The Government of Ethiopia (GoE) successfully reduced the country’s poverty rate from 30% in 2011 to 24% in 2016, yet 30 million Ethiopians remain in poverty, especially in rural regions [1]. Multidimensional poverty incidence was 36.8% and 91.8% in urban and rural households of Ethiopia in 2016, respectively [2]. Health-related challenges also exist. For example, pregnancy-related mortality ratio was 412 per 100,000 live births and the infant mortality rate was 48 per 1,000 live births in 2016 [3]. Levels of child malnutrition vary considerably across regions with 46% of children under the age of 5 years in Amhara stunted compared to 15% in Addis Ababa. The percentage of women exclusively breastfeeding for the first 6 months of their child’s life has improved from 52% in 2011 to 58% in 2016 [3], but this still falls short of exclusive breastfeeding recommendations in the first six months of life. Despite improvements in health outcomes and reductions in poverty across Ethiopia, many challenges remain and vulnerability of rural populations still presents a concern. Thus, examination of approaches to alleviate poverty and its accompanying vulnerabilities, particularly in rural Ethiopia, is warranted.
Social protection in Ethiopia
One major strategy to achieve the Sustainable Development Goals (SDGs) related to poverty and health is social protection programming [4]. The Productive Safety Net Programme (PSNP), started in 2005, is Ethiopia’s flagship social protection programme. The PSNP aims to address determinants of poverty to promote the livelihoods of Ethiopia’s most vulnerable, extremely poor, and food insecure households [5]. The PSNP has reached more than 8 million people since its inception [1, 6] and has traditionally comprised two groups: those eligible for Direct Support (permanent [PDS]) and Public Works (PW) groups. The latter group participates in PW programmes to maintain eligibility for cash payments, while the former comprises households with no able-bodied members and thus receives unconditional cash transfers. A third group was introduced under the fourth phase of the PSNP (PSNP4; 2015–2020): the temporary direct support (TDS) group. This group includes pregnant and lactating women from PW households and caregivers of malnourished children. Pregnant and lactating women are exempted from work requirements from the time the pregnancy is reported until the child is 12 months of age, provided that the child does not have malnutrition problems. On the other hand, caretakers in PW households with malnourished children transition to TDS as soon as a malnourished child is identified until the child fully recovers from acute malnutrition.
Under integrated social protection, complementary programmes across sectors are meant to help households leverage the cash payments from the PSNP to improve livelihoods, health, and nutrition. Integrated social protection programming is increasingly implemented to more holistically address multidimensional poverty and improve well-being. However, the success of these intersectoral endeavors depends on key cadres implementing those linkages. In Ethiopia, these frontline workers include Social Workers (SWs), Health Extension Workers (HEWs), and Development Agents (DAs).
An example of an integrated social protection pilot aiming to strengthen intersectoral linkages is the Integrated Safety Net Programme (ISNP) being piloted between 2019 and 2023 within selected PSNP districts (locally referred to as “woredas”) in the Amhara region. Implemented by the Ministry of Labor and Social Affairs (MoLSA) and the Bureau of Labor and Social Affairs (BoLSA) with technical assistance from UNICEF, the ISNP targets PSNP households which already receive cash transfers with additional linkages of services around nutrition and health and seeks to facilitate enrolment into community-based health insurance (CBHI). An innovative feature of the PSNP allocates certain co-responsibilities related to basic health, nutrition, and education services to TDS clients. Programme aims are achieved through collaborations between frontline workers (SWs, HEWs, and DAs) and woreda offices to promote access to and utilisation of these essential services among programme beneficiaries. The specific components of the ISNP include: 1) Behaviour Change Communication (BCC) sessions; 2) facilitation of enrolment into the CBHI among PW households and exempting PDS clients from paying the enrolment premium; 3) Case management by SWs to support linkages between PSNP clients and health and social services, informing clients of their co-responsibilities (including children’s school enrolment and attendance and other health related service visits), monitoring compliance with co-responsibilities and providing follow-up advice or support in cases of non-compliance; and 4) a Management Information System (MIS) intended to allow client information and needs to be stored and shared more efficiently across programmes. The ISNP seeks to enhance the collaboration among frontline workers to improve engagement, introduce strengthened messaging, and provide and facilitate BCC sessions for improved knowledge of health and nutrition services and needs. HEWs and SWs serve critical roles in the programme’s delivery. In the ISNP, frontline agents, specifically SWs, are tasked with the implementation of inter-sectoral collaboration and linkages between beneficiaries and social services. These workers represent pivotal intermediaries between PSNP households and programme components that operate at many levels. Thus, their understanding of the programme, its objectives, their roles and services rendered, and knowledge of the populations they serve are critical to the successful implementation of the programmes that they operate under. These cadres must not only be well resourced and trained, but program participants must be aware of their existence and the types of help they can offer.
Findings from a previous integrated social protection pilot, Ethiopia’s Improved Nutrition through Integrated Basic Social Services and Social Cash Transfer (IN-SCT) pilot programme, suggest that frontline workers were aware of their roles, the collaborations needed to promote intersectoral linkages, and could readily identify barriers and facilitators to the successful implementation of the IN-SCT programme [7]. However, actual capacity to carry out their work was hampered by technical restraints, high staff turnover, heavy workloads, and low pay. Similarly, high turnover of DAs, HEWs, school principals, and others was identified as a barrier to effective SW service delivery by an evaluation of the Tigray Social Cash Transfer Pilot programme (SCTPP), a social protection programme that sought to improve access to basic social services among clients [8].
