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The traditional health systems that are officially recognized in India include Ayurveda,Yoga, Unani, Siddha, Homeopathy, and so on,which are represented by the acronym AYUSH.(Since Homeopathy is not indigenous to India,the acronym AYUSH in reference to the present article does not include Homeopathy.) AYUSH systems have been absorbed into the national healthcare delivery system in India and are integral parts of it. However, the mainstream healthcare system remains conventional biomedicine, known also as Western medicine,biomedicine, or allopathy. Although, all AYUSH systems run parallel to Western Medicine in terms of education and practice,some steps toward integration have been taken of late [8] .
Prior to Indian independence, vaidyas (Ayurveda practitioners) were largely unsanctioned by official governing boards,with the exception of a few provincial boards that recognized specific qualifications. Once Western Medicine received official recognition from the colonial rulers, and as its acceptance grew, Ayurveda had to reinvent itself in order to maintain its relevance. The home-based Ayurvedic pharmacies were slowly converted into bulk drug manufacturing units, and commercial production of formulations started.Even after independence it took more than 20 years to formally integrate Ayurveda, Unani,and Siddha into the national healthcare system.More than seven expert committees were formed by the government and were asked to furnish their reports. The committees’ reports represented different priorities and points of view. The important committees and their recommendations have been summarized in Table 1–4 [9] .
The four non-allopathic systems of medicine — Ayurveda, Unani, Siddha, and Homeopathy — were legally recognized in the 1970s. Before the enactment of Indian Medicine Central Council (IMCC) Act, 1970,several state governments had passed various legislation establishing the requirements for Ayurvedic degrees and regulating the practice of indigenous medicine. The earliest statute appears to be the Board of Indian Systems of Medicine Act, 1947, of Mysore State, followed by the East Punjab Ayurvedic and Unani Practitioners Act, 1949. Chennai, Maharashtra,Hyderabad, the Andhra area, enacted their own legislation. The Andhra Ayurvedic &Homeopathic Medical Practitioners Registration Act,1956, was specifically introduced to regulate and recognize practitioners in the Andhra area. In 1964, a special chapter,Chapter IV A, was included under the Drugs &Cosmetics Act 1940 [10] .
At present, the education and practice of the Ayurveda, Siddha, and Unani (ASU) systems of medicine is regulated by the Central Council of Indian Medicine (CCIM), a statutory organization established by a central enactment. The medicine system (popular in the Himalayan region), was included in the regulations of CCIM in 2011. The Central Council of Homeopathy (CCH) oversees the education and practice of Homeopathy. Yoga and Naturopathy are also taught throughout the country by different institutions; however,there is no central registry maintained for registration of the practitioners of these systems [10] .
The Central Government established an independent Department for the Indian Systems of Medicine & Homeopathy in 1995. The Department of ISM & H was renamed AYUSH in 2003. The status of this department was upgraded to that of an independent ministry in 2014. Among AYUSH systems, Ayurveda currently dominates the healthcare scenario in terms of the number of educational institutions,practitioners, hospitals, pharmacies, and dispensaries [8] .
Under the IMCC Act, 1970, the Central Council of Indian Medicine (CCIM) was established to ensure a standard and uniform ASU medical education system. It adopted the same framework as that of the Medical Council of India (MCI) under the MCI Act,1956. A system for membership and election to the General Body and the Executive Body of the CCIM was also introduced. In the list of changes that aimed to bring the standards for traditional medical systems up to par with those for Western Medicine, the CCIM recommended the requirements for MBBS/BAMS/BSMS and BUMS degrees include five and a half years of training [10] .
