Linking PSNP and NNP: experiences and challenges

Summary of report¹

Audience of drama held during PSNP meeting (Laygiant)

A recent pilot project focused on identifying implementation and eventually scale-up opportunities to link two nationwide programmes in Ethiopia - the Productive Safety Net Programme (PSNP) and the National Nutrition Programme (NNP).

The selection of the pilot woredas within each region was based on the presence of both PSNP and NNP, and specifically on availability of the Community Based Nutrition (CBN) programme, a sub-component of the NNP. A further selection of one kebele in each woreda was made, based on agro-ecological signifiers and were as follows:

Tigray Region - Hintalo Wajirat, Fikre Alem kebele

Amhara Region - Lay Gayint, Shesho kebele

SNNP Region - Domot Sore, Shiamba kebele

Oromia Region - Gameches woreda, Kokuriftu, Agemti, Sre Kelo Geto and Homicho kebeles.

Preparatory study

A preparatory study was conducted at regional and community levels between 21st July and 22nd August 2009. Primary data were collected from 39 PSNP/NNP stakeholders through key informant interviews (KIIs). In addition, a total of eight focus-group discussions (FGDs) were conducted in four pilot kebeles involving 28 female and 23 male PSNP beneficiaries.

It was found that stakeholders held some common perspectives of malnutrition, causes and solutions. While those interviewed recognised that pregnant and lactating women (PLW) and children are the most nutritionally vulnerable groups, their answers indicated a narrow focus on:

• Quantity of food, rather than quality and appropriateness of diet for PLW and young children.
• Productivity and marketability of foods, rather than their nutritional content for improved household diet.
• Dietary intake and food security with limited attention given to other well known contributing factors to malnutrition like disease, child care, access to health services and environmental conditions.

The most effective institutional arrangement for coordination at woreda and kebele levels appeared to be the Food Security Task Forces (FSTF). According to KIIs findings, the active involvement of multiple-sector partners in the FSTF was the result of continuous working relationships, strengthened through shared objectives and basic compatibility of interests. In contrast, at regional level, it was noted there were too many coordination platforms, with overlapping functions resulting in increased fragmentation.

Drama (counselling by a HEW) conducted during PSNP pay day session (Tigray-Hintalo Wajirat)

Primary data from KIIs revealed a number of inter-sectoral experiences of cooperation at kebele level, although not strictly linked with addressing malnutrition. Findings from FGDs highlighted that a genuine community involvement required understanding and taking into account economic, practical and cultural motives that influence food production and access, as well as consumption decisions at household level.

These findings from the preparatory study are in line with recommendations by others² to "plan multi-sectorally but continue to implement sectorally". Many of the institutional barriers for improved inter-organisational relationships first reflect administrative organisation in sectors/programmes and second, nutrition as a cross-cutting issue, fitting poorly within this framework. Working in an incremental and opportunistic manner appears likely to succeed with the current institutional structures in Ethiopia. 'Coordination' and 'cooperation' over specific issues like quality of dietary intake for children and PLW appear to be a promising focus of exchange between PSNP and NNP stakeholders. Mainstreaming of nutrition into the PSNP is expected to maximise the impact of the programme among beneficiaries.

PSNP/NNP linkage opportunities

Findings from the preparatory study together with a general overview of the PSNP/NNP policy framework were used to inform the Consensus Building Workshops conducted in all four pilot woredas and kebeles between 28th September and 16th October 2009. Three major 'linkage' opportunities between PSNP and NNP were agreed upon for implementation at institutional and community levels:

• Capacity Building on Nutrition Security for key members of the FSTF at woreda, kebele and community levels.
• Behavioural Change Communication using Education Entertainment (BCCEE) during payday sessions and other public gatherings. BCCEE encourage PSNP beneficiaries to optimise use of both local and transferred resources for improved nutrition security.
• Focused attention to PSNP PLW to protect and enhance their nutritional status and that of their children under two years of age.

