy, cost-effectiveness, mechanisms of action, consumer demand, and supply-side regulation. Although >50% of WHO member states have T&CM policies, scant research has focused on these policies and their public health implications. This paper defines a novel term “therapeutic pluralism,” and it aims at characterizing related policies in Latin America.

Methods:

A qualitative content analysis of Latin American therapeutic pluralism policies was performed. Policies' characteristics and the reported social, political, and economic forces that have made possible their development were assessed. Pre-defined policy features were categorized on an MS-Excel; in-depth text analyses were conducted in NVivo. Analyses followed the steps described by Bengtsson: decontextualization, recontextualization, categorization, and compilation.

Results:

Seventy-four (74) policy documents from 16 of the 20 sovereign Latin American countries were included. Mechanisms for policy enactment included: Constitution, National Law, National Policy, National Healthcare Model, National Program Guideline, Specific Regulatory Norms, and Supporting Legislation, Policies, and Norms. We propose a four-category typology of policy approaches in Latin America: Health Services-centered, Model of Care-based, Participatory, and Indigenous People-focused. Common themes countries used when justifying developing these policies included: benefits to the health system, legal and political mandates, supply and demand, and culture and identity. Social forces these policies referenced as influencing their development included: pluralism, self-determination and autonomy, anticapitalism and decolonization, safeguarding cultural identity, bridging cultural barriers, and sustainability.

Conclusion:

Policy approaches to therapeutic pluralism in Latin America go beyond integrating non-biomedical interventions into health services; they offer perspectives for transforming health systems. Characterizing these approaches has implications for policy development, implementation, evaluation, international collaboration, the development of technical cooperation tools and frameworks, and research.

Introduction

Non-biomedical therapeutic systems, frequently known as Traditional and Complementary Medicine (T&CM), have received increased public, political, and scholarly attention during the past few decades. Scant research has examined T&CM policies, their characteristics, and public health implications, since attention has focused on clinical efficacy, cost-effectiveness, mechanisms of action, consumer demand, and supply-side regulation.¹ This paper aims at contributing to closing this gap through characterizing related policies in Latin America, identifying enactment mechanisms, proposing a typology of approaches, and describing the social forces that have influenced and justified their development.

Through policies, countries can streamline T&CM interplay within the health care system, seeking safety, rational use, quality, and surveillance to protect the public and simultaneously take advantage of its potential contributions.^2,3 The World Health Organization's (WHO) 2019 global report showed that 98 (50.5%) of member states have T&CM national policies, 109 (56%) have national or state-level laws or regulations, and 124 (63%) regulate herbal medicines.⁴

Most health care systems, however, are based on Biomedicine, a “clinical medicine based on the principles of physiology and biochemistry,”⁵ often marginalizing T&CM. Biomedicine's limits have been described and it is now also regarded as a “sociocultural system” resulting from a specific cultural history, cosmology, values, beliefs, and rituals, as any other medical system.^6

–9

International health context

The 1978 Alma Ata Declaration opened a new era in the formal recognition of non-biomedical healing systems and their relevance for delivering care to the world's populations. A vast array of healing approaches has existed throughout history, evolving in a dynamic interplay with repercussions at the local, regional, and global levels.^2,10 Although the advent of national health systems ignored non-biomedical approaches, Alma Ata called for investigating their contributions to health and considering traditional medicine practitioners as part of primary health care teams.^11,12 The 2018 Astana Declaration reaffirmed the importance of traditional knowledge for strengthening primary health care to “improve health outcomes and ensure access for all people to the right care at the right time and at the most appropriate level.”¹³

Building on World Health Assembly (WHA) resolutions since the 1970s calling for the study and the active inclusion of T&CM into national health systems,^{14

–25} the WHO issued its Traditional Medicine Strategy. First published in 2002 and updated in 2013, it provided incipient guidance for policy development.^2,26 Supporting the WHO's Strategy, other international instruments have renewed the call on member states to harness the potential contributions of T&CM to health, wellness, and people-centered health care, including self-care practices.^27,28 In many contexts, those non-biomedical healing systems and therapeutic methods are a primary source of health care, including in countries with well-established health care systems.^2,29
–31

Theoretical framework

The WHO defines T&CM policies broadly: “guiding principles regarding policy, planning or future direction”⁴ on the topic. They can either be specifically designed or a component of other policies. The WHO definitions for non-biomedical healing systems and practices are contextual by nature.² What is “traditional” in one country could be understood as “complementary” in another. They also take for granted biomedicine's dominance. Further, they may imply that the boundaries between one another are clear, whereas at the user end, and often, at the practitioner level, such edges are blurry.^32,33

In Latin America, country-specific usage of the T&CM terms seldom corresponds with WHO definitions. In Cuba, for example, their use of the term “traditional medicine” corresponds to the WHO's “complementary medicine” notion. Mexico proposed the term “clinical-therapeutic and health strengthening models” instead of “complementary” medicine. In Brazil, “health practices” is preferred over “medicine” when referring to T&CM. The term “natural” medicine is used in countries such as Cuba and Nicaragua. In other contexts, such as Chile, Colombia, Ecuador, Guatemala, and Peru, the “alternative” [medicine or therapies] notions are still in fashion.

Further, in Latin America, interculturality, “the existence and equitable interaction of diverse cultures and the possibility of generating shared cultural expressions through dialogue and mutual respect”³⁴ has been a conceptual avenue through which T&CM made inroads into national health systems. Interculturality is often understood as “the possibility of articulating biomedicine and traditional medicine through ‘parallel [or horizontal] relationships instead of dominance or hegemony/subalternity.”³⁵ It has been proposed as a decolonizing mechanism “to develop symmetries in power relations” and a “principle” to promote new social contracts beyond neoliberal and capitalist proposals.³⁶

To acknowledge the conceptual complexities in terminology cited earlier, we adopted “therapeutic pluralism” and proposed a definition. We believe it adds nuance to “medical pluralism,” currently used widely. Although helpful in highlighting the “power and inequalities between providers inside [the] stratified market,”³⁷ and an “active engagement with diversity or plurality,”³⁸ it contains the problematic adjective “medical.” In current usage, “medical” has incorrectly become a de facto synonym of biomedicine.

