The WHO aims to release a new 10-year T&CM strategy in 2025. The aim of this paper is to (1) describe the status of academic medicine, the integration of T&CM and the role of integrative medicine (IM) in this process, (2) identify remaining challenges related to the objectives of the 2014–2023 WHO strategy document, from the perspective of four academic consortia for integrative medicine, including the establishment of a global matrix of academic consortia for IM and (3) contribute to the future WHO strategy (2025).

Many terms and definitions have been used to describe or define non-conventional forms/systems/methods of medicine/healthcare (6), which can lead to confusion. In this paper we use the terminology and definitions as depicted in Table 1.

To clarify the differences between biomedicine, lifestyle, traditional, complementary, and IM, it is important to place these within the contextual framework of health care interventions as shown in Table 2: mechanism (is the proposed working mechanism of the treatment plausible from modern scientific perspective?), effectiveness (how much evidence is there for its effectiveness?) and acceptance (to what degree are these treatments accepted and implemented in health care?) (11). Acceptability to patients varies depending on the population but is important to ascertain. Patient centered care with shared decision making is critical to an effective intervention.

Biomedicine’s efficacy and mechanisms are obviously most researched and accepted. Hypotheses on mechanisms follow generally accepted modern concepts of science and medicine. Most clinicians agree that treatments should be evidence-based (e.g., established efficacy in at least two high quality randomized clinical trials; RCTs), and many of the biomedicine treatments are, although certainly not all of them (12–14).

Research shows that lifestyle medicine is insufficiently appreciated, taught, and utilized in health care, even though there is growing evidence for its efficacy (15–17).² A lifestyle program consisting of diet / nutrition, movement and relaxation has been proven effective for reversal of coronary heart disease and early-stage prostate cancer (18, 19). Lifestyle interventions have shown to be a safe and cost-effective measure to reduce the risk of progression to type 2 diabetes (20), and to effectively lowering blood pressure in patients with hypertension (21). Promoting lifestyle changes is also an effective intervention for mental health (22). Several studies have shown improvements in overall (mental) health and reduced relapse risk upon lifestyle interventions (22–24). Furthermore, a systematic review on lifestyle interventions adapted to persons with serious mental illness has reported on promising reductions in weight loss and reduction of some risk factors for metabolic syndrome (25). Lifestyle medicine is still underutilized in conventional health care settings, although acceptance is growing (26).

It is argued that T&CM often presents weak or conflicting evidence of effectiveness (27). Possibly not all available evidence is well known. In 2019, at the initiative of the Latin American and Caribbean Center for Health Sciences Information of PAHO/WHO (BIREME/PAHO/WHO), an official Virtual Health Library (VHL) specialized in MTCI was created to gather and systematize evidence in the area (28).³ There are currently more than 1.5 million bibliographic references on this platform and more than 2,000 systematic reviews grouped into 28 evidence maps that assess the quality of studies and the effect of more than 300 specific interventions on clinical outcomes, e.g., depression, anxiety, quality of life, stress, quality of sleep, pain relief, hypertension, diabetes, and cancer. The T&CM evidence maps prepared in collaboration with the Brazilian Academic Consortium for Integrative Health are all available in open access (29).

Besides concerns about its effectiveness, the proposed mechanisms of action of some of these modalities (for example homeopathy or Reiki) are often based on theories that are not part of modern concepts in science and biomedicine (30, 31). These medicines are therefore generally not accepted and not applied in biomedical healthcare. However, some T&CMs (32, 33) are brought closer to acceptance by contemporary science through rigorous research on effectiveness and underlying mechanisms involved. For example, acupuncture appears to be effective in the treatment of non-specific low back pain (34) and the underlying analgesic mechanism of how acupuncture can modulate the nervous system and pain pathways to alleviate pain have been demonstrated (32, 33, 35–37). Likewise, yoga seems to be effective, e.g., for back pain (38) or cancer-related symptoms (39), and plausible biological mechanisms for these effects have been proposed (40). There is some evidence for dietary supplements such as omega-3 fatty acids (41) and folate (42) for mental disorders. The efficacy of herbs such as St. John’s wort (Hypericum perforatum) for depression (43) and Ginkgo (Ginkgo biloba) for mild cognitive impairment and dementia (44) have been demonstrated. The supplement melatonin has proven efficacy for sleep disorders (45), and probiotics have been shown to have a beneficial and effective role in the prevention and treatment of several diseases including diarrhea (46) and irritable bowel syndrome (47). There also appears to be some evidence for multimodal naturopathic medicine as a complex intervention for cardiovascular disease, musculoskeletal pain, type 2 diabetes, polycystic ovary syndrome, depression, anxiety, and other chronic conditions (27, 41).