Frontline workers
HEWs in Ethiopia considered themselves both competent and reliable although many received on the job training and even more received inadequate pre-service training [9]. HEWs considered monitoring data and acting as clinical preceptors to be critical to service delivery and improved outcomes but also that these tasks were performed too infrequently [9]. DAs in the Southern Nations, Nationalities, and Peoples (SSNP) region of Ethiopia reported overwhelming workloads, the need to supplement income with additional jobs which compounds the encumbering nature of their work, and experienced high turnover rates as a result of these factors [10].
Knowledge and attitudes among the populations served by SWs and HEWs can also present demand-side barriers to effective service delivery and uptake. A study in Ethiopia assessed client knowledge of and interaction with their community DAs, SW, and HEWs in Oromia and SNNP regions and found that clients in SNNP were twice as likely to know their HEW than their Oromia counterparts (83% vs. 41%). Knowledge of SWs in these regions was significantly lower as 8% and 11% of clients reported knowing their SWs in Oromia and SNNP, respectively [7]. A cross-sectional community-based study among households in the district of Abuna Gindberet (Oromia region) found that less than half of the respondents had knowledge of the health extension services, and even fewer (39%) utilised these services. Lack of knowledge was associated with a 75% reduced odds of service utilization when compared to those who were considered knowledgeable [11]. Findings from other studies further underscore the positive relationship between increased education and information on health services and subsequent utilisation [12, 13]. Transportation, distance, opportunity costs, and cultural norms were all found to be barriers to health seeking behaviour among individuals in low- and middle- income countries [12]. Taken together, these reported barriers suggest that a comprehensive, integrated approach is needed to address the myriad barriers to health care access and utilisation.
Direct and indirect challenges to the daily operations and overall tasks of frontline workers described above highlight the importance of considering both demand- and supply-side barriers to access and utilisation of social services. In the current paper, we aim to 1) assess baseline rates of PSNP beneficiary knowledge of and interactions with SWs and HEWs; 2) examine the associations between sociodemographic factors, knowledge of and interactions with these frontline workers; and 3) assess challenges faced by frontline workers using a mixed-method approach.
Conceptual framework
This research is informed by the conceptual framework illustrated in Supplementary Fig. 1. This conceptual framework is intended to provide a general guide as to how intersectoral linkages to social protection programmes work at various levels and has been adapted from the work of Vinci and Roelen [14]. Given the complex intersectoral and multi-level operations of the ISNP and other social protection programmes, it is imperative to understand, at all levels, how knowledge of and interactions with frontline agents may be determined by programme objectives, implementation, and effectiveness. At the national level, establishment of intersectoral linkages is largely influenced by political economy factors, government and administrative structures, and capacity of institutions. Establishment of linkages can occur as a result of policy windows which in some instances are informed by robust evidence or when are imposed by national strategies. Memoranda of understanding between ministries is one way to increase the likelihood of success of integrated, intersectoral initiatives. To further ensure the success of these linkages, social protection and the linked programmes must be adequately financed in the national budget and, subsequently, these allocations must be disbursed to sub-national levels and implementing agencies in a timely fashion. Moreover, specific bodies responsible for the facilitation of cross-sectoral programming need to be adequately funded and with adequate institutional capacity.
At the regional level, programme personnel must be adequate and its roles and responsibilities clear. This contributes to promote intersectoral planning, delivery, and monitoring of social protection interventions. Intersectoral work would benefit from coordination mechanisms such as operational and programmatic guidance for staff and tools for joint work planning. Timely disbursement of programme funding and clear communication of programme objectives to district-level staff can also ensure proper programme implementation and successful linkages across sectors. Moreover, monitoring and evaluation mechanisms can contribute to inform programme outcomes and activities about what is working well and what is not, so that adjustments can be made accordingly.
At the community level, capacity of government workers to perform their respective activities is influenced by a clarity of roles and responsibilities, coordination mechanisms for horizontal intersectoral work, and improved awareness of policy and programmes objectives. That is to say, the cadres responsible for the facilitation of cross-sectoral programming need to be adequately funded, have sufficient space in their daily activities to carry out programmatic linkages in a quality manner, and must receive adequate communication and information about target populations, programme objectives and motivation for linked programming, so that such programming can be carried out as intended. Similarly, performance and motivations of frontline workers could be augmented with incentives for intersectoral collaboration, improved training, reduced overlap of frontline worker responsibilities, better understanding of roles and responsibilities, and transportation met with the ability to meet target populations.
Intersectoral collaboration is influenced (moderated) by numerous operational factors including quality of institutions (from the separate, linked sectors) involved in integrated programme implementation and quality of the implementation itself. Functioning community structures contribute to quality of services provided as well as quality of programme implementation. In order to ensure this component, services should be timely, relevant, and of acceptable quality, grievance mechanisms should be clarified to clients, and informal support systems and local political administration function should be recognized and integrated into procedures accordingly. Infrastructure is an essential component to implementation and institutional quality. For example, distance to services can influence client perceptions and attitudes and affect frontline worker ability to engage with the most vulnerable households and monitor co-responsibilities.