Keywords
RBSK - challenges - barriers - implementation - Rajasthan
Introduction
The Rashtriya Bal Swasthya Karyakram (RBSK) is an innovative and ambitious initiative
of the Ministry of Health and Family Welfare, Government of India.[1] Launched under the National Health Mission, this initiative subsumes the existing
school health program and envisions child health screening and early intervention
services to provide care, support, and treatment to children.[2] Child health screening and early intervention services refer to early detection
and management of a set of 30 preidentified health conditions such as birth defects,
deficiency conditions, and developmental delays including disabilities (4Ds) that
are prevalent in children of less than 18 years of age.[3]
In India, out of every 100 live births, 6 to 7 have birth defects, which translate
to 1.7 million birth defects annually and lead to 9.9% of all newborn deaths.[4]
[5]
[6] Development delays are common in early childhood, affecting at least 10% of the
children.[7] If not intervened in a timely manner, these delays may lead to permanent disabilities,
resulting in cognition imbalance and hearing and vision disabilities.[8]
[9]
[10] With an aim to reduce the extent of disability and improve the quality of life through
health screening and early interventions, this program is aimed to be a step toward
“health for all,” benefitting an estimated 270 million children between age of 0 to
18 years attending Anganwadi centers and government schools.[9]
Although the RBSK program has been running in the country since 2013, there is a paucity
of studies on RBSK, particularly in this part of the country, which comes in with
the additional challenges associated with the remotely located areas of the Thar desert.
Moreover, the few studies that have been conducted in the context of RBSK are only
knowledge, attitudes and beliefs, and practices (KAP) based. It is evident from these
studies that the health team deployed under any project or program faces varied challenges
and barriers related to the work conditions such as cooperation, support, resistance
from community, and burden of work.[11]
[12]
[13]
The task taken up in the program is quite enormous but possible nevertheless. Only
through a systematic approach and implementation, rich dividends in protecting and
promoting the health of the children can be achieved.
Challenges and barriers affect the progress of any program, and if these factors are
identified, then measures could be planned to overcome them for betterment. Every
program has some good practices as well, which reveal the progress of the program,
and are necessary to be identified, as these could be adopted ubiquitously for the
beneficence of the beneficiaries and providers.
Keeping the above in mind, this study was planned to assess the challenges, barriers,
and good practices in implementation of RBSK program.
Methods
A community-based descriptive cross-sectional study was planned in 11 medical blocks
of Jodhpur district of Rajasthan, India. The MHT was taken as primary unit of study,
since an MHT works at the grassroot level for the implementation of this program.
Purposive sampling was used and all the members of the MHT of all 11 medical blocks
were invited to participate in the study. Ayurveda, Yoga and Naturopathy, Unani, Siddha
and Homeopathy (AYUSH) medical officers, auxiliary nurse midwives (ANMs), and pharmacists
of the MHT were included, and those who were on maternity, casual or medical leaves
were excluded.
For the quantitative component, a semistructured questionnaire was used, based on
the formative research report of RBSK, Assam, while for the qualitative component,
in-depth interviews of the members of MHT were conducted. The questionnaire comprised
questions related to manpower, sociodemographic information, perception regarding
trainings, support and resistance from officials and community, and challenges faced
by the teams. The data collection was done at the time of visit to individual blocks
by the interviewer, and data pertaining to the manpower, equipment, transport facilities
and good practices were noted through observations. Data related to satisfaction,
perception about trainings, resistance from community, and support from the officials
were recorded along with the demographic details from all the staff members present
on the day of visit through the interviews and questionnaire. Quantitative data was
processed using SPSS software and qualitative observation were presented in semiquantitative
form using qualifiers.
Results and Observations
Under the RBSK program, children of age 6 to 18 years are screened in government and
government-aided schools, with the block serving as the hub of all activities, and
villages in the jurisdiction of the block distributed among the MHTs. At least three
dedicated MHTs in each block were engaged to conduct the screening, and the number
of teams varied, depending upon the number of Anganwadi centers, remoteness and number
of children enrolled in the schools.
Every MHT is composed of 2 AYUSH medical officers (1 male and 1 female), 1 ANM or
staff nurse, and 1 pharmacist having proficiency in computers for additional task
of data management. Screening was found to be conducted at least twice a year in children
enrolled in Anganwadi centers and at least once a year for school children.
A toolkit with essential equipment for screening of children was provided to the MHT
members, including equipment for screening of development delays: bell, rattle, torch,
one-inch cubes, bottle with resins, squeaky toys and colored wool (for 6 weeks–6 years)
and vision charts, reference charts, blood pressure (BP) apparatus with age-appropriate
cuffs (for 6 years–18 years). Age-appropriate anthropometry equipment such as weighing
scales, height-measuring stadiometers, and tapes and bangles for midarm circumference
and head circumference were also found along with a development checklist to record
milestones for identification of developmental delays. Vehicles were hired for movement
to different locations (Anganwadi centers, government and government-aided schools).
