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CHAPTER 2 : INDIAN COUNCIL OF MEDICAL RESEARCH

2.1 Regional Medical Research Centre for Tribals, Jabalpur

Highlights

  • The objectives of the Centre, set up to deal with health problems unique to tribals and plan suitable intervention programmes could not be fully achieved due to shortage of funds, scientific manpower and infrastructure.

  • A building to house 50 laboratories and 57 other rooms constructed in 1996 at a cost of Rs 348.45 lakh was yet to be occupied, thereby hampering the proper functioning of several key departments.

(Paragraph 2.1.6)

  • Centre completed only seven out of 11 in-house projects undertaken during 1995-99. It ignored promotion and transfer of effective health care delivery system to existing health infrastructure. It did not address special socio-economic needs of the tribals.

(Paragraph 2.1.7 (a) & (b)

  • Centre had no understanding with State Government for percolation of benefits of research activities to tribals. Impact of its intervention programmes was not assessed.

(Paragraph 2.1.7 (c) & (d)

  • Centre did not document information on herbs used by tribals for treatment of different ailments.

(Paragraph 2.1.8)

  • The existing system of monitoring by ICMR/Scientific Advisory Committee of the working of the Centre was deficient.

(Paragraph 2.1.10)

2.1.1 Introduction

Almost a fourth of the tribal population resides in 46 groups in Madhya Pradesh and as they have distinctive life styles and social roles requiring suitable health intervention programmes, ICMR (Indian Council of Medical Research) established a Regional Medical Research Centre for Tribals (Centre) at Jabalpur in 1984 with a view to investigate their diverse health problems. The main objectives of the Centre were :

  • To plan, conduct and co-ordinate applied research in the areas of community health and nutrition amongst tribals.

  • To develop appropriate models of health and nutrition delivery system to suit the special socio-cultural and economic needs of the tribals.

  • To assist the State Government, not only in the implementation of such programmes but also to monitor and evaluate periodically, the impact of such interventions on the life style of the tribals.

  • To provide orientation and training to the implementing personnel of various departments and agencies concerned with tribal development.

2.1.2 Scope of Audit

The records maintained by the Centre at Jabalpur for the period 1994-99 were test checked with a view to ascertain the extent to which the Centre had achieved its objectives. Related records for the period prior to 1994-95 were also test checked wherever necessary to get a comprehensive picture.

2.1.3 Organisational set-up

Centre is headed by a Director, who in discharge of his duties, is assisted by a Deputy Director and two Assistant Directors. The research activities of the Centre are co-ordinated by a SAC (Scientific Advisory Committee) consisting of Heads of Department, Professors of various disciplines from Medical Colleges, representatives from Directorate of Health Services and Department of Tribal Welfare, Government of Madhya Pradesh, etc. Director General, ICMR is the chairperson of SAC.

2.1.4 Manpower Planning

The position of the sanctioned staff strength of the Centre during 1998-99 and actual deployment under each cadre was as under :

Cadre

Sanctioned

Filled

Vacant

Percentage of vacant posts

Remarks

Scientific

17

11

06

35

7 Posts were lying vacant from 1992-1996 while 6 posts remained vacant from 1996 to 1999

Technical

81

78

03

04

Vacancy position improved from 9 in 1992-93 to 3 in 1998-99

Administrative

47

46

01

02

Vacancy position improved from 4 in 1992-93 to one by 1998-99

Total

145

135

10

   

Despite repeated request, ICMR did not provide adequate scientific manpower

Scientific personnel are primarily engaged in research and application oriented studies. From the above, it is clear that there have been persistent shortages in the scientific cadre. The Centre took up the matter with ICMR, as early as in 1989 and intimated that in the absence of appropriate specialists in the medical field, the studies have been conducted by available social scientists, which has affected the output of medical research. In April 1995, Director of the Centre again intimated the Director General of ICMR about the persistent shortage of staff in the scientific cadre which made it extremely difficult to carry out more than one or two projects in a year, and if there was no change in this situation, the research activities of the Centre would come to a stand still. However, there had been no improvement so far.

