Traditional,Complementary,and Integrative Medicine Governance in the Americas Region: An Analytic Framework

Abstract

Introduction:

This work presents an analytic framework for describing the unique features of Traditional, Complementary, and Integrative Medicine (TCIM) governance, based on datasets from across the Americas, a region globally notable for its cultural and legal pluralism. In response to World Health Organization (WHO) guidance, the Pan American Health Organization expanded its TCIM technical cooperation, investing in governance-related research and fostering a TCIM regional network.

Methods:

Using the Framework method developed by Richie and Spencer, the authors iteratively constructed the framework with reference to over 500 TCIM-related policy instruments, court cases, and other governance approaches.

Results:

Seven primary analytic categories comprise the framework: (1) jurisdiction, (2) governance type, (3) specificity, (4) TCIM type, (5) health systems elements, (6) intersectoral dimensions, and (7) TCIM aspects addressed. Together, these categories (along with related subcategories and analytic tags) enable systematic tracking of diverse Indigenous, state, civil society, and private sector governance approaches applied to TCIM systems, practitioners, practices, and products. The framework facilitates detailed monitoring of numerous TCIM governance issues (e.g., financing, human resources, service provision, information management, biodiversity, traditional knowledge protection). It also accounts for the influence of international and regional governance instruments and recognizes the intersectoral character of TCIM governance in many settings.

Conclusion:

The framework offers a harmonized analytic approach to tracking TCIM governance and may be transferable to other regions. As such, it provides a preliminary architecture for a future digital online repository of global TCIM governance. This kind of resource, aligned with WHO recommendations, would help to close expertise gaps—such as those related to regulatory frameworks, health systems integration, and culturally responsive practices—identified by countries as barriers to TCIM governance. It also has the potential to support horizontal cooperation among diverse interest-holders, including policymakers, health professionals, private sector representatives, researchers, Indigenous peoples, and community-based actors.

Keywords

analytic framework complementary medicine governance health equity health policy traditional medicine

Introduction

For over four decades, the World Health Organization (WHO) has formally recognized that traditional, complementary, and integrative medicine (TCIM) practitioners, practices, and products, as well as their affiliated systems of knowledge, have important roles to play in advancing primary health care around the world. The WHO’s commitment to advancing public health through TCIM’s inclusion in national health systems has been evident in its Declarations of Alma Ata (1978),¹ Beijing (2008),² Astana (2018),³ and Gujarat (2023),⁴ as well as three Traditional Medicine Strategies (2002–2005,⁵ 2014–2023,⁶ 2025–2034⁷) As these and other related WHO documents recognize, TCIM’s widespread worldwide use in primary health care includes jurisdictions where TCIM “practitioners are the first contact and sometimes the only health providers available.”⁸ As an important source of culturally responsive, people-centered care in many settings, TCIM is especially relevant to historically marginalized communities, including but not limited to Indigenous peoples, ethnospecific groups, and rural or underserved populations. TCIM’s interface with health systems offers transformative opportunities to advance health equity and well-being-focused societies.

While the number of WHO member states implementing national policies related to TCIM, as well as regulations governing related practitioners and products, has steadily increased in recent decades, many governance-related challenges remain. Although “lack of research data” has been identified as the primary difficulty faced with regard to TCIM regulatory issues, member states also highlight numerous specific challenges directly related to TCIM governance.⁹ These include a “lack of expertise within national health authorities and control agencies”; a “lack of appropriate mechanisms” for governing TCIM practitioners, practices, and products; and a “lack of cooperation channels” between countries for information sharing about TCIM governance.

The WHO’s most recent Traditional Medicine Strategy (2015–2034) prioritizes the advancement of TCIM-related governance of various kinds around the world, as well as related research and information sharing.⁷ Echoing earlier versions,^5,6 the current strategy prioritizes the regulation of TCIM practitioners, practices, and products to support the safe inclusion of related services within primary health care.⁷ Expanding on the scope of what was stipulated in previous strategies, this document also recognizes that TCIM governance takes place at the international, national, and subnational levels, and across multiple sectors, requiring coordinated action. It recognizes that TCIM governance must be context-appropriate and calls for the involvement of diverse stakeholders in policy development. It also emphasizes cross-sectoral dialogue and policy action across the health care system, with the education and private sectors, and regarding such matters as biodiversity, traditional knowledge protection and benefit sharing, well-being, cultural appropriateness, and affordability. To monitor countries’ success in achieving these aims and to identify contextually transferable best practices, a systematic, rigorous approach will be needed.

The WHO currently monitors just three types of governance mechanisms for TCIM: National Policies, National Legislation, and National Regulation on Herbal Medicines.⁹ However, as the WHO’s Traditional Medicine Strategy 2015–2034 recognizes,^9,10 TCIM governance across the globe is complex. For example, at the state level, it spans the entire spectrum of states’ hierarchy of the law, from the constitution down to regional, municipal, and institutional mechanisms.¹¹ Moreover, TCIM governance approaches extend well beyond statal mechanisms and are evident in Indigenous communities, the private sector, and civil society.¹² To date, however, there are few guidance resources available for decision makers seeking to govern TCIM and its elements (e.g., practitioners, practices, products, devices).^11–13 Nor are there rigorous analytic tools available for scholars that are specific to TCIM governance and address the sphere’s complexity. To help fill these gaps, and with reference to TCIM governance-related datasets from the Americas region, this work proposes a descriptive analytic tool for classifying diverse TCIM governance approaches, including and beyond statal mechanisms.

Methods

Because this research involved only document review and no human participants, no ethics review was required. In developing this work’s analytic framework for TCIM governance, the authors engaged with an applied policy research method called “Framework,” introduced by Ritchie and Spencer.¹⁴ Applied policy research can take various forms, including “contextual” research (such as the current work) focused on “identifying the form and nature” of a particular domain’s elements. According to Ritchie and Spencer, some advantages of the Framework method are that it is “grounded” (in data), “dynamic” (in the sense that the resulting analytic model, that is, framework may be iteratively amended), and “systematic” (in that the framework may be repeatedly applied to similarly treat related units of analysis).

