Integration of complementary and alternative medicine in the Indian health system: how the state inadvertently...

India's AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homeopathy) integration policy emphasizes medical pluralism. However, implementation occurs within a complex health system where the state apparatus, through its governance and policy processes, affects health services and outcomes. This study explores how state and policy complexities shape AYUSH integration processes and practitioners' capacities in primary healthcare. Qualitative research was conducted in an eastern Indian state and involved observations (19 days) and interviews (37) with AYUSH doctors, biomedical doctors, nurses, pharmacists, and administrators. Thematic analysis enabled identification of themes. State-level employment rules placed AYUSH doctors on low-paid, short-term rolling contracts, but the effects of this marginalized position were intensified by irregular AYUSH medicine supplies and shared governance between two directorates. Governance of integrative facilities and AYUSH medicine stock-outs shifted practice patterns towards biomedical treatments by AYUSH doctors to keep health services functioning, which increased biomedicine demand and further narrowed the scope of AYUSH in a self-reinforcing cycle. Inter-departmental collaboration between the directorates was fragmented, lacking accountability and prioritization of AYUSH integration activities. Limitations in AYUSH medicines and the absence of promotional campaigns narrowed the scope of AYUSH services and facilitated the 'biomedicalization' of AYUSH integration. Local governance bodies offered occasional support, but their involvement was neither formalized nor consistent. Thus, integration processes emerged not from linear policy structures but from feedback mechanisms in which changes in policy priorities at the state and district levels produced disproportionate effects on AYUSH integration, demonstrating a system responsive to resource and information flows. Achieving medical pluralism will require adaptive governance: setting iterative integration targets, establishing cross-directorate collaboration and learning platforms, and increasing the resource independence of AYUSH.