Even out of the available 11 scientific officials, one Research Officer in community medicine had not been attending to duties since December 1993. Despite the Director’s request in April 1995 to terminate his service and fill up the vacancy, ICMR had not completed the disciplinary proceedings against him as of October 1999. ICMR stated in October 1999 that an enquiry has been initiated and the report was awaited.

While sufficient number of medical specialists were desirable, out of the 10 scientific officers available, only four belonged to the field of medicine. Of the four MBBS Doctors, one was on study leave from December 1997 onwards.

No Scientists/Research Officers were available in respect of the following Departments from the dates indicated against them. As a result, these departments have not carried out any activity since the dates mentioned in the table below :

Major departments remained non-functional for want of scientists

Name of the Department

Date from which working without scientist

Activity affected

Demography

4 January 1991

Conducting demographic studies on age, sex, fertility and association of the demographic variation with diseases on the tribals

Anthropology

24 January 1991

Conducting socio-cultural aspect of the health care of the tribals, birth related practices, factors affecting accessibility of modern health care, etc.

Microbiology

3 October 1991

Studying the microbiological aspect of the diseases

Immunology

17 January 1994

Studying immune status of individuals, co-relation of diseases with the immune status of individuals, assessing the potency of vaccine for effective implementation of immunisation programme, imparting advanced training for the officials on immunological techniques.

Nutrition

10 July 1995

Conducting detailed analysis and nutritional value of the food taken by the tribals

There was no norm prescribing the relationship between administrative, technical and scientific posts. ICMR stated in October 1999 that it was not feasible to prescribe such norms for various categories of staff on percentage basis in a scientific organisation. Besides, they attributed vacancies in scientific cadre to poor response to advertisements, unsuitability, ban on recruitment etc.

However, the reply has to be viewed in the light that in the absence of scientific posts being operated, it was not clear whether the technical staff was being gainfully utilised. In addition, it was noticed that due to failure of ICMR to fill up scientific posts promptly, two crucial posts related to scientific research, viz. Assistant Director, Genetics and Assistant Director, Microbiology had lapsed.

2.1.5 Financial position

The table below summarises the trend of expenditure under various heads.

(Rs in lakh)

Year

Pay and allowances

Other charges

T.A.

Equipment

Total

Percentage of Pay and allowances to total revenue expenditure

1994-95

57.87 (63.96)

18.90 (31.60)

1.62 (2.20)

9.81 (40.00)

88.20

65.61

1995-96

62.49 (69.93)

20.00 (35.00)

1.52 (2.25)

6.26 (45.00)

90.27

69.22

1996-97

74.31 (75.22)

29.43 (29.80)

1.49 (2.40)

4.57 (25.00)

109.80

67.68

1997-98

103.49 (103.80)

22.79 (84.25)

1.50 (2.30)

1.84 (40.93)

129.62

79.84

1998-99

120.67 (123.19)

28.94 (29.38)

2.40 (2.91)

1.46 (62.00)

153.47

78.63

(Figures in bracket indicate budget demanded)

The above table disclosed the following facts:

Adequate funds for capital expenditure were not provided by ICMR

(i) The percentage of pay and allowances to total revenue expenditure gradually increased from 66 in 1994-95 to 79 in 1998-99. Coupled with this was the fact that during the same period, funds made available by ICMR for the purchase of equipment etc. were far below projected requirements, as shown in table above, thereby resulting in decrease in real terms as far as expenditure on research activity was concerned.

(ii) The expenditure on TA during the period of review varied between Rs 1.62 lakh and Rs 2.40 lakh as against Rs 3.30 lakh in 1991-92. This sharp decline, despite increased cost of travel, indicated that field visits in tribal areas during the past five years were actually reduced hampering research activities, as was evident from the fact that field visits dwindled from 3517 man days in 1994-95 to 584 man days in 1998-99.