Therapeutic, although a synonym of “medicine,” is more closely related to “the art of healing”³⁹ in a generic way. Using Fligstein and McAdam's theory of fields,⁴⁰ we preliminary defined therapeutic pluralism as the “strategic action field in which a variety of social actors, perceiving life, health, and healing according to diverging (or converging) cosmologies and cultures, mobilize for social space and the transformation of socially constructed systems and agency for inclusive action in health.”⁴⁰

The Latin American context

Latin America is home to about 10% of the world's population. Despite a shared social and cultural heritage, it exhibits great diversity, reflected in the variety of healing systems and practices used.^41,42 The idea of a “Latin” America is rooted in colonialism. This Eurocentric notion denotes a purview from inside (the Europeanized component of its population) and outside (the “othering” that Europe and the U.S. subjected the region to).⁴³

The region's definition as “Latin” reflects the seed of pervading inequalities; the “Latin” character was accepted and promoted by Europeans-descendant's elite.⁴³ Defining the region as “Latin” amounted to marginalizing the Indigenous populations and African-descendants, although constituting the majority of the population in several countries (Table 1).⁴³ There are >500 Indigenous languages in “Latin” America!⁴⁴ This “Latin” depiction would substantially affect how non-European traditions (and their healing practices) would be looked upon by the newly formed states and their institutions, including “medicine.” And as it will be shown, it would have policy implications.

Table 1.

Indigenous and Afro-Descendent Population in Latin America (2010)

Country	Total population	Indigenous population, %		Afro-descendent population, %
Argentina	40,117,096	96,2810	2.4	160,468	0.4
Bolivia	9,995,000	6,216,890	62.2	19,990	0.2
Brazil	190,755,799	953,779	0.5	97,094,702	50.9
Chile	16,341,929	1,797,612	11	9805	0.06
Colombia	46,448,000	1,579,232	3.4	4,877,040	10.5
Costa Rica	4,301,712	103,241	2.4	335,534	7.8
Cuba	11,167,325	n/a	n/a	4,009,070	35.9
Dominican Republic	9,445,281	n/a	n/a	1,497,621	15.8
Ecuador	14,483,499	101,3845	7.0	1,042,812	7.2
El Salvador	6,218,000	12,436	0.2	6218	0.1
Guatemala	14,334,000	5,876,940	41	5734	0.04
Haiti	9,949,322	n/a	n/a	9,501,603	95.5
Honduras	7,619,000	533,330	7.0	106,666	1.4
Mexico	112,336,538	16,962,817	15.1	1,348,038	1.2
Nicaragua	5,813,000	517,357	8.9	29,065	0.5
Panama	3,405,813	418,915	12.3	313,335	9.2
Paraguay	62,32,511	112,185	1.8	12,465	0.2
Peru	29,272,000	7,025,280	24	585,440	2.0
Uruguay	3,251,654	78,040	2.4	149,576	4.6
Venezuela	27,227,930	735,154	2.7	925,750	3.4

Source: Centro Latinoamericano y Caribeño de Demografía (CELADE) (2013) Los pueblos indígenas en América Latina, Avances en el último decenio y retos pendientes para la garantía de sus derechos. Banco Mundial (2018) Afrodescendientes en Latinoamérica: Hacia un marco de inclusión. Santacruz Palacios, Marcia (2019) Pueblos afrodescendientes en América Latina: realidades y desafíos. Simms TM, et al. The genetic structure of populations from Haiti and Jamaica reflect divergent demographic histories. Am J Phys Anthropol 2010 May;142(1):49–66. Oficina Nacional de Estadística (ONE) (2015) República Dominicana: Indicadores estimados y proyectados de la estructura de la población, 1950–2050. Central Intelligence Agency (2021) The World Factbook, Dominican Republic.

Methods

This study (part of the first author's doctoral dissertation) focuses on a qualitative content analysis of therapeutic pluralism policies from the 20 sovereign Latin American countries, where a Romance language or a local derivative is predominantly spoken (Table 1).^45,46 Aiming at proposing a therapeutic pluralism typology of policy approaches in the region, we assessed policies' characteristics and the reported social, political, and economic forces that have made possible their development.

Qualitative content analysis is a method to systematically organize and analyze written text's manifest, contextual, and latent information.^47

–51 We identified policy documents via governmental websites, WHO publications, references from the literature, key informants (health officers, academics), and the Virtual Health Library on Traditional, Complementary, and Traditional Medicine of the Americas (VHL TCIM Americas).⁵²

Only documents confirmed as representing some aspect of a country's therapeutic pluralism policy by key informants (37 semi-structured interviews) were included in the analysis. Medicinal products regulation has mainly developed independently of T&CM policy⁵³; thus, they were excluded from the analysis. Norms that solely regulate the implementation of sanctioned therapeutic pluralism laws were jointly analyzed with those laws to prevent duplication. Current and repealed/obsolete documents were included in the analysis to allow a historical perspective. No time limits were set.

Seventy-four (74) policy documents from 16 of the 20 sovereign Latin American countries were included. We identified “policy mechanisms,” defined as the choice of political, legislative, regulatory, or administrative avenues through which policy initiatives are enacted.

Categorizing pre-defined policy features was performed on an MS-Excel spreadsheet, including fields such as reach (practices, practitioners, products); therapies/systems mentioned/recognized; governmental body responsible for its adoption; and type of administrative act; scope; among others. In-depth text analyses were conducted utilizing NVivo qualitative data analysis software (QSR International), and they followed the steps described by Bengtsson (2016)⁵⁴: decontextualization (data familiarization through the first round of inductive coding, defining meaning units); recontextualization (second round of reading and coding, ranking of code priorities for concept development); categorization (definition of concepts, themes, and categories, comparisons across policies); compilation (analysis of manifest and latent text, describing categories, themes, and concepts).

Boston University's Medical Campus IRB exempted the study from full review (IRB Number: H-39339).

Results

The majority (16 out of 20) countries have some form of therapeutic pluralism policy. Using WHO's T&CM policy definition and the described methods, we identified an additional seven countries (Argentina, Colombia, El Salvador, Guatemala, Haiti, Paraguay, and Venezuela) to the nine WHO reported in 2019 (Bolivia, Brazil, Chile, Cuba, Ecuador, Mexico, Nicaragua, Panama, Peru) as having T&CM policies.⁴ We did not find related policies in Costa Rica, Honduras, the Dominican Republic, and Uruguay. Later, we describe the mechanisms countries in the region used to enact such policies (further details in Table 2) and propose a typology of current policy approaches (further details in Table 3). We also describe common themes used when justifying therapeutic pluralism policies (Table 5) and the social forces that influence the development of such policies in Latin America (Table 6).

Table 2.

