dr. vinay gupta : rbsk can be made much better

8/9/2019 DR. VINAY GUPTA : RBSK CAN BE MADE MUCH BETTER

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R.B.S.K: A Multi-Crore Mission An Introduction

and How we can Make it Better

Vinay Gupta

Medical Officer (Dental), District Early Intervention Centre, (Rashtriya Bal Swasthya Karyakram),

Kaithal, Haryana, IndiaEmail:[email protected]

Abstract: Rashtriya Bal Swasthya Karyakram (RBSK) is a new initiative by National Rural Health Mission(NRHM) aimed at screening over 27 crore children from 0 to 18 years for 4 Ds - Defects at birth, Diseases,

Deficiencies and Development Delays including Disabilities. Children diagnosed with illnesses will receive

follow up including surgeries at tertiary level, free of cost under NRHM. The task is gigantic but quite possible,

through the systematic approach that RBSK envisages. Implemented in right earnest, it would yield rich

dividends in protecting and promoting the health of our children.

Keywords: M.H.T, Screening, DEIC, RBSK, 4-Ds, Defects, Diseases, Deficiencies, Development Delays,Anganwadis, Schools, Dental Diseases, Referral, Diagnosis, Treatment.

Accepted On: 23.10.2014

1. Introduction

The Ministry of Health & Family Welfare under

the National Rural Health Mission has launchedthe Child Health Screening and Early

Intervention Services, a systemic approach of

early identification and link to care, support and

treatment to meet these challenges. It is

estimated that about 270 million children (Table1) including the new-born and those attending

Anganwadi Centres and Government schools

will be benefitted through this programme.

Table 1. Target Group For RBSK

1.1 Magnitude of Birth Defects, Deficiencies,

Diseases, Developmental Delays and Disabilities

In Children

1.1.1 Defects at Birth

Globally, about 7.9 million children are bornannually with a serious birth defect of genetic or

partially genetic origin which accounts for 6 per

cent of the total births. Serious birth defects canbe fatal at times. For those who do not receive

specific and timely intervention and yet survive,

these disorders can cause irreversible life-long

mental, physical, auditory or visual disability.Atleast 3.3 million children under five years of

age die from birth defects every year and

another 3.2million of those who survive may bedisabled for life. More than 90 per cent of all

infants with a serious birth defect are born in


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low and middle income countries. Cutting acrosscountries and their economic status, 64.3 infants

per thousand live births are born annually withbirth defects. Of these, 7.9 have cardiovascular

defects, 4.7 have neural tube defects and 1.2have some form of hemoglobinopathy, 1.6 have

Downs Syndrome and 2.4 have G6PD

deficiency [2] (All figures are in per thousand).With a large birth cohort of almost 26 million

per year, India would account for the largest

share of birth defects in the world [1]. This

would translate to an estimated 1.7 millionbabies born with birth defects annually.[1] In the

study conducted by National NeonatologyForum, congenital malformations were the

second commonest cause (9.9%) of mortality

among stillbirths and the fourth commonest

cause (9.6%) of neonatal mortality and thataccounted for 4 per cent of under-five mortality.

Preliminary reports of metabolic studies fromfive zonal centres covering 5 lakh new-borns has

revealed an incidence of congenitalhypothyroidism of 1 in 1000 live births[2].

Messages emerging from this study connote that

diagnosis is often delayed due to lack ofawareness among the professionals and

ignorance about the technical expertise requiredto handle such cases of birth defects.

A similar prevalence rate of 1 in 1000 was

reported for Downs syndrome in India [1].There are several reports of the incidence of beta

thalassemia trait from different parts of the

country which varies from less than 1 per cent toas high as 17 percent [2] making it imperative to

have a policy on universal screening in selectedgeography and population groups.

1.1.2 DeficienciesEvidence suggests that almost half of children

under age five years (48%) are chronicallymalnourished [2]. In numbers it would mean that

more than 47 million children under five yearsare stunted, 43 per cent of children under age

five years are underweight for their age andabout 20per cent of children younger than five

years of age are wasted. Over 6 per cent ofchildren less than five years of age suffer from

Severe Acute Malnutrition (SAM). However,recent survey conducted in 100 worst affected

districts showed SAM prevalence of 3 per centin children less than five years of age. Anaemia

prevalence has been reported as high as 70 per

cent amongst under five children largely due toiron deficiency. The situation has virtually

remained unchanged over the past decade.

During pre-school years, children continue to

suffer from adverse effects of anaemia,malnutrition and developmental disabilities,

which ultimately also impact their performancein the school.