The Framework method consists of a series of five stages characterized together by a “systematic process of sifting, charting, and sorting materials according to key issues and themes” of interest in relation to a particular area of inquiry. Framework’s five stages are: (a) data familiarization, (b) identification of a thematic framework, (c) indexing, (d) charting, and (e) mapping and interpretation. In developing the analytic framework presented in this work, the authorship team engaged primarily with the first three stages of the Framework method. However, all five stages are relevant to the authors’ larger scholarly project of tracking and analyzing TCIM governance approaches from around the world. The authorship team’s work engaging with Framework’s fourth and fifth stages (through which the authors are actively conducting in-depth analyses of TCIM governance approaches in specific countries and regions) is ongoing and will be reported elsewhere.

Below, the authors present a detailed account of the methods used to develop the analytic framework and to detail the specifics of this tool’s concomitant elements and their application utility. This account is intended to provide knowledge users with sufficient information to not only engage with the tool themselves, but also to evaluate future reporting of the tool’s application.

As Ritchie and Spencer indicate, the Framework method’s stages are “highly interconnected” and may proceed in an iterative, recursive (rather than prescriptive, linear) manner. This was very much the authors’ experience with this methodological approach. The project’s origins are multiple, initially arising from separate bodies of policy analytic work in the Americas region by Gallego-Perez and Ijaz, respectively. In a doctoral dissertation, Gallego-Perez had proposed a set of policy analytic parameters for TCIM practitioners and practices with respect to the civil law contexts of Latin America.^11,15 This work applied the construct of the “hierarchy of laws”¹⁶ to characterize the wide range of state governance approaches at play across the analyzed contexts, ranging from national constitutions and laws to a wide range of (formal and informal) policy-setting mechanisms, including national policies, regulations, and position documents without administrative sanction.

Independently but in tandem, Ijaz had been conducting analyses of TCIM governance within the hybrid civil/common law contexts of Canada and the United States of America.^12,17–20 These analyses not only addressed statutory governance in terms of national and subnational policy making, but also with respect to governance taking place within civil society and the private sector. Like the work of Gallego-Perez, Ijaz’s research drew attention to the limitations of current WHO reporting around global TCIM governance. In dialogue, these authors began a collaborative process, aligned with the framework method, aimed at developing an analytic model capable of comprehensively describing the wide range of TCIM governance approaches in use across the Americas region. From the outset, the intention was to create a data-driven analytic model that could ultimately be used around the world.

Following the Framework method’s first stage (data familiarization),¹⁴ the lead authors immersed themselves in their respective TCIM governance datasets (some published, some unpublished) from Latin America, Canada, and the United States. They also familiarized themselves with the contents of an expanded database of TCIM governance instruments from Latin American and Caribbean countries, which extended Gallego-Perez’s compilations to include TCIM products and intercultural health instruments. This expanded database was developed by coauthor de la Ossa as part of a consultancy with the Pan American Health Organization, supervised by coauthors Bascolo and Rosell De Almeida. Altogether, these datasets tracked over 550 distinct TCIM-related governance mechanisms across the region. In this process of data familiarization, the authors iteratively and collaboratively engaged with the framework’s second stage (identification of a thematic framework), seeking to construct analytic parameters capable of classifying the wide range of TCIM governance approaches in the engaged datasets.

As a team, the authors iteratively constructed a thematic classification model from their analytic codes and categories to account for the distinct features of TCIM governance across the Americas region. To this end, they engaged with the Framework method’s third stage, indexing, which enabled consistent labeling and categorization of governance mechanisms for systematic analysis.” In data immersion, the authors used a descriptive content analysis approach of data coding and categorization to classify the range of policy approaches in their datasets. Using the qualitative research principle of saturation (rather than an exhaustive coding process), the authors determined that the framework was robust once the team’s existing categories consistently accounted for the features of the wide range of governance approaches in the project datasets.

Overall, the authors privileged an inductive approach to category building. However, in areas where relevant classification systems existed, the authors took them into consideration in constituting the otherwise inductively derived categories. Where this was the case, the authors make it explicit in the Results section. Further, some design decisions were made with an inclusive view to supporting the framework’s transferability to other regions moving forward. All coauthors validated the analytic model based on their specialized expertise in health governance and regional knowledge of the Americas. The framework described in what follows is the result of this process. Illustrative exemplars of TCIM governance from the engaged datasets support the overview provided of each of the framework’s thematic categories.

Results: The Framework

This framework is designed as a descriptive analytic tool for classifying the range and characteristics of diverse TCIM governance mechanisms. To track the specific governance mechanism being classified, the framework invites users to begin by collecting that mechanism’s basic identifying details (name, year enacted, instrument number, etc.) along with a synthetic narrative account of its objectives and TCIM-related scope. As shown in Table 1, the framework itself is comprised of seven primary thematic categories (each of which has subcategories and/or additional descriptive “tags”). These categories are: (1) jurisdiction, (2) governance type, (3) specificity, (4) TCIM type, (5) health systems elements, (6) intersectoral dimensions, and (7) TCIM aspects addressed. The sections that follow provide a brief overview of each category’s aims and primary features, along with illustrative exemplars for each, drawn from the authors’ Americas regional datasets. Where elements of the framework draw upon or represent modifications of other analytic instruments, this is made explicit.

Table 1.