Table 1–4 Summary of Major Recommendations of Seven Expert Committees Concerning the Education and Practice of Ayurveda and Other Indigenous Systems of Medicine (ISM)
Recently, the National Commission for Indian System of Medicine (NCISM) Act 2020) has come into effect from 11 th day of June 2021, replacing the provisions of Indian Medicine Central Council (IMCC) Act 1970 (48 of 1970). It proposes to introduce a paradigm shift in regulation of ASU education in INDIA.Functionally, it is set to take over the role of CCIM. One of the important features is a new regulatory hierarchy comprising a commission,an advisory council, and various autonomous boards with a mandate to operate within specified domains. It proposed the establishment of two boards: one charged with ensuring ethics in education and practice and overseeing regulation of the registration process, and another responsible for assessing and rating of educational institutions. Another prominent feature is the replacement of the current norm of “elections” with a transparent merit based “selection” process. This new selection process would apply to key positions on the Commission and its constituent boards. It also has replaced the current input-based regulatory mechanism with an outcome-based one. Other significant provisions include the following:the inclusion of experts in fields such as botany,pharmacology, management, economics, and law in the framework of the Commission;introduction of a national entrance examination to ensure a transparent merit-based admission process; the development of an examination to certify the competency of graduates to practice professionally and to enter postgraduate programs; and ongoing collaboration with the NMC to ensure interaction between all branches of healthcare delivery [11] .
One of the important features of this bill is the introduction of a new regulatory hierarchy comprising a commission, an advisory council, and various autonomous boards with a mandate to operate within specified domains. The bill proposes the establishment of two boards: one charged with ensuring ethics in education and practice and overseeing regulation of the registration process, and another responsible for assessing and rating educational institutions. Another prominent feature of the draft is a proposal to replace the current norm of “elections” with a transparent merit-based “selection” process.This new selection process would apply to key positions on the Commission and its constituent boards. The draft also calls for replacing the current input-based regulatory mechanism with an outcome-based one. Other significant provisions of the draft include the following:the inclusion of experts in fields such as botany,pharmacology, management, economics, and law in the framework of the Commission;introduction of a national entrance examination to ensure a transparent merit-based admission process; the development of an examination to certify the competency of graduates to practice professionally and to enter postgraduate programs; and ongoing collaboration with the NMC to ensure interaction between all branches of healthcare delivery [11] .
According to the 2017 data, there are 11 national institutes operating under various AYUSH councils. [12] .
The following is an abridged list of officially recognized degree programs for Ayurvedic physicians:
Graduate-Level Programs These programs,which comprise five and a half years of coursework leading to a Bachelor of Ayurveda Medicine and Surgery, are currently operating throughout the country under IMCC Act, 1970.
Postgraduate-Level Programs Thes three-year programs provide advanced training in various specialties. Currently available postgraduate programs for Ayurvedic physicians span 22 fields of specialization.
Postgraduate Diploma Programs Thes two-year programs span 16 specialty fields.
Table 1–5 lists the courses taught to students training to become Ayurvedic physicians during the first four and half years of a graduate-level program [13] .
Table 1–5 Subjects Taught to Graduate Students of Ayurveda during their First 4.5 Years of Professional Training
The following table (Table 1–6) provides a statistical breakdown of the population of registered practitioners across the four categories of AYUSH systems as of January 2017 [14] .
Table1–6 The Number of Registered Practitioners of AYUSH Systems in India
The Ayurvedic, Unani, and Siddha systems vary considerably in their approach to education and practice. Ayurveda is practiced countrywide, and there are several approaches that derive from either regional/traditional custom or university based training. For instance, the use of panchakarma procedures and botanical preparations is popular in southern India,whereas rasa shastra-based practice is more popular in the northern states. Public trust also differs widely across regions. The Unani system is more dominant in the pradeshes of Uttar Pradesh, Bihar, Andhra Pradesh, Maharashtra,Delhi. The practice of Siddha Medicine is mostly confined to the state of Tamilnadu [10] .
