CAM legislation in European countries

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doi: 10.12032/TMR20190718125
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Public Health
Complementary and alternative medicine in European countries—
legislative framework
Jovana Milenkovic1*
, Sergey Bolevich2
, Gvozden Rosic3
1
Department of Dentistry, Faculty of Medical Sciences, University of Kragujevac, Kragujevac 34000, Serbia. 2
Department of
Human Pathology, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow 119991, Russia.
3
Department of Physiology, Faculty of Medical Sciences, University of Kragujevac, Kragujevac 34000, Serbia.
*Corresponding to: Jovana Milenkovic. Faculty of Medical Sciences, University of Kragujevac, Svetozara Markovica 69,
Kragujevac 34000, Serbia. E-mail: jovannakg94@gmail.com.
Highlights
The present article reviews the available data regarding the use of the complementary and alternative
medicine and the legislation behind it in European countries.
Traditionality
Complementary and alternative medicine has been used for centuries. Since ancient times to date, these
methods have been improved in line with the progress of Western medicine. Today, these methods have
been applied in many countries around the world.

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TMR | May 2020 | vol. 5 | no. 3 | 126
Abstract
Complementary and alternative medicine (CAM) is a set of different diagnostic and therapeutic procedures, as well
as the use of natural products for the treatment of patients, derived from previously known traditional methods and
enriched with modern scientific knowledge. The present article reviews the available data regarding the use of
CAM and the legislation behind it in European countries. The use of CAM is recorded in Europe as a whole and
varies between 10–70% of the population of individual European countries. At least 300,000 registered CAM
providers have been identified in the European Union (EU), of which slightly more than half includes non-medical
practitioners. The most practiced discipline is acupuncture, followed by homeopathy. CAM regulation and
legislation in Europe is not precisely defined and is constantly striving to find a common approach. Since legal
frameworks for CAM are not defined, each European country has its own regulations and legislation. In order to
define universal legislation for CAM, the EU created the CAMbrella project, a project of the EU designed to find a
unique system that would include the treatment of CAM in Europe. According to the data from CAMbrella, from
39 countries in the EU, 17 have general CAM legislations. The status of CAM in Europe is characterized by
enormous heterogeneity in all aspects, including terminology, methods, prevalence and ultimately, legal status,
regulations and legislation.
Keywords: Complementary and alternative medicine, European countries, Methods of therapy, Legal status,
Regulation, Legislation
Abbreviations:
CAM, Complementary and alternative medicine; EU, European union; UK: United Kingdom; TCM,
Traditional Chinese medicine.
Competing interests:
The authors report no conflicts of interest.
Citation:
Jovana Milenkovic, Sergey Bolevich, Gvozden Rosic. Complementary and alternative medicine
in European countries—legislative framework. Traditional Medicine Research 2020, 5 (3): 125–135.
Executive Editor: Pan Shao, Nuo-Xi Pi.
Submitted: 4 June 2019, Accepted: 17 July 2019, Online: 25 July 2019.

REVIEW doi: 10.12032/TMR20190718125
Submit a manuscript: https://www.tmrjournals.com/tmr TMR | May 2020 | vol. 5 | no. 3 | 127
Background
Since ancient times, various medical and non-medical
healing practices have been used for providing general
health and well-being of people. Today, various
alternative methods of treatment, derived from
previously known traditional methods, are enriched
with modern scientific knowledge and known as
complementary and alternative medicine (CAM) [1].
CAM presents a set of different diagnostic and
therapeutic procedures, as well as the use of natural
products for the treatment of patients. They are used as
supplemental therapy with standard forms of medical
treatment, but also for rehabilitation and prevention of
certain conditions and diseases. The term
complementary medicine points to the possibility that
certain complementary systems are used as a
supplement to the well-established medical therapeutic
procedures, while the term alternative medicine is used
to state that the methods of therapy differ from and are
not applied as methods in modern medicine. There are
insufficient evidences for the efficacy and safety of
these methods and for this reason, they are labeled and
critically known as CAM [2].
