National Health Mission Govt. of uttarakhand

Rashtriya Bal Swasthya Karyakaram (RBSK)

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. Comprehensive Child Health screening and management as a public health approach assures a package of health services for all children from birth to 18 years of age under the Rashtriya Bal Swasthya Karyakram (RBSK) initiative.

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 as already has 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.

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 out would also reduce the out-of –pocket expenditure of the poor and the marginalized population in the State. Additionally, the child health screening and early intervention services will also provide state wide epidemiological data on the 4Ds (i.e. Defects at birth, Diseases, Deficiencies and Developmental Delays including Disabilities). Such a data is expected to hold relevance for futures planning of area specific services.

There are also groups of diseases which are very common in children e.g. dental caries, otitis media, rheumatic heart disease and reactive airways 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 hospitalization and resulting in improved school attendance.

Rashtriya Bal Swasthya Karyakaram (RBSK) is being implemented in the State from the financial year 2012-13. This programme is being run in the state in convergence with education, ICDS, Social Welfare and other departments. There are 148 Mobile health teams functional in the state for health examination of the school and Aaganwadi children. Total 12.22 lakhs children enrolled in schools and 8.26 lakhs are targeted for health examination in 2016-17. Due to difficult geographical conditions, distance of school and AWCs from road head and sparse population, existing number of team per district are able to examine each child once a year in school and twice in a year in Aaganwadi Centres.

Since 2012-13 this programme is being implemented in the state through a dedicated Mobile health team which includes two MO’s (BAMS) (01 male & 01 female), one pharmacist, and one ANM/Staff Nurse at block level. One/two RBSK Managers are positioned at District level to facilitate the block teams. Besides this there are 2 Regional Coordinators (Garhwal and Kumoun) are in position for monitoring and monthly report compilation of the programme. 

Under the RBSK Program 4Ds are covered :

1. Defect at Birth
   1. Neural Tube Defect
   2. Down’s Syndrome
   3. Cleft Lip & Palate/Cleft Palate alone
   4. Talipes (Club foot)
   5. Developmental Dysplasia of the Hip
   6. Congenital Cataract
   7. Congenital Deafness
   8. Congenital Heart Disease
   9. Retinopathy of Prematurity
2. Deficiencies

10.  Anemia especially Severe Anemia

11.   Vitamin A Deficiency (Bitot spot)

12.  Vitamin D Deficiency (Rickets)

13.  Severe Acute Malnutrition

14.  Goiter

1. Diseases (Childhood)

15.  Skin conditions (Scabies, Fungal Infection and Eczema)

16.  Otitis Media

17.  Rheumatic Heart Disease

18.  Reactive Airway Disease

19.  Dental Caries

20.  Convulsive Disorders

1. Developmental Delays and Disabilities

21.  Vision Impairment

22.  Hearing Impairment

23.  Neuro-Motor Impairment

24.  Motor Delay

25.  Language Delay

26.  Cognitive Delay

27.  Behaviour Disorder (Autism)

28.  Learning Disorder

29.  Attention Deficit Hyperactivity Disorder

30.  Congenital Hypothyroidism, Sickle Cell Anaemia, Beta Thalassemia (Optional based on epidemiological situation and availability of testing and specialized support)

District Early Intervention Centre (DEIC)

Under the RBSK Program 04 District Early Intervention Centres are functioning at Regional level. These four District Early Intervention centres are situated in Dehradun, Haridwar, Nainital and Almora district i.e. DEIC, Coronation Hospital, Dehradun; DEIC, Combine Hospital, Roorkee; DEIC, Base Hospital Haldwani and DEIC Base Hospital Almora.  The main function of the DEIC is: to confirm diagnosis of the children referred for Defects at Birth, Deficiencies, Diseases and Developmental Delays including disabilities, by the Mobile Health Team, Delivery Points, ASHAs and self referral. To coordinate tertiary level treatment and children beyond six years of age with Neuro-motor impairments will be referred for further continuation of therapy and education to the rehabilitative and educational institutions etc. During holidays in the schools, these school health teams will be involved in the examination of children in VHNDs and organization of Adolescent Health Camps under the ARSH programmes.

