2.1. Study design, population, and settings

This study employed a phenomenological approach [21], cemented by qualitative approaches (i.e., Key Informant Interviews (KIIs), and Focus Groups Discussions (FGDs)) to fully understand role of individual, organizational, prevailing barriers, and opportunities of organizations in enhancing access of health care services and socio-protection among CLWS in Mwanza city, Nyamagana District northwest Tanzania. The city is reported to have around 39.6% of the entire population as young population. Children have been reported to migrate from rural to urban areas for ecological and historical reasons [4]. Social services in rural areas are inadequate and consequently these areas could not attract people and they had to migrate to urban areas to search for work [4]. It is on this basis, Mwanza city qualified as a study area. Mwanza city has 34 public health facilities which includes 2 hospitals, 5 health centers, and 27 dispensaries.

A systematic random sampling procedure technique was applied to select primary health care facilities where health care workers participating in the study could be located [22]. A purposive sampling procedure was used to recruit CSO involved with CLWS [23], Nyamagana District social welfare department staff, and health care workers who were involved in the provision of health care and socio-protection services among CLWS. For a sub-group of CLWS, a convenient sampling technique was used with the guide and assistance from the Nyamagana District Social welfare department [24].

The study was divided into three phases: 1^st–Identifying specific CSO involved in supporting and strengthening access to health care services and socio-protection among children living and working in different streets in Mwanza city. 2^nd–Inviting individuals working with CSO, and Nyamagana District Social Welfare department to a face-to-face interview (i.e., through KIIs and FGDs) on issues related to the support and strengthening access to health care services and socio-protection among CLWS in different streets in Mwanza city. 3^rd–Inviting individual CLWS to a face-to-face interview regarding the types and kinds of support they get in accessing health care services and socio-protection in Mwanza city.

2.2. Data collection

In observing the existing phenomena and practices, we collected data using three different methods to triangulate sources of information as follows; 1^st—One interview with CSO and social welfare department Key Informants at Nyamagana District (i.e., KIIs) who are involved in support and strengthening access to health care and socio-protection services among CLWDs in different streets of Mwanza city. Therefore, using purposively sampling, at least 14 KIIs were conducted until thematic saturation was attained. Each KII took at least 30 to 45 minutes. 2^nd FGDs with members of the CSOs, Nyamagana District social welfare department and sub-group of children living and working in different streets in Mwanza city were also conducted. A total of 12 FGDs were conducted to saturation of emerging themes. Each FGD took at least 45min to 1 hour.

2.3. Data analysis

Thematic content analysis was used to categorize emerging themes after every interview [25]. We commenced with one interview, transcribe verbatim, code and analyze for emerging themes and review the questions to see if the right question is asked [26], and continue with another interview until no new theme is emerging (maximum saturation). Additional interviews were conducted as needed to pursue relevant themes as they emerge, with a goal of theoretical saturation. The audio files from KIIs and FGDs were transcribed verbatim and later translated from Swahili to English and then back to Swahili to ensure we have common understanding. Data obtained at every interview was used to guide coding rather than imposing a coding scheme. Coding was done by two people to increase investigator triangulation [27]. Finding themes from data was done and then documented and finally emerging themes were analyzed, and inferences made. NVivo 12 computer software—QSR International 20—was used to enhance data analysis [28].

2.4. Ethical consideration

Ethical approval for the present study was granted from the Joint Catholic University of Health and Allied Sciences and Bugando Medical Centre Research and Ethics Review committee (Ref., CREC/594/2022). Then, permission to conduct this study was requested from Regional administrative office (Ref., No. GB.47/333/03), City Council executive office, and from selected CSO in Mwanza. Permission was obtained from the respective CSOs, Nyamagana District social welfare department, respective health care facilities followed by written consents among individuals selected from such organizations and institutions before being invited to participate in the face-to-face interviews (KIIs) and/or FGDs. Since individual CLWS are under the age of 18, efforts were made to ensure they are protected. Individual CLWS had to fill assent forms to show their agreement and willingness to participate before being allowed to participate in the study. In instances where participants had low literacy or were apprehensive about signing formal documents–efforts were made to read and explain about the scope of the study. All participants were informed that they could withdraw from the study at any time without impacting the care and/or services they receive.

