Understanding the role of context in health policy implementation: a qualitative study of factors influencing traditional medicine integration in the Indian public healthcare system

ABSTRACT India's public health system aims to foster pluralism by integrating AYUSH (Ayurveda, Yoga & Naturopathy, Unani, Siddha, and Homeopathy) with mainstream biomedical care. This policy change provides an opportunity to explore the complexity of health system innovation, addressing the relationship between biomedicine and complementary or alternative medicine. Implementing health policy depends on local, societal, and political contexts that shape intervention in practice. This qualitative case study explores contextual features that have influenced AYUSH integration and examines the extent to which practitioners are able to exercise agency in these contexts. Health system stakeholders were interviewed (n = 37) and integration activities observed. The analysis identifies contextual factors in health administration, health facilities, community, and wider society which influence the integration process. In the administrative and facility spheres, pre-existing administrative measures, resource and capacity deficits limit access to AYUSH medicines and opportunities to build relationships between biomedical and AYUSH doctors. At the community and society levels, rural AYUSH acceptance facilitates integration into formal healthcare, while professional organisations and media support integrative processes by holding health services accountable. The findings also demonstrate how, amid these contextual influences, AYUSH doctors navigate the health system hierarchies, despite issues with system knowledge against a background of medical dominance.


Introduction
The relationship between traditional, complementary and alternative medicine (TCAM) practitioners and the mainstream health system differs between high-income countries and low and middle-income (LMIC) countries.In LMIC countries such as India, TCAM practitioners are employed in primary healthcare services and contribute to health promotion, illness prevention and treatment (WHO, 2013).
India has a chronic shortage of biomedical doctors; hence the national government has pursued a policy of integrating TCAM into the public health system since 2005 (NHM, 2010).TCAM in India generally refers to Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homeopathy (AYUSH) therapies.AYUSH doctors have institutionally recognised status in India; they are trained at dedicated public colleges and statutorily regulated by the national Ministry of AYUSH, and expected to practice complying to their respective code of conduct.The AYUSH integration policy denotes the use of stand-in AYUSH doctors in place of biomedical doctors, and the co-location of AYUSH doctors and biomedical doctors in primary healthcare centres.AYUSH doctors' roles were to attend AYUSH outpatient clinics, implement national health programmes, and supervise community health workers, while biomedical doctors' roles were to attend biomedical outpatient and inpatient clinics, supervise facility-level practitioners, including AYUSH doctors, and govern primary healthcare facilities.In 2017, the doctor-to-population ratio was 1:1285 (World Bank, 2018), well below the World Health Organisation's recommended ratio of 1:600 for high-quality healthcare provision (WHO, 2007).Meanwhile, there were 628,634 AYUSH doctors in 2012 (CBHI, 2012, p. 154), for a doctor-to-population ratio of 1:1908.A purpose of introducing the AYUSH integration policy and recruitment of registered AYUSH practitioners at the primary healthcare level was an attempt to improve the combined doctor-per-population ratio and improve access to health services.
Previous health policy and system analyses have recognised the need to take the interrelated socially-constructed and organisational elements of the health system into account to understand how primary healthcare systems function (Sheikh et al., 2014;Sheikh & Ghaffar, 2021).As seen through a health system lens, it is argued that primary healthcare system performance should be analysed in terms of the interconnectedness of PHC activities and functions (Espinosa-González et al., 2019).Evidence from high-income countries shows that the success and performance of a primary healthcare system are dependent on its structural components, such as governance, human resources, and service organisations, and critical processes, such as policy implementation and supervision (Kringos et al., 2010).
In the case of TCAM, the difficulties of integration and of retaining the distinctive contributions of TCAM in real-world health systems have been described in previous sociological studies from high-income countries (Keshet, 2013;Ning, 2012;Wiese et al., 2010).These studies challenge the dichotomy between biomedicine and TCAM (Keshet, 2013) and examine the extent to which practitioners can exercise agency in the process (Ning, 2012).They note the importance of context in determining the form that integration takes in practice.Elsewhere, research on the significance of context for the implementation of health policies has begun to highlight how organisational, environmental, and cultural factors shape the way that policies can affect practices (Belaid & Ridde, 2015;George et al., 2015;Marinacci et al., 2017).This qualitative study investigates how contextual factors affect AYUSH integration in Indian integrative facilities and contributes to the literature on TCAM integration by providing a new empirical example of what integration means, beyond Western countries.More broadly, without seeking to evaluate the policy of TCAM integration itself, we use the case of integrated primary health care in India to contribute to emerging understandings of the role of context in shaping policy implementation.