The Central Council for Research in Ayurveda (CCRA) was set up as an advisory body in 1962, and the Central Council for Research in Indian Medicine and Homeopathy(CCRIM&H) was established in 1969. The Central Council for Research in Ayurveda and Siddha (CCRAS), an apex body charged with formulating, coordinating, and developing research in Ayurveda and Siddha along scientific lines, was established in March,1978. The purpose of its efforts was to validate Ayurvedic knowledge in “scientific terms”. In 2011, the CCRAS was renamed the Central Council for Research in Ayurvedic Sciences. The Council has been executing its research programs across a network of 30 peripheral institutes/centers/units and has assigned responsibility for oversight of these programs to its headquarters.The Council relies on more than 700 officers and staff, as well as on collaborative studies with various universities, hospitals, and institutes to conduct its research. CCRAS programs span a wide variety of research areas, including Clinical Research, Fundamental Research,Pharmacology (Pre-clinical Safety/Toxicity and Biological Activity Studies), Medicinal Plants(Medico-Ethno Botanical Surveys, Cultivation,Pharmacognosy), Drug Standardization, and Literature Reviews, and Documentation [15] .
While the efforts to systematize the development and propagation of Ayurvedic,Unani, and Siddha Medicine gained momentum through the creation of an independent department, the first ISM health policy was announced only in 2002. It spoke of mainstreaming the AYUSH sector across all aspects of education, research, and practice.
In order to promote the medicinal plants sector, the Government of India set up the National Medicinal Plants Board (NMPB) on November 24, 2000. Currently the board is located in the Ministry of AYUSH (Ayurveda,Yoga & Naturopathy, Unani, Siddha, and Homeopathy), Government of India. The primary mandate of NMPB is to develop an appropriate mechanism for coordination between various ministries/departments/organizations in India and to implement support policies/programs for overall (conservation,cultivation, trade, and export) growth of medicinal plants sector at both the central/state and international levels [16] .
To meet increasing demand for medicinal plants, the NMBP focuses on in-situ and exsitu conservation and on augmenting local medicinal plants and aromatic species of medical significance. The NMPB also promotes research and development, capacity building through training, and raising awareness through promotional activities like creation of home/school herb gardens. NMPB also supports programs for quality assurance and standardization through development of Good Agricultural and Collection Practices (GACPs);development of monographs laying down standards of quality, safety and efficacy; and development of agro-techniques and credible institutional mechanism for certification of quality of raw drugs, seeds, and planting material. The NMPB’s overall aim is to develop the medicinal plants sector through strong collaboration between various ministries/departments/organizations charged with implementing policies/programs that address that sector’s concerns [16] .
Traditional Knowledge Digital Library(TKDL) is an initiative to prevent misappropriation of India’s traditional medicinal knowledge at International Patent Offices. In 2005, the TKDL expert group estimated that about 2,000 inappropriate patents related to Indian systems of medicine were being granted every year at the international level. Because India’s traditional medicinal knowledge is documented in languages such as Sanskrit, Hindi, Arabic,Urdu, and Tamil, it is neither accessible nor comprehensible to patent examiners in international patent offices [17] .
With the help of information technology tools and the innovative Traditional Knowledge Resource Classification (TKRC) system, the Traditional Knowledge Digital Library has been able to translate about 0.29 million medicinal formulations documented in the ancient texts of Ayurveda, Siddha, Unani, and Yoga into five international languages (i.e., English,Japanese, French, German, and Spanish).The TKRC has organized traditional Indian medicinal knowledge into approximately 25,000 subgroups for Ayurveda, Unani, Siddha,and Yoga. Under A61K 36/00, the TKRC has enabled incorporation of about 200 subgroups into International Patent Classification, far surpassing the limited number of subgroups on medicinal plants available under A61K 35/00 and thus enhancing the quality of searches and examination of previously filed patent applications in the area of traditional knowledge. TKDL has also been able to establish international specifications and standards for setting up TK databases. The Committee adopted these standards in 2003 in the fifth session of the Intergovernmental Committee (IGC) of World Intellectual Property Organization (WIPO) on Intellectual Property and Genetic Resources, Traditional Knowledge,and Expression of folklore [17] .