Prior to obtaining consent and assent from study informants, a detailed explanation of the purpose and procedures of the study and why the participant was selected was done. Participants were also assured of strict confidential management of the data, and that, the information they provide would remain anonymous. Identification numbers were used in the study instead of names. The study informants were issued with a copy of the signed informed consent/assent form while the researcher retained the other copy.

3.1. General characteristics of the study participants

Information to enable answering the study objectives were collected from individuals working with CSOs (N = 29) (Four CSOs were recruited), individuals working with health facilities that were responsible for provision of health care services to CLWS (Two Public Health Facilities and One Private health facility, and a sub-group of CLWS (N = 22). The distribution of their demographic characteristics are summarized in Table 1.

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Table 1. General characteristics of the study participants.

https://doi.org/10.1371/journal.pgph.0001916.t001

3.2. Identified themes in enhancing access to health care and socio-protection services among civil society organizations to CLWS

Four key themes and one sub-theme emerged from interviews, FGDs, and a review of CSOs’ documentation, all of which revolved around the need for support to improve access to healthcare and social protection services among CSOs to CLWS.

4.1. General overview

Several CSOs were found providing some basic social services and social protection among CLWS around Mwanza city. Indicating prevailing social initiatives from both the CSOs and the governmental social welfare departments. Individual CLWS do live and stay in groups in some specific locations (namely, Nyegezi, Pamba Rd, Mabatini, Muslim cemeteries, Kamanga Ferry, Igogo, Kirumba market, and Mwaloni area) within the city. The number of CLWS is not clear even though the great size remains high it is not well documented. One CSO reported attending a total of 1400 CLWS in a year by provision of food, medical care and re-connecting with their families.

Gender inequality emerged among CLWS where majority of the present children were male. It was learnt that, among the CLWS individual female children get employed easily as compared to their counterpart male children. It is important however, to make a follow up on the labor market among such girls as there were no records of where they work, to whom do they report, and how are they treated. Our findings are consistent with a previous quantitative study where the percentage of male was dominant among CLWS as compared to female (70.6% vs 29.4% [20]. This is also supported by studies from three cities in Cameroon where the number of female CLWS were 19.8% whereas their male counterparts were 80.2% [21].

It was also reported that stranger kids arriving from their local villages are subject to victimization and harassment from individual children or from the surrounding and interacting communities. This is a vital alert as they may be victims of assaults including sexual abuse from individual children or from the surroundings and interacting communities. In a sub-group of CLWS, 59.1% reported to have been sexually abused. Incidences of rape among CLWS are said to be common and have been reported from other places in India, Sudan, South Africa, and Cameroon [21–23].

Our findings indicated that, individual CLWS are subject to environmental stress associated with weather risks and lack of appropriate and reliable shelter. This forced them to use ditches and trenches, subjecting them to potential infections and other health challenges. Also, previous studies have reported such children sleeping in half-destroyed houses, abandoned basements, under traffic bridges and in the open suburbs–a homeless lifestyle [19]. These findings are like those reported among street children in N’Djamena Chad, South Africa, Morocco, Peru, and Pakistan [21, 23–25]. It is also important to examine current environmental exposure health related problems as CLWS mentioned to be sleeping in half-destroyed houses, abandoned basements, under traffic bridges, trenches, and ditches.

In a discussion with a subgroup of CLWS, 63.6% reported to be engaged with collecting plastic bottles where 22.7% were engaged in sweeping public buses at their respective boarding areas. It is important to note that, such activities are conducted with bare feet, and without any protective gears. This could be increasing their risk to infection including the novel Corona Virus (COVID-19).

It also emerged that individual CLWS are sexually abused so often, and it is always hard to find the abuser. Some of the CLWS are so exposed to sexual abuse such that, they get used to it for money or some bribe incentives from the surrounding adult men and women. This marginalized group is also exposed to homeless adults such as disabled individuals as well as drug addicts [23]. On this regard, it came out that, male children were more victims of sodomy as compared to their counterpart female children. Our findings are similar to those reported elsewhere, where high-risk behaviors such as early sexuality, concurrent sex partners, engaging in unprotected sex, drug use, sex worker, illness due to sexually transmitted diseases and other infectious diseases including HIV/AIDS are common among CLWS [4].