The challenges of TCAM integration
TCAM integration has been attempted internationally in various health systems, yet the functional aspects have often been impeded by real-world challenges, involving inequitable administrative procedures and power relations.Integration often appears to have been limited and to have resulted in the marginalisation of TCAM.Most sociological studies of the integration processes and the evolving relationships amongst the various professions have suggested that biomedicine continues to dominate healthcare systems, including TCAM practitioners and their work (Hollenberg, 2006;Mallick, 2016;Patel et al., 2021;Shuval et al., 2002).For example, Mallick's sociological study of eight public Ayurveda health institutions in Delhi found that neither were the patients able to get the best treatment nor was the integrity of the Ayurveda being maintained in the actual practices.The study indicated that the treatment problems did not lie in a particular medical system, but rather in their contexts and the healthcare governance (Mallick, 2016).Low budgets for Ayurveda, irregular salaries, non-functional laboratories, and bureaucratic hospital norms were factors in the mainstreaming process.Mallick limited their investigation of contextual factors to the health facility and did not determine additional realms that influenced AYUSH integration.Here we analyse the wider context of integration and its impacts on Indian primary healthcare settings where AYUSH and biomedical doctors work side-by-side.

Theoretical context: (T)CAM and AYUSH in India
Research in the sociology of CAM conducted in Western nations emphasises patients' lived experiences, shifts in the paradigm of health and illness, and complex interprofessional relationships and hierarchies (Adams et al., 2009;Broom & Tovey, 2007a, 2007b, 2008).In these countries, the project of adapting a biomedical paradigm into the education and practice models of TCAM is best referred to as the biomedicalisation of CAM (Ning, 2008) rather than an attempt to produce a thoroughly pluralistic medical system.The process of biomedicalisation has also been identified in India, in Ayurveda education and research, posing challenges to medical pluralism and pointing to the possible loss of important Ayurveda knowledge, teaching and practices (Mathpati et al., 2020).However, sociological work in the Indian health system context has also identified the emerging integration of biomedicine and AYUSH, the influence of medical pluralism in cancer care, and different facets of the integration process (Broom et al., 2009;Broom & Doron, 2012;Lambert, 2012;Priya, 2012).
The Indian national program of encouraging medical pluralism offers an opportunity for a detailed examination of contextual factors which overcome dualism and promote or hinder agency and integration of different types of practitioners.Contextual analysis examines how social characteristics affect health policy implementation and service delivery (Marinacci et al., 2017;Scott et al., 2017).A nuanced understanding of the contexts interacting with policy initiatives is required to understand complex policy processes and different approaches to exploring context are emerging.Our analysis builds on a framework developed by George et al. (2015), which emphasises the dynamic relationships and linkages between contextual features, identifying four porous and interconnected spheres: health administration, health facility, community, and society (George et al., 2015).The AYUSH integration policy is within the governance of health administrations and society and is operating in health facilities to deliver services to the community.Therefore, George et al.'s framework was identified as relevant to this study.It was found that the spheres of health administration, health facility, community and society could be mapped onto themes identified in our data and that each sphere mediated particular integration processes to cast light on the AYUSH integration and highlight the agency or lack of agency of the practitioners involved.

Research settings and site selection
This study was conducted in an eastern-Indian state -a key target for the government's National Health Mission because of its poor health indicators.In 2016, the state's maternal mortality ratio (MMR) was 180 per 100,000 live births against 130 for India overall (SRS, 2019).There are 31 districts in the state.Three districts that contrasted in their development, health indicators, geography, and AYUSH education were purposively identified (Patton, 1990) to capture a range of contexts and experiences of health system actors (Table 1).Within each district, data collection took place in one or more Community Health Centres (CHC) and Primary Health Centres (PHC).To ensure confidentiality, pseudonyms have been used for the district names, research sites and all the participants.