Experiences from SNNP and Oromia showed that at an institutional level, nutrition security can be incorporated in the capacity building process of Food Security Task Forces, which comprise multi-sector members from agriculture, water, health, education, and Youth and Women's Affairs. Half-day sessions were included in Watershed Management Training (Domot Sore, SNNP) and in the PSNP review meeting (Oromia, Gameches) targeting over 100 people including 70 Development Agents (DAs). Basics on nutrition were provided during Consensus-Building Workshops to increase understanding of the nutritional value of different types of foods and on specific dietary requirements for PLW and young children. Improved awareness of the nutrition outcomes to which PSNP could contribute was discussed amongst food security and agriculture stakeholders, considering more rigorously who benefits from their interventions. For example, the nutrition value of selected crop varieties should be included and accounted for. Meanwhile activities with a direct nutritional benefit, like poultry-management schemes, improved post-harvest storage and food processing techniques or home gardening can be promoted in household business or investment plans for increased food and nutrition security.

Drama conducted during PSNP meeting (Laygiant)

Experiences from Tigray, Amhara and SNNP show that BCCEE can be mainstreamed within PSNP pay-day sessions and/or public gatherings to promote changes within the households and the community. Nutrition and care-related behavioural problems were initially identified by a technical team composed of volunteer members from the kebele FSTF. Technical teams chose drama as the medium and emphasised messages around the life-cycle sequence from pregnancy, lactation, to young child feeding from six to 24 months of age. PSNP beneficiaries involved as performers received an orientation on drama and rehearsed under the guidance of a professional theatre performer. Key people at kebele level, such as the Chairman, the Manager, the DAs and Health Extension Workers (HEWs), facilitated events. Woreda level PSNP/NNP stakeholders attended the events in all regions. Regional and zonal food security stakeholders participated in SNNP where the drama addressed family planning and childbirth spacing issues, a reflection of the common concerns of both the food security and health sectors, as well as those of the community.

Challenges in implementation

Implementation of the linkage opportunity with the PSNP to target PLW has proved to be challenging in all regions. To monitor the utilisation of health and nutrition services by PSNP PLW, 'on the job 'orientation sessions were organised with HEWs and DAs in all pilot kebeles. These sessions examined key indicators using registers and records from available routine services and nutrition programmes. Additional behavioural indicators related to dietary habits of PLW and young children were also included in the checklist. The initial PLW identification was expected to happen during the annual PSNP registration but this proved to be either impossible or where figures were available, the numbers were questionable (e.g. registered 12% PLW while the commonly estimated percentage is 3.5%).

The establishment of work teams among PSNP PLW was also discussed with the kebele FSTF to promote PLW involvement in 'light' works during the non-exemption time from public work (i.e. before four months of pregnancy and ten months post partum). Work teams were foreseen to be the basis for the formation of Interest Groups among PSNP women/PLW to engage in production activities with nutritional benefits. Further links were expected with existing development programmes, such as the Household Asset Building Programme (HABP) or community-based services, such as micro-finance and technical assistance. While interviewed PSNP-HABP stakeholders were open to diversifying production investments, they pointed out that other partners like the Women's Affairs, NGOs or Youth Affairs should be involved in forming and supporting these groups. This 'linkage' opportunity goes beyond the PSNP and requires much more time and inputs from different partners to become operational.

Interviewed PSNP stakeholders emphasised the potential contribution of the health sector in monitoring the PSNP key indicators but acknowledged limited information sharing between them both. Monitoring of malnutrition among children under two years can be ensured through the dissemination of Community-Based Nutrition (CBN) monthly data and Community Health Days (CHD) quarterly data. Currently, CBN programme provides data on underweight and severe underweight among children under 2 years. CHD programme provides data on MUAC<12cm MUAC<11cm or bilateral oedema among children 6-59 months and MUAC<21com among PLW. In addition, monitoring of access and utilisation of essential health and nutrition services by PSNP PLW can generate communal data for joint planning among members of the Food Security Task Forces.

A 'linkage' evaluation was conducted informally with key PSNP and NNP stakeholders, focusing on their view of feasibility and scalability of identified and implemented linkage opportunities. None of the stakeholders believed that scaling-up should be a challenge, especially for capacity building or for the BCCEE. Furthermore, no institutional barrier could be identified to 'monitoring access and utilisation of health and nutrition services by PSNP PLW'.

Recommendations

For immediate scale up of identified linkages at institutional level:

The NNP Coordination Body and PSNP Joint Strategic Oversight Committee work together to ensure that identified linkages are mainstreamed in their respective programmes. The NNP document (2008), the PSNP document (2009) and the revised PSNP Planning Implementation Manual (PIM) (2010) already provide the policy framework to justify the need for a multi-sectoral approach.