TCIM Governance Framework Map: Categories and Subcategories

1	2	3	4	5	6	7
Jurisdiction	Governance type	Specificity	TCIM types	Health systems elements	Intersectoral dimensions	TCIM aspects addressed
a. Global body b. WHO region c. Regional body d. Country e. Subnational	a. Indigenous Governance b. State Governance^a c. Civil Society d. Private Sector	a. TCIM-specific b. TCIM-inclusive c. Contextual	a. Orally transmitted ethnomedical systems and practices b. Codified ethnomedical systems and practices c. Whole nonethnomedical systems d. Complementary therapeutics e. Community-based care f. Integrative therapeutics g. Unspecified	a. Culturally relevant care/interculturality b. Health financing c. Health systems principles/priorities d. Health Tourism e. Human Resources for Health f. Indigenous peoples’ health and well-being g. Information management h. Infrastructure/Facilities i. Medicines and other health technologies j. Operations/Service provision k. Parameters of the legal practice of medicine	a. Economics b. Education c. Food systems/Nutrition d. International affairs e. Military/Defense f. Natural resources/Biodiversity g. Research/Development h. Social/Cultural development i. Not applicable	a. National TCIM vision and strategy b. Right to use TCIM c. TCIM—biomedical interface d. TCIM coverage and reimbursement e. TCIM practitioners and practices^b f. TCIM products and devices^c g. TCIM research and development h. Traditional knowledge, intellectual property and benefit sharing i. Wellness j. Other

Additional tags for 2b include: i. Constitution; ii. Treaties/International Agreements; iii. Statutes/Legislation; iv. Public Policy; v. Regulations; vi. Common Law; and vii. Other.

Additional tags for 7e include: Acupuncture; ii. Anthroposophic Medicine; iii. Ayurvedic Medicine; iv. Birth Work (any type); v. Chinese Medicine; vi. Chiropractic Medicine; vii. Expressive Therapies (any type); viii. Herbalism/Herbal Pharmacy; ix. Homeopathic Medicine; x. Indigenous Medicine; xi. Integrative Medicine; xii. Massage/Bodywork (any type); xiii. Naturopathic Medicine; xiv. Osteopathic Medicine; xv. Unani Medicine; xvi. Yoga; and xvii. Other.

Additional tags for 7f include: i. Animal-Based Medicines; ii. Dietary Supplements; iii. Herbal Medicines; iv. Homeopathic Medicines; v. Mineral/Metal-Based Medicines; vi. Psychoactive Medicines; vii. Devices; and viii. Other.

TCIM, traditional, complementary, and integrative medicine.

Jurisdiction

This category classifies TCIM governance approaches according to their territorial jurisdiction, beginning with their affiliated WHO region, country, and (where relevant) subnational jurisdiction (e.g., state, province, municipality).

Examples: In Brazil, there are country-level as well as subnational policy instruments related to TCIM, reflecting the country’s three-tiered health governance structure. At the federal level, Brazil has several TCIM-related policies (on Indigenous Peoples’ Health [2002], Complementary and Integrative Health Practices [2006], and medicinal plants [2006]). Some states (e.g., Sao Paulo, Minas Gerais, Espirito Santo, Rio Grande do Sul) and municipalities (e.g., Porto Alegre, Rosario do Sul) have also issued various subnational TCIM-related policies to support (and in some cases expand) implementation of national policies according to their jurisdictional competencies.

Because TCIM governance in specific regions and countries is impacted by larger global policy contexts, the framework also tracks instruments put in place by a global body, which bear on how countries govern TCIM within their borders.

Examples: Two examples help to illustrate the importance of policy instruments developed by a global body. First, the International Labour Organization’s 1989 Indigenous and Tribal Peoples’ Convention, for example, calls for governments to recognize Indigenous peoples’ “social, cultural, religious and spiritual values and practices,” including in the context of health care.²¹ That Convention, subsequently ratified in 15 countries across the Americas, is also explicitly referenced in some countries’ TCIM-related policies (e.g., Chile’s [2006] and Paraguay’s [2009] Policies on Indigenous Peoples’ Health, respectively). Second, in 2002 and 2013, the WHO released its first and second Traditional Medicine Strategies, which call for governments to enact TCIM-related policies. National TCIM-related policies in Brazil (2006) and Chile (2024), among other governance instruments across the region, directly cite the WHO strategy.

The framework similarly documents governance instruments produced by a regional body, which impact nations’ specific TCIM governance approaches.

Examples: In 2009, the Latin American and Caribbean Parliament (Parlatino) enacted two TCIM-focused framework laws, one addressing traditional medicine and the other complementary medicine. These resolutions are explicitly cited in several Mexican policy instruments addressing the inclusion of TCIM within the country’s health care system.

Governance type

In recognition of the multisectoral nature of public health governance, this category enables classifications of the sector in which a TCIM governance mechanism is being enacted, with reference to four primary domains: Indigenous governance, state governance, civil society, and the private sector. In addition to being data-driven, the first domains are informed by the JuriGlobe classification model of legal systems around the world²²; the second two derive from PAHO’s recognition in its Essential Public Health Functions framework,²³ of the range of stakeholders involved in health systems governance. Because the authors identified governance mechanisms in the region with overlapping sectoral domains, the framework permits multiple classifications for a single governance mechanism.

Examples: In Canada, TCIM governance extends across all four primary governance domains. An Indigenous governance body in the province of British Columbia, the First Nations Health Authority, is responsible for the delivery of a range of health services for Indigenous people, informed by First Nations healing knowledges and practices. State governance is evident federally (in the country’s Natural Health Products regulations) as well as across the provinces, where a range of TCIM occupations (e.g., chiropractic, homeopathy, massage therapy, naturopathy, traditional Chinese medicine/acupuncture) are licensed. Numerous civil society organizations set voluntary standards for unlicensed TCIM practitioner groups (e.g., Osteopathy). In the private sector, third-party insurers reimburse TCIM care delivered primarily but not exclusively by statutorily licensed TCIM practitioners, in some cases relying on standards set by civil society organizations to inform their reimbursement decisions.