Specific modalities do not necessarily stay in one of the categories as depicted in Table 2. They can move from traditional to complementary and even to biomedicine when evidence on their effectiveness and mode of action emerges. In the case of mindfulness-based interventions, several high-quality studies have shown that programs such as Mindfulness-Based Stress Reduction led to clinically relevant improvements in outcomes in several conditions and disorders and are being accepted and implemented to a greater extent within the health care system (48). Specific modalities can also move into the other direction when evidence emerges that they do not work. For example, research does not support the often-heard claim that high-dose oral vitamin C supplements boosts the immunity and decreases the risk of respiratory infections in the general population (49).

The incidence of adverse side effects of drugs and interventions have made iatrogenesis one of the major public health problems in developed societies, whose causes, in addition to errors and negligence, are of a systematic nature (55). Patient safety has become a major concern in health care worldwide. Of patients admitted to hospitals, 3.7 to 17.7% are inadvertently harmed by the way their health care is delivered. Avoidable adverse events lead to a greater annual loss of life than traffic accidents, AIDS, or breast cancer (56–58).

Healthcare costs continue to escalate, taking 17 percent of gross domestic product (GDP) in the United States, 9.5 percent in Brazil, and 10 in the Netherlands (59).⁴ The increase of costs seems largely related to chronic disease and lifestyle behavior such as diet, exercise and smoking (60). Indeed, the contribution of lifestyle to modern chronic disease has been estimated at 80% (61, 62) and even 95% (63). One possible strategy to reducing costs is inviting patients to take a more active role in their recovery, for instance by applying therapeutic lifestyle changes like exercise, diet and relaxation (15, 22). There is growing evidence for the effectiveness of lifestyle changes for improving health (20, 21, 25). There is also evidence for the cost effectiveness of lifestyle changes, which can run up to 2,360 dollars per person per year (64). For every $1 invested in the truth anti-smoking campaign, the United States saved more than $6.80. This campaign decreased youth smoking by 22% from 1999 to 2002 and averted $1.9 billion in future health care costs. Every $1 spent on evidence-based programs that increase physical activity, improve nutrition, and prevent tobacco use saves $5.60 in health spending within 5 years and up to $6.20 within 10 years (65).

Another concern in medicine is the quality of the therapeutic relationship, which seems threatened by managed care, focus on protocols and evidence-based medicine at the expense of patient centered approaches, and a tendency to reductionism, narrowing the view to diseases or symptoms and losing sight of the whole person in their context. The original definition of evidence-based medicine is ‘(1) the conscientious use of current best evidence in (2) making decisions about the care of individual patients or the delivery of health services, (3) taking preferences and needs of patients into account’ (66, 67). However, the last part of this definition is often neglected. This, together with a tendency toward uniformity and efficiency (in the form of guidelines, treatment protocols and clinical pathways) can lead to a ‘one size fits all approach’, which can impair the therapeutic relationship and is in clear contrast to the original idea of evidence-based medicine (66). The reduction of length of visits to the bare minimum limits the capacity to engage patients in sustainable behavior change, further driving a medication and procedural predominant practice style.

These concerns and challenges in academic medicine call for a change in the current paradigm and practices, including patient care, scientific research, education, clinician training, and policy (68, 69). Indeed, in biomedicine there is a growing awareness of the need for a multi-dimensional perspective beyond the current paradigm that is primarily focused on medication and technology (70, 71) taking the whole person into account (72). This can be observed in concepts like ‘personalized medicine’ (73–75), ‘shared decision making’ (76), ‘patient-centered care’ (77) and positive health (78).

One such new paradigm is ‘integrative medicine’, which was introduced by a consortium of Academic Health Centers in the United States in the late 1990’s in response to the before mentioned challenges in biomedicine. Currently, this IM consortium has more than 75 active academic health centers as its members (including Duke, Harvard, Stanford, Yale) (16, 79).⁵ The Consortium defines IM as: ‘the practice of medicine that (1) reaffirms the importance of the relationship between practitioner and patient, (2) focuses on the whole person, (3) is Informed by evidence making use of all appropriate therapeutic approaches, healthcare professionals and disciplines (including T&CM) to (4) achieve optimal health and healing (80).”⁶ Other national consortia for IM were founded in Brazil (2017) (81) the Netherlands (2018) (82),⁷ and Germany (2024). This third principle includes the integration of T&CM and biomedicine and may help to overcome (some of) the before mentioned challenges to biomedicine by combining their strengths and balancing their weaknesses.

