Make a comparative analysis between RBSK and INAP schemes launched by Government of India. Which scheme you think to be best applicable in the scenario of Assam?

The health of its citizens, particularly its most vulnerable populations like children and newborns, remains a cornerstone of India’s national development agenda. Recognizing the critical need to address preventable mortality, morbidity, and developmental challenges, the Government of India has launched a series of targeted interventions under the overarching framework of the National Health Mission (NHM). These initiatives reflect a deep commitment to achieving Universal Health Coverage and meeting the Sustainable Development Goals (SDGs) related to health and well-being.

Among the myriad of programs designed to bolster child health, the Rashtriya Bal Swasthya Karyakram (RBSK) and the India Newborn Action Plan (INAP) stand out as two pivotal schemes. While both are integral components of the country’s public health strategy, they possess distinct objectives, target populations, and intervention mechanisms. A comprehensive comparative analysis of these two schemes is crucial to understanding their individual strengths, their complementary roles, and their collective impact on the health trajectory of India’s future generations.

• Rashtriya Bal Swasthya Karyakram (RBSK)
• India Newborn Action Plan (INAP)
• Comparative Analysis: RBSK vs. INAP
• Applicability in the Scenario of Assam

¶Rashtriya Bal Swasthya Karyakram (RBSK)

The Rashtriya Bal Swasthya Karyakram, launched in February 2013 under the National Health Mission (NHM), is a comprehensive and proactive child health screening and early intervention program. Its primary aim is to improve the quality of life of children by providing early detection and management of health conditions, encompassing a broad spectrum of issues from birth defects to developmental delays. The scheme conceptualizes child health not merely as the absence of disease but as a holistic state of physical, mental, and social well-being, emphasizing long-term health outcomes and reduced burden of disability.

Objectives and Scope: RBSK specifically targets what are known as the “4 Ds”:

1. Defects at birth: This includes congenital anomalies such as neural tube defects, Down syndrome, congenital heart diseases, cleft lip/palate, clubfoot, and developmental dysplasia of the hip, among others.
2. Deficiencies: Nutritional deficiencies like anemia, Vitamin A deficiency, severe acute malnutrition (SAM), and iodine deficiency disorders are addressed through screening and appropriate supplementation or management.
3. Diseases: Common childhood illnesses, including skin conditions, ear infections, dental caries, vision impairments, and certain infectious diseases prevalent in childhood, are screened for.
4. Developmental Delays including Disabilities: This critical component focuses on early identification of developmental delays, including cognitive, motor, language, and socio-emotional delays, as well as disabilities like cerebral palsy, hearing impairment, vision impairment, and autism spectrum disorder.

The program aims to screen children from birth up to 18 years of age. This vast age group is categorized into two main segments for operational purposes:

• 0-6 years: Screening is conducted at Anganwadi Centres (AWCs) and through home visits for newborns and infants by Mobile Health Teams (MHTs), Auxiliary Nurse Midwives (ANMs), and Accredited Social Health Activists (ASHAs).
• 6-18 years: School-going children in government and government-aided schools are screened by dedicated Mobile Health Teams.

Services and Implementation: The core of RBSK’s implementation strategy revolves around a multi-tiered approach:

• Screening at Community and School Levels: Dedicated Mobile Health Teams (MHTs), comprising a doctor (AYUSH), a male nurse, and a female nurse, are deployed to conduct regular health screenings at Anganwadi Centres and schools. For infants and newborns, screenings are integrated into existing home-based newborn care visits and routine immunization sessions.
• Referral and Linkages: Children identified with any of the “4 Ds” during screening are referred to higher health facilities, ranging from District Early Intervention Centres (DEICs) to tertiary care hospitals. DEICs are crucial hubs, designed to provide comprehensive diagnostic, therapeutic, and rehabilitation services, including speech therapy, physiotherapy, occupational therapy, and special education.
• Comprehensive Management: A key strength of RBSK is its commitment to providing free treatment, including surgeries for congenital defects, corrective aids (e.g., hearing aids, spectacles, calipers), and long-term management for chronic conditions. This ensures that financial barriers do not impede access to essential care for identified health issues.
• Capacity Building: Training of health personnel, including ANMs, ASHAs, and MHT members, is crucial to ensure accurate screening, identification, and referral.