CAM can be provided by medical personal whose
knowledge of the methods was acquired through
medical education, but also can be provided by
non-medical person whose knowledge was obtained
from generation to generation or through courses that
are differently regulated. In some countries, there is a
legally regulated law that states that CAM courses can
only be completed by health care providers (doctors,
dentists, pharmacists), while a small number of
countries even registered certain alternative methods as
a profession, regulated by higher education [3].
CAM implies health practice, beliefs, approaches
and knowledge relating to plant-based products,
spiritual therapy, manual techniques and exercises for
the purpose of treatment, diagnosis and prevention of
disease. A holistic approach is a key element of any
CAM method. Holism implies a universal
understanding that the organism in the psychological,
physiological and social sense should be viewed as a
whole. Although they are often different from modern
scientific knowledge in both the interpretation of the
signs and symptoms of the disease and the course of
treatment, CAM is effectively used alongside modern
medical practice. In CAM, the emphasis is on the
balance and the harmony of the individual [4]. This
type of treatment is based on the needs of the patient
and must be individual in order to fully correspond to
the current patient's condition. The most common
alternative methods are traditional Chinese and Indian
medicine, while in the west the dominant alternative
methods are acupuncture, naturopathy and homeopathy
[5].
The aim of this article was to review the available
data regarding the use of the CAM and the legislation
behind it in European countries.
The most used methods of CAM
Traditional Chinese medicine
Traditional Chinese medicine (TCM) is a system of
diagnostic and treatment methods developed around
4–5 thousands years ago [5]. TCM is still being used
today, primarily in East Asia. Due to the lack of
understanding the influences of these therapeutic
methods, TCM is less used in Western countries [6].
The foundation of TCM holds the theory of
“opposition forces”, Yin and Yang, which are believed
to be connected with the energy of “Qi” (a vital force
forming part of any living entity in traditional Chinese
culture). The principle of Yin and Yang is the
fundamental concept of Chinese philosophy and
culture that dates back to the 3rd century B.C.E. This
principle implies that all things exist as a blend of
inseparable opposites. Two opposites attract and
complement each other. Neither side is superior to
another, but an increase of one contributes to the
reduction of another. The right balance has to be
achieved in order to achieve harmony. Yang is a male
principle, while Yin is a female. In TCM, all physical
processes, signs and symptoms can be categorized into
Yin and Yang. The basic task of TCM is to establish a
balance of previously disturbed Ying and Yang, or,
when interpreting this statement through the modern
medical understanding, to stimulate the immune
system and to establish homeostasis [7]. TCM treats
individuals based on a holistic approach, comparing
the differentiation of syndromes, which is a
comprehensive analysis of the health status of
individuals according to Yin Yang theory. Symptoms
are used for the syndrome differentiation, however, the
treatment of TCM is based on disease pattern
differentiation of the syndromes rather than on one
symptom. Therefore, people with various diseases
causing the same syndrome would be treated in the
same way, while persons with the identical disease
would be treated in different ways depending on their
syndromes. Western medicine, in contrast to TCM,
focuses on the disease treatment after proper diagnosis
based on the symptoms of a disease. TCM is involved
within the Chinese health care system, and is
differently available to the global population. It is
estimated that more than 90% of the urban and rural
population in China have at least once in their life,
requested or used TCM [8].
Indian traditional medicine
India is a country with an extremely rich history of
alternative medicine. Throughout history, six
alternative medicine systems existed of which
Ayurveda is the oldest, most widely accepted and the

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most practiced method. Ayurveda is also one of the
most famous traditional methods of alternative
medicine that survived since ancient times. It bases its
principles on “all life-forms and the natural way of
living”. Human life and health are looked at and
analyzed through the unity of the body, mind and spirit
[9]. In therapy, Ayurveda includes procedures, the use
of medicinal herbs, meditation, diet, breathing
exercises and specific breathing techniques. Ayurveda
procedures in India are applied in treatment of various
diseases such as neurological, cardiovascular, diabetes
and others. However, clinical studies that confirm the
success of these procedures are missing. Ayurveda
emphasizes the early detection of imbalance in the
body. This aspect of disease prevention in Ayurveda is
considered critically important. It also emphasizes the
importance of mental or spiritual health. One of the
basic approaches in Ayurveda is that even though the
person is physically cured, the disease returns if a
person does not find spiritual healing. Practices of
Ayurveda commonly include the use of substances of
natural origin, which includes herbs, preparations of
etheric oils and minerals in the form of tea, capsules or
tablets, alone or in combination. The good physical
condition of body is of great importance for the over
health of body and mind, and can be acquired with
proper diet, exercises, meditation and yoga [10].
