| 4. In which ways is the initiative creative and innovative?
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The ideation seminar organised for developing a blueprint for intervention resulted in series of meetings with partners in action like Dr. Arun Singh (IPGMER). Dr. Arun Singh, former Head, Department of Neonatology, IPGMER provided guidance in designing technical support on facility-based protocols and later training of specialists of the Samarpan facility at IPGMER. The screening test for community level application- Reaching and Programming for Identification of Disabilities (RAPID) which has been developed by NIHM. Identification of nodal officers from ICDS (Women and Child Development), District Rehabilitation Centre (Social Justice Department) District Hospital (Health Department) and District Disability Rehabilitation Centre (DDRC) was carried out. In a series of meetings at the district level convergence model for facilitating implementation was worked out.
A lot of stress was given to awareness generation, and Information Education and Communication (IEC activities). Various tools such as nukkadnatak, Wall paintings related to disability in strategic locations, duggipitnapamphlets and advertisements were used to sensitise community. Panchayat secretaries, Ashas and AWWs were trained and were encouraged to spread consciousness through word of mouth.
The societal reluctance towards bringing their children to DDRC and resistance within family to accept possibility of disability in their child led to renaming DDRC with a more positive sounding name Samarpan.
The groundwork before implementation required activities such as:
Contextualizing RAPID to local needs and develop Samarpan Screening Test.
Doctors, Anaganwadi Workers (AWW), Accredited Social Health Activists (ASHA) were sensitised about disability.
Preparing training material and literature for the surveyors – AWWs and ASHAs.
AWWs were then trained accordingly on conducting the survey.
AWWs conducted door to door survey, suo- motte and en-masse for identifying children with development delays.
Identifying the children in the entire district showing signs of delayed development through a screening test.
Simultaneously, the strengthening of infrastructure was carried out by improving the facilities in existing District Disability Rehabilitation Centre and by procurement of essential equipment. The facility was equipped to provide services such as the neurological assessment, physiotherapy, occupational therapy, psychological Services like DSCII & DDST, cognitive development for socialization, vison, speech and language and hearing.
A Screening test was conducted by the AWWs and ASHAs en-masse and suo-motto to identify children with development delays The identified potential cases were registered at the facility with details entered in the system. The software ensured smooth monitoring as the details of facility functioning could be assessed by the supervisors at click of a button.
The next step was to bring these identified cases to the facility to conduct specialised diagnoses by specialists and suggest intervention. In order to facilitate the children and their parents, Transportation facilities for children and their parents were also arranged.A route chart was prepared according to the capacity of the facility to screen children for investigation in one day, and accordingly, AWWs were informed. The identified children were then suggested for specialised intervention with training given to their care-givers, often mothers and the AWWs for ensuring that home-based interventions are provided. The figure 1 gives details of the process flow at the facility.
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| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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The initiative was conceptualised by the then district collector of Hoshangabad District, Mr. Nishant Warwade along with his team of officials in District administration as well as officers from various departments such as Integrated Child Development Services, Women and Child Development, Department of Social Justice, National Rural Health Mission, District Disability Rehabilitation Centre, Department of Public Relations, Department of Rural Development and Department of Education.
Apart from the officials of Hoshangabad & later in Bhopal district, the initiative developed and evolved significantly as a result of the participants of the national level seminar held. More specifically, Dr. Arun Singh, former Head, Department of Neonatology, IPGMER provided guidance in designing technical support on facility-based protocols and later training of specialists of the ‘Samarpan’ facility at IPGMER. Dr Amita Chand of NIPI-UNOPS supported Samarpan throughout.
As many as 6000 grass roots level government functionaries such as the village level Anganwadi workers and Accredited social health activist formed the backbone of the program along with the parents of the children who participate in the screening tests for identification and those who participate in the long drawn process of intervention.
The Red Cross Society financed the development of ‘Samarpan’ software. The State Bank of India donated a bus to Samarpan facility for picking and dropping children from their CSR fund. The Rotary chapter contributed by arranging for food & beverages for suspected cases and their families and workers at the district facility.
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| 6. How was the strategy implemented and what resources were mobilized?
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Since the initiative was an inaugural effort on part of the district administration, there was no clear budget assigned for it. The implementation heavily depended on the convergence of available funds from various departments such as the District Women and Child Development Department, the District Health department, the District Disability Rehabilitation Centre, the Social Justice Department. Some private entities also assisted in small measures. Convergence with NRHM also aided the implementation.
The Red Cross Society financed the development of Samarpan software. The State Bank of India donated a bus to Samarpan facility for picking and dropping children from their Corporate Social Responsibility fund. Similarly, UNDP-NIPI financially assisted in developing the Samarpan facility at DDRC in Hoshangabad.
The Samarpan Centre at Hoshangabad required one time investment in infrastructure, machine, and equipment such as EIC equipments ,furniture, computers & printers, fax , photo copy machine, AC & Interior, LCD with DVD, Raw Material for P&OE, EIC Software, Play therapy Hall, BERA Electrode, web cam & camera, Sound proofing etc. and provision for recurring expenditure for salary of Administrative Officer and Physiotherapist, Psychologist, Audiologist/Ear Mould Technician., Speech Therapist, Optometrist, P&OE Technician, Mobility Instructor, MRW, Accountant, Counselor, ANMs, Peon ,Night Guard, Cleaner , Training for Staff, Training for ASHA &Anganwadi Workers , electricity bill, printing of formats etc. In all, the recurring component of the initiative is approx. INR ~ 2 million and one time establishing component is approx. INR 8 million.
