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In an African nation where abortion was only recently legalized, the barriers to access are public education, medical training and money. An $18-million Canadian project is trying to help, and Mozambicans say it’s saving lives.
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Population, health, and environment (PHE) programming is an approach to global development that addresses the complex connections that exist between population dynamics, human health, and environmental conservation. The key objective of PHE programming is to simultaneously improve access to health services while also helping communities manage their natural resources in ways that improve their health and livelihoods and conserve the critical ecosystems that they depend upon. Despite the interdependency of environmental degradation, human health, and food and livelihood security, development efforts have frequently taken a single-sector focus (e.g., focusing on health alone or biodiversity conservation in isolation), while people’s most critical challenges, such as feeding their families and accessing life-saving health care, do not exist in a vacuum. These needs are multi-faceted.
A community health worker educates a mother about family planning.
At minimum, PHE programs deliver family planning, basic health care, and environmental management or conservation information and services to rural communities in a coordinated, integrated fashion. PHE programs share a common understanding that human populations can be one of the major threats to the environment they inhabit, that human health is inextricably linked to the environment, and that it is more effective to work across the human health and environment sectors than to pursue interventions in isolation.
Conservation and natural resource management organizations have also found that they can build stronger rapport with local communities by facilitating the delivery of needed health services. Health organizations find they are better able to reach underserved communities in remote areas by partnering with environmental organizations that are already established in those communities. Many projects have also experienced added benefits by integrating across the P, H, and E sectors—including engaging women in natural resources management activities, bringing men in to reproductive/maternal health and family planning decisions, and reaching underserved communities in remote and often biologically diverse areas.
Children planting a young tree sapling in Uganda.
In September 2015, the international community reached a consensus on 17 Sustainable Development Goals that should guide global health and development programming from 2016 to 2030. These goals are integrated and they include action on climate change, all life below water and on land, gender equality, clean water, poverty, and health and well-being. All these goals resonate with PHE programming, making PHE an appropriate means of implementation in certain regions and communities to meet the Sustainable Development Goals.
Pathfinder International and DSW, The Integrated PHE Conceptual Framework, 2013
The Lake Victoria Basin is home to more than 42 million people spread across five countries who depend on the lake and its ecosystem services for their survival. It is also of vital global significance for its network of more than 52 key biodiversity areas and rich fisheries. Over the last half century, a multitude of factors—now also including climate change—have converged to threaten both human and the environment’s health in the Basin. The Health of People and Environment–Lake Victoria Basin (HoPE-LVB) project (2011-2019) aims to address these challenges and foster healthy, engaged communities in lake-adjacent regions of Kenya and Uganda.
From its inception, the project was designed to develop and test a scalable PHE model and set of interventions that could be adopted by Ugandan and Kenyan communities as well as local, national and regional governments. The project was implemented in two phases. In Phase I (2011-2014), the project developed and tested PHE interventions that reduced threats to biodiversity conservation and ecosystem degradation in the LVB while simultaneously increasing access to family planning and maternal, newborn, and child health services in project communities.
Following successful implementation of Phase I, the project began Phase II (2014-2017), which focuses on scale-up of successful interventions. Phase II has focused on expanding the PHE approach to additional communities in Kenya and Uganda and supports the institutionalization of PHE approaches at the national and regional levels in Kenya, Uganda and to a lesser extent the other countries surrounding Lake Victoria that are member nations of the East African Community’s Lake Victoria Basin Commission (Tanzania, Rwanda, and Burundi). The major emphasis in Phase II has been to build the capacity of governmental and non-governmental organizations to implement PHE interventions using the HoPE-LVB project as an example. This toolkit is designed to facilitate the effective expansion of those interventions.
A number of partners contributed to HoPE-LVB’s implementation. They include:
Pathfinder International is the managing partner for the HoPE-LVB project. Established in 1957, Pathfinder champions sexual and reproductive health and rights worldwide, mobilizing communities most in need to break through barriers and forge their own path to a healthier future. Pathfinder is known for its technical expertise in areas such as strengthening community and health systems for sexual and reproductive health, advocacy, adolescents, safe abortion care (in countries where it is legal), HIV and AIDS, family planning service delivery, maternal and newborn health, cervical cancer prevention, behavior change, and gender. For more than 60 years, Pathfinder has managed large programs with multiple partners and sub-awards. Pathfinder works on a daily basis with national and international level stakeholders and donors, and has in-house technical expertise on PHE.