To account for the wide range of state mechanisms used to govern TCIM, this category also includes a second classification layer involving seven subcategories. These are: constitution, treaties/international agreements, legislation, public policy, regulations, common law, and other governance instruments. These categories were informed by the hierarchy of laws model developed by the International Foundation for Electoral Systems¹⁶ and modified to better account for TCIM governance approaches identified in the project datasets. In this framework, state policy instruments are classified into the highest applicable level within the hierarchy of laws. For example, an instrument titled “National Policy,” issued or enacted through a law, is classified as “Legislation” rather than “Public Policy.”

Examples: Bolivia is a country that illustrates how TCIM governance may span multiple layers in the hierarchy of laws. Constitutional provisions recognize Indigenous peoples and their distinctive health-related knowledges and practices and entrench Indigenous traditional medicine (and peoples’ right to access it) as part of the national health system. Various pieces of Legislation, both specific to and inclusive of traditional medicine, support the broad implementation of the constitutional provisions. These include Bolivia’s Law of Traditional Medicine (2013), Policy on Intercultural, Family, and Community Health (2010), and Social and Economic Development Plan 2021–2025. Regulations in Bolivia govern administrative and service-related processes, such as the establishment of a traditional medicine registry and information system; the functioning of consultative bodies addressing medicinal plants; care guidelines (e.g., for traditional midwives, COVID-19) and a national list of natural, traditional, and artisanal products. Furthermore, Bolivia has also issued policy-setting documents (classified as “other governance instruments” in this framework) without an associated administrative act, such as the 2012 “Strategic Guidelines for Traditional Medicine and Interculturality.”

Further, there are various examples of public policy across the region, such as Haiti’s National Health Policy (2012) and National Pharmaceutical Policy (2014), which both address the governance of traditional Haitian medicine as a central element of the country’s health care. With respect to common law (established through judicial precedent), there are court rulings in some US states (e.g., Oregon, 2014) that have determined in which licensed professions’ scopes the use of acupuncture needles is permitted.

Specificity

This category classifies TCIM governance approaches by their degree of TCIM-specificity, that is, according to whether they “only” address TCIM (TCIM-specific), address TCIM as well as other matters (TCIM-inclusive), or bear indirectly on TCIM’s governance in a nonexplicit way (contextual). A particular governance approach may only be classified with reference to one of the three subcategories of specificity.

Examples: Chile has TCIM state governance approaches across all three levels of specificity. For example, the country’s National Policy on Complementary Medicine and Wellness-Focused Health Practices (2024), as well as regulations governing acupuncture (2008), homeopathy (2010), and naturopathy (2012) as “auxiliary health professions” are all TCIM-specific. An example of TCIM-inclusive governance is Chile’s National Policy on the Health of Indigenous Peoples (2006), which explicitly refers to the recognition, protection, and strengthening of Indigenous peoples’ traditional health systems as one component of a larger national agenda. Finally, the Chilean constitution includes a provision that guarantees people’s right to choose their preferred type of health system as part of the larger human right to health; while TCIM is not explicitly mentioned (contextual), this has been interpreted as giving people the right to preferentially choose TCIM care.

TCIM types

The purpose of this category is to permit analytic differentiation between the mechanisms used to govern a wide range of TCIM approaches in use around the world. To this end, the framework engages (in an unmodified form) the six “types” elaborated in Ijaz’s operational typology of TCIM,²⁴ which differentiates between diverse TCIM systems, practices, products, and devices based on their historical, cultural, and paradigmatic features. There are countries where a single governance approach may encompass multiple TCIM types; in other cases, specific TCIM elements are addressed through individual governance mechanisms.

Examples: In Colombia, the Law on Human Talent for Health (2007) governs forms of TCIM that extend across all six “types.” That law, which governs health professionals’ scopes of practice, explicitly recognizes traditional Indigenous medicine (orally transmitted ethnomedical systems and practices), traditional Chinese and ayurvedic medicine (codified ethnomedical systems and practices), naturopathic and homeopathic medicine (non-ethnomedical whole systems), and manual therapies and therapeutic movement (complementary therapeutics). The same law also implicitly addresses another TCIM type (integrative therapeutics) by largely limiting the practice of the aforementioned approaches to licensed biomedical practitioners. The final TCIM type (community-based therapeutics) is also addressed in this law through an exemption mechanism that allows for traditional knowledge holders to practice their own systems and practices of medicine within their specific community contexts.

Health systems elements

This category aims to contextualize particular TCIM governance approaches by identifying which elements of a jurisdiction’s health system they address. The 11 subcategories used for this purpose were dually informed by an iterative coding and classification process using data from the Americas region. In addition, some elements of the Pan American Health Organization’s Essential Public Health Functions framework,²³—in particular, its conceptualization of resource allocation as an essential public health function—informed the narrative framing of three of the subcategories* outlined below. These are: culturally relevant care/interculturality, health financing*, health systems principles/priorities, health tourism, human resources for health*, Indigenous peoples’ health and well-being, information management, infrastructure/facilities, medicines and other health technologies*, operations/service provision, and parameters of the legal practice of medicine. Table 2 briefly explains each subcategory’s scope and provides illustrative examples.

Table 2.