Policy Mechanisms for Therapeutic Pluralism Policy Development in Latin America

Policy mechanisms^a	No. of documents	Countries
(1) Constitution	4	Bolivia, Ecuador, Mexico, Venezuela
(2) National Law	4	Bolivia, Nicaragua, Panama
(3) National Policy	14	Brazil, Chile, Cuba, Guatemala, Peru
(4) National Healthcare Model	5	Bolivia, Ecuador, Guatemala, Mexico, Peru
(5) National Program Guideline	10	Bolivia, Brazil, Chile, Colombia, Ecuador, Mexico
(6) Specific Regulatory Norms	10	Chile, Cuba, Ecuador, Mexico, Panama, Venezuela
(7) Supporting Legislation, Policies, and Norms	27	Argentina, Bolivia, Chile, Colombia, Cuba, Ecuador, El Salvador, Haiti, Mexico, Nicaragua, Panama, Paraguay, Peru, Venezuela

Criteria for policy mechanism definition and grouping included (a) the hierarchy of law,^* and (b) the focus on therapeutic pluralism. For example, a national-level legislative act was only classified as “National Law” if it focused on therapeutic pluralism. If equivalent-in-rank legislation focused on another health-related topic yet embodied an aspect of therapeutic pluralism policy in the country, it was classified as “Supporting Norms & Legislation.”

Table 3.

Therapeutic Pluralism Policies of Regional Integration Organizations

Organization	Constituent countries	Policies and main mandates
Latin American and Caribbean Parliament (PARLATINO)	Argentina, Aruba, Bolivia, Brazil, Chile, Colombia, Costa Rica, Cuba, Curacao, Dominican Republic Ecuador, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, San Martin, Suriname, Uruguay, Venezuela	(Resolution No. 13 of 2009) Framework Law of Traditional Medicine for Latin America and the Caribbean: It advocates for recognition, protection, practice, research, regulation, and integration of traditional medicine in health systems. It recommends countries delegate traditional medicine practitioners' recognition and regulation to Indigenous communities, the protection of traditional knowledge, and sustainable use of natural resources.
Latin American and Caribbean Parliament (PARLATINO)		(Resolution No. 14 of 2009) Framework Law on Complementary Medicines for Latin America and the Caribbean: It seeks to establish guidelines for regulating complementary medicine practice, teaching, and research. It recommends defining complementary medicine systems/modalities to be recognized, training standards, and practitioners' registration for their incorporation in national health systems.
Andean Health Organization-Hipólito Unanue Agreement (ORAS-CONHU), of the Andean Integration System	Bolivia, Colombia, Chile, Ecuador, Peru, Venezuela	Andean Policy of Intercultural Health (2019): It proposes human resources capacity strengthening on intercultural health, the recognition, protection, and articulation of traditional medicine in health systems. It encourages the development of information systems, research capacity strengthening, intercultural health transversalization across the health system, and social participation.
Central American Parliament (PARLACEN), of the Central American Integration System—SICA	Guatemala, Dominican Republic, El Salvador, Honduras, Nicaragua, Panama	(Resolution-AP-6-CCLXXXIX-2017) Incorporation and application of Integrative Medicine in Health Systems in the SICA Member States: It recommends that member states recognize and protect Indigenous and Afro-descendant traditional medicine. It highlights the importance of complementary medicine/therapies recognition in national health systems as components of “integrative medicine.”

Policy mechanisms

We identified seven mechanisms through which countries set therapeutic pluralism policy: (1) Constitution, (2) National Law, (3). National Policy, (4) National Healthcare Model, (5) National Program Guideline, (6) Specific Regulatory Norms, and (7) Supporting Legislation, Policies, and Norms. A summary of document classification by policy mechanism and country of origin is shown in Table 2. All documents included in the analysis, with their classification and other characteristics, are listed in Supplementary Table S1.

Constitution: Four countries recognize therapeutic pluralism in their constitution, framing it within the right of Indigenous peoples to preserve their identity, culture, and traditions. Three of them (Bolivia, Ecuador, Mexico) mandate the government to include traditional medicine in the health system's services. Ecuador's and Venezuela's constitutions also include complementary medicine/therapies. Constitutions from other countries don't explicitly mention T&CM. Still, some have enshrined principles that support related policy developments, such as the right to choose the health system (Chile) or the need to protect ethnic and cultural diversity (Argentina, Brazil, Colombia, Guatemala, Haiti, Panama, and Peru).

National Laws: Bolivia (in 2013),⁵⁵ Nicaragua (in 2011),⁵⁶ and Panama (in 2016)⁵⁷ passed traditional medicine-specific laws. All incorporate establishing national consultative bodies, mechanisms for the protection of cultural heritage, biodiversity, medicinal plants, intellectual property rights, traditional knowledge, and medicine, including research safeguards and health system integration. Bolivian and Nicaraguan laws explicitly include the Afro-descendant's traditions. Nicaragua is the only country in the region with a complementary medicine law (2011).⁵⁸

National Policy: A specific public policy document, often dedicated to either traditional or complementary medicine. Guatemala's policy on traditional midwives (Política Nacional de Comadronas de los Cuatro Pueblos de Guatemala)⁵⁹ is the only in the region dedicated to a specific type of practitioner. In Peru, the existing policy (2016)⁶⁰ focuses on intercultural health. Half the documents in this group are from Cuba, which started structuring these policies in the 1990s.

National Healthcare Models: Bolivia, Ecuador, Guatemala, Mexico, and Peru utilized this mechanism (further discussed in typology of policy approaches section). They are structured using intercultural health frameworks, including articulating traditional healing systems with biomedical-oriented health care services.

National Program Guidelines are “instruments” for implementing existing policies or for setting policy. They are directed to health systems' stakeholders, and decision makers, including health managers and practitioners. These guidelines often do not require an administrative act, easing the policy-setting political maneuvering. In some cases, they are steppingstones for further policy developments.

Specific Regulatory Norms primarily set policy by regulating therapeutic pluralism “practice,” defining licensure pathways for health professionals, establishing statutory regulation for new types of practitioners, or regulating the registration of traditional health providers.

Supporting Legislation, Policies, and Norms is a heterogeneous category comprising over one-third of all documents found. Documents range from national development plans to laws and policies framing the organization of health systems. These documents do not focus on therapeutic pluralism but include it as a component.

In addition to national initiatives, regional integration organisms in Latin America have issued therapeutic pluralism policies seeking to influence their constituent countries' agendas (summarized in Table 3).

Proposing a typology of Latin American policy approaches in therapeutic pluralism

Based on intrinsic policy characteristics, implementation orientation derived from the qualitative content analysis, we propose a four-category typology of policy approaches in Latin America: Health Services-centered, Model of Care-based, Participatory, and Indigenous People-focused (Table 4), that builds on a previous effort.⁶¹

Table 4.