Poorly designed study protocols have attracted a lot of criticism when it comes to clinical trials pertaining to Ayurveda. To overcome these constraints, the department of AYUSH created a set of Good Clinical Practice guidelines in 2013 that span every stage of the clinical trial process from the design, conduct,termination, audit, and analysis of the trial to clinical study reports and the documentation of the trial’s participants. The guidelines describe in detail the most essential scientific and ethical steps a researcher needs to follow while conducting a clinical trial [18] .
In 2014, the department of AYUSH published a manual entitled Good Manufacturing Practice (GMP) Guidelines that was based on the requirements for ASU drug manufacturing units laid down by the Drugs and Cosmetics Rule 157, 1945. GMP guidelines comprise a series of general principles that ASU pharmaceutical establishments must be observed during manufacturing. These guidelines ensure that raw materials used in the manufacture of drugs are authentic, meet prescribed quality requirements, and are free from contamination;that the manufacturing process conforms to the prescribed standards; that adequate quality control measures are adopted; and that the drug released for sale is of acceptable quality [19] .
In the era of globalization, concerns are being raised regarding the clinical safety of contemporary ASU formulations. There is a prevailing misconception that all drugs of natural origin are safe. Other false assumptions include the belief that natural medicines ensure both safety and efficacy and that there is a little or no chance of drug interactions. Contrary to these beliefs, an increasing number of published case reports document potentially adverse effects associated with AYUSH interventions.To tackle this issue, the Ministry of AYUSH has initiated the Pharmacovigilance Program for ASU & H drugs [20] .
The All India Institute of Ayurveda, New Delhi, is the National Pharmacovigilance Coordination Center (NPvCC) for implementation of the pharmacovigilance program for ASU &H Drugs. The NPvCC receives input in terms of suspected ADRs from the Intermediary Pharmacovigilance Centers (IPvCs). The National Pharmacovigilance Coordination Center undertakes the pharmacovigilance activities under the guidance and technical support of Indian Pharmacopoeia Commission( t h e W H O C o l l a b o r a t i n g C e n t r e f o r Pharmacovigilance), and the relevant program officers at WHO Country Office-India. If required, the National Pharmacovigilance Co-ordination Center, in consultation with the Pharmacopoeial Commission of Indian Medicine and Homeopathy (PCIM&H),conducts the Causality Assessment of the signals received from the Intermediary Pharmacovigilance Centers and then reports confirmed cases of Adverse Drug Reactions and misleading advertisements to the Ministry of AYUSH to enable suitable action [20] .
The Central Council for Research in Ayurvedic Science has initiated Tribal Health Care Research Program (THCRP) in 14 states through 15 institutes that operate under it. This program aims to study the living conditions of tribal peoples, collecting health statistics on tribal populations and studying their dietary habits,the nature and frequency of prevalent diseases,and the use of common medicinal plants in the area. It also strives to provide medical aid at the doorsteps of tribal peoples while also propagating knowledge of the Ayurvedic concept of Pathyapathya (wholesome and unwholesome food), including hygiene habits and dietary practices. It also collects information pertaining to LHTs/folk medicines/traditional practices prevalent in the area. This study has been implemented under TSP (Tribal Sub Plan) and,as of 2018, has covered approximately 842,959 people from 1,003 villages [21] .
The Swasthya Rakshan Program was initiated through Central Council for Research in Ayurvedic Sciences (CCRAS), the Central Council for Research in Unani Medicine(CCRUM), the Central Council for Research in Homeopathy (CCRH), and the Central Council for Research in Siddha (CCRS) in selected districts/villages. The program aims to organize Swasthya Rakshan outpatient departments,Swasthya Parikshan camps (Health camps), and health/hygiene awareness programs and to raise awareness of the importance of cleanliness of domestic surroundings and environment. It also documents the demographics, dietary habits,hygiene conditions, seasons, lifestyle, and incidence/prevalence of disease associated with each district [22] .
Initiated under the Scheduled Castes Sub Plan (SCSP), this program provides door-to-door healthcare services in areas with officially recognized castes pockets [22] .
