Practitioners therefore spend much of their time responding to these inadequacies. There were also shortcomings in the design of diagnostic services and an inadequacy of human resources. Homoeopathic and Ayurvedic practitioners in Kerala noted the recourse to outsourcing diagnostic investigations

because of the lack of facilities in selleck chemical their institutions. Further, there was reliance on the contractual recruitment of human resources to address shortages, which, in their view, affected the stability and reliability of service delivery. When we asked an administrator of one of Delhi’s newest, state-of-the-art Ayurvedic facilities what kind of coordination occurred across departments as part of the hospital’s functioning, he shrugged and replied, ‘Nothing as such!’ Discussion The most striking feature in our findings is the emergence of individual experiences and interpretations as enablers or facilitators of integration, in the form of collegiality, recognition of stature, exercise of personal initiative among TCA practitioners and of personal experience of TCAM among allopaths. In contrast, barriers to integration seemed to exist at a systems level. They included fragmentation of jurisdiction and facilities, intersystem isolation,

lack of trust in and awareness of TCA systems, and inadequate infrastructure and resources for TCA service delivery. It is a system where ‘little somethings’ of individuals that catalyse integration are met with ‘nothing as such’ at the systems level. Some of our findings are not new—the experience of a lack of interaction has emerged in Hollenberg’s study on an integrated practice, which reported that weekly doctors’ meetings included only biomedical doctors, not CAM.19 This study also reported the ‘geographical dominance’ of biomedical doctors in

terms of location of consulting rooms, as was found in our study. A study by Broom et al20 found tension and mistrust, as well as inconsistencies in practice and values related to biomedicine and TCAM, among Indian oncologists. AV-951 Such challenges were also seen in our study. Our study also revealed some unique findings with respect to the extant literature. Chung et al21 attributed low referrals from biomedicine to TCAM in Hong Kong to the lack of articulated and enforced procedures of referral in an integrated medical establishment. In the Indian case, it appears that the vagueness of process allows ad hoc interactions and referrals based on personal rapport and, at the same time, discourages the kind of predictable, routine interactions that would allow such rapport to be built. Speaking of integration of Sowa-Rigpa in Bhutan since 1967, Wangchuk et al22 suggest that there are managerial lessons offered by the juxtaposition and collaboration of conceptually distinct systems within a single administrative and policy unit, such as a ministry.