Rashtriya Bal Swasthya Karyakram
(RBSK)
(Child Health Screening and
Early Intervention Services under NRHM)
In a vast country like
India, the need for ensuring a healthy and dynamic future for a large populace
and creating a developed society, agile and able to compete with the rest of
the world, is of paramount importance. The dream of such a healthy and developed
society can be achieved through concerted efforts and initiatives undertaken in
a systematic manner at all levels. Equitable child health, care and early
detection and treatment can be the most pragmatic initiative, or rather
solution, at this juncture!
The ‘Child Health
Screening and Early Intervention Services’ Programme under National Rural
Health Mission initiated by the Ministry of Health and Family Welfare,
therefore, aims at early detection and management of the 4Ds prevalent in
children. These are Defects at Birth, Diseases in Children, Deficiency
conditions and Developmental Delays including Disabilities.
Health screening of
children is a known intervention under the School Health Programme. It is now
being expanded to cover all children from birth to 18 years of age. The
Programme has been initiated as significant progress has already been made in
reducing child mortality under the National Rural Health Mission. However,
further gains can be achieved by early detection and management of conditions
in all age groups.
Out of every 100 babies
born in this country annually, 6 to 7 have a birth defect. In Indian context,
this would translate to 1.7 million birth defects annually and would account
for 9.6 per cent of all newborn deaths. Various nutritional deficiencies are
affecting the preschool children range from 4 percent to 70 percent.
Developmental delays are common in early childhood affecting at least 10
percent of the children. These delays, if not intervened timely, may lead to
permanent disabilities with regard to cognition, hearing and vision.
There are also groups of
diseases which are very common in children e.g., dental caries, otitis media,
rheumatic heart disease and reactive airways diseases which can be cured if
detected early. It is understood that early intervention and management can
prevent these conditions to progress into more severe and debilitating forms,
thereby reducing hospitalisation and resulting in improved school attendance.
The ‘Child Health
Screening and Early Intervention Services’ will also translate into economic
benefits in the long run. Timely intervention would not only halt the
condition to deteriorate but would also reduce the out-of-pocket (OOP)
expenditure of the poor and the marginalised population in the country.
Additionally, the Child Health Screening and Early Intervention Services will
also provide country-wide epidemiological data on the 4 Ds. Such a data is
expected to hold relevance for future planning of area specific services.
Target Group
The services aim to
cover all children of 0-6 years of age group in rural areas and urban slums, in
addition to older children up to 18 years of age enrolled in classes 1st to
12th in Government and Government-aided schools. It is expected that these
services will reach and benefit about 27 Crore children in a phased manner.
Magnitude of Birth
Defects, Deficiencies, Diseases, Developmental Delays and Disabilities in
Children
Defects at Birth
With a large birth
cohort of almost 26 million per year, India would account for the largest share
of birth defects in the world. This would translate to an estimated 1.7 million
babies born with birth defects annually. 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.
Deficiencies
Evidence suggests that
almost half of children under age five years (48%) are chronically
malnourished. In numbers it would mean that more than 47 million children under
five years are stunted, 43 percent of children under five years are
underweight for their age and about 20 percent of children younger than five
years of age are wasted. Over 6 percent 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 percent in
children less than five years of age. Anaemia prevalence has been reported as
high as 70 percent 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.
Diseases
As reported in different
surveys, the prevalence of dental caries varies between 50-60 percent 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 be 4.75 percent.
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.
Health Conditions
Identified for Screening
Child Health Screening
and Early Intervention Services under NRHM envisage to cover 30 identified
health conditions for early detection and free treatment and management. Based
on the high prevalence of diseases like hypothyroidism, sickle cell anaemia and
beta thalassemia in certain geographical pockets of some States/UTs, and
availability of testing and specialized support facilities, these States and
UTs may incorporate them as part of this initiative.
Implementation
Mechanisms
The Operational
Guidelines outline the following mechanism to reach all the target groups of children
for health screening
For new born Facility-based
newborn screening at public health facilities, by existing health manpower
& Community based newborn screening at home through ASHAs for newborn till
6 weeks of age during home visitation.
For children 6 weeks to
6 years Anganwadi Center based screening by the dedicated
Mobile Health Teams
For children 6 years to
18 years Government
and Government aided school based screening by dedicated Mobile Health Teams.
Facility based newborn
screening This includes screening of birth defects in institutional
deliveries at public health facilities, especially at the designated delivery
points by ANMs, Medical Officers/ Gynaecologists. Existing health service
providers at all designated delivery points will be trained to detect, register
report and refer birth defects to the District Early Intervention Centers in
District Hospitals.
Community Based Newborn screening
(age 0-6 weeks) for Birth Defect
Accredited Social Health
Activists (ASHAs) during home visits for newborn care will use the opportunity
to screen the babies born at home and the institutions till six weeks of age.
ASHAs will be trained with simple tools for detecting gross birth defects.
Further ASHAs will mobilise caregivers of children to attend the local
Anganwadi Centers for screening by the dedicated Mobile Health Team.
In order to ensure
improved and enhanced outcome of the screening programme by Mobile Health
Teams, ASHAs would particularly mobilise the children with low birth weight,
underweight and children from households known to have any chronic illness
(e.g., tuberculosis, HIV,haemoglobinopathy etc.). Line lists maintained by the
ANMs and AWWs would also be used to mobilise children.