Osienala was selected as a HoPE-LVB partner in Kisumu for Phase I as it is the key environmental NGO with an exclusive focus on Lake Victoria. They are long-term partners of the Lake Victoria Basin Commission, local government agencies, fisheries organizations, and other regional structures, but also has experiences and knowledge of water, sanitation and hygiene activities, agroforestry, and community mobilization. The Lake Victoria Center for Research and Development hosts OSIENALA’s headquarters including broadcasting studios for Radio Lake Victoria FM, and several other programs.
ECO was selected as a HoPE-LVB partner in Uganda for field implementation for Phase I and continued into Phase II. ECO’s main program areas include natural resources governance, climate change and livelihoods, and integrated water resources management. ECO was chosen for its strategic positioning in the policy arena for climate action in Uganda: it was the coordinator for Population & Climate Change Africa Forum for the Horn of Africa, the Chair of Climate Action Network–Uganda, and a member of Climate Action Network International. Before joining the HoPE-LVB team, ECO implemented projects aimed at promoting resilience of communities to the impacts of climate change, enhancing good governance and management of natural resources and promoted integrated water resources management.
CTPH was selected as a HoPE-LVB partner in Uganda for advocacy activities in Phase I. CTPH has over 10 years of health and environment integration experience and has been playing a leadership role advocating for role of integration at country and international levels. CTPH achieves conservation by enabling people, wildlife, and livestock to coexist through improving their public health care in and around protected areas in Africa.
Nature Kenya was selected out of several NGOs who competed for a sub-award for Phase II of HoPE-LVB. Nature Kenya’s strength is its familiarity and long history with the Yala swamp ecosystem, which is an important conservation site for HoPE-LVB stakeholders, especially donors. Nature Kenya was also chosen for its long history in Kenya and its strong visibility internationally, with well-established vehicles of communicating project results to a broad audience.
In September 2008, USAID’s Office of Population and Reproductive Health awarded a PHE technical leadership project to the Coastal Resources Center (CRC) at the University of Rhode Island, called the Building Actors and Leaders for Advancing Community Excellence in Development (BALANCED) project. BALANCED was a five-year project and its partners included PATH Foundation Philippines Inc. (PFPI) as well as Conservation International. The BALANCED project was able to contribute a number of activities to HoPE-LVB Phase I, including supporting HoPE-LVB team members’ participation in a PHE training workshop at the start of the HoPE-LVB project, the cost of evaluation consultants, the ExpandNet activities that laid the groundwork for the scaling up strategies in Phase II, the production of the behavior change strategy, technical assistance by a fisheries expert from the United States, HoPE-LVB project director’s participation in a month-long course at URI-CRC on coastal management and fisheries, and other ad hoc support provided by BALANCED and PFPI staff in the production of other peer education materials and monitoring trips.
PRB was a partner for HoPE-LVB in Phase I under the USAID-supported Informing Decision-makers to Act (IDEA) project. PRB has over 30 years of experience translating demographic and other social science data to policymakers. It serves as a bridge between the research and policy communities by helping to ensure that research results are understood and used. PRB has a solid history of engagement in PHE with dedicated staff. It also has a strong track record in champion identification, documentation and dissemination, as well as working with the media on population, sexual and reproductive health, women’s empowerment, youth, and environment issues. PRB supported the HoPE-LVB team in a number of ways including guiding the effort to create the HoPE-LVB logo and first project brochure; supporting advocacy activities at the regional, national, and local levels; providing technical assistance on strategic communication on multimedia platforms from print to video documentaries; conducting training on advocacy and communications to project partners and PHE champions; creating advocacy strategies; and hosting the annual meeting of the project team with the HoPE-LVB donor group.
ExpandNet is a global network of public health professionals and scientists seeking to advance the practice and science of scaling up successful health innovations tested in experimental, pilot and demonstration projects. ExpandNet was a designated partner of HoPE-LVB from the start to ensure that the project could achieve scale-up in other communities beyond the pilot phase, and demonstrate localization, institutionalization and sustainability of PHE efforts and the HoPE-LVB model in Uganda and Kenya, and even in other Lake Victoria Basin countries, beyond the life of the project.
The project receives funding from the David and Lucile Packard Foundation, the John D. and Catherine T. MacArthur Foundation, USAID’s Office of Population and Reproductive Health, the Evidence to Action project, the Barr Foundation, and the Winslow Foundation. Additional US-based PHE technical assistance to the project was funded by another private donor.