1.1.3 Diseases

As reported in different surveys, the prevalenceof dental caries varies between 50-60 per cent

among Indian school children. Rheumatic heartdisease is reported at 1.5 per thousand among

school children in the age group of 5-9 years and0.13 to 1.1 per thousand among 10-14 years. The

median prevalence of reactive air way disease

including asthma among children is reported tobe4.75 per cent.

1.1.4 Developmental Delays and Disabilities

Globally, 200 million children do not reach their

developmental potential in the first five yearsbecause of poverty, poor health, nutrition and

lack of early stimulation. The prevalence of

early childhood stunting and the number ofpeople living in absolute poverty could be used

as proxy indicators of poor development inunder five children. Both of these indicators are

closely associated with poor cognitive and

educational performance in children and failureto reach optimum developmental potential [1].

Further, Special New-born Care Units (SNCU)Technical Reports have reported that

approximate 20 per cent of babies dischargedfrom health facilities are found to suffer from

developmental delays or disabilities at a laterage [2].


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Table. 2 Health Conditions Covered Under RBSK

1.2 Mobile Health TeamsEach Mobile Health Team constitutes TwoAyush Medical Officers (each male and female)

, One Pharmacist and One ANM. The numbers

of teams depend upon the size of the District and

according to the target screening population ofthe rural areas. In some areas Urban Teams arealso deployed to cover the government schools

and Anganwadis in urban area of district. Thesemobile health teams screen every child

meticulously, from height to weight, bloodpressure, eyesight etc. Each student is given aunique ID which is quoted in all the future

correspondences among the RBSK staff and forfurther follow up of the child. All the studentsare given screening cards cum referral card on

which their unique ID, name, parents name,

age, class in which they study, their vitalparameters are written by Pharmacists. Online

entries are also done in the software of NRHM

website, means each and every students name,

age, school, height, weight, etc. CUG (Closed

User Group) numbers are given to everymember of Mobile Health Teams to

communicate with each other free of cost and to

take follow up. Teams screen all the children for

Different Health Conditions (Table 2) up to 6years of age registered with the AnganwadiCentres and all children enrolled in Government

and Government aided schools. In order tofacilitate implementation of the health screening

process, vehicles are hired for movement of theteams to Anganwadi Centres, Government andGovernment aided schools. A tool kit (Table 3)

with essential equipment for screening ofchildren is also be provided to the Mobile HealthTeam members. Some students are given

medicines on the spot by Ayush Doctors like

Albendazole tablets, Iron folic acid tablets,analgesics etc. Children and students

presumptively diagnosed to have a disease/

deficiency/disability/ defect and who require

confirmatory tests or further examination are


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referred to the nearest PHC (Primary HealthCentres) or CHC (Community Health Centres)

(Table 4) , D.E.I.C (District Early Intervention

Centres) or to the designated tertiary level publicsector health facilities through the DEICs.

Table 3. Tools Provided to Mobile Health Teams

Table 4. Referral Process for Different Health Conditions

1.3 District Early Intervention Center (DEIC)An Early Intervention Centre is established at

the District Hospital. The purpose ofEarlyIntervention Centre is to provide referral

support to children detected with health

conditionsduring health screening. A teamconsisting of Paediatrician, Medical officer,

Dentist, Staff Nurses, Paramedics, etc.(Table 5)

are engaged to provide services. There is also aprogramme managerwho carries out mapping of

tertiary care facilities in Government institutions

for ensuringadequate referral support.


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Table 5. Composition of Staff in DEIC

The DEIC team promptly responds (Table 6) to

and manage all issues related to developmentaldelays, Hearing defects, vision impairment,

neuro-motor disorders, speech and languagedelay, autism and cognitive impairment. Beside

this, the team at DEICs are involved in new-born

screening at the District level. This Centre hasthe basic facilities to conduct tests for hearing,

vision, neurological tests and behavioural

assessment. Once a referred patient comes toDEIC, Data Entry Operator at DEIC makes and

entry of students/childs unique ID and send her

to the respective Staff for which he/she has been

referred. Every staff member has his own entryregister in which against the entry of the child,

his final diagnosis, treatment plan and treatmentgiven to the child is recorded. A status to this

child is allotted (either treated or Under

treatment) the under treatment children arecontacted and called for further follow ups.

Some Patients can be treated at the DEIC level,

but some need to be referred to higher institutesfor tertiary level treatments (Fig.1.), mostly

surgeries.

Table 6. Goals of DEIC


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Fig. 1. Flow Chart of Referral SystemObviously its a wonderful programme with a

huge mission to achieve, we have to have makeextra efforts and make some of the changes and

additions to this programme to make it asuccessful edition of the National Rural Health

Mission.

2.

How Can we Make R.B.S.K.