Examples of Therapeutic Pluralism Policy Approaches Typology in Latin America

Category	Countries	Example (year)
Health Services-Centered	Cuba, Haiti, Mexico, Nicaragua.	Programa para la Generalización y Desarrollo de la Medicina Tradicional y Natural–(Cuba, 2011)
Model of Care-based	Bolivia, Ecuador, Guatemala, Peru.	Nuevo Modelo Sanitario de Bolivia “Modelo de Salud Familiar Comunitario Intercultural” (Bolivia, 2008)
Participatory	Brazil, Chile, Colombia.	Política Nacional de Práticas Integrativas e Complementares no SUS-PNPIC-SUS (Brazil, 2006)
Indigenous Peoples' Health-Focused	Argentina, El Salvador, Panama, Paraguay, and Venezuela.	Política Nacional de Salud Indígena (Paraguay, 2009)

1) Health services-centered policy approach

It focuses on the articulation of T&CM to government-run health care services. This group of policies tends to be centrally formulated and implemented and often relies on a “top-down” approach to policy design. The WHO has proposed it as a means to enhance access to therapeutic interventions.² Cuba's integrated policies have structured nationwide T&CM service delivery across all levels of care, facilitating the development of a highly trained workforce. Mexico focused on articulating traditional Indigenous medicine, complementary medicine, and intercultural initiatives (such as culturally relevant models for birth care) within government-run health facilities. Nicaragua, through its national T&CM institute (Instituto de Medicina Natural y Terapias Complementarias, IMNTC), has trained a health care workforce to implement T&CM clinics in every municipality.

2) Model of care-based policy approach

It relies on the transformation of the national health care model, focusing on intercultural health perspectives to integrate therapeutic pluralism into health systems reform.

The Pan American Health Organization (PAHO/WHO) launched the primary health care renewal initiative starting in the mid-2000s in the wake of Alma Ata's 30th anniversary,^62
–64 emphasizing health systems transformation through the development of “national models” that put communities at the center, offering culturally and gender sensitive care⁶⁴ The “Model of Care-based” policy approach adheres to this PAHO/WHO initiative. The integration of therapeutic pluralism under this policy approach has depended on intercultural health frameworks.

Examples include the Bolivian, Ecuadorian, Guatemalan, and Peruvian models. Shared features include ensuring the right to health; conceptual grounding on notions of integrality,⁶⁵ interculturality,⁶⁶ inclusivity,⁶⁷ and “Good Living” (Sumak Kawsay in Kichwa, or Suma Qamaña in Aymara); perspectives of gender and equity, spirituality, social determinants of health, and the promotion of a harmonious relationship with the territory and the natural environment.

3) Participatory policy approach

It relies on the ample participation of social actors in policy development. They are often perceived as developed “from the bottom up.”

Although health ministries typically facilitate policy development, they reflect various perspectives (such as multiprofessionalism) and the complex nature of the therapeutic pluralism field within a country. Examples of this approach include the policies developed by Brazil, Chile, and Colombia. Brazil's National Policy on Integrative and Complementary Health Practices in the Unified Health System,⁶⁸ developed in response to society-wide demands, was greatly influenced by national stakeholders and the health system's democratic oversight council. Chile's Policy on Complementary Medicine and Wellbeing Practices, yet to be sanctioned, aims at formalizing the existing “implicit” policy. Rather than following a technocratic design, the policy formulation process involved creating a national platform reflecting the reality on the ground that could further facilitate the therapeutic pluralism articulation in the health system.

4) Indigenous peoples' health-focused policy approach

Therapeutic pluralism policy developments are mostly limited to Indigenous health policy initiatives recognizing traditional healing systems and practices.

These policies recognize the significance of traditional healing systems for preserving Indigenous people's identity and attending to their health needs. These policies often call for articulating traditional healing systems with biomedically-oriented health services. This articulation, however, is often proposed as a strategy to improve biomedical services utilization by Indigenous peoples. This policy approach predominates in Argentina, El Salvador, Paraguay, and Venezuela. Of note, several countries with a broader spectrum of therapeutic pluralism policies might also have (often as an initial policy development step) Indigenous people's health-focused policies, such as was the case of Brazil and Chile.

Justifying therapeutic pluralism policy developments

The qualitative content analysis revealed five recurrent themes that Latin American countries use to justify therapeutic pluralism policies development: benefits to the health system, legal and political mandates, national security, supply and demand, and culture and identity (Table 5).

Table 5.

Common Themes Used by Latin American Countries to Justify Therapeutic Pluralism Policy Development

Policy justification theme	Description
Benefits to the health system	Justifications rely on the perceived positive impacts of integrating T&CM or developing intercultural interventions within the health system. Portrayed benefits include improving health services' efficiency, decreasing pharmaceuticals use, decreasing costs, enhancing health goals achievement, decreasing adverse effects, environmental protecting, decreasing access barriers, promoting health agency and self-care, improving user satisfaction, addressing health equity, social determinants of health, and improving uptake of biomedical interventions. They cite the existence of scientific evidence.^58,80
Political and legal mandates	Rely on the acknowledgment of international frameworks that recommend such policies; the existence of constitutional or law provisions granting the right to access T&CM.^80 –83 In some instances, policies quote the will of political figures and other countries' experiences.
National Security	Some countries justify therapeutic pluralism policies development on national security reasons, such as T&CM's potential contributions to emergencies and disasters preparation (natural, bellic, man-made).⁸⁴ Other national security reasons include elements for preserving life, such as traditional knowledge, conservation of biological and cultural diversity.
Culture and Identity	Reference social contracts renewal (and transformation from monocultural to multicultural notions of the state). T&CM protection is seeing as a mechanism for safeguarding traditional Indigenous knowledge, cultural identity, traditional values, autonomy, and spirituality.^56,85 They are referenced as means to include marginalized sectors of the population.^60,85
Supply and demand	Justify policy development on the existence of T&CM services in the public health network and popular demand for these services. The relevance of T&CM in primary health care delivery in some contexts and its use by broad sectors of the population (regardless of the availability of biomedical health services) are also cited.^80,86

T&CM, traditional and complementary medicine.

Social forces that influence therapeutic pluralism in Latin America

Therapeutic pluralism policies often include references to the social forces that influence their development. The renewed relationship between the state and Indigenous people, brought about by Indigenous movements, has been one of the most transformative forces in the region. These movements and other forces/ideas (Table 6) have sparked social, political, historical, and cultural transformations that translate into health systems' re-conceptualization.

Table 6.

