|Year : 2021 | Volume
| Issue : 1 | Page : 3-7
Rapid assessment of Rashtriya Bal Swasthya Karyakram program implementation and beneficiary feedback at two district early intervention centers in Chhattisgarh State in India
Shruti Atul Prabhu, Nikhil Keshav Shukla, Mandala Sai Roshni
Department of Public Health, Sri Sathya Sai Sanjeevani Hospital, Naya Raipur, Chhattisgarh, India
|Date of Submission||02-Jul-2020|
|Date of Decision||12-Sep-2020|
|Date of Acceptance||03-Oct-2020|
|Date of Web Publication||13-Jan-2021|
Dr. Shruti Atul Prabhu
Department of Public Health, Sri Sathya Sai Sanjeevani Hospital, Sector-2, Atal Nagar, Nava Raipur - 492 101, Chhattisgarh
Source of Support: None, Conflict of Interest: None
Background: The Government of India launched the child health screening and early Intervention programme called Rashtriya Bal Swasthya Karyakram in 2014 to screen children from 0 to 18 years for the early detection of 4 D's (Defects, Diseases, Deficiency, and Developmental Delays including disabilities). Under this program, district early intervention centers (DEICs) are set up as nodal centers at the district level to manage the cases of 4Ds. There are few studies published evaluating the functioning of DEICs or reflecting the feedback from beneficiaries. Aims: The aim of this study is to assess the functioning and infrastructure of DEIC and beneficiary feedback. Methods: One good performing district (Raigarh) and one poor performing district (Raipur) were selected for rapid assessment. Observational check list according to norms was used for assessment of facilities, staffing pattern, and semi-structured questionnaire used for beneficiary feedback. Data were entered in Microsoft excel for the analysis. Results: DEIC Raipur was deficient in staff and infrastructure. Among all the referred cases, only 38.9% and 31.5% reached DEIC Raipur and Raigarh, respectively. DEIC Raigarh deserves special mention. It has special Orthotics unit, “Sensory garden,” and Disability Rehabilitation Center. Beneficiaries face many difficulties at DEIC despite having necessary referral forms. 73.4% parents said loss of daily wages was a deterrent to go to DEIC repeatedly for follow-up. Conclusion: There was a deficiency of staff and infrastructure in DEIC Raipur. DEIC Raigarh had a well-equipped rehabilitation center. It should be developed as “Model DEIC” for Chhattisgarh and explore the possibility of telemedicine to provide services to neighboring underserved districts. Beneficiary feedback was below satisfaction.
Keywords: Chhattisgarh, district early intervention centers, evaluation, Rashtriya Bal Swasthya Karyakram
|How to cite this article:|
Prabhu SA, Shukla NK, Roshni MS. Rapid assessment of Rashtriya Bal Swasthya Karyakram program implementation and beneficiary feedback at two district early intervention centers in Chhattisgarh State in India. Curr Med Issues 2021;19:3-7
|How to cite this URL:|
Prabhu SA, Shukla NK, Roshni MS. Rapid assessment of Rashtriya Bal Swasthya Karyakram program implementation and beneficiary feedback at two district early intervention centers in Chhattisgarh State in India. Curr Med Issues [serial online] 2021 [cited 2021 Apr 20];19:3-7. Available from: https://www.cmijournal.org/text.asp?2021/19/1/3/306930
| Introduction|| |
The Government of India launched the nationwide Rashtriya Bal Swasthya Karyakram (RBSK), a Child Health Screening and Early Intervention Services Programme to provide comprehensive care to all the children in the age group of 0–18 years in the community. The objective of this initiative is to improve the overall quality of life of children through the early detection of birth defects, diseases, deficiencies, development delays, and disability. For negating the impact of early adversities on the development and ensuring a healthy, dynamic future for all children, this program aims to improve the quality of life with special focus on improving cognition and survival outcomes for “at risk” children. It has a systematic approach of prevention, early identification, and management of 30 health conditions distributed under 4Ds: Defects at birth (Group A), diseases (Group B), deficiencies (Group C), and developmental delays including disabilities (Group D).
Through this program dedicated mobile health teams (MHTs) are placed in every block in the country. These teams carry out screening of all children in the preschool age enrolled at preschool (Anganwadi) centers twice a year besides screening of all children studying in Government and Government aided schools.