2.1.6 Infrastructure facilities

The complex constructed in 1996 at a cost of Rs 348.45 lakh is yet to be taken over

Since the Centre did not have a proper administrative building, housing laboratories etc., various research departments and other facilities were functioning at nearby Jabalpur Medical College building and at the residential quarters of the Centre at Jabalpur. CPWD (Central Public Works Department) completed a building with a floor area of 5152.70 sq. m. (55443 sq. ft.) at a cost of Rs 348.45 lakh with facility to accommodate 50 laboratories and 57 other rooms. However, even after completion of the building in March 1996 the building has not been taken over by the Centre till date. This was due to many lapses in execution by CPWD, which were noted by the Centre, leading to the building being declared structurally weak. Items of work worth Rs 47.96 lakh were found to be far below specification.

In June 1999 Jabalpur Medical College authorities insisted on immediate vacation of the areas occupied by the Centre in the Medical College Building. Absence of proper infrastructure affected several crucial departments. Immunology Department of the Centre, housed in Medical College premises was closed with effect from November 1995 as the Medical College authorities insisted for its vacation. Oral Polio Vaccine Testing Centre functioning in the Centre with effect from April 1991 under the Ministry of Health and Family welfare was wound up in August 1994 due to non-availability of good laboratory.

ICMR stated in October 1999 that since the CPWD did not remove the defects in construction, and replace sub-standard material and as the executive channel for redressal had failed, legal recourse has been resorted to by filing a writ petition in High Court, Jabalpur. Therefore, the building is not likely to be available for functional use in the near future.

Further, the infrastructure created was disproportionate to requirement of the Centre, which had a sanctioned staff strength of 147 only comprising 17 scientists, 81 technical and 47 administrative personnel and some of the departments were non-functional in the absence of necessary scientists.

ICMR stated that the infrastructure has been created keeping in mind the future expansions. Reply has to be viewed in the light of the fact that ICMR has failed to fill up even the sanctioned posts of scientists in the existing departments, and possibility of creating and operating new departments in the future is remote.

2.1.7 Achievement of objectives

(a) Planning and co-ordination of Applied Research

The Centre was established with an objective to plan, conduct and co-ordinate applied research in the areas of community health and nutrition among tribal population. While SAC approved 26 projects to be taken up during 1995-99, the Centre took up only eleven projects of which it completed seven projects (including one taken up before 1995-96) till 31st March 1999. The
discipline-wise details of completed projects was as under :

Sl. No.

Disciplines of research

1994-96

1996-98

1998-99

Total

1.

Community Medicine

01

01

01

03

2.

Genetics

02

-

-

02

3.

Statistics and Demography

-

01

-

01

4

Health Economics

01

-

-

01

 

Total

04

02

01

07

While during the first decade after its setting up, the centre completed 50 projects, it could complete only seven projects during 1994-99. Moreover, the Centre had not completed any studies in areas like Microbiology, Entomology, Anthropology, Immunology and Nutrition during 1994-99.

Even the field visits which were necessary for investigating the magnitude of the health problems of the tribes, their inter-relationship with their socio-cultural habits and for planning suitable intervention programmes for each tribe, had declined drastically as detailed below :

Year

1994-95

1995-96

1996-97

1997-98

1998-99

No. of mandays spent on field visits

3,517

849

976

1,184

584

In February 1987, October 1987 and May 1988, SAC had directed the Centre to concentrate more on problem solving activities, action oriented programmes, diagnosing health needs and problems of the tribal areas, testing out innovative remedies and finally transferring technology to the existing health care infrastructure, rather than carrying on research of academic importance. However, the Centre had transferred only one technology namely “Genetic counselling on prevalence of Haemoglobinopathies” during the period of review.

ICMR attributed in October 1999 the decline in completed projects to the fact that in the initial years there was unlimited scope for studies and these were meant for generating baseline data. Later on, after 1994, more analytical studies were undertaken which required longer time. ICMR further stated that the decline in the number of completed projects and field visits undertaken were due to shortage of scientific manpower, funds, vehicle and a proper laboratory.

(b) Development of appropriate model of health and nutrition delivery system

Centre failed to study weakness in existing health care services and suggest remedies

The Centre did not take up any research work for development of health and nutrition delivery system to suit the special socio-cultural and economic needs of the tribals after 1989. Even prior to 1989, only data collection was done. While sanctioning a project “Monitoring system for Primary Health Centres in tribal districts of Madhya Pradesh”, SAC directed the Centre in August 1990 to probe in detail, the performance of health services in one district with a view to suggest remedial measures if defects were found in implementation. SAC also observed that mere collection of data did not serve any purpose, as the data was already available with State Government. The Centre proposed only in October 1998 to SAC to study the existing health care system in primitive tribes and to develop appropriate model for primitive tribes of Madhya Pradesh.