Data collection and participants
To uncover and explore the contextual factors affecting AYUSH integration, and to encapsulate a broad range of similar and contrasting experiences of health system actors, different integration stakeholders were interviewed, and daily integration activities were observed.Interview and observation approaches are commonly used in qualitative research to complement each other with new sets of information for further exploration and to retain methodological rigour (Jamshed, 2014).
The participant information statement was distributed throughout the research sites by district-level administrators, and the lead author (GP) visited health centres to circulate the PIS.Individuals who agreed to participate were recruited after signing a written consent form.All those who agreed to participate were included in the study.GP conducted 19 days of observation over six months, focusing on AYUSH integration processes, including patient consultations, inter-staff interactions, primary healthcare centre-level meetings with community health workers (CHW), monthly PHC and CHC meetings, and fieldwork activities such as immunisations and village health nutrition days (VHND).The preliminary findings of the observations were discussed in the interviews for further exploration.Thirty-seven interviewees were purposively sampled to include perspectives from the AYUSH doctors, biomedical doctors, pharmacists, nurses, and health system administrators (HSA) at the PHC, CHC, district and state level (Table 2).The in-depth interviews were guided by a semi-structured interview schedule and lasted 20-70 min.The AYUSH doctor participants comprised Ayurveda and Homeopathy practitioners specificallyrepresenting the largest groups of AYUSH doctors in this state.Observations were recorded in fieldnotes, and the interviews were audio-recorded with the written consent of the participants, then translated from the local language and transcribed into English.GP and a professional transcriber worked closely on the transcription and translation, with GP verifying the transcriber's translations.Ethical approvals were received from the Human Research Ethics Committee, University of Newcastle, Australia (approval no -H-2017-0310).

Data analysis
We inductively developed a coding frame premised on the significant findings (Attride-Stirling, 2001).The coding frame was applied across the data Using Nvivo12.The data outputs for each code were then read and re-read, and codes were deductively grouped into organising themes Using the contextual framework developed by George et al. (2015).
Following analysis, GP re-contacted all study participants, and 11 agreed to participate in member-checking.However, due to their out-of-hospital work, five of them withdrew, leaving six to participate in the member-check.We conducted member-checking by sharing a document describing the themes that emerged from the data and meeting participants to discuss their views.GP took brief notes of the discussions and subsequently produced an extensive report.The analysis of the member-checking data contributed to our findings on the contextual factors.Results: the role of context in AYUSH integration The AYUSH doctors' work included a range of activities associated with the purposes of the integration policy, such as delivering AYUSH-related primary healthcare services, supervising CHWs and implementing national health programs at the primary healthcare level.The AYUSH doctors discussed benefits of integration, including wider professional opportunities and more patients; however, they also expressed extensive frustrations.Numerous issues were raised in the context of the health system, which significantly affected the integration processes.Most enabling factors emerged at the individual level, where the AYUSH doctors attempted to integrate their own practices and the AYUSH systems of medicine.
The contextual features that affected the AYUSH integration activities are discussed below across the four spheres of George et al. (2015)'s conceptual framework: health administration, health facility, community and society.We identified extensive contextual factors entrenched in the health system, at the health administration and health facility levels, because this study includes data from health system actors.The contextual factors in the community and society are seen through the perspective of the health system actors, not the community and the patients.Therefore, the health administration and health facility spheres are analysed in more depth and include more contextual factors than the community and society sections.

