Samarpan-EIRC
District Administration,Bhopal,MP,India

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Out of every 100 babies born in India 6 to 7 are born with a birth defect. This translates to about 1.7 million birth defects annually and would accumulate to 9.6 percent of all new born deaths. About 10-15 percent of the births in the country are pre-term births and these are at a higher risk of not being able to reach their full genetical potential. Developmental impairment is a common problem in children that occurs in approximately 10% of the childhood population. This amounts to a huge number in our country having the second largest population in the world.These delays if not intervened timely, may lead to permanent disabilities severely impacting the life of an individual .Impairment leads to problems of cognition, hearing, vision and natural physical well being. There are also deficiencies like anaemia, iodine deficiency disorder, vitamin D deficiency, protein energy malnutrition, vitamin A deficiency, rheumatic heart diseases and reactive airway diseases quiet prevalent in preschool childre

B. Strategic Approach

 2. What was the solution?
1. The solution would first and foremost require capacity building of grass root workers to screen repeatedly, en masse all children for developmental delays and diseases so as to harness neuroplasticity. 2. Secondly a robust team to identify the vulnerable children from amongst the suspected population. 3. Lastly providing holistic intervention of therapy and treatment at the initial primal stages and the facility or by institutional referral mechanisms.

 3. How did the initiative solve the problem and improve people’s lives?
The initiative involved en masse screening of all the children below the age of 6 years amongst the entire under six population of both the districts. A stout group of about 3000 rural and 500 urban grassroots level workers (crèche Social health activists) screened the entire population, combing the population for children with delays/disabilities and diseases. To support their screening, they were provided predesigned formats on which they recorded the findings of each and every child screened and earmarked the ones suspected to be missing their milestones and were predisposed to any developmental delays or impairments. The entire group of social health activists received intensive trainings for capacity building to understand the screening process. Equipped with the knowledge they performed a number of tests on all the vulnerable population at repeated intervals and referred these children to a center located at the district. The center at the district level provided a team of experts who after a battery of comprehensive tests enunciated the status of the child. If the child was found positive for the findings treatment or therapy was instituted accordingly. The center is one of its kinds which provides all services under the same roof and the patient does not need to run from pillar to post for his treatment. A child who is true positive at any given time may be having multiple impairments that in some other situation would have to visit different center for different treatment, but here the child can avail all services under one roof. The first visit of the child ensures he gets screening done for all his conditions. Then successive visits provide for treatment and therapies whatever has been advised by the specialists.The center provides multi-disciplinary evaluation and treatment by experts of different fields. The services are which are being provided at facility or through convergence with NGOs and related institutions are Medical treatments, Occupational therapy, Physical therapy, Psychological, Audiology, Speech-language pathology, Vision, Health, Nutrition, Social work, Special Instruction. It also offers cardiology,neurology,endocrinology,urology,dermatology and genetics related super specialty services under the medical services.Special clinics are conducted on designated days of the week for better focus.Various private practitioners, healthcare providers and other non-governmental health care organizations provide these services by joining hands with each other. Children requiring surgical intervention are referred to higher centers across the country.The best hospitals have a tie- up with the center to provide best treatments possible with advanced testing and services. The cost of all the procedures and treatment is borne by the Centre. The beneficiaries have no out of pocket cost bearing. No direct costs are imposed on the beneficiaries as they even have a transportation facility available which they can avail as often possible. The program provides an end to end solution for all their requirements and the treatments offered at the center are custom designed for each and every child. It is due to the intend of this program that people who could never have been able to afford the treatments for their children are availing the benefits for their kids and the future generation of the country. In addition, it’s a paradigm shift in approach where suspected cases are actively searched to harness neuroplasticity which is relatively poor after 5-6 years meaning the delay of the child will be more or less of permanent nature. It thus is a program for disability prevention & reduction. It is in the betterment of the society that these children are availing services and looking forward to a quality life reducing the morbidity due to impairment.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
