ASSESSMENT OF USAID’S POPULATION AND ENVIRONMENT PROJECTS AND PROGRAMMING OPTIONS DECEMBER 2007 This publication was produced for review by the United States Agency for International Development. It was prepared by John Pielemeier, Lori Hunter, and Robert Layng through the Global Health Technical Assistance Project. Assessment of USAID’s Population and Environment Projects and Programming Options December 15, 2007 Assessment Team John Pielemeier Lori Hunter Robert Layng DISCLAIMER The authors’ views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government. This document (Report No. 07-001-47) is available online. Online documents can be located in the GH Tech web site library at www.ghtechproject.com/resources/. Documents are also made available through the Development Experience Clearinghouse (www.dec.org). Additional information can be obtained from The Global Health Technical Assistance Project 1250 Eye St., NW, Suite 1100 Washington, DC 20005 Tel: (202) 521-1900 Fax: (202) 521-1901 info@ghtechproject.com This document was submitted by The QED Group, LLC, with CAMRIS International and Social & Scientific Systems, Inc., to the United States Agency for International Development under USAID Contract No. GHS-I-00-05-00005-00. Assessment of USAID’s Population and Environment Projects and Programming Options i ACKNOWLEDGEMENTS The assessment team would like to thank USAID staff members, especially Heather D‘Agnes, for providing excellent, timely support. We also would like to thank the many, many representatives from cooperating agencies, governments, donors and other interlocutors who made themselves available for our interviews and questionnaires, and who were willing to provide frank and open, constructive answers to our many questions and prompt responses to our requests for additional documentation. ii Assessment of USAID’s Population and Environment Projects and Programming Options CONTENTS ACKNOWLEDGEMENTS .................................................................................................. i ACRONYMS .....................................................................................................................iii EXECUTIVE SUMMARY .................................................................................................. 1 I. BACKGROUND AND PURPOSE OF THE ASSESSMENT .......................................... 6 II. ASSESSMENT METHODOLOGY .............................................................................. 11 III. PHE PROGRAM HISTORY SUMMARY .................................................................... 12 IV RESULTS ACHIEVED ................................................................................................ 15 ANNEX 1. LIST OF KEY INFORMANTS ........................................................................ 46 ANNEX 2. KEY DOCUMENTS CONSULTED ................................................................ 50 ANNEX 3. SCOPE OF WORK (key elements) ............................................................... 53 ANNEX 4. PHE: A HISTORY OF CONVERGING INTERESTS ..................................... 59 ANNEX 5. IMPACT OF USAID/WASHINGTON PORTFOLIO IN KEY COUNTRIES ..... 64 ANNEX 6. SUMMARY OF OPERATIONS RESEARCH RESULTS ............................... 70 ANNEX 7. ROSTER OF PE FELLOWS .......................................................................... 73 ANNEX 8. BUDGET TABLES ......................................................................................... 74 ANNEX 9. PHE STRATEGIC FRAMEWORK (October, 2006) ....................................... 75 ANNEX 10. FUTURE DIRECTIONS FOR USAID PHE FUNDING ................................. 76 Assessment of USAID’s Population and Environment Projects and Programming Options iii ACRONYMS ADB Asian Development Bank ADRA Adventist Development and Relief Agency ASOS Action Socio-Sanitaire Organisation Secours AusAID Australian Government Aid program BGH USAID/Washington Bureau for Global Health BRIDGE Bringing Information to Decisionmakers for Global Effectiveness (USAID project) CA Cooperating agency (USAID-funded organization) CARPE Central Africa Regional Program for the Environment (USAID project) CBD Community-based distribution or distributors CDM Camp Dresser McKee CFUG Community forest users group CHW Community health worker CI Conservation International CMM USAID/Washington Office of Conflict Management and Mitigation CPR Contraceptive prevalence rate CRM Coastal resource management CTPH Conservation through Public Health (Uganda NGO) DKT Philippines NGO DRC Democratic Republic of the Congo EGAT USAID/Washington Office of Economic Growth, Agriculture, and Trade EHP Environmental Health Project (USAID project) ERI Ecoregional Initiative ECSP Environmental Change and Security Program (Woodrow Wilson Center program) FISH Fisheries Improved for Sustainable Harvest (USAID/Philippines project) FP Family planning GDA Global Development Authority (USAID program for public-private partnerships) GEF Global Environment Facility GHTech Global Health Technical Assistance Project (USAID project) GHFP Global Health Fellows Program (USAID project implemented by PHI) GLP Global Leadership Program HIDN USAID/Washington Office of Health, Infectious Diseases, and Nutrition IEC Information, education, and communication IPOPCORM Integrated Population and Coastal Resource Management IQC Indefinite quantity contract IR Intermediate result JGI Jane Goodall Institute JSI John Snow Inc. LGU Local Government Unit M&E Monitoring and evaluation MOH Ministry of Health MPA Marine protected area NICHD National Institute for Child Health and Development NGO Non-governmental organization NRM Natural resources management OR Operations research PAI Population Action International PATH Program for Applied Technology for Health PE Population and environment PESCODEV People and Environment Coexistence Development PFP Population Fellows Program (University of Michigan/USAID project) iv Assessment of USAID’s Population and Environment Projects and Programming Options PFPI PATH Foundation Philippines Inc. PHE Population-Health-Environment PHI Public Health Institute PMP Performance monitoring plan PRB Population Reference Bureau PRH USAID/Washington Office of Population and Reproductive Health PSI Population Services International PVO Private voluntary organization REDSO/EA Regional Economic Development Support Office/East Africa (USAID regional office in Nairobi, Kenya) RH Reproductive health RIMS Resource Information and Management Society (Nepal NGO) SO Strategic objective SSPHERe Studies in Security, Population, Health, and Environment Relationships Program (Woodrow Wilson Center) STD Sexually transmitted disease STTA Short-term technical assistance TA Technical assistance TC Technical coordinator TL Technical leadership TO Task order (activity funded under an IQC) UGADEC Union des Associations de Conservation des Gorilles Pour le Développement Communautaire à l‘Est de la R.D. Congo UK United Kingdom UN United Nations UNC University of North Carolina UNDP United Nations Development Programme UNEP United Nations Environment Programme UNFPA United Nations Population Fund USAID United States Agency for International Development VS Voahary Salama WB World Bank WCS Wildlife Conservation Society WN World Neighbors WWF World Wildlife Fund WWIC Woodrow Wilson International Center Assessment of USAID’s Population and Environment Projects and Programming Options 1 EXECUTIVE SUMMARY In 2002, USAID initiated its Population-Health-Environment (PHE) Program in response to legislative language originally included in the FY02 Foreign Operations Appropriations bill—and repeated in subsequent bills—stating that under the Child Survival and Health Programs Fund, an unspecified portion of funds allocated for family planning (FP) and reproductive health (RH) should be used ―in areas where population growth threatens biodiversity or endangered species.‖ In addition, successive editions of the accompanying Manager‘s Report included language that ―urges USAID to develop performance goals and indicators which promote cross-sectoral collaboration‖ on PHE programming, and the FY08 House Appropriations Committee Report recommended ―to build upon...past investments in (PHE) programs by expanding and scaling up projects in communities inhabiting areas rich in biodiversity, particularly in Africa and Asia.‖ In response to this directive, USAID‘s Bureau of Global Health‘s Office of Population and Reproductive Health (PRH) moved from funding a small, disparate set of activities initiated as early as the late 1980s (for example, the Michigan Population-Environment (PE) Fellows program) to financing a more substantial portfolio of PE, and later PHE, projects subsumed within an explicit PRH/PHE strategy. During the subsequent six years, USAID moved from being a relative newcomer to the PE and PHE field to being the primary financial supporter for PHE activities globally. Much that has been broadly accomplished in PHE, especially during the latter years of this period, can, therefore, be attributed to USAID, particularly the PRH PHE program. These accomplishments have come with an extremely modest price tag of about $19.4 million over six years, an average of about $3.2 million per year. This PHE activity assessment, funded by the PRH, was commissioned to determine the effects and contributions of the PRH-funded PHE programs since 2002. The assessment results should also inform the Office‘s new strategy for future PHE investments scheduled to begin in October 2008. The assessment is limited to activities funded through PRH core and Global Leadership Program (GLP) sources, rather than the entirety of USAID‘s PHE programs (such as Mission funded activities). Specifically, the four primary purposes for conducting this assessment are: 1. To review the results of in-country PHE projects and determine their effects, especially on increasing access to quality FP and RH products and services in underserved communities near ecologically significant areas of high biodiversity 2. To determine USAID/PRH‘s contributions in providing technical leadership in the PHE field 3. To determine the barriers and challenges facing USAID/PRH‘s PHE portfolio 4. To make suggestions for USAID‘s follow-on strategy for PHE Purposes 1, 2, and 3 are addressed in the core assessment report, available to the public. Purpose 4 is addressed in a separate annex, available only to USAID staff due to procurement sensitivity. USAID/PRH‘s PHE strategic framework encompassed three intermediate results (IRs) that are mirrored in a three-pronged strategy for PE/PHE programming: IR1. Funding pilot field-based implementation of PHE activities IR2. Developing research, tools, and communications to provide PHE technical leadership IR3. Providing support to field programs to improve PHE technical capacity This summary of results and much of the following assessment report follows the IR framework. IR1: PHE FIELD PROJECTS For this sub-portfolio, it is useful to consider funding for field projects in three phases that, although overlapping in time, have differing objectives (termed Clusters 1, 2, and 3 in the text): Timely USAID financial support for carefully planned and fully integrated Phase 1 projects, especially the Path Foundation Philippines/Integrated Population and Coastal Resources Management (IPOPCORM) and PESCODEV, played a complementary but vital role in providing the ―gold standard‖ models for PHE planning and execution. High quality information, education, 2 Assessment of USAID’s Population and Environment Projects and Programming Options and communication (IEC) materials, training manuals, and mobilization techniques were developed, tested, and re-tested and are now available for adaptation and use by PHE projects globally. USAID grants to Conservation International (CI), World Wildlife Fund (WWF), Jane Goodall Institute (JGI), and Wildlife Conservation Society (WCS) for PHE field projects are gradually fostering greater institutional interest in bringing FP (and health) to other target ―hotspots.‖ For both organizations, including FP and health activities in their project areas is becoming ―more of the fabric of what we see ourselves as doing.‖ Even so, field interest in PHE projects is probably growing more quickly than interest in the environment private voluntary organization (PVO) headquarters where PHE project activities are less well known. There is a growing consensus that the best ―package‖ of interventions for remote areas of biodiversity significance cannot be limited to FP and conservation, but must include basic health care and livelihood activities. These interventions should be carefully sequenced so that short-term visible results occur and trust is gradually developed as new program elements are added. PRH PHE-funded projects in the Philippines have helped establish a vibrant national PHE network. PRH PHE projects in Madagascar have the potential of doing the same, although the attempt to foster an effective PHE coordinating institution has not yet been successful. In the Philippines, where government decentralization is relatively well advanced and local funds are available, local governments are demonstrating that they can sustain PHE projects once donor funding ends. In countries such as Madagascar, with weaker local government structures, more recent decentralization, an earlier stage of demographic transition, and impoverished local governments, the path to PHE project sustainability is less apparent and may be donor-dependent over a longer period. More recent Phase 3 field projects have responded in a timely fashion to USAID Mission interests for PHE activities in unusual settings (conflict resolution in Nepal, veterinary and human health linked to conservation in Uganda) and have helped expand the concept of PHE. Significant FP and health results can be achieved at the community level, even in remote locations, at a modest cost within three years. These results can be achieved by a variety of implementing organizations (environment-based, livelihood-based, and health-based) if projects are carefully planned and implemented with early, effective training and close supervision of community health workers by health professionals. Obtaining the gender-based value-added from PHE projects appears to be more difficult when FP components are added to ongoing environment programs unless there is a special effort to integrate IEC messages and structure IEC sessions with both women and men present and specifically identify them as key target groups. Most Phase 2 projects did not make adequate use of the mobilization techniques, training manuals, and IEC materials developed by Phase 1 projects. Some had no special programs to access youth and males, two target groups that were successfully accessed by Phase 1 projects. This may be, in part, because few Phase 1 results were available and the programs had not been thoroughly evaluated when Phase 2 projects were planned. However, the tendency to ―re-invent the PHE wheel‖ is disturbing. IR2: TECHNICAL LEADERSHIP (TL) Within this sub-portfolio, early years supported an ―expansion phase‖ of PHE while latter years have seen more focus on ―consolidation‖ of lessons learned. The Environmental Change and Security Program at the Woodrow Wilson International Center for Scholars has played an important role in bringing objective PHE information to a wide variety of audiences, primarily DC-based. During the expansion phase, TL provided by the Population Reference Bureau (PRB) was essential in the development of a very successful emerging network of PHE practitioners and advocates in the Philippines. Similar support to a network of fledgling PHE programs in East Africa appears Assessment of USAID’s Population and Environment Projects and Programming Options 3 promising, while Environmental Health Program (EHP) efforts to establish a PHE coordinating mechanism in Madagascar have been disappointing. Operations research funded or co-funded by USAID in the Philippines and Madagascar has proven to be technically difficult, but has provided the only empirical research findings on the value-added of PE and PHE projects in comparison with stand-alone FP or environment projects. Early results provide some evidence of integrated programs‘ greater effectiveness in bringing declines in youth fertility (PFPI 2007), as well as increases in contraceptive prevalence (EHP 2004). Additional analyses are underway, and involved researchers should be encouraged to disseminate findings rapidly, including publication in academic outlets, to enhance credibility and offer the most substantial contribution to the PHE field. During the recent consolidation phase, a rather astonishing number of high quality documents have been produced that will be extremely valuable to future planners and practitioners. These include manuals or documents on project design and monitoring and evaluation (M&E) for PHE projects, best practices in multisectoral partnerships, scaling up opportunities in the Philippines and Madagascar, an analysis of how population pressure and biodiversity hotspots overlap geographically, and a compilation of best practice tools, training materials, and mobilization methodologies. Most of these new materials are now being disseminated and are available on a new PHE website. WWF stands out as an implementing cooperating agency (CA) dedicated to documenting lessons both for internal program improvement as well as for the broader PHE field. The PHE Task Order (TO) represents an important component of the current PHE portfolio as the community finds itself in need of documentation, outreach and dissemination of that documentation, and technical assistance (TA). The TO should be more effectively used, including to advocate for PHE both within and outside of USAID. IR3: SUPPORT TO USAID MISSIONS AND CAS Within this sub-portfolio, three CAs have specific responsibilities and roles in regard to the provision of TA to other PHE implementing organizations. Additional TA has been provided by the PHE Technical Advisor within USAID, as well as through the PHE Task Order. The Michigan PE Fellows program introduced a cadre of young professionals to PE and PHE and at the same time provided relatively inexpensive but valued technical support to CAs and USAID Missions experimenting with PHE. Only a few of these PE fellows have found subsequent employment in areas that fully use their PE experience. PE Fellows are now hosted by the Public Health Institute and there is concern that the human capital and ―community‖ generated through the previous program will be lost. MEASURE/Evaluation is playing an increasingly important role in providing PHE support, particularly through the development of much-needed ―toolkits,‖ such as an M&E manual. High quality, short-term technical assistance (STTA) has been provided to USAID Missions, CAs, and non-governmental organizations (NGOs) for project design and evaluation through easy-to￾access indefinite quantity contract (IQC) mechanisms. The PHE Technical Advisor position in PRH has been well used to manage the PHE portfolio, to provide direct STTA to USAID Missions, and to advocate for PHE within USAID/Washington. A small but growing number of USAID Missions have demonstrated interest in PHE programs and methodologies. Additional efforts should be put into engaging these organizations. Summary of the Impact in Key PHE Focus Countries: Philippines: Initial PRH investments in the Philippines, made in close collaboration with the Packard Foundation, helped make the IPOPCORM and PESCODEV projects into ―gold standard‖ models. PRH and Packard also jointly supported PRB leadership training and advocacy activities which, over time, have led to formation of a very impressive and active PHE Network of 600 members. PRH funds subsequently used to encourage WWF and CI to test PHE in two remote sites have demonstrated that these environmental 4 Assessment of USAID’s Population and Environment Projects and Programming Options PVOs can successfully integrate FP in their broad landscape programs, and both PVO national offices are demonstrating increased interest in either including FP future projects or including PHE in their policy advocacy. USAID support to complete IPOPCORM‘s major operations research (OR) program and the placement of PE Fellows to support PVO activities have been effective. In sum, despite very little USAID Mission investment in PHE, USAID/Washington funds have been essential in fostering a growing number of PHE field projects, training for a strong cohort of PHE leaders and advocates, and establishing an active overarching PHE network that has been essential in creating a vibrant PHE movement in the Philippines. Replication of PHE activities in neighboring counties has already occurred through advocacy by involved mayors and NGO, and the country is ready for a major, scaled-up PHE program. A well planned scale-up program for a major ecosystem, building on the IPOPCORM model, has recently received start-up support from Packard and could lay an important foundation for future USAID/Washington investments. Madagascar: PRH/PHE investments in Madagascar have built on long-standing USAID Mission support for integrated programming in environmentally threatened areas and have successfully linked activities to Mission objectives, programs, and funding. The first major USAID/Washington investment (via EHP using USAID Office of Health, Infectious Diseases, and Nutrition (HIDN) and PRH funds) piloted largely successful PHE field projects in two major USAID-supported landscapes and initiated a major PHE OR effort in these landscapes. This water-focused project and subsequent PHE field projects have made Madagascar the global leader for integrating health interventions into what was previously known as a PE program. EHP also helped create a national PHE coordinating institution, Voahary Salama (VS). VS has not yet demonstrated strong advocacy, research, or information exchange capacity, but continues to receive some support from the USAID Mission, and may provide a foundation on which to build future networking efforts. PRH funds have supported pioneering WWF, CI, and, more recently, WCS pilot PHE projects in very remote landscapes are stimulating national office interest for including FP and PHE in future programs. Madagascar‘s national government now aggressively supports both FP and environment programs, and, as such, the time is ripe to scale up and replicate relatively successful PHE models. Although there is some interest in PHE among donors, USAID will need to play the lead role in expanding the PHE concept in Madagascar to take full advantage of past investments and help address the nation‘s environmental degradation and rapid population growth. Other Locations: PHE and PRH investments to date have been concentrated, appropriately, in only a few countries, so that projects and implementing institutions could learn from and build on each other‘s work, and a national network could be created. A few initial PRH investments were made in Central America (Guatemala Pro-Peten) and Bolivia, but like the Packard Foundation, USAID decided that the expanding presence of national FP programs throughout most Latin American countries made the PHE approach less relevant. East Africa and Asia (Kenya, Uganda, Democratic Republic of Congo (DRC), Cambodia, and Nepal) have been the sites for some Phase 2 and 3 investments. A major JGI program in eastern DRC has added much needed FP and health services into an ongoing Central Africa Regional Program for the Environment (CARPE) landscape program. A recent PRB-led workshop for PHE in East Africa found strong interest in the region for discovering more effective ways to introduce FP, health, and livelihood and conservation activities into remote communities that have not received government services. This interest may provide the foundation for strategic PHE investment in this region. Impact on the Broader PHE Field The PHE portfolio has had little impact to date in raising the profile of PHE issues among other potential donors, foundations, and academic audiences. This is partially because PHE, as a particular ―self-identified‖ form of community-based development, is relatively new, and PRH PHE investments have been fairly opportunistic. However, it is also because there has been no strategic, concerted effort thus far by USAID, engaged CAs, and other community members to work towards raising PHE‘s profile with these groups. PHE Program Results in Relation to PRH and PHE Objectives Overarching PHE program results, which have been structured to mirror the PRH September 2007 strategic framework, clearly make some contributions to the overall objectives. PHE would appear to be particularly effective in addressing the following aspects of the PRH‘s IRs 1 and 2: Assessment of USAID’s Population and Environment Projects and Programming Options 5 IR1: PHE programs may be particularly useful in facilitating partnership building, especially with organizations that do not traditionally focus on FP and RH (for example, environmental NGOs). Such partnerships also facilitate the introduction of FP and RH services to the underserved populations resident in regions where non-FP organizations are more likely to have presence. In this way, these new partnerships help USAID/PRH better meet some of the organization‘s broader objectives. Also relevant to the objectives of IR1, PHE programs may be particularly useful in leveraging funds from non-USAID sources, given their appeal to a variety of agencies working within and across sectors, and may be avenues to learning how best to provide FP to youth and males. IR2: Since PHE, as labeled, is a relatively new approach to integrated development programming, the field is ripe for knowledge generation and dissemination, key aspects of PRH‘s IR2. Indeed, a plethora of new tools, methodologies, and guides with demonstrated programmatic value have recently been developed or are currently near completion. This new information is just now becoming more readily available to the community of practitioners and others engaged in PHE, and this enhanced availability will facilitate scale￾up efforts and/or replication. Also, given the cross-sectoral nature of PHE, there is a wide variety of relevant target audiences, therefore expanding the potential utility and impact of this body of informational material. IR3: As related to IR2, since PHE is relatively new, support to the field for implementation is essential, as is the establishment of mechanisms for implementing agencies (including Missions) to access central expertise. These efforts directly address PRH‘s IR3. Principal Barriers and Opportunities for Expanding PHE Activities The principal barriers facing the PHE field relate to: Inadequate funding, which is linked to the complexity of integrated efforts The limited evidence base for the integrated PHE program model The growing but still limited capacity to implement PHE field programs These barriers are related to the need for additional advocacy to expand