Every MHT prepared a microplan prior to a visit to Anganwadi and schools, considering
route chart for daywise visits, logistics management, reporting system, and identification
of all relevant stakeholders.
The in charge medical officer (MO) of the block takes the lead in the microplanning
process and is supported by members of the mobile team and local health staff. In
urban areas, the district chief MO designates a nodal hospital/dispensary with a key-in-charge
staff for overseeing the activities and preparing microplans related to RBSK.
Socio Demographic Information
Out of the total participants (n = 54) surveyed from 11 medical blocks of Jodhpur, 44 were female, and majority of
participants (57.4%) were of age group between 30 to 40 years in this survey. Among
all participants, there were 32 medical officers, 11 ANMs, and 11 pharmacists. Mean
salary of the MOs, ANMs, and pharmacists were Rs. 17,061 ± 374.51, Rs. 6,075 ± 386.70,
and Rs. 8,314 ± 412.61, respectively ([Table 1]).
Table 1
Showing demographic characteristics of the participants surveyed from 11 medical blocks
of Jodhpur
|
Characteristics
|
n = 54
|
%
|
|
Abbreviations: ANM, auxiliary nurse midwife; MO, medical officer.
|
|
Age
|
|
20–30
|
19
|
35.19
|
|
30–40
|
31
|
57.41
|
|
40-above
|
4
|
7.40
|
|
Gender
|
|
Male
|
30
|
55.46
|
|
Female
|
24
|
44.44
|
|
Post Profile
|
|
MO
|
32
|
59.3
|
|
ANM
|
11
|
20.4
|
|
Pharmacist
|
11
|
20.4
|
Challenges and Barriers Faced by the Members of MHTs
Majority of the MOs (90.6%; n = 29) agreed that training provided to them through RBSK was sufficient to carry
out the screening activities and overcome the field challenges, while only 36.4% (n = 4) of ANMs agreed with the same. On the other hand, all MOs (n = 32) and pharmacists (n = 11) considered that their salary was not in accordance with the designation and
workload. MHT staff agreed that more training sessions were required for screening
and management of issues related to defects at birth and development delays and disabilities
([Table 2]).
Table 2
Showing perception of participants regarding various issues
|
|
MHT staff
|
Total
(n = 54)
|
|
MO
(n = 32)
|
ANM
(n = 11)
|
Pharmacist
(n = 11)
|
|
Abbreviations: ANM, auxiliary nurse midwife; MHT, mobile health team; MO, medical
officer.
|
|
Perception regarding RBSK training fulfilling daily work needs
|
Strongly agree
% (n)
|
28.1 (9)
|
0 (0)
|
18.2 (2)
|
20.4 (11)
|
|
Agree
% (n)
|
62.5 (20)
|
36.4 (4)
|
45.5 (5)
|
53.7 (29)
|
|
Neutral
% (n)
|
3.1 (1)
|
18.2 (2)
|
9.1 (1)
|
7.4 (4)
|
|
Disagree
% (n)
|
3.1 (1)
|
27.3 (3)
|
18.2 (2)
|
11.1 (6)
|
|
Strongly Disagree
% (n)
|
3.1 (1)
|
18.2 (2)
|
9.1 (1)
|
7.4 (4)
|
|
Perception regarding need for more training session for different diseases
|
Defects at birth
% (n)
|
37.5 (12)
|
27.3 (3)
|
27.3 (3)
|
33.3 (18)
|
|
Deficiencies
% (n)
|
9.4 (3)
|
0 (0)
|
0 (0)
|
5.6 (3)
|
|
Childhood disease
% (n)
|
18.8 (6)
|
0 (0)
|
9.1 (1)
|
13 (7)
|
|
Development delays and disabilities % (n)
|
31.3 (10)
|
18.2 (2)
|
36.4 (4)
|
29.6 (16)
|
|
Others
% (n)
|
3.1 (1)
|
54.5 (6)
|
27.3 (3)
|
18.5 (10)
|
|
Perception of respondents regarding salary
|
Satisfactory
% (n)
|
0 (0)
|
18.2 (2)
|
0 (0)
|
3.7 (2)
|
|
Unsatisfactory
% (n)
|
81.3 (26)
|
36.4 (4)
|
63.6 (7)
|
68.5 (37)
|
|
Very low
% (n)
|
18.8 (6)
|
45.5 (5)
|
36.4 (4)
|
27.8 (15)
|
|
Perception regarding job satisfaction and future prospects
|
Stay in same job
% (n)
|
6.3 (2)
|
27.3 (3)
|
18.2 (2)
|
13 (7)
|
|
Job is promising
% (n)
|
31.3 (10)
|
54.5 (6)
|
9.1 (1)
|
31.5 (17)
|
|
Dissatisfied
% (n)
|
46.9 (15)
|
18.2 (2)
|
45.5 (5)
|
40.7 (22)
|
|
Leave as soon as possible % (n)
|
15.6 (5)
|
0 (0)
|
27.3 (3)
|
14.8 (8)
|
|
Perception regarding provided targets
|
Achievable
% (n)
|
78.1 (25)
|
72.7 (8)
|
45.5 (5)
|
70.4 (38)
|
|
Not achievable
% (n)
|
18.8 (6)
|
27.3 (3)
|
54.5 (6)
|