Key Features and Impact: RBSK represents a paradigm shift from a purely curative approach to a more preventive and promotive one in child health. By focusing on early detection and intervention, the program aims to minimize the impact of health conditions on a child’s growth, development, and quality of life, thereby reducing the lifelong burden of disability and healthcare costs. It integrates school health programs into a broader child health strategy, ensuring that children, irrespective of their socio-economic background, have access to basic health screening services. The program also emphasizes community participation and parental engagement, fostering a health-conscious environment.

Challenges: Despite its robust framework, RBSK faces several implementation challenges. These include ensuring consistent availability of trained MHTs, adequate follow-up mechanisms for referred cases, timely provision of corrective surgeries and aids, and the establishment and optimal functioning of DEICs. Furthermore, generating sufficient awareness among parents and school authorities, and overcoming geographical barriers in remote areas, remain ongoing hurdles. The quality of screening and the accuracy of diagnosis, especially for developmental delays, require continuous monitoring and capacity building.

¶India Newborn Action Plan (INAP)

The India Newborn Action Plan (INAP), launched in September 2014, represents a concerted national effort to accelerate the reduction of newborn mortality and stillbirths. India’s high burden of neonatal deaths and stillbirths necessitated a dedicated, high-impact strategy, aligning with global commitments such as the Every Newborn Action Plan (ENAP) and the Sustainable Development Goals (SDGs), particularly SDG 3.2, which targets ending preventable deaths of newborns and children under 5 years of age. INAP specifically aims to achieve a single-digit Neonatal Mortality Rate (NMR) and single-digit Stillbirth Rate (SBR) by 2030.

Objectives and Scope: INAP’s overarching objective is to end preventable newborn deaths and stillbirths. It recognizes that the neonatal period (the first 28 days of life) is the most vulnerable phase for a child, accounting for a significant proportion of under-five mortality. The plan addresses the leading causes of newborn deaths, including prematurity and low birth weight, birth asphyxia, and infections like sepsis and pneumonia. It also crucially focuses on stillbirths, acknowledging their devastating impact on families and their role as indicators of gaps in maternal and perinatal care.

Strategic Interventions/Pillars: INAP’s strategic framework is built upon six pillars, ensuring a continuum of care from preconception to postnatal life:

1. Pre-conception and Antenatal Care: This pillar emphasizes improving maternal health and nutrition before and during pregnancy. Interventions include ensuring adequate iron and folic acid supplementation, counseling on healthy lifestyles, early registration of pregnancy, and quality antenatal check-ups to identify and manage high-risk pregnancies, prevent infections (e.g., syphilis, malaria), and promote institutional deliveries.
2. Care during Birth: This is a critical pillar focused on ensuring skilled attendance at every birth. Key interventions include promoting institutional deliveries, ensuring availability of essential newborn care (EENC) at the time of birth (e.g., immediate drying, warmth, cord care, early initiation of breastfeeding), and resuscitation services for babies who do not breathe at birth.
3. Care after Birth: This pillar focuses on postnatal care for both mother and baby. It includes timely postnatal home visits by ASHAs and ANMs, identification of danger signs in newborns, management of sick newborns through referral to higher facilities, and promotion of Kangaroo Mother Care (KMC) for low birth weight and premature babies. Establishing and strengthening Special Newborn Care Units (SNCUs) at district hospitals and Newborn Stabilization Units (NBSUs) at FRUs are central to this.
4. Care of Sick Newborns: This pillar focuses on effective management of sick newborns at all levels of the healthcare system. It involves prompt identification and referral, quality care at SNCUs and NBSUs for conditions like sepsis, jaundice, respiratory distress, and providing follow-up care for high-risk babies.
5. Addressing Stillbirths: INAP explicitly highlights the need to reduce stillbirths by improving the quality of antenatal care, ensuring skilled intrapartum care, and conducting stillbirth audits to understand causes and implement preventive measures.
6. Cross-cutting Interventions: This pillar encompasses foundational elements necessary for successful implementation across all pillars. These include strengthening human resources (training and deployment), improving infrastructure and equipment, ensuring robust supply chains for essential drugs and consumables, adequate financing, community mobilization, and strengthening data systems for monitoring and evaluation.