the PHE funding base. Advocacy is also needed within USAID/Washington as well as with Missions, where population pressures have a negative impact on environmental conditions. The inflexibility in the use of FP and HIDN funds to meet the multisectoral needs of field projects is also a barrier. Still, important opportunities now exist. With the strong support of the PRH PHE program (and the Packard Foundation PE program), much of the stage is now set for a major expansion of PHE or PHE-like activities that could provide FP services to remote and underserved populations. Components of this ―stage setting‖ include: ―Gold standard‖ PHE projects and a strong network in the Philippines Growing PHE ―buy-in‖ by several international environment PVOs working in remote regions Existing IEC materials A library of materials on design, implementation, and evaluation available electronically Continued decentralization of government authorities and services in developing countries Specific characteristics of PHE efforts may also yield opportunities, such as: Potentially facilitating cross-office collaboration within USAID and acting as a model for other USAID community and region-based programs Fostering south-south collaboration and learning, using technical capacity from the Philippines and Madagascar Efficiently providing multisectoral services to remote areas as part of equity-focused programs Efficiently providing multisectoral services to remote areas as part of environment-focused landscape, corridor, integrated conservation and development (ICDPs), or climate change programs 6 Assessment of USAID’s Population and Environment Projects and Programming Options I. BACKGROUND AND PURPOSE OF THE ASSESSMENT PURPOSE This assessment of PHE activities, funded by the Bureau of Global Health‘s Office of Population and Reproductive Health (PRH), was commissioned to determine the effects and contributions of the PRH￾funded PHE programs since 2002. This document is also designed to inform the office‘s strategy for future PHE investments when the current PHE portfolio ends in September 2008. The assessment is limited to activities funded through PRH core and GLP sources, rather than the entirety of USAID‘s PHE programs (such as Mission-funded activities). The four primary purposes for conducting this assessment are: 1. To review the results of in-country PHE projects and determine their effects, especially on increasing access to quality FP/RH products and services in underserved communities near ecologically significant areas of high biodiversity 2. To determine PRH‘s contributions in providing technical leadership in the PHE field 3. To determine the barriers and challenges facing PRH‘s PHE portfolio 4. To make suggestions for USAID‘s follow-on strategy for PHE Purposes 1 to 3 are addressed in the core assessment report, available to the public. Purpose 4 is addressed in the expanded report, available to USAID only, due to procurement sensitivity. BACKGROUND General Rationale for PHE Programs Roughly one-sixth of the world‘s population—approaching 1.1 billion people—live in ecological hotspots, areas rich in biodiversity threatened by human activity. While these hotspots comprise just 12 percent of the planet‘s land surface, they hold nearly 20 percent of its human population and are typically characterized by little access to basic government services, such as health care and education. Further, hotspot populations are growing nearly 40 percent faster than the world‘s population generally. PHE projects acknowledge and address the complex connections between humans, their health, and the natural environment. The key objective of PHE projects is to simultaneously improve access to FP and health services, while helping communities manage natural resources in ways that improve health and livelihoods, and also conserving the critical ecosystems on which they depend. The central hypothesis for integrating FP, health, and natural resource management (NRM) or conservation activities is that the synergies produced will make these interventions more effective and sustainable, as compared to vertical, sector-specific efforts. Unmet demand for FP is often quite high in remote rural areas, which are simultaneously characterized by rich and unique arrays of plants and animals often clinging to a precarious existence. In these settings, PHE interventions appear especially relevant. For those working in the health field, the PHE approach increases access to remote, underserved communities with a need for FP and basic health services. By partnering with environmental organizations that often have ongoing projects and established relationships in these settings, integrated programs can more effectively reach these underserved populations. Paired with simultaneous strategies to improve natural resources management in these fragile ecosystems, the health and family planning empowers families and communities with an additional strategy for influencing the well-being of their families and environments. It is hoped that ultimately this trust-building will yield environmental gain. The natural environment, itself, also benefits. Offering basic health services can dramatically reduce community morbidity and mortality and lessen dependence on natural resources for livelihoods. Also, FP enables couples to achieve a desired family size, which has positive effects on health and wellbeing while also potentially contributing to better NRM and conservation. Of course, in the longer term, population pressures on local ecosystems are also reduced. Assessment of USAID’s Population and Environment Projects and Programming Options 7 USAID’s Strategy for PHE Programming USAID‘s PRH has supported PE initiatives since 1993, when the office partnered with the University of Michigan‘s Population-Environment Fellows Program to develop a cadre of professionals specializing in PE issues. Since then, the PE program has expanded to include field programming in response to legislative language originally included in the FY02 Foreign Operations Appropriations bill—and repeated in all subsequent bills—stating that under the Child Survival and Health Programs Fund, some portion (unspecified) of the funds for FP/reproductive health (should be allocated) in areas where population growth threatens biodiversity or endangered species. In addition, successive editions of the accompanying Manager‘s Report included language that urges USAID to develop performance goals and indicators that promote cross-sectoral collaboration. To address this Congressional directive, USAID‘s PRH PHE program has developed collaboration with USAID Bureaus and Missions, as well as NGOs and private donors such as the Packard Foundation, to develop, implement, and fund PHE programs. USAID‘s PHE program focuses on areas of high biodiversity—often national parks and protected areas—and emphasizes working with local communities. Since 2002, USAID‘s PRH has employed a three-pronged strategy for PE programming1 : 1. Funding pilot field-based implementation of PHE activities 2. Developing research, tools, and communications to provide PHE technical leadership 3. Providing support to field programs to improve PHE technical capacity The PHE strategy has been funded through a combination of core PRH funds and Global Leadership Priority (GLP) funds. GLPs represent cutting-edge issues identified by the PRH front office that affect FP and RH programming and require dedicated attention. Each GLP has a coordinator or ―champion‖ and a working group who together establish a strategic direction, identify priority areas of investment, and coordinate activities undertaken across a number of existing centrally-managed agreements. The PHE GLP was established in 2002 and mainstreamed in 2006, which means that PHE activities are now expected to be fully funded under centrally-managed agreements, rather than receiving separate funds. Annual PHE funding over the past six years has averaged approximately $3.2 million, fluctuating from a high of about $4.1 million in FY2004 to a low of about $2.55 million in FY 2005. The following is a list of all PRH investments in each IR strategy. All activities have been funded through USAID/PRH using a mix of core and GLP funds. Additional funding leveraged by these activities and organizations through other donors or Missions is indicated. IR1: Fund pilot field-based implementation of PHE activities, usually through core funds, though at times using GLP funds. Some of these activities were co-funded by other donors as indicated. Conservation International (Madagascar, Cambodia, Philippines). Three PHE projects are implemented by CI, who partners with local health organizations that work in collaboration with CI staff to deliver community-based FP/RH information and services in the same communities where NRM activities are underway. World Wildlife Fund (Madagascar, Kenya, Philippines). Three PHE projects are implemented by WWF and local health partners, who work in collaboration with WWF staff to deliver community￾based FP/RH information and services in the same communities where NRM activities are underway. The only exception is the Philippines, where WWF was unable to find a health partner and has hired dedicated staff to work directly with the municipal government. Jane Goodall Institute (DRC). JGI partners with EngenderHealth to deliver FP/RH information and services in a CARPE landscape where JGI is also implementing livelihood activities in partnership with the local government and pre-existing conservation and development partners. EngenderHealth provides clinical training and technical assistance to JGI and selected health center 1 The PRH PHE strategic framework is found in Annex VIII. 8 Assessment of USAID’s Population and Environment Projects and Programming Options staff, but JGI actually implements the community-based FP/RH interventions. This project receives DRC Mission co-funding. PATH Foundation Philippines/Integrated Population and Coastal Resources Management Project (Philippines). This project fully integrates the FP/RH and coastal resource management (CRM) interventions at the community level, with one organization delivering all services to the community. The project also has an OR component, which provides data on control sites, single sector (i.e., FP, CRM) sites, and integrated sites. This project was largely funded by the Packard Foundation, and received additional funding from USAID/PRH to replicate and scale up activities in one province and conduct OR data analysis. In the last two years, the project has received modest funding from USAID and the Philippines Office of Energy and Environment to replicate PHE interventions in project areas where the FISH project is underway. Environmental Health Project (Madagascar). This project fully integrated FP/RH and NRM interventions at the community level, with one organization providing technical assistance and training to implementing NGOs to deliver the services in an integrated fashion. The project also had an OR component, to provide a comparison across single sector and integrated sites. This project was primarily funded through EHP with HIDN and PRH co-funding. Save the Children Philippines PESCODEV project (Philippines). The SAVE PESCODEV program was carried out in 11 municipalities within the West Visayas region with a total population of 375,203. The project, which ended in late 2004, focused broadly on population and health needs within these sites, many of which had received some previous support for improved CRM activities. PESCODEV was implemented primarily in concert with local government health officials rather than via NGOs. Among other techniques, the project trained and supported peer educators, using ―family planning action sessions‖ as an approach to encourage groups of 10 to 12 couples to make firm decisions about beginning to use FP. The project also focused attention on adolescent RH needs for both sexes. The project provided capital funding for the renovation or construction of government health ―stations‖ and counseling rooms in those facilities. Local Government Units (LGUs) were responsible for providing FP commodities via local government facilities and local government health personnel to support the project. WCS Makira Forest Project (Madagascar). This new Wildlife Conservation Society (WCS) project, in collaboration with Population Services International (PSI) Madagascar and CARE International, addresses biodiversity protection and resource conservation in the face of expanding rural human population pressure. This project demonstrates the importance of PHE in linking improved health and productivity with improved livelihoods and land stewardship. Specific objectives of the project are to: 1. Establish community awareness of and needs for health and FP information, products and services 2. Link health and FP education with access to PSI health and FP products 3. Increase the use of improved health and FP methods within the communities. In the long term, integration of a PHE component into a wider suite of development activities will reinforce the links between improved human health and productivity, improved livelihoods, improved land stewardship, and resource conservation. Conservation through Public Health (CTPH) (Uganda). CTPH promotes conservation and public health by improving primary health care to people and animals in and around protected areas, especially Bwindi National Park. CTPH works in three primary fields: 1. Wildlife health monitoring, human public health and IEC 2. Controlling disease transmission where wildlife, people, and their animals meet 3. Cultivating a winning attitude toward wildlife conservation and public health in local communities CTPH integrates FP and RH interventions into ongoing CTPH activities and the work of local health clinics. FP and RH will ultimately lead to reduced human-wildlife conflict, increased Assessment of USAID’s Population and Environment Projects and Programming Options 9 survival of the mountain gorillas, and greater tourism revenue and income for the local population, who will, in turn, have a smaller family size and budget to make better use of the family income. Integrating Population and Health into Forest Management Agendas (ADRA) (Nepal). In this pilot PHE Project, ADRA is providing technical assistance and oversight to the integration of FP and RH into ongoing NRM work implemented by WWF and Resource Information and Management Society (RIMS) Nepal, a local NGO that is focusing on community forest user groups (CFUGs). The project tests the concept of using community forestry institutions to plan, implement, and monitor community-based and integrated PHE strategies and activities that improve human and ecosystem health and contribute to post conflict rebuilding in Nepal. With over 14,000 CFUGs and federations operating nationwide and the presence of large conservation projects covering several globally-significant protected areas, national forests, and nature reserves in Nepal, the potential for rapid scale-up of successful PHE approaches on a district-wide, landscape-wide, or ecoregion-wide basis is promising. IR2: Demonstrating leadership in the PHE field at large by analyzing, communicating, and disseminating the benefits of the PHE approach through OR, development of M&E tools, and the analysis and dissemination of best practices and results. This technical learning and capacity building sub-portfolio has been based on the analysis of ongoing pilot PHE projects. The activities were funded primarily with PRH Global Leadership Priority (GLP) funding. Woodrow Wilson Center Environmental Change and Security Project. This project promotes dialogue and disseminates PHE information among policy and program audiences primarily in Washington, DC. Population Reference Bureau (PRB) Population and Environment Program. This program communicates PHE linkages based on the analysis and synthesis of research, builds local PHE advocacy coalitions, and disseminates PHE information to policymakers, the media, and practitioners. The Philippines and Madagascar have been focus countries in the past, and East Africa is currently a focus region. Camp Dresser McKee (CDM) Environmental Health IQC and its PHE Task Order (TO). Under this contracting vehicle, CDM develops tools to guide PHE program development and share information on and advocate for PHE. This activity receives co-funding from HIDN. PATH Foundation Philippines’ IPOPCORM. This program provides OR data processing and analysis for IPOPCORM‘s hypothesis examination. WWF. WWF‘s program, described above, contains a learning component that documents lessons and best practices from its PHE projects. IR3: Providing support to the PHE field for effective programming by building capacity and providing technical assistance. Michigan PE Fellows Program. This program provides technical assistance and capacity building to new and ongoing PHE projects and their organizations by placing Fellows within those organizations. MEASURE Evaluation. This program provides STTA to field projects, builds M&E systems, and develops M&E tools. PRB’s Population and Environment Program. This program provides training on program development and implementation and trains practitioners, the media, and researchers to analyze and present information on PHE linkages. Reflecting the evolution of the field towards a broader interpretation of cross-sectoral health and environmental programs, the PE program changed its name to the PHE program in 2005 to encompass and integrate maternal and child health, sanitation, nutrition, and food security issues. This emerged from experiences in successful field programs that provided FP as part of a broader health package to local communities. In addition, this broader interpretation allows the PHE program to provide greater leadership and technical assistance to Missions, who often wish to address emerging health issues in addition to 10 Assessment of USAID’s Population and Environment Projects and Programming Options population and environmental issues in their programs. Four USAID Missions—Madagascar, Rwanda, Nepal, and the Philippines—are funding separate PHE interventions using Mission funds. The following table indicates the level of PRH PHE funds obligated during the strategy period. Table 1: PRH/PHE Funding Obligations, 2002-2007 (in thousands) Year Obligation ($ thousands) 2002 $3,338 2003 $2,949 2004 $4,120 2005 $3,237 2006 $3,202 2007 $2,552 Total $19,398 Assessment of USAID’s Population and Environment Projects and Programming Options 11 II. ASSESSMENT METHODOLOGY This assessment was conducted as a ―program assessment‖ and, as such, its conclusions are largely programmatic rather than project-specific. In order for learning to occur, the assessment team took a participatory approach with USAID and CA staff members, who were given opportunities to reflect on the performance of individual grants as well as the overall program. Those staff members were also asked about suggestions for improvements in PHE activity design, implementation, and evaluation. Participation was structured to prevent the objectivity of the final report from being compromised. Specifically, the assessment team performed the following tasks: Meetings and interviews in September 2007 with key USAID and CA staff to gather data and opinions. These inputs were supplemented by phone and in-person interviews with experts on population, health, and the environment, including consultants, those involved in academia, and the donor community. In addition, the team spoke with many individuals and organizations not funded under this program that could provide outside perspectives on the value of PHE approaches and some of the PRH-funded PHE activities. Review and analysis of program and project documentation Preparation, distribution, and analyses of on-line questionnaires to USAID field Missions Preparation, distribution, and analyses of on-line questionnaires to the Michigan PHE Fellows (all fellows since 2002 were contacted), PRB workshop participants (participants in two workshops were contacted), and Wilson Center PHE presentation participants Field trips by two assessment team members to Madagascar and the Philippines to visit country headquarters for PRH-funded PHE projects and selected project field sites. The team members also interviewed USAID Mission personnel, as well as other relevant donors, NGOs, and government officials. Interviews in person, by phone, or via e-mail with grantees not visited by the team Preparation of a draft report, submitted to USAID on December 3, 2007 Preparation of the final report, submitted to USAID on December 12, 2007 after receipt of comments on the draft report Presentation of the major assessment conclusions and recommendations on December 13, 2007 to USAID (which included the full report) and to the participating CAs (which included everything but future strategy recommendations) 12 Assessment of USAID’s Population and Environment Projects and Programming Options III. PHE PROGRAM HISTORY SUMMARY For more than 50 years, organizations have been providing assistance that integrated elements of NRM, health, and FP as components of a set of solutions for households, families, and communities. This integrated assistance has continued to address real needs while the concepts, delivery strategies, and justifications behind this work have continued to evolve. Even now, depending on one‘s organizational perspective, integrating elements of PHE into development interventions may make sense for different reasons and achieve different goals. However, these different motivations often converge, and this convergence provides an opportunity to address multiple needs simultaneously, with each activity intended to reinforce the goals of the other. These converging interests have led to integrated PHE activities with the aim of yielding greater outcomes for all stakeholders than had each worked in isolation. The following provides a brief history of this evolution of PE and PHE programs that is not limited to those funded by USAID. By the end of the 1950s, World Neighbors (WN), a community development organization, was working in its project sites to address household needs, often providing advice related to FP and NRM in an integrated way. Since then, WN has applied this same logic to many of its project sites around the world and has documented strategies and techniques to provide guidance to others seeking to address PHE in the field. Other efforts to integrate multiple elements of development into one program, specifically near national parks or protected areas, became more popular by the early 1990s. Organizations involved in ICDPs and addressing multiple issues related to conservation in a development context often worked to address FP as well. But many of these integrated projects struggled to meet expectations of funding agencies and project beneficiaries. Even so, while ICDPs did not return the results hoped for by the conservation community, they reflected an understanding that opportunities exist to link conservation objectives with broader community needs. Another attempt to integrate PHE began in the early 1990s with the Michigan Population Fellows Program (PFP), which began in the early 1980s to provide both career opportunities to promising professionals in the population field and technical assistance to organizations addressing population-related issues. On the premise that the conservation community was an important constituent in efforts to address rural FP issues, PE Fellows began to be assigned to work in organizations already addressing this link. Opportunistic at first, these placements later became more strategic, often coinciding with a PE-focused grant from one of several foundations with an active PE portfolio in the 1990s. By 2001-2002, USAID began to direct its grant-making and PE Fellow placements based on strategy developed by the PRH office. This strategic effort became increasingly focused during the next six years. As the development community was reflecting on the importance of integrated development and the failures of some ICDPs, Population Action International (PAI) was writing about the link between population and environment and became involved in research, publishing, coordination, and advocacy in PHE. In addition to documenting the breadth of activities linking NRM, RH, and conservation and building consensus on the way, PAI organized several international gatherings on PHE and built a strong network for advocacy on behalf of those working on this in developing countries. PAI‘s contribution to the field was highlighted in 2001 with the inclusion of PHE funding language into the Foreign Operations appropriations bill, which led to the establishment (though not the design) of USAID‘s PHE portfolio. Also in the early 1990s, WWF began working on PHE, motivated in large part by a large donation from the Summit Foundation for the explicit exploration of population-related activities. During the subsequent decade, WWF published several documents addressing FP, gender, migration, and community health issues and how these could be understood and addressed in a conservation context. By 2002, when USAID‘s funding became available, WWF was a natural partner and received one of the first PHE grants. This allowed WWF to expand its PHE work to include Kenya, Madagascar, and the Philippines—priority countries for USAID‘s PHE work. During the 1990s, many organizations began making the PHE link in the field; some were searching for models to replace ICDPs, while others were exploring the link more conceptually. Considerable attention and resources were dedicated to exploring these links with several private foundations actively making PHE Assessment of USAID’s Population and Environment Projects and Programming Options 13 grants. With the Packard Foundation‘s approval of its PE Initiative in 2000, the Foundation joined others (Summit, MacArthur, Hewlett, and Turner) that had funded such programs at smaller levels during the mid￾to-late 1990s. Private funding during this time supported: 1. An increase in the number of grantees testing PE field projects 2. An increased the number of overall field sites 3. Operations research at two PE field projects 4. M&E data collection at other sites 5. Establishment of new leadership programs in key U.S. institutions 6. Increased funding for programs that alerted the American public to global PE issues and the impact of U.S. consumption patterns Still, this dynamic funding environment was short-lived for the PHE field. The stock market decline before and after September 11, 2001 led several foundations to reduce or eliminate funding for PE activities. About the same time, a new major funder of PE activities entered the field. The U.S. Foreign Assistance Act of 2002 directed USAID to use some of its FP funds in ―areas where population growth threatens biodiversity or endangered species.