Category 5, Health Systems Elements: Illustrative Examples from the Americas Region

Health systems elements	Examples
a. Culturally relevant care/interculturality	Governance approaches classified here explicitly recognize the centrality of culture in health and health care, offering conceptual and/or tangible parameters for advancing interculturality in various aspects of health systems design and health care delivery. In some countries (e.g., Bolivia [2008], Ecuador [2012], Peru [2016]), specific governance instruments set out models of care for transforming health systems that encompass a recognition of traditional medicine as one element of cultural responsiveness and inclusivity. In addition, there are policy instruments that focus on specific elements of culturally relevant care delivery, for example, by traditional birth attendants in Peru (2005), Ecuador (2008), Guatemala (2016), or by promoting traditional dietary practices (‘dieta de la milpa’, Mexico 2019, 2025). Some countries have policies supporting health care aligned with the ancestral cosmovision and therapeutic practices of particular ethnocultural communities, such as Indigenous and Afrodescendent people (e.g., Honduras 2016). Another type of governance approach classified in this category involves religion as an element of culture. In the United States, for example, the federal American Indian Religious Freedom Act (1978), and two court rulings (Supreme Court, 2006; Oregon State Court, 2009) have provided religious exemptions to the federal prohibition on specific sacred psychoactive medicines for members of particular Indigenous groups.
b. Health financing	Governance mechanisms that address various aspects of health care financing related to TCIM are classified here. For example, Cuba’s 2014 Council of Ministers Agreement requires that the purchase of natural health products needed within the health care system is financed by the country’s national budget. A Colombian regulation (2015) stipulates that all health insurance providers (whether public or private) may opt into covering TCIM care within their plans. In Nicaragua, a 2011 law on complementary medicine requires that the country’s Ministry of Health be allocated sufficient resources to implement all of the law’s provisions, including TCIM clinical care delivery.
c. Health systems principles/priorities	Governance approaches classified here articulate overarching goals, values, or priorities that guide the organization and functioning of the health system in relation to TCIM. These principles often include commitments to equity, universality, integration, people-centeredness, and interculturality. In Bolivia (2008), the Política de Salud Familiar Comunitaria Intercultural (SAFCI) outlines a health system model based on community participation, interculturality, and integrality, aiming to eliminate social exclusion in health and to integrate biomedical and Indigenous medical systems. In Colombia (2015), Statutory Law 1751 establishes the right to health as a fundamental right and defines key principles for the health system, including interculturality, protection of Indigenous and ethnically diverse populations (e.g., Afro-Colombian, ROM, Raizal, Palenquero), and recognition of traditional knowledge and practices.
d. Health tourism	Classified in this subcategory are governance approaches that address forms of TCIM offered within a tourism context. Governance of health tourism is an area in which formal governance is just beginning to emerge within the Americas region. However, a nonstatutory body, the Caribbean Spa and Wellness Association, has introduced harmonized safety and health standards for the corporate spa and wellness sector, in which consumers access services often extracted from or rooted in TCIM systems of knowledge and practice. There have been calls for increased governance of tourist usage of Indigenous peoples’ sacred and psychoactive medicines within the region.
e. Human resources for health	This subcategory focuses on the regulation, recognition, training, and integration of TCIM practitioners within health systems. In Grenada, the Health Practitioners Act and its 2019 amendment assign responsibility to the Grenada Allied Health Professions Council (GAHPC), a statutory body mandated to protect the public, uphold professional standards, and ensure continued competence across allied health professions. These include a wide range of TCIM-related roles, such as herbalists, homeopaths, acupuncturists, naturopaths, reflexologists, and massage therapists. The Act provides a formal regulatory framework that acknowledges the diversity of health providers beyond conventional medical fields and establishes mechanisms for their oversight, licensing, and public accountability.
f. Indigenous peoples’ health and well-being	Governance mechanisms in this subcategory safeguard and promote the health of Indigenous peoples by recognizing their worldviews, traditional knowledge systems, and collective rights. Across the Americas, several countries have adopted national instruments specifically focused on Indigenous health. In Argentina (2019), Brazil (2022), and El Salvador (2018), for example, there are policies aiming to improve health outcomes for Indigenous communities through intercultural approaches, recognizing traditional medicine and promoting active participation in health governance. In Mexico, a national intercultural health framework guides the transformation of services to better serve Indigenous and Afro-Mexican populations. Bolivia’s 2009 Constitution enshrines the rights of Indigenous peoples to their traditional medicine, knowledge systems, and cosmovision, within a universal, free, and culturally respectful national health system.
g. Information management	This subcategory refers to instruments that support the systematic collection, organization, and use of data related to TCIM to inform decision-making, improve service delivery, and strengthen oversight. In Bolivia, the 2009 Regulation on the National Registry of Ancestral Traditional Medicine (RUMETRAB) establishes procedures for registering traditional medicine practitioners and practices, while the 2022 Traditional Medicine Information System (SISMET) consolidates data from TCIM services provided in public health facilities nationwide. In Peru (2017), the Manual for the Registration and Coding of Activities in Alternative and Complementary Medicine Care provides detailed guidance for recording and classifying TCIM-related health services, helping standardize data entry and facilitate integration with national health information systems.
h. Infrastructure/Facilities	Governance approaches in this subcategory address the regulation, development, or adaptation of physical spaces designated for TCIM service delivery. These may involve facility standards and licensing requirements. Peru (2006) and Colombia (2019) regulate health establishments and services, including requirements for TCIM service facilities. In Chile (2004), a regulation on TCIM practitioners establishes that the facilities in which they operate must be authorized and subject to supervision by local health authorities. In Ecuador (2020), national technical specifications for childbirth sites incorporate intercultural health principles and ancestral midwifery knowledge, complementing a broader guideline on culturally appropriate childbirth.
i. Medicines and other health technologies	Governance mechanisms in this subcategory focus on the regulation, production, and quality control of TCIM-related products and devices. In Chile (2012), for example, a ministerial decree regulates the storage, repackaging, and labeling of traditional herbal medicines; Uruguay (2016) has a distinct regulatory framework for homeopathic medicines. Some countries, like Cuba (2018), explicitly include natural health products in the national essential medicines list; others, like Peru (2016), authorize the use of specific TCIM products in public health services. In the United States, sterile, single-use acupuncture needles are regulated as medical devices by the Food and Drug Administration.
j. Operations/Service provision	This subcategory describes mechanisms for organizing, delivering, and integrating TCIM services within national health systems. In Bolivia (2013), for instance, a national care guide for traditional midwives establishes coordination and referral mechanisms with biomedical health services, while safeguarding traditional knowledge. In Chile, technical guidelines addressing TCIM in primary care make stipulations for standardizing service quality. Regulatory provisions in Ecuador (2017) support equitable delivery of culturally appropriate care (including TCIM) by reducing barriers to access, particularly for users from remote communities.
k. Parameters of the legal practice of medicine	Governance instruments in this subcategory define the legal boundaries of what constitutes the practice of medicine and who is authorized to perform it. In Argentina, acupuncture is explicitly defined as a medical act that must be carried out exclusively by licensed physicians. Similarly, Uruguay governs TCIM practices—such as acupuncture (2001) and homeopathy (2009)—as the exclusive domain of biomedical physicians and/or dentists. In the United States, several states have enacted “safe harbor” laws that explicitly allow unlicensed practitioners to practice specific forms of TCIM care that would otherwise be legally constituted as falling within licensed biomedical clinicians’ exclusive scope.

