International Journal of Pharmacy, Biology and Medical Sciences Vol. 3. No. 2.

ISSN 2319 -3026 (July-Dec 2014)

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: thevinaygupta@gmail.com

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

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
Downs 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 Downs 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

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

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, parents 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 students name,
age, school, height, weight, etc. CUG (Closed
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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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International Journal of Pharmacy, Biology and Medical Sciences Vol. 3. No. 2. ISSN 2319 -3026 (July-Dec 2014)

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

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

Fig. 1. Flow Chart of Referral System

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

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 cant 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 dont 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

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There are many children who are in slums who

either dont 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 Softwares 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 weeks end
or months 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
childs 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 cooperation 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, Its a
brilliant chance to inspect these for the basic
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International Journal of Pharmacy, Biology and Medical Sciences Vol. 3. No. 2. ISSN 2319 -3026 (July-Dec 2014)

infrastructure and basic facilities that directly

relates to the childrens 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 childs 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

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

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. Page5 . 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.

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