Homeopathy
Homeopathy is an alternative method practiced in
Europe, Asia, and South America for mild diseases. In
addition to acupuncture, it is one of the most
commonly practiced alternative medicine methods [11].
It was developed in Germany, by the teachings of a
German physician - Samuel Christian Hahnemann
(1755–1843 C.E.). It quickly spread from Europe, to
North and South America and Australia. Today, it is
used in over 30 countries. Homeopathy methods are
used in hospital care in Europe. The principle of action,
is that drugs and substances of plant and animal nature
are used and tested on healthy volunteers in order to
record developing specific symptoms. The theory
being, a substance that causes certain symptoms of a
disease in healthy people will cure opposite symptoms
in the case of the illness. The treatment involves
examining all aspects of the patient's medical condition,
which implies physical, mental and emotional state [5,
12].
Homeopathy uses diluted substances for the
treatment of various disorders and illness. Today it is
extremely popular and over 200 million people take
homeopathic medicines. Health systems involving this
method in countries such as Switzerland, India,
Mexico, Brazil, Pakistan. Switzerland has the most
developed homeopathy incorporated into their national
health system, followed by the United Kingdom (UK)
and Norway [13].
Acupuncture
Acupuncture is a method of CAM that dates back to
3,000 years ago. The beginning of this method is
recorded in China. It was introduced into Korea and
Japan in the 6th century B.C.E. and in the 16th and
17th century it migrated to Europe and North America
[14]. The therapy is carried out by trained practitioners
who insert filiform needles subcutaneously and even
deeper into muscle and tendon tissue to stimulate
specific points on the body, the so-called trigger zone.
The method is based on the fact that stimulation of
certain trigger points can stimulate the release of
endorphins, as a natural medication and pain reliever
[11]. Acupuncture analgesia was used in treating acute
and chronic pain, especially in musculoskeletal and
connective tissue disorders/illness. Acupuncture is
used to treat headaches and achieves great success in
the treatment of migraine. This method has long been
used in symptoms of allergic diseases. Clinical results
are showing that acupuncture is effective in eczema, it
can decrease the susceptibility and itching. The
effectiveness of the method shows equivalent effect to
the use of oral antihistamines. Acupuncture could
significantly improve the quality of life in patients with
seasonal allergic rhinitis and reduce the use of
antihistamines [15, 16]. It has also been noted to assist
in osteoarthritis therapy, but efficacy has not been fully
proven [17].
Naturopathy
Naturopathy is a discipline that uses appropriate
nutrition to achieve optimal health and manage many
diseases. It is the youngest method, created at the end
of the 19th century in America [5]. In the 21st century,
the culture of healthy life style and proper diet and
nutrition are adopted, so many naturopathic principals
have been developed. There are six basic naturopathic
principles that are used in North America but these
principles are not uniformly accepted by other
naturopaths. These principles are: health is the power
of nature, identification and treatment of the cause of
the disease, the concept do not harm first, the therapist
is a teacher, treatment of a complete individual and
prevention. All of these principles point to a timely and
accurate diagnosis, finding the cause and acting on it.
The organism should be viewed as a whole and the
treatment must include a complete analysis of the
individual and not just action on the causative agent. In
doing so, one should not forget the basic goal,
primarily not to harm the patient.
The difference between nutritionists and naturopaths
is that nutritionists are required in the public health
system while naturopaths are exclusively represented
in private practice [18]. It is most commonly used in
the United States (US), Europe, Canada and Australia.
Naturopathic practitioners rely on natural healing,
rather than introducing substances to fight disease.
They try to restore healthy and normal functioning of

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the organism. Symptoms are used to determine the
causes and nature of the disease and then determine the
treatment. Therapy is complex and takes various forms
of diets, herbs, hydrotherapy, massage and healthy
lifestyle. The opinion and the advice of a medical
doctor with a combination of this treatment protocol
seem to be the most appropriate approach used by
patients [19].