Intersectoral dimensions

This category and its subcategories emerged inductively as it became clear that some governance approaches addressing TCIM do not limit their scope to the health care sector alone. The resulting seven data-driven subcategories are: economics, education, food systems/nutrition, international affairs, military/defense, natural resources/biodiversity, research/development, and social/cultural development. Importantly, many TCIM governance approaches are not explicitly intersectoral and may be classified here using the “not applicable” category.

Examples: Cuba has a 40-year history of an intersectoral approach to TCIM governance, expressed most recently in Council of Ministers Agreement #7551 (2014), updating an earlier (2002) instrument. In addition to creating a national commission on TCIM composed of six government ministries and the National Regulatory Authority for Medicines and Medical Devices, this Agreement mandates multiple intersectoral engagements related to TCIM. For example, addressing the economics, food systems/nutrition, and natural resources/biodiversity sectors, Cuba’s Ministry of Finance is directed to stimulate the production and consumption of natural health products and functional and ecological foods. The Agreement stipulates that this should take place through state-subsidized incentivization of stable and sustainable relations between the country’s agriculture and natural health products industries. With respect to the military/defense sector, Agreement #7551 directs the country’s armed forces to promote TCIM usage within their ranks. Regarding international affairs, the Ministry of Public Health is directed to take advantage of Cuban medical missions abroad to learn about TCIM experiences in other countries. The Agreement also includes intersectoral mandates for promoting TCIM-related education and research/development among health professionals and scholars, in turn focused toward social/cultural development through TCIM usage across the country, including in national disasters and epidemics.

TCIM aspect addressed

This category uses 10 subcategories that identify the specific thematic aspect or facet of TCIM being governed. Developed through a thematic coding process, these subcategories, shown in Table 1, address (among others) TCIM-related national visions/strategies, practitioners and practices, products and devices, and coverage and reimbursement, as well as issues related to wellness, intellectual property rights, research and development, the TCIM-biomedical interface, and the right to use TCIM. Table 3 provides illustrative exemplars for each of these subcategories.

Table 3.

Category 7, TCIM Aspects Addressed: Illustrative Examples from the Americas Region

