October 2007, United States Agency for International Development
EXECUTIVE SUMMARY
Achieving environmentally-sustainable development in situations of surging population growth, declining biodiversity, and chronic poverty requires strategic planning, multi-disciplinary interventions and crosssector linked approaches that mirror the livelihood strategies of poor households and communities. This manual was designed with such a need in mind using evidence from programs in Madagascar, the Philippines, and other countries where integrated approaches to development have been explored and brought to scale over the past decade.
Defining PHE and Integrated Approaches
Population-health-environment (PHE) is a development approach that recognizes the interconnectedness between people and their environment, and supports multi-sector collaboration and coordination. The target audience for this manual includes individuals who are interested in designing field-based projects that apply integrated approaches to promote balanced and sustainable development. While the manual was developed primarily for program designers and planners, other audiences such as donor representatives and government decision makers may find its contents useful for understanding how PHE linkages work – both conceptually and operationally in the field, and how PHE might fit into a future where climate change, natural disasters, and ecosystem changes pose threats to human health and sustainable development. Appendix 1 provides a long list of suggested questions donors can use to determine if a proposed PHE project has considered the most important factors. The first two chapters of the manual summarize the evolution of cross-sectoral approaches and discuss several reasons why governments, donor organizations and civil society groups support PHE initiatives – namely because they are cost efficient, generate added value and can create synergies not found in vertical programs and projects. This was demonstrated in a five-year study in the Philippines, which showed that integrated approaches to population and coastal resource management (CRM) generate significantly higher impacts on reproductive health and CRM outcomes – and cost less to field – compared to the cost of implementing independent reproductive health (RH) and independent CRM approaches. Four strategies for integrating PHE are also delineated in this section of the manual, and the general steps in creating a sustainable and scaleable PHE project are outlined in a visual chart that also serves as a prelude to succeeding chapters.
Designing an Integrated PHE Project Although historically PHE focused on interlinkages between RH and biodiversity conservation, in this manual the scope has been expanded to includeprojects working on other types of natural resource management (NRM), such as sustainable agriculture or fisheries management, as well as other relevant health issues such as HIV/AIDS or water and sanitation. Chapter Three examines the role of a PHE initiative with the larger policy landscape where the project is located. It illuminates the procedures for creating a well linked (integrated) approach to population, health, and environment that will yield improved outcomes for each sector while at the same time contributing to a common goal. This process hinges on the formulation of a logic model or conceptual framework that graphically depicts the causal linkages and assumptions between environmental factors and health factors at the project site. A well planned conceptual framework is essential for identifying the factors and opportunities underlying the situation or condition at the site which the project aims to remediate. It is also useful for formulating the project’s objectives and selecting appropriate interventions, activities and monitoring and evaluation indicators for effective remediation and measurement of success. Important criteria to take into consideration when assessing whether or not a site is appropriate for a PHE project are analyzed in the third chapter of the manual. Chapter Three also examines potential implementation models, delivery mechanisms, and field-level interventions that can be applied at the community level. These include high-impact evidence-based interventions, such as family planning and insecticide-impregnanted bednets, and systems-focused interventions that can enable communities to participate in PHE planning processes and access resources for project activities. The different reward systems that can help influence individual decisions that drive behavior are also deliberated in this section of the manual. Various types of institutional arrangements an organization can form in order to manage and implement the project are also highlighted, together with inputs that may be required to increase capacity and knowledge of local implementing partners and enhance the sustainability of project activities. Funding sources for PHE projects are not always evident and for this reason the manual examines a number of approaches to resource mobilization and lists several international, national and local sources of potential funding.
Creating Longer, Larger Impact
Sustainability and scalability are often overlooked in the planning phase of the project as there is a great focus on beginning implementation. But in order to achieve sustainability and bring interventions to scale, such mechanisms must be created during the design phase. Chapter Four focuses on selected PHE projects that were implemented on a larger scale in the Philippines and Madagascar. Common features of these PHE projects that facilitated rapid scale-up include decentralization, private-public partnerships, the presence of existing allianceand the leadership role that local Mayors played in convergence of national or sub national policies and local PHE initiatives. Both countries also have been able to sustain PHE approaches after the termination of external funding. Some of the elements that were built into project designs that contributed to sustainability include cost recovery mechanisms for family planning and other essential health products; alternative economic opportunities that enabled resource-dependent families to maintain and diversify their sources of household income; and strategic IEC campaigns that used overarching themes - such as food security - that improved peoples’ understanding of PHE linkages and helped sustain institutional and community interest and involvement in integrated population-health-environment initiatives.
Additional Resources and References
Each chapter of the manual concludes with additional references that the reader can explore for more detailed information about each topic. Several appendices follow with questions that donor agencies may find useful when reviewing PHE proposals. Other appendices offer additional tips on managing PHE. Finally, a list of key contributors is attached as a way of acknowledging their contributions to the evolving PHE field and to the information contained in this manual.