Reflexology
Reflexology is a method of massage therapy,
discovered in ancient Egypt [20]. It implies a certain
pressure on the target points on the foot usually, less so
on the palms and ears. There are the so-called reflex
zones in those body parts that can represent a map of
the body. It is based on the principles of CAM, also on
the energy flow through the body. Stimulation and the
release of blockages, tension and knots bring healing.
Many people are choosing reflexology for the method
of solving health problems. The main advantage is
safety, lack of significant side effects and not require
the use of medication and supplements during
treatment. It is especially useful in the relief of stress,
since it is known that stress significantly contributes to
disease development by up to 80%. It is generally not
used in diagnostics. The objective of stimulation and
massage of a particular body parts by bringing the
relaxation of the target region and relaxation of the
entire organism [21].
Use of CAM in Europe
CAM has been used since ancient times, but their use
has dramatically increased in many countries in recent
years. Early research has shown that the use of CAM
in the US has increased significantly between 1990 and
1997, from 25% to 42% of the total population, with
people admitting to at least one use of CAM. Surveys
show increasing interest and confidence in the methods
and practitioners of CAM [22]. Since CAM is widely
used, it is considered that the prevalence of CAM use
is from 9.8 to 76%. It is important to note that 80% of
the population in Africa and Asia rely on CAM in
primary health care, regardless of the accessibility of
modern medicine and medical products (jumping to
90% of the Indian polulation) [23]. The Indian
government is striving to actively use traditional
medicine and homeopathy in national health programs
and primary health care [24].
The increase in CAM usage has been recorded in
Western countries and the rate of utilization from year
to year is considerably higher [25]. The use of CAM is
recorded in countries throughout Europe and it is
known to vary between 10 and 70% of the population
[26]. At least 300,000 registered CAM providers have
been identified in the European Union (EU), of which
slightly more than half includes non-medical
practitioners, the rest are medical doctors who provide
CAM services. The most affordable discipline is
acupuncture. Acupuncture is provided by medical
(80,000) and non-medical practitioners (16,380). It is
followed by homeopathy with 45,000 medical and
5,800 non-medical practitioners. Anthroposophical
medicine and neurotrophy are mainly provided by the
doctors of medicine, while on the other hand, herbal
medicine and reflexology are almost exclusively
provided by non-medical practitioners [26].
The prevalence of CAM use is different in each
country and is shown in Table 1. The most common
diseases to use CAM are musculoskeletal problems,
respiratory infections, urinary tract infections, allergies
and psychiatric disorders [27].
The reason for the growing interest in CAM is
generally considered to be insufficient care from
allopathic medical practitioners and the fact that
for some diseases modern scientific medicine has no
valid solutions. Other reasons why CAM is increasing
is that CAM methods generally cost less than modern
medicine methods. Healthcarecosts are enormous in
the 21st century and therefore people who are not
covered materially turn to traditional methods. CAM is
also on the rise because traditional medicine
practitioners generally give more of their time to their
patients and clients. By listening to patients and paying
Table 1 Percentage of CAM usage in different
European countries
Country Prevalence rate (%)
United Kingdom 6–71
Germany 4.6–62
Turkey 48–86
Switzerland 5–57
Sweden 5–64
Norway 9–53
Denmark 45–59
Italy 16–84
Israel 5–43
Finland 11–43
Spain 5–47
France 21
Ireland 15
Netherlands 17.2
Poland 14.4
Portugal 43.7
Slovenia 6.6
Data from: Eardley S, Bishop FL, Prescott P, et al. A
systematic literature review of complementary and
alternative medicine prevalence in EU. Forsch
Komplementmed 2012, 19 Suppl 2: 18–28 [27].
CAM, Complementary and alternative medicine.

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Table 2 Who can use CAM?
Country Who is implementing CAM? Insurance Additional education
Austria
There are no legal regulations that
confirm that use is allowed, but
allopathic doctors are allowed to
use it.
The Health Insurance Fund does
not cover services. Some private
companies cover CAM.