Health administration
AYUSH integration was found to be significantly affected by features of the health administration.George et al. (2015) described the role of the health administration as crucial to the functioning of the health services because it controls the financial resources and other capacities, and includes resources, capacity building and decentralisation mandates.Our analysis of contextual factors within the health administration identified issues with the supply of medicines and the management of human resources.Although some issues related to service delivery were addressed at the local level, most issues were controlled and decided at a higher administrative level.The administrative contexts affected the extent to which the AYUSH doctors could practice their own modalities and the types of work offered to them.
The integration was expected to bring together diverse actors from the Ministry of Health and Family Welfare (MoHFW) and the Ministry of AYUSH.This mandate was intended to promote collaboration between the National Rural Health Mission (NRHM) of the Directorate of Health Services, which was responsible for human resources, and the Directorate of AYUSH, which was meant to provide AYUSH medicinescrucial for the practice of Ayurveda and Homeopathy.However, the AYUSH doctors on the ground did not receive formal support from either of these directorates.In many cases, the AYUSH doctors lacked system knowledge; they were unaware of the division of responsibilities, and they submitted applications for medicines and supplies to their supervisors or the HSAs, but these supervisors represented the Directorate of Health Services while the supply of AYUSH medicines was expected to be done by the Directorate of AYUSH.This fragmentation created confusion and frustration, as one Ayurveda doctor said: When AYUSH medicines ran out, we spoke with sir [biomedical doctor and administrator] here, and with Chief District Medical Officer but they said they'd do something.Nothing happened.They again said they can't regulate medicine supply and would forward our complaint to the state.Whether they did, whom at state, we don't know.It's like a maze.(Soor_Ayurveda_11) The above quote indicates that the AYUSH doctors were unaware of the systemic accountability for the supply of AYUSH medicines and the mechanism for redressing grievances.While being integrated, the AYUSH doctors adopted the governance mechanisms of the mainstream health system and drew the attention of the administrators to their problems at the primary healthcare centres.However, they did not know if their concerns were being addressed above the district administration level.Meanwhile, the lack of intersectoral coordination between the Directorate of Health Services and the Directorate of AYUSH led to ineffectual health system responsiveness, especially in the AYUSH integration process, as one CHC level administrator expressed: The unavailability of AYUSH medicines can be traced to pre-existing higher-level regulation which was not designed for AYUSH and often produced paradoxical results.The state public health system follows guidelines to maintain service quality.One requirement is that government procurements of medicines come from a manufacturer holding good manufacturing practice (GMP) certification and Quality Certification.Originally associated with biomedicine, in 2012 this guideline was extended to the procurement of AYUSH medicines.However, none of the AYUSH medicine manufacturers held the required certifications, so none were eligible to supply medicines to the government.The GMP framework is based on biomedical standards and did not translate easily to Ayurvedic medicines: Allopathy needs GMP since everything must be sterile to prevent adverse effects.Ayurvedic medicines need microorganisms.Kutajarista [an Ayurvedic medicine] is prepared by fermenting roots, barks, leaves, and jaggery.If Ayurveda company makes medicine with microorganisms, you decide how they can get GMP certification. (Soor_Ayurveda_11) This process of 'bio-medicalising' the manufacture and procurement of AYUSH medicines had triggered a chronic unavailability of medicines, which severely hindered the integration process and posed challenges to the AYUSH doctors to practice at the primary healthcare level.
Overall, the fragmentation of funding and authority in the administration meant that the capabilities of the AYUSH doctors did not meet the priorities of the primary healthcare centres, so their role was diminished or converted to supporting biomedical practice.The findings showed that they were often unable to contribute significantly to the patient consultation and treatment aspects of the primary healthcare centres using their own modalities because they lacked access to their medicines.However, heavy patient loads in the biomedical outpatient departments (OPDs) meant that the biomedical doctors and local administrators saw the available AYUSH doctors as skilled health workers who could deliver health services using biomedicine practices to meet immediate needs.The regulatory guidelines state that the AYUSH doctors are not allowed to practice biomedicines, so this created dilemmas for administrators trying to meet patient needs at the overloaded centres, as this response demonstrates: I will have to assign someone to manage the long queues of patients.They [AYUSH doctors] know about the [bio]medicines, and the patients are for minor ailments.So AYUSH doctor can do that.(Kolhaban_Administrator_06) Despite the challenges, there were some enabling factors for AYUSH integration in the health administration context as the scarcity of biomedical doctors in the health workforce led to the deployment of AYUSH doctors in the biomedicine OPD.It was found that only a few PHCs were fully staffed and many PHCs were without a biomedical doctor.Either the positions were vacant, or if biomedical doctors were recruited, they often did not attend the PHCs for months and preferred to be deployed in urban areas (Rao et al., 2013).The absence of biomedical doctors in these PHCs empowered the AYUSH doctors to develop and execute leadership roles in the day-to-day functions of the centres, including being a 'nodal officer' and supervising CHWs, and acting as district and regional trainers for all health workers, including the doctors, for the implementation of national health programs.Being nodal officers meant holding administrative and financial authority over the CHWs at the periphery.These leadership roles were seen by AYUSH doctors as opportunities to assimilate themselves and to become 'insiders' in the public health system.This possibility was recognised by the administration: This quote from an Ayurveda doctor demonstrates that there were valued opportunities to develop and to execute leadership roles.In this case, the AYUSH doctors were valued for their skills and not seen as challenging the hierarchy, however, biomedical dominance was evident because the role disappeared when more biomedical doctors were available.