27.8 (15)
|
|
Achievable but quality suffers
% (n)
|
3.1 (1)
|
0 (0)
|
0 (0)
|
1.9 (1)
|
|
Perception about atmosphere at screening camp
|
Helpful
% (n)
|
75 (24)
|
90.9 (10)
|
63.6 (7)
|
76 (41)
|
|
Neutral
% (n)
|
12.5 (4)
|
9.1 (1)
|
27.3 (3)
|
14.8 (8)
|
|
Noncooperative
% (n)
|
12.5 (4)
|
0 (0)
|
9.1 (1)
|
9.3 (5)
|
|
Perception about resistance from community
|
Always
% (n)
|
0 (0)
|
9.1 (1)
|
0 (0)
|
1.9 (1)
|
|
Sometimes
% (n)
|
68.8 (22)
|
54.5 (6)
|
63.6 (7)
|
64.8 (35)
|
|
Not at all
% (n)
|
31.3 (10)
|
36.4 (4)
|
36.4 (4)
|
33.3 (18)
|
As much as 78.1% of the MOs and 72.7% ANMs perceived the targets provided to them
to be achievable, but the perception was not so among the pharmacists, 54.5% of whom
considered the targets to be unachievable.
Most of the MOs (62.5%) and pharmacists (72.8%) did not seem satisfied with their
job, whereas 81.8% ANMs were found to be satisfied; 75% MOs, 90.9% ANMs and 63.6%
pharmacists perceived the work atmosphere at screening camp helpful and mutually cooperative.
Nevertheless, majority of the MHT staff (68.8% MO, 63.6% ANMs and 63.6% pharmacists)
shared experiences of facing resistance from the community during screening camps.
Other challenges that were brought forward during the interviews were those of harsh
climatic conditions, difficult terrain and inaccessible areas, and prevalence of superstitions
among villagers and tribes.
Adverse working conditions:
“Most of the time during our work, temperature is too high.”
“Areas adjacent to the Thar desert have extremely high temperatures, which do not
allow us to work with full potential.”
Superstitions and local practices:
Caregivers were reported to be not ready for treatment of their children even when
the government provided it free of cost; instead, they made different excuses and
were reluctant for availing treatment or suggestions provided by the RBSK team.
“Superstition prevails among the villagers at various levels, few villagers think
that tantriks can treat disease better than the doctors, they consider everything (deeds and spirits)
and not just our illness.”
“Diseases and deformities, according to the rural caregivers, is a curse of their
past life deeds”
Manpower:
Certain MHTs reported to be deficient in human resources and thus unable to meet targets
repeatedly.
“We do not have sufficient manpower required for our block size, so we are missing
deadlines repeatedly.”
“We have MOs but not sufficient data entry operators and nurses, so our reporting
is often delayed.”
Transport facilities:
Proper roads for transportation seemed to be lacking in most of the remote villages,
and the RBSK team considered it to be one of the major issues against reaching out
to maximum population.
“Sometimes, team needs to walk a long distance to reach remotely located Anganwadi
centers and schools.”
“Many times, RBSK vehicles cannot cross difficult terrains, and we have to walk to
reach our destination.”
Support from Anganwadi centers:
In some instances, support from Anganwadi center was lacking. In such Anganwadis,
attendance of children was low during the screening camp.
“Few Anganwadi workers do not take interest in RBSK program, and when forced, they
bring unregistered children to increase the attendance at RBSK screening camp.”
Salary and renumeration:
While taking in-depth interviews, most of the MOs had concerns about their salary.
“Our salary is very low as compared to other states’ RBSK Mos.”
“Considering the workload, salary should be similar to permanent MOs.”
AYUSH medicines:
Majority of MOs were of view that AYUSH medicine should be incorporated in medicine
kit, as MHT MOs were from AYUSH background.
“AYUSH medicine are very effective in childhood diseases and should be provided along
with allopathy.”
“Authorities should provide provision of AYUSH system of medicines in the medicine
kit.”