District early intervention centers
These are established at the district hospital to provide referral support to children detected with health conditions during health screening by MHTs. In India, developmental delays are common in early childhood affecting at least 10% of children. Further SNCU technical reports have reported that approximately 20% of the babies discharged from the health facilities are found to suffer from developmental delays or disabilities at a later stage. These delays if not intervened timely may lead to permanent disabilities with regard to cognition, hearing, and vision. Children with disabilities are often denied access to appropriate services. According to the National Sample Survey (2018), the total number of disabled population in India is approximately 22 million (2.2% of the population); however, the actual estimates may be higher.
The district early intervention centers (DEIC) aim to respond to manage all issues related to speech, language and developmental delays, vision and hearing impairment, autism, neuromotor, and cognitive impairment. DEIC has basic facilities to conduct hearing, vision, neurological tests, and behavior assessment.
The idea behind early intervention is to intervene early and minimize disability. Once the disability is already established, then the intervention would include enhancement of child development for the child to reach the highest potential for the child possible and prevent progression to handicap that may arise from activity limitation. Research has proved that the period from birth to 6 years is the most critical years for all children. This is especially true for children with developmental delay. Therefore, it stands that early identification and early intervention programs can significantly improve the quality of their lives.
DEICs are established with the aim to have more accessible health facilities with infrastructure and resources for interdisciplinary evaluation and interventions to be delivered under one roof.
The broad goals and services for DEIC include:
- Screening of children from birth to 18 years for 4D's referred from periphery by MHTs
- Early identification of selected health conditions
- Holistic assessment
- Psychosocial interventions.
The proposed team composition at the DEIC, is [Table 1]:
The WHO has stated that defect or developmental delay leads to functional disability, and these functional disabilities, in turn, lead to handicap if not addressed adequately. The burden of this handicap is borne by the family and also by society.
There are few studies published evaluating the implementation of this programme at DEIC or reflecting the feedback from beneficiaries. This study evaluates RBSK program implementation in two DEICs-one each in Raipur and Raigarh districts of Chhattisgarh state in Central India. The aim of this study is to assess whether DEIC functioning is as envisaged in the national guidelines for RBSK, identify potential roadblocks in providing treatment and rehabilitation to referred children, and obtain feedback from beneficiaries.
| Methods|| |
Assessment was conducted in December 2018. Around this time, Chhattisgarh government had undertaken an exercise for the assessment of its few health programs including RBSK. National Health Mission, Government of Chhattisgarh invited Department of Public Health, Sri Sathya Sai Sanjeevani Hospital, Nava Raipur as an external organization to conduct assessment of its RBSK program. This manuscript is a sub-part of the detailed report. Since this assessment was conducted as a directive from NHM, Chhattisgarh Government due to its felt need, their office had sent approval letters and instructions to the district nodal agency for co-operation to the evaluation team for this exercise. Ethics Committee approval (reference number SSSSH/IEC/2019/10) for publication of this manuscript was received.
Selection of districts
Purposive sampling was used for the selection of districts for the assessment of RBSK performance. Since the National Health Mission, Chhattisgarh Government office had requested the assessment to be completed within 3 weeks for prompt implementation of recommendations; hence, a rapid assessment was planned involving two districts-best performing district and poor performing district, to identify the best practices and gaps in RBSK implementation in respective districts. All districts were assessed for RBSK performance till date from the data available online on RBSK e-portal and list of good and poor performing districts was drawn from the report. One good performing district Raigarh and one poor performing district Raipur were selected. [Table 2] denotes the comparison of performance indicators of best performing district (Raigarh) and poor performing district (Raipur). Each district has DEIC at district hospital.
|Table 2: Comparison of performance indicators of best performing district (Raigarh) and poor performing district (Raipur)|
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An observational checklist drawn from RBSK guidelines, was used for the assessment of facilities, staffing pattern, and functioning. A list of beneficiaries at both DEICs was drawn from their register. One hundred beneficiaries (children and their parents) across the two DEICs (50 beneficiaries at each of the two DEICs) were interviewed randomly using semi-structured questionnaire to obtain beneficiary feedback from the beneficiary register. If any beneficiary was not available, then next beneficiary was selected for feedback. For each DEIC, the number of children referred by MHTs to DEIC, trends of referral and data regarding children availing services at DEIC was obtained from RBSK online portal and reporting registers available at both DEICs. Data were entered in Microsoft excel for the analysis.