ICMR attributed (October 1999) shortage of trained staff and a laboratory as reasons for not taking up the study suggested by SAC and was exploring the possibility of providing funds. The fact remained that in 15 years, the Centre, had yet to undertake a meaningful study of the performance of health services.

With regard to development of nutrition delivery system, the Centre had not taken up any studies during 1994-1999. The Nutrition Department had not been conducting any research as no research officers were posted since July 1995. According to ICMR (October 1999), due to absence of Nutrition Delivery Scheme of the State Government, the Centre had not taken up any study. This ignores the fact that developing an appropriate model of nutrition delivery system, and suggesting it to the State Government was a priority area of the Centre.

(c) Assistance to State Government in implementation of programme

Centre has no understanding with State Government for implementation of its recommendations on tribal health

(i) One of the objectives of the Centre is to advise and assist the Government in implementation of tribal health programmes. Even though the Centre was formed in 1984, there is no Understanding with the State Government to ensure effective implementation of programme for the health upliftment of tribals based on the results of Centre’s research. In the absence of such machinery, it is doubtful whether the benefits and objective of the Centre’s research findings percolate to the tribals in real terms. Director of the Centre informed SAC in October 1998 that in the absence of any co-ordination between the Centre and the State Government, the achievements of the Centre were not being utilised by the State Government. On suggestion by Audit in July 1998 that there should be understanding and coordination in this regard, the Centre stated in April 1999 that action had since been initiated for finalising a Memorandum of Understanding with State Government.

However, ICMR stated (October 1999) that a Memorandum of Understanding with State Government was not necessary as the Intersectoral Committee and district level committees set up in 1993, in which the Centre is also a participant, could oversee implementation of the recommendations of the Centre.

(ii) In addition to rendering the assistance to State Government, the Centre was also required to periodically monitor and evaluate the impact of intervention programme initiated by State Government and to study impact of intervention on the life style of the tribals. The Centre did not monitor/evaluate the impact of the programmes. Out of 46 main tribal groups in Madhya Pradesh, the Centre conducted studies only in respect of 10 tribes and 7 primitive tribes during the past fifteen years. The Centre did not revisit any tribal group to see whether its intervention had any impact on their health and morbidity profile. Thus, the achievement of its own objective was not assessed by the Centre so far.

According to ICMR (October 1999), most of the primitive tribes had been studied within ten years, and revisiting them could be planned later as no significant changes could be expected in short period. However, out of 46 tribal groups only 17 were covered and for successful implementation of any programme or ascertaining impact of the programmes periodic appraisal and interaction are essential.

(d) Orientation and Training on tribal development

Centre had no action plan to train officals concerned with tribal development

Even though one of the objectives of the Centre was to provide orientation and training to the implementing personnel of various departments and agencies concerned with the tribal development, the Centre had not chalked out any action plan in this regard. The Centre conducted only one training course in September 1997 in which it trained 55 para-medical staff of the State Government for grass-root level counselling on HIV. While accepting this fact, in October 1999, ICMR attributed the non-realisation of this objective to the lack of facilities like building and staff for full-fledged training programme.

2.1.8 Failure to document knowledge on medicinal plants handed down by generations

Tribal health strategy inter-alia provided for identification of indigenous herbs for medicinal use. A joint meeting of the Regional Medical Research Centres held in June 1995 also directed that the Centre should conduct a study of regional herbs used by tribal people for treatment of different ailments and document valuable knowledge regarding medicinal plants handed down through generations.