This program has been undertaken by the Ministry of AYUSH and Ministry of Health and Family Welfare to promote prevention of noncommunicable diseases in three identified districts of three pradeshes: Bhilwara (Rajasthan),Surendra agar (Gujrat), and Gaya (Bihar) [22] .
This initiative of the Department of Health and Family Welfare and Ministry of AYUSH aims to strengthen healthcare facilities in remote areas [22] .
The Ministry of AYUSH has recently developed a comprehensive web portal for Standardized Terminologies and National Morbidity Codes of Ayurveda, Siddha, and Unani Systems of Medicine and WHO-ICD-10 and ICD-11. This aims at pan-India implementation of ASU National Morbidity Codes for reporting morbidity and treatment outcomes along with ICD-10/11 (Dual Coding System) and is expected to serve as reference repository of A-S-U terminologies and Morbidity Codes for further development of ASU international terminologies and ICD-11 Morbidity Codes [23] .
A standardized prakriti assessment scale has been launched by the Ministry of AYUSH in April 2018. It has been developed by conducting one year study by 8 peripheral centers of CCRAS.It aims at solving the problem of assessment of prakriti at Oot Patient Department level, which helps to prescribe medicine, diet, and lifestyle to maintain one’s health.
A comprehensive IT platform has recently been developed to effectively manage all functions of healthcare delivery systems and patient care in AYUSH facilities. The Ministry of AYUSH has created AYUSH GRID to bring all the IT projects under one umbrella. The platform integrates all IT projects that are dedicated exclusively to the improvement and facilitation of AYUSH healthcare delivery across India [24] .
This plan has been implemented under Schemes for Public Health initiatives scheme of AYUSH. Its main objective is to spread awareness among public about remedies available in AYUSH system of medicine. This scheme has 5 components focusing on spread of knowledge in public.
A voluntary product certi fi cation scheme for selected AYUSH products aimed at enhancing consumer confidence has been initiated by the ministry of AYUSH. The Quality Council of India (QCI) is the partner institute in this initiative. It offers two levels of certification: AYUSH Standard Mark,which is based on compliance to the domestic regulatory requirements, and AYUSH Premium Mark, which is based on GMP requirements,WHO Guidelines, and product requirements with flexibility to certify against any overseas regulation provided these are stricter than the former criteria.
Due to emerging demands for natural medicine and the process of globalization, a few initiatives in the AYUSH sector have been made through electronic means. Use of such information technology can add dimensions to the domain and scope for modernization of the AYUSH sector for its better accessibility to the stakeholders. All major classical textbooks have been made available in digital format for free use by National Institute of Indian Medical Heritage, Hyderabad, an institution that is governed by CCRAS.
This acronym stands for E-Channel for Herbs, Aromatic, Raw Material, and Knowledge and is a platform for enabling information exchange between various stakeholders involved in the medicinal plants sector. E-Charak has been jointly developed by the National Medicinal Plants Board (NMPB) and the Center for Development of Advanced Computing (CDAC) [25] .
This initiative is aimed at preparing a skilled workforce in the AYUSH sector. Under this initiative, the All India Institute of Ayurveda has developed curricula for different courses leading to different levels of certification, such as AYUSH Sports Therapist.
Until recently there were virtually no good peer-reviewed journals dedicated exclusively to publishing AYUSH research. This gap has now been filled by several journals that are indexed in standard databases such as PubMed and Scopus. According to Scopus data, approximately 6,321 articles have been published to date that contain the keyword“Ayurveda”. Of those, 4,274 came out in the last decade alone. Most of the articles on Ayurveda that have been published appeared in the Journal of Ayurveda and Integrative Medicine ( J-AIM ) . Bulletin of the Indian Institute of History of Medicine and the Journal of Ethnopharmacology are the oldest publications among the top five journals [26] .