TCIM aspects addressed	Examples
a. National TCIM vision and strategy	This subcategory tracks governance instruments that address nationwide strategies regarding TCIM’s place in health systems. For example, Chile’s National Policy on Complementary Medicine and Wellness-Focused Health Practices (2024) lays out a set of widely encompassing objectives for maximizing TCIM’s contributions to health and well-being across the health care system. Nicaragua’s 2008 National Health Policy, supported by a subsequent related law (2011) and regulation (2014), sets out nine strategic priorities for the health care system, which include the recovery of popular and traditional medicine, and other non-biomedical therapeutics.
b. Right to use TCIM	Governance mechanisms classified here legally constitute and support people’s rights, in a given jurisdiction, to access and/or use TCIM. Mexico (2001), Ecuador (2008), and Bolivia (2009), for example, have constitutional provisions defining it as the state’s responsibility to include traditional medicine as part of the services provided to citizens, as a right, within their respective national health care systems. Another approach is evident in Colombia, where a statutory health law (2015) defines interculturality (which includes TCIM knowledges and practices) as an essential element of the fundamental right to health.
c. TCIM—biomedical interface	This subcategory tracks governance mechanisms that specify the relational dynamics between biomedical and TCIM approaches within health systems. In several countries, interculturality policies (Guatemala, 2016; Honduras, 2016; Paraguay, 2009) stipulate that Indigenous traditional medicine approaches be respected as distinct systems of knowledge and practice within biomedically dominant health systems and services. Elsewhere, governance approaches clearly reinforce biomedical dominance over TCIM knowledges, practitioners, and practices. In Chile, for example, patients must receive a referral and diagnosis from a biomedical physician in order to receive care from a licensed acupuncturist (2006), homeopath (2009), and naturopath (2012). In Canada, some provincial health professional regulators stipulate that TCIM practitioners may not advise against certain normative biomedical practices (e.g., immunization). Many Canadian private health insurance companies also require patients to submit referrals from biomedical physicians and/or nurse practitioners to access reimbursement for the care of certain licensed TCIM practitioners (e.g., massage therapists).
d. TCIM coverage and reimbursement	Governance approaches tracked here address the governmental and/or private insurance-based financing of TCIM, which might include coverage of reimbursement models. In Brazil, Bolivia, and Cuba, various mechanisms mandate governmental coverage of specified TCIM services within their respective national health systems. In Peru, governmental coverage for a defined list of TCIM services is provided for all employed persons, under the country’s social security insurance. In the United States, reimbursement programs are in place for senior citizens and persons with disabilities under federal “Medicare” plans for some forms of chiropractic care, as well as acupuncture for low back pain delivered under the supervision of a biomedical physician or nurse practitioner. In some states, public ‘Medicaid’ insurance programs for low-income persons reimburse some forms of chiropractic, naturopathic, and birth doula care. The US Veterans Health Administration also subsidizes some forms of TCIM care, at times with a patient’s co-payment, to eligible military veterans. Further, in more than 40 US states, statutory provisions require private insurance companies to reimburse chiropractic care and some other forms of TCIM.
e. TCIM practitioners and practices	This subcategory includes governance mechanisms that recognize, regulate, or define the scope of TCIM practitioners and/or practices. In Canada, for example, provincial regulations variously govern TCIM practitioner groups as direct-entry professions (e.g., Chinese medicine and acupuncture, massage therapy, naturopathic medicine, chiropractic, homeopathy), in some cases with a ‘doctor’ title. Several provincial regulatory bodies lay out requirements for the use of TCIM therapeutics by biomedical physicians. In some Canadian provinces (e.g., Ontario), specified TCIM therapeutic practices (e.g., acupuncture) are constituted as ‘restricted acts’ that may only be practiced by a subset of licensed (biomedical and TCIM) health care professionals. In addition, several unlicensed Canadian TCIM occupations (e.g., Western herbalists) self-govern via civil society credentialing organizations, some of which (e.g., osteopaths) are recognized by private insurers. Elsewhere, such as in Uruguay (2001, 2009), some forms of TCIM (e.g., acupuncture, homeopathy) remain within the exclusive scope of certain biomedical professionals (e.g., physicians, dentists). In Panama and Bolivia, traditional Indigenous medicine practitioners recognized within their communities are required to become registered with the state; other countries, such as Chile, have determined that such registries impinge on Indigenous peoples’ right to self-determination.
f. TCIM products and devices	Mechanisms in this subcategory pertain to the governance of natural health products, herbal medicines, and medical devices used in TCIM care. For example, Brazil (2013), Cuba (2012), and Colombia (2018) have established national frameworks to ensure that herbal and natural products meet standards of good manufacturing practices. Chile (2010) and Venezuela (2006) formally include herbal medicines within their national pharmaceutical regulatory systems, defining standards for such medicines’ technical review and regulatory approval. In the United States, sterile, single-use acupuncture needles have been approved by the Food and Drug Administration as a Class II medical device, and, in Cuba (2009), ozone therapy devices are regulated by the state.
g. TCIM research and development	This subcategory tracks governance approaches that formally address various elements of research and development in the TCIM sphere. In the United States, for example, the National Center for Complementary and Integrative Health (NCCIH)—established by Congress in 1999 and renamed in 2014—serves as the federal government’s lead agency for scientific research on TCIM. In Peru, following early institutional efforts toward the establishment of a TCIM-focused research body within the national health system (1991), the country adopted a set of institutional research priorities for TCIM (2022), which includes five strategic objectives and 41 priority research needs for a TCIM-focused research center (Centro Nacional de Investigación Social e Interculturalidad en Salud—CENSI) within the country’s National Institute of Health.
h. Traditional knowledge, intellectual property, and benefit sharing	Governance approaches categorized here address the protection and preservation of traditional medical knowledges, and/or address matters of benefit sharing and intellectual property rights in the context of TCIM. Panama’s Law 17 (2016), for example, aims to recognize, revitalize, and safeguard Indigenous medical knowledges and practices, promote their articulation with the national health system, and ensure fair benefit sharing from the commercialization of products derived from such knowledge.
i. Wellness and well-being	Governance approaches tracked here explicitly address TCIM’s salutogenic—that is, health-promoting, wellness-focused—elements rather than the treatment or palliation of ill health per se. In Bolivia, Peru, and Ecuador, for example, multiple governance instruments entrench Indigenous peoples’ relational, ecological conceptions of wellness (e.g., sumak kawsay, suma qamaña, vivir bien) as elements essential to health systems structuring and health care delivery. Further illustrating this subcategory’s scope, in Mexico, national guidelines (2020) address the inclusion of health-promoting traditional diets, exercise, and good humor within the country’s health strengthening initiatives.

To permit further analytic nuance, the framework uses additional “tags” for two of the most widely used subcategories in the authors’ experience to date (see Table 1). In the first case (TCIM practitioners/practices), a pragmatic decision was made to explicitly list particular TCIM practitioner types for which the authors had identified more than seven country examples in our datasets (or around the world). In the second case (TCIM products/devices), the principle of comprehensiveness was used to iteratively create, with reference to the project datasets, seven distinct tags that could account for the range of TCIM medicinal products being governed.

Discussion

This work’s data-driven analytic framework provides, for the first time, a systematic classification model for describing the unique features of TCIM governance across diverse contexts, national and legal constructs, and governance mechanisms. Iteratively constructed with reference to over five hundred TCIM-related policy instruments, court cases, and other governance approaches tracked across the Americas region, the framework is comprised of seven primary analytic categories. These categories, along with their concomitant subcategories and analytic tags, permit detailed tracking of a wide range of Indigenous, state, civil society, and private sector governance approaches used across countries to govern diverse TCIM systems, practitioners, practices, products, and devices. Importantly, the framework reflects the cross-sectoral and multilevel nature of TCIM governance, extending well beyond what has been previously tracked by the WHO. As illustrated through numerous regional exemplars, TCIM governance may be enacted across the entire hierarchy of state law, from national constitutions to nonstatutory administrative documents. While some countries may govern TCIM strictly in relation to service provision and product safety, others engage TCIM approaches, including Indigenous knowledge, to foundationally inform health systems design. The framework also recognizes the range of substantive issues that TCIM governance may address, from culturally relevant care delivery and Indigenous peoples’ health and intellectual property rights to reimbursement, health tourism, and information management. Further reflected in the framework are the influences of international and regional governance instruments on the ways in which countries govern various aspects of TCIM.

