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ORIGINAL ARTICLE
Year : 2022  |  Volume : 66  |  Issue : 3  |  Page : 307-312  

Evaluation of the rashtriya bal swasthya karyakram (RBSK): A national children healthcare program in a health district of West Bengal, India


1 Assistant Chief Medical Officer of Health, Department of Health and Family Welfare, Government of West Bengal, Kolkata, West Bengal, India
2 Associate Professor, Department of Community Medicine, Medical College, Kolkata, West Bengal, India
3 Associate Professor, Department of Gynaecology and Obstetrics, Medical College, Kolkata, West Bengal, India
4 Senior Resident, Department of Community Medicine, Midnapore Medical College, Kolkata, West Bengal, India
5 Senior Resident, Department of Community Medicine, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India
6 Health Counsellor, Department of Transfusion Medicine and Blood Centre, Institute of Child Health, Kolkata, West Bengal, India

Date of Submission24-Aug-2021
Date of Decision31-Jul-2022
Date of Acceptance04-Aug-2022
Date of Web Publication22-Sep-2022

Correspondence Address:
Shibaji Gupta
1C-1003, Avishikta 2, 369/3, Purbachal Kalitala Road, Kolkata - 700 078, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.ijph_1690_21

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   Abstract 


Background: The Rashtriya Bal Swasthya Karyakram (RBSK) was launched in 2013 to screen and manage birth defects, deficiencies, diseases, and developmental delays including disabilities in Indian children, with the help of designated mobile health teams and grassroot workers across the country. Objectives: Performance of the RBSK program in three selected blocks of a health district of a large Indian state (West Bengal) was assessed. Methods: The performance assessment was based on input, process, and output performances, using checklists based on RBSK operational guidelines. Results: While some essential evaluation tools were available in required numbers at the block level, many were unavailable. There were deficiencies in the number of health staff appointed. Although most screening camps were conducted as per microplan, some were not. Anthropometric measurements were not done in some camps; Information, Education, and Communication (IEC) materials were not used adequately. Issues with fund management were also noted. The intervention rate at higher centers (District Early Intervention Centre) was low with regard to the children referred for management. Involvement of grassroot workers such as ASHA was also found to be lacking. Conclusion: Frequent orientation training of medical officers and staff is needed along with the efforts to strengthen the referral system and the patient tracking system. Sensitizing the children and their guardians regarding the importance of the relevant health issues is also needed with the help of the proper implementation of IEC services.

Keywords: 4D, children, evaluation, India, Rashtriya Bal Swasthya Karyakram, West Bengal


How to cite this article:
Chakraborty S, Chakraborty A, Mitra S, Gupta S, Lahiri A, Banerjee N. Evaluation of the rashtriya bal swasthya karyakram (RBSK): A national children healthcare program in a health district of West Bengal, India. Indian J Public Health 2022;66:307-12

How to cite this URL:
Chakraborty S, Chakraborty A, Mitra S, Gupta S, Lahiri A, Banerjee N. Evaluation of the rashtriya bal swasthya karyakram (RBSK): A national children healthcare program in a health district of West Bengal, India. Indian J Public Health [serial online] 2022 [cited 2022 Oct 2];66:307-12. Available from: https://www.ijph.in/text.asp?2022/66/3/307/356592




   Introduction Top


In India, an estimated 26 million of children are born every year. As per the Census of India done in 2011, the share of children (0–6 years) accounts 13% of the total population in the country.[1]

Children are generally viewed as healthy when they are assessed by adult standards, and there has been a great deal of progress in reducing childhood death and diseases. Recent improvements in children's health need to be sustained and further efforts are needed to optimize it. To accomplish this, the nation must have an improved understanding of the factors that affect health and effective strategies for measuring and using the information on children's health.

An estimated 12.7 lakh children die every year before completing 5 years of age, in India.[1]

However, in a positive sense, under-five mortality rate (U5MR) in India has declined to 45/1000 live births in 2015.[2] The country has demonstrated a 4.5% reduction in U5MR from 1990 to 2019.[3] Many states including West Bengal have already achieved MDG-4 goal (<41/1000 live births).[2],[4]

To address the concerns related to child health, the Government of India took a leap forward in 2013, with the launch of the Rashtriya Bal Swasthya Karyakram (RBSK), an ambitious program aimed to cover the children in India, with an aim to screen and manage children from birth to 18 years of age for defects at birth, deficiencies, diseases, and developmental delays including disabilities (4Ds).[5]