Upgrading 3–4 years
Belgium
There is a specific law, CAM is
administered only by doctors
licensed for this practice.
It is not covered by the health
insurance fund. Private
companies partially compensate
for acupuncture and chiropractic.
There is an education in
the form of training and
courses.
Denmark
Non-allopathic doctors are not
recognized as official providers
of health care. The exception is
chiropractors.
The insurance fund covers partial
costs (1/3).
?
Finland
Only allopathic doctors and
registered chiropractors,
naprapathy and osteopaths can
practice CAM.
Covered by the fund if
administered by allopathic
doctors. There is no private
insurance.
Upgrading 3–4 years
France
Allopathic doctors provide CAM,
while they are not allopathic
criminally prosecuted.
Chiropractic is legal in France.
There is only CAM provided by
allopathic doctors.
There is education in
courses.
Germany
All licensed doctors can
implement CAM practice.
It covers some forms of CAM
practice. There is also private
insurance.
courses.
Hungary
There is a specific law. Not
allopathic doctors are allowed to
use CAM if they pass the exam.
?
courses.
Ireland
Only allopathic doctors can do
CAM.
It is covered when CAM services
are provided by allopathic
doctors.
Courses and trainings
do not exist.
Italy
Only registered allopathic doctors
can administer CAM.
Every Italian region is regulated
differently.
There is additional
education in the form of
courses but not legally
recognized.
Latvia
Local laws regulate CAM.
Allopathic doctors may apply it.
CAM is not covered by
compulsory health insurance.
?
Liechtenstein
No specific law. CAM practice in
allopathic doctors is not
regulated.
It is not covered by compulsory
health insurance.
Training in foreign
countries
Luxembourg
CAM.
Only homeopathy is covered by
insurance, other disciplines are
not covered.
There is no officially
recognized education.
Malta
CAM, while they are not
allopathic.
There is a partial coverage of
CAM costs.
?
Netherlands
In addition to allopathic doctors,
they can also be practiced by
qualified practitioners.
NO YES
Data from: World Health Organization. Legal Status of Traditional Medicine and Complementary/Alternative
Medicine: A Worldwide Review. World Heal Organ 2001: 1–199 [24]. CAM, Complementary and alternative
medicine. ?: Data was too unclear and undefined.

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Table 3 The status of acupuncture, homeopathy and chiropractic in different European countries.
Country
Acupuncture Chiropractic Homeopathy
1 2 3 4 1 2 3 4 1 2 3 4
Albania + + +
Austria + + +
Belgium + + +
BiH + + +
Bulgaria + + +
Croatia + + +
Cyprus + + +
Czech Republic + + +
Denmark + + +
Estonia + + +
Finland + + +
France + + +
Germany + + +
Greece + + +
Hungary + + +
Iceland + + +
Ireland + + +
Israel + + +
Italy + + +
Latvia + + +
Liechteistein + + +
Lithuania + + +
Luxemburg + + +
Macedonia + + +
Malta + + +
Montenegro + + +
Netherlands + + +
Norway + + +
Poland + + +
Portugal + + +
Romania + + +
Serbia + + +
Slovakia + + +
Slovenia + + +
Spain + + +
Sweeden + + +
Switzerland + + +
Turkey + + +
UK + + +
Data from: Norway’s National Research Center in Complementary and Alternative Medicine. CAM Regulation.
2019. Available from: http://cam-regulation.org/en [39].
1-Regulated profession and EU registered; 2-Regulated profession, Not EU registered; 3-Regulated treatment, Not
regulated profession; 4-No regulation. CAM, Complementary and alternative medicine; EU: European Union; UK:
United Kingdom.
attention to them, CAM practitioners are gaining more
trust. Because of the clinical success of CAM therapies
leading to patient satisfaction, the increase in the use of
CAM is significant [28].
CAM regulation and legislation
The European Parliament clearly indicates that any
non-conventional medicine must be clear and precisely
identified and defined. Similarly, the EU proposes that
each member state should establish, organize and
regulate its health system to compulsorily include
CAM [29].
There are three types of CAM regulations:
(1) Exclusive licensing regimes—This kind of
regulation is usually self-regulation delegated by the
government. The rights to implement CAM are given

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to practitioners with a license, while practitioners
without a license are illegal.