Good Practices
Along with the challenges and barriers, certain good practices were also observed
in the implementation of RBSK by various MHTs during the course of study, such as
fully functional and adequately equipped MHTs of RBSK Jodhpur along with appropriate
vehicles that were readily available and maintained prior to every field visit. Most
of the MHTs were found to be able in providing information education communication
(IEC) for creating awareness during screening camps related to newborn diseases and
healthy lifestyles.
In the state of Rajasthan, Bhamashah Bima Yojana (BSBY) covers RBSK surgical cost
of the patient, which was found to be able to provide for better patient compliance,
coverage and acceptability. At the level of data collection, most of the screened
data was sent to the district early intervention center (DEIC) through an online portal,
which made the data entry transparent and rapid with limited errors.
Discussion
The RBSK project was launched in February 2013 with the objectives of early detection
and management of the 4Ds, and in this study, we tried to assess challenges, barriers,
and good practices in center so far toward achieving this objective of RBSK in Jodhpur,
Rajasthan.
It was evident in this study that RBSK team is getting supportive environment for
their work in communities, but myths and misconceptions of the rural community were
posing major challenges to their functioning. Education and sensitization with reinforcement
could help to overcome this barrier.
In the present study, findings revealed that MHT of medical block (Baap, Phalodi,
and Balesar) were deficient in human resources required to complete the target. Most
of the medical officers were from Ayurvedic (Bachelor of Ayurvedic Medicine and Surgery
[BAMS]) background and a few from other streams (Bachelor of Homeopathic Medicine
and Surgery [BHMS], Bachelor of Unani Medicine and Surgery [BUMS]), but there was
a deficiency of data entry operator and nurses. Similar findings were highlighted
in the study conducted by Singh et al.[14]
The challenges, barriers, and good practices of all MHTs of RBSK were assessed using
a pretested questionnaire, and majority of MOs agreed that the training provided by
RBSK fulfils the basic need of organizing screening camps.
It was found in the study that RBSK was successful in maintaining the satisfaction
level of grassroot level team worker (ANMs), but a contrast was observed in context
of the salaries in the perception of majority of MOs and pharmacists. The salaries
were considered very low compared with other states where RBSK program is running.
Most of the pharmacists thought that work target provided to them were not achievable,
because they had dual roles of work as a pharmacist as well as that of a data entry
operator. Similar challenges were reported in the implementation of other national
programs in the country, as highlighted by the studies conducted by Sogarwal et al
and Best and Kumar.[15]
[16]
Most of the MOs, pharmacists, and ANMs perceived that atmosphere at screening camp
was helpful. However, sometimes, resistance was created by community, and seldom by
school teachers and Anganwadi staff, which affected the screening program. Furthermore,
most of the MOs faced challenges while convincing caregivers of the children, because
of prevailing superstitions among the villagers, which posed a major barrier in implementation.
Rural caregivers said that diseases are a curse of their past lives’ deeds, and they
seemed reluctant to avail treatment or suggestions provided by the RBSK team. Similar
challenges in health seeking behaviors were observed in studies conducted by Sagar
et al and Kaur et al.[17]
[18]
Findings from the present study revealed that majority of MOs viewed that AYUSH medicine
should be incorporated in medicinal kit, as MHT MOs were from AYUSH background, and
they perceived that AYUSH medicines are very effective in childhood diseases.
While certain good practices such as fully occupied MHTs of RBSK Jodhpur with screening
equipment, availability of appropriate vehicles for field visits, and ANMs perceived
to be satisfied with their job were seen, nevertheless most of the MOs and pharmacists
were not satisfied with their jobs. It may be due to the fact that majority of MOs
and pharmacists considered that their salary was very low compared with other states
running RBSK program.
Conclusion and Recommendations
Conclusion and Recommendations
With this study, we inferred that the certain good practices as well as many challenges
were major determinants in the achievement of objectives of the ongoing RBSK program.
Lesser salary and dual workload for pharmacists were major barriers which along with
challenges such as harsh weather conditions, poor terrain, and resistance created
by local community hindered the working up to full potential by the MHT staff. There
is a requirement of more training sessions on birth defects, and issues such as lack
of manpower in certain blocks need to be addressed.
Through the study, few systematic recommendations are suggested, which if implied
might prove to improve program implementation. There is a need for an equality in
the wages of MHT staff in comparison with other RBSK running states and a need for
rapport-building activities with community stakeholders prior to the scheduled screening.
Awareness activities for the community with major involvement of local stakeholders
would be helpful in reducing the community resistance experienced by MHT staff. Recruitment
of dedicated data entry operators, responsible for data entry of a group of MHTs,
would further increase the efficiency of the pharmacists while not straining the budgetary
restraints. Provision of AYUSH medicines in the medicine kit to be used along with
allopathic treatment modalities, provision of air condition vehicles to combat the
harsh weather conditions, and frequent feedback from MHT staff regarding training
requirements and regular training activities regarding the same are further expected
to increase staff compliance and ensure program success.