The program has two main goals:

  1. Early detection and management of the 4Ds, prevalent in children


  2. These are (i) defects at birth, (ii) diseases in children, (iii) deficiency conditions, and (iv) developmental delays including disabilities[5]

  3. Reduction of out-of-pocket expenditure related to health expenditure.[5]


Mobile health teams (MHTs) dedicated to the screening of children, having two AYUSH doctors (one male and one female), a General Nursing and Midwifery (GNM) nurse and a pharmacist have been made available for RBSK services in every community development block, where they are supposed to screen the children attending Anganwadi centers and government and government-aided schools.[5] As per the national report 2015–2016, the total number of children screened was 11.6 crore and those who availed secondary and tertiary care for 4Ds was 62.2 lakhs.[6]

The logic model of evaluation of RBSK program based on a resource guide[7] is given in [Figure 1].
Figure 1: Logic Model of evaluation of RBSK program. RBSK: Rashtriya Bal Swasthya Karyakram. IEC: Information, Education, and Communication

Click here to view


Regular evaluation of any health program is essential for its functioning, as it ultimately helps to improve the initiative by providing the required information to the policymakers and concerned strategists.

The present study was conducted to read the status of RBSK program in terms of its input, process, and output in selected blocks of the South 24 Parganas Health District of the Indian state of West Bengal. Very few studies have been done in any state of India regarding performance evaluation of RBSK program, with hardly any conducted in West Bengal.


   Materials and Methods Top


This community-based observational study of cross-sectional design was conducted in the South 24 Parganas Health District, which has three subdivisions, namely, Sadar, Baruipur, and Canning, in 2018. These subdivisions are further divided into administrative blocks, each block having two RBSK MHTs each. For purpose of the study, one block from each subdivision was chosen randomly, and all RBSK MHTs (n = 6) were assessed from the selected blocks.

Information related to various “input” components was collected by a predesigned checklist, based on the operational guideline of the RBSK program. Information regarding “process” component was obtained by direct observation of different camps with a predesigned structure checklist. Details about “output” components were obtained from the secondary data such as monthly reports, screening, and referral registers from different blocks. Data validation was done by cross-checking the compiled report at district-level program cell.

The variables considered under “input,” “process,” and “output” components are provided in [Table 1].
Table 1: Components of evaluation and the associated variables

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The collected data were entered and analyzed using the Statistical Packages for the Social Science (SPSS)® (SPSS Inc, Chicago, IL, USA) version 16.0, and results were derived based on objectives.

The study was approved by the Institutional Ethics Committee of IPH, Kalyani, for conduction of the study (Ref No.: SHDS/EC/167/14, dated November 27, 2017).


   Results Top


With regard to materials considered under the “input” components, all MHTs of the concerned blocks had adult weighing machines, laptops, and dedicated vehicles for their use. However, there was a gap between the number sanctioned and the number available with regard to items such as measurement tapes, torches, stethoscopes, drug lists, and referral forms. Few articles, namely red ring, rattle, bell, raisins, one-inch cubes, infant weighing machine, and sphygmomanometer, were not available with any of the blocks. Considering the human resource input component, all blocks had the required number of medical officers (four MOs in each block), however, they worked with half the strength of pharmacists (out of two pharmacists, one was available in each block). All the existing RBSK MOs and pharmacists received the preservice training. In spite of the sanctioned two posts of staff nurses, none were present during the study. The selected blocks, namely, Basanti, Budge Budge II, and the Sonarpur block, were found to have utilized 90.06%, 93.56%, and 33.74% of their allocated total funds during the previous financial year (2016–2017). The variables associated with the “process” component were studied across the 20 RBSK camps that were conducted during the data collection period. The Budge Budge II block and Sonarpur block were found to have conducted the maximum number of camps (n = 8 each), while the Basanti block conducted four camps. All camps were held as per the microplans and got sanctions from the respective authorities (Budge Budge II [8/8] and Basanti block [4/4]). About 50.00% (4/8) of the camps held at Sonarpur were not as per microplan; 25.00% (2/8) of camps were not sanctioned. Prior information to the screening center regarding the camp was given in all cases; screening and referral registers were maintained by all. Timely reports were sent in all instances [Table 2].
Table 2: Status of input components with respect to the three blocks under stud

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In Sonarpur block, screening tools were used in all the screening camps (100.00%; 8/8); the medical officers were found to conduct Information, Education, and Communication (IEC) sessions in five such camps out of eight (62.50%). Out of these eight camps, anthropometric measurements were taken in six camps (75.00%). General survey was conducted in children of 25.00% of camps (2/8). About 1.96% (13/664) of the children screened for 4D's were referred to higher centers (i.e., District Early Intervention Centre [DEIC]) for further management, from the camps organized at Sonarpur. Pictorial job aids were not used in any of the camps.