This initiative works on a very unique model of convergence which is an ideal administrative paradigm. It is a paradigm shift for it seeks suspected cases in community repeatedly. Initiative allows better utilization of Government resources resulting in their optimum use, in particular neglected “resource of time” through interdepartmental, intersectoral and inter institutional convergence frame work and involvement of NGOs and civil society. The grassroots workers are not highly qualified but judiciously trained to screen the delays leading to impairment. Their timely early intervention in identification of the children in the field leads to referral where they receive treatment/therapy.Regular camps are held for the population with the help of these workers so as not to miss out on even a single child. All stakeholders; government department, non government organizations, private practitioners, private healthcare organizations, citizens of civil society collectively provide their services with intent to productively contribute in the lives of children. They judiciously follow up and assess the amount of work done and brainstorm ideas for better functioning of the centre .It is a group of administrators, specialists,therapists working together,solving problems and enhancing capabilities illustrating a perfect example of what convergence can achieve with joint efforts.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The initiative was implemented by the district administration in Hoshangabad and Bhopal district, MP. The entire program was rolled out on the total population of under six in the district. A team of social health activists and crèche workers from women and child health department initiated the program on ground zero. After initiation and multiple rounds of massive screening which stretched to approximately 7.5 lac children being screened under the program. Out of the total children screened about 74,265 were identified as suspected cases. They were comprehensively examined and out of these six thousand three hundred seventy-three (6373) children have been registered at the center with some or the other or a combination of various physical and mental developmental delays. At the center a medical dairy/file is maintained for every child and details of investigations, treatment advised, therapy and progress made is recorded for future references. Effective rehabilitation is a huge concern and is possible only if it is provided with intensive coaching, with increased intensity and frequently, sometimes required more than once in a week.Currently 1800 children are receiving occupational therapy for various motor impairments and about 2500 are receiving audio and speech therapy. As many as 2119 have been identified as slow learners or suffering from attention/hyperactivity disorders. They are regularly monitored for their skills adaptation. Some are afflicted with other psychological problems for which they are undergoing therapy too. A total of 2095 are receiving special education so that they can learn personal, social and academic skills for inclusion. About 1008 have received treatment for vision related problems.The initiative not only touches the lives of children who otherwise would have been impaired in future but also vicariously helps about 100000 plusfamilies whose infants are screened suomotu.
 6. How was the strategy implemented and what resources were mobilized?
The strategy includes prevention of disability or minimizing the effect of disability from birth to six years of age and above six years by prevention of disability becoming a handicap. The implementation highlights of strategy are : o Situational analysis of early intervention services in current scenario &Conceptualization of EIRC o Workshop to discuss on concept, roll out plan, activities and requirements for EIRC in which problems and their solutions were solicited from stakeholders o Mapping of resources & Identification of Nodal Officers and personnel from Women and Child Development, District Disability Rehabilitation Centre & Social Justice, and Health Departments. More than 50 meetings conducted for developing action plan, HR mobilization and planning of training and subsequent training for empowering AWWs, strengthening of infrastructure and procuring equipments etc. o Tailor made capacity building of concerned officials of various departments particularly of grass root level functionaries o Reaching out and screening each and every U5 child in the districts using self developed Screening Test suomotu by empowered crèche workers o Roll out of EIRC resulting into evaluation and intervention services in a holistic way by an interdisciplinary approach of a multidisciplinary team comprehensively along with referral linkages for specific domain. 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. Convergence with NRHM also aided the implementation. The Red Cross Society financed partly. 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. Once the initiative was replicated by the Govt of India, funding became a non issue The Samarpan-EIRC initiative 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 and NGOs 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.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
The stakeholders are district collector 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,Department of Health & family welfare, National Health Mission, District Disability Rehabilitation Centre, Department of Public Relations, Department of Rural Development and Department of Education andlocal NGO’s of the district-Red Cross, Umeed,Adhar,sight savers,private practitioners,private hospitals, clinicians therapists and members of the civil society and over 6000 grassroot workers and families of the children in the district .Various stakeholders provided manifold services from ideating the concepts to clinical counsel.In addition,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. DrAmita Chand of NIPI-UNOPS supported throughout. The stakeholders played a significant role in design &implementation too.Many brainstorming sessions and regular meetings later a framework for the entire program was formulated.Planning ahead for providing holistic treatment/therapy to the child was the focus around which the group envisaged the program.The roles and responsibilities of all the stakeholders were assigned based on their core expertise. Capacity building and refresher training of all the concerned members was effectively designed to achieve best results. Protocols and procedures were established for smooth flow of work amongst the group. A dedicated weekly meet for the coordination of activities was held . Regular review and monitoring of tasks assigned to all the stakeholders was conducted to streamline the activities . The road map for entire initiative planned with the stakeholders. The stakeholders contributed in capacity building of staff at the grassroots levels. Feedback from all stakeholders always sought for course correction .