‖ This ―directive‖ has been included in all subsequent foreign aid legislation and USAID‘s PHE program has provided an average of $3.2 million annually in funding from 2002 to 2007. Initially, USAID targeted its resources to projects initiated by Packard or other foundations where funding was being withdrawn. This allowed these activities to continue to their logical end, enabling the PHE field to gain the lessons from the PE activities initiated before USAID began funding in this field. Since 2002, when this language first appeared in legislation, similar language appeared in the Manager‘s Report and has evolved over the ensuing seven years. The first language encouraged USAID to develop ―goals and indicators that promote cross-sectoral integration on community-based PHE programs,‖ and later included instructions to consult with the committee on the goals and indicators. In 2008, the manager‘s report acknowledged USAID‘s leadership in PHE and included language that ―urges USAID to build upon its past investments in population-health-environment programs by expanding and scaling up projects in communities inhabiting areas rich in biodiversity, particularly in Africa and Asia.‖ This new wording reflects the role USAID has played during the past few years while also validating past (and future) efforts, focusing investments in the PHE field on consolidating best practices and investing in countries where priorities overlap. USAID started funding conservation organizations interested in integrating FP in their initiatives as a way to respond to the congressional directive and expand FP access in rural areas. This first generation of USAID PE projects was focused on determining if the partnership could work at the implementation level and, in most cases, the conservation organizations integrated population and FP by partnering with a local organization with this capacity. Recently, USAID worked with MEASURE/Evaluation to establish a set of core indicators that all grant recipients would use to track accomplishments and report on in the Performance Management Plan. The MEASURE/Evaluation activity funded under the PHE portfolio has provided the basis for tracking output and some impact indicators. Presently, USAID is the only bilateral donor with an explicit PHE program that finances (and often co￾finances) field projects. Most USAID funds are provided through a program managed by the Bureau for Global Health (BGH). Funding has been provided for field projects in all four of the countries where Packard‘s PE program has been operating: Philippines, Madagascar, Tanzania, and Mexico. More importantly, the USAID funding has gone where the Packard programs were taking root and interest was strong. In addition, funds have been provided to Kenya, Cambodia, DRC, and Nepal. USAID monies for field projects have been transferred via grants to implementing PVOs and NGOs—such as WWF, CI, JGI and Pro-Peten, PATH/Philippines, and Save the Children—or transferred via the centrally-funded EHP. USAID/Washington program managers encourage USAID Missions to add their own funds to those provided by the BGH, and four USAID Missions have done so. USAID PE funds also financed the Michigan PE Fellows program and a series of ―Environmental Security‖ workshops and presentations organized by the Woodrow Wilson Center in Washington, DC. 14 Assessment of USAID’s Population and Environment Projects and Programming Options During the past few years, funding for USAID‘s environment and population sectors have both declined. However, since USAID‘s PRH and HIDN offices are looking for project models with the proven capacity to reach rural areas and scale up, PHE may yet be able to provide a strong return on investment. The USAID Environment Office, on the other hand, is not yet convinced that PE projects would meet its program objectives more effectively and efficiently than more traditional environment and biodiversity programs. Finally, as noted in other sections of this report, several NGOs have accepted the value of PE and PHE programs and have internalized these integrated approaches in many of their field projects whether they use their own funding or solicit funds from other sources. WN, for example, now includes FP activities in ―the way it works‖ and addresses broader rural poverty issues worldwide. The JGI is expanding its programs to the DRC using a PE framework. ProNatura/Chiapas and some other host country NGOs with PE experience also state that they plan to include PE in their standard operating practices and in their solicitations for funding. With USAID support, WWF and CI now see PHE as ―part of the fabric of what we do‖ in remote biodiversity landscapes, and other major PVOs, such as the Wildlife Conservation Society and CARE, are also experimenting with PHE projects. In conclusion, just as these various strands of history have been important factors in shaping USAID‘s current PHE strategy, USAID‘s future PHE investments will be critically important in shaping the field‘s continuing evolution. Assessment of USAID’s Population and Environment Projects and Programming Options 15 IV RESULTS ACHIEVED PILOT FIELD PROJECT COMPONENTS OF PHE PORTFOLIO (IR1) The PRH PHE sub-portfolio of field projects can be represented by three clusters that differ importantly in their timing, purpose, and type of implementing agent: Cluster 1: Support for best model integrated projects implemented by health-based organizations. In fiscal years 2002 and 2003, the program provided timely financial support for two major ongoing projects primarily funded by the Packard Foundation in the Philippines: IPOPCORM (PATH Foundation Philippines, International (PFPI)) and PESCODEV (Save the Children). These programs had been carefully planned as integrated PE and PHE programs, were each initiated by health PVOs, and have now been completed with final results available. IPOPCORM and PESCODEV are, to date, among the most successful PHE projects worldwide. Both carried out integrated programs at multiple sites in the Philippine‘s Central Island region, typically characterized by heavily populated coastal fishing communities with declining coastal resources and a lack of health services. Cluster 2: Support for PHE projects in very remote sites implemented by environmental PVOs. Projects in this cluster encouraged environmental PVOs to determine whether PHE projects might be a viable model for providing integrated services to populations in very remote, biodiversity-endangered regions that those organizations had targeted as hotspots or key ecosystems. With the exception of EHP, which ended in FY2005, the projects at these seven locations are now nearing completion. Partial, but not final, results are currently available. In fiscal years 2002 and 2003, two major U.S.-based environmental PVOs, CI and WWF, submitted successful proposals to fund new PHE projects in very remote locations in the Philippines (CI and WWF), Madagascar (CI and WWF), Kenya (WWF), and Cambodia (CI). In almost all cases, these projects added an FP or FP and health component to ongoing or new WWF and CI environmental activities. In addition, the Global Bureau‘s PRH and HIDN offices collaborated in fiscal years 2000-2004 to fund a multifaceted PHE program (EHP) in Madagascar where field activities (and related OR) were conducted in isolated communities in two ―landscapes‖ where USAID environmental programs were already working.2 Finally, in FY2004, PRH began incremental funding, which continues, that allowed another environmental PVO, JGI, to add FP and livelihood3 components to an ongoing environmental program in the Kahuzi-Beiga landscape of the DRC under the USAID-funded CARPE program. Cluster 3: In fiscal years 2006 and 2007, modest support was provided for new PHE opportunities. PRH provided support in to three projects where FP has been added to Mission-supported programs that have more unusual environment foci: A Uganda project that addresses the interface of animal and human health as well as population pressure on the perimeter of Bwindi National Park, one of two homes for endangered mountain gorillas. Animal health aspects of this program have been supported by the USAID/Uganda EGAT office. A major ongoing USAID/Nepal community forest management program as part of an expanded Mission effort to reduce conflict in rural Nepal. A growing WCS project around a new national park in northeast Madagascar as part of a USAID/Madagascar program entitled ―The Extra Mile.‖ Few results are yet available from these newly funded activities. PHE Project Objectives: Notwithstanding variations in timing, geographic location, and implementing 2 This program provided funds for pilot PHE projects with a water focus, established a new PHE coordinating entity in Madagascar (Voahary Salama), and funded a significant PHE OR study to determine if value was added through integrated projects. 3 The livelihood component was to be supported with USAID/GDA and JGI funds. 16 Assessment of USAID’s Population and Environment Projects and Programming Options organization, the objectives of all of these PHE projects are relatively similar: improvements in FP or FP/health outcomes (especially increased contraceptive prevalence rate (CPR)); improved outcomes in CRM or NRM and, often, changes in policy and regulatory frameworks that support the first two outcomes. Given the small size of these pilot projects and their relative isolation, planned end-of-project results have been modest, although nearly all project reports indicate that their stated objectives are being met, sometimes with delays. Project costs per site have been modest, averaging from $70,000 to $100,000 per year, and project beneficiaries range between 500,000 in the eastern DRC to 15,000-20,000 in most WWF and CI project sites. Without providing detailed results, the following paragraphs respond to specific questions about the pilot projects, as posed in the assessment‘s scope of work. Are PHE projects increasing access and use of quality RP/RH services within underserved communities? The PHE portfolio, especially Clusters 2 and 3, has been directed towards some of the most remote, ecologically rich regions of the world, often characterized by little or no previous health service provision. Without a doubt, these projects have increased access to FP/RH services within these remote communities. The WWF activities are located in the Spiny Forest of southern Madagascar, in the Philippines portion of the South Asian Coral Triangle, and at Kenya‘s northernmost marine and biosphere reserve near the Somalia border. The CI pilots are equally remote and environmentally significant: in the Sierra Madre Biodiversity Corridor of Luzon island in the Philippines, the very isolated Cardamom region of southwestern Cambodia, and the Zahamena forest corridor of eastern Madagascar where many project villages are at least a day‘s walk from any road. Similarly, the JGI project in eastern DRC is ―at the right place,‖ according to conservation specialists—at the border of the Albertine Rift and the Congo Basin Forest, where the health district population is twice the national average. In two of these regions, the DRC and the Philippines‘ Sierra Madre Mountains, access to government health services is further restricted by the presence of armed opposition militia groups. In both locations, these groups have thus far allowed free passage to PHE project visits, realizing the communities benefit from delivered services.4 Also providing evidence of reaching underserved populations, the Uganda project is the only NGO program operating near Bwindi Park, one of only two global sites established to protect the mountain gorilla, although it is threatened by a dense, impoverished human population. While the Cluster 1 projects, IPOPCORM and PESCODEV, are not near officially designated national parks,5 they are located in the Visayas region and Danagon ecosystem of the Philippines, where population densities compare to central Java. In these regions, the population growth rate is 50 percent higher than the rest of the Philippines, and poverty is escalating due to declining fisheries. Prior to project initiation, the communities in these environmentally sensitive regions, with few exceptions, were completely unserved by FP (and health) services. Government health provision typically does not reach these isolated regions or the nearest health facility is often distant (e.g., a minimum of 10 kilometers from project communities, often as much as a two-day walk, or an uncertain boat ride on the open ocean). At best, relatively high-priced pills or condoms were available at weekly regional markets. The exceptions to the generalization of PHE regions being typically underserved are in the Philippines, where USAID￾supplied FP commodities6 were provided via the Ministry of Health (MOH) services present in larger towns of the Visayas, Sierra Madre, and Palawan regions. Still, these commodities rarely reached the more rural PHE sites. What success have PHE projects had in increasing access to and use of FP services? Without exception, during a two-to-three-year period, the PRH PHE programs have reported significant 4 In addition, the WWF Kiunga project, which abuts the Somalia-Kenya border, has been affected by population movements related to the insecurity in Somalia. 5 All identified IPOPCORM sites fall within Marine Conservation Priority Areas and are within the Philippine Biodiversity Conservation Priorities by the Philippines Department of Environment and Natural Resources. 8 In accordance with the Phillippine government‘s Contraceptive Independence Initiative, USAID began phasing out donations of condoms in 2003; phaseouts of other commodities are in progress and will be completed in 2008. Assessment of USAID’s Population and Environment Projects and Programming Options 17 improvements in access to and use of FP services.7 8 Most projects focused on increasing the use of FP services rather than explicitly measuring increased access. CA Total new users (6/05–6/06) Total health service providers trained Total population served Total Women of Reproductive Age (WRA) CI 532 29 45,884 10,223 WWF 550 167 54,674 - NA - JGI 4,376 205 509,765 - NA - IPOPCORM 6,678 2,181 356,461 71,292 The CI Sierra Madre reports that CPR has increased from 59 percent in 2003 to 67 percent in 2007. IPOPCORM reported a CPR increase from 17.2 percent in 2001 to 23.6 percent in 2004. The new Uganda project reports 73 new users, plus eight users of NFP among 1,500 homes visited in the project‘s first nine months. This success has sometimes come in spite of strong opposition from religious leaders (some, but not all, local Catholic priests in the Philippines and in the DRC and initial opposition from imams in the Kiunga project area of Kenya). The most remote and traditional populations, such as the cattle herders in Madagascar‘s Spiny Forest and the very isolated Cambodian Cardamom forest dwellers, have responded more slowly. Early rumors circulating in rural Madagascar led people to believe that the use of FP pills could result in death. For all projects, initial counseling includes discussion of the full range of FP methods and choices, while service delivery occurs through community based approaches. In African sites, Depo Provera is replacing pills as the method of choice, although it requires greater initial outlay of scarce income to procure and has normally requires a visit to the health center for injection.9 In reality, longer-term methods such as tubal ligation and vasectomy have been available only when special medical ―missions‖ visit these isolated regions or if the regional health officer is trained in these surgical techniques.10 Implants such as Norplant and Implanon are also essentially not available to these populations. Continuing unmet need: In most PHE project settings, even after three years, most implementers feel that significant unmet need for FP services remains, especially among the more remote and impoverished households and where traditional cultural and religious beliefs are strong. However, many implementing agents also feel that they should move on to work in other villages after three years of periodic visits, leaving behind a cadre of early adopters and trained CHWs to gradually encourage others to adopt FP with much less support.11 Reaching special target groups: Operations research has attempted to validate the hypothesis that integrated programs provide better FP outcomes than stand-alone projects (summary of results presented in Annex V). Although lacking overwhelming quantitative evidence of ―value added,‖ practitioners generally report that integrated programs provide better FP outcomes, especially for two groups: youths and males. 7 Reporting against a common framework is still a challenge for both WWF and CI for three reasons: the projects were already three to four years underway when the common framework was introduced by PRH; there was limited training and monitoring for field based staff; and site differences mean reporting different results, particularly in the conservation sector. 8 In remote areas of Madagascar and other countries in this early stage of their demographic transition, strong cultural barriers and supply issues often result in slow increases in traditional FP indicators such as CPR or couple-years protection. As pointed out in a 2007 report on PHE in Madagascar, increased access and equity may be more valid programming goals than just the size or proportion of the target population reached, and measures such as proportional increase (from 5 to 10 percent of the population) or increase in FP service coverage (villages reached through community-based agents or social marketing) may better reflect the initial value of FP funds being allocated to remote areas (Gaffikin 2007, p. 45). 9 PHE-trained community health workers (CHWs) have been among those CHWs selected to pilot test CHW injection of Depo in Madagascar, and the PHE Bwindi project hopes to become the first test site for CHW injection of Depo in Uganda. 10 Even in Palawan, probably the most accessible PRH/PHE site, such missions depend on demand being generated, a formal request for a mission from the provincial government, and the availability of mission personnel from another Filipino province. 11 Projects often have special names for volunteer CHWs. This report consistently uses the term CHW for these volunteers. 18 Assessment of USAID’s Population and Environment Projects and Programming Options Youths: The recently completed IPOPCORM OR results indicate that youths respond more positively in integrated PHE sites than in FP-only sites. Changes in the reported use of modern FP methods by young females during last sex showed a statistically significant increase in integrated sites when compared with stand-alone sites. Project-wide, reported female use increased from 5.6 percent in 2001 to 15.6 percent in 2004, while reported male condom use increased from 4.5 percent to 5.8 percent during the same period.12 The improved youth outcomes are attributed by PFPI to the use of young adults (many unmarried) as community health outreach workers and as peer educators, and an IEC strategy that centered on food security and sustainability of coastal resources for future generations. The PESCODEV project also used 66 youth peer educators to provide youth counseling and pilot theater groups with adolescents who translated key behavioral messages into 10-minute street performances for youth audiences. One of the most successful integrated messages for youths of both sexes has been the concept of stewardship: the need to be simultaneously a steward of one‘s body and a steward of one‘s environment. In African PHE settings, most projects in remote areas have not targeted the youth audience, although youth develop and participate in theatre and drama skits for the Bwindi project and for ASOS (the Malagasy NGO that works with both the CI and WWF projects in Madagascar). Males: Cluster 1 PHE projects in the Philippines have reported greater success in promoting FP with males than in FP-only projects. Kiunga appears to be the only African PHE site that has made special efforts to encourage males to either allow their wives to practice FP or to practice contraception themselves. No PHE project in an upland NRM setting has reported particular success with male acceptance of FP. In the coastal settings, FP messages are delivered when CRM messages are discussed with fishermen and mangrove associations and through special meetings with couples. Successful approaches have been: Couples classes, obligatory for all new Filipino married couples, were traditionally taught for a half-day in a rote manner by the local government unit (LGU) health officer. With adaptations suggested by SAVE, these sessions within PHE projects have now become participatory FP action sessions that conclude with filling out an FP Action Card. Completion of the card encourages discussion of FP and child spacing, and indicates what FP method a woman or couple would like to use. A copy of the card is provided to the community health worker who makes a follow-up visit. SAVE successfully integrated an environment module into these sessions, a practice now borrowed by the WWF-Palawan project. Family budgeting sessions that focus, in sequence, on family size, nutritional requirements to keep the family healthy, and the additional time the fisherman will need to spend fishing if another child is added to the family. A similar approach has been successful in Kiunga, via discussions with men by community-based distribution systems (CBDs) (30 percent of whom are male) regarding the relationship between family size and disposable income. In many PHE sites, male early adopters are used as peer educators and role models. What is the Quality of FP Services Provided by PHE projects? A key question in assessing the impact of PHE pilot projects is whether the quality of FP services being provided to remote populations is adequate. Three traditional indicators of quality are: the impact of IEC materials on behavioral change, continuity in the availability of FP methods, and the continuity and quality of training and supervision for volunteer community health agents13. It is useful for this analysis to return to the three clusters of PHE projects noted at the beginning of this chapter. IEC materials: The Cluster 1 projects, IPOPCORM and PESCODEV, which were initiated by international health PVOs, developed high quality IEC materials, training manuals, and innovative cross-sectoral messages for PE and PHE projects that were successfully used in their sites.14 12 However, project-wide results indicate that the average age of pregnancy (19) did not change, nor did the age of sexual debut (18.1 years). 13 Data are not available on beneficiary perception of the quality of FP services provided through PHE projects. 14 IPOPCORM also institutionalized a Behavioral Monitoring Survey to actually measure behavior changes by target communities. Assessment of USAID’s Population and Environment Projects and Programming Options 19 Cluster 2 projects, implemented by environmental organizations, have almost always partnered with domestic or international health NGOs to deliver FP and health services in their project areas. The lead organizations—WWF, CI, and JGI—have depended on these partner NGOs or other USAID-funded projects to provide IEC materials. Operating with shoe-string budgets, the partner NGOs have rarely developed new IEC materials for their sites and have, at best, relied on flip charts, brochures, FP method primers, and other IEC materials begged or borrowed from other USAID health or donor health projects in the country. Still, most Cluster 2 PHE projects have resulted in significantly increased demand for FP services and behavior change. This is probably due to the use of the traditional communication modes of rural African (and Cambodian) communities—oral presentations, marionettes, and story telling (community theatre) —techniques used for decades by the local NGO partners. Radio broadcasts and the establishment of radio listening groups are also being introduced in the Spiny Forest and Zahamena project sites and in the Uganda project to gain better access to remote, often illiterate populations. Despite the relative success of traditional IEC, it is disappointing that Cluster 2 projects have not taken advantage of well-tested written IEC materials with a specific PHE focus. Continuity in the Availability of FP Methods: Most PHE projects have established and relied on CBDs to make FP methods available in remote communities. CBDs are operated through small community shops (sari sari shops in the Philippines), the ―health rooms‖ in the homes of volunteer health workers (Palawan), or via home visits made by CBD agents (most African sites). Revolving funds have been established and are functioning in nearly all project sites, with the delivery agent receiving a small fee (about 10 percent) above her/his cost to obtain the commodities.15 Re-supply has typically been timely so long as project personnel regularly travel between the communities and the supply center (normally the closest health center). Sustainability is occurring or likely to occur in Philippines PHE sites through a variety of mechanisms. In Sierra Madre, the LGU midwife and FP coordinator has gradually taken over the re-supply coordination responsibilities. IPOPCORM has achieved continuity after project completion by franchising CBD arrangements in conjunction with DKT Philippines, and in Palawan, the system will be sustainable once a supplier is established in the capital of the island. Continuity of supply is much less certain in the more remote Cluster 2 sites in Africa where government services are non-existent or weak. Only the Kiunga project feels confident that the Kenyan MOH will continue to deliver FP services to CBDs due to strong demand demonstrated during the project16. In Madagascar, the Spiny Forest project reports that the MOH is now regularly supplying 75 percent of the CBDs but continuity of supply is likely to be a function of site proximity to a well functioning health center. Otherwise, supplies must continue to be maintained by environment organizations, their health partners, or other donors. Training and Supervision of Volunteer CHWs: For most PHE projects, the project staff has provided initial training for CHWs, typically selected by the communities or by community leaders. During the project, these volunteers receive counseling, retraining, and support from the multidisciplinary project technical staff who usually visit each community at least monthly. They should also receive cross-sectoral training. The skills of these project technical staff vary. FP and health skills are strongest among personnel of health￾focused NGOs, such as ASOS and PFPI. SAVE and CI-Philippines have relied on LGU health staff (often re-trained by the project) to train and supervise CHWs throughout the project (and hopefully after project completion). In remote Cluster 2 sites, where environment or livelihood-related NGOs are already in place and trusted by local communities, these NGOs often provide CHW and CBD training. Of course, they must themselves be trained by either the conservation PVO or, more likely, via an in-country training program carried out by another USAID or donor health project (such as Madagascar‘s SanteNet). The FP and health technical 15 Revolving funds are working even where the national government (Madagascar) has decreed the FP methods must be available at no cost, since the MOH has accepted the need for CBD agents to receive the ―prime‖ for their services. In almost all projects, the initial supply of methods is purchased and delivered to the CBD agents by the project, or, as in Palawan, with ―seed money‖ provided by the LGU and by each participating local government neighborhood unit (barangay). 