The focus on an optimal relationship and the holistic approach of IM may increase disclosure and communication, adherence to the treatment plan, improve the therapeutic relationship (83) and enhance treatment outcome (84–86). Treatment outcome has been shown to be highly dependent on the quality of the therapeutic alliance (87–90), while a personalized approach may also improve outcome (74). IM represents a higher-order system of systems of care that emphasizes wellness and healing of the entire person (bio-psycho-socio-spiritual dimensions) as primary goals, drawing on both conventional and T&CM approaches in the context of a supportive and effective physician-patient relationship (71). This approach encourages consideration of how symptoms fit together with a particular focus on how physical and psychological health interplay.

Findings from economic modeling research suggest that combining T&CM and biomedicine may improve cost-effective long-term outcomes (91–95), although cost-effectiveness for the majority of T&CM still needs to be evaluated. Examples of interventions that were found to be cost effective compared to usual care are: acupuncture for migraine, manual therapy for neck pain, spa therapy for Parkinson’s, self-administered stress management for cancer patients undergoing chemotherapy, pre- and post-operative oral nutritional supplementation for lower gastrointestinal tract surgery, biofeedback for patients with “functional” disorders (e.g., irritable bowel syndrome), and guided imagery, relaxation therapy, and potassium-rich diet for cardiac patients (91).

IM stimulates scientific research on the safety and effectiveness of T&CM which could prevent false claims and increase safety by providing reliable information to the public. Currently, a collaborative project is ongoing between the Brazilian academic consortium on IM in partnership with the Latin American and Caribbean Center on Health Sciences Information of the Pan American Health Organization (PAHO) to develop evidence maps of clinical effectiveness in T&CM based on systematic reviews of clinical studies (29). Accordingly, it can be expected that the increasing academization and organization of T&CM in the sense of IM will lead to a general promotion and systemization of research activities in this field.

Taking T&CM use more seriously, increasing public attention and stimulating research and policy making will also improve regulation of products and therapists. This is reflected in the increasing number of WHO member states who have regulations on herbal medicine in all six regions of the world. Again, the academization of IM will lead to an increased public awareness on the importance of regulation of this field.

This could be achieved by developing novel therapies. For instance, Dr. Youyou Tu was awarded the Nobel Prize in 2015 for the discovery of antimalarial properties of artemisinin, a herb that is part of Ayurveda and T&CM (96). Improved outcomes may be achieved by not only looking at symptoms and problems and trying to eradicate them (pathogenesis), but also at the strengths and qualities of patients and finding ways to increase them (health promotion or salutogenesis) (97). For example, it has been shown that integrative oncology, i.e., the combination of biomedical cancer therapies with T&CM, can lead to higher health-related quality of life in cancer patients than biomedicine alone (98).

IM has always stressed the importance of a healthy lifestyle. Motivating and teaching patients to improve lifestyle comes with less costs and can increase self-esteem, responsibility for one’s own health and more independence from therapists (15, 22–24). It may not only reduce pathology, but it may also enhance health and wellbeing by fostering positive emotions like calmness, empathy and self-actualization (99, 100). Lifestyle medicine, as previously described, is increasingly adopted by biomedicine (101) and may as such may guide the integration process of T&CM into conventional healthcare.

Three examples of specialties in which integrative medicine has been applied successfully are:

Despite these successful initiatives, academic medicine frequently regards T&CM with criticism, dismay, and distrust. In many countries biomedicine and T&CM are still largely separate worlds, sometimes with hostile attitudes toward another. However, in the last decades this seems to change. The foundation of four academic consortia for integrative medicine is an indication for this. This apparent change in openness to T&CM may be because integration is not only a current tendency in medicine, but also a trend fitting the contemporary spirit of the age in which integration seems to be the most common focus. It can be observed in religion, philosophy, spirituality and psychotherapy as well (105). It is also reflected in the WHO Traditional Medicine strategy 2014–2023.