Health facility
AYUSH integration was strongly affected by local contextual features in the health facility sphere.George et al. (2015) described the health facility as a prism through which to view the initiatives of a health system.In their example of health committees, awareness amongst the community of the available health services and trust of health workers affected the functions and outcomes of the health programs.They concluded that any interventions should balance the interests of the health facilities and the beneficiaries to influence and engage them in the process.
The context of severely under-resourced health facilities shaped and, in some ways, inhibited the AYUSH integration process.AYUSH doctors were sometimes able to build collaborative relationships with other health professionals because there were so few other staff in the facilities.Almost every AYUSH doctor who participated in the study described the challenges of governing the AYUSH-OPD by themselves and argued that it was particularly important to have an AYUSH pharmacist in the PHCs and CHCs.
AYUSH doctors in the PHCs were required to undertake patient consultation, disease identification, medicine preparation, packaging, and medicine dispensing.Additionally, the AYUSH doctors were providing instructions on the dosages of the medications and health promotion activities.These day-to-day practicesincluding tasks normally performed by pharmacists -resulted in long waiting times, which annoyed the patients, as a Homeopathy doctor noted: I'm a "one-man army" here.I open the OPD door, see patients, keep records, write prescriptions, prepare medicines, and measure and put globules into bottles … I also advise eating behaviour.If an AYUSH pharmacist can be employed, I can concentrate on the patient and not the preparation of medications.You may have seen people/patients get angry due to long wait times.We can avoid it and remain safe.(Kohrampur_Homeopathy_03) The chronic unavailability of AYUSH medicines was a significant hindering factor.Since 2014-15, the disruptions in the supply of AYUSH medicines had directly affected the integration processes.AYUSH doctors could only practice their respective systems of medicine while there were remaining stocks at the primary healthcare centres.Some continued to practice by procuring medicines out of their own pockets or by advising patients to purchase them.This response from a Homeopathy doctor was typical: AYUSH OPD must have certain medicines, else patients may avoid visiting us.What is the point of us if they will not come?So, I keep a little quantity of medicine out-of-pocket to manage patients, just like other AYUSH doctors.We've no other alternative.(Korhampur_Homepathy_02) It was also found that AYUSH doctors were denied access to funds which were available at the primary healthcare level and intended to increase the functional, administrative, and financial autonomy of various facilities under the NRHM reform process.Financial provisions have been made for these field units at different levels in the form of annual maintenance grants and untied funds (the Rogi Kalyan Samiti or RKS) to undertake any innovative or responsive facility-specific, needs-based activity.The AYUSH doctors sought access to the RKS funds for the procurement of essential AYUSH medicines and supplies: I have requested for some fund from RKS to sir [biomedical doctor-administrator] at least 5-6 times, but he refused.Even the previous administrator also didn't allow any money for [Ayurveda] medicines.(Kohrampur_Ayurveda_02) Elsewhere, an administrator said: They often ask me about medicines.I can only notify the higher officials.We don't have enough money.The RKS fund is limited; how we'll manage the other CHC expenses if we use all that money for AYUSH medicine?We use RKS fund for hospital logistics like, furniture, fuel for ambulance, etc. (Kolhaban_Administrator_03) The administrators acknowledged that the funds can be used in the maintenance of the primary healthcare centres, and that the RKS funds were utilised for biomedicine procurement at the local level, but that the requests of the AYUSH doctors had been denied.The AYUSH doctors described this as discrimination towards the AYUSH modalities.
Another dimension of the integration process involved the AYUSH doctors visiting the sub-centres and villages to supervise CHWs such as the ANMs.As described in the previous section, this role offered an opportunity to gain some insider status.However, financial support in the form of government vehicles for travel was not provided, and when AYUSH doctors travelled using their personal transport, some locallevel administrators declined their expenses claims.As a result, the AYUSH doctors often did not travel to provide supervision to the CHWs.They also missed state-level training opportunities for lack of funds: We travel 10-20 kilometres to the different villages … No finance is given for these travel.Sometimes we attend state-level training at [the state capital], they [state-level organisers] say you'll receive the travel reimbursement from the CHC-level, and the CHC administration say the state-level organiser would cover us.So, eventually those expenses are outof-pocket.Obviously, we'll be de-motivated.(Kolhaban_Ayurveda_05).
The imbalances in the funding for travel and training purposes represented a significant barrier to integration and symbolised the position of the AYUSH doctors in the system.Overall, the AYUSH doctors said that they felt powerless to make decisions for themselves and their healthcare practices.Rather than being able to practice autonomously, they had to seek approval from the biomedical doctors prior to almost any aspect of their work because of the hierarchies of governance that were embedded in the health system.However, there were other avenues through which the AYUSH doctors could promote integration.
Despite the lack of support, AYUSH doctors took the opportunity of fieldwork to promote AYUSH healthcare practices through health promotion and behaviour change activities.As part of the implementation of national health programs, AYUSH doctors visited the sub-centres and surrounding communities.Their interactions with people included providing information about disease prevention, health behaviour changes and the importance of a balanced diet.They also promoted AYUSH systems of medicine and practices for healthy lifestyles.For example, in a non-communicable diseases camp in Kolhaban district, an Ayurveda doctor suggested that people should introduce turmeric into their diets and consume fenugreek seeds soaked in water every morning to control blood sugar levels.Similarly, a district-level administrator explained, in relation to another Ayurveda doctor: Whenever, he attends the camp and the VHND, he speaks about the health issues for people's understanding … making villagers understand about the benefit of Ayurveda medicines … I've witnessed people started asking for Ayurveda medicines.(Korhampur_Administrator_01) The presence of AYUSH doctors in primary healthcare centres raised community awareness of alternative medicines and their benefits.Their presence also fostered trust relationships with the communities: I stayed here to gradually become a part of the community.Initially, people weren't interested interacting with me.Whenever they needed me … I reached their door with my basic equipment and medicines.I knew medicine isn't that important; the most important aspect is psychology; they knew if anything happens to anyone, that Ayurveda doctor is there.(Soor_Ayurveda _08) The patient-centred approaches of the AYUSH doctors acted as a significant enabler for the integration process.Almost all of the AYUSH doctors who participated in the study agreed that the primary philosophy of their treatments was to consider the patient as a whole, reflecting findings of the global literature (Meissner & Tabish, 2008;Robinson, 2011;Sagli, 2010).The AYUSH doctors explained that their consultations included a detailed discussion of the patient's disease history, lifestyle, food, travel and stresses.Emotional support and patient education on illnesses, medication, diet, habits and behaviour changes were also offered.AYUSH doctors considered the patient's social circumstances and purchasing ability.As the free AYUSH medicines were out of supply, if the patient could not afford to purchase the AYUSH medicines out of pocket, the AYUSH doctors referred the patients to the biomedicine OPD to obtain the free biomedicines.An Ayurveda doctor articulated how the patient-centred approach had influenced people to utilise AYUSH services for their wellbeing, thus facilitating the integration of AYUSH into the primary healthcare services: People prefer Ayurveda because they see us more frequently at the hospital and in their villages, discussing their health personally.They enjoy discussing with us.Many female patients say talking with me heals them by half.They frequently ask for advice on home remedies … I recommend locally available medications, like aloe-vera, which is abundant in this area but underutilised.(Korhampur_Ayurveda_02) The development of trusting relationships between the AYUSH doctors and their patients promoted the use of locally available traditional medicines and health behaviour changes.