| Results|| |
DEIC of Raipur and Raigarh district were running in the same building of district hospital at both places. In terms of staffing, at DEIC Raipur-Audiologist, Speech therapist, Optometrist, Lab technician posts were vacant, whereas in DEIC Raigarh – Pediatrician, Psychologist, Optometrist, Lab technician posts were found vacant at the time of assessment, the process of recruitment was in process. These being key members of the multi-disciplinary team required at DEIC, in absence of these staff, quality of care provided to beneficiaries is compromised. Equipment was mostly available at DEIC Raigarh; however, DEIC Raipur lacked few important equipment for physiotherapy. Services lacking the most at DEIC were treatment and support services for Group D – developmental delays/disability conditions.
District early intervention centers beneficiaries
[Table 3] denotes the number of children screened by MHTs across both the districts from January 2018 to November 2018. It shows the number of children who were detected with any morbidity, number treated at screening site, and number who were referred to DEIC for higher center management. Children needing referral means all those children who were identified with morbidity requiring assessment for treatment at a higher center, for example, District Hospital and Medical College. Children referred means all those children who were eventually given reference slips by the MHTs. Difference between the two was investigated, and the cause was multifactorial. Unwillingness on the parents part and oversight by MHTs are the most common causes for this difference. In Raipur, 311 children were referred to DEIC but only 121 (38.9%) availed care at DEIC, whereas in Raigarh, 333 children were referred to DEIC but only 105 (31.5%) finally reached DEIC for further management. This represents a huge gap in service provision.
|Table 3: Referral pattern of children detected with any morbidity at district early intervention enter Raipur and district early intervention Center Raigarh (January 2018–November 2018)|
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Out of all referred children with Developmental Delays and Disabilities, only 4.66% were supported through DEIC Raipur on a regular basis (at least 3 days per week) and 7.33% were supported through DEIC Raigarh on a regular basis (at least 3 days per week). There was a big difference in the number of referred children and those supported by DEIC in both the districts demonstrating a lack of proper referral system and treatment provided by DEIC. This has to be remedied immediately and effectively if we wish to improve the program outcome.
Source of referral
It was studied for all children availing the treatment at both DEICs. [Figure 1] shows a bar diagram representing the source from where the children were referred to DEIC. At both DEICs, majority of children were referred directly from Pediatrics OPD of District hospital. However, under RBSK program, it is envisaged to have maximum referrals from the periphery by MHTs. Collective efforts should be made to improve this indicator.
|Figure 1: Source of referral of beneficiaries to district early intervention centers Raipur and district early intervention centers Raigarh.|
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District early intervention center Raigarh
It deserves special mention. Center is housed in a separate building, is well equipped, with trained and highly motivated staff. This should be developed as “Model DEIC” for CG state. It provides the following services:
- Unique “Sensory garden” for therapy for children with developmental delay, sensori-motor disturbances, MR-CP, blindness [Figure 2]
- District Disability Rehabilitation Center (DDRC) including Orthotics unit for physiotherapy for physical disability, etc. All materials for making Orthotics aids is available, Orthotics technician is well trained, possesses skills to make orthotic aids, and takes keen interest in his work
- Psychology unit performs intelligence quotient test: as part of National Mental Health Programme.
|Figure 2: District Early Intervention Centre (DEIC) Raigarh and Sensory garden for therapy for children with developmental delay, sensori-motor disturbances, cerebral palsy, etc. The sensory garden has different textured objects like grass, stones, sand etc. for teaching children different textures.|
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Detailed interviews were conducted for 50 children, and their parents at each DEIC regarding their experience of accessing care at DEIC. Feedback from the parents of beneficiaries gave important insights into the struggles they faced during referral and accessing treatment at DEIC. When enquired about their experience at DEIC, 53.0% beneficiaries were satisfied with the services at DEIC. These were parents of children hearing or vision impairment and mild-moderate physical disability. However, parents of children with autism, developmental delay were not satisfied as specialists for this treatment were not present at DEIC [Table 4]. 36.0% parents mentioned too much paperwork, whereas 55.3% felt that since specialized tests or treatment were not available at DEIC, the whole exercise was futile. 73.4% parents said loss of daily wages was a deterrent to go to DEIC repeatedly for follow-up. Higher investigations such as X-ray or computed tomography (CT) scan prior to case selection for Cochlear implant for the treatment of sensorineural deafness was not available within in DEIC or government facilities in Raigarh, children are referred to Raipur district for CT scan. Therefore, in places where higher investigations are not available in government facilities, there should be a provision to get it done in private facilities at government fixed rates, paid through RBSK Chirayu and free of cost to the children.