The HoPE-LVB project relied on many external consultants for its baseline survey, mid-term review, GIS mapping, and ecological assessments, including those based in the US with global expertise in conservation, reproductive health, and PHE, as well as consulting teams in Uganda and Kenya, often made up of a group of ecologists, biologists, fisheries experts, and other scientists working together.
The HoPE-LVB project also had the privilege of working with fellows and interns. The project had a PHE fellow for a year during Phase I based in Kampala under USAID support, who worked on project activities, documentation, and supporting efforts to finalize the baseline survey reports. In Phase II, a PhD doctoral student from University of North Carolina spent time with the project to analyze data from the baseline survey and document further findings and value added aspects of HoPE-LVB based on the mid-term review results and direct field observations.
As the project planning began in late 2011, many of the HoPE-LVB partners listed above asked: how can a project within limited areas of the Lake Victoria Basin (see map below) catalyze progress towards broad-scale actions and policies that bring benefits for both conservation and human well-being in 2-3 short years?
HoPE-LVB Project Sites across Phases I and II.
Our response to this question was to implement a PHE program as a pilot with an explicit focus on the science of scaling-up from the beginning, to develop careful and well-documented plans with the systematic and well-phased technical assistance of our partner, ExpandNet. The need for an integrated PHE approach was also clear in this region: the connection between human activities and the natural environment in communities within the Lake Victoria Basin is interrelated and interdependent. The driving forces behind the rapidly changing and degraded basin ecosystem included: exploitative livelihood practices for both subsistence and income generation purposes (e.g. overfishing and use of illegal nets); pollution (e.g., from chemical waste and poor sewage disposal); and poor agricultural practices (e.g. pesticide use and forest clearing), compounded by rapid population growth and inadequate government policies. Only an integrated response could address these challenges.
In addition, advocacy for the benefits of such an approach was planned as a key project strategy at multiple levels: local, national and regional, and the recruitment of PHE integration “champions” was a critical element for its success. PHE champions needed to also exist at the household level in “model households,” exhibiting positive behaviors and becoming leading catalysts for community-wide behavior change that promotes critical positive health and conservation practices. Eventually, a critical mass of these model households would result in “model villages” that would support the sustainability of the new behaviors.
The long-term goal of the HoPE-LVB project is to reduce threats to biodiversity conservation and ecosystem degradation in the LVB while simultaneously improving maternal and child health in project communities as interdependent needs. We posit that change in these two goal components will increase equity and resilience of some of the region’s poorest people and will also increase resilience of the lake, wetlands, and forest systems that ensure functioning of the overall basin ecosystem.
The strategic objective of the Phase I of HoPE-LVB was “to develop and demonstrate/test a model for PHE integration in LVB sites that can be adapted and scaled up in communities, as well as by local, national and regional governments.” To truly effect basin-level change for both maternal and child health outcomes and conservation threats, the emphasis on scale was incorporated from the very beginning, and regional inter-governmental bodies such as the Lake Victoria Basin Commission and the East African Community were advocacy targets. (see Section 5 for Theory of Change and Section 4 for more details on scaling up).
Two synergistic approaches contribute to the overall project goal. First, increasing access to family planning is known to be a very effective means of achieving improvements in maternal and child outcomes; it also contributes to biodiversity conservation through several indirect pathways including women’s empowerment and reduced family size. Second, increasing the capacity to manage natural resources, thereby improving livelihoods for subsistence and income security, helps to reduce conservation threats while also contributing to improvements in maternal and child health outcomes. Consequently, these approaches form two of the project’s intermediate outcome objectives.
Boys along the river banks of Bussi Island, Uganda.
Change in human behavior requires motivation at the personal and community level. Health, empowerment, income and general well-being all serve as personal motivators. Community involvement/ownership and management of integrated actions, led by local government and governance entities, are required to motivate change at the community level. Thus, a third objective of the project focuses specifically on increasing this motivation and support for the project at all levels—community and beyond—through well-designed and well-timed advocacy activities.
The HoPE-LVB “minimum package” is the set of interventions that the project team agrees would be required for successful replication of the HoPE approach. Because the HoPE-LVB model is based on an integrated PHE approach, Pathfinder International and its implementing partners had to establish a logical framework that addressed multiple stakeholder interests while ensuring that the three arms of PHE are adequately addressed. Coming to a consensus on what the HoPE-LVB minimum package was challenging. To overcome this challenge, HoPE-LVB team held a series of facilitated meetings led by ExpandNet to agree to a minimum package of interventions that were considered the most impactful interventions for the communities served by the HoPE-LVB project. The HoPE-LVB minimum package incorporates these principles: participatory planning; a rights based approach; a focus on gender, youth, and the community; and continued improvement and refinement of approaches.