The authors’ primary aim in this work was to use the Framework method to construct a thematic framework capable of tracking the range of TCIM-related governance approaches in the Americas region. The authorial team is currently applying this framework in a systematic way to their existing datasets. The results of these analyses will be published elsewhere, further illustrating the framework’s utility. For example, the framework’s capacity to track the range of TCIM governance approaches in a single country will permit multilayered, multisectoral analyses that account for statal and nonstatal mechanisms. This includes “ecological” analyses of the ways in which a country’s range of TCIM governance mechanisms intersect to produce a broader TCIM governance ecosystem. Such analyses may specifically illuminate the ways in which Indigenous and state governance may be interfacing, and how civil society and private sector actors may be intervening to address state governance gaps. At the subregional or regional level, the framework’s categories can support comparative studies of different approaches to governing similar TCIM elements (e.g., service coverage/reimbursement, practitioners, products). It could also enable analyses of the value of specific governance instruments (e.g., constitutional provisions, national policies) in supporting health systems transformations that center on TCIM knowledges and practices. Likewise, the framework allows for comparative analyses of how specific TCIM systems (e.g., Indigenous traditional medicine, Ayurvedic medicine, Chinese medicine), practices (e.g., massage therapy, mindfulness), or products (e.g., psychoactive herbal medicines) are being governed across jurisdictions.

Consistent with the Framework method’s iterative character, the authors consider this analytic framework for TCIM governance to be an adaptive tool and anticipate that additional subcategories and tags may be added as the framework gets applied across contexts. This includes applications to other regions, which some of the authorship team members are currently undertaking in an effort to determine the framework’s potential transferability beyond the Americas. The authors are aware, for example, that in the Eastern Mediterranean and African regions, there are a number of countries in which religious law is a key component of the legal system, which the authors anticipate may have implications for TCIM governance that were not evident in the Americas region. This may require adaptations or additions to the framework in the future. Nevertheless, the Americas region is uniquely diverse among global regions in its multifaceted representation of low-, middle-, and high-income countries, as well as the presence and combination of different legal frameworks (e.g., civil and common law, centralized and federal states). In addition, the region’s strong presence of Indigenous peoples, who have actively and effectively struggled for recognition of their self-determination, including their healing traditions, has strongly impacted TCIM governance across the region. Together, these factors, which are reflected in the datasets that informed the framework’s design, lend robustness to the prospect of its potential relevance for tracking TCIM governance more globally.

The WHO’s Traditional Medicine Strategy 2025–2034 has called for global information sharing about TCIM governance.⁷ This work’s framework has the potential to advance that goal by offering a preliminary architecture for a searchable digital repository of TCIM governance approaches around the world. This vision aligns closely with calls within the 2023 Gujarat Declaration of the WHO’s first Global Summit on Traditional Medicine for “digital health resources on TCIM” to be used in advancing “people’s health and well-being supported by the development of comprehensive governance models, policies, [and] regulatory frameworks.”⁴ There have to date been several global and regional efforts to track TCIM governance, each with strengths and limitations. Globally, the WHO has, since 2005, disseminated the results of three global surveys tracking national policies and legislation on TCIM, as well as herbal medicine regulations.^9,10,25 While valuable, governance approaches outside of these three categories have not been systematically monitored in that process. At the regional level, there have been focused efforts to more comprehensively track a broader range of statal TCIM governance instruments,^{11,12,26–30} including as part of a virtual health library in the Americas region.³¹ However, the authors are unaware of efforts to track the important place of non-statal TCIM governance (e.g., Indigenous, civil society, private sector) around the world. Nor has there been, to date, a centralized platform where decision makers might access, in a searchable, indexed format, the kinds of TCIM governance approaches being adopted across jurisdictions.

The WHO is currently developing an online Global Traditional Medicine Library to make available a range of informational resources relevant to TCIM stakeholders.³² Sharing of governance-related information on this platform would strongly support efforts to advance TCIM governance across jurisdictions. The categories, subcategories, and tags that constitute this work’s analytic framework offer a rigorous basis for an indexed online compilation of TCIM governance around the world. Such a resource would enable decision makers, researchers, occupational groups, and civil society actors to systematically sort, filter, and cross-reference information relevant to specific governance needs. A digital database of this kind would help knowledge users to better understand how countries around the world are addressing similar issues. It could also help close the expertise gaps identified by WHO member states as barriers to TCIM governance. Critically, the tool could promote horizontal cooperation between countries (among other stakeholders) by making accessible the range of instruments and strategies deployed in TCIM governance across contexts. By identifying exemplars of TCIM governance addressing particular issues, decision makers could, in turn, conduct more detailed analytic reviews and meaningful experience exchanges. In this way, as multisectoral stakeholders seek to transform health systems in culturally relevant, people-centered ways, the authors hope that this work may support a more encompassing understanding of the role of TCIM governance in advancing universal health and well-being.

In conclusion, this framework addresses critical gaps in the systematic analysis and classification of TCIM governance mechanisms. By enabling consistent tracking and comparison of governance approaches, the tool can guide policymakers, researchers, and practitioners toward more coherent, context-sensitive, and integrated health systems.

Authors’ Contributions

Conceptualization: D.F.G.P. and N.I. Data curation: D.F.G.P., N.I., and M.D.O. Formal analysis: D.F.G.P., N.I., and M.D.O. Investigation: D.F.G.P., N.I., and M.D.O. Methodology: D.F.G.P. and N.I. Supervision: G.R.A. and E.B. Validation: D.F.G.P., N.I., M.D.O., G.R.A., and E.B. Writing—original draft: D.F.G.P., N.I., and M.D.O. Writing—review and editing: D.F.G.P., N.I., M.D.O., G.R.A., and E.B.

Footnotes

Author Disclosure Statement

The authors have no conflicts to declare.

Funding Information

The Pan American Health Organization/World Health Organization (PAHO/WHO) partly funded time on this project for D.F.G.P., M.D.O., G.R.A., and E.B. N.I. was partly funded by a Project Grant [PJT-175030] from the Canadian Institutes of Health Research.

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