Community
It was found that awareness and trust were key to AYUSH integration, in both the health facilities and the broader community level.It has been argued that these significant contextual features influence the existence and functioning of any health program (George et al., 2015).In this case, the integration processes was facilitated by the people's acceptance and trust in the AYUSH doctors and their treatments.
The AYUSH systems of medicine and their practitioners were accepted by the community, and they tended to utilise the services at the primary healthcare level.The traditional medicines were widely trusted by people in both the semi-urban and extremely remote areas.People in the semi-urban regions had both the awareness, as well as the resources, to access the AYUSH systems of medicine.However, several AYUSH doctors said that people in very remote regions were also still using some forms of AYUSH medication and practices in their day-to-day life as the knowledge of traditional medicines and plants remains historically embedded in regional societies.Hence, people in these remote areas consumed traditional medicines by themselves to treat their illnesses, and only visited the primary healthcare centres if their medications could not control the symptoms.One administrator explained how women and geriatric patients often preferred Ayurveda medicines over biomedicines for their treatment in the regional primary healthcare centres: Elderly and women Patients prefer Ayurveda medicines; there is a demand for Ayurveda medicines in village areas; they know it as Chera Muli [herbal] medicines.Thus, it is easy for our doctors to prescribe Ayurveda medicines to rural and tribal people, and patients are satisfied.(Kolhaban_Administrator_05) On the other hand, some other rural populations equated medicines with injections and preferred injectable medications over AYUSH treatments.This strong belief in biomedicine treatments amongst the regional communities in Kolhaban and Soor district acted as a hindering factor to integration.This highlights important differences between local contexts in which integration is attempted and community-level factors that will drive variation in uptake of AYUSH despite the same policy being in operation.