Not surprisingly, most of the articles on indigenous Indian Medicine that are being published and indexed, are authored by the Indian researchers. Out of the approximately 6,300 published, 4,417— around 70% of the total number — originated in India. The next largest number of articles (705) came from the U.S,followed by the UK with 193, while Germany,the sole European contributor, published 138 articles. Researchers from Japan, Australia, Sri Lanka, and Canada have published 91, 86, 75,and 71 papers respectively [26] .
The majority of the articles published(3,141) fell under the category of medicine.Around 2,873 dealt with pharmacology and pharmaceutics; 975 related to biochemistry,genetics, and molecular biology; and 521 of the articles published fell under the category of agriculture and biological sciences. While researchers in chemistry and the social sciences contributed 269 and 251 papers, respectively,those in the allied health professions and nursing categories published only 179 and 157,respectively [26] .
The quality of research in Ayurveda has long been a concern. The fundamental difficulty of testing the effectiveness of Ayurvedic interventions is rooted in the complexities of Ayurvedic diagnosis and treatment. Of late,however, a few models for conducting clinical trials without compromising the Ayurvedic approach to disease have been proposed that look promising. The problem of poor quality research also appears to stem from the failure of college and university level courses in Ayurveda to sufficiently stress the importance of following standard research protocols. The same training deficiencies are reflected in the scarcity of high-quality Ayurvedic research publications. These challenges must be tackled so that Ayurvedic research can become more visible and earn wider respect from the mainstream scientific community [27] .
A 2009 nationwide survey of students and teachers from more than 30 colleges of Ayurveda raised concerns about the field’s lack of high-quality educational standards. The study suggested the curriculums of Bachelor of Ayurvedic Medicine and Surgery (BAMS) programs failed to deliver the skills that practitioners need. Participants complained that college syllabi lacked sufficient information on certain relevant topics such as intellectual property rights, standardization of medicinal products, toxicity of medicinal products,healthcare management, and cultivation of medicinal plants. The study also suggested that the Ayurvedic academicians were not following the accepted standard methods of research and documentation, and that the educational institutions should be urged to do more to shore up the evidence base for Ayurveda. In addition,survey respondents noted that Ayurveda graduates need more exposure to basic clinical skills in order to be able to deal effectively with the challenges of primary healthcare delivery.Since that time, the Central Council of Indian Medicine has introduced a series of curricular reforms designed to address these deficiencies.To determine their success, a critical evaluation of the present situation is now required [28–29] .
Exhaustive field work conducted by Shailaja Chandra, the former Secretary of the Department of AYUSH, resulted in the 2011 and 2013 publication of a two-volume report titled “Status of Indian Medicine and Folk Healing, with a Focus on Benefits the Systems Have Given to the Public”. Since the report’s publication, many changes have been implemented that warrant re-evaluation of the situation described in the report [9] . A major concern raised by all these reports was that the mushrooming growth of substandard colleges was diluting the rigor of Ayurvedic medical training. Other concerns included the presence of corruption in the educational system, which manifested in the emergence of many colleges whose resources existed only on paper, and the failure of AYUSH faculty to provide undergraduates with a strong foundation in the biomedical sciences and insufficient hands-on training in clinical settings [10] .
Teaching/learning methods in Ayurveda have received negligible attention in the contemporary literature on Ayurvedic education.While serious research in this area has been minimal, a few promising studies have been published recently. One study that looked at various integrative approaches to teaching and another on problem-based learning modules pointed to the potential benefits of implementing these innovative methods in Ayurvedic educational programs [30] .
Based on the requirements, NCISM have now implemented the outcome based education model to the graduation level Ayurvedic program.