T&CM contribute to the Sustainable Development Goal (SDG-3; ‘ensure healthy lives and promote well-being for all at all ages’) of achieving Universal health Coverage (UHC) and ensuring that all people have access to care (United Nations 2019). Several World Assembly (WHA) resolutions requested the WHO to provide technical support and guidance to member states, for the integration of healthcare services (106). In European countries, T&CM are mostly used complementary to the conventional system (107). The top three reasons for T&CM use are: (1) having an expectation of benefits of T&CM, (2) dissatisfaction with conventional medicine and (3) the perceived safety of T&CM (37%) (108). Another reason reported is that T&CM resonates with one’s values or perspectives on health (108, 109). Tangkiatkumjai et al. (108) found that internal health locus of control as an influencing factor for T&CM use is more likely to be reported in Western populations, whereas the social networks is a common factor among Asian populations. Affordability, easy access to T&CM were significant factors among African populations. These factors, along with the greater availability of health information on the internet, and similar degree of satisfaction between T&CM and biomedicine, seem to be driving forces behind the growth in the use of T&CM in Western and Eastern countries in recent decades (110).

T&CM is present in almost every country in the world and the demand for its services is increasing (1). Up to 76% of the world population uses some form of T&CM each year (111). In many countries, they are the main healthcare services to the population since ancestral times (2). T&CM are an important and often underestimated health resource with many applications, especially in the prevention and management of lifestyle-related chronic diseases, and in addressing the health needs of aging populations. In an ideal world, traditional medicine would be an option provided by a well-functioning, people-centered, evidence-informed health care system that balances curative services with preventive care (2).

In the WHO’s 2019 Global Report on Traditional and Complementary Medicines (2) it is described that T&CM is an important and often underestimated health resource, specifically in the prevention and management of lifestyle-related chronic diseases, by stimulating a healthy lifestyle and in addressing the health needs of aging populations. In the light of the recent surge of healthy lifestyle interventions in biomedicine and a call for more prevention, in policy making, countries could benefit from the experience and knowledge of T&CM in these field.

Recently, the WHO has introduced the term TCIM (Traditional Complementary and Integrative Medicine) to emphasize the world-wide need to take different kinds of medicine into account. TCIM includes traditional medical systems such as Ayurveda and Traditional Chinese medicine, non-traditional and complementary ones such as Naturopathy, lifestyle medicine (nutrition, exercise, sleep), Homeopathy and Anthroposophic Medicine, and use of natural medicines such as herbs, and mind–body interventions (mindfulness, yoga), besides biomedicine (2).

Whether T&CM is fully integrated, partly integrated or not integrated in the country’s dominant health system depends on factors such as national regulations, appropriate education, funding, information, availability of services and multidisciplinary collaboration (2). Different models have been developed and described on how T&CM can be integrated into the conventional health system. They can be classified into five models ranging from coexistence, cooptative, cooperative, collaborative, to patient-centered care (112). The more coexistence and cooptative models for T&CM integration have distinct roles for different health care professionals, whereas the cooperative and collaborative models are team-based, with formalized interaction between the conventional health care professionals and T&CM practitioners (112).

At present, the practice of T&CM highly varies per country and is idiosyncratic. Such practice depends on the personal philosophies, values and clinical perspectives of its practitioners, and the goals of diverse training programs, clinics or hospitals where integrative treatment approaches are employed (113). Asian countries such as China, Japan, and the Republic of Korea have well-established systems of T&CM integration, including supportive legislation, well implemented regulatory systems for herbal medicines, T&CM practices and practitioners, as well as T&CM education systems (114). In African countries, traditional healers and natural medicines are widely used by its population, but hardly integrated into the mainstream health systems (115, 116). An illustrative example of the integration process of T&CM in a European conventional health system is that of integrative oncology in the German speaking countries. An active group of clinicians, researchers and practitioners have systematically developed a step-by-step basis for integrative oncology care in Germany and Switzerland. They have defined education competencies for oncology physicians regarding T&CM (117). As a next step, they have developed and tested a consultation framework for the training of oncology physicians to advise their patients about the effectiveness and safety of T&CM (118). Furthermore, they also have developed criteria for guiding cancer patients to find a reputable T&CM practitioner (119). Within this collaborative, they also work in parallel to further identify the needs, provide reliable information, foster communication, and support decision-making about T&CM for patients with cancer (120). In sharp contrast to the German speaking countries, in Finland there seems to be no integration of T&CM into the conventional health system. Finland lacks any regulation or guidelines on T&CM, and there is very little academic research on the subject (121). Such world-wide variety in the integration of T&CM seems undesirable, specifically from the needs and perspectives of patients.

