More than 20 percent of the world’s population live in ecological hotspots, places rich in biodiversity but often lacking basic government services. Population, health, and environment – or PHE – programs address compounding stresses in these areas by helping to meet people’s needs for basic health services, including reproductive health care; promoting food security and poverty reduction; and teaching sustainable natural resource management.

This fall, BALANCED – Building Actors and Leaders for Advancing Community Excellence in Development– finished a five-year project funded by USAID’s Office of Population and Reproductive Health to advance and support PHE approaches in Africa and Asia. Ultimately, BALANCED trained 2,000 people from 72 organizations and eight countries on how to start or run community-level integrated programs.

In a lively discussion at the Wilson Center on September 10, moderated by ECSP Director Roger-Mark De Souza, BALANCED leaders from the University of Rhode Island’s Coastal Resources Center, PATH Foundations Philippines, Inc. (PFPI), and Conservation International (CI) shared lessons learned from their partnership over the last five years and ideas for new ways forward.

Dr. Enrique “Ricky” Hernandez, who worked in the field with partners in East Africa, said “key to the success of this project” was collaboration with the private sector and governments. “It would be difficult for a single organization to implement PHE all by itself.”

But in places where PHE interventions have taken root, they are often “more effective and sustainable as compared to vertical single-sector interventions,” said Matthew Erdman, USAID’s PHE technical advisor.

Money Well Spent in the Philippines

PHE programs may vary greatly in appearance from community to community; there is no silver bullet or standard template, explained Elin Torell, BALANCED’s monitoring and evaluation specialist.

In the Philippines, the BALANCED Project built on the success of existing integrated development work by PFPI, which helped pioneer the approach more than a decade ago. PFPI’s Joan Castro credited the partnership with making it possible for PFPI to work in every village of two regions teeming with marine biodiversity. BALANCED and its partners improved access to family planning services in rural coastal areas and provided conservation incentives for communities living near marine protected areas. They also trained community members to be “PHE champions” to help spread the message.

Communities take quickly to PHE programs, said Torell, because they live interconnected lives. The Philippines has a rapid population growth rate and low access to reproductive health services, and its people rely heavily on fishing for their livelihoods. A fisherman struggling to feed more children with a smaller catch readily understands the connection between family planning and food security.

BALANCED trained coastal law enforcers to be peer educators, encouraging fishermen and other community members to “plan [their] families; manage [their] resources for a better future, for a brighter future, for a secure household, healthy environment, and healthy people,” said Castro.

The integrated project also brought together funding streams in innovative ways. In the final three years, BALANCED Philippines was funded by both USAID’s Office of Health, Infectious Diseases, and Nutrition and its Office of Energy, Environment, and Climate Change – the first dual buy-in from separate USAID offices in the Philippines since PFPI’s initial proposal in 2000.

In the midst of a national conversation in the Philippines about improving access to family planning, BALANCED successfully encouraged local government units to pass four ordinances that allocate funds for PHE programing in their budgets. These ordinances serve as a “measure of the commitment of the local governments to sustain and to maintain the gains of the project,” said Castro, and ensures the sustainability of PHE programming beyond its USAID funding.

Entrepreneurship in East Africa

The BALANCED Project took a different route in East Africa, focusing more heavily on individual PHE champions and providing seed grants to local environmental non-governmental organizations. “It’s very different in the Philippines where there is enough local government autonomy versus the very centralized governments in East Africa,” explained Hernandez.

“Ethiopia is bursting at the seams with PHE,” said BALANCED Director Linda Bruce. BALANCED gave a seed grant to Ethio-Wetlands and Natural Resources Association, a wetlands conservation organization in southwest Ethiopia, to add health components to their work, and lent support to the PHE Ethiopia Consortium, which works to facilitate networking between the country’s various integrated development efforts. Since 2007, the David and Lucile Packard Foundation has co-funded the PHE Consortium alongside a series of other PHE projects in Ethiopia with encouraging results.  According to the Population Reference Bureau, investment in Ethiopian PHE programs has contributed to increased contraception use; increased male involvement in family planning; increased female involvement in environmental rehabilitation activities; and improved parent-child communication, among other positive changes.

