rbsk : rashtriya bal swasthya karyakram : dr. vinay gupta medical officer dental deic kaithal

International Journal of Pharmacy, Biology and Medical Sciences Vol. 3. No. 2. ISSN 2319 -3026 (July-Dec 2014)

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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, India

Email: [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 launched

the 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 (Table

1) 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 born

annually with a serious birth defect of genetic or

partially genetic origin which accounts for 6 per

cent of the total births. Serious birth defects can

be 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 be

disabled 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 across

countries and their economic status, 64.3 infants

per thousand live births are born annually with

birth defects. Of these, 7.9 have cardiovascular

defects, 4.7 have neural tube defects and 1.2

have some form of hemoglobinopathy, 1.6 have

Down’s 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 million

babies born with birth defects annually.[1] In the

study conducted by National Neonatology

Forum, congenital malformations were the

second commonest cause (9.9%) of mortality

among stillbirths and the fourth commonest

cause (9.6%) of neonatal mortality and that

accounted for 4 per cent of under-five mortality.

Preliminary reports of metabolic studies from

five zonal centres covering 5 lakh new-borns has

revealed an incidence of congenital

hypothyroidism of 1 in 1000 live births[2].

Messages emerging from this study connote that

diagnosis is often delayed due to lack of

awareness among the professionals and

ignorance about the technical expertise required

to handle such cases of birth defects.

A similar prevalence rate of 1 in 1000 was

reported for Down’s 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 to

as high as 17 percent [2] making it imperative to

have a policy on universal screening in selected

geography and population groups.

1.1.2 Deficiencies Evidence suggests that almost half of children

under age five years (48%) are chronically

malnourished [2]. In numbers it would mean that

more than 47 million children under five years

are stunted, 43 per cent of children under age

five years are underweight for their age and

about 20per cent of children younger than five

years of age are wasted. Over 6 per cent of

children 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 cent

in children less than five years of age. Anaemia

prevalence has been reported as high as 70 per

cent amongst under five children largely due to

iron 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 performance

in the school.

1.1.3 Diseases As reported in different surveys, the prevalence

of dental caries varies between 50-60 per cent

among Indian school children. Rheumatic heart

disease is reported at 1.5 per thousand among

school children in the age group of 5-9 years and

0.13 to 1.1 per thousand among 10-14 years. The

median prevalence of reactive air way disease

including asthma among children is reported to

be4.75 per cent.

1.1.4 Developmental Delays and Disabilities Globally, 200 million children do not reach their

developmental potential in the first five years

because of poverty, poor health, nutrition and

lack of early stimulation. The prevalence of

early childhood stunting and the number of

people living in absolute poverty could be used

as proxy indicators of poor development in

under five children. Both of these indicators are

closely associated with poor cognitive and

educational performance in children and failure

to reach optimum developmental potential [1].

Further, Special New-born Care Units (SNCU)

Technical Reports have reported that

approximate 20 per cent of babies discharged

from health facilities are found to suffer from

developmental delays or disabilities at a later

age [2].


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Table. 2 Health Conditions Covered Under RBSK

1.2 Mobile Health Teams Each Mobile Health Team constitutes Two

Ayush 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 of

the rural areas. In some areas Urban Teams are

also deployed to cover the government schools

and Anganwadis in urban area of district. These

mobile health teams screen every child

meticulously, from height to weight, blood

pressure, eyesight etc. Each student is given a

unique ID which is quoted in all the future

correspondences among the RBSK staff and for

further follow up of the child. All the students

are given screening cards cum referral card on

which their unique ID, name, parent’s name,

age, class in which they study, their vital

parameters are written by Pharmacists. Online

entries are also done in the software of NRHM

website, means each and every student’s name,

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

User Group) numbers are given to every

member 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 6

years of age registered with the Anganwadi

Centres and all children enrolled in Government

and Government aided schools. In order to

facilitate implementation of the health screening

process, vehicles are hired for movement of the

teams to Anganwadi Centres, Government and

Government aided schools. A tool kit (Table 3)

with essential equipment for screening of

children is also be provided to the Mobile Health

Team 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 Health

Centres) or CHC (Community Health Centres)