The historical and cultural diversity of various countries is a key source of the wide disparities among them in regard to the evolution and adoption of traditional indigenous medical systems such as Ayurveda.Differences in economic conditions, religious beliefs, government healthcare policies, and scholarly opinions also help account for these disparities. The current status of Ayurveda in countries outside India is reflected in its increasing visibility in forms ranging from Ayurvedic cooking methods and massage therapies, panchakarma centers, Ayurvedic spas, and yoga retreats to products such as nutrition supplements, herbal remedies, and aphrodisiacs. While these traditional Indian wellness applications have been enthusiastically embraced in many Western countries, most Westerners have yet to realize the value of Ayurveda as a medical system whose scope encompasses the prevention, treatment, and management of a plethora of diseases. In the US,Ayurveda is, at best, relegated to the category of complementary and traditional medicine; yet unlike many better known alternative medical systems such as chiropractic and acupuncture,Ayurveda is ineligible for health insurance coverage. Another potential barrier to its official recognition as a healthcare discipline in the West, is the presence of heavy metals in some traditional Ayurvedic remedies. While the therapeutic use of heavy metals has been extensively documented in Ayurvedic texts,these formulations violate the stringent drugmanufacturing norms that prevail in most Western countries. Due to the risk of toxicity from heavy metals like mercury, arsenic, and lead, the US, Britain, and the EU have banned the importation and sale of these preparations [31] .
The Ministry of AYUSH has set up information centers in more than 30 countries to disseminate authentic knowledge of AYUSH systems. The Ministry has also signed a number of memorandums of understanding (MoUs) with various countries to encourage productive communication and cooperation among ISM stakeholders.
WHO has played a key role in spreading Ayurvedic knowledge worldwide. Along the same lines, it has recognized Morarji Desai National Institute of Yoga (MDNIY) and Institute for Post Graduate Teaching & Research in Ayurveda (IPGTRA) as its Collaborative Centers in Traditional Medicine. As an initiative to standardize its terminology according to contemporary needs, a Project Collaboration Agreement (PCA) has been signed between the Ministry of AYUSH and the WHO, Geneva, for developing WHO Terminologies for Ayurveda,Unani, and Siddha.
Various associations and organizations in different countries, led primarily by eminent Indian scholars, have been involved in the development of Ayurveda abroad. They are mainly offering Ayurvedic treatments and training. To gain an overview of the status of Ayurveda globally, the countries can be broadly classified into four groups:
Ayurveda is indigenous to India and enjoys a strong foothold in other member states of the South Asia Association for Regional Cooperation(SAARC). Because SAARC countries recognize Ayurveda as an independent medical system,they regulate its trade and practice standards through various Acts and statutes.
Other Asian Countries Ayurveda and Traditional Chinese Medicine are recognized in many other Asia countries. While each of these countries has its own traditional medical system, Ayurveda still plays a major role in delivery of primary healthcare services.
Developed Countries This group includes America, Europe and Australia, where Ayurveda is widely practiced as a form of wellness therapy, with no official recognition or regulation. The medicines are sold more often as food supplements and cosmetics, without the intervention of any Ayurveda practitioner, often as over-the-counter (OTC) products. There are many educational institutions that offer Ayurveda courses in these countries, some with and some without accreditation and recognition.
Europe and Other Countries Approximately 70%～80% of Ayurvedic drugs are banned from import into the EU. Per the EU Directive for Traditional Herbal Medicines (2005 only those drugs being sold as OTC products with a minimum of 15 years of documented use within the EU can be marketed there). The directive restricts the sale of newly developed Ayurveda drugs and all drugs that use animal products such as milk products and honey, including formulations containing metals and minerals along with herbal components. The opinion expressed in the directive deems these drugs a potential threat to public health as well as to the reputation of the healthcare system. Despite these concerns about the safety of traditional medicines, the majority of medical tourists who visit India are Europeans with various chronic disorders seeking treatment with Ayurvedic therapies and medicines [31] .
Other Countries A large number of consumers of Ayurveda treatment and services reside in Africa, Latin America, Russia, and other Commonwealth of Independent States(CIS). Ayurveda is recognized as an alternative system of medicine in these regions, andvarious Ayurvedic services are popular there.