Another key lesson to keep in mind is that a PHE minimum package is not, nor can it be, a prescribed package. It must be flexible to adapt to local situations, and absorptive to ensure that key stakeholders are incorporated into project activities and interventions. Considering this challenge, all implementing partners and donors hoping to replicate the model should come on board with clear expectations and goals about what they want to achieve, after which common ground can be reached. Subsequently, a minimum package for a project model, using ExpandNet’s “Beginning with the End in Mind” framework1, can be established. Finally, the key to the success of the HoPE-LVB project has been the inclusion of affected communities. Their engagement in HoPELVB programming ensured that the minimum package remains flexible to ensure ownership and sustainability of the positive health and environmental outcomes of the project.
The HoPE-LVB Integrated PHE Model below illustrates the HoPE-LVB model. The HoPE-LVB model is comprised of a set of “core” interventions and processes that were promoted jointly with communities in project sites to help them adopt, own, and apply the PHE concept. The HoPE-LVB approach consists of efforts to implement all the elements related to the areas/sectors of Population, Health, and Environmental conservation together wherever possible (figuratively called the interventions), using a set of managerial and organizational processes geared to enhancing inter-sectoral collaboration.
HoPE-LVB Integrated PHE Model.
1 Downloadable on the WHO website.
According to the experience of the HoPE-LVB team, packaging the model has been a major challenge, partly due to the following reasons:
Very often the project teams and the project champions have faced skepticism about the value added of the integrated PHE model, especially since the observability of the successes needs to be assessed at many different levels in terms of changes in attitudes, behaviors, and practices, and the effects or outcomes of these changes also take significant time (e.g. increase in birth intervals or contraceptive prevalence rates, increase in staple crop yields, improvement of tree coverage and tree canopy or biodiversity, etc.). Thus, it is difficult to construct and tell a story that is “convincing” enough for everyone in order garner wider-scale support to start promoting the model as a whole.
A small Technical Advisory Group for the project was formed in Phase I to further define some key “measures of success” based on a request from donors. The project identified increased access to family planning (particularly to methods of contraception that the women wanted) and to maternal health services, as two of the “measures of success” for the health area. Success was defined in terms of the following 5 key elements: Service availability/quality; Adequate knowledge; Social acceptability; Financial Accessibility, and Geographic Accessibility. Other measures of success were: reduced conservation threats as they were designed to be countered by appropriate project responses; and what the project contributed towards gender equality, such as women’s chore burden, women’s participation in various project activities, women’s leadership in championing PHE, men’s participation in FP and maternal health activities, and male involvement also in alternative livelihoods. The Strategic Objective of developing and demonstrating/testing a model for PHE integration that can be adopted and scaled up in the LVB region was also reviewed and documented by the team throughout Phase I2 and into Phase II.
The success of the HoPE-LVB project was predicated on a number of other important assumptions:
2 L Ghiron et al. Beginning with sustainable scale up in mind: initial results from a population, health and environment project in East Africa. Reproductive Health Matters 2014;22(43):84–92.
Appropriate monitoring and evaluation (M&E) activities are crucial to understanding whether activities are having the intended impact. For the first phase of the HoPE-LVB project, our approach to baseline data collection included a cross-sectional descriptive study that involved the use of both qualitative and quantitative data collection methods. Other PHE initiatives might opt to take a modified but similar approach. Our study included the following components:
For Phase II, we relied primarily on existing secondary data to establish the quantitative baseline for sector-specific outcomes and effects in Phase I and Phase II communities. We complemented this data with a rapid assessment in Phase II sites that included:
HoPE-LVB’s M&E Framework in the image below was created at the start of Phase I. The team had to come to an agreement regarding which indicators to measure for management purposes, which ones to measure that most likely led to desired outcomes, which ones could be considered as reflecting the value added of an integrated design, which ones were important to report to the communities on progress they were making, and which ones were affordable and feasible to measure. This process naturally took multiple efforts and long discussions among M&E staff at HQ and field offices, and indicators did also evolve over time based on lessons learned and additional program staff and donor interests to seek more information on certain outputs.
HoPE-LVB M&E Framework.