Social Forces Influencing the Development of Therapeutic Pluralism Policies in Latin America

Pluralism	Several states have moved from mono to pluricultural self-definitions. In Bolivia, for example, the state was reconceived as “plurinational” where political, economic, legal, cultural, and linguistic pluralism are integral aspects of the renewed social contract.⁸⁷ These pluralism notions also extend to health and all the available “options to procure and maintain physical and mental health.”⁶⁶
Self-determination and autonomy	Renewed recognition of the rights of Indigenous, Afro-descendants, and other ethnic groups “to decide and autonomously assume control of their institutions and ways of life, their economic practices, their identity, culture, law, uses and customs, education, health, worldview, protection of their traditional knowledge, use, protection and defense of their habitat and lands and, in general, of the daily management of their community life within their lands to maintain and strengthen their cultural identity.”⁸⁸ This includes their right to participate in the public policies formulation and access to intercultural health services. Some policies highlight the importance of social mobilization for community empowerment and improving social, economic, and environmental conditions.
Anticapitalism and Decolonization	The failure of the capitalist model to eradicate poverty, social inequality, and exclusion, and the impossibility of current models to define and protect all aspects of life on the planet has fueled calls for alternative models. Capitalism is often seen as inherited from the colonial social order, which countries have attempted to transform by embracing traditional values and knowledge, integrating notions such as “good living” (Sumak Kawsay) and “reciprocity” (Ayni) as the goals of the pluralist society.³⁶ Interculturality has been proposed as “an engine of development.” Explorations for proposing new economic models have advocated for the potential economic value of traditions and natural resources. Decolonization is a cited social struggle in therapeutic pluralism policies, portrayed as a mechanism to address discrimination, exploitation, social injustice, and the consolidation of pluralistic national identities. Some policies present therapeutic pluralism as part of their countries' “recovery of the ability to decide,” a sign of national sovereignty. Dismantling colonialism is seen as a requisite to reimagine government and its institutions, social relations, and the relationship with nature.³⁶
Safeguarding Cultural Identity	Policies have embraced Indigenous peoples' right to maintain and strengthen their identity, sense of belonging, ancestral traditions, and forms of social organization.⁸⁹ In health, cultural values are being incorporated in the variables that determine the organization of health services, including the incorporation of traditional medicine as a central cultural identity component. Revaluation of the coca leaf in Andean countries, seen as an essential element of their identity for its medicinal, nutritional, traditional, and religious uses, for example, has shifted policy considerations in therapeutic pluralism.
Bridging cultural barriers	The need to bridge communities and health services has prompted the re-conceptualization of their relationship and the search for mechanisms that could bring them closer. Therapeutic pluralism has been proposed as one such mechanism, along with initiatives for providing health services in local languages, and approaches to develop people-centered health systems.^56,83
Sustainability	The expansion of the environmental movement and its calls for a renewed relationship with nature have influenced therapeutic pluralism policies. This is seen as essential in promoting a holistic approach to the health. In some instances, it might be related to the spiritual dimensions of Indigenous cosmovision and a necessary condition to protect natural and cultural heritage.

Discussion

We used a qualitative content analysis to characterize therapeutic pluralism policies in Latin America, describing policy mechanisms, proposing a typology of policy approaches, describing themes countries used to justify their development, and the social forces that have influence them.⁴

The recognition of policy mechanisms is helpful in gauging the level of political commitment to therapeutic pluralism. The mechanisms identified here reveal a high level of political support for these policies in Latin America and the use of an ample spectrum of legal/administrative instruments for policy setting. It is remarkable that four countries recognize forms of therapeutic pluralism in their constitution, and several countries have high-level legislation mandating therapeutic pluralism inclusion within their health systems. The new Chilean constitution draft includes traditional medicine, and several legislative and policy initiatives are underway in various countries.

We propose a policy approaches' typology that is not meant to classify countries but to highlight policy structuring tendencies. As shown, there might be partial overlapping. The typology built on a previous attempt that inadequately conflated “policy mechanisms” with governmental administrative structures for policy implementation.⁶¹ Of the four policy approaches described, “Health Services-centered” is likely found across the globe. This approach follows the WHO frameworks for T&CM integration within health systems, which tend to rely on a “top-down” style of policy design. However, as described, several other approaches within the Latin American region exist, some of which might be region exclusive.

Approaches such as the “Model of Care-based” can be far-reaching, as it seeks to transform how the entire system is conceptualized and structured. As shown, the emergence of that approach was directly related to PAHO/WHO's primary health care renewal initiative,^62
–64 intersecting with the renewal of social contracts brought about by Indigenous movements. Traditional Indigenous concepts have been used to develop a renewed identity in several Latin American countries.

Those concepts have permeated the conceptualization and organization of health systems. The “Good Living” concept (Sumak Kawsay in Kichwa, or Suma Qamaña in Aymara), for example, was integrated into the Bolivian and Ecuadorian constitutions. The notion, often used to promote the de-commodification of life and societal values such as reciprocity, coexistence, and harmony with nature,⁶⁹ is also widely used in the Model of Care-based policy approach. Critics have, however, pointed out potential conceptual misappropriation to justify the continuity of extractive economic models that contravene “Good Living” postulates.⁶⁹

Participatory approaches to policy development reveal the possibilities of influencing formal policy design from the ground up. This approach may grow from local and provincial experiences, illustrating the value of innovation and advocacy at the local level.

These approaches intersect with how countries have justified developing such policies and the underlying social forces. Societal pressure to advance toward recognizing cultural pluralism, safeguarding cultural identity, self-determination and autonomy of Indigenous peoples, Afro-descendants and other ethnic groups has been critical for policy development in the region. These forces are aligned with evolving anticolonial movements. Dismantling colonialism has been seen as a requisite to reimagining government and its institutions, social relations, and the relationship with nature in several contexts.

In light of environmental degradation, climate change, and spiritual dimensions of Indigenous cosmovision, a renewed relationship with nature has been an integral component of the identity struggle, with calls for conservation, sustainability, and innovative economic models.

Enhancing our awareness of therapeutic pluralism policies and approaches has implications for policy development, implementation, bilateral collaboration, international technical cooperation, policy evaluation, and research. This understanding should inform updates of existing WHO frameworks, which have been criticized as universalistic, de-contextualized, simplistic, and biomedicine-centered.^70,71 Previous efforts have aimed at describing policy developments on the field.

The WHO has engaged in regular global exercises, the last one published in 2019.⁴ Regional efforts, such as reviews performed by the WHO South-East Asia Region,⁷² the CAMbrella project in Europe,⁵³ or a Southern Africa sub-regional study by Abrams et al.⁷³ have offered useful descriptive overviews. In Latin America, PAHO compiled a legislation and regulation review in the late 1990s,⁷⁴ and Lovera in 2014,⁷⁵ for selected countries. The work presented here is perhaps the first attempt to analytically assess policy characteristics and approaches within a region.