Although the Centre considered it an important project and realised the importance of documentation of traditional system of all medicines of tribals, it did not initiate any work in this direction. It submitted the project report on "A study on traditional system of medicines in Tribal Districts of Madhya Pradesh" to SAC for approval in 1998. However, SAC did not approve the project and directed the Centre to re-submit the project after comprehensive study of the literature and re-designing the project. ICMR clarified in October 1999 that the activity was put on hold until the issue of sharing of Intellectual Property rights with tribals was settled, and in view of the fact that proposals were underway to establish a Regional Medical Research Centre at Belgaum to carry out extensive studies related to medicinal plants. The reply is to be viewed in the background of dwindling population of the tribes and the risk that this valuable knowledge could become extinct unless tapped in a time bound programme. The fact also remains that even after recommendation/direction in June 1995, nothing has been done in this regard.

2.1.9 Implementation of Projects

Scrutiny of implementation of some of the projects undertaken revealed the following deficiencies in the achievement of objectives :

(a) Incomplete project

Haemoglobin disorders {The clinical complications formed due to various diseases of haemoglobinopathies e.g. Sickle cell disease and B-thalassaemia}, mainly sickle cell disease {Sickle Cell Disease:- Common complication severe anaemia, joint pain, swelling of bones, gall stones, acute and chronic chest syndrome, jaundice, recurrent infections of common infectious diseases, etc.} and B-thalassaemia {Severe anaemia at young age (from 6 months onwards), iron overload in the vital organs of the body, recurrent infection, extreme weakness. The child is survived only through blood transfusions. Later on, the child has a high risk of developing many/various transfusion related problems.} are common afflictions among the population of Central India. Detailed clinical and haematological profile of sickle cell disease and B-thalassaemia patients in relation to their genetic make up was not known in Indian context. To fill up this gap, SAC in 1992 approved a project “Prevention and Management of Haemoglobinopathies in Central India” at a cost of Rs 74 lakh and attempts were to be made to get the funds from external sources. The project aimed at the establishment of the infrastructure facility for the development of technical knowledge for prenatal diagnosis, prevention and management of
B-thalassaemia and its related disorders. As requisite funds were not forthcoming from the external sources, SAC in 1994 modified the scope of the project and restricted the project to an academic study of "prevalence of B-thalassaemia in Jabalpur area" with the following objectives :

  • To study prevalence rate of B-thalassaemia and other haemoglobinopathic disorders among the various ethnic groups of Jabalpur area.

  • To study the spectrum of B-thalassaemia mutation of Jabalpur.

  • To study the proportion and level of anaemia.

With the reduced scope of the project the cost was also pruned down to Rs 14.25 lakh. The project was scheduled for completion by November 1997.

At the request of the Centre, ICMR extended the duration of the project till October 1998. Even with the restricted scope, the project was not completed as of March 1999 due to in-house delays such as in procurement of equipment required for the project.

ICMR stated in October 1999 that genetic disorder like B-thalassaemia could not be cured and for providing clinical management in sickle cell diseases, a modified project report was prepared and presented to SAC in 1998 and the possibility for funds was being explored. The reply of ICMR indicates low concern for the health care needs of the tribals.

(b) Delay in completion of a project

Project could cover only one out of seven tribes

SAC in August 1996 approved a Project “Epidemiology of Malaria” in Primitive tribes of Madhya Pradesh to study the rate of prevalence of Malaria in Primitive tribes; composition of vector species and their role in transmission and the management of disease. As per the directives of the SAC, the study was to cover at least two primitive tribes every year so that study on all the seven primitive tribes in Madhya Pradesh could be completed in about 3-4 years. Even though, the Centre was to cover 3-4 primitive tribes by March 1999 it covered only one tribal community viz. Bharia having a population of only 1430 till March 1999.

ICMR stated in October 1999 that though the project was to be carried out in collaboration with other centres and these centres could not be involved due to prior commitments, one entomologist of the Centre at Jabalpur was covering one community at a time and fresh efforts were being made to involve field stations of the Malaria Research Centre for expeditious coverage of all tribes. ICMR’s reply underscores failure of the centre to anticipate and provide for such aspects while committing to undertake the project to SAC.

(c) Diversion of study to non-core area

The Centre conceived a project in 1998 to study the impact of genetic counselling of prevalence of hereditary anaemia in Sindhis (Non-tribals) in order to generate awareness among the Sindhis of Jabalpur district and to impart genetic counselling to high risk couples and to evaluate the effect of genetic counselling on prevalence of the disease. The project was not covered under the objectives of the Centre.