 8. What were the most successful outputs and why was the initiative effective?
1. After initiation and multiple rounds of screening by grassroots workers on about 7,50,000 plus U5 children district Hoshangabad & Bhopal, 74,265 children have been comprehensively examined out of which 6373 were identified as true positive. 2. Provides multi disciplinary evaluation and treatment by experts of different fields .Following services are being provided at facility or through convergence with NGOs and related institutions: Medical, Occupational therapy,Physical therapy, Psychological, Audiology, Speech-language pathology, Vision,Health, Nutrition, Social work, Special Instruction.Tertiary linkages for domain specific services have also been established for comprehensive intervention. A total of treatable 142 cardiac surgeries have been successfully performed,55 cochlear implants,102children have undergone cleft lip and palate surgeries,103 successful CTEV surgeries,5 neural tube surgeries,43 eye surgeries and 337 dental surgeries .An astonishing number of approximately 1800 children have undergone/undergoing physiotherapy for motor delays.Around 2500 children are undergoing audio and speech therapy.About 1900 are undergoing psychotherapy for various psychological delays and 2095 are undergoing special education including sensory stimulation. 3. Thus, universal screening of U5 children has not only led to early detection of early diseases, delays and disability, resulting in timely intervention but has also led to a reduction in morbidity and lifelong disability. Initiative is, therefore, a paradigm shift in comprehensive child care as dividends of early intervention not only enhances 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. 4. It has increased awareness on disability, delays & disease and early identification and intervention in Govt. functionaries as also in society. The massive increase in capacity of Government human resource available (4000 +) through tailor made capacity building programme is an evident benefit. 5. Better utilization of Government resources resulting in their optimum use, in particular the often neglected resource of time through interdepartmental, intersectoral and inter institutional convergence frame work and involvement of NGOs and civil society is a key benefit. Initiative was replicated in the entire country by Govt of India under the name Rastriya Bal SwathyaKaryakarm which is now benefitting 27 crore of country’s population. Initiative also has paved way for establishment of an apex Multi Department Resource Centre at Bhopal for promotion of EI services through evaluation, treatment, management, education, training and research. An amount of Rs 4.5 crores have been sanctioned by MH&FW, Govt of India and is supported annually