This study has limitations. Although efforts were made to identify all policy-setting documents, some might have been inadvertently excluded. The use of multiple sources and experts' verification aimed at minimizing that risk. Experts from all countries but two (Argentina, Haiti) where policies were found were interviewed. This study only included national policies. However, sub-national entities (states, provinces, municipalities) have developed therapeutic pluralism policies, either independently or in alignment with national ones.

Excluding sub-national policies could have prevented the identification of other potential policy characteristics or approaches. Draft legislative proposals were also excluded, which might have limited our capacity to identify emerging trends. This study did not assess policy-practice congruence/paradox,⁷⁶ or the models⁷⁷ and levels⁷⁸ of T&CM integration with national health systems.

Research is needed to assess implementation progress across approaches. Results and impact measures that could be used across various policy approaches should be developed, and the potential differences among approaches should be assessed. Further research should also examine policy-practice congruence, as well as the models and levels of integration.

Characterizing policy approaches in other world regions would be essential in understanding global trends and building technical cooperation and policy development tools responsive to existing realities. Further understanding of ongoing successful therapeutic pluralism integration initiatives, such as the model developed by the Social Security Health Insurance (EsSalud) in Peru, could inform policy developments and should be extensively evaluated.

Historians and anthropologists have contested notions, not only of Latin-America as a receptive periphery in the history of medicine,⁴² but also of biomedicine as a universal, a-cultural, system.^6,8,79 They have demonstrated that despite western medical institutions' efforts to dominate the healing landscape and marketplace in Latin America, Indigenous, African and folk practices not only remained influential but also permeated all spheres of life.⁴² The therapeutic pluralism cultural and social imprint in the region is palpable, and continuously being transformed. Latin American policy developments help us understand the multiple avenues for approaching the relationship between the therapeutic pluralism field and the predominantly biomedical-oriented health systems and their implications.

Conclusion

There are several therapeutic pluralism policy approaches in Latin America, some going beyond integrating non-biomedical interventions into health systems. Therapeutic pluralism can also offer perspectives for transforming health systems' conception and organization. Traditional Indigenous knowledge has influenced new ways of understanding national identity in several Latin American countries and therapeutic pluralism policy approaches. Characterizing these approaches has implications for policy development, implementation, evaluation, international collaboration, the development of technical cooperation tools and frameworks, as well as research.

Footnotes

Acknowledgments

The authors thank all health officials and experts who participated in the study, all those who contributed to make the study possible, including Veronika Wirtz, Cesar Abadía, Maria LaRusso, as well as colleagues at the TCIM Americas Network, the ICTHP Section of the American Public Health Association, and the Australian Research Center for Integrative and Complementary Medicine (ARCCIM), University of Technology Sydney. They also thank the anonymous referees for their constructive and helpful feedback.

Authors' Contributions

D.F.G.-P. conceptualized the study with the assistance of E.D., L.L.B., R.B.S., and J.W. All authors contributed to the methodology design. D.F.G.-P. performed project administration, investigation, data curation, formal analysis, and writing of the original draft. All authors contributed to manuscript review and editing.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

The project received no external funding. Final stages of manuscript writing were possible through NCCIH's Training Grant (T32AT003378) of the Program on Integrative Medicine, Physical Medicine and Rehabilitation Department, University of North Carolina at Chapel Hill.

Supplementary Material

Supplementary Table S1

References

Bodeker

, Burford

, Kronenberg

(eds). Traditional, Complementary and Alternative Medicine: Policy and Public Health Perspectives. GBR: Imperial College Press: London; 2007.

World Health Organization. WHO Traditional Medicine Strategy 2014–2023. WHO: Geneva; 2013.

Jütte

(ed). Medical Pluralism: Past—Present—Future. Medizin, Gesellschaft Und Geschichte: Beiheft. Franz Steiner Verlag: Stuttgart; 2013.

World Health Organization. WHO Global Report on Traditional and Complementary Medicine. 2019. World Health Organization: Geneva; 2019.

Quirke

, Gaudillière

J-P

. The era of biomedicine: science, medicine, and public health in Britain and France after the Second World War. Med Hist, 2008; 52(4):441–452; doi: 10.1017/S002572730000017X.

Gaines

, Davis-Floyd

. Biomedicine. Encyclopedia of medical anthropology health and illness in the world's cultures Volume I: Topics. Cultures, 2004; 95–109.

Jones

RK.

Schism and heresy in the development of orthodox medicine: The threat to medical hegemony. Soc Sci Med, 2004; 58(4):703–712; doi: 10.1016/S0277-9536(03)00222-3.

Hahn

, Kleinman

. Biomedical practice and anthropological theory: Frameworks and directions. Annu Rev Anthropol, 1983; 12(1):305–333; doi: 10.1146/annurev.an.12.100183.001513.

Kleinman

Concepts and a model for the comparison of medical systems as cultural systems. Soc Sci Med, 1978; 12:85–93; doi: 10.1016/0160-7987(78)90014-5.

10.

Ernst

Plural Medicine, Tradition and Modernity, 1800–2000. Routledge Studies in the Social History of Medicine. Taylor & Francis: London; 2002.

11.

International Conference on Primary Health Care. Declaration of Alma-Ata. WHO Cronicle, 1978; 32(11):428–30; doi: 10.1016/S0140-6736(79)90622-6.

12.

World Health Organization. Primary Health Care; Report of the International Conference on Primary Health Care; Alma-Ata, USSR, 6–12 September 1978. USSR: Alma-Ata; 1978.

13.

Global Conference on Primary Health Care. Declaration of Astana. 2018.

14.

Twenty Second World Health Assembly. WHA22.54 Establishment of Pharmaceutical Production in Developing Countries. 1969;1969(July).

15.

Twenty Ninth World Health Assembly. WHA29.72 Health Manpower Development. WHO: Geneva; 1976.

16.

Thirtieth World Health Assembly. WHA30.49 Promotion and Development of Training and Research in Traditional Medicine. WHO: Geneva; 1977.

17.

Thirty First World Health Assembly. WHA31.33 Medicinal Plants. WHO: Geneva; 1978.

18.

Fortieth World Health Assembly. WHA40.33 Traditional Medicine. WHO: Geneva; 1987.

19.

Forty First World Health Assembly. WHA41.19 Traditional Medicine and Medicinal Plants. WHO: Geneva; 1988.

20.

Forty Second World Health Assembly. WHA42.43 Traditional Medicine and Modern Health Care. WHO: Geneva; 1989.

21.

Forty Forth World Health Assembly. WHA44.34 Traditional Medicine and Modern Health Care. 1991.

22.