Screening tools were used in all the eight camps held at Budge Budge II block (100.00%). In four such camps, it was observed that the medical officers were involved in IEC sessions. In no camps pictorial job aids were used. Anthropometric measurements were taken in 50.00% of cases (4/8 camps); general survey was done in the children of 87.50% of such camps (7/8). About 5.67% (31/547) of children from the camps at Budge Budge II were referred for management of the 4D's.

All four camps at Basanti block used screening tools (100.00%); IEC sessions were conducted by the medical officers in all such camps (100.00%). Pictorial job aid was used in one camp (25.00%). Three out of the four camps (75.00%) conducted general survey in children. Anthropometric measurements were taken in two out of the four camps organized at Basanti (50.00%). About 7.32% (51/697) of children were referred from the camps at Basanti, for further management of 4D's.

The output performance was analyzed based on the secondary data collected from the performance records of the last 6 months preceding the study period. As per these records, Sonarpur block conducted 227 out of 233 planned screening camps (96.60%) as per their microplan, while the Budge Budge II block and Basanti block conducted 93.97% (265/282) and 92.91% (118/127) of their screening camps as per microplan, respectively. The average rate of screening in the last 6 months was 50.06 children per medical officer per working day. A total of 72,089 children were screened for 4D's, with maximum screening done at Budge Budge II block (32.98%; 23775/72089). Out of these 72,089 children, 3296 were referred to higher centers for further management, with Basanti block contributing 67.11% (2212/3296) to the tally. About 1.13% (25/2212) of the children referred from the block received intervention at the higher centers, while the rest were only counseled before letting them go. About 0.29% (2/684) and 0.75% (3/400) of children referred from Budge Budge II and Sonarpur block respectively, received intervention. Convergence meetings which are required to be organized every month were actually held once at Sonarpur and five times at Budge Budge II block in the last 6 months. No such meetings were held at Basanti block in the said time period [Table 3].
Table 3: Details of children screened in the camps

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   Discussion Top


This study was conducted to find out the status of input, process, and output of RBSK program in three randomly selected blocks (Sonarpur, Budge Budge II, and Basanti) of the South 24 Parganas Health District of West Bengal. The findings have pointed out the successes and failures of the RBSK program being implemented here. Although much of the required tools were available, significant shortages in health staff were noticed, along with the scarcity of some material resources that are mandatorily recommended in the program guidelines.[5] Staff nurses and pharmacists hence need to be recruited; essential unavailable items also need to be supplied to the concerned MHTs. A similar study from Madhya Pradesh found a deficiency in staff and tools as well.[8]

Although the majority of the camps were conducted as per microplan, in some cases, it was not. Recommended evaluative procedures on children were not always fully practiced. Health education has a very important role in disease prevention. It was noticed that the majority MHTs in each block conducted IEC sessions but hardly had any IEC material displayed during the camps. Average number of children screened by medical officers in a day was below the standards.[9] All these reflect upon the need of orientation training of medical officers and staff. It was also observed that the percentage of referrals was at par with the national and state average. An unconfirmed cumulative report from the office of the district authority of health from last year, however, suggested a referral rate more than the national and state average (10.92%).

Fund utilization was also an issue, which needs proper management for the best results.

Intervention rate at higher centers (DEICs) was low compared to national and state standards.[10] Low intervention rates have been highlighted in a similar study from Central India.[11] This might have been due to a lack of transport support provision in the current program. A poor tracking system for follow-up might also have been a reason of them being lost from the radar. A study from Madhya Pradesh has highlighted the losses to follow-up that occurred in Ujjain and Indore districts of the state from the referral process.[11] Long waiting time associated with the referral mechanism might have also demotivated the care seekers to use the services. A similar study has pointed out at the dissatisfaction that stemmed up in the care seekers due to the expenses associated with referral and patient management in these higher centers.[11] The above facts indicate the need for strengthening the referral system and the patient tracking system. Sensitizing the children and their guardians regarding the importance of the relevant health issues is also needed to generate the eagerness for following up.