Better

2.1 By Changing the Objective Diseases and

Format of ReportingThe present format contains only 29 or 30diseases and also the diagnosis cannot be made

on the spot my Mobile Health Team, because apain in ear cannot be said Otitis Media on the

spot. Also there are vast numbers of diseaseswhich also need to be included in the screening

format. The formats for the DEIC and mobilehealth teams need to be changed, instead going

into complications of males females columns,

age group columns, the main objective should behow many total are diseased and referred to

DEIC and how many of them are treated or

under-treatment. The format of the mobile healthteam should be in the form of organ systems,

like we have in physiology and medicine

subjects. There should be a list of organs

systems, like if any child complains of weakeyesight the disease should be noted as

provisional diagnosis in the neurosensorysystem. Later on the disease should be

diagnosed in the DEIC. This will help in

thorough screening of childrens organ systems

and full body and will simplify the procedureand chief complaint of the child can be moreproperly understood and a final diagnosis is

reached. The reporting format of DEIC shouldbe disease wise because here the final diagnosis

is made. In the above example the disease willcome as refractive error. I cite you a loophole in

the present format of reporting. There is a pointin format Dental Conditions or Dental Diseases.

This point slips the other oral health problems.

The child is only screened for dental caries. Achild with fluorosis is referred to the DEIC

because the MHTs cant properly diagnose and

differentiate between extrinsic and intrinsicstains of teeth, in a normal child with erupting

teeth they may diagnose as malocclusion, a

proper orientation and training in this regardshould be made. These cases are false positives

and only create hindrance in detecting andfollowing up the true positives. The column

name can be changed to Oro-Dental System,so


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that the screening can be done much betterbecause the chief complaint will be much better

addressed. Most important is, in present systemchild is screened physically by the mobile health

teams, many serious diseases which are bloodborne and students may be carrier of such

diseases goes undetected, like Hepatitis B and C,

HIV, typhoid etc. A blood sample collectionarrangement should also be made in the Mobile

Health Team, a lab technician post can be

created in MHT.

2.2 Monitoring OF MHT

There should be regular monitoring of MobileHealth Teams on weekly or daily basis, to check

whether they are screening children and students

properly according to the guidelines. In some

states G.P.S is fitted in the vehicles of MobileHealth Teams to track their locations. But

besides location there are other things too to bemonitored. The monitoring is not an easy task;

every time state headquarters cant make a vigilon the working of field. The DEIC staff should

be engaged in this. Members of DEIC turn by

turn can randomly check any mobile health teamabout their punctuality, presence and screening

procedure and should report to the Manager orCivil Surgeon of the District.

2.3 Take Private Medical and Dental Colleges

on Panel of RBSK

Our government hospitals and Government

institutes already remain packed with patients,but our goal is to treat every child with care and

on first preference basis. We have large numberof private medical and dental colleges, in which

under the supervision of expert staff medical and

dental students provide treatment to the publicand too at very low cost or sometimes free of

cost. In the present system suppose a child hasfluorosis, the treatment is capping of teeth. But

in RBSK now we dont arrange the cosmetictreatment for the patient, but if we will take the

private dental colleges on the panel the child canbe referred there and treatment can be done

without any charges or minimal charges. Thetreatment in these colleges is done by students

under supervision of the senior professors. Thesame can be done in the case of medical

treatments. The child can be referred to nearby

empaneled private medical colleges for smallerand prosthetic treatments.

2.4Screening of Children in Slums

There are many children who are in slums whoeither dont go the school or anganwadi, a

special Mobile Health Team should be createdfor such children in every district, or monthly or

weekly duties can be assigned for screening ofsuch children. There is a column in reporting

format labelled as self, such children can be

screened and treated under this column.

2.5 Softwares should be Designed for Easy

Reporting

The register system should totally be discarded.

Because a lot of manpower and time is wasted inmanaging registers. There should be special

softwares designed for on the spot entry of thescreened children that operate without internet

connection. Because 3G internet connection ornetwork is not everywhere, also it will cut off

the expense that comes on the individual internet

connections given to the Mobile Health Teams.Entries can be made easily in the specially

designed softwares and later on after weeks end

or months end the software can be connected tointernet in DEIC by all teams that automatically

uploads all the data to the internet without

manual entries. Digital Thumb Impressionshould be taken on the spot and should be saved

in the software so that tracking of child can beeasily done because the students class change

from year to year, time wasted in searching thechilds card will be saved also the fake entries if

any can be prevented, also it will be ensured that

same child is receiving the treatment at DEIC orTertiary Centres who is screened in field. See

we have to make work more clinical not clerical.The whole reporting should be revised and made

more efficient.