Australia The evolution of Ayurveda inAustralia dates back to 1970s when the FirstInternational Congress on Traditional AsianMedicine, known as ICTAM, was organized.This event initiated a dialogue betweenstakeholders in various traditional medicinesystems around the globe. It was followedby the establishment of the InternationalAssociation for the Study of Traditional AsianMedicine (ASTAM) by the Australian AyurvedaAssociation. Currently, the Australian Instituteof Higher and Further Research (AIHFR) runsa nationally recognized program that leads to anadvanced diploma in Ayurveda. The programdelivers all the theoretical lectures online andrequires a minimum of 400 hours of supervisedclinical training.
Europe In Europe, the European Institutefor Ayurveda Medicine (EIFAM) provides a12-month foundation course on AyurvedicMedicine for healthcare professionals, as wellas a collaborative program with the EuropeanUniversity Viadrina that leads to a master’sdegree in complementary medicine. Theinstitute is also involved in Ayurvedic researchand development and is working towarda vision of integrative medicine. Anotherleading contributor to the advancement ofAyurveda is the European Ayurveda Association(EUAA), a network of organizations,hospitals, educational institutions, therapists,manufacturers, and suppliers and distributorsof Ayurvedic products that extends across16 countries in the European EconomicArea (EEA). The group is actively involvedin issues of major interest to the Ayurvediccommunity such as freedom of choice inmedicine, health insurance reimbursement, the quality of Ayurvedic products and services and patient safety. It works in collaboration with European government health authorities, health insurance companies, professional associations, universities, training institutes, the Ministry of AYUSH, and the Ministry of Health and Family Welfare, Government of India.
The Rosenberg European Academy of Ayurveda (REAA), a nonprofit organization funded by students’ tuitions and patients’ treatment fees and donations, runs various treatment and training centers in Germany, Switzerland, and Austria. It offers a number of courses for Ayurveda enthusiasts, including Ayurveda seminars for beginners, further training for doctors, Ayurveda as complementary medicine, and postgraduate studies in Ayurvedic nutrition, massage, and marma therapy. It also provides training for alternative practitioners, Ayurveda and yoga health coaches (IHKs),and Ayurvedic nutritionists, health consultants, cooks, and medical phytotherapists [32] . In addition, the academy is partnering with Middlesex University, the School of Health and Education (London, UK), and Charité University Medical Center Berlin (Master module) in a program that leads to the first recognized Master of Science degree in Ayurveda. The four-year university course is divided into three parts and features a flexible curriculum that meets the needs of graduate students. It includes clinical internships in India and Europe and home studies.
United States In the US, Ayurveda is gaining ground through the efforts of the National Ayurvedic Medical Association (NAMA), a renowned organization dedicated to the growth of Ayurveda in the West. Founded in 2000, its primary goal is to support Ayurvedic education and professional practices. The Standards Committee surveys the Ayurvedic education system and is involved in setting standards for Ayurvedic professionals. There are currently around 30 NAMA-recognized schools of Ayurveda operating in various regions of the country. The organization strives to serve as an official spokesperson for and representative of the Ayurvedic profession in the United States. Its efforts are oriented toward regulating education, ethics, professional competency and licensing, and research. Along with establishing recognition and acceptance of the Ayurvedic profession and forging connections with government agencies, policymakers,and numerous Ayurvedic organizations, and businesses, NAMA hosts yearly conferences that consistently attract a broad swath of the Ayurvedic community [33] .
Russia Although there is no legal recognition of the Ayurvedic profession in Russia, the government and the public have acknowledged Ayurveda as a healing system. A large medical center in Moscow called NAAMI that included a team of vaidyas from India on its staff in the late 1990s has been successful in generating awareness of Ayurveda. NAAMI has also signed an MOU with the Indian government, agreeing to dedicate government aid from India to promote the development of Ayurveda in Russia. In addition, upcoming translations of works by Charaka, Sushruta, and Vagbhata will soon enable Russians to read the classics of Ayurveda in their native language.
Japan Ayurveda in its present form, has a history of 30 years in Japan, where its traditions are perpetuated by respected institutions,including the Society of Ayurveda, founded by Osaka Medical School; the Japan School of Ayurveda (Tokyo); and the Institute of Traditional Oriental Medicine (Tokyo).