The results are organized in two major themes: Process involved in the linkages between PSNP and health services for the temporary direct support (TDS) clients and barriers to effective linkages.
Section 1: Stakeholders knowledge about the linkages between PSNP and health services - this focused on the knowledge and roles of the stakeholders at the regional, woreda and kebele levels about the process for transition of eligible households to temporary direct support (TDS) clients from public works and the co-responsibilities of the beneficiaries.
1.1 Knowledge and role in transition of eligible households to temporary direct support (TDS) clients
The Key informants were asked about their knowledge and roles in the process for transition of eligible households to temporary direct support (TDS) clients. All the key informants interviewed were familiar with the recommended process and their roles in the transferring of pregnant and lactating women and households with children with malnutrition from the public work to temporary direct support clients which exempt them from the public work. However, there was variation in their knowledge about the exact duration the TDS clients are to be exempted from public work as detailed in the project implementation manual (PIM).
Regional perspective :
Even though actual implementation of linkage is done at the kebele level, however the regional and woreda team are involved in the process and expected to provide needed monitoring and support to ensure this is effectively done.
‘PSNP is a multi-sectoral project in its nature and has relations with health, and when a mother is around three months pregnant, she contacts the DA who completes a form and that allows the pregnant mother to get a leave from the public work until her return when her child gets 10months old. This linkage exists at regional, woreda and Kebele level.’
( Regional Key Informant 1)
Woreda Perspective
‘At the community level there is DA and HEW assigned in each kebele to implement the linkage but the woreda health office and the agriculture office provide support to the kebele level team in ensuring linkages between the PSNP and health services.’
( Woreda key Informant 1)
‘Actually, the health office is more involved with the Temporary direct support group where we support at the kebele level with the identification of the eligible beneficiaries (pregnant, lactating and Households who have malnourished children).’
( Woreda Health Office Key Informant II)
Kebele perspectives
Generally, the role of health extension workers (HEWs) is to identify pregnant women, lactation women and households of children with malnutrition who are engaged in public work and provide letter upon confirmation in the health facilities to the Development Agents so they can be exempted from public works. The Development agents who keep the names of all PSNP beneficiaries are to effect their transfer to temporary direct support groups and continue to provide them with the support throughout the duration until they return back to public work. However, the DAs and HEWs interviewed provided different expected duration of exemption from public works.
‘ As the development agent, my role is to check and follow up to see that TDS beneficiaries ( Pregnant and Lactating women and households with child with malnutrition) are transferred from public work into TDS category and still get their support which PSNP gives them.’
( Development Agent Key Informant 1)
‘My role is to connect the variety of categories like the Public Work, TDS, and the Permanent Direct Support in the community to the health centre and the project activities as well. I engage in encouraging them to connect the health centre and receive health services.’
(Development Agent Key Informant 2 )
‘ When pregnant women tell us that they are pregnant or we notice it ourselves, we asked them to bring confirmation letter from the health facility and based on that we exempt them from public work.’
(Development Agent Key Informant 2)
‘As a Health extension worker, my role is to register the lactating, pregnant mothers and malnutrition children and send them to the DA to transfer them until 6 months after they deliver, and the child is cured from malnutrition.’
( Health Extension Worker Key Informant 1)
‘As HEW my responsibility is that when mothers realize they are pregnant they come to me ,I give them a confirmation letter which will be used to exempt her from working during her pregnancy and six months after delivery.’
( Health Extension Worker Key Informant 2)
‘When mothers claim to be pregnant it’s our task as HEWs to confirm their pregnancy and then write confirmation report to the kebele DA for the project to transfer the status of the pregnant women to TDS group and exempt them from work until a year after delivery.’
( Health Extension Worker Key Informant 3)
1.2 Knowledge about the co-responsibilities of temporary direct support (TDS) clients/
The Key informants were aware the Temporary direct support (TDS) clients are supposed to participate in some activities referred to as co-responsibilities in replacement of the public work. However, they did not appear to have more precise knowledge of co-responsibilities about clients’ specific obligations other than the general advice of coming to the health facilities, but the schedules and number of visits expected not well articulated
The development agents and health extension workers are expected to orientate the TDS beneficiaries about their co-responsibilities as detailed in the PIM and follow them up to monitor compliance.
However , after linking them up with the development agents who registers them, they do not follow strictly to monitor the co-responsibilities but manage them like other patients who are to come to the health facilities routinely.
Kebele perspective
“Once we transfer them and exempt them from public work, they are to be seen and monitor by the health workers in the clinics to ensure they go to the clinic regularly to receive services.”
( Development Agent Key Informant 1 ).
‘It is the responsibility of the HEWs to monitor their attendance in the clinic, we don’t work in the clinic, we only keep their record of transfer and provide them with the money and other supplies monthly services.’
( Development Agent Key Informant 2 ).
“They are supposed to come to the clinic regularly to receive ANC, immunization for themselves and post-natal visit for their pregnancy can progress very well and their child since they are exempted for work so should have time to come regularly.’
(Health Extension Worker Key Informant 1)
‘The mothers of malnourished children are to attend OTP clinic regularly and give their children plumpy nuts as provided for them.’
(Health Extension Worker Key Informant 2)
‘There is no special clinic for them, we are busy, so we attend to them like other patients when they come and sometimes, they don’t come to the clinic again. We don’t have a special register for them.’
(Health Extension Worker Key Informant 3)
‘Anytime the pregnant and lactating women or malnourished children come we provide them with health awareness and all the services and drugs they need and ask them to always come back.’
(HEW Health Extension Worker Key Informant 4)
‘Many only come to the clinic so they can be given letter to stop working but later they don’t come to the clinic and we are busy to follow them to their house, some of them leave very far.’