Wider society
The public health system in India is influenced by the wider society and interacts with other social institutions.The society sphere in the contextual analysis framework incorporates legislative reforms, political parties, markets, media, social inequalities, and nongovernment organisations (George et al., 2015).Our study identified the media and AYUSH associations as key societal influences shaping the context of integration.
The regional and state-level media appeared to be an enabling factor in the societal sphere as they acted as whistle-blowers for issues around government institutional practices, which pressured decision-makers to address issues in the public system.During the data collection period, the media brought up issues around AYUSH integration, such as the scarcity of medicines, low wages, and AYUSH doctors practicing biomedicine.However, the media outlets failed to bring changes to the integration guidelines, although the NRHM issued a letter which stated that AYUSH doctors should not attend biomedicine OPDs and practice biomedicine.
Professional institutions such as the 'AYUSH association' acted as an enabler of integration by lobbying or mediating between politicians and the health system decisionmakers to strengthen the ongoing integration processes, and to initiate systems of accountability for the welfare of AYUSH doctors.The AYUSH association lobbied politicians to include AYUSH issues on the agenda in the legislative assembly of the state to bring political attention and to produce potential solutions in the form of guidelines and policies.The AYUSH association advocated strongly for an unobstructed medicine supply, salary rises and tenured job opportunities for AYUSH doctors working in the public health system.One Ayurveda doctor, also a district representative for the AYUSH association, explained how they were initiating meetings with politicians to resolve the issues around medicines and the salaries of the AYUSH doctors: We informed him [politician] by phone that all AYUSH doctors face these challenges, AYUSH doctor makes less than an ANM, thus they [ANMs] won't cooperate with us.In the meeting, we reminded him again and gave him a letter signed by 50-60 AYUSH doctors.Let's see.The problem isn't with politicians, but with state officials; they don't want AYUSH doctors to arise, they only want to use us as labour for them.(Soor_Ayurveda_11) Several AYUSH doctors mentioned these attempts as an opportunity to improve their welfare and professional practices.Some AYUSH doctors allied with the AYUSH association saw the challenges in the processes of advocacy as a part of the biomedical dominance in the health system, another major contextual factor in society that we discuss elsewhere (Patel et al., 2021).