In the past decades, the number of countries that have implemented some form of regulation on T&CM has grown. In 1999, only 25 WHO member states had a national regulatory policy on the subject, 45 had national legislation, and 65 countries had specific regulations on herbal medicine. In 2018, a total of 98 of the 194 WHO member states had a national policy, 109 had legislation, and 124 countries had regulations on herbal medicine in all six regions of the world (2). Despite this apparent increase, T&CM is still not regulated appropriately in almost half (49.5%) of the countries world-wide. Take the example of the European Union, where most T&CM modalities are practiced in a very similar way. There are European countries where T&CM or some of its modalities are regulated either as conventional medicine (e.g., chiropractic in the United Kingdom), complementary medicine (e.g., Switzerland), alternative medicine (e.g., Norway), or not regulated at all (e.g., Finland) (122). From the perspectives of its users and open border policies, it becomes apparent that this confusing and disharmonized regulation on T&CM should be addressed more prominently. An often-heard argument against T&CM regulation is that regulation may grant these non-conventional types of medicine and T&CM practitioners undue legitimacy or recognition (123). However, a recent systematic review on the subject concluded that there appears to be broad support for the regulation of T&CM, but that there is wide variation in opinions among the different stakeholders as to how this should be applied (123).

Recommendations regarding goal 1:

Despite its increasing popularity, the field of T&CM is faced with many challenges, such as problems with quality standards, unsupported claims for safety and or effectiveness, challenges with sufficient research funding and appropriate research methodologies, lack of familiarity by conventional healthcare providers about evidence-based T&CM, absence of reimbursement mechanisms for T&CM, non-disclosure of T&CM use by patients, and unreliable sources of information. These challenges that T&CM is facing are described in more detail below.

We have argued that the concept and principles of IM provide concrete healthcare actions and measures that are worth to further implement and investigate in the light of the increasing global health threats such as chronic diseases, pandemics, and ever-increasing healthcare cost. We made suggestions concerning the three main strategies in the 2014–2023 WHO Traditional Medicine strategy. We propose three additional suggestions:

There is currently no global platform or organization that represents clinical practice, education, and research on T&CM from the perspective of Western academic medicine.

To facilitate the global integration of T&CM, we therefore propose to establish a Global Matrix of Academic Consortia for Integrative Medicine and Health and the WHO, its global and national collaborative centers, T&CM providers, International society for T&CM research (ISCMR), other stakeholders and patient organizations.

The establishment of a Global Matrix of Academic Consortia was originally proposed by the former head of the WHO’s T&CM Unit (Dr Zhang Qi) a few years ago. Subsequently, the three national academic IM consortia United States, Brazil and the Netherlands elaborated further on the idea and drafted a first outline. This outline was presented to many stakeholders in May of 2022 during the International Congress on Integrative Medicine & Health in Arizona, USA and during the International Congress on Integrative Medicine in Rome in September 2023. Based on their feedback and suggestions the present paper was drafted and finalized. The next step is to establish a Global Matrix (GM) and to formulate its vision, mission, goals, and objectives. Besides, models for collaboration will be developed centered around the GM’s goals and objectives.

The overall goal of our proposed GM is to support the world-wide integration of T&CM by advancing research, academic education, clinical guidelines, policy, and communication on IM, from the perspective of academic medicine. To reach this goal, we foresee the following objectives in the next 5 years:

An important step forward to address the challenges regarding the lack of (good quality) evidence for (cost)effectiveness, safety and the conduct and application of T&CM research is to develop an international research agenda based on ‘gaps’ and then address research priorities. This should also include cost-effectiveness studies, as controlling costs is a major challenge in healthcare. Ongoing mapping studies on the clinical effectiveness of T&CM of the BIREME/PAHO, Brazilian Academic Consortium for Integrative Health and the WHO can assist in this research prioritization by identifying the evidence gaps and weaknesses in methodological designs.

The use of AI in generating evidence could be considered, as there are many research questions and a shortage of people and funds.

Besides (cost) effectiveness of T&CM, there is also a need to focus on implementation science, as there seems to be a gap between the existing evidence and current practices, especially in academic health centers.

The status of integration of T&CM varies considerable between member states and depends mainly on personal philosophies, values and perspectives of regulators, clinicians, and practitioners in each country. We recommend that the main challenges regarding quality assurance, safety, proper use, effectiveness, and integration of T&CM as identified in this paper, are addressed in an updated or new WHO Traditional Medicine strategy. However, to tackle these challenges and further the field, we propose that a new policy (strategy) of the WHO is closely linked to the clinical, academic and research practice of T&CM. We are of the opinion that a direct and dynamic interaction between policy, research and practice will support, facilitate, and accelerate the integration of biomedicine and T&CM. To do so a worldwide network of cooperating (consortia of) academic healthcare centers and researchers is needed. A Global Matrix may be the best way to facilitates this, as it connects all involved in T&CM while at the same time ensuring everyone’s autonomy.