Fifty Sixth World Health Assembly. WHA56.31 Traditional Medicine. WHO: Geneva; 2003.

23.

Sixty First World Health Assembly. WHA61.21 Global Strategy and Plan of Action on Public Health, Innovation and Intellectual Property. WHO: Geneva; 2008.

24.

Sixty Second World Health Assembly. WHA62.13 Traditional Medicine. 2009.

25.

Sixty Seventh World Health Assembly. WHA67.18 Traditional Medicine. WHO: Geneva; 2014.

26.

World Health Organization. WHO Traditional Medicine Strategy 2002–2005. WHO: Geneva; 2002.

27.

WHO Congress on Traditional Medicine. Beijing declaration. In: WHO Congress on Traditional Medicine. Beijing, China; 2008; doi: 10.1177/0022034511399085.

28.

United Nations. Political Declaration of the High-Level Meeting on Universal Health Coverage “Universal Health Coverage: Moving Together to Build a Healthier World.”. 2019.

29.

World Health Organization. Traditional and Complementary Medicine in Primary Health Care. 2018.

30.

Lolas

[The integration of the behavioral sciences and biomedicine: the need for a metatheory]. Bol Oficina Sanit Panam, 1990; 109(1):38–45.

31.

Zhang

Traditional and complementary medicine in primary health care. In: Health for All: The Journey of Universal Health Coverage. (Medcalf A, Bhattacharya S, Momen H, et al. eds.) Orient Blackswan: Hyderabad (IN); 2015.

32.

Stoner

BP.

Understanding medical systems: Traditional, modern, and syncretic health care alternatives in medically pluralistic societies. Med Anthropol Q, 1986; 17(2):44–48.

33.

Hsu

Medical pluralism. In: International Encyclopedia of Public Health. (Heggenhougen HK. ed.) Academic Press: Oxford; 2008; pp. 316–321; doi: 10.1016/B978-012373960-5.00147-7.

34.

UNESCO. Basic Texts of the 2005 Convention on the Protection and Promotion of the Diversity of Cultural Expressions. 2013.

35.

Menendez

, Eduardo Luiz

. Intercultural health: Proposals, actions and failures. Ciencia e Saude Coletiva, 2016; 21(1):109–118; doi: 10.1590/1413-81232015211.20252015.

36.

Supreme Decree No. 29272 (National Development Plan “Dignified, Sovereign, Productive and Democratic Bolivia to Live Well: Strategic Guidelines,” 2006–2011. [In Spanish]. 2007.

37.

Dinges

Medical pluralism—Past and present: Towards a more precise concept. In: Medical Pluralism: Past—Present—Future. (Jütte R. ed.) Franz Steiner Verlag: Stuttgart; 2013; pp. 195–205.

38.

Stollberg

Medical plurality and medical pluralism in Germany (19th and Early 20th Century). In: Medical Pluralism: Past—Present—Future. (Jütte R. ed.) Franz Steiner Verlag: Stuttgart; 2013; pp. 141–151.

39.

Oxford English Dictionary. “therapeutic, n.” OED Online Oxford University Press, June 2022, Available from: www.oed.com/view/Entry/200459. [Last accessed: June 30, 2022 ].

40.

Fligstein

, McAdam

A Theory of Fields. Oxford University Press: New York; 2012.

41.

Bodeker

, Ong

C-K

, Grundy

, et al. WHO Global Atlas of Traditional, Complementary and Alternative Medicine. WHO Centre for Health Development: Kobe, Japan; 2005.

42.

Cueto

, Palmer

Medicine and Public Health in Latin America: A History. New Approaches to the Americas. Cambridge University Press: New York; 2014.

43.

Mignolo

The Idea of Latin America. Blackwell Manifestos, Wiley; 2005.

44.

The World Bank. Indigenous Latin America in the Twenty-First Century: The First Decade. World Bank: Washington, DC; 2015.

45.

Encyclopaedia Britannica. History of Latin America. Encyclopaedia Britannica Online Academic Edition 2015.

46.

Skidmore

, Smith

, Green

. Modern Latin America. Oxford University Press; 2014.

47.

Mayring

Qualitative content analysis. Forum: Qualitative Social Research (FQS), 2000; 1(2, Art.20); doi: 10.1111/j.1365-2648.2007.04569.x.

48.

Drisko

, Maschi

. Content Analysis. Oxford University Press: New York;, 2015; doi: 10.1093/acprof:oso/9780190215491.001.0001.

49.

Forman

, Damschroder

Qualitative content analysis. In: Empirical Methods for Bioethics: A Primer (Advances in Bioethics Series, Vol.11). (Jacoby L, Siminoff LA. eds.) JAI Press: Oxford (UK); 2008; pp. 39–62.

50.

Elo

, Kääriäinen

, Kanste

, et al. Qualitative Content Analysis: A Focus on Trustworthiness. Sage Open, 2014; pp. 1–10; doi: 10.1177/2158244014522633.

51.

Erlingsson

, Brysiewicz

. A hands-on guide to doing content analysis. African J Emerg Med, 2017; 7(3):93–99; doi: 10.1016/j.afjem.2017.08.001.

52.

Gallego-Pérez

, Abdala

CVM

, Amado

, et al. Equity, intercultural approaches, and access to information on traditional, complementary, and integrative medicine in the Americas [In Spanish]. Pan American Journal of Public Health, 2020; 44:1; doi: 10.26633/rpsp.2020.143.

53.

Wiesener

, Falkenberg

, Hegyi

, et al. Legal status and regulation of complementary and alternative medicine in Europe. Forsch Komplementarmed, 2012; 19(SUPPL 2):29–36; doi: 10.1159/000343125.

54.

Bengtsson

How to plan and perform a qualitative study using content analysis. NursingPlus Open, 2016; 2:8–14; doi: 10.1016/j.npls.2016.01.001.

55.

Estado Plurinacional de Bolivia. Asamblea Legislativa Plurinacional. Law 17 of June 27, 2016; Establishing the Protection of the Knowledge of Traditional Indigenous Medicine [In Spanish]. 2013.

56.

Asamblea Nacional de la República de Nicaragua. Ley de Medicina Tradicional Ancestral (Ley No. 759 de 2011). Nicaragua; 2011.

57.

Asamblea Nacional de Panamá. Law 17 of June 27, 2016; Establishing the Protection of the Knowledge of Traditional Indigenous Medicine [In Spanish]. Asamblea Nacional de Panamá: Panamá; 2016.

58.

Asamblea Nacional de la República de Nicaragua. Law of Natural Medicine, Complementary Therapies and Natural Products in Nicaragua (Law 774 of 2011) [In Spanish]. Asamblea Nacional de la República de Nicaragua: Managua; 2011.