In the Pangani district of Tanzania, BALANCED worked with two powerful advocates who were profiled in ECSP’s Healthy People, Healthy Environment short film.

The energy-saving cookstove used by Rukia Sefu, from the village of Mkwaja, needs only a third of the wood required by a regular cookstove, which reduces pressure on the forests in nearby Saadani National Park. It also gives women, who are often responsible for gathering firewood, more time to pursue income-generating activities. “In the past women had few rights and weren’t in business. Since joining [this project], we, the women, are now awake and have moved forward,” she explains in Healthy People.

BALANCED’s efforts with local partners to improve access to and knowledge about reproductive health care similarly empowered Fidea Dastani Haule, from the village of Sakura. She encourages members of her community to plan their family before having their first child, stating proudly in Healthy People, “I feel very confident because I have been educated. I have expanded my ideas, intelligence, and the ability to be able to speak with anyone.”

Torell said they have seen an increase in contraceptive use and interest from both men and young people in Pangani. Furthermore, 31 percent of contraceptive-pill users get them from BALANCED-supported, certified community-based distributors, whose reach extends further than that of district government services. Meanwhile, some women are doubling their income by switching to sustainable seaweed farming instead of using illegal fishing methods (including dynamite and poison).

To build on the success of programs like those in Pangani, CI’s Janet Edmond built a PHE Toolkit, hosted on the K4Health site, which organizes much of the experience the PHE community has gained around the world. Edmond and the BALANCED team also compiled about 20 personal stories from PHE champions, since, as she explained, “these topics can be kind of esoteric sometimes, but when you look at Rukia and you see what’s happening, you really do understand that it’s important to bring all these elements together.”

What’s Next?

Wherever they worked, the BALANCED partners learned the importance of local context. “You have to build experience on the ground to be able to scale it up to a national level,” said Castro, “because PHE is a community-based initiative wherein you get goodwill and support from the communities themselves.”

For example, Hernandez said he wishes he had better understood Tanzania’s government structure and local communities’ information pathways earlier on in the project. “In East Africa it’s centralized all the way up to the district level,” he said. “So at the district level there is enough autonomy, although there might not be enough resources, but there is enough planning going on at the district level…It’s just a matter of identifying those entry points and seeing in what ways PHE can be integrated.”

Looking forward, PHE programs could expand by working in a wider variety of ecosystems beyond ecological hotspots. For example, in regions suffering from lack of access to clean water, PHE programs could combine freshwater conservation incentives with a water, sanitation, and hygiene (WASH) campaign to reduce water-borne illnesses.

The integrated approach could also be applied to other related sectors, such as sustainable energy, gender mainstreaming, or youth outreach, said the panelists.  Flexible seed grants to organizations that are already working at the community level could support PHE scale-up and expansion in new regions and sectors. Such “horizontal” expansion into other sectors or ecosystems could prove just as potent as scaling up vertically.

Restrictive funding is likely to remain PHE programs’ most difficult challenge, said Bruce. As long as governments and foundations assign money based on single-sector goals, integrated programming will be difficult to implement on a large scale. Building upon the PFPI experience, more integrated funding from multiple offices of large donor organizations may support PHE efforts more smoothly – and efficiently – than piecemeal, single-sector funding.

“The most important lesson I think we learned and validated is that PHE can be replicated and scaled up,” said Hernandez. “PHE was implemented in different settings within the context of improving people’s lives and addressing the issue of population pressure on natural resources.”

Event Resources:

• Healthy People, Healthy Environment: Integrated Development in Tanzania
• Photo Gallery

Drafted by Laura Henson, edited by Schuyler Null.