4.2. Role played by CSOs in enhancing access to health services

Regarding the roles played by individual CSOs in Mwanza city, it was revealed that the overall scope of the CSOs and social welfare departments around the city in enhancing access to health services and in soliciting social protection to CLWS are diverse. For instance, most of the CSOs, are involved in resources mobilization, provision of basic life skills and education on self-protection, human rights among CLWS, provision of shelter, food provision and mobilization of health care services such as medicine. The provision of medicine, however, is not based on medical laboratory diagnostic reports; and monitoring of dosing has always been a challenge. Also, it emerged that incomplete dosage for given medication was likely among CLWS as older children tend to take medication from the young ones. This could be contributing to drug resistance and/or escalating the public health challenges against drug resistance as declared by the World Health Organization [26]. This contention agrees with an analytical cross-sectional study in Mwanza city where gram-negative isolates and Salmonella species isolates were resistant to third generation cephalosporins [27]. Our findings are similar to those reported elsewhere in Chad and Cameroon, where self-medication has been reported creating some potential for drug resistance [21, 23]. Since there is a potential for self-medication and lack of dosage treatment compliance, a follow up study is therefore needed to examine the drivers and possible interventions to stop this Public Health calamity of which the consequences are beyond CLWS and could be affecting those in their environmental vicinity.

Other activities included but not limited to enhancing re-unification of CLWS with their families, provision of child support to families staying with the re-united child, provision of business support to children’s family. Provide a one-time annual insurance plan which guarantees access to treatment to health facilities among individual families staying with the child. However not all individual children do get health insurance and some services may not be covered by such insurance. The issue of affordability has been reported in previous studies in different cities in Cameroon [21].

Individual CSOs are also engaged in provision of education to parents regarding some possible reasons for a child to escape, network tracing of respective children in efforts to identify their origin for possibly sending them back to their families. It also emerged that, CSOs are engaged in provision of sexual reproduction and HIV/AIDS education to CLWS. Since CLWS have been exposed to different environmental and social challenges, they need some special program before being integrated back into their respective communities. To address this concern, CSOs currently provide therapy sessions for CLWS and their parents regarding their problems encountered in their lives as rehabilitation sessions.

4.3. Potential barriers in enhancing access to health services and social protection to CLWS

The current findings indicated that individual CLWS are limited in accessing health services and lack social protection from those interacting with, and the community around. Even though there are efforts to bring individual CLWS back to their original homes, such efforts have not proven to be effective as most of the children return to the city. This could be caused by several factors; one being not addressing the root cause of the problem which may have contributed to the escape from their home communities to the city in the first place. It could also be attributed to the fact that most of the CLWS are getting used to street life and freedom of moving without being supervised. This could be associated with being so intoxicated with street life and the need not to be moved away.

This study revealed that underreporting of child violence from communities is the norm, as everyone wants to protect one another–protecting the abuser. Individual children can be brutalized by a member of a community and such incidences remain unreported. Even in the health care system, where to get a medical report when a child is brutalized and/or raped is not any easier and often impossible. This denies individual children justice as the abuser is not brought to justice and is likely to continue with such behaviour in the future. Incidences of rape among CLWS are said to be common and have been reported from other places in India, Sudan, South Africa, and Cameroon [21–23].

Also, community members who operate different businesses around the city among other Samaritans—identified as community champions in assisting CLWS—have been reported to be uncompliant with laws, regulations and child rights protecting children. For instance, some individuals have been reported to take such CLWS to stay to their homes without reporting or obtaining an approval from social welfare authorities within the city. There could also be some potential child assault in the umbrella of social protection among those who take the children to their homes that need to be investigated. In 2001, the International Labor Organization (ILO) in collaboration with the Tanzania Ministry of Labor reported a prevalence of 40% and 48% for economic activities and domestic child labor [28]. Most of the CLWS are reported to be engaged with scavenging, food services and food selling among others. Previously, in Mwanza city, 23.9% of CLWS were reported to be involved in cooking and food services for food vendors [20].

It was also revealed that, the CSOs do not stay or work for, or work on, even work with CLWS 24hrs a day or 7 days a week. This is one of the barriers in social protection for CLWS as in most cases such children are left roaming in the city during the night subjecting themselves to possible assault.