16 However, they would have to do so by boats that are not yet available except via WWF. 20 Assessment of USAID’s Population and Environment Projects and Programming Options support structure for environmental PVOs and their non-health NGOs, such as Mateza, is very weak as they establish initial PHE projects. The immediate supervisor for the partner NGOs is often located at the regional WWF or CI office, where there are no health personnel on staff. For both WWF and CI, their national offices in the Philippines and Madagascar also do not include an experienced health officer, nor do they have FP and health IEC materials in stock and available to replenish field offices or partner NGOs. To access a trained health officer to resolve an FP or health issue or to access IEC materials within their organization, WWF and CI field officers must typically communicate with their PHE coordinator in their international home offices in Washington, or make local contacts with other NGOs on their own.17 The absence of a dedicated health staffer in the country office of an environmental NGO is probably understandable when only a single pilot project is being implemented, but the structure will need to change if and when PHE integrated projects become more common in its country portfolios18 . In the long term, nearly all the PHE pilots hope to see local governments take responsibility for regular supervision visits and re-training of CHWs. This process is reportedly on track to occur in the Philippines, in Kiunga, and even in the DRC. However, local health units in Madagascar have small staffs, are normally without vehicles or fuel for them, and are unlikely to move closer to these very remote project communities in the near future. In these remote regions, no clear picture is emerging as to how CHWs will be trained, supported, and supervised after the projects end.19 IMPROVED HEALTH, ENVIRONMENT, AND LIVELIHOOD RESULTS THROUGH PHE What results have been attained from the health and environment components of PHE field projects funded by the PRH PHE program? Health: Many PE and PHE projects in remote, environmentally sensitive regions have explicitly used basic health care as an ―entry point‖ to gain community favor and to gradually earn trust and support for longer￾term conservation and FP objectives.20 The rehabilitation of rural health clinics to provide FP services has often encouraged the MOH to place staff in those centers and provide broader services. For Kiunga, WWF boats that function as mobile clinics includes MOH health staff who provide other health services, such as immunization, vitamin A, and pre-and post-natal checks. In other cases, the projects have found other funding (CARE in Cambodia, Johnson and Johnson in Kiunga) to fund essential health services desired by the communities (more than they desire FP, in most cases). More and more environmental PVO country offices are recognizing not only the value of health services as an ―entry point,‖ but also the natural links between NRM objectives and maternal-child health, nutrition, clean water, and a broad approach to RH, including HIV/AIDS awareness. In upland forest corridors in Madagascar, the need for a clean and abundant water supply has become a useful connection for bringing in discussion of infant mortality, improved household and community hygiene, increased agricultural production, better nutrition from small vegetable gardens, and, finally, the need to protect the forest cover since it ―brings the rain.‖21 In several PHE locations, the CHWs and CBDs are also the lynchpins for delivering mosquito nets, water purification tablets, vitamins for babies, as well as FP methods. Basic health services are normally at or near the top of the ―wish lists‖ of remote communities, and in many locations, it is simply not acceptable to these 17 The WWF/Palawan project coordinator learned about SAVE‘s use of Family Action Sessions from a chance meeting with a university friend, rather than through any support from WWF/Manila or the PHE network. 18 This is perhaps similar to CARE/Madagascar, which employs a ―health officer‖ in its headquarters office to provide technical support for CARE activities throughout the country. 19 Solutions to this problem could include: expansions of MOH facilities and staff into remote areas or MOH sub￾contracting with local NGOs to continue to deliver FP and health services. 20 This entry point strategy is used explicitly by CI in Cambodia. In the remote Cardamom region, there was a great community demand for maternal-child health care and ―just delivering family planning information and services would have been unacceptable and inappropriate.‖ The program is now gradually increasing its focus on FP (responsible sexuality and delayed sexual debut), especially among youth audiences, and is blending this message with the message of being responsible stewards of the environment. 21 The PHE project near Bwindi has a unique approach to human health. The project began when it was determined that the deteriorating health of mountain gorillas was due to their susceptibility to scabies, intestinal parasites, and tuberculosis transmitted by unhygienic human populations living near the park. Assessment of USAID’s Population and Environment Projects and Programming Options 21 communities for a CA to attempt to deliver FP services without also providing a basic package of health services. Since even most USAID PHE projects don‘t include funding for health, most CAs do little reporting on health results. It is clear, nevertheless, that health programs have benefited in several ways from the presence of PHE or PE projects in remote areas: 1. Immunization rates increase markedly because all donor-funded field staff are required by most governments to participate in periodic vaccination campaigns and the PHE staff can reach very remote communities. 2. Malaria programs benefit, since almost all CHWs and CBDs, although selected and trained by PHE projects, are also asked to distribute mosquito nets and malaria prophylaxis. 3. Nutrition and child health indices normally improve in PHE project areas due to the introduction of livelihood activities such as fruit trees, fish ponds, and ―green gardens,‖ as well as cleaner water, latrines, chlorine for water purification and composting. 4. In most PHE projects, IEC focused on the prevention of HIV/AIDS and sexually transmitted infections are a standard part of reproductive health counseling. Environment and Livelihoods: Nearly all of the projects report meeting most or all environment-related objectives, typically defined as improvements in CRM or NRM in upland forest areas.22 At the early stages of an environmental program, a primary objective is simply to gain the trust and acceptance of the local communities. Often, this is achieved by introducing a set of non-environmental activities that provide quick and visible results, such as basic health services, clean water, construction of a health or education center, or improving mountain paths to markets. This appears to be succeeding in the CI and WWF program areas of Madagascar and in the Cardamoms in Cambodia. CRM: The Cluster 1 programs focused on a series of CRM objectives, such as community involvement in coastal resource inventories, establishment of marine protected areas (MPAs) and fish nurseries, zoning of bays and fishing areas used by multiple communities, reduction in the use of illegal fishing gear, paralegal training and deputizing villagers as fish wardens, encouraging local government funding MPA surveillance by the communities, and carrying out coastal and mangrove cleanup and replanting campaigns. These activities were supplemented in IPOPCORM by ―livelihood‖ projects that used micro-credit and technical support to encourage sustainable harvesting and the use or sale of coastal resource products. The longer term (20-year) CRM project objectives are typically to protect and rejuvenate corals and sea grass, to provide safe habitats for endangered biodiversity (for example, turtles and dugongs), and to increase and maintain marine productivity. Both IPOPCORM and PESCODEV were very successful in meeting their CRM objectives (as well as FP and health objectives). Some tangible results, such as increases in the fish stock, were evident to local fishermen in only two to three years, and strong interest has been expressed among neighboring LGUs in copying these programs.23 Cluster 2 includes only two CRM projects: WWF projects in Palawan and Kiunga. In both cases, the CRM activities were funded with moneys raised by WWF.24 In Palawan, the PHE project has allowed WWF activities previously initiated with a private donation to continue for three more years. Thus far, five MPAs have been established and planning is being completed for zoning the larger bay area. Participatory coastal resource assessments of local resources (for example, sea grass, mangroves, coral reefs, and fisheries) have been completed and 32 fish wardens have been trained and deputized to monitor the MPAs and the use of illegal fishing gear. Fishermen report that the fish stock has begun to increase in their traditional fishing zones. The Kiunga project in northeast Kenya also reports considerable success in reducing the use of 22 A few projects, such as WWF‘s Ridge to Reef program, try to simultaneously address both NRM and CRM problems as part of broad watershed programs. Many projects also include a policy component that encourages local governments to enact regulations and provide funding to support CRM or NRM objectives. 23 Under IPOPCORM, the number of MPAs increased from 17 in 2001 to 88 in 2006. 24 However, it is not practical for staff at community-based projects to work only on FP or environmental activities. PRH‘s growing insistence on isolating PRH funds for use only on FP is causing major difficulties for PHE program CAs. 22 Assessment of USAID’s Population and Environment Projects and Programming Options illegal fishing nets, decreased by-catch of endangered species, and a gradual increase in young turtle survival. An innovative livelihood component (for example, Trash for Cash and Flip Flop Art) fabricates toys, jewelry, and artisanal products from beach debris. Household income has reportedly increased by $130 per month due to these livelihood projects. NRM: Four of the six CI and WWF pilot projects have a NRM focus: Cambodia Cardamom Mountains (CI), Madagascar Spiny Forest (WWF), Madagascar Zahamena Corridor (CI), and the CI Philippines Sierra Madre project. The JGI project in DRC has been added to an ongoing landscape program where other partners (CI and Dian Fossey) implement the environmental activities. In addition, the primary long-term objective of the Uganda project is to protect the health of the mountain gorilla to continue attracting tourists and providing livelihood opportunities for the local people. The new Nepal PHE project hopes to reduce population pressure and land conflict in remaining areas of the Nepalese forest. The typical package of NRM activities is similar to CRM activities and includes: community participation in resource assessments, community action to reduce off-take of forest cover (used as firewood, sold as charcoal, or sold as timber), increasing use of energy saving stoves, reducing uncontrolled forest and bush fires, planting local species in community woodlots, planting fruit trees for domestic use and for soil conservation, and improving basic agricultural practices to retain soil nutrients. In Madagascar and the Philippines, an additional NRM objective is typically to establish a forest or natural resources management plan. Once a plan is approved by the government, surveillance and control of communal lands is transferred from the Forest Service to the community. NRM activities are also normally supplemented by a variety of livelihood activities (for example, poultry and small ruminant raising, fishponds, beekeeping, and use of improved rice seed and rice production methods) that are increasingly seen as essential to gain community buy-in for longer term conservation objectives. As a prime example, JGI was invited to join the CARPE program‘s Maiko-Kahuzi-Beiga and Tayna Landscape effort because of the clear need to add two new components: FP/health and livelihood initiatives. The USAID-funded FP and health activities have been relatively successful thus far; however, the JGI livelihood activities, to be funded by JGI, are behind schedule. Environmental PVOs are increasingly aware that both local communities and central governments expect them to add livelihood components to their environmental programs. For example, in 2004, when Madagascar‘s president announced a goal to triple the nation‘s land under protected status, he also stressed that this could only happen if communities living in or near the newly protected areas would not be negatively affected and, ideally, that their livelihoods would improve due to complementary income generation and social service activities provided to them. In the DRC, the CARPE environmental program determined that its objectives would be attained more quickly if both health/FP and livelihood components were added to an ongoing program. In general, progress towards attaining the NRM and livelihood objectives of the PRH PHE field projects is felt to be slow but steady. Most environmental PVOs working in hotspots or environment zones are working toward longer-term conservation goals. The major constraints to NRM and CRM success are reported to be: 1. Restrictions in the use of USAID funds for non-FP purposes 2. The difficulty in finding funds from other sources 3. The absence of economically-viable livelihood alternatives, partly due to the difficulty in marketing products from remote regions 4. The lack of NGO and PVO staff expertise in designing and implementing livelihood projects25 What is the Added Value of an Integrated Approach? During the past few years, anecdotal evidence gathered through PE and PHE program assessments as well as OR results have identified several specific areas where integrated programs provide greater added value 25 ASOS technical advisors in Zahamena report that they have received little training from CI or elsewhere on how to introduce environmental interventions ―beyond reforestation.‖ Assessment of USAID’s Population and Environment Projects and Programming Options 23 than stand-alone FP, health, or environmental programs. These are: Advantages to FP efforts: Greater access to isolated, underserved communities; greater access to men; and greater access to adolescent boys. FP also benefits when it is packaged with the quickly perceived effects of health interventions, such as immunization and improved water quality. Advantages to environmental and conservation efforts: Greater female involvement in CRM and NRM activities and organizations, increased participation of adolescents of both sexes, and provision of an ―entry point‖ function whereby integrated projects can quickly and visibly respond to the priority demands of the community (often health needs) and gradually gain the trust of the community. Over the long term, a major threat to endangered biodiversity—population pressure— should be mitigated. In programmatic terms, PE and PHE projects are often both cost-efficient and cost-effective. A large number of NGOs have demonstrated that they can successfully implement integrated programs with the positive effects of expanding target audiences, reducing operating expenses, and fostering community goodwill and trust. Integrated programs are also valued by communities and community leaders for being more efficient in the use of their time (fewer community meetings, less paperwork, interaction with one implementing agency rather than two or more). Have the Results of the PRH/PHE Portfolio Reinforced or Weakened these Conclusions? Indeed, much has been learned from the USAID-funded field projects and related OR. 1. Gender-related added value (both for population and environment) has been most evident where PHE programs are integrated from initiation (rather than adding a population component to an ongoing environment program) and when men and women are brought together to receive population and environment messages (such as couples classes, family budgeting, and youth￾focused programs). Without these program characteristics,26 project results do not yet suggest clear gender value added. 2. Health interventions, including FP, provide an effective ―entry point‖ for long-term conservation programs in remote regions. Environmental PVO leaders increasingly see an imperative to respond to high-priority community requests to gain ―trust‖ and a long-term commitment to conservation. Health and livelihood activities with visible short-term payoffs build this trust.27 3. In very remote areas, the ―cost efficiency‖ argument has been reinforced as the environmental PVOs and their partners are often the only active implementing organizations. Increasingly, government leaders, such as the President of Madagascar, expect these PVOs to provide other services (quid pro quo) to substitute for lost livelihood opportunities resulting from new protected areas.28 4. Reduced conflict may be another added value for integrated programs. When health and FP (and sometimes livelihood) services have been offered as part of environmental programs, rebel militias in the Sierra Madre and DRC project areas have allowed secure program access to communities and the areas have reportedly experienced less conflict. 5. Strengthening local governance: PHE projects in some cases are also providing, for the first time, a venue for local government officials to do coordinated planning and programming. In Palawan the mayor established a broad PHE project management committee that includes local government and NGO officials from those three sectors plus the LGU planning officer and police chief. Similarly, broad committees and task forces have been established to support the Sierra Madre project. In both 26 Other program characteristics that encourage gender-related added value are identifying subpopulations of men or women as target audience for activities and designing activities that include both sexes. 27 In Cambodia and Kenya, prior to initiation of health and FP activities, environmental PVOs had tense relationships with communities and local leaders (―You don‘t do anything for us and only say no.‖). The entry point argument should perhaps be re￾phrased as a long-term development and maintenance of ―trust‖ relationships between the local communities and environmental PVOs. 28 In Cambodia, CARE implementers of USAID- and ADB-funded health and FP programs did not work in more remote Cardamom villages due to the cost of access. Now that CARE is responsible for also providing environmental services, the expense of reaching these remote communities is justifiable and the program has moved deeper to access more remote villages. 24 Assessment of USAID’s Population and Environment Projects and Programming Options cases, officials report that their monthly meetings provide their only opportunity to discuss multisectoral issues and to plan coordinated activities. 6. OR carried out in Madagascar and the Philippines with at least partial PRH PHE support provides modest evidence of improved FP and conservation outcomes resulting from program integration as compared to single-sector approaches. Summary of Results Achieved and Lessons Learned (IR1) A variety of important results and lessons learned have emerged from the PRH‘s PHE portfolio‘s field projects: 1. Timely USAID financial support for carefully planned and fully integrated Cluster 1 projects, especially IPOPCORM and PESCODEV, played a complementary but vital role in providing the ―gold standard‖ models for PHE planning and execution. High quality IEC materials, training manuals, and mobilization techniques were developed, tested, and re-tested, and are now available for adaptation and use by PHE projects globally. 2. USAID grants to CI and WWF for PHE field projects are gradually fostering greater institutional interest in bringing FP (and health) to other targeted landscapes. For example, WWF/U.S. has developed a strong relationship with Johnson and Johnson for health interventions, and hopes to sign a tripartite GDA with USAID to fund PHE projects in three to five countries.29 For both organizations, including FP and health activities in their project areas is becoming ―more of the fabric of what we see ourselves as doing.‖ Even so, field interest in PHE projects is probably growing more quickly than interest in the environmental PVO headquarters where PHE project activities are less well known. 3. There is a growing consensus that the best ―package‖ of interventions for remote areas of biodiversity significance cannot be limited to FP and conservation, but must include basic health care and livelihood activities. These interventions should be carefully sequenced so that short-term visible results occur and trust is gradually developed as new program elements are added. 4. PRH-funded PHE projects in the Philippines have resulted in environmental PVOs participating in a vibrant national PHE network and sharing lessons learned. PRH PHE projects in Madagascar (CI, WWF, and WCS) have the potential of doing the same, although the attempt to foster Voahary Salama as an effective PHE coordinating institution has not yet been successful. 5. In the Philippines, where government decentralization is relatively well advanced and local funds are available, Cluster 1 and 2 projects are demonstrating that LGUs can potentially sustain PHE projects once donor funding ends. In countries such as Madagascar, with weaker local government structures, more recent decentralization, and impoverished local governments, the path to PHE project sustainability is less apparent and may be donor-dependent over a longer period. 6. Cluster 3 field projects have responded in a timely fashion to USAID Mission interests for PHE activities in unusual settings (conflict resolution in Nepal, veterinary and human health linked to conservation in Uganda) and have helped to expand the concept of PHE. 7. Significant FP and health results can be achieved at the community level even in remote locations at modest cost within three years. These results can be achieved by a variety of implementing organizations (environment-based, livelihood-based, and health-based) if projects are carefully planned and implemented with early, effective training and close supervision of CHWs by health professionals. 8. There is still no single ―best‖ intervention package. Context-specific factors such as community needs, local capacity, government structures, and policy setting must be brought together to inform the development of a PHE project. 9. Operations research has proven difficult to implement effectively in remote regions and across sectors. Many current projects remain at the pilot phase and, although local community members 29 However, WWF has identified a total of ten landscapes where they had hoped J&J and USAID would jointly fund PHE projects. Assessment of USAID’s Population and Environment Projects and Programming Options 25 are often interested in project expansion or scale-up, donors and policymakers often require evidence and documentation of the added value from an integrated program. Streamlined M&E plans and possibly more modest forms of OR, least cost analysis, or cost-effectiveness analysis should be incorporated into project design from the start. 10. Obtaining the gender-based value added from PHE projects appears to be more difficult when FP components are added to ongoing environmental programs unless there is a special effort to integrate IEC messages and structure IEC sessions with both women and men present and specifically identify them as key target groups. 11. Most Cluster 2 projects were unable to make adequate use of the mobilization techniques, training manuals, and IEC materials developed by Cluster 1 projects. Some had no special programs to access youths and males through existing social organizations (for example, fishermen associations), although these two target groups were successfully accessed by Cluster 1 projects. This may be, in part, because few Cluster 1 results were available and the programs had not been thoroughly evaluated when Cluster 2 projects were planned. However, the tendency to ―reinvent the PHE wheel‖ is disturbing and suggests the need for mechanisms to facilitate the sharing of lessons learned. 12. Sustainability of PHE projects has been most evident where local government has decentralized authorities, some revenues that it can allocate and a reasonable level of trained technical staff. At sites where local government services and professional staff are weak or non-existent and where funds are not available from the central government or donors for local allocation, PHE project sustainability is uncertain, especially for FP and health services, and is likely to rely for longer periods on the original PHE initiator. This may require a long-term commitment to health and FP from environmental PVOs that plan to remain in a landscape for 10 to 20 years to achieve their environmental objectives. DEVELOPING RESEARCH, TOOLS, AND COMMUNICATIONS TO PROVIDE PHE TECHNICAL LEADERSHIP (IR2) Another component of the PRH PHE portfolio is designed to support organizations demonstrating leadership in the PHE field at large by analyzing, communicating, and disseminating PHE information. This ―technical leadership‖ (TL) is accomplished, in part, through the support of OR, as well as analyses and dissemination of best practices and results. Development of this portfolio component was based on examination of the needs of ongoing pilot PHE projects and has been funded primarily through the PRH GLP funding. Given the unique contributions of organizations funded within the TL portfolio, each is reviewed separately below. Woodrow Wilson Center for International Scholars A key component of the PHE portfolio‘s technical leadership is supporting activities of the Environmental Change and Security Program (ECSP) at the Woodrow Wilson International Center for Scholars (Wilson Center) in Washington, D.C.30 The Wilson Center provides a nonpartisan, non-advocacy forum and a link between ideas and policy by fostering research, study, discussion, and collaboration between individuals concerned with policy and scholarship in national and world affairs. The Center extends its impact beyond Washington through publications, broadcasts, and the Internet. ECSP‘s objective with regard to PHE is to examine PHE linkages and improve awareness of these linkages through: 1. Increased dialogue on PHE linkages 2. Expanded dissemination of PHE information 3. Strengthened collaboration among PHE audiences These objectives are accomplished through hosting meetings and panel discussions, giving presentations on PHE to wide variety of audiences, as well as generating and disseminating publications. As an example of PHE-related presentations, Theresa Finn of MEASURE Evaluation reviewed the ―PHE M&E Field 30 With minimal additional funding by the USAID/Washington EGAT and Conflict Management and Mitigation offices. 