Population-Health-Environment Programs: Assessing the Past, Planning the Future

In the poorest areas on the planet, people "are living off primary extraction of resources, so their interaction with the environment is very intimate. They don't have a lot of leisure time to do conservation as a hobby. If they're going to do it, they're going to do it very integrally with their livelihoods," said David Carr of the University of California, Santa Barbara, discussing the importance of including sustainable livelihood projects in development programs that integrate population, health, and environment (PHE) issues. By simultaneously working across multiple sectors, a single PHE program can often produce greater improvements—at lower total cost—than multiple projects that each target only one sector.

At "Population-Health-Environment Programs: Assessing the Past, Planning the Future," an event sponsored by the Woodrow Wilson Center's Environmental Change and Security Program (ECSP) on March 13, 2008, Carr was joined by Lori Hunter of the University of Colorado, Boulder, and John Pielemeier, an independent consultant, to present the results of their assessments of PHE programs. Systematic assessments of development programs are critical in identifying and expanding best practices and minimizing unsuccessful approaches. Hunter called ECSP a key player in "the provision of technical leadership for the PHE community," adding that events like this one have been instrumental in "creating a community" of practitioners and researchers committed to improving and expanding the PHE approach.

Cross-Sectoral Integration: Challenges and Benefits

Targeting multiple sectors at the same time can help PHE programs achieve greater success in each sector, explained Hunter. For instance, in the Philippine community of Roxas, where fishing is one of the primary livelihoods, Hunter observed that men were more willing to discuss reproductive health and family planning when these topics were framed in terms of their connections to livelihoods. "If men link the size of their family to the amount of time they have to spend fishing, they might be interested in thinking about how big their family is," she said. The ability to connect different, but related, aspects of people's lives is perhaps the paramount asset of the PHE approach. Highlighting the relationship between family planning and livelihoods, for example, makes PHE programs more relevant to local people, improving the odds of success within the target community.

Family planning can make it easier for men to earn a living, but it could also aid in efforts to preserve the environment. "When women are better able to manage their childbearing," Hunter suggested, "they may be able to better manage natural resources. Empowerment of women should have environmental gains," because when women have control over the timing of their childbearing and can expect that their children will be healthy, their day-to-day lives become more stable, and they are less likely to engage in environmentally destructive practices—which will ultimately hurt their own livelihoods—to ensure the survival of their families.

USAID's PHE Projects: A "Gold Standard" for the Field

Pielemeier and Hunter evaluated USAID's portfolio of PHE projects, which includes projects in Rwanda, Uganda, the Democratic Republic of the Congo, Kenya, Tanzania, Madagascar, the Philippines, Cambodia, and Nepal. Pielemeier praised USAID for funding and developing "gold standard" PHE projects, and urged other organizations to take advantage of the "vast array of materials" that USAID has developed. The high profile of USAID PHE projects has "encouraged other environmental organizations…to become interested and involved and have money available so they can test PHE programs," Pielemeier said. For example, a Conservation Through Public Health project in Uganda embraced the PHE approach when it realized the diseases its veterinarians were treating in animals were being transmitted between people and animals with alarming frequency. Consequently, and with great success, the program shifted its focus to address human as well as animal health issues.

Pielemeier and Hunter's assessment reaffirmed that PHE is a cost-effective and successful model for development projects. It also concluded that, with proper training and guidance, environmental NGOs can significantly improve health and family planning in a community. However, it found that PHE projects tended to make little use of the myriad high-quality PHE manuals, toolkits, and analyses that have been developed over the past several years. The assessment observed that many opportunities exist for scaling up PHE projects (in Madagascar and the Philippines, for example), but that funding—both from USAID and nongovernmental sources—is lacking.

Keys to Success and Sustainability: Livelihoods and Local Commitment

Pielemeier noted that there is a growing consensus in the development field that "if you want to deal with remote areas…you have to have a…multi-sector approach that may even go beyond population, and environment, and sometimes health, and often includes livelihoods." If impoverished communities are to be convinced that a development program offers them worthwhile benefits, that program must rapidly improve their quality of life. Pielemeier contended that livelihood projects are the most visible and effective way to produce these improvements, as conservation interventions take years to produce concrete results, and even family planning programs usually take a year or more to have an impact. Providing short-term results creates a foundation of trust within a community and allows projects to work toward longer-term objectives.

Pielemeier explained that some PHE projects in the Philippines can now largely be sustained without external donor funding because there is local demand for the continuation of these projects, and due to the Philippines' decentralized government structure, local governments have access to resources they can allocate to effective programs. Prospects for scaling up PHE projects are better in areas where planning and funding take place at the local level. State-level ministries can be reluctant to share responsibility, control, and funding with other ministries, but these jealousies can be avoided by working directly with local governments and organizations.

According to Carr's recent qualitative and quantitative analysis of the World Wildlife Fund's (WWF) PHE projects in the Philippines, Nepal, India, Madagascar, Mozambique, Kenya, the Central African Republic, and Cameroon, an important predictor of a PHE project's success and sustainability is "local buy-in"—a community's commitment to and support for a program. A WWF project in Kenya dramatically improved childhood immunization rates by teaching local community health distributors to train other community distributors to dispense vaccines. A WWF program in Cameroon to build pit latrines "took off like wildfire" when those who were originally taught to build the latrines trained others, and neighboring villages competed to see who could construct the most latrines.

"Selling" PHE to Donors, Communities

"Why is it…that people and organizations are not grabbing hold of this concept," asked Pielemeier, which "shows that you can get the results at the community level, from several sectors, in one to two years, in a cost-efficient way? Why wouldn't that be attractive?" He theorized that "maybe the name is getting in the way"; if PHE programs were packaged as quality-of-life interventions, they would be more readily adopted by NGOs, donors, and governments. Carr agreed: "To sell the PHE message…it needs to be framed in terms of livelihoods."

Emphasizing quality of life and livelihoods could not only strengthen PHE projects' appeal to donors and NGOs, it could also generate more support for them at the local level, where communities may resent funding for conservation projects that appear to overlook their basic needs. As a park director in Kenya who was involved with a WWF program explained to Carr, "I don't talk about population, health, environment…I talk about your livelihoods—how to improve your income and your quality of life."

Drafted by Sonia Schmanski and edited by Rachel Weisshaar and Meaghan Parker.