59.

Ministerio de Salud Pública y Asistencia Social. National Policy for Midwives of the Four Peoples of Guatemala 2015–2025 [In Spanish]. 2015;29.

60.

Presidencia de la República de Perú. Decreto Supremo—N° 016-2016-SA. Aprueban La Política Sectorial de Salud Intercultural, 2016; 582230–582240.

61.

Wardle

, Gallego-Perez

, Chung

, et al. Traditional, Complementary, and Integrative Medicine: Policy, Legal and Regulatory Perspectives. In: Public Health and Health Services Research in Traditional, Complementary and Integrative Health Care. (Adams J. ed.) World Scientific (Europe): London; 2019.

62.

Ocampo-rodríguez

, Betancourt-urrutia

, Montoya-rojas

, et al. Sistemas y modelos de salud, su incidencia en las redes integradas de servicios de salud * Healthcare systems and models, their impact on integrated networks of health services. Rev Gerenc Polit Salud, 2013; 12(24):114–129.

63.

Pan American Health Organization. Renewing Primary Health Care in the Americas: A Position Paper of the Pan American Health Organization/World Health Organization (PAHO/WHO). 2007.

64.

46th Directing Council of the Pan American Health Organization. Regional Declaration on the New Orientations for Primary Health Care (Declaration of Montevideo). 2005.

65.

Ministerio de Salud Pública. Comprehensive Care Model of the National Family Community and Intercultural Health System [In Spanish]. MAIS. Ministerio de Salud Pública: Quito; 2012.

66.

Presidencia de Bolivia. Supreme Decree No. 29601. Establishes the Care Model and the Health Management Model within the framework of Intercultural Community Family Health – SAFCI [In Spanish]. 2008;(11 de Junio); doi: 10.1017/CBO9781107415324.004.

67.

Ministerio de Salud Pública y Asistencia Social. The Inclusive Health Model [In Spanish]. 2016;15.

68.

Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. National Policy on Integrative and Complementary Practices in the SUS - PNPIC-SUS [In Spanish]. Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Atenção Básica: Brasilia; 2006.

69.

Bretón

, Cortez

, García

. In search of sumak kawsay [In Quechua]. Íconos Revista de Ciencias Sociales, 2014; 48(enero 2014):9–24.

70.

Kadetz

Challenging a universal approach to health care integration: China, Cuba, and the Philippines. Eur J Integr Med, 2013; 5(1):54–61; doi: 10.1016/j.eujim.2012.11.006.

71.

Kadetz

Assumptions of global beneficence: Health-care disparity, the WHO and the outcomes of integrative health-care policy at local levels in the Philippines. Biosocieties, 2011; 6(1):88–105; doi: 10.1057/biosoc.2010.43.

72.

World Health Organization—Regional Office for South-East Asia. Traditional Medicine in the WHO South-East Asia Region; Review of Progress 2014–2019. New Delhi;, 2020; doi: 10.4324/9780429310232-10.

73.

Abrams

, Falkenberg

, Rautenbach

, et al. Legislative landscape for traditional health practitioners in Southern African development community countries: A scoping review. BMJ Open, 2020; 10(1):1–10; doi: 10.1136/bmjopen-2019-029958.

74.

Pan American Health Organization. Traditional Health Systems in Latin America and the Caribbean: Base Information. Washington, D.C.; 1999.

75.

Lovera Arellano

. TT—Regulation in complementary and alternative medicine in Latin America: Experience and regulation in selected countries [In Spanish]. Thesis (Masters on Public Health). 2014.

76.

Knox

, Fønnebø

, Falkenberg

. Emerging complementary and alternative medicine policy initiatives and the need for dialogue. J Altern Complement Med, 2009; 15(9):959–962; doi: 10.1089/acm.2009.0030.

77.

Lin

, Mph

, Canaway

, et al. Interface, interaction and integration: how people with chronic disease in Australia manage CAM and conventional medical services. Health Expect, 2014; 18:2651–2665; doi: 10.1111/hex.12239.

78.

Park

, Canaway

. Integrating traditional and complementary medicine with national healthcare systems for universal health coverage in asia and the Western Pacific. Health Syst Reform, 2019; 5(1):24–31; doi: 10.1080/23288604.2018.1539058.

79.

Good

MJD.

Cultural studies of biomedicine: An agenda for research. Soc Sci Med, 1995; 41(4):461–473; doi: 10.1016/0277-9536(95)00008-U.

80.

Ministerio de Salud de Colombia. Technical Guidelines for the Articulation of Medicines and Alternative and Complementary Therapies, Within the Framework of the General System of Social Security in Health [In Spanish]. Ministerio de Salud y Protección Social; 2018.

81.

Secretaría de Salud; Subsecretaría de Innovación y Calidad; Dirección de Medicina Tradicional y Desarrollo Intercultural. Implementation Guide: Therapeutic and Health Strengthening Clinical Models [In Spanish]. 2017.

82.

Ministerio de Salud de Chile. Regulations for the Exercise of Alternative Medical Practices as Auxiliary Health Professionals and the Venues Where They Are Practiced [In Spanish]. Decreto N^o 42 de 2004. 2004; 1–35.

83.

Ministerio de Salud Paraguay. National Indigenous Health [In Spanish]. 2009.

84.

Consejo de Ministros de la República de Cuba. Agreement No. 7551, Update of the National Natural and Traditional Medicine Program [In Spanish]. 2014.

85.

Ministerio de Salud y Deportes (Viceministerio de Medicina Tradicional e Interculturalidad). Strategic Guidelines of Traditional Medicine and Interculturality in Health [In Spanish]. 2012;44.

86.

Republique d'Haiti—Ministère de la Santé Publique et de la Population. National Pharmaceutical Policy [In French]. 2014.

87.

Asamblea Constituyente. Political Constitution of the Plurinational State of Bolivia [In Spanish]. 2008.

88.

la Asamblea Nacional de la República Bolivariana de Venezuela. Organic Law of Indigenous Peoples and Communities [In Spanish]. 2005.

89.

Mexico. Political Constitution of the United Mexican States [In Spanish]. Cámara de Diputados del Honorable Congreso de la Unión: Mexico D.F.; 1917.

90.

Clegg

, Ellena

, Ennis

, et al. The Hierarchy of Laws; Understanding and Implementing the Legal Frameworks That Govern Elections. International Foundation for Electoral Systems: Arlington, VA; 2016. Available from: https://www.ifes.org/sites/default/files/2016_ifes_hierarchy_of_laws.pdf [Last accessed: June 21, 2021 ].

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.25 MB