Services and Implementation: INAP is primarily facility-based for critical care but extends to the community for prevention and follow-up. It leverages the existing public health infrastructure and workforce.

• Community Level: ASHAs are crucial for promoting institutional deliveries, providing home-based newborn care (HBNC) through multiple post-natal visits, identifying danger signs, and referring sick newborns.
• Facility Level: Sub-centres, Primary Health Centres (PHCs), Community Health Centres (CHCs), First Referral Units (FRUs), and District Hospitals are strengthened to provide essential and comprehensive newborn care. The establishment and functionalization of SNCUs are central to providing specialized care for sick and premature babies.

Key Features and Impact: INAP’s strength lies in its comprehensive, evidence-based approach that spans the entire continuum of care, from pre-pregnancy to the critical neonatal period. It emphasizes skilled care at birth, which is a powerful intervention for preventing birth-related complications and infections. By focusing on facility-based care for sick newborns and strengthening referral networks, it aims to reduce the gap between where babies are born and where they can receive life-saving care. The explicit inclusion of stillbirths is a progressive step, highlighting the broader reproductive health context.

Challenges: Challenges for INAP include achieving universal skilled birth attendance, especially in remote and underserved areas, ensuring the quality of care provided in all health facilities, addressing critical human resource shortages (especially skilled nurses and doctors for SNCUs), ensuring efficient referral transport systems, and overcoming socio-cultural barriers that may delay health-seeking behavior. Maintaining equipment, ensuring uninterrupted supply of essential medicines, and strengthening data quality for effective monitoring are also persistent challenges.

¶Comparative Analysis: RBSK vs. INAP

While both RBSK and INAP operate under the umbrella of the National Health Mission and aim to improve child health, they differ significantly in their primary focus, target population, and intervention strategies.

Complementarity: Despite their distinct focuses, RBSK and INAP are highly complementary. INAP ensures that a newborn survives the critical first 28 days by addressing immediate life-threatening conditions. Once a child navigates this vulnerable period successfully, RBSK steps in to ensure their healthy growth and development through childhood and adolescence. For instance, a child saved from birth asphyxia by INAP’s interventions might later benefit from RBSK’s screening for developmental delays or disabilities resulting from the initial insult. Similarly, RBSK’s focus on screening for congenital heart diseases or neural tube defects in early childhood relies on the fact that the child survived the neonatal period, often due to interventions promoted by INAP. Thus, they represent a seamless continuum of care for children from conception through adolescence.

¶Applicability in the Scenario of Assam

Assam, a state in Northeast India, presents a unique set of demographic, socio-economic, and geographical challenges that significantly influence its health indicators. The state has historically struggled with high rates of maternal and child mortality, though significant progress has been made in recent years through concerted efforts under NHM. As per recent National Family Health Survey (NFHS) data, while indicators have improved, child mortality rates, including infant and neonatal mortality, still remain a concern, often above the national average in certain districts. Other significant health challenges include high rates of malnutrition, anemia among children and women, prevalence of infectious diseases, and difficulties in accessing healthcare due to varied terrains, including flood-prone plains, hills, and remote tribal areas.

Given this context, both RBSK and INAP are critically important for Assam, but their immediate applicability for addressing the most pressing health challenges can be weighed differently.