On the other hand, it was revealed that, CLWS are reported to be engaged in illegal activities such as robbery and sexual activities limiting the surrounding communities with a fear to be engaged in offering support, creating what is called social exclusion. It emerged that CLWS practice robbery even to people who attempt to provide some support. For instance, health care workers reported cases of theft of patients’ properties when such children are admitted in hospitals. This among other things has led to limited access to proper health services among CLWS as health providers have a negative attitude towards them. Such negative attitude towards CLWS among health care workers has been reported among street children in Chad, Cameroon, and Bangladesh [21, 23]. It is important to understand that life on the street exposes children to a myriad of risks, omits their safety and comfort that a family environment can offer. Evaluation studies tracing medical services and care given to respective CLWS should be encouraged to understand the scope of medical care individual CLWS are given.

It was also revealed that CLWS do not provide full cooperation as they are used to and like to be in streets and do not support initiatives to send them back to their families. Also, the information provided, in most cases, is not correct and cannot be reliable. This could be one of the barriers and a driving force to the escalating number of CLWS in Mwanza city, however a follow up study is needed to confirm the same. Various studies in other parts of the world revealed that most CWLS are not ready to go back to their homes because they feel safe in streets than home, as the violence they experience in streets is lesser than that experienced in their homes.

Another potential barrier is donor dependency syndrome as most of the individual CSO operate their activities based solely on donor funds. Such CSOs lack self-generating sources of funds. This limits what they can offer and the number of those who can benefit from their activities. It is important to understand that, even though some of the CLWS get health insurance, the subscription provided does not cover high level medication and tends to cover basic medical care only, and not all CLWS get health insurance. This could limit those in need to access health care services. On the other hand, CLWS face some barriers in accessing health care services as health care workers refuse to sign their police required incidence reporting forms for individual children hence prolonging the waiting time the child would have to take before being attended to.

4.4. Opportunities

Even though CLWS lack direct social protection services; training provided by some of the CSOs provide essential basic skills and opens an avenue for learning how to avoid and seek help against sexual abuse among other harassment and torture from the surrounding communities and the public. Reported community champions within the city (namely; food vendors and good Samaritans) who assist children to get basic needs is another opportunity for reaching CLWS to enhance access to health services and in enhancing social protection.

The presence of hotspots as common areas for CLWS where they are found most often provides a platform for potential entry in provision of basic social services such as health education, health seeking education, and social life skills. Emphasis on education and health promotion have been suggested elsewhere [21]. Another opportunity which seems to be a mixed paradox, is the reliability of CSOs to national and international events, festivals, and commemorations where health services are offered for free. Individual CLWS in need of health services are therefore mobilized to reach such events for possible medical care. This can be seen as an opportunity in one hand for accessing health services but also a barrier in the other hand. Relying solely on such events and exhibitions would be risking the health of those in need as they do not occur as often. It is also important overemphasizing on the reality that health challenges do not respect calendar days; can occur at any time.

There is also an emerging community-based opportunity for enhancing access to health services and creating social protection to the children at home and those working and living in the street from some of the CSOs. It was reported that CSO initiated financial supportive groups that aim at building capacity to communities so that they can take initiatives to protect their individual children in accessing health care and strengthening their social protection. It is important to understand that most of the rural-urban migration among CLWS is involved with poverty and need for secured livelihood [28]. It is also important to appreciate that CSO enhances better environment for children so that they do not feel the sense of being stressed and/or cohesive. Some CSOs provide training regarding realization of the rights of the child as well as the rights and obligations of the parents. It is also important to note that some CSO provide positive parental care education at the antenatal care clinics to enable parents to live in harmony with their children.

Study strength

The use of phenomenological qualitative approach in the present study, enabled us to understand fully the individual, organizational, and social context factors regarding the role, prevailing barriers, and opportunities of CSOs in provision of health and social protection services to CLWS.

Limitations of the study

In the study, we did not go across patient files to confirm that individual CLWS accessed health care services to the mentioned health facilities. Tracing medical records and care given to respective CLWS should therefore be given priority in future evaluation studies involving such vulnerable and marginalized groups. It was also difficult to access meeting minutes as well CSOs’ evaluation reports, it seems that no evaluations are conducted. Another limitation in this study is failure to access records of brutal actions against CLWS.