| Discussion|| |
DEIC is the referral point for all Category D cases. It is important for upgrading DEIC for providing quality service and motivating beneficiaries for regular follow-up. Hence, it is vital to fill all vacant posts immediately, equip and fund the DEIC in a way such that it is able to provide all services that it is expected to offer. In a study by Panigrah and Swain, vacant posts and lack of infrastructure were identified at DEICs in Odisha state, India.
In Raipur, 311 children were referred to DEIC but only 121 (38.9%) availed care, whereas in Raigarh, 333 children were referred to DEIC but only 105 (31.5%) finally reached DEIC for further management. This represents a huge gap in service provision. In a study by Parmar et al., in Madhya Pradesh state in India, among all the referred cases, 5.2% and 6.01% reached the DEIC Indore and Ujjain, respectively. The authors noted that out of all referred children with Developmental Delays and Disabilities, only 0.89% were supported through DEIC Indore and 2.62% were supported through DEIC Ujjain.
Regarding feedback from parents, similar concern was voiced in a Delloitte report wherein parents had to undertake repeat visits due to nonavailability of staff or equipment and still did not receive the “benefits of free treatment and care” as envisioned in the program. During such episodes, they usually tend to give up on the government health system and try treatment from the private sector. Tiwari et al. also identified dissatisfaction among the beneficiaries and need for strengthening the RBSK program in their region.
Children from neighboring districts should be referred to DEIC Raigarh or details can be sent to this center and orthotic aid can be prepared here and then sent to the referring MHT/DH. Possibility of using telemedicine for the same should be explored. As per information received, currently, the Orthotics wing is part of DDRC funded by Red Cross, and the only unit in Chhattisgarh state providing this service. It was recommended to National Health Mission, Chhattisgarh state to incorporate this service in its upcoming program implementation plan and develop this as a “Model DEIC” for the state.
For common morbidities drawing high referrals to DEIC/MC such as vision impairment, disabilities, developmental delays, other centers (private, nongovernmental organization, not-for-profit, etc.) offering services should be explored to reduce time lag and waiting time. Government may inspect such centers and fix rates for services. Beneficiaries can then avail treatment at government approved centers and prices.
- Upgrade and fill all vacant positions at DEIC
- Develop DEIC RAIGARH as “MODEL DEIC” for Chhattisgarh state
- Co-ordination with other National Health Programmes
- Regular co-ordination and review meetings with Medical College, district education officer and integrated child development services nodal agency.
Due to the shortage of time, a rapid assessment was performed and best and poor performing districts were selected. This can be considered as a limitation as only extremes were selected.
| Conclusion|| |
There was a deficiency of staff and infrastructure in DEIC Raipur. DEIC Raigarh had a well-equipped Disability Rehabilitation and Orthotics Center. It should be developed as “Model DEIC” for Chhattisgarh and explore the possibility of Telemedicine to provide services to neighboring underserved districts. Beneficiary feedback was below satisfaction. Further, strong advocacy should be carried out with National/State Governments to expedite operationalization of DEICs so that caregivers are able to avail all services under a single umbrella instead of being sent from one facility to another.
Research quality and ethics statement
The authors of this manuscript declare that this scientific work complies with reporting quality, formatting and reproducibility guidelines set forth by the EQUATOR Network. The authors also attest that this clinical investigation was determined to require Institutional Ethics Committee review, and the corresponding protocol reference number is SSSSH/IEC/2019/10 dated November 15, 2019. We also certify that we have not plagiarized the contents in this submission and have done a Plagiarism Check.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]