 9. What were the main obstacles encountered and how were they overcome?
The main obstacles encountered while evolving Samarpan-EIRC 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 initiative 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 machines & 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. It was decided that to overcome the ignorance and lack of knowledge of disability in general and early identification and intervention in particular, National level a seminar of leading experts on the topic would be carried out. IEC programme for society were then launched to create awareness in society. The overlapping nature of objectives of initiative necessitated evolving a convergence model involving govt departments, public and private institutes and civil society . 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 and human resources .Poor monitoring and evaluation was overcome by taking regular and focused meeting of all concerned and feedback was used as a developmental tool.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
7,50,000 plus U5 children district Hoshangabad & Bhopal have been screened and 74,265 children have been comprehensively examined out of which 6373 were identified as true positive. These children were screened by Anganwadi Workers using Samarpan Screening Test and 6412 U5 children have been identified as having one or more than one type of developmental delay, deficiency or disability. The impact is most visible in such Positive cases of delay, deficiency, disability, disease in children who were identified by grass root level worker through their enhanced capacity of carrying out the screening test. Initiative provide multi-disciplinary evaluation and treatment by experts of different fields under a single roof in a single, dedicated building. Apart from screening more than six hundred thousand U5 children, registered in Anganwadi Centres and screening of ‘high risk’ new-born children in district Hoshangabad/Bhopal, following services are being provided at centres: • Medical services • Dental services • Occupational therapy • Physical therapy • Psychological services • Audiology • Speech-language pathology • Vision services • Health services. • Nutrition services • Social work services Tertiary linkages for domain specific services have also been established for comprehensive intervention. Based on Samarpan Hoshangabad model, In March 2013, Ministry of Family Welfare & Health, Govt. of India launched RasthriyaBalSurakshaKaryakram (RBSK), a child health screening and early intervention programme to provide comprehensive care to all the children in the community. The screening and early intervention services is expected to cover more than 30 identified health conditions for early detection, free treatment and management through dedicated teams all across the country. District early intervention centres, based on SamarpanHoshangabad, are set up as first referral point for further investigation for treatment and management. RBSK focuses on effective health intervention, which intends to reduce both direct cost and out of pocket expenditure as also reducing the extent of disability and improving the quality of life and enabling all persons to achieve their full potential. It focusses on not only new born and those attending Anganwadi Centre but also school going children and will ultimately benefit more than 27 crore children in the country. The model is being replicated in 676 districts across the country. Initiative has thus facilitated direct policy intervention at national level where there was a huge policy gap. Additionally, provision of comprehensive child health care also provides country-wide epidemiological data on various diseases of children for future planning of area-specific services.Initiative has increased awareness on disability, delays & disease and early identification and intervention in Government functionaries and in society. Theincrease in capacity of Government human resource available at all 3 tiers -district, block and grass root through tailor made capacity building programme and better utilization of Government resources resulting in their optimum use, in particular the often neglected resource of time is an evident benefit resulting in in enhanced public delivery and have contributed to awareness.Initiative is a paradigm shift in public service delivery from demand-driven to suomotto reaching out to the society by screening all U5 children ,from mortality to overall enhancing the quality of life. Initiative also has paved way for establishment of an apex Multi Department Resource Centre at Bhopal for promotion of EI services through evaluation, treatment, management, educationtraining and research. The impact of initiative at different stages have been evaluated and measured by Administrative Staff College , Department of Preventive and Social Medicine,Bhopal, Arushi(NGO) etc. A detailed evaluation covering all aspects is under process by AIIMS,Bhopal.Initiative has been showcased for ensuring better public service delivery in the country in Social sector Service delivery: Good Practices Resource Book, 2015 which is is a joint effort ofNITIAayog, Government of India and UNDP.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
Initiative has led to improvement in integrity and accountability of Govt service providers. The increased awareness on delays and diseases and proactive approach of actively seeking suspected cases has led to huge increase in demand for services which often acts as a check on Govt. service providers Dedicated meetings are conducted at block level 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. Similarly voice of stakeholders are given space in revveiws. This regular review in a non threateningenviornmenthas enhanced both intregrity and accountability.Dependence on each other and strong hand holding given by district administration further contributes to accountability . Feedback from stakeholders and discussions in review meetings reflects the measure of these aspects of the initiative

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
As delay , disease or disability makes no distinction of sex,caste, creed, race,rich/poor or religion, the initiative has benefitted children as screening is carried out on all children in the districts. The initiative has benefitted all but reaching out to community has definitely helped the poor and vulnerable more as the net of services are often non accessible to them . Vicariously, the burden of bringing up children is mostly with women weather mother or sister hence the identification of delay in children helps not only the child but to this extent also women of the house.

Contact Information

Institution Name:   District Administration,Bhopal,MP,India
Institution Type:   Government Department  
Contact Person:   Nishant Warwade
Title:   DM  
Telephone/ Fax:   +917552540494
Institution's / Project's Website:  
E-mail:   nishantias@gmail.com  
Address:   office of collector,old secretariat,Bhopal,MP,India
Postal Code:   462001
City:   Bhopal
State/Province:   Madhya Pradesh
Country:  

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