NNP/PSNP regional and federal coordination bodies endorse and ensure the inclusion of linkages in respective sector plans, enforce implementation through mutually agreed monitoring mechanisms and evaluate performance jointly.

Nutritional objectives and outputs associated with PSNP impact and outcome indicators such as 'reduced malnutrition' and 'increased access and use of health services' are incorporated in PSNP annual plans at community, kebele and woreda levels. This will enable management of resource allocations, incentives and systems of accountability around them. In line with the NNP Sub-Component 2(d), the NNP ensures that young children and PLW in families receiving aid are being nutritionally monitored and that their nutritional anthropometry is included in the evaluation of the PSNP.

NNP and PSNP stakeholders at federal and regional levels work together on how to mainstream nutrition security within the existing training curriculum.

The links between food production and consumption should become part of the discussion on how to incorporate agricultural and nutritional considerations from the outset. The existing Training Manual could be the starting point. The Ministry of Health could support these joint trainings so that key members of the FSTF at different levels become change agents to promote adequate and diversified diet for PLW and children under two years.

For immediate scale up of identified 'linkages' at community level:

Capacity building on nutrition security rolled out to kebele and community FSTF members. DAs, HEWs, Community Health Workers (CHWs), women's and youth representatives are well placed to engage with male and female PSNP farmers for designing interventions and developing/adopting technologies. Interventions and technologies should take into account agro-ecology, household economy, livelihood strategies and cultural norms that influence household decisions over food production, access and use.

Kebele FSTFs should integrate BCCEE during pay-day sessions and public gatherings. Experiences from implementation show that this activity can be managed at community level provided the quality of the technical content is supervised by the HEWs. DAs and HEWs can play a significant role in facilitating the dialogue with the community to influence intra-household dynamics that affect nutritionally vital decisions with regards to allocation of different quantities and types of food to PLW and young children.

For implementation of identified linkages at institutional and community levels:

It is recommended to start the component which 'focuses attention on PSNP PLW' in one pilot woreda looking more carefully at the role that PSNP and NNP key stakeholders can have on actual operational output.

A small number of indicators should be prioritised by PSNP and NNP stakeholders for monitoring of PSNP PLW utilisation of essential health and nutrition. The initial 'window of opportunity' could be reduced to pregnancy up to 11 months post partum instead of pregnancy to 24 months (as this corresponds more or less to the exemption time of PSNP PLW from Public Work).

Direct links should be established between the FSTF (particularly the early warning system (EWS)) and nutrition programming such as CBN and CHD for monthly and quarterly sharing of data on nutritional status of children and PLW in PSNP kebeles.

The establishment of Interest Groups among PSNP PLW/women needs the involvement of other partners like the Women's Affairs and/or Youth Affairs to support groundwork.

Product-value chain assessment and technical assistance will still remain the responsibility of agricultural partners.

PSNP and NNP stakeholders should optimise the role of home economists in SNNP, Oromia and Tigray by linking them with the HEWs and CHWs to strengthen post-harvest activities, as a necessary link between food production and consumption.

Potential linkages for further discussion:

Drama conducted during PSNP meeting (Laygiant)

Protection and enhancement of nutritional status of PSNP Orphans and Vulnerable Adolescents (OVAs) through their involvement in 'Healthy Life Style' clubs.

Food fortification, such as inclusion of home fortification micronutrient powders for children under two years and PLW during food or cash transfers and fortification at milling stage of the PSNP food transfer.

Supplementation of PSNP food/cash transfers through local production of 'special blended food' for children 6-11 months and PLW. On a small-scale, this activity could be linked with the establishment of Interest Groups and with an increased role of the Home Economists at woreda level.

Promotion of high-nutrient bio-fortified crops (e.g. high protein maize and orange flesh sweet potato) and improved breeds of poultry, small ruminants and cows through collaboration with research institutes to test and promote selected varieties.

For more information, contact: Patrizia Fracassi, email: pat.fracassi@gmail.com

¹Linkages Report (final draft). By Patrizia Fracassi and Lioul Berhanu (2010). Edited by Simon Rolph.

²Maxwell, S. & Conway, T. 2000. Perspectives on partnership. OED Working Paper Series, No. 6, World Bank, Washington, DC.