In terms of human resources, personnel of department(s) of Women and Child development; Health & family welfare; Social justice and Revenue roughly numbering about 6000 were involved to roll out the initiative.
Financial resources were mobilized primarily from the allocated budget of the line department(s). The unspent allocation under disabled funds which every district collector has for his disposal was also harnessed. Activities which were not a mandate of any of the concerned department were taken care off by agencies such as Red Cross and Rotary. The initiative was also marginally aided by NIPI-UNOPS financially, towards one time establishment cost.
Human resources were mobilized by the district administration under the leadership of collector. Various line departments were asked to align their human resources as per the plan developed on mandate. Often neglected resource of time was effectively harnessed all through the initiative.
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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1. Universal screening has led to early detection of early diseases and disability, resulting in timely intervention and a reduction in morbidity and lifelong disability. Dividends of early intervention not only enhance the improvement of survival outcome but also results in reduction of mal-nutritional prevalence, enhancing community development and educational attainment and overall improvement of quality of life. After initiation in 2010 and six rounds of Samarpan SST on about 6 lakh plus U5 children registered in ICDS in the district Bhopal and Hoshangabad till August, 2014, 14448 U5 children have been comprehensively examined at Samarpan out of which 6412 U5 children were identified as true positive. Out of these, 6412 U5 children have been identified as having one or more than one type of developmental delay, deficiency or disability.
2. Samarpan initiative has thus facilitated direct policy intervention at national level where there was a huge policy gap. Because of Samarpan 270 million children are getting screenedall acrossIndia.
3. Samarpan initiative has increased awareness on disability, delays & disease and early identification and intervention in Government functionaries and in society. The increase in capacity of Government human resource available at all 3 tiers -district, block and grass roots through tailor made capacity building programme is an evident benefit. Effective implementation of scientific concept(s) of critical period and Neuro plasticity by a practical and robust mechanism, resulting in early identification of U5 children having one or more confirm sign of onset of disability and their consequent intervention is a significant achievement .
4. In addition, home based intervention, awareness and capacity building has been carried out for concerned AWW and parents. Better utilization of Government resources resulting in their optimum use, in particular the often neglected resource of time through interdepartmental, intersectoral and inter institutional frame work is a key benefit. Last but not the least, the change in mode of Government service provider/department(s) from one of demand based to that of suomotu reaching out to societyby screening all U5 children for possible signs of disability is a paradigm shift and is a significant benefit arising out of initiative.
5. Samarpan centres provide multi-disciplinary evaluation and treatment by experts of different fields under a single roof in a single, dedicated building. Further, Tertiary linkages for domain specific services have also been established for comprehensive interventions.
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| 8. What were the most successful outputs and why was the initiative effective?
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Dedicated meetings were conducted at block level once in a month and at the district level twice a month. In the three departments- department of health, Women and child development and social justice- nodal persons were identified and given the responsibility for interim course correction to address the day-to day challenges.
The initiative had an in-built mechanism of monitoring as the entire process was digitised. Once a suspected case was caught in the net by preliminary screening, the details of child and their assessment by experts for development delays in all possible domain , along with their comments and diagnosis were fed into Samarpan software that was specially designed in order to store case specifics such as, parental history, detailed birth history of the baby, developmental assessment, and assessment of hearing and visual functions, intervention strategy, and periodic evaluation.
The identified potential cases were registered at the facility with details entered in the system. The software ensured smooth monitoring as the details of facility functioning could be assessed by the supervisors at click of a button.
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| 9. What were the main obstacles encountered and how were they overcome?
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The main obstacles encountered while evolving Samarpan were acute resource gaps in terms of knowledge, finance and Human resources. In human resources, there was a gap in technical, managerial and field level trained personnel. There was obscurity about concept of early identification of disability and principle of neuroplasticity and critical period of development both in society and in governmental setup. An essential need to roll Samarpan out through convergence of more than one Government department(s) and Institutions, including NGOs , due to overlapping of mandates was felt.Negative mind set of departments to defend their so called “turf”; the serious gap in knowhow and knowledge of procedures; non-availability latest machines and equipments; Logistical gap such as transportation etc.; lack of monitoring and evaluation; question of increasing the net; miscellaneous impediments were other challenges.
Planning was carried out after many a brainstorming sessions by the administration under the then collector. It was decided that to overcome the ignorance and lack of knowledge of disability in general and early identification and intervention in particular, through National level a seminar of leading experts on the topic in Hoshangabad. IEC programme for society were then launched to create awareness in society.
The overlapping nature of objectives of Samarpan necessitated evolving a convergence model involving departments such as Social Welfare, Women and Child Development, Health. A well thought of convergence model was development keeping in mind the resources and mandate of Government departments as well as other institutions. The gap in technical manpower, machines and equipment was sought to be filled by recruiting suitable professionals as well as procuring state of the art machines by pooling financial resources of Social justice and Health.Poor monitoring and evaluation was overcome by taking regular and focused meeting of all concerned.
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