Discussion and conclusion
This research provides an insight into the complex health system and policy contexts within which AYUSH integration is operationalised in India.Although the structure of AYUSH integration was brought into practice by the Indian government, the study casts light on the way in which integration functions in practice, shaped by the pathways through which policy guidelines interact with the context of the health system, spoken and unspoken institutional rules, and the inter-professional and community-level relations and interactions.The findings demonstrate constraints on AYUSH practice due to pre-existing regulations, lack of system knowledge and a background of biomedical dominance.
The study identified the contextual features in the health administration, health facilities, communities and wider society that have facilitated or hindered AYUSH integration in an eastern-Indian state.Aligning with the notion of interconnectedness, the four spheres were not necessarily exclusive, and each factor could influence other factors and/or correlate with (Tiberghien et al., 2011).While George et al. (2015) noted the potential for virtuous cycles across spheres, whereby the success of the innovations in a health system can stimulate more significant action and improvements in health services, this study also revealed that the context and their features can negatively influence the practices of the health system.
This study provides evidence of the challenges to integration that arise from centralised policy implementation practices in the Indian public health system.Several studies have illustrated the problems of implementing healthcare policies centrally, in particular how top-level decision-makers have not considered the perspectives of lowlevel healthcare workers in the implementation processes (Atkinson et al., 2000;Mooij & Prasad, 2004;Sakyi et al., 2011).Our findings identify challenges in the centralised implementation of the integration policy and demonstrate that top-down policies and mandates were insufficient to integrate AYUSH systems of medicine at the local level.The primary healthcare system functions by complying with a set of pre-defined administrative and quality assurance processes, which have been designed primarily for the governance of biomedicine and its practitioners.These processes were not ideal for the functions of AYUSH practices and the purpose of integration.Thus, the impediments described in the health administration and health facility were evident.Fragmented government systems and biomedicalisation of AYUSH medicine procurement hindered the supply of AYUSH medicines, which triggered the AYUSH doctors to practice biomedicine in health facilities rather than their own modalities, further stalling the integration process.Biomedicalisation (Ning, 2008) involved the application of biomedicine ideologies and policies to the governance of AYUSH supplies, training and practices.The biomedicalisation of AYUSH integration emanating from the administrative sphere was anchored at several levels of the health system.Aligning with the concept of centralised decision-making, biomedicalisation was pervasive at the statelevel policymaking and facility-level healthcare practices.
A lack of system knowledge (Willis et al., 2016), by AYUSH doctors prevented them from navigating the system to address administration and facility-level contextual factors that negatively influenced AYUSH practices.System knowledge becomes significant in healthcare settings where there is information asymmetry (Chang et al., 2016) and an outsider-insider dichotomy in healthcare governance system.The AYUSH doctors, being outsiders, were integrated into the mainstream biomedical health system with a duality in access to resources and autonomy in practices.Furthermore, the integrative settings were sites of power relations (Patel et al., 2021) and the low status and position of AYUSH doctors within the health system structure ultimately curtailed their capacity to negotiate hindering factors.The role of medical dominance was evident when AYUSH practitioners were compelled to carry-out minor biomedical practices to address the service delivery gap but were excluded when biomedical practitioners were available.Moreover, medical dominance also had an influence over access to local facility-level resources.
Despite various barriers at different levels, the AYUSH doctors made efforts to practice and promote their systems of medicine and to request services and improvements in resources.The contextual barriers in the different spheres were not insurmountable, shown by the fact that the AYUSH doctors continued to deliver healthcare services using some forms of AYUSH systems and to mobilise people to use AYUSH treatments.
This case study of a centrally directed policy of medical pluralism demonstrates that despite the explicit government policy, the AYUSH doctors and their systems of medicine were assimilated into the primary healthcare centres and their services to a limited extent only and remained peripheral.The contextual factors that would support successful integration include the essential resources for AYUSH doctors, namely: additional human resources; clear guidelines and administrative pathways of accountability; improved intersectoral coordination by the government at higher administration levels; and extending the decentralisation of power to the local administration level so that context-specific issues can be resolved in the primary healthcare centres themselves.Although our findings are specific to the study settingindeed, our central argument is that such context matters -they illustrate the wider significance of contextual factors in policy implementation.They also widen the focus of the sociology of TCAM by identifying how knowledge and power asymmetries shape integrative medicine initiatives outside of the West.Both local and global differences should be taken into account in future research and policies that focus on CAM integration.

Limitations
The term AYUSH is used throughout the paper, however, the participants of the study are limited to Ayurveda and Homeopathy doctors.Hence, it is crucial to undertake further research on the experiences of Unani, Siddha, Yoga and naturopathy practitioners to understand the similarities and differences.
The findings presented in this study are derived from the perspectives of health system actors and do not encompass the patients' perspectives.There may be different sets of contextual factors and patient experiences which may affect the AYUSH integration.Future research should focus on patient perspectives of AYUSH integration to understand the determinants.
As this qualitative study used interview data, there was an implicit subjectivity in some forms of information, such as patient load in PHCs.Hence, future research should employ quantitative methods to examine the extent of contextual factors and their effect in AYUSH integration.

Disclosure statement
No potential conflict of interest was reported by the author(s).
Two lady AYUSH doctors are working as nodal officer, Hinga and Dunpali sector.They are nodal officers, and nodal persons of Accredited Social Health Activists (ASHA) and ANM, and they are doing a good job.(Kolhaban_Administrator_02) This type of work was valued by the AYUSH doctors as it involved both patient care and training health workers, although prescribing medicines was done by others: MOIC personally invited me and I agreed to train other health workers.That involves understanding foetal heart sound measurements.The ANMs were happy when I monitor them and the ANC throughout the day.They prescribe the medicine, and I perform the check-up.But I haven't been in 2-3 months [because of availability of more biomedical personnel].MOIC appreciated these roles.(Kolhaban_Ayurveda_05)

Table 1 .
Characteristics of the study sites.

Table 2 .
Numbers of participants across the districts.
know what their problem is.I've submitted many letters requesting AYUSH doctors' refresher training but haven't heard back from state-level official.(Soor_Administrator_09)