Convergence of multiple sectors is essential for a successful RBSK campaign.[12] Shortage in input tools can be effectively met with the help of intersectoral coordination - the vital role of ASHAs and Anganwadi workers in complementing the RBSK initiatives have been stressed upon in the national guideline. Their involvement can help in the early identification of birth defects or health issues, and early sensitization of the baby's caregivers to seek medical advice from the dedicated MHT. However, their role was found to be negligible in the district studied. Hence, steps should be taken to ensure their active participation and coordination.

Strength and limitation

Studies evaluating RBSK program have been rarely conducted before, as is evident from the scarcity of literature available in the public domain. Hence, the present study adds vital evidence to this field of knowledge. As a limitation, RBSK services in DEICs where the children with 4Ds were being referred for intervention could not be evaluated, as this was beyond our purview.


   Conclusion Top


Since its birth in 2013, the RBSK program has gone on to serve millions of children in India. Any health program needs regular evaluation for better functioning, however, evaluative statistics for RBSK are hardly available even now, at least in the public domain. The present research undertakes to fulfill this existing gap of knowledge and makes available vital insights into the practicalities of the program, including its hurdles, for policymakers to note and address.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Census of India Website : Office of the Registrar General & Census Commissioner, India; 2011. Available from: https://censusindia.gov.in/2011-common/censusdata2011.html. [Last accessed on 2020 Dec 29].  Back to cited text no. 1
    
2.
Under 5 Mortality Rate (U-5MR) (per 1000 Live Births) | NITI Aayog, (National Institution for Transforming India), Government of India; 2020. Available from: https://www.niti.gov.in/niti/content/under-5-mortality-rate-u-5mr-1000-live-births. [Last accessed on 2020 Dec 29].  Back to cited text no. 2
    
3.
India Sees a Decline of 70 Per Cent in Under-Five Mortality Rate in Past Three Decades, What is the Way Forward | News. NDTV-Dettol Banega Swasth Swachh India; 2020. Available from: https://swachhindia.ndtv.com/india-sees-a-decline-of-70-per-cent-in-under-five-mortality-rate-in-past-three-decades-what-is-the-way-forward-50151/. [Last accessed on 2020 Dec 29].  Back to cited text no. 3
    
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Nath A. India's progress toward achieving the millennium development goals. Indian J Community Med 2011;36:85-92.  Back to cited text no. 4
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5.
Ministry of Health & Family Welfare, Government of India. Operational Guidelines Rashtriya Bal Swasthya Karyakram. Nirman Bhawan, New Delhi; 2013. Available from: https://www.researchgate.net/publication/266021748_Operational_Guidelines_Rashtriya_Bal_Swasthya_Karyakram. [Last accessed on 2020 Dec 29].  Back to cited text no. 5
    
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Press Information Bureau, Ministry of Health and Family Welfare, Government of India. RBSK; 2016. Available from: https://pib.gov.in/newsite/PrintRelease.aspx?relid=144955. [Last accessed on 2021 Feb 11].  Back to cited text no. 6
    
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Silverman B, Mai C, Boulet S, O'Leary L. Logic Models for Planning and Evaluation – A Resource Guide for the CDC State Birth Defects Surveillance Program Cooperative Agreement; 2007.  Back to cited text no. 7
    
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Parmar S, Bansal SB, Raghunath D, Patidar A. Study of knowledge, attitude and practice of AYUSH doctors, evaluation of MHTs working in RBSK and client satisfaction. Int J Community Med Public Health 2017;3:2186-90.  Back to cited text no. 8
    
9.
Rashtriya Bal Swasthya Karyakram – Participant's Manual (For Mobile Health Teams). New Delhi: Ministry of Health & Family Welfare, Government of India; 2014. p. 11.  Back to cited text no. 9
    
10.
District Early Intervention Centres under RBSK; 2015. Available from: https://pib.gov.in/newsite/PrintRelease.aspx?relid=117481. [Last accessed on 2021 Feb 11].  Back to cited text no. 10
    
11.
Parmar S, Raghunath D, Dixit S, Bansal SB, Ananad P. A cross-sectional study to evaluate the functioning and infrastructure of DEIC, and client satisfaction Ujjain and Indore districts established under RBSK. IOSR J Dent Med Sci 2016;15:92-4.  Back to cited text no. 11
    
12.
Kansara K, Saxena D, Puwar T, Yasobant S, Trivedi P, Savaliya S, et al. Convergence and outreach for successful implementation of Rashtriya Kishor Swasthya Karyakram. Indian J Community Med 2018;43:S18-22.  Back to cited text no. 12
    


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