Screening of Children
Aged 6 Weeks till 6 Years Attending Anganwadi Centers
Children in the age
groups six weeks to six years of age will be examined in the Anganwadi Centers
by the dedicated Mobile Health Teams.
Screening of Children
Enrolled in Government and Government aided schools
For children in the age
groups 6 to 18 years, who will be screened in Government and Government -aided
schools, the Block will be the hub of activity for the programme. At least
three dedicated Mobile Health Teams in each Block will be engaged to conduct
screening of children. Villages within the jurisdiction of the Block would be
distributed amongst the mobile health teams. The number of teams may vary
depending on the number of Anganwadi Centers, difficult-to-reach areas and
children enrolled in the schools. The screening of children in the Anganwadi
Centers would be conducted at least twice a year and at least once a year for
school children to begin with.
There is also a
provision for engaging a Block Programme Manager for providing logistic support
and for monitoring the entire health screening process. The Block Programme
Manager is also expected to ensure referral support and manage compilation of
the data. The Block teams will work under the overall guidance and supervision
of the CHC Medical Officer. The Block Programme Manager will chalk out a
detailed screening plan for all the three teams in consultation with schools,
Anganwadi Centers and CHC Medical Officer.
District Early
Intervention Center (DEIC)
An Early Intervention
Center will be established at the District Hospital. The purpose of Early
Intervention Center is to provide referral support to children detected with
health conditions during health screening. A team consisting of Paediatrician,
Medical officer, Staff Nurses, Paramedics will be engaged to provide services.
There is also a provision for engaging a manager who would carry out mapping of
tertiary care facilities in Government institutions for ensuring adequate
referral support. The funds will be provided under NRHM for management at the
tertiary level at the rates fixed by the State Governments in consultation
with the Ministry of Health and Family Welfare.
Children and students
presumptively diagnosed to have a disease/ deficiency/disability/ defect and
who require confirmatory tests or further examination will be referred to the
designated tertiary level public sector health facilities through the DEICs.
The DEIC would promptly
respond 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 will also be
involved in newborn screening at the District level. This Center would have the
basic facilities to conduct tests for hearing, vision, neurological tests and
behavioural assessment.
The States/UTs would
conduct mapping to identify public health institutions through collaborative
partners for provision of specialized tests and services. Private sector
partnership/ NGOs providing specialised services can also be explored in case
services at public health institutions providing tertiary care are not
available. Accredited health institutions will be reimbursed for the
specialised service provided as per the agreed cost of tests or treatment
packages.
Training and
Institutional Collaboration
Training of the
personnel involved in Child Health Screening and Early Intervention Services is
an essential component of the programme as it would be instrumental in
imparting necessary information and skills required for child health screening
and enhancing the performance of all the personnel involved in the health
screening process at various levels.
A ‘cascading training
approach’ would be adopted in order to ensure free ‑flow of skills and
knowledge at all levels and to maximize skill distribution. Standardized
training modules/tools would be developed in partnership with technical support
agencies and collaborative Centers as their technical knowledge and expertise
will contribute to making the training process all comprehensive.
Reporting and Monitoring
A Nodal Office at the
State, District and Block level will be identified for programme monitoring.
The Block will be the hub of activity for all Child Health Screening and Early
Intervention Services activities. The Block Programme Manager will assist the
CHC Medical Officer in programme supervision and monitoring.
The ‘Child Health
Screening Card’ is to be filled up by the Block Health Teams for every child
screened during the visit. The health care providers at all delivery points
will screen the newborns and fill the same card, if referral is required.
These children should be issued unique identification number from the Mother
and Child Tracking System (MCTS). The birth defects detected by ASHAs during
home visits are to be referred to DH/ DEIC for further management. All children
detected should be referred to the District Early Intervention Center for
further management at the District or identified tertiary level health
institution.
Roll-Out Steps for Child
Health Screening and Early Intervention Services
· Identification
of State Nodal Persons for the Child Health Screening and Early Intervention
Services.
· Dissemination
of ‘Operational Guidelines’ to all Districts.
· Estimation
of the State/ District magnitude of various diseases, defects, deficiencies,
disabilities as per available national estimates.
· State
level orientation meeting.
· Recruitment
of District Nodal Persons.
· Estimation
of the total requirement of dedicated Mobile Health Teams & recruitment of
the Mobile Health Teams.
· Mapping
of facilities/institutions (public and private for treatment of specific
health conditions).
· Establishment
of DEIC at the District Hospital.
· Procurement
of equipment for the Block Mobile Team and District Hospital (as per the list
provided in the ‘Operational Guidelines’).
· Translation
of tools, training packages, printing of formats, training material.
· Training
of Master Trainers.
· Block
micro-plan for school and community visits monthly outreach plan based on the
mapping of educational institutions and Anganwadis and enrollment in them.
· The
schedule of visits of the Block Mobile Teams should be communicated to the school,
Anganwadi Centers, ASHAs, relevant authorities, students, parents and Local
Government well in advance so that required preparations can be made.
· Anganwadi
Centers and school authorities should arrange for prior communication with
parents and motivate them to participate in the process.
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