(2) Official certification—Certified practitioners are
practicing CAM, usually under the self-regulation
regime delegated by the government. Uncertified
practitioners are not excluded, they can practice on
specific domains but under certain labels.
(3) Voluntary private certification regimes—They
are managed by private professional associations [30].
CAM regulation and legislation in Europe is not
precisely defined and is constantly striving to find a
common approach. Since there is no common
approach and legal frameworks are not defined, each
European state has its own regulations and legislation.
This results in significant diversity in regional, national,
European and international legal regulations. Unlike
CAM, plant products are regulated in a similar manner
in each country [31]. In order to advance future
research, this diversity in regulation and legislation,
which creates a serious problem, should be
summarized and precisely defined. Adequate
regulation and supervision of CAM practitioners and
therapies are of great importance and require special
knowledge in the field of CAM, in order to take into
account, the specificities of this domain of health care.
Due to the extreme distribution and increasing use
of non-conventional medicine, it would be inadequate
for CAM legislation to be regulated by adapting the
criteria of conventional medicine only [32]. Previous
research has shown an exceptional diversity in terms of
who can apply CAM practice, whether there are
courses and different trainings that would allow the
non-allopathic doctors to acquire the appropriate
knowledge and skills to put a certain method into
practice and thus help patients, which was the main
goal of any type of medicine. Some countries cover the
health insurance fund for CAM services and in some
there are private insurance companies that compensate
for certain CAM disciplines [24]. Table 2 shows who
can conduct CAM, which countries are covered by
insurance and whether there is additional education for
CAM methods.
More than 4000 doctors, physiotherapists and other
health workers in the UK use acupuncture regulated by
the statute. Also, about 2000 medical practitioners
apply the method of acupuncture, although the process
of legal regulation continues. In addition to these two
groups, there are countless completely unregulated
practitioners. The homeopathic practice is not
regulated in the UK - anyone can be described as a
homeopath [33]. The interest of patients from Europe,
the US and Australia has led to a significant increase in
the use of CAM. Such a significant increase in the use
of CAM resulted in insurance coverage for some
therapies [34]. Table 3 describes the regulation of CAM
methods (acupuncture, homeopathy and chiropractic).
An economic overview of the implementation
of CAM legislative framework
Interest in CAM has increased in the last few years and
the general population attitude towards CAM is
generally positive. People with multiple chronic
conditions are increasingly using CAM, so it is
expected that the use of CAM in the coming years will
increase even more [35, 36]. As a result of wider use,
CAM is increasingly incorporated into medical
education.
Due to the non-exigent definition of terminology,
regulation and legislation, it is difficult to precisely
define global costs for CAM. However, previous
studies have shown that a significant amount of money
is spent out-of-pocket on CAM [36]. The beginnings of
CAM are recorded in China [6], and China is a state
that seeks to finance comprehensive health care in the
coming years [37]. The development and creation of
modern medicine was extremely expensive. The
formation of new medical technology, education and
the creation of a professional staff resulted in the
creation of extensive medical networks of funding, and
the pooling of social and private insurance with the
personal funding of patients. By 2020, most people in
the world will live in countries that have regulated the
comprehensive status of national systems that provide
and finance health care [38]. Today, CAM is
increasingly incorporated into national health systems.
In some European countries, public national insurance
covers the cost of various CAM treatments and in
some countries, there are private insurance companies
that partially cover CAM costs. In order to precisely
define the cost status and insurance of CAM, it is
necessary to undertake new surveys that would include
a detailed overview of the economic and health
outcomes of the CAM treatment in order to cover the
cost of their expenses [24, 36].
CAMbrella is a project of the EU designed to find a
unique system that would include the treatment of
CAM in Europe. CAMbrella is a pan-European
research network for CAM. The goal of this
collaboration is to develop a roadmap for future
European research in CAM that is appropriate for the
health care needs of EU citizens and acceptable to the
EU Parliament as well as national research funders and
healthcare providers. It has enabled meaningful,
reliable comparative research and communication in
Europe. The goals are to develop an EU network that
includes centers of excellence in research for
collaborative research, then develop a consensus-based
terminology widely accepted in Europe to describe
CAM interventions to create a knowledge base that
facilitates our understanding of patient demand for
CAM and its prevalence, review the current legal
status and policies governing the provision of CAMs in
the EU and the EU to explore the needs, beliefs and
attitudes of EU citizens in relation to the CAM.