(Health Extension Worker Key Informant 5)
1.3 Knowledge of the TDS clients about their rights, selection process and co-responsibilities
1.3.1 Knowledge of the TDS clients about their Right and selection process
The knowledge of the pregnant women, lactating mothers and mothers of children with malnutrition seen during the various focus group discussions( FGDs) show that they are aware of the process for identification of households eligible to be excluded from the public work and transferred to the TDS categories and still receive their monthly benefits both money or food or other materials.
“When a woman gets pregnant, she comes to the hospital for the nurse to confirm her pregnancy and give her a letter to the DA and then she will not work again until baby reaches two years and she will still continue to collect the money even though not working.’
( FGD participant I)
“When we become pregnant, we become free from the public work until we give birth and that child become one year, after that we return back to the public work.’
(FGD participant 2)
“When the women is lactating and breastfeeding her children she is given a free service and not expected to work in the public work, also she gets the payment and other supportive and need materials, she has been getting even though she is not working in the public work.”
(FGD participant 3)
“When a malnourished child is seeing in the clinic, the mother will be given a letter so the family will be free from the public work until the child recovers so they can have time to treat their child, and they will get the payment without working.’
(FGD participant 4)
1.3.2. Knowledge of the temporary direct support(TDS) clients about their Co-responsibilities
Most of participants in the focus group discussions were not aware of the specific obligation and required number of visits to the health facility for their co-responsibilities in lieu of the public work other that the general advice on health seeking behaviour and clinic attendance for relevant services.
‘We are expected to participate in different community awareness related activities and attend immunizations before and after delivery for our children and ourselves.’
(FGD participant 1)
‘We are expected to go to the health clinics always to see the health workers to monitor us and our babies, to deliver in the health center and to participate in different meeting and awareness creation of the project.’
(FGD participant 2)
‘We are to continue to breast feed our children and keep ourselves and environment clean and take them for immunization in the health centers regularly until we go back to public work.’
(FGD participant 3)
‘We take our children with malnutrition to the clinic in our kebele regular to receive plumpy nuts until the child is ok or if not ok, they will transfer us to the woreda health centre to continue treatment.’
(FGD participant 4)
‘Sometimes we don’t go to the clinic regularly because the clinic is far from our house and no means of transportation in our area.’
(FGD participant 5)
‘There is no specific time to go to the clinic but regularly for immunization or for nutrition clinic for malnourished children and antenatal care or when our children are sick.’
(FGD participant 6)
Section 2:
- The barriers to effective linkages between the PSNP and health services; this focused on identification of barriers to effective linkages by the stakeholders at all levels.
Most of the barriers/challenges to the linkages were expressed by the woreda key informants and this ranges from poor coordination and communication between the key actors( HEWs and DAs), poor knowledge due to lack of training on the project especially clear guideline to clarify the expected role of each of the actors especially in reference to the monitoring of the beneficiaries. Other barriers mentioned included lack of dedicated budget for the health sector either to follow up and monitor the compliance, no clear guideline on reporting template or mechanism for the co-responsibilities and limited access to health services for TDS beneficiaries who live far from health centers or in kebele with no health facilities. Some also mentioned that the project is seen and being implemented more as belonging to the agricultural sector and not as a key element of local development planning as designed.
Regional perspective:
‘ There is poor awareness and capacity regarding linkage between the two sectors. There is lack of clear and simplified linkage guides for DA, HEWs and woreda steering committee on implementation of the linkages.’
( Regional key Informant 1)
“The DAs and HEWs are expected to monitor the TDS clients to ensure they fulfil the obligation even tough without any sanction, but the record is kept at the kebele level, we don’t include this in our report at the regional level but we have noticed that there is poor documentation system at woreda and kebele level about the TDS record of compliance.’
( Regional Key Informant 1)
‘Except participating the meeting there is no intersectoral collaboration between PSNP and regional/ woreda health offices, there is no regular weekly, monthly, or quarterly coordination platform to discuss PSNP performance at regionally.’
( Regional key Informant 3)
‘There is no adequate knowledge about the project , many people see it in different administrative people think that PSNP project is owned by agriculture bureau only.’
( Regional Key Informant 4)
Woreda perspective:
‘The understanding of the project as we know PSNP is multi-sectoral project it has effect on different offices but we think it is only part of agriculture office who get the capacity buildings and other benefits of the project so it has to be shared with the other offices.’
(Woreda Health Office Key Informant 1)
‘It seems there is no enough awareness and understanding /complete information about the project among the stakeholders and the beneficiaries especially about the role expected by each person for effective linkage of the PSNP with health services.’
(Woreda Health Office Key Informant 2)
Kebele perspectives:
‘Development Agents and health extension workers in each kebeles are responsible for the monitoring and flow up the beneficiaries after being transfers to TDS category but this doesn’t usually happen because the HEWs are always busy.’
(Development Agent Key Informant 1 )
“ Sometimes the health team do not participate in our meeting and so not aware of many things we do and can’t get report from them about the TDS clients they see in the clinic.’
( Development Agent Key Informant 2 )
“Some of the pregnant women or malnourished children are from kebeles or sub kebele where there are no health facilities and have to travel a lot distance which sometime make them not to come to the nearest health facilities and difficult to follow them up.’
(Health Extension Worker Key Informant 1)
‘We don’t have regular meeting with the PSNP team to discuss about the issues of the health services we provide for the beneficiaries which would have been a good opportunity for better working relationship and understanding of the problem we face.’
(Health Extension Worker Key Informant 2)
“We don’t have fund to move around in the budget to follow up the TDS clients if they don’t come , no good communication with the PSNP team, we have not been trained on the project unlike the DAs and no reporting format to be used for recording our activities and share.’
(Health Extension Worker Key Informant 3)