26 Assessment of USAID’s Population and Environment Projects and Programming Options Manual‖ in November 2006, while in February 2007, the ECSP hosted a breakout session for the National Council for Science and Environment Conference entitled ―Population, Health, Gender, and Justice.‖ In addition, ECSP activities represent important catalysts for introducing the PHE concept to new audiences, particularly security audiences, but also to the UN and European audiences. Since 2002, USAID/Washington has provided $2.5 million in PHE support to the Wilson Center‘s ECSP, averaging about $400,000 annually. Between 2002 and early 2006, ECSP received funds for PHE TL through USAID/Washington‘s support of the University of Michigan PE Fellows Program. Since early 2006, ECSP has been undertaking its USAID PHE activities through the Studies in Security, Population, Health, and Environment Relationships Program (SSPHERe), a 3½-year project funded through the Grant Solicitation Mechanism (GSM) administered by World Learning. ECSP has been successful at leveraging funds to complement those provided by USAID/Washington. As an example, during 2006 and 2007, SSPHERe leveraged $306,472 to complement USAID/Washington funded programs from the UN Environmental Programme (UNEP) and the Wilson Center. Twenty-three responses to the approximately 80 surveys sent had primarily positive feedback on ECSP seminars and publications. The seminars, in particular, appear well received with comments such as ―the discussion opportunities at the ECSP seminars are very helpful in keeping abreast of the thinking and experiences of experts in the field as well as the impact of interventions in target countries.‖ Others noted they make use of published materials in their own writings, and many pass the information on to potentially interested colleagues and students. Even so, there was concern that the seminars tend to ―preach to the choir‖ since those already engaged in a topic are the same that make time to attend. In this way, critical consideration of how to reach other audiences would be useful. Conclusions The Wilson Center is a highly respected institution, and the ECSP within the Wilson Center plays an important role in bringing objective PHE information to a wide variety of audiences. These activities are primarily DC-based, although ECSP also engages some international audiences while facilitating the development of regional PHE networks (as in the assistance provided for 2007 PHE meeting in Ethiopia). The Wilson Center‘s proximity to USAID is a key strength, since it provides convenient opportunities for USAID staff to interact with scholarly and practitioner leaders, while also facilitating interaction within different USAID offices and bureaus. Given the multisectoral nature of PHE, this cross-boundary communication is particularly important and may facilitate the generation of increased interest in PHE among other relevant USAID audiences. Output from the ECSP is of high quality. The committed, experienced ECSP staff members are important members of the PHE community and have a strong understanding of PHE. The staff has successfully generated creative panel ideas and is making excellent use of technological innovations. For example, an upcoming series of discussions on the future of PHE provides an important opportunity for critical consideration of integrated program design and implementation, related research, and potential to attract additional donors. Most of the activities of the ECSP are DC-focused, by nature, and there has been excellent collaboration between a group of DC-based CAs (especially PRB and WWF).31 The ECSP staff works to engage security audiences by giving talks and providing other PHE-related support to the security community. Although these contributions are of high quality and hold value for the security community, the impact of these activities on the PHE field remains unclear and should be considered as part of a broader strategic effort to move the PHE field forward. The ECSP staff is occasionally contacted by media representatives, and contacts during the 2006–2007 reporting year resulted in 20 stories related to PHE. The impact of these stories remains unclear, and future 31 Exceptions include workshops presented at key PHE conferences in the Philippines and Ethiopia. Assessment of USAID’s Population and Environment Projects and Programming Options 27 efforts may do well to target particular media outlets with specific messages, including details from field projects. PRB The PRB disseminates information on population issues by transforming technical data and research into accurate, easy-to-understand language. The organization also undertakes journalist and policy communications training, coalition building, and data workshops to encourage the use of information to enlighten decision making. PRB‘s PHE program works to increase awareness of the linkages among the three sectors and to promote a better understanding of PHE problems, their causes and consequences, and the ways in which they can be addressed. Specifically, PRB: 1. Disseminates information on key PHE linkages to policy and technical audiences 2. Helps developing-country researchers develop their capacity to contribute to policy discussions on PHE issues 3. Facilitates information exchanges among journalists and environmental professionals Since 2003, PHE activities at the PRB have taken place within the BRIDGE Project (Bringing Information to Decisionmakers for Global Effectiveness). The project runs through September 30, 2010, with the strategic objective of contributing to improved health, population, and nutrition policies and programs through effective policy-learning activities. The BRIDGE Project supports PHE objectives through dissemination, outreach, and media work to support capacity building and in-country technical assistance. Since 2003, USAID/Washington has provided nearly $1.4 million in PHE support to the PRB, averaging about $275,000 annually, with the amount fairly stable over this period. Over the years, PRB has been successful at leveraging some additional funding for PHE activities. For example, support from the David and Lucile Packard Foundation was used to undertake a PHE assessment in Ethiopia. During the past several years, PRB has worked with a number of partners to assess, support, and share information on PHE projects and interventions. Related activities include a presentation of results of a 2005 assessment of Packard Foundation and USAID PHE projects, working with PFPI to support its work on PHE integration in coastal communities that addresses FP needs and food security and developing relationships in preparation for a workshop in East Africa to establish assessment teams. The East African PHE assessments were presented at the November 2007 conference on ―Population, Health, and Environment: Integrated Development for East Africa,‖ organized, in part, by PRB. As another example of PHE-related PRB efforts, PRB surveyed Latin American PHE experts to determine their greatest needs. This survey identified the need for tools to link PHE issues for policy decisions, program planning, and community mobilization. To respond to that need, PRB designed a training manual in Spanish to give PHE experts a comprehensive and practical tool on how to design, conduct, and evaluate PHE training programs. The manual, Puntos de Partida para Desarrollar un Programa de Capacitación (Guidelines for Developing a Training Program: PHE Training Tools), included a CDROM with 30 practical tools that users can adapt to their specific needs. The manual was mailed in 2003 to more than 3,000 recipients in Latin America, and in the month following the initial mailing, PRB received requests for an additional 139 copies. User comments were very positive, including, ―This is a very valuable document which will help us to solve many of our problems.‖ As part of this assessment, online surveys were sent to participants of two PRB-led PHE activities. First, 18 responses were received from approximately 80 survey queries sent to participants of a communication and advocacy workshop held in the Philippines in March 2006. The workshop‘s objective was to teach participants to maximize policymakers‘ and planners‘ use of project and research results that illustrate the interaction of population, health, and environment variables. Respondents included researchers, educators, practitioners, and advocates. Respondents unanimously found great value in the concrete, ―nuts and bolts‖ components of the workshop, such as information on making presentations, writing policy briefs, and ways to consider policy issues within project design. Teachers noted that they included the lessons learned within their curricula, thereby passing the information on to their students. Following the workshop, many participants drew on PRB PHE printed materials for reference. 28 Assessment of USAID’s Population and Environment Projects and Programming Options Approximately 35 participants of a PHE workshop entitled Healthy People, Healthy Planet: Strategic Planning for Linking Population, Health, and Environment Interventions, held in Bangkok, Thailand in 2004, also received survey queries. Ten participants responded. The workshop included several different activities and training approaches, including classroom interactive learning, individual and group exercises, site visits, and peer-to-peer teaching. The majority of respondents were practitioners and all found the Bangkok workshop of value, stating that they make use of lessons within their professional lives. As described by one respondent: ―I made valuable connections with people working in other parts of the world; I gained new knowledge about PHE activities underway and options for research collaboration; I established a network that continues to help me in my efforts to strengthen my own institution's involvement in such efforts.‖ Others offered specific examples of how workshop discussions enabled completion of PMPs and enhanced the communication strategy of particular projects. The respondents strongly argued for continued workshops, with particular needs related to designing and implementing PHE projects, including M&E, working with partners, and considering scale up. Such discussions are seen as mechanisms for linking field staff to broader PHE issues, advocacy, and policy considerations. Participants also noted that they made use of PRB PHE reference materials as follow-up to the workshop. Conclusions Among PHE practitioners, PRB is seen as a key resource in the provision of general PHE information as well as specific technical assistance. Importantly, the PRB PHE staff has a good sense of PHE across the globe, regardless of the source of funding, and, in this way, broadens contributions to the PHE community beyond those efforts supported by USAID/Washington. Its activities have been essential in building linkages within the PHE field. PRB‘s early work in the development of PHE in the Philippines was essential in laying the foundation that underlies current efforts. Particularly notable was PRB‘s work with journalists and advocates and its support in the development of the country‘s PHE network. PRB‘s connection to the PHE and PE academic community is less well developed, although there are efforts to link with in-country academics in regions where field projects are implemented. Although PRB has made noteworthy contributions to academic course development in Thailand and Tanzania, additional effort could be placed on publishing and encouraging PHE science. PRB has historically also been adept at responding to the PHE community‘s needs, as evidenced by the recent training manual and documentation of case studies and lessons from USAID-sponsored PHE projects. PHE‘s placement within the larger BRIDGE project does not appear to hamper the program‘s progress and may, in fact, result in synergies within the organization. Still, concern arises with the need to hire a new PHE Technical Director, although PRB‘s commitment to maintaining a PHE program is encouraging. Worth noting, within PRB, the PHE work is somewhat different in that it includes more applied efforts (workshops, coalition building, etc.) in addition to the more typical PRB-style research syntheses. CDM Environmental Health IQC and PHE Task Order (TO) The TO was awarded to a consortia led by CDM in September 2005. The TO became operational in February 2006 with the contracting of a technical coordinator. It focuses on developing tools to guide PHE program development, sharing PHE information, and advocating for PHE. There are five task areas within the TO: 1. USAID program support, including focused, Mission-specific TA 2. Advocacy and resource mobilization within USAID, focusing specifically on Missions, but also on USAID offices 3. Knowledge management, focusing on web resource design to be coordinated with the EH IQC Knowledge Management TO Assessment of USAID’s Population and Environment Projects and Programming Options 29 4. Programmatic leadership, focusing on programmatic and operational justification of the PHE approach—capture of field approaches, programmatic frameworks, and models for scale and sustainability 5. Advocacy and resource mobilization outside of USAID, a minor role in supporting communication and liaison with other donor groups and other implementing organizations engaged in integrated programming Key activities undertaken thus far include: 1. The provision of TA for the design and implementation of PHE activities in Nepal and Uganda 2. The design and development of a PHE website 3. The facilitation of the recent creation of a PHE e-learning course 4. The development of a programming manual to guide program designers and managers in development of integrated cross-sectoral PHE projects On USAID Program Support, TA provided under the TO has been crucial to Cluster 3 PHE projects, those ―new opportunities‖ in Nepal and Uganda. In Nepal, the Mission has provided $495,000 for the two-year PHE activity. Implementation is done through two NGOs who are currently implementing USAID/Nepal￾funded CFUG activities—RIMS (an indigenous NGO) and WWF. ADRA, with Nepal field experience in RH programming, provides coordination and technical support in RH to RIMS and WWF. The work plan and performance monitoring plan (PMP) preparation for this PHE activity was accomplished during a workshop in early November 2006 in Kathmandu, facilitated by a technical consultant supplied through the TO. The consultant continues to monitor progress against the NGOs respective work plans throughout 2007. In Uganda, the one-year PHE activity is implemented by a local NGO, CTPH. This activity will be funded for a second year through the TO. At the project‘s start, a technical consultant supplied through the TO stayed in frequent contact with CTPH and supported preparation of the work plan, PMP, and indicator agreement. The consultant also assisted the CTPH director in organizing a stakeholder workshop at the project‘s initiation, and she stays in frequent contact with CTPH to support ongoing activities at a distance. The project has selected and trained community resource health workers and peer counselors, developed IEC materials and programs (such as theater), and has facilitated improved access to FP commodities by local commodity providers. An ongoing objective of the TO‘s ―USAID Program Support‖ component has been to provide TA to a third Mission, although due to USAID programmatic realignment, the TO has not pursued starting up PHE support activities in a third country. On the objective of advocacy and resource mobility within USAID, little progress has been made since the PHE Coordinator was instructed to not act on this task area during the reorganization taking place at USAID and the State Department. On the task of knowledge management, a key contribution of the TO has been the design, development, and implementation of a PHE website. The PHE website was introduced at a PHE ―town hall‖ meeting held at PRB in early 2007. The website provides access to PHE project summaries, a selection of programming tools, and links to USAID PHE CAs and other PHE organizations. The PHE coordinator developed the one￾page project summaries for the 17 ongoing PHE projects supported by PRH PHE funds. The PHE coordinator facilitated the website‘s review by the PHE community and made requested changes. A PHE e-learning course for USAID staff, also part of knowledge management, was completed by a consultant supplied through the TO. The e-learning course, entitled ―Population, Health, and Environment Basics,‖ was made available in Fall 2007 through the Office of Global Health E-learning Center. The course is designed to take 2.5 hours and includes a PHE overview, background information on programs, discussion of the advantages of PHE integration, presentation of models of PHE and community mobilization, and a discussion of future directions and challenges. The course concludes with a checklist of preliminary questions that individuals interested in PHE might ask to determine the appropriateness of a model for their setting. 30 Assessment of USAID’s Population and Environment Projects and Programming Options The IQC/PHE Task Order also includes ―Programmatic Leadership‖ as an activity, and the first activity within this category remains underway. The “Integrating Population, Health, and Environment (PHE) Projects: A Programming Manual” was developed by two PHE consultants, one with strength in FP and RH, the other with more expertise in environmental programs. The manual was presented at the PHE Conference in Ethiopia and is available on the PHE website. Discussions are underway to identify a second Leadership Task Area product in the third year of the TO. A final task under the TO is ―advocacy and resource mobilization outside of USAID.‖ Key objectives here are the identification of potential PHE field implementation organizations and potential PHE donor organizations. No progress toward this objective appears to have been made. Conclusions The TO represents an especially important component of the current PHE portfolio as the community finds itself in need of documentation, outreach and dissemination of that documentation, and TA. Key to this is the hiring of an experienced and highly committed PHE technical coordinator. However, the technical coordinator was not filled for the first six months of the TO. After being filled for 18 months, the technical coordinator position was released, with the TO manager taking on the technical coordinator duties. This decision was based on the nature of the activities at the time as well as budgetary constraints. A strength of the TO is its flexibility in allowing CDM to draw upon an experienced cadre of consultants. The early TA in program development provided to PHE projects in Nepal and Uganda was essential in laying strong program foundations for these Cluster 3 projects. The ongoing TA is also important in keeping projects on track. Very little has been undertaken with regard to ―Advocacy/Resource Mobilization‖ either within or outside of USAID. 32 The evaluation team believes that these outreach activities are absolutely essential at this stage in the development of a PHE community of donors, implementers, advocates, and scholars. The PHE website will be an important clearinghouse of information for the PHE community. It remains in early stages. At this stage, the effort has been more successful at aggregating information than at organizing it in a user-friendly way. There is also concern that the site will ultimately contain too much material, making its navigation cumbersome. The identification of a core set of documents might enhance the site‘s effectiveness. The e-learning course is well constructed and will provide a useful foundation for those interested in PHE. General information is included as well as specific details related to individual projects. Information on the course‘s availability should be widely disseminated within and outside USAID. Course users should be contacted for feedback and entered into a database for future contact in the event that an online PHE community is created. PFPI/IPOPCORM The IPOPCORM initiative was a multi-year initiative (2001–2006) funded primarily by the David and Lucile Packard Foundation and implemented by PFPI and local collaborators. A description of the full IPOPCORM project is found in the Background chapter of this report. The IPOPCORM initiative is included under technical leadership due to its OR component, which aimed to provide a technical, scientific evaluation of the value of the integrated PHE approach. PRH provided funds to support two phases of OR and analysis using a quasi-experimental evaluation design to test hypotheses about cross-sectoral program synergies between RH, NRM, and food security in four study municipalities. To provide comparative data, some study target areas had only RH activities, others had only CRM, and others had integrated RH and CRM. A control region was also identified in which there were no interventions. All of the areas were poor with coastal populations located in geographically remote, high priority, marine ecosystems. 32 CDM comment: ―However, it is important to note that work in this area was discussed with the USAID PHE advisor and it was agreed the advocacy tasks in the TO SOW should not be pursued at this time.‖ Assessment of USAID’s Population and Environment Projects and Programming Options 31 Demographic and socioeconomic surveys were undertaken in 2001 and 2004, while behavioral monitoring surveys were undertaken annually from 2002. Biophysical data on corals, reef fish, sea grass, and mangroves were collected in 2001 and 2004 to gauge the status of marine habitats and resources. Results of the study suggest that, when implemented together, the IPOPCORM approach generated significant impact and positive trends for reef benthos, reef fish, sea grass, and mangroves. Malnutrition in pre-school children also declined, suggesting improvements in food security at the level of the household. Further, the integrated program generated a higher impact than single-sector approaches in the use of modern FP methods. CRM as a stand-alone intervention did not yield positive biophysical results, while RH as a stand-alone effort yielded no environmental benefits and lesser RH gains. In April 2007, a final round of post-project surveys was conducted in the same OR sites. The data are currently being analyzed in comparison with the pre-project (2001) datasets. Multivariate regression analyses are being performed between the socio-demographic data collected at the household level and the biophysical data collected at the marine protected area level to determine the correlations between the health and environmental variables. The final results will be available in early 2008. Preliminary analyses of trends and cost information suggest the IPOPCORM approach generated comparable or higher impact on both RH and CRM variables and at a significantly lower cost. Conclusions IPOPCORM represents one of the few attempts to demonstrate empirically the value added by PHE integrated programs versus single-sector approaches. In this way, the project represents an important contribution to the PHE community, and this large OR effort yielded many lessons regarding the difficulties inherent in designing and implementing field-based research. Key to the difficulties of undertaking quasi-experimental field-based research is the inability to truly ―control‖ comparison sites. Other NGOs became active in IPOPCORM‘s no-intervention comparison site, thereby negating any insight to be gained from comparing trends across intervention and non-intervention settings. In addition, the RH-only site experienced some marine development that affected its biophysical setting. The CRM-only site was plagued by a lack of municipal support for law enforcement, thereby resulting in negative environmental effects due to the use of cyanide and compressors in fishing. These various factors combined to undermine the effectiveness of the research design. Although comparisons may be difficult, examination of trends within the integrated site provides important evidence of program impact with regard to health and environmental benefits. In addition, the ongoing post￾project analyses will provide important empirical insight into PHE program impacts. Such evidence remains very much needed by the PHE community, with regard to environmental and health gains. As stated by one PE Fellow ―The field needs real evidence and numbers to move forward.‖ Another stated with regard to future needs within PHE, ―Monitoring and evaluation! We must be able to show that our projects have value-added and work to benefit the community to garner more support.‖ Additional informants across a variety of roles have emphasized this ongoing need. WWF The PRH-funded WWF program also contains a learning component that documents lessons and best practices from their PHE projects. Funding levels for leadership activities, separate from WWF field projects, have not been ascertained by the assessment team. WWF efforts in TL are motivated by the desire to build capacity within WWF and its partners to engage in PHE activities. Examples of efforts toward this end include: 1. The publication of four case studies in Disappearing Landscapes: The Population/Environment Connection. The publication is intended to stimulate and contribute to a dialogue about population dynamics and their impact on conservation of biodiversity. As noted in the publication, ―WWF hopes that these cases will stimulate others to review their own programs and contribute to the design of a new generation of action so that joint interventions that will meet the challenges of today and create the opportunities for a more sustainable future.‖ 32 Assessment of USAID’s Population and Environment Projects and Programming Options 2. Creation of decision-making tools for conservation managers to decide when and how to integrate FP and RH into planning and program and project design. This includes an analysis of basic population trends for the WWF priority ecoregions. 