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Table 4 CAM legislation in different countries
With CAM law With general CAM legislation in health laws Without general CAM legislation
Belgium Switzerland Austria
Denmark Malta Croatia
Germany Bulgaria Cyprus
Portugal Macedonia Czech Republic
Iceland Albania Estonia
Liechtenstein Bosnia & Herzegovina Finland
Norway France
Hungary Greece
Slovenia Ireland
Romania Israel
Serbia Italy
Turkey (since 2015) Latvia
Lithuania
Luxemburg
Montenegro
Netherlands
Poland
Slovakia
Spain
Sweden
UK
Data from: Norway’s National Research Center in Complementary and Alternative Medicine. CAM Regulation.
2019. Available from: http://cam-regulation.org/en [39]. CAM, Complementary and alternative medicine; UK:
United Kingdom.
Each of the 39 countries has done study of its own
CAM approach [31]. According to the data from
CAMbrella, from 39 countries in the EU, 17 have
general CAM legislation. Out of these 17 countries, 11
have a CAM law and 6 states have parts of CAM
health care law. Some countries have regulated
specific treatments in addition to the general CAM
regulation. CAM regulations and legislation are
generally different for countries that have CAM law
and countries with only specific CAM treatment
regulated. Norway and Hungary have a general CAM
law. However, in Norway CAM law is general and
does not describe the specificity of the treatment itself
and those who practice CAM. Hungary, on the other
hand, also has CAM law, but it can be considered as an
integral part of the health care system [29]. In Table 4
there are the data of CAM legislation in different
countries.
CAM is regulated in Germany since 1939. The
protected title heilpraktiker is used for non-medical
skilled practitioners and only doctors and
heilpraktikers can practice CAM. Hungary has a
clearly defined CAM status. CAM legislation has been
integrated into the public health system and all CAM
providers must be part of the official health system. In
order to practice CAM practice, they must have a
license. In Serbia, CAM has been regulated since 2005
and can only be applied by healthcare professionals,
doctors, dentists, pharmacists and medical staff after
appropriate education. In France, there is no CAM law,
so only lawfully trained staff can treat patients and
only medical-qualified experts practice CAM. The
regulation of the Swiss system is decentralized.
Legislative authority in the cantons is a unicameral
parliament, and each canton has its own individual
regulations. In Malta, only acupuncture, chiropractic,
osteopathy and physiotherapy are regulated [39]. In
some countries, if CAM is applied without a
license/permit, or if an unqualified person is applying,
a fine or imprisonment is enforced. In Belgium, they
shall be fined or suspended and in some cases the
revocation of the CAM license. In Liechtenstein, a fine
or imprisonment of 3 months is imposed on
unqualified practitioners [24].
Prospective
The status of CAM in Europe has its own specificities.
It is characterized by enormous heterogeneity in all
aspects, starting with the terminology, method,
prevalence and ultimately legal status, regulations and
legislation. CAM regulations and legislation are

REVIEW
doi: 10.12032/TMR20190718125
TMR | May 2020 | vol. 5 | no. 3 | 134
expressed differently from country to state and
sometimes there are differences in multiple regions of
the same country. Due to this heterogeneity, access to
CAM research is difficult for the EU [40]. Therefore, it
is important to carry out harmonization, to precisely
define the methods, regulation and legislation of the
CAM. Voluntary harmonization is possible under the
existing legislation. It is important to encourage
countries within culturally similar regions to
harmonize CAM legislation. For example, the status of
a physiotherapist is regulated and recognized
throughout Europe and it is thought that this can be
done for CAM. Physiotherapy has a long tradition as a
recognized profession, with clearly defined attitudes
and the importance and effect of physiotherapy
treatment is described. Successful mutual recognition
of physiotherapists throughout Europe shows how this
can be done [41].
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