Why INAP is Crucial and Arguably More Immediately Applicable in Assam:

1. High Neonatal Mortality Burden: Assam’s Neonatal Mortality Rate (NMR) has been a significant concern. INAP directly targets the reduction of newborn deaths, which are primarily caused by prematurity, birth asphyxia, and infections. These causes are highly prevalent in settings with suboptimal maternal and newborn care. By focusing on skilled birth attendance, prompt management of complications during delivery, and strengthening Special Newborn Care Units (SNCUs), INAP addresses the most critical survival bottlenecks for the youngest and most vulnerable population group.
2. Addressing Causes of Neonatal Deaths: The geographical challenges and socio-economic disparities in Assam often translate into delayed access to quality healthcare. INAP’s emphasis on strengthening facility-based newborn care (SNCUs, NBSUs) means that even in remote areas, sick newborns can receive specialized care if referred promptly. Its focus on Essential Newborn Care (EENC) at the time of birth, even for home deliveries (though institutional deliveries are promoted), is vital for immediate survival.
3. Community-level Impact: The Home-Based Newborn Care (HBNC) component of INAP, delivered by ASHAs, is particularly critical in Assam’s scattered populations, tribal areas, and flood-prone regions where access to facilities might be challenging. ASHAs can identify danger signs early and facilitate timely referrals, thereby bridging the gap between community and facility-level care.
4. Stillbirth Reduction: The focus on stillbirths under INAP is also highly relevant for Assam, as stillbirths often indicate gaps in quality antenatal care and intrapartum management, areas that need significant strengthening in the state. Reducing stillbirths also contributes to improving overall maternal and reproductive health.
5. Foundational Impact: Without ensuring newborn survival, the long-term benefits of RBSK cannot be fully realized. A child must first survive the neonatal period to then grow and be screened for developmental delays or deficiencies in later childhood. Therefore, INAP lays the fundamental groundwork for child health.

Why RBSK is Also Indispensable for Assam (Complementary Role):

1. Addressing Chronic Childhood Morbidity: While INAP focuses on survival, RBSK addresses the subsequent health and developmental needs. Assam faces significant challenges related to malnutrition (especially anemia and SAM), which RBSK directly screens for and manages.
2. Early Identification of Disabilities: Given the potential for congenital anomalies and developmental delays in any population, and possibly higher undetected rates in underserved areas, RBSK’s systematic screening for ‘Defects at Birth’ and ‘Developmental Delays including Disabilities’ is crucial. Early detection allows for timely intervention, rehabilitation, and integration of children with disabilities into mainstream society, reducing lifelong burden.
3. School Health Programs: The school-based screening component of RBSK is excellent for reaching children who might otherwise not access healthcare services. It integrates health education and screening into a structured environment, which is highly beneficial for improving general health awareness among children and their families.
4. Long-term Health Trajectory: RBSK ensures that children, once they have survived the vulnerable neonatal period (thanks to INAP’s interventions), receive continuous health oversight through their formative years, addressing emerging health issues and promoting overall well-being and productivity.

Conclusion for Assam’s Scenario:

While both RBSK and INAP are indispensable components of a holistic child health strategy for Assam, if one were to prioritize based on the most immediate and critical health challenges, the India Newborn Action Plan (INAP) would be considered more fundamentally applicable in the scenario of Assam. This is because INAP directly targets the reduction of preventable newborn deaths and stillbirths, which constitute a significant proportion of the state’s child mortality burden. Ensuring the survival of a newborn baby is the absolute first step in their health journey. Without successful navigation of the neonatal period, the subsequent benefits offered by RBSK become moot for those who do not survive.

INAP’s focus on strengthening institutional deliveries, providing essential care at birth, establishing and operationalizing SNCUs, and promoting home-based newborn care directly addresses the leading causes of neonatal mortality in a state like Assam, where access to quality care at the time of birth and in the immediate postnatal period can be challenging. By securing the survival of newborns, INAP lays the foundational stone upon which all subsequent child health interventions, including RBSK, can build. RBSK then serves as the crucial continuum of care, ensuring that these surviving children grow into healthy individuals, free from preventable disabilities and diseases, thus complementing and enhancing the impact initiated by INAP. Therefore, for Assam, a dual emphasis with a strong initial push on INAP’s objectives, followed by robust implementation of RBSK, presents the most effective strategy for improving child health outcomes.

The concerted implementation of both INAP and RBSK, while recognizing INAP’s foundational role in child survival, is essential for Assam to achieve its child health goals. A synergistic approach, where the successful outcomes of INAP (reduced newborn deaths) feed into the broader scope of RBSK (healthy childhood development), will yield the most impactful and sustainable improvements in the state’s child health indicators.