3. Publication of an overview of human migration entitled ―People on the Move: Reducing the Impact of Human Migration on Biodiversity,” in collaboration with CI and the University of North Carolina. The publication includes a wealth of information on the ―push‖ and ―pull‖ factors of migration, data reflecting contemporary patterns and trends, and concrete recommendations on how the conservation sector might enhance its understanding of migration and develop more effective approaches to dealing with this form of human-induced environmental pressure. Recommendations include increasing awareness of the impacts through research and using this understanding to inform interventions. This publication was supported by the Gordon and Betty Moore Foundation and USAID‘s Global Conservation Program/Office of Economic Growth and Trade. 4. Documentation of how to make PHE partnerships work most effectively, within a publication entitled Healthy Relationships: Examining Alliances within Population-Health-Environment Projects. The document provides conceptual information on alliances, but also more ―nuts and bolts‖ on how to identify potential partners, structure and maintain alliances, and define success. 5. Facilitation of a workshop and development of two working papers on how to scale up PE interventions in which the lessons learned by WWF and other organizations undertaking PE projects will be considered. The working paper focuses on PHE activities in Madagascar and provides a useful summary of these activities and critical consideration of the potential for PHE expansion. The WWF PHE staff engages in a variety of additional technical leadership activities, including assisting PRB in establishing contacts and networks in East Africa, in an effort to assess PHE scaling up opportunities in the region. These efforts were in preparation for the November 2007 East Africa PHE Conference in Addis Ababa organized jointly by PRB and WWF. Also representing TL, the WWF PHE staff has provided input on PHE indicators to MEASURE/ Evaluation and they have played the leadership role in the D.C.-based ―Policy and Practice‖ PHE working group. With regard to dissemination of PHE information, the WWF staff works to raise awareness of PHE issues within WWF and beyond. Such contributions are illustrated by WWF‘s efforts in organizing special panel discussions and presentations at the 2007 international meeting of the Society for Conservation Biology. Formal outreach has also included a presentation at the USAID-George Washington University Mini￾university and participation in a panel at the University of California-Berkeley. They have also held informal discussions on PHE with several other organizations, and have integrated PHE approaches into presentations on migration and biodiversity, HIV/AIDS and the environment, and conflict and the environment. Within WWF, the PHE staff takes various opportunities to raise awareness of PHE issues during visits to WWF field offices and when the field staff visits Washington, D.C. Conclusions WWF has been actively engaged in TL for the PHE community since its early involvement in PHE activities. Indeed, ―learning‖ components were included in an early proposal for PHE submitted to USAID/Washington. This demonstrates organizational commitment to learn from their own field experiences to strengthen future programs, as well as to offer lessons through the provision of technical leadership to the PHE community. WWF‘s PHE team appears committed to self-reflection and using lessons from that reflection to respond to informational needs of WWF and the general PHE community. Indeed, the PHE materials produced by WWF staff, either for distribution through WWF or others (for example, PRB), are of high quality and great value to the PHE community. An excellent example of contributions to the field is the recent development of the working paper exploring scale-up potential in Madagascar. The paper offers a comprehensive overview of regional PHE activities and critical consideration of the challenges facing PHE within this context. The material will be of value to those interested in Madagascar efforts, but also contains lessons of use to PHE practitioners elsewhere. Assessment of USAID’s Population and Environment Projects and Programming Options 33 Finalized efforts, such as those noted above, and others (for example, Conservation on a Crowded Planet: A Population Sourcebook for Conservation Practitioners (2002); Mapping the Connections: The Population￾Environment Lessons From Madagascar (2002)) are no doubt of tremendous use in advocacy efforts. Information on their availability should be widely disseminated through PHE networks. Summary of Results Achieved (IR2) USAID/Washington-supported technical leadership within PHE has engaged multiple CAs and taken a variety of forms. The Wilson Canter‘s ECSP has provided an important forum through which to bring PHE information to primarily DC-based audiences, while also accessing other audiences through increasing use of technology for broader dissemination of publications and panel discussions. Enhanced representation of field staff and implementers within ECSP publications and panels would increase the connection between PHE policy and field audiences. The PRB has been a key player in the provision of TL, with early efforts in training and advocacy in the Philippines providing evidence of the importance of these activities in laying a strong foundation for PHE within a national context. WWF, as an implementing CA, stands out in its efforts in considering and documenting lessons from the field. Although each of these organizations and activities has been effective at meeting its own programmatic objectives, enhanced effort to coordinate TL activities would increase the impact of USAID/Washington support in this area. Also related to TL, important insights on the complexity of OR have been learned from efforts by PFPI‘s IPOPCORM project, and project implementers should be encouraged to document these lessons and perhaps provide TA on OR to emerging and ongoing projects. Early OR results from IPOPCORM suggest that program integration was associated with lesser youth fertility as compared to stand-alone RH or environmental interventions. Positive environmental outcomes were also apparent from integration. CPR data are still being analyzed, along with post-project information. Preliminary analyses of post-project information on trends and cost information suggest the IPOPCORM approach generated comparable or higher impact on both RH and CRM variables and at a significantly lower cost. Results should be available in early 2008. OR results from EHP work in Madagascar (reviewed in Annex V) also provide early evidence of specific benefits of program integration. Specifically, EHP reports that PHE integration yielded increases in contraceptive prevalence rates, immunization coverage, and access to safe water and basic sanitation. Even so, health indicators, such as malnutrition and diarrhea prevalence, remained high with poverty and natural disasters from cyclones as important contributing factors. On environmental outcomes, the practice of destructive NRM methods (slash and burn) decreased (EHP 2004). Final results from multivariate analyses are anticipated in 2008. As related to OR, throughout this assessment‘s data collection, respondents across a variety of geographic settings and representing various PHE constituencies noted the importance of evidence-based program and policy development. As such, results from both PFPI‘s IPOPCORM OR and EHP‘s OR in Madagascar are critically important to the PHE field, and researchers should be encouraged to finalize and disseminate research results. The final analyses should make best use of the available data, including multivariate analyses as feasible, and should ultimately be subject to scientific peer review and published in scientific outlets. This process will enhance the credibility of the results and offer the most substantial contribution to the PHE field. TA provided through the TO has also been important, especially for new Cluster 3 PHE field projects, and efforts at consolidating and disseminating PHE information via a new website will have a significant impact on the field. Activities under the TO are especially vital to the current PHE portfolio, as the community finds itself in need of documentation, outreach and dissemination of that documentation, and TA. The lack of a long-term technical coordinator has had negative impact on meeting the TO‘s objectives. 34 Assessment of USAID’s Population and Environment Projects and Programming Options PROVIDING SUPPORT TO THE PHE FIELD BY BUILDING CAPACITY AND PROVIDING TECHNICAL ASSISTANCE (IR3) The PHE field has benefited from TA provided by many organizations and individuals from several countries. Much of this has been STTA funded by USAID, although there has also been considerable TA provided to the field by USAID‘s PHE technical advisor. Three CAs have specific responsibilities and roles to play in regard to TA to other PHE implementing organizations. This section will discuss the role of USAID‘s technical advisor, the PE Fellows program, and MEASURE/Evaluation in providing TA to leading organizations in the PHE field.33 Other organizations provide TA as part of their contract deliverables to USAID, notably PRB with its coalition-building efforts, but this is discussed elsewhere in this report. USAID PHE Technical Advisor Two USAID technical advisors have played central and strategic roles in the development of the PHE field since 2002. Their TA has often extended to CAs on contract compliance, placement of fellows, Mission strategies, project design, and other discrete activities supporting PHE field project implementation. However, their participation has also included strategic guidance to USAID‘s PRH office in its communications with Congress, the development of strategic plans for the sector, and the design of management tools for supporting PHE activities at CAs. In short, this advisor is at the center of USAID‘s strategy, the tools for carrying out this strategy, and the network of implementing organizations. Michigan Fellows/ PE Fellows The University of Michigan Population Fellows Program ended in 2006 with the award of a contract for PE Fellows to the Public Health Institute (PHI). Therefore, this section will provide a historical reflection on the Michigan Fellows Program and initial reflections on PHI and its Global Health Fellows Program (GHFP) activities related to PHE. The Michigan Population Fellows program was originally developed to provide early career opportunities to promising professionals in the population field and to provide technical assistance to organizations addressing population-related issues. In addition to filling positions addressing population topics, this provided an incentive to young professionals to enter the field and supplied population organizations with well-prepared applicants to staff future positions. With the establishment of the PE Fellowships, the purpose of the fellowship was stretched to support innovations in the emerging field of PHE. In the early years of the PE Fellows program, fellowships matched existing organizational interest, and fellows‘ activities lacked strategic intent related to the development of the field. As the PHE sector matured to include more pilot field activities and implementing NGOs, placement of fellows shifted to supporting and developing these new activities and institutions. Throughout, the fellows‘ placements appear to have maintained a consistent balance between responding to existing opportunities and using fellows‘ placements to catalyze expansion of the PHE sector. At least 18 PE fellows served part or all of their fellowships since 2002. Six of these fellowships have been in Madagascar and the Philippines (three in each) and at least half of all fellows since 2002 have worked on PHE activities funded (at least in part) by USAID. Only three of these fellows have worked directly for USAID or at a USAID Mission, while two fellows were placed with indigenous NGOs (Pronatura and Pro-Peten) and one with a USAID project (SanteNet). PE fellows surveyed indicated that the most useful support provided by the PFP included exchange visits with other PE fellows, PE fellow workshops, small grants for PHE activities, professional development funds, and networking opportunities with other PHE professionals. Most of the survey responses point to the existence and access to a network of PHE professionals as the most helpful support. The Michigan program staff was central to cultivating this network over the many years that PE fellows were placed. In addition to the benefits accrued directly to PHE implementation, the Michigan PE fellows themselves reflected on the importance of the program in building their own capacity. Survey responses clearly revealed the value of the applied experiences and the importance of contact with other PE fellows. The 33 STTA provided by CDM is discussed in IR2. Assessment of USAID’s Population and Environment Projects and Programming Options 35 importance of the ―community‖ in contributing to their professional development was also routinely noted. Indeed, many commented that the development of professional relationships, and the supportive network facilitated by the Michigan program were key aspects of the Michigan program‘s success. PE fellows are now hosted by the Public Health Institute (PHI) and are among more than 60 Fellows hosted by PHI‘s GHFP. 34 The PHI staff and the PHE technical advisor anticipate hiring two PE fellows each year, with about four PE fellows in the field at any one time. All GH fellows will benefit from networking and professional development resources aimed at enriching their professional focus and capacity. However, the PE network established by the Michigan program and most of the technical resources focused on PE will not be continued. Most of the professional development resources available to GH fellows look promising, but have yet to be tested and refined to meet the needs of PE fellows. PE fellows are a relatively small percentage of fellows who have been or will be hired and supported by the PHI as part of the GH Fellows program. PHI staff, who were not required under their agreement with USAID to design a specific program for PE Fellows, are understandably unsure how to connect PE fellows to USAID‘s PHE strategy. However, they express willingness to support such connections in PE fellow placements if their specific role can be clarified. MEASURE/Evaluation Since 2004, USAID/Washington has provided $475,000 of support to MEASURE/Evaluation PHE activities based at the University of North Carolina-Chapel Hill, with an average of approximately $120,000 annually. Support to MEASURE/Evaluation is based on the premise that the integration of PHE activities is a new technical area in need of assistance in developing appropriate M&E systems. MEASURE/Evaluation PHE activities focus on building the capacity of conservation organizations to undertake M&E of their PHE activities. MEASURE staff has also worked on a conceptual framework to guide PHE M&E and to improve evaluation designs for PHE programs. A key output of MEASURE/Evaluation activities is the forthcoming publication of an overview of indicators entitled A Guide for Monitoring and Evaluating Population￾Health-Environment Programs. As examples of MEASURE/Evaluation PHE activities since 2004, staff has: 1. Provided TA to CI/Cambodia for the development of an M&E plan for its integrated PE project in the Central Cardamoms Protected Forest, including a field site visit 2. Provided TA to USAID/Madagascar, including identification of information needs, sources, and data collection methods to support the Champion Communes approach, development of an evaluation method determining the effectiveness of the Eco-regional Alliance as a facilitator of integration, and assistance to Voahary Salama in revitalizing its M&E procedures 3. Provided assistance in planning the agenda and implementing a PHE workshop in Kigoma, Tanzania in June 2005 As noted, beyond these location-specific activities, a key contribution by MEASURE/Evaluation to moving PHE forward more generally is the forthcoming publication of an overview of indicators, entitled A Guide for Monitoring and Evaluating Population-Health-Environment Programs. The guide, informed by conversations with the USAID/Washington PHE TA and PHE CAs, has been completed and is available on the PHE website. As noted in the guide‘s forward section: ―[N]o single implementing organization can be a technical expert in all three fields [population, health, and environment]. Therefore, PHE field practitioners who are designing PHE M&E systems need an easy-to-use guide to the most important and trusted indicators across the population, health, and environment fields. This guide will meet these needs within a realistic framework that was developed in consultation with current leading PHE practitioners. Their guidance helped select the most highly recommended indicators in each field, with emphasis on those that have been tested in past PHE projects.‖ 34 The Michigan Fellows program was included, along with three other fellows programs, in a new contract competition in 2007. PHI was awarded the new consolidated contract. 36 Assessment of USAID’s Population and Environment Projects and Programming Options Summary of Results Achieved (IR3) PHE Advisor: The USAID PHE advisor position has been a strong and essential link between actors in the PHE field. Its ability to stitch together PHE themes from many sources in a coherent way and track the evolution of the field as a whole has been an essential service to USAID and its investments in this field. This advisor has consistently received praise from colleagues and contractors for attention to detail, strategic vision, and ability to bring issues together, from the field level to the policy and management level. Advisors have played essential roles in providing technical support to USAID Missions, perhaps spending too much of their time responding personally to STTA requests, when consultant STTA might have been used if it were easily available. Because of advisors‘ focus on personally providing STTA, there appears to have been little effort to play a much needed advocacy role within the donor community and with ―non￾traditional‖ PHE audiences, such as the non-conservation community. Noteworthy sectors for potential advocacy include institutions and programs focused on poverty reduction, equity, climate change adaptation, livelihoods, and food security. Their conceptual overlap with the PHE field could be significant. Taken together, this could possibly expand the funding base for PHE while also building the avenues for technical collaboration with other multidisciplinary development sectors. Michigan Fellows: The participation of fellows was noted as particularly central in the development of a PHE community in the Philippines, as well as early efforts in Madagascar. PE fellowships also have been an important training ground for future leaders in the PHE field. Those who have completed their fellowships have routinely gone on to consult on PHE activities for other organizations, and many PE fellows remain engaged in PHE work and are, indeed, key contributors to the field. In the past, there has been a tension between the Fellows program‘s role to train young professionals and USAID‘s need to have a mechanism to hire and retain entry-level professionals. This tension was balanced under the University of Michigan, and a minority of fellows worked directly with USAID. As designed by USAID, the fellows under GHFP, fellows work directly with USAID in Washington or in the field and are provided with salaries and benefits comparable to USAID employees of the same grade. GHFP is currently seeking applications for two PE fellows to work for implementing partners of USAID in the field. Once filled, these will be perhaps the only fellows not working directly with USAID, and GHFP may encounter complexities supporting these fellows that they do not have supporting those placed with USAID. Placing PE fellows within USAID Missions could contribute positively to the development of the PHE field by helping USAID staff to think and work across sectoral boundaries. However, recruitment will be for more seasoned personnel rather than entry-level personnel, and the per-fellow costs will be considerably higher. The transition to a fellows program in which PE fellows are part of a broad pool of fellows under GHFP is generally perceived as a loss to the PHE community. As noted by one fellow: ―It is a huge loss for…..the PHE community that [Michigan] no longer run[s] the program. Now, there is no program for early career professionals to gain these types of key experiences, and no one is creating the PHE leaders of the future right when we need them! I am saddened personally and professionally by the loss of the Michigan program.‖ This frustration with the loss of the separate PE Fellows program and concern that the PE fellows ―community‖ will lose strength as numbers wane and they become situated under a broader umbrella of fellows with different specialties was regularly expressed by CAs as well. MEASURE/Evaluation: PHE activities undertaken by MEASURE/Evaluation represent important components of the current PHE portfolio, as the community finds itself in need of documentation, outreach and dissemination of that documentation, and TA. The M&E guide appears to be as close to a consensus document as possible and should help to stabilize definitions in the PHE field. While the guide will serve as an important tool for CAs, it may be even more significant in its contribution to defining PHE by anchoring the field to certain terms, metrics, and definitions. This will provide significant benefits to any organization or individual working in PHE, as it provides boundaries and a solid structure within which to work. This will also contribute to the specific identity of PHE as a field and may serve to encourage other donors through demonstrating that the field is Assessment of USAID’s Population and Environment Projects and Programming Options 37 organized and specific enough to use funding effectively. The Guide should also have the long-term impact of allowing USAID‘s PRH office and others engaged in PHE work to aggregate results, compare them across implementers and locations, and easily include results in reporting documents. The provision of location-specific TA has been important to the implementation of PHE activities in particular sites, and more STTA will be necessary as the Guide becomes widely available to put this into practice by CAs. More generally, the indicators guide will make an important contribution to the PHE community‘s ability to demonstrate programmatic impact. Summary: Technical assistance provided under the PHE portfolio during the six years of funding under review has been an essential element to the establishment of best practices in PHE. Support for individuals to provide this TA was available when the need arose (PE fellows, STTA consultants, and institutional contractors). Even more broadly, TA in this field has made a significant contribution to the identity of the field as a whole by serving as a link between separate investments in PHE made in different countries, using different methodologies and by various implementing organizations. IMPACT OF USAID/WASHINGTON PORTFOLIO IN KEY COUNTRIES—SUMMARY35 1. The Philippines PHE Activities and the Impact of PRH PHE funds in the Philippines: In 2001, two large pioneering PHE projects were funded in the Philippines by the Packard Foundation: IPOPCORM, designed and implemented by PATH Foundation Philippines; and PESCODEV, designed and implemented by SAVE/Philippines. Both have been completed and are viewed as successful pilots. PRH provided timely, supplemental funding for both projects: $650,000 in FY2002 to support expansion of the IPOPCORM project, and, later, a total of $240,000 in fiscal years 2005 through 2007 to support a province-wide scale-up and OR data analyses; and $100,000 in bridge funding in FY 2002 for the PESCODEV project between two Packard grants.36 Two USAID/Washington-funded PHE pilots, initiated in 2003 by CI and WWF, are providing information on additional PHE models. WWF/Philippines is hoping to find resources to fund program expansion from seven to all 31 of the barangays in Roxas. CI/Philippines, however, does not plan to continue its program focus in the Sierra Madre region in the absence of major funding and intends to continue supporting PHE via policy-level interventions. The PHE portfolio has supported a major PRB advocacy effort (see below), and has provided two strong PE fellows who supported the SAVE, PFPI and CI PHE programs. PRB has helped to establish a very impressive PHE Network, chaired by the Philippine Legislators‘ Committee on Population and Development Foundation, Inc. The Network is well structured with three regional sub-groups (Manila, Mindanao, and Visayas) and has agreed on three primary objectives (advocacy, research, and information exchange). The network has effectively used the bi-annual national conferences to transfer lessons, build broader membership, and gain consensus and support for future objectives. The PHE network has had an impact on developing consensus on the need for FP as an essential ingredient of livelihood and development efforts and on providing a platform for local government leaders and NGOs to explain their successful PHE activities to a broader audience, including the private sector. Present Status of PHE in the Philippines: The national offices of WWF and CI express strong support for PHE, although neither has yet actively marketed the PHE concept to gain additional funding nor used its own funds for PHE (with the important exception of CI providing staff time as the lead institution for the Third National PHE Conference). CI/Philippines has been a pioneer for CI worldwide in producing the PVO‘s first comprehensive strategy for addressing ―Human Wellbeing,‖37 including FP, as part of biodiversity protection programs. 