The broad goals and services for DEIC include:

a. Screening of Children from Birth-18 Years for 4D’s

b. Early Identification of Selected Health Conditions

c. Holistic Assessment

d. Investigations

e. Diagnosis

f. Intervention

g. Referral

h. Prevention

i. Psycho-social Interventions

Services Provided by DEICs:

a. Core Services :

• Medical services – for diagnostic or evaluation purposes. Medical treatment of children suffering from diseases and deficiencies.
• Dental services – for problems of teeth, gums and oral hygiene in children from birth to 6 years esp. “Early Childhood Caries”
• Occupational therapy & Physical therapy – services that relate to self-help skills, adaptive behavior and play, sensory, motor, and postural development i.e. services to prevent or lessen movement’s difficulties and related functional problems. Sensory Integration, oro-motor and feeding difficulties.
• Psychological services – administering and interpreting psychological tests and evaluation of a child’s behavior related to development, learning and mental health as well as planning services including counseling, consultation, parent training, behavior modification and knowledge of appropriate education programs.
• Cognition services – identifying cognitive delays and providing intervention to enhance cognitive development, adaptive and learning behavior.
• Audiology – identifying and providing services for children with hearing loss among children from birth to 6 years for both congenital deafness and also acquired deafness.
• Speech-language pathology – services for children with delay in communication skills or with motor skills such as weakness of muscles around the mouth or swallowing.
• Vision services – identification of children with visual disorders or delays and providing services and training to those children. Retinopathy of Prematurity (RoP) – for premature or preterm children.
• Health services – health-related services necessary to enable a child to benefit from other early intervention services.
• Lab services – for routine blood investigations among children to begin with but slowly would develop services for confirming congenital hypothyroidism, Thalassemia and Sickle cell anemia or other inborn error of metabolism depending on the prevalence of such diseases.
• Nutrition services – services that help address the nutritional needs of children that include identifying feeding skills, feeding problems, food habits, and food preferences.
• Social support services – preparing an assessment of the social and emotional strengths and needs of a child and family, and providing individual or group services such as counseling. Socio economic evaluation of the family and linkages with the need based social services.
• Psycho-social services – includes designing learning environments and activities that promote the child’s development, providing families with information, skills and support to enhance the child’s development.
• Transportation and related costs – providing or reimbursing the cost of travel necessary to enable a child and family to receive any tertiary level services.
• Service coordination
• Referral services following referral guidelines – children who are diagnosed for any of the selected health conditions would receive follow-up referral support and treatment including surgical interventions at tertiary level.
• Documentation and maintenance of case records, data storage for service delivery, follow up and research.
• Training and enhancing capability of multi-skilled community personnel in the district and helping in operationalizing of early intervention services at blocks and in the community and provide supportive supervision and domain specific referral services in the community.

b. Supplementary services:

• „Disability certificates : with other members of the disability board
• „Liaison with other departments under various ministries:  e.g.

A) Disability division of Ministry of Social Justice and Empowerment (MoSJE):

• Assistive technology devices and services – equipment and services that are used to improve or maintain the abilities of a child to participate in such activities as Hearing, Seeing (Vision), Moving, Communication and learning to compensate with a specific biological limitation.
• Special Education services for School age groups from six to sixteen, Pre-Vocational training for age 16-18 years and Vocational training for the age of 18
• Aids and appliances: Assistance to Disabled Persons for Purchase / Fitting of Aids and Appliances under the “Assistance to Disabled Persons for Purchase/Fitting of Aids/Appliances (ADIP)” Scheme, with the objective of assisting needy persons with disabilities in procuring durable, sophisticated and scientifically manufactured standard aids and appliances that can promote their physical, social and psychological rehabilitation.
• Rehabilitation of the differently able child above 6 years of age at the Rehabilitation centers in that state e.g. District Disability Rehabilitation Centers(DDRCs) for the districts where they are functional or Composite Regional Centers (CRCs) or National Institutes/Regional Centers etc.
• Family support services esp. for children having Autism, Cerebral palsy, Mental retardation, multiple disabilities. These Services would be to support those children who would require long term support and would focus on supporting the child in their natural environments and in their everyday experiences and activities. All services would be provided using a family-centered approach, recognizing the importance of working in partnership with the family. However whenever a detailed domain specific management would be required they would be referred to the DEIC.
• Guardianship
• Parent Associations
• Promoting advocacy for right-based society
• Social security’s such as disability scholarship and disability pension

B. Linkages with Ministry of Human Resource Development (MoHRD), Department of School Education & Literacy under “Education of Children with Special Needs in “Sarva Shiksha Abhiyan”

• Provide inclusive education and support to children from age of 6 -14 years
• Provide Aids and appliances to school going children with special needs and support of trained special educators to these children.
• To provide home based educational services to children with special needs on need basis.