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

Centres) or to the designated tertiary level public

sector 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 of

EarlyIntervention Centre is to provide referral

support to children detected with health

conditionsduring health screening. A team

consisting of Paediatrician, Medical officer,

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

are engaged to provide services. There is also a

programme 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 developmental

delays, Hearing defects, vision impairment,

neuro-motor disorders, speech and language

delay, autism and cognitive impairment. Beside

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

screening at the District level. This Centre has

the basic facilities to conduct tests for hearing,

vision, neurological tests and behavioural

assessment. Once a referred patient comes to

DEIC, Data Entry Operator at DEIC makes and

entry of student’s/child’s unique ID and send her

to the respective Staff for which he/she has been

referred. Every staff member has his own entry

register in which against the entry of the child,

his final diagnosis, treatment plan and treatment

given to the child is recorded. A status to this

child is allotted (either treated or Under

treatment) the under treatment children are

contacted and called for further follow ups.

Some Patients can be treated at the DEIC level,

but some need to be referred to higher institutes

for tertiary level treatments (Fig.1.), mostly

surgeries.

Table 6. Goals of DEIC


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Fig. 1. Flow Chart of Referral System

Obviously it’s a wonderful programme with a

huge mission to achieve, we have to have make

extra efforts and make some of the changes and

additions to this programme to make it a

successful 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 Reporting The present format contains only 29 or 30

diseases and also the diagnosis cannot be made

on the spot my Mobile Health Team, because a

pain in ear cannot be said Otitis Media on the

spot. Also there are vast numbers of diseases

which also need to be included in the screening

format. The formats for the DEIC and mobile

health teams need to be changed, instead going

into complications of males females columns,

age group columns, the main objective should be

how many total are diseased and referred to

DEIC and how many of them are treated or

under-treatment. The format of the mobile health

team 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 weak

eyesight the disease should be noted as

provisional diagnosis in the neurosensory

system. Later on the disease should be

diagnosed in the DEIC. This will help in

thorough screening of children’s organ systems

and full body and will simplify the procedure

and chief complaint of the child can be more

properly understood and a final diagnosis is

reached. The reporting format of DEIC should

be disease wise because here the final diagnosis

is made. In the above example the disease will

come as refractive error. I cite you a loophole in

the present format of reporting. There is a point

in format Dental Conditions or Dental Diseases.

This point slips the other oral health problems.

The child is only screened for dental caries. A

child with fluorosis is referred to the DEIC

because the MHTs cant properly diagnose and

differentiate between extrinsic and intrinsic

stains of teeth, in a normal child with erupting

teeth they may diagnose as malocclusion, a

proper orientation and training in this regard

should be made. These cases are false positives

and only create hindrance in detecting and

following 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 better

because the chief complaint will be much better

addressed. Most important is, in present system

child is screened physically by the mobile health

teams, many serious diseases which are blood

borne and students may be carrier of such

diseases goes undetected, like Hepatitis B and C,

HIV, typhoid etc. A blood sample collection

arrangement 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 Mobile

Health 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 Mobile

Health Teams to track their locations. But

besides location there are other things too to be

monitored. The monitoring is not an easy task;

every time state headquarters can’t make a vigil

on the working of field. The DEIC staff should

be engaged in this. Members of DEIC turn by

turn can randomly check any mobile health team

about their punctuality, presence and screening

procedure and should report to the Manager or

Civil 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 number

of private medical and dental colleges, in which

under the supervision of expert staff medical and

dental students provide treatment to the public

and too at very low cost or sometimes free of

cost. In the present system suppose a child has

fluorosis, the treatment is capping of teeth. But

in RBSK now we don’t arrange the cosmetic

treatment for the patient, but if we will take the

private dental colleges on the panel the child can

be referred there and treatment can be done

without any charges or minimal charges. The

treatment in these colleges is done by students

under supervision of the senior professors. The

same can be done in the case of medical

treatments. The child can be referred to nearby

empaneled private medical colleges for smaller

and prosthetic treatments.

2.4 Screening of Children in Slums

There are many children who are in slums who

either don’t go the school or anganwadi, a

special Mobile Health Team should be created

for such children in every district, or monthly or

weekly duties can be assigned for screening of

such children. There is a column in reporting

format labelled as ‘self’, such children can be

screened and treated under this column.

2.5 Software’s should be Designed for Easy

Reporting

The register system should totally be discarded.