2.6 M.H.T should have More Powers

There are reports that the Anganwadis andschool staff does not co-operate well with the

mobile health teams. Strength of the students inschool may differ as routine, but it must be full

or near full on the day of screening of Mobile

Health Team. Teachers or Principal should be

made responsible for this and to provide fulltechnical and other support to the Mobile Health

Teams. These kind of problems can be solved bygiving MHT more teeth by giving them

feedback form for the behaviour and co-

operation of school and anganwadi staff, thatshould be directly reportable to the District

Commissioner. Also the MHT are going in each

and every school and anganwadi of India, Its a

brilliant chance to inspect these for the basic


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infrastructure and basic facilities that directlyrelates to the childrens health, like toilets,

drinking water facility, first aid boxes etc. andthey can also be used to take a vigil on the other

school health programmes like Weekly IronFolic Acid Supplement (WIFS) etc.

2.7 More and More on the Spot TreatmentsWe cannot wait for every detected screened

child to come to DEIC and receive treatment,

because there are many factors associated with

it. The students we screen in the governmentschools are so poor to bear travel expenses to the

DEIC, parents of children are daily wagers whocannot miss a single day of their work as they

earn their daily bread from it, we have to bridge

up that gap. On the spot treatments by DEIC

staff should be made available on monthly basis,like organising DEIC camp in the area where

most number of diseased children is found.Mobile dental van should be deployed in every

district, the mobile dental vans from nearestdental colleges can be hired on weekly or

monthly basis, because on the spot dental

treatment for dental patients is nearly impossiblewithout proper setup. And number of dental

patients is highest among screened children.Roadways buses can be hired to transport

students from their areas to DEIC. Students who

can be treated in a single visit and could not beartravel expenses can be filtered out and they

should be taken to DEIC.

2.8 Taking Parents and Guardians into

Confidence and Provision of Consent FormIn the dealing with the diseases and treatment of

children and students, we cannot surpass

parents, because they know better about withwhich problem their ward is suffering from, also

they must be taken into confidence before doingany treatment of their child. There should be a

provision of consent form on which parents andguardians must sign before rendering any

treatment specially surgical treatment, suppose achild arrives in the clinical setup and needs

dental extraction, we must take childs parentinto confidence and their guardians before

proceeding, sometimes child comes with sibling,or relatives or teacher, in that case the surgical

treatment should be put on hold, if no

emergency and proper follow up of that childshould be taken.

2.9 Incentives to Mobile Health Teams

and DEIC Staff

Mobile Health Teams are backbone of thisprogramme, to increase their efficiency, there

should be special incentives for teams which areperforming outstandingly. This will help

pumping confidence in them, because we needextraordinary efforts to make our mission

accomplished, this can only be done if give

credit is given to persons who are really workingtowards this mission from their body and soul.

Likewise for the DEIC staff special incentives

should be granted, who work efficiently. If we

can sanction lakhs to a referred child for his / heroperation, cant we give incentives to those who

are making this programme to function and asuccess.

3. Future of R.B.S.K.

India, a country where implementation of a

programme at a level of billion populationsbecomes a mission, and we have seen many

missions that are completed and targets havebeen achieved. Best to mention is Pulse PolioProgramme. Although the RBSK is in its

budding stage and it needs un tired efforts tomake it a successful carnival, but if grown fully

it will not stop to the boundaries of Anganwadisand Government schools, but its reach would be

widened to private schools and colleges, because

future not only lies in the toddlers and schoolgoing children, but also in the youthful

generation that is being nurtured in the colleges

and private schools and healthy life is after alltheir right too.

4.

Conclusion

Needless to say, those dividends of earlyintervention would be huge includingimprovement of survival outcome, reduction of

malnutrition prevalence, enhancement of

cognitive development and educational

attainment and overall improvement of qualityof life of our citizens. Bringing down both out of

pocket expenses on belated treatment of diseases

/ disabilities (many of which become highlydebilitating and incurable) and avoidable

pressure on health system on account of theirmanagement are among obvious benefits.

Additionally, the Child Health Screening and

Early Intervention Services will also providecountry-wide epidemiological data on the 4 Ds

(i.e., Defects at birth, Diseases, Deficiencies andDevelopmental Delays including Disabilities).


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Such a data is expected to hold relevance forfuture planning of area specific services.

References:

[1]

Ministry of Health and Family Welfare,

Government of India. Operational

Guidelines: Rashtriya Bal SwasthyaKaryakram. Page5 . National Rural Health

Mission : New Delhi. 2013. Print.

[2] Ministry of Health and Family Welfare,

Government of India. OperationalGuidelines: Rashtriya Bal Swasthya

Karyakram. Page - 6. National Rural HealthMission: New Delhi. 2013. Print.

dr. vinay gupta : rbsk can be made much better

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