ICMR stated that the study was taken up in view of high incidence of B-thalassaemia in Sindhi Community in Jabalpur and the result of this project would be utilised among the tribal population. However, while the project is still underway, there is no evidence that the results obtained so far have been utilised to deal with similar problems among the tribals.

(d) Specific recommendations not made to State Government

Centre made no specific recommendations after completing a study on Economic Aspects of Health Care in tribal areas

A study conducted by the Centre during 1987-1990 on “Economic Aspect of Health care in a tribal area of Madhya Pradesh” disclosed that the health care situation in the tribal community was far from satisfactory and called for steps to improve the economic level of the people, thereby increasing the purchasing power so that they could get proper treatment. While reviewing the study, SAC observed that it was already a known fact that the economic status of the community had a direct bearing on its health-seeking behaviour. SAC, therefore, suggested that the findings of the study should be reviewed with an aim to provide specific recommendation to State Government. However, the Centre did not prepare any such specific recommendation after reviewing the findings of the study.

The Centre stated in April 1999 that Dr. D.K. Mishra, Principal Investigator had not taken the matter seriously in spite of instructions from the Director and hence the Centre could not send concrete recommendation to State Government. However, ICMR reply was silent about action against the Principal Investigator, if any, in this regard.

(e) Delay in the completion of a project for providing safe water free from fluoride

An analysis made by the Centre revealed that the children consuming water from the bore well provided to the Public by State Government in the district of Mandla, Madhya Pradesh were affected by skeletal deformities dental mooting and flourosis, due to higher percentage of fluoride content in the water. As a result of these findings of 1995-96 all the bore-wells were examined/analysed and wells which were contaminated with fluoride were closed down by the State Government.

In view of this finding, Centre conceived a Project for the extensive survey to map out the endemic area in Mandla district for fluorosis with an aim to provide safe drinking water. The SAC approved the Project in August 1996.

Delay in completion denied people a safe and sustained source of drinking water

The first phase of the project “Assessment of the severity and magnitude of the problems of fluorosis” was to be completed within 10 months from the commencement at an estimated cost of Rs 4.24 lakh out of the funds provided under Rajiv Gandhi National Drinking water mission by Ministry of Rural areas and Employment. The second phase of the project “The introduction of intervention programme for safe and sustained source of drinking water provision” was to be undertaken in collaboration with Public Health Engineering Division, State Ground Water Board, Geological Survey of India etc. Release of funds were linked to the progress of the project. First instalment of Rs 1.69 lakh was released in August 1997. The first phase of the project suffered from delays and has not been completed even as of March 1999. The Centre attributed the time overrun in the completion of phase-I of the project to the delay in receipt of second instalment of grant. Delay in release of second instalment was primarily due to failure of the Centre to furnish requisite progress report and utilisation certificate. Further, a perusal of accounts of the project revealed that enough funds were available with Centre as closing balance at various dates. Thus, the implementation of intervention programme for providing safe water to the people could not commence so far denying the people of the affected area a safe and sustained source of drinking water.

2.1.10 Improper Monitoring System

The SAC consisting of eminent scientists is the agency responsible for reviewing the working of the Centre and monitoring the progress of the laboratories. SAC, which approves the projects to be executed by the Centre is required to meet once in a year. However, between 1994-95 and 1998-99, SAC meetings were held only on three occasions viz. February 1995, August 1996 and October 1998, pointing to deficiency in monitoring of ongoing schemes.

2.1.11 Conclusion

It is evident from above that Regional Medical Research Centre for Tribals, Jabalpur, has been plagued by persistent deficiencies, viz. paucity of funds, dearth of scientific manpower and shortage of infrastructure. Ironically, the massive complex constructed to house all departments/laboratories, is unlikely to be used in near future due to legal wrangles. These constraints have seriously hampered research activities of the Centre and affected the functioning of its several departments, some of which are non-functional for nearly five to ten years, in the absence of scientists and research officers. Despite being aware of all this, ICMR has demonstrated nothing on its part to address any of the issues. In this background there is a serious need to review the continued functioning of the Centre.