Because a lot of manpower and time is wasted in

managing registers. There should be special

softwares designed for on the spot entry of the

screened children that operate without internet

connection. Because 3G internet connection or

network 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 week’s end

or month’s end the software can be connected to

internet in DEIC by all teams that automatically

uploads all the data to the internet without

manual entries. Digital Thumb Impression

should be taken on the spot and should be saved

in the software so that tracking of child can be

easily done because the students’ class change

from year to year, time wasted in searching the

child’s 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 or

Tertiary 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 and

school staff does not co-operate well with the

mobile health teams. Strength of the students in

school 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 full

technical and other support to the Mobile Health

Teams. These kind of problems can be solved by

giving MHT more teeth by giving them

feedback form for the behaviour and co-

operation of school and anganwadi staff, that

should be directly reportable to the District

Commissioner. Also the MHT are going in each

and every school and anganwadi of India, It’s a

brilliant chance to inspect these for the basic


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infrastructure and basic facilities that directly

relates to the children’s health, like toilets,

drinking water facility, first aid boxes etc. and

they can also be used to take a vigil on the other

school health programmes like Weekly Iron

Folic Acid Supplement (WIFS) etc.

2.7 More and More on the Spot Treatments We 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 government

schools are so poor to bear travel expenses to the

DEIC, parents of children are daily wagers who

cannot 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 nearest

dental colleges can be hired on weekly or

monthly basis, because on the spot dental

treatment for dental patients is nearly impossible

without 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 bear

travel expenses can be filtered out and they

should be taken to DEIC.

2.8 Taking Parents and Guardians into

Confidence and Provision of Consent Form In the dealing with the diseases and treatment of

children and students, we cannot surpass

parents, because they know better about with

which problem their ward is suffering from, also

they must be taken into confidence before doing

any treatment of their child. There should be a

provision of consent form on which parents and

guardians must sign before rendering any

treatment specially surgical treatment, suppose a

child arrives in the clinical setup and needs

dental extraction, we must take child’s parent

into 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 child

should be taken.

2.9 Incentives to Mobile Health Teams

and DEIC Staff

Mobile Health Teams are backbone of this

programme, to increase their efficiency, there

should be special incentives for teams which are

performing outstandingly. This will help

pumping confidence in them, because we need

extraordinary efforts to make our mission

accomplished, this can only be done if give

credit is given to persons who are really working

towards 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 / her

operation, can’t we give incentives to those who

are making this programme to function and a

success.

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

India, a country where implementation of a

programme at a level of billion populations

becomes a mission, and we have seen many

missions that are completed and targets have

been achieved. Best to mention is Pulse Polio

Programme. Although the RBSK is in its

budding stage and it needs un tired efforts to

make it a successful carnival, but if grown fully

it will not stop to the boundaries of Anganwadis

and Government schools, but its reach would be

widened to private schools and colleges, because

future not only lies in the toddlers and school

going children, but also in the youthful

generation that is being nurtured in the colleges

and private schools and healthy life is after all

their right too.

4. Conclusion

Needless to say, those dividends of early

intervention would be huge including

improvement of survival outcome, reduction of

malnutrition prevalence, enhancement of

cognitive development and educational

attainment and overall improvement of quality

of life of our citizens. Bringing down both out of

pocket expenses on belated treatment of diseases

/ disabilities (many of which become highly

debilitating and incurable) and avoidable

pressure on health system on account of their

management are among obvious benefits.

Additionally, the Child Health Screening and

Early Intervention Services will also provide

country-wide epidemiological data on the 4 Ds

(i.e., Defects at birth, Diseases, Deficiencies and

Developmental Delays including Disabilities).


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Such a data is expected to hold relevance for

future planning of area specific services.

References:

[1] Ministry of Health and Family Welfare,

Government of India. Operational

Guidelines: Rashtriya Bal Swasthya

Karyakram. Page–5 . National Rural Health

Mission : New Delhi. 2013. Print.

[2] Ministry of Health and Family Welfare,

Government of India. Operational

Guidelines: Rashtriya Bal Swasthya

Karyakram. Page - 6. National Rural Health

Mission: New Delhi. 2013. Print.

rbsk : rashtriya bal swasthya karyakram : dr. vinay gupta medical officer dental deic kaithal

Health & Medicine

serious birth defects

magnitude of birth defects

ds defects

largest share of birth

cardiovascular defects

crore children

children table

neural tube defects