35 The full text of this section is found in Annex E. 36 $3.95 million provided by the Packard Foundation 37 Framework and Strategy for Human Wellbeing (complete) 38 Assessment of USAID’s Population and Environment Projects and Programming Options USAID/Philippines has limited its role in PHE to being an observer, with the exception of a small PHE component in the Environment Office‘s FISH project. A mid-term evaluation indicated that FISH‘s PHE component is working successfully. The USAID Mission‘s Health Office apparently has no vehicle with which to provide operational funding for scaling up successful PHE models. Although it directs some of its program attention to providing TA and training to LGUs, the Health Office does not appear interested in trying to make a connection with Filipino technical specialists with successful PHE experience. The Environment Office has been more willing to use its funds for integrated projects but has no money available for new projects. Despite its successful pilot PESCODEV project, SAVE/Philippines has decided not to include PHE as an explicit subcomponent of its new country strategy. This decision flows from a strategic review that determined that PHE was not likely to bring in new funds. However, SAVE is open to building on its positive PHE reputation if donor funds become available. PFPI has been working with the Philippines Anti-Poverty Commission, the LMP, and other groups to design a Poverty-Population-Environment project that will replicate the integrated approach in several of the country‘s poorest coastal municipalities. The Packard Foundation will provide initial funding ($250,000 through 2009), while local partners will contribute an estimated $43,000 worth of resources for project implementation. PFPI will build the capacity of the LMP and 21 LGUs to design and implement integrated approaches in selected coastal areas of six provinces, namely: Mindoro Oriental, Western Samar, Leyte, Southern Leyte, Bohol, and Cebu. Included in the plan is support to the multi-provincial CeBoLeSoLe Council to implement linked RH-CRM activities throughout the Danajon Bank ecoregion—one of the poorest, most densely populated and imperiled marine eco-regions in the Philippines. 2. Madagascar PHE Activities in Madagascar: USAID has been the major initiating force for testing PHE programs in Madagascar. As early as 1995, Mission management and influential technical staff strongly encouraged linkages between sectoral programs, arguing for a holistic approach to rural development around protected areas and elsewhere in rural Madagascar. A USAID health contractor provided the Packard Foundation with a proposal to fund a major PHE program in key biodiversity areas, which Packard accepted and funded as a five-year Green and Healthy Communities program. This program provided sites to test the expanded use of a community mobilization concept—Champion Communities—from a health-and-FP-only tool to a broader tool that encourages communities to make progress in other sectors (environment, livelihoods, and, eventually, government and education). Recent efforts to scale up this expanded program to the commune level is reportedly facing significant operational challenges, but, meanwhile, the use of the original Champion Community mobilization tool is spreading to a number of donor projects in Madagascar. In 2000, another major PHE program was initiated with HIDN and PRH funding provided through the EHP project. This program, with water as the main theme for linking forest conservation with improved health and FP practices, was geographically focused in two USAID-supported landscapes. This water theme has taken root in the landscapes of Madagascar, and $1 million in new HIDN water-earmark funding was authorized in September 2007. EHP also supported the establishment of a coordinating agency for PHE activities, Voahary Salama (VS). Unfortunately, this new organization has been only marginally effective in advocating for donor funding, providing technical support to PHE programs run by member organizations, and providing a visible platform for information exchange between PHE programs. The Mission has continued to provide modest health sector funding through VS, helping to keep the institution alive. EHP also funded a major OR study designed to determine whether the integrated PHE approach led to better results than in stand-alone environmental or health interventions and how best to implement these programs (see Annex IV for the results of this research). Since 2002, three Michigan PE fellows have served in Madagascar, initially working with rural NGOs that were, for the first time, implementing PHE programs. A Johns Hopkins fellow, co-funded with PRH PHE and Mission funds, was assigned to work with the Mission and with VS from 2005 to 2007. PRB visited Madagascar in 2002, using PHE funding to determine whether it might play a role in capacity building and Assessment of USAID’s Population and Environment Projects and Programming Options 39 advocacy as it was doing in the Philippines. It appears that because EHP was already supporting VS, PRB did not elect to work in Madagascar, which, in retrospect, was a major loss. USAID/Washington and Mission funding have encouraged the expansion of PHE models in Madagascar. USAID/Madagascar believes PRH funds have been ―hugely helpful‖ in encouraging and supporting integrated initiatives in Madagascar. Using new PHE grant funds provided in 2002, both WWF and CI chose to place one of their three pilot sites in remote areas of Madagascar. In 2005, the Mission provided funding to the WCS for a new PHE activity with CARE field support around a new, and very remote, protected area as part of a novel ―Extra Mile‖ program that attempts to meet FP needs in remote areas. With the addition of WCS, each of the three major U.S.-based environmental organizations now working in Madagascar is presently testing PHE pilot programs. Each of these national offices indicates a desire to continue and expand its PHE program as part of a broader package of health and livelihood activities as a way to gain the trust and support of local communities around protected areas and in landscapes. USAID Mission funds have continued to encourage integrated programming that includes FP and conservation in novel ways, such as establishing the EcoRegional Alliance that strongly encouraged USAID sector program CAs to work in a coordinated fashion in target regions, and encouraging P.L. 480 Title II grantees to include FP in their food security programs. With the completion of the Packard ―Green and Healthy Communities‖ program, other donor funding for PHE in Madagascar has been scarce, although new proposals are being generated. UNESCO has funded small pilot programs, and CARE now believes that it may have funding for scaling up the CI pilot program. Donor staff in Madagascar are mostly unaware of PHE programs that have been piloted. Use of PE or PHE as a program title is not viewed as advantageous by most actors in Madagascar and is seen by some as an impediment to broad acceptance of the concept of a ―comprehensive‖ or ―integrated‖ program. The PHE concept might be repackaged to emphasize poverty alleviation or as a means to achieve equity in service provision (like the ―Extra Mile‖ concept). The demand for PHE-type programs in Madagascar is expanding with strong Presidential leadership for FP and ensuring that health and livelihood support is provided to communities affected by the tripling of the country‘s protected area network. International and Malagasy NGOs believe that for these remote areas, health is an excellent entry point (with FP as one of several components) and can provide quick visible results, but it must be accompanied by livelihood interventions that directly address poverty. However, central government support for multisectoral or integrated programs remains fragmented, with MOH reportedly being more supportive than the Ministries of Environments and Decentralization. Finally, while there is growing donor and international NGO interest in PHE and integrated programming in Madagascar, funding is scarce and is effectively limited to either USAID/Washington or USAID/ Madagascar sources. In sum, there is now considerable potential for scaling up, but the potential has not been fully realized. 3. Other locations PRH PHE investments to date have been concentrated in only a few countries, appropriately, so that implementing institutions could learn from and build off of each other‘s work, and national networks could be created. A few initial PRH investments were made in Central America (Guatemala Pro-Peten) and Bolivia, but, like the Packard Foundation, USAID decided that the expanding presence of national FP programs throughout most Latin American countries made PHE unnecessary. East Africa (Kenya, Uganda, DRC) and Asia (Cambodia, Nepal) have been sites for some Cluster 2 and 3 PRH investments. The recent PRB-led workshop for PHE in East Africa revealed strong regional interest in more effective ways to bring FP, health, livelihood, and conservation activities to remote communities that have not been reached by government services. However, PRH has not had adequate funding to encourage a concentrated number of PHE project sites and network building in East Africa or other countries or regions. 40 Assessment of USAID’s Population and Environment Projects and Programming Options IMPACT OF USAID/WASHINGTON PORTFOLIO ON THE BROADER PHE FIELD The PHE portfolio has had little impact to date in raising the profile of PHE issues among other potential donors, foundations, and academic audiences. This is primarily because PHE, as a particular ―self￾identified‖ form of integrated development, is relatively new and USAID PRH PHE investments (key within the PHE field) have been opportunistic; and there has been no strategic, concerted effort, thus far, by USAID, engaged CAs, and other community members to work towards raising PHE‘s profile. 1. Donor Community There is little evidence that the USAID PRH PHE portfolio has led to increased donor interest and funding for PHE activities, except for modest interest in target countries. Donor Headquarters: It appears that no concerted effort has been made to bring information about, or results from, PRH-funded PHE initiatives to decision makers and technical specialists at the headquarters of other potential donors. These potential donors could be either environment- or health-based, and the possibility of ―value-added‖ in each sector could yield interest among both. Most of the larger donors (such as multilateral banks, the Millennium Challenge Corporation, European Union, various UN organizations) tend to have sector-based staff and projects that inhibit entrée for PHE. Furthermore, even FP, as a particular issue within a sector, has had difficulty in retaining priority as a major funding category for most donors (for example, all World Bank current FP activities, save one, are integrated into broader health sector projects). As an additional constraint, the small size of most PHE projects to date is of little interest to larger donors. Some senior FP program leaders believe that the ―Asian model‖ of FP success (strong government leadership along with widespread reliable access to FP methods) should continue to be the model for FP programs and that PHE programs are simply too bureaucratically difficult and time consuming to warrant a special program effort. Other potential donors might include those that either: Have environment as their specialty, such as the United Nations Environment Programme (UNEP) and the Global Environment Facility (GEF), Have FP as their specialty, like UNFPA, or Specialize or focus attention on community-based projects, such as the United Nations Development Programme (UNDP), AusAID, some European bilaterals, and regional and national trust funds. Still, there is no evidence that these types of organizations have been formally approached to support PHE efforts, and it is difficult to find anyone familiar with PHE at the headquarters of these types of organizations. Donors in Target Countries: The PRH PHE portfolio writ-large (as funded by USAID and Packard) has generated somewhat greater interest among potential donors in target countries. Such interest is, no doubt, a result of invitations to a variety of donors to attend the national PHE conferences in the Philippines and, recently, the East Africa regional PHE workshop in Addis Ababa. Still, representatives of these potential donors often express surprise at (and interest in) the strong local support for PHE activities. Although these gatherings often include a ―donor‘s luncheon,‖ there has apparently been little follow-up. The new donor funding that has been successfully elicited in target countries (AusAID and UNFPA in the Philippines, UNICEF in Madagascar) has probably been in response to specific funding proposals sent to them rather than in reaction to a concerted PHE network advocacy effort. How might new donors be attracted to PHE? By demonstrating that PHE can provide value-added approaches to help achieve their priority objectives. These might include poverty alleviation (World Bank), equity (European bilaterals), or various environmental and reproductive health targets. Among potential donors focused on FP, strategic priorities for the future appear to include African settings, youths, males, and long-term methods. IPOPCORM has demonstrated through projects Assessment of USAID’s Population and Environment Projects and Programming Options 41 activities and research that the PHE approach provides better results with youths relative to stand￾alone FP projects. Such lessons should be strategically documented and disseminated. Among donors focused on environment and biodiversity, there is a growing acceptance of the need to address a variety of expressed community needs along with the conservation issues, especially in biodiversity-rich regions. In this way, PHE can position itself as a proven means to gain the trust required to achieve conservation goals. Among donors focused on community and participatory development, the Champion Community PHE projects might provide a convincing alternative to historical community development techniques. PHE may provide the focus lacking in earlier efforts. By accessing donor funding in an indirect manner. For example, individual Filipino LGUs or Malagasy Communes might request funds provided by the WB or European Union to support LGU or communal development plans, and use these funds for PHE projects. By gathering and reporting research-based evidence that PHE has added value or by presenting existing evidence at a ―Potential Donors‖ forum where potential funders could discuss mutual interests, especially related to integrated interventions in remote areas or where population pressures are a major threat to the environmental resource base. By fostering and supporting advocacy by mayors, implementing NGOs, and other local leaders and by encouraging the media to report PHE successes. By downplaying the PHE ―label,‖ which may be a constraining factor for potential donor organizations that are generally interested in poverty alleviation or equity-based programs but that are less familiar with PHE in particular. 2. Foundations The PRH PHE program has made no visible effort to attract foundations to finance PHE. There appears to be very little awareness of the USAID program, although foundations that have funded some PE grants in the past (Hewlitt, Compton, MacArthur) are aware of the Packard Foundation PE initiative and some of its results. However, the PRH PHE program has maintained close contact with program officers at the Packard Foundation through PRB and the PHE Technical Advisor. In the early years of the USAID PHE program, USAID funds were often used to ―fill in‖ lapses between Packard grants or to provide complementary funding. Packard seems open to continuing this collaboration with USAID, although PHE is no longer an element of their core population strategy. 3. Academic Community The impact of PRH PHE activities on the academic and research community is virtually non-existent. Scholars engaged in PE research and key national organizations funding such research, have little awareness of USAID or other donor programs with PE at their core. Reasons for the gap are many, but include: The longer timeframe required for the development of academic research endeavors as compared to the time PHE projects have to get into the field Incentive structures that do not encourage academic researchers to engage in applied research related to development efforts The complexity of working across multiple sectors combined with working across multiple organizations How might the academic community be attracted to PHE? Reach out more broadly to relevant academic audiences, perhaps creating an academic working group that would contribute writing, presentations, and ideas at the Wilson Center and PRB Facilitate connections between PHE Fellows and relevant academic audiences, especially in local PHE intervention settings Think creatively and in collaboration about new modes of OR that may be less costly in terms of energy, time, and funds 42 Assessment of USAID’s Population and Environment Projects and Programming Options Continue to build linkages between practitioners, and scholars and M&E experts to build sound research into new and ongoing field projects This issue could be included in discussions with other donors and implementers (donors and implementers forums). This could also be done through discussion research funding agencies (NICHD) to encourage support of scholarship that links academic researchers with development interventions. SUMMARY OF RESULTS ACHIEVED During the six years of this PRH PHE program strategy, USAID has moved from being a relative newcomer to the PE and PHE field to being the primary financial supporter for PHE activities globally. Much that has been broadly accomplished in PHE, especially during the latter years of this period, can therefore be attributed to USAID, and especially to the PRH PHE program. These accomplishments have come with an extremely modest price tag of about $19.4 million over six years. Categorizing results by sub-elements of the portfolio and this report, what has been achieved? IR1: Field Projects a. Timely and well-designated support for ongoing PE projects initiated with Packard Foundation funding helped bring to fruition the ―gold standard‖ Cluster 1 PE field projects that now provide the methodologies, tools, and technical skills for future PHE efforts. b. Cluster 2 project investments have provided additional project models in new locations, but, more importantly, have allowed environmental PVOs to determine whether FP (and health) should become more integral parts of ―the fabric of what they do‖ in biodiversity hotspots throughout the world. Among these PVOs, WWF appears poised to expand PHE programs rapidly; JGI would like to expand them as well if funding were available, while CI and WCS headquarters personnel are not yet as convinced as many of their field staff in countries where PHE has been tested. c. More recent Cluster 3 investments demonstrate a flexible responsiveness to USAID Mission requests for programs that include FP in special circumstances. These projects have normally been carried out with Mission co-financing. d. There is growing consensus that the best package of interventions for remote areas of biodiversity significance cannot be limited to FP and conservation, but must include basic health care and livelihood activities. These interventions should be carefully sequenced so that short-term visible results occur and trust is gradually developed as new program elements are added. IR2: Technical Leadership For this portfolio, the early funding supported an ―expansion phase,‖ while funds in latter years have focused more on ―consolidation of lessons learned and best practices.‖ a. The ECSP at the Wilson Center has played an important role in bringing objective PHE information to a wide variety of audiences, primarily D.C.-based. b. During the expansion phase, technical leadership and training provided by PRB was essential to initiation of a very successful emerging network of PHE practitioners and advocates in the Philippines. Similar support to a network of fledgling PHE programs in East Africa appear promising, while EHP-led efforts to establish a PHE coordinating mechanism in Madagascar have been disappointing. c. OR funded or co-funded by USAID in the Philippines and Madagascar has proven be technically difficult, but has provided the only empirical research findings on the added value of PE and PHE projects in comparison with stand-alone FP or environmental projects. Although patterns of the results would support the hypothesis that integrated programs improve FP and environmental outcomes, few differences across data collection points achieve statistical significance. Assessment of USAID’s Population and Environment Projects and Programming Options 43 d. During the recent consolidation phase, an astonishing number of high-quality documents have been produced that will be extremely valuable to future planners and practitioners. These include manuals on project design and M&E for PHE projects, documents describing best practices in multisectoral partnerships, histories of PHE and scaling up opportunities in the Philippines and Madagascar, analysis of how population pressure and biodiversity hotspots overlap geographically, and a compilation of ―best practice‖ tools, training materials, and mobilization methodologies. Most of these materials are widely available on a new PHE website. IR3: Support to USAID Missions and CAs a. The Michigan PE Fellows program introduced a cadre of young professional to PE and PHE and, at the same time, provided relatively inexpensive but valued technical support to PVOs, NGOs, and USAID Missions who were experimenting with PHE. Only a few of these PE fellows have found subsequent employment in areas that fully use their PE experience. b. The PHE technical advisor position in PRH has been well used to manage the PHE portfolio and to provide direct STTA to Missions and to advocate for PHE within USAID/Washington. c. A small but growing number of USAID Missions have demonstrated interest in PHE programs and methodologies. d. High quality STTA has also been provided to USAID Missions, CAs, and NGOs for project design and evaluation through easy to access IQC mechanisms. Impact on the Broader PHE Field The PHE portfolio has had little impact to date in raising the profile of PHE issues among other potential donors, foundations, and academic audiences. This is partly because PHE, as a particular ―self-identified‖ form of community-based development, is relatively new and PRH PHE investments have been opportunistic. It is also because there has been no strategic, concerted effort thus far by USAID, engaged CAs, and other community members to work towards raising PHE‘s profile among these groups. Program results in relation to PRH Objectives During the six-year PHE strategy period, there have been several modifications in the broader strategy of the PRH Office and, during much of this period, no detailed office strategy has been in place. However, the September 2007 draft PRH strategic framework does not appear to differ greatly from the broad goals of previous office objectives. The three IRs are: 1. Global leadership demonstrated in FP/RH policy, advocacy, and services 2. Knowledge generated, organized, and communicated in response to field needs 3. Support provided to the field to implement effective and sustainable FP and RH programs Overarching PHE program results, which have been structured to mirror this office-wide framework, clearly contribute to the overall objectives. PHE would appear to be particularly effective in addressing the following aspects of the PRH‘s IRs: IR 1: PHE programs may be particularly useful in facilitating partnership building, especially with organizations that do not traditionally focus on FP/RH (such as environmental NGOs). Such partnerships also facilitate the introduction of FP/RH services to the underserved populations resident in regions where non-FP organizations are more likely to have presence. In this way, these new partnerships help USAID PRH better meet some of the organization‘s broader objectives. Also relevant to the objectives of IR1, PHE programs may be particularly useful in leveraging funds from non-USAID sources, given their appeal to a variety of agencies working within and across sectors. IR 2: Since PHE is a relatively new approach to integrated development programming, the field is ripe for knowledge generation and dissemination, key aspects of PRH‘s IR2. Indeed, numerous new tools, methodologies, and guides with demonstrated programmatic value have recently been developed or are near completion. This new information is just now becoming more readily available to the community of practitioners and others engaged in PHE, and this enhanced availability will facilitate scale-up efforts and 44 Assessment of USAID’s Population and Environment Projects and Programming Options replication. In addition, given the cross-sectoral nature of PHE, there is a wide variety of relevant target audiences, therefore expanding the potential utility and impact of this body of informational materials. IR 3: As mentioned elsewhere in this report, PHE represents an attempt to address FP/RH programs in some of the most underserved and remote communities, and successful activities may serve as a model for doing so elsewhere in the world. In addition, TA provided to this growing field has sought to apply existing best practices in FP and RH programs in new ways by taking these lessons to rural areas and through non￾traditional partners. What could have been done, but was not accomplished, during this timeframe? More advocacy with donors that might have lead to expansion of the PHE funding base. Acceptance of the PHE concept in Missions, where population pressures have a negative impact on environmentally sensitive areas and where Missions manage FP, health, and environment funds. Broader knowledge and acceptance of the value of PHE within USAID/Washington. More flexibility provided in allowing the broad use of FP and health funds to meet the multisectoral needs of field projects (especially in the last years of the strategy). PRINCIPAL BARRIERS AND OPPORTUNITIES FOR EXPANDING PHE ACTIVITIES Barriers The principal barriers facing the PHE field relate to inadequate funding, which is linked to the complexity of integrated efforts; the limited evidence base for the program model; and the growing but still limited capacity to implement PHE field programs. Funding: There remains an absence of major donor and foundation funding for both the scale up of successful PHE models and for testing PHE in new locales. Of course, the complexity of integrated programs is a partial reason for this absence. Cross-sector efforts are difficult to structure, fund, and manage at greater scale since donors and, often, central governments find PHE bureaucratically unwieldy. USAID‘s sectoral stovepipes also make it an unwieldy donor for PHE. Implementers working on integrated programming find it difficult to deal with budgets that support only particular program components, especially if these components are not perceived as top priority by local communities. Evidence Base: Complexity and stovepipes also make it difficult for PHE programs to demonstrate added value. The cross-sectoral nature of PHE demands cross-sector impact measurements, but measuring the value of integration, per se, is substantially more challenging. Sectoral stovepipes also mean that different organizations place greater value on measurements of relevance to that particular sector (for example, CPR for those with an RH focus, coral density for those with an environmental focus). OR has, thus far, proven difficult to design and manage, given the ever-changing nature of the socioeconomic settings in which these programs operate. It has also been difficult for implementers to engage academic researchers in collaborative PHE research efforts. Although PHE programs appear potentially sustainable in regions with decentralized and effective local government structures, additional effort is needed to understand routes to sustainability in bringing FP to remote regions where local governments have less capacity to reach these communities with services. There is some concern that the ―PHE‖ label is limiting in that it inhibits recognition by and, potentially, collaboration with others engaged in similar integrated efforts. PHE advocates have not yet made a major effort to demonstrate results that could fit these programs into a larger donor focus on equity, poverty alleviation, food security, or conflict mitigation. Capacity: A great deal of PHE leadership and technical capacity has been fostered in specific focus PHE countries, especially in the Philippines, as well as via the PE Fellows programs. The PRH leadership portfolio has produced high quality manuals and analyses and collected best practices. However, there remains a strong need to build and maintain leadership and ―champions‖ for PHE and integrated programming. The field remains too dependent upon a handful of central organizations and individuals and, Assessment of USAID’s Population and Environment Projects and Programming Options 45 in this way, is vulnerable to the loss of important human capital as these organizations and individuals move on to other topics and professional opportunities. Opportunities With the strong support of the PRH PHE program (and the Packard Foundation PE program), much of the stage is now set for a major expansion of PHE or PHE-like activities that could provide FP services to remote and underserved populations. Very successful ―gold standard‖ PHE field projects and the Philippines PHE Network are available as models for future programs with both field and policy components. Several international environmental PVOs have learned the value of PHE and are increasingly including FP and health as common components of their new remote area livelihood or human wellbeing programs. PHE programs have developed successful IEC materials and methodologies for encouraging youths and men to accept FP services. The IR2 consolidation phase has helped produce and make available a basic library of materials on how to design, implement, and evaluate PHE projects using successful methodologies and IEC materials from previous projects. The continued decentralization of government authorities and services in developing countries provides opportunities, similar to the Philippines, for county and district-level planning and funding to include PHE activities. Local governments in the Philippines have also demonstrated that PHE projects can be sustained at a modest cost using local government funds. PHE programs are a proven approach for efficiently providing multisectoral services to remote areas as part of ―equity‖ focused programs. PHE programs are also a proven approach for efficiently providing multisectoral services to remote areas as part of environmentally-focused landscape and corridor programs, and they have developed improved multisectoral approaches that could be used for a new, improved phase of ICDPs or ―climate change‖ programs. PHE programs provide an opportunity to foster south-south collaboration and learning, using technical capacity from the Philippines and Madagascar. Finally, PHE may represent precisely the type of programming that could facilitate cross-office collaboration within USAID and act as a model for other USAID regional and community-based programs. 46 Assessment of USAID’s Population and Environment Projects and Programming Options ANNEX 1. LIST OF KEY INFORMANTS COOPERATING AGENCIES Camp Dresser McKee (IQC/PHE Task Order) Fred Rosensweig Dan Campbell Conservation International Headquarters Staff, Arlington, VA Fred Boltz, VP People, Protected Areas and Conservation Corridors Janet Edmond, PHE Advisor Madagascar Office James MacKinnon, Technical Director Daniela Raik, NRM Advisor Philippines Office Romeo B. Trono, Country Director Rowena R. Boquiren, Leader of SocioEconomics and Policy Unit Aloy Duya, Sierra Madre Biodiversity Coirridor Manaager Mar Viernes, PHE Project Manager Field Project Staff, Zahemena Mantadia Biological Corridor, Madagascar Hanta Ravololonanahay, Regional Coordinator Zo Zatovonirina, PHE Project Director NGO Sub-Contractor MATEZA Mamitiana Rakotozafy and technical outreach personnel NGO Sub-Contractor ASOS Jean Claude Rakotomalala and four technical outreach personnel Conservation Through Public Health—Uganda Gladys Kalema-Zikusoka, Executive Director Global Health Fellows Program Sharon Rudy, Program Director Susan Masse, Program Deputy Director Jane Goodall Institute Headquarters Staff Keith Brown, Executive Vice President, Africa Programs Alice Macharia, Project officer George Strunden, Director Africa Programs Democratic Republic of the Congo Field Project Staff Dario Merlo Kasuka MEASURE/Evaluation Sian Curtis Theresa Finn PATH Foundation Philippines, Inc. (Headquarters Staff, Philippines) Joan Castro, Program Director Enrique ―Ricky‖ Fernandez, Policy Advisor Assessment of USAID’s Population and Environment Projects and Programming Options 47 Leona D‘Agnes, Senior Technical Advisor Ronald Quintana, Program Manager Population Reference Bureau William Butz, President Richard Skolnik, Director International Programs Melissa Thaxton, Acting PHE Project Director SAVE the Children Headquarters Staff, Washington DC David Oot, Director, Health programs Philippines Office Norma Chan-Pongan, former director of PESCODEV University of Michigan Fellows Program Frank Zinn, former program director Wildlife Conservation Society (Madagascar Office) Helen Crowley, Country Director Christopher Holmes, Principal Technical Advisor World Wildlife Fund Headquarters Staff, Washington DC Ginette Henley, Senior Program Director Judy Oglethorpe, Director Community Conservation Cara Honzak, Senior Program Officer PHE Philippines Office David Valdes, Country Director AnaLucia Baskinas, Senior Program Officer Madagascar Office Voahanginirina Rasoarinoro, PHE Project Officer Fidy Denis Raobelison, PHE Field Project Manager Field Project Staff, Roxas, Palawan, Philippines Bella Sheila L. Albasin, Project Director Aireen L. Cornel Emmalyn N. Tura Jenny M. Palarca Zenaida P. Estrada Eduardo B. Bolen NGO Sub-contractor ASOS Harinesy Rajeriharindranto, Director, ASOS-Southern Region East Africa Programs Sam Weru, Program Manager Ali Amwachui, Senior Project Assistant, Kiunga Woodrow Wilson International Center for Scholars (Environmental Change and Security Project) Geoffrey Dabelko, Director, Environmental Change and Security Program Gib Clarke, Program Associate, ECSP program 48 Assessment of USAID’s Population and Environment Projects and Programming Options Others David Carr, Assistant Professor of Geography, University of Santa Barbara, PHE Evaluation Consultant Roger-Mark De Souza, Past PRB PHE Technical Director Robert Engelman, Past Population Action International Director Thomas Erdmann, Eco-Regional Initiatives Program, Madagascar Greg Foster, Industrial College of the Armed Forces Mark Freudenberger, Eco-Regional Initiatives Program, Madagascar Lynne Gaffikin, Past PE Fellow, PHE Consultant Eckhard Kleinau, Past Environmental Health Project Robin Marsh, Director, Beahrs Environmental Leadership Program Kathleen Mogelgaard, Past PE Fellow PRB; Assistant Director for Government Relations, National Audubon Society. Tom Outlaw, Past PHE Technical Advisor, USAID Yvette Ribaira, Past director of Green and Healthy Communities PHE project, Quality of Services Officer, Population and Environment Services Madagascar Adranto Razafimandinily, Voahary Salama, General Manager. Philippine Legislators‘ Committee on Population and Development (PLPCD): Ramon San Pascual Executive Director, Maria Christina ―Kit‖ Onate, consultant; Josephine Joson, Policy Analysis and Research Unit Manager, Committee on Population and Development. Janina Narvaez, Family Planning Organization of the Philippines (FPOP), Advocacy officer. Lydio Espana, Philippine Commission on Population, Program Officer. Jennifer Talbot, former Michigan PE Fellow, Program Officer, The Nature Conservancy Steven Sinding, Rockefeller Fund and former USAID Population Director Duff Gillespie , Johns Hopkins University and former USAID Population Director Tom Merrick, Senior Advisor, PRB and former Population Policy Director of the International Bank for Reconstruction and Development USAID WASHINGTON STAFF Reproductive Health Scott Radloff, PRH Office Director Ellen Starbird, Deputy Director, PRH Elizabeth Schoenecker, Chief Policy and Communication Division, PRH. Heather D‘Agnes, PHE Technical Advisor, PRH Environment Cynthia Gill, Biodiversity Team Leader, EGAT/NRM Doreen Robinson, Biodiversity and Natural Resource Specialist, EGAT/NRM Hannah Fairbank, Biodiversity and Natural Resource Specialist, EGAT/NRM Health Elizabeth Fox, Deputy Director, HIDN Irene Koek, Office Director, Infectious Diseases John Borrazzo, Chief, Environmental Health Program Rochelle Rainey, Environmental Health Advisor Assessment of USAID’s Population and Environment Projects and Programming Options 49 USAID MISSION STAFF (OTHER MISSION STAFF WERE GIVEN THE OPPORTUNITY TO CONTRIBUTE TO THE ASSESSMENT THROUGH A QUESTIONNAIRE FORMAT) Philippines Rene Acosta, Natural Resources Officer Marichi G. de Sagun, Senior Health and Family Planning Officer Madagascar Wendy Benazerga, Team Leader, HPH Lisa Gaylord, Team Leader, ENV/NRM DRC Thibaut Mukaba, Health and Family Planning advisor Lina Piripiri, Health and Family Planning advisor John Flynn, CARPE program manager Rwanda Eric Kagame, Health officer Ethiopia Anita Gibson, Reproductive Health Advisor Kidest Lulu, Reproductive Health Specialist OTHER DONORS Packard Foundation Sona Aibe Lana Dakan Don Lauro, Program Officers Sahlu Haile, Country Officer, Ethiopia. Summit Foundation Suzanne Petroni ACADEMIC COMMUNITY Alex deSherbinin, CIESIN, Columbia University Rebecca Clark, National Institutes of Health (NICHD) Barbara Entwisle, UNC-Chapel Hill Caryl Feldacker, UNC-Chapel Hill Emilio Moran, Indiana University Landis MacKellar, IIASA, Editor Population and Environment ADVOCACY GROUPS Sierra Club Sarah Fairchild Annette Souder, Global Population & Environment Program National Wildlife Federation Caron Whitaker, Past Population & Environment Program Manager 50 Assessment of USAID’s Population and Environment Projects and Programming Options ANNEX 2. KEY DOCUMENTS CONSULTED Camp Dresser McKee EH PHE Quarterly Reports 2006–2007 18 Month Work Plan, 2006 Results Review PHE TO, 2006 EHP Environmental Health Project. Healthy People in a Healthy Environment: Integrating Population, Health and the Environment in Madagascar. EHP Brief. No. 25 July 2004. Environmental Health Project. Integration of Health, Population and Environment Programs in Madagascar. Midterm Progress Report. Activity Report 115. 2004. Environmental Health Project. Impact of an Integrated Population, Health and Environment Program. Final Report, May 2005 Conservation International Population-Environment Final Report, 2002–2005 CI PE FY07 Work Plan Population-Environment Semi-Annual Report, July–Sept 05 Cambodia PE FY08 Work Plan Madagascar PE FY08 Work Plan Philippines PE FY08 Work Plan PHE PMP Indicator Status July–Dec 2006 Combining Conservation and Care: Lessons Learned Jane Goodall Institute JGI Quarterly Reports, 2005–2007 JGI DRC Progress Reports, 2005–2007 JGI DRC Quarterly Reports, 2005–2007 JGI DRC CCC Program Design and Implementation MEASURE/Evaluation PHE Request 2007 Draft, M&E Guide PATH Foundation Philippines, Inc. Mainstreaming Reproductive Health and Integrated Coastal Management into Local Governance: the Philippines Experience. 2004. IPOPCORM Monograph Series No. 1. Overview, Key Lessons and Challenges. 2007 IPOPCORM Monograph Series No. 4. Integrated Coastal Management Matters. 2007. Population Reference Bureau BRIDGE Annual Reports, PHE Sections, 2004–2007 PRB Management Review, Oct 03–June 06 Assessment of USAID’s Population and Environment Projects and Programming Options 51 Population Reference Bureau Web and Printed Documents (www.prb.org) – Breaking New Ground in the Philippines: Opportunities to Improve Human and Environmental Well-Being – Critical Links: Population, Health and the Environment – Integrated Population, Health, and Environment in Ethiopia – Integrated Population, Health, and Environment in Kenya – Integrated Population, Health, and Environment in Tanzania – Making the Link: Population, Health and the Environment – Population, Health, and Environment Assessments In Ethiopia, Kenya, and Tanzania – Review of Population-Health-Environment Programs Supported by the Packard Foundation and USAID (J. Pielemeier) USAID PRH/PHE Population-Environment Rationale USAID PHE Strategic Framework D‘Agnes Trip Reports, Cambodia, Madagascar, Philippines, Uganda CI PHE PMP Indicator Status, Jan–June 2007 Woodrow Wilson Center for International Scholars, Environmental Change and Security Program SSPHERe Management Review, April 2007 Strategic Framework ECSP Indicator Matrix List of Events, 2006–2007 Various publications including: – Environmental Change and Security Project Reports, 2004–2007  Population, Development and Environment in Ethiopia (Issue 10, 2004)  Population-Environment Funding: A Place for the Demographic Case (Issue 11, 2005)  Report from Africa; Population, Health, Environment and Conflict (Issue 12 (2006–2007) World Wildlife Fund WWF Annual Report, Jan–June 06 WWF Semi-Annual Reports, 2004–2007 WWF Madagascar Workplan, July 07–June 08 WWF Kenya Workplan July 07–June 08 WWF Phlippines Workplan July 07–June 08 WWF PMP Global June 06–Oct 06 WWF Semi-Annual Report July–Dec 06 WWF Population Analyses, Priority Places 52 Assessment of USAID’s Population and Environment Projects and Programming Options Various Background Documents (many available through the PHE website: http://www.ehproject.org/phe/phe.html ) Cincotta, R. and R. Engleman. 2000. Nature’s Place: Human Population and the Future of Biological Diversity. Population Action International. D‘Agnes, H, Castro, J. D‘Agnes L, and R. Montebon. 2004. Gender Issues within the Population￾Environment Nexus in Philippine Coastal Areas. Engelman, R. 2007. Sustainability from the Ground Up-Working on Reproductive Health and the Environment in Communities. Population Action International. Hermann, C. 2004. The Rewards of Innovation: A Review of Successful Piloting of the Integrated Population and Coastal Resource Management Project. Kleinau, E., Randriamananjara, O., and Rosensweig, F. 2005. Healthy People in a Healthy Environment: Impact of an Integrated Population, Health, and Environment Program in Madagascar. Washington, D.C./USAID: Environmental Health Project. Margoluis, R. 2001. An Ounce of Prevention. Making the Link Between Health and Environment. Mogelgaard, K., & Patterson, K. P. (2006). Linking Population, Health, and Environment in Fianarantsoa Province, Madagascar. Washington, D.C.: Population Reference Bureau. Population Action International, (2005). What You Need to Know to Apply for U.S. Government Funding for Community-Based Projects Linking Reproductive Health and Natural Resource Management. Pielemeier, J. (2007). Lessons from the First Generation of Integrated Population, Health, and Environment Projects. FOCUS on Population, Environment, and Security. Washington, D.C.: Woodrow Wilson Center/USAID. Assessment of USAID’s Population and Environment Projects and Programming Options 53 ANNEX 3. SCOPE OF WORK (key elements) PURPOSE OF THE ASSESSMENT This assessment will focus on PRH core and GLP funded activities rather than the entire scope of USAID‘s PHE programs (i.e. Mission funded activities). The assessment will determine the effects and contributions of the PRH-funded PHE programs since 2002 and provide recommendations for PRH‘s future strategy and investments in the PHE field. This will inform PRH‘s decisions regarding how population-health￾environment programming should be addressed within the PRH portfolio when the current portfolio of PHE projects ends in September 2008. The four primary purposes for conducting the assessment are: To review the results of in-country PHE projects and determine their effects, particularly on increasing access to quality FP/RH products and services in underserved communities near ecologically significant areas of high biodiversity. To determine USAID/PRH‘s contributions in providing technical leadership in the PHE field. To determine the barriers and challenges facing the PHE portfolio. To make suggestions for USAID‘s follow-on strategy for PHE. Summary of Activities to be Assessed Project Name Cooperating Agency Mechanism Countries Award Duration Projects with PHE Field Programs Successful Communities from Ridge to Reef World Wildlife Fund Associate Award Madagascar, Philippines, Kenya 9/03–9/08 Healthy Families, Healthy Forests Conservation International Associate Award under EGAT Leader with Associates Madagascar, Philippines, Cambodia 9/02–9/05 9/05–9/08 Community Centered Conservation Jane Goodall Institute / EngenderHealth GLP activity (through ACQUIRE) DRC Funding started ‘04 Technical Leadership Activities PHE Task Order CDM/ARD Task Order under EH IQC NA Funding started 4/06 Population, Environment Program Population Reference Bureau GLP activity (through BRIDGE) NA 9/05–9/07 SSPHERe Woodrow Wilson Center Subgrant first under Michigan then under GSM NA 12/00–1/06 2/06–6/09 IPOPCORM PFPI GLP activity Philippines 7/02 – current Technical Capacity Building Activities MEASURE/ Evaluation Carolina Pop Center GLP activity NA Since 7/04 PE Fellows Program U. of Michigan Population Fellows program 54 Assessment of USAID’s Population and Environment Projects and Programming Options STATEMENT OF WORK A. Review in-country pilot PHE projects and determine effects. The consultants will thoroughly review all project documents and reports (including PMPs) from PHE projects with field level activities and implementation—CI, WWF, JGI, IPOPCORM, and EHP—to determine their effects, providing a summary of key results across the projects. After this analysis, USAID in consultation with the consultants will select 3 countries where the consultants will conduct site visits and further explore these initial findings. The purpose of the site visits is to verify reported results and further explore analysis findings, not to capture the full impact and results at the sites. In assessing the effects of on-the-ground pilot PHE projects, the following questions must be answered: Are PHE projects increasing access and use of quality FP/RH services within underserved communities? Communities can be defined as underserved because they are located in remote and isolated areas where quality FP/RH services and commodities are limited. Communities may also be underserved because certain sub-sections of the communities are not being reached through existing FP/RH services due to age, gender, income, culture or religion. Quality FP/RH services should include, but are not limited to, a choice of services, accurate technical information and performance, and continuity of services and methods. What is the value of delivering the FP/RH services in an integrated fashion with the NRM interventions? In the context of this assessment, integrated service delivery means that the NRM and FP/RH services are purposefully delivered together in an ecologically significant area. This is in contrast to a health organization delivering FP/RH services in the same ecologically significant area where NRM interventions are ongoing (in parallel), without any concerted effort to link. Which approach produces the best FP results and why? Are the integrated projects deriving some additional value which is a direct result of the integrated approach? Of secondary importance, is the integrated approach producing improved NRM results as compared to the parallel approach? Since each project has different environmental assumptions and interventions, the definition of these benefits will depend on the expected outcomes of each PHE project. What are the most important results and successes that have emerged from these programs and how they were attained? What approaches should be replicated in future PRH funded PHE projects? B. Assess USAID/PRH’s contributions in providing technical leadership in the PHE field. The consultants will assess the technical leadership and capacity building components of the PHE portfolio and determine USAID‘s effectiveness in providing technical leadership in this field. The consultants will thoroughly review all project documents from PRB, WWC, WWF‘s learning component, IPOPCORM‘s OR research component, and CDM/PHE TO. The consultants will also conduct interviews with program staff from these organizations in DC, as well as other donors and implementing organizations in order to determine perspectives on USAID/PRH‘s technical leadership in the PHE field. The following questions should be addressed: Has the PHE portfolio had an impact on the field writ large by raising the profile of PHE issues and encouraging PHE implementation among key audiences such as donors, policymakers, the current community of PHE practitioners, and future implementing organizations? To what extent has USAID‘s PHE portfolio played a technical leadership role in advancing PHE programming? What strategies have been the most effective in advancing PHE programming? To what extent do current USAID funded PHE activities reflect the most promising approaches and best practices in PHE? Assessment of USAID’s Population and Environment Projects and Programming Options 55 Assess the barriers and challenges facing the PHE portfolio. Key questions to answer are: What are the main barriers and challenges to PHE projects achieving their outcomes (as stated in their PMPs)? Are other donors, including USAID Missions, considering funding PHE initiatives? If the PHE field is facing an environment of declining donor resources, should USAID continue to support PHE programming? How can USAID assist the PHE field in overcoming these identified challenges? C. Identify appropriate options for filling the PHE technical leadership role within the GH/PRH portfolio in the future (after Sept 08), and the configuration of projects and activities with the greatest potential to strengthen PRH programming within PRH and within USAID in general. Key questions to answer are: What types of discrete activities should be included in PRH‘s future PHE portfolio? How should we position the PHE portfolio in order to make a significant contribution to the PRH strategy, primarily, and the GH strategy secondarily? Is there a demand or need in the field for central leadership in PHE? What is PRH‘s role in PHE as a centrally funded activity vis-à-vis Mission-funded activities? Are there specific program approaches that PRH should replicate and/or fund at scale in the next phase of PHE programming? Is there a need for a specialized PHE technical leadership project after the current portfolio ends? If so, what specific PHE technical areas should the primary focus of this specialized PHE activity? If there is no anticipated need for a specialized project, how can the PHE technical leadership function be integrated into other existing or proposed projects? Methods and Time Frame for Completion A. Data Sources As mentioned in Section IV, the consultants will first conduct a thorough desk review of PHE project and associated documents before interviewing key informants. Upon completion of these two activities, the PHE advisor, in consultation with the consultants, will choose 3 countries in which to conduct site visits and interviews. The consultants will develop a more detailed methodology in consultation with and for approval by Heather D‘Agnes. Desk review of project publications Important publications to be considered are: USAID/PRH‘s PHE Strategy and PMP PRH Vision and Mission statement, PMP, and draft document on role of centrally funded projects. PHE Project annual and semi-annual reports USAID PHE results review documentation Review of Population-Health-Environment programs supported by the Packard Foundation and USAID (Pielemeier, 2005) Other documents as assigned by PHE Technical Advisor Key Informant Interviews On-site interviews with domestic stakeholders will be conducted in Washington DC at their respective on￾site locations or by telephone, whichever is most expedient and cost effective. Additional telephone 56 Assessment of USAID’s Population and Environment Projects and Programming Options interviews with overseas interviewees may be conducted from the U.S. The consultants will conduct extensive key information interviews and focus group discussions in the 3 countries where site visits will occur with PHE program staff, USAID staff, and relevant community groups. USAID interviews PRH staff (a select number) Other GH staff relevant to PHE programming (e.g. HIDN) EGAT staff (i.e. NRM/Biodiversity team) Mission staff—PHN officers and Environment officers from Missions with current or past PHE programs or interests (i.e. Madagascar, Philippines, Rwanda, Nepal, DRC, Kenya, Cambodia) External key informant interviews CAs—both headquarters staff in DC, and in country project staff PHE community at large (i.e. Sierra Club, Audubon) Past and current PE Fellows Past, current, and potential donors Implementers who might adopt the PHE approach in the future Academia with knowledge of PHE research and programs Site Visits of USAID/PRH funded PHE projects 3 Countries will be visited, to be determined from the following list of criteria in close consultation with and with approval by Heather D‘Agnes. Those visits will include site visits of PHE projects and interviews with key informants, as discussed above. One USAID/PRH funded JGI site (DRC) One site where policy advocacy work has been scaled up (East Africa, Philippines, Madagascar) One successful PHE site (Madagascar, Philippines) or one site where there have been no prior PHE evaluations (Kenya, Cambodia) Duration and Timing The evaluation will take place between July–September, 2007 for a total of 112 person days. An illustrative timeline and distribution of the LOE is shown below. A final time line with distribution of LOE will be developed in consultation with the Team at initial meeting and Team Planning meeting. Presentation of findings must take place before September 15, 2007; final report must be submitted by September 30, 2007 Team Composition and Level of Effort It is anticipated that the team will be made up of two consultants: A: Team Leader who will oversee all aspects of the project, liaise with the other consultant and with USAID/GH/PRH, oversee data collection and analysis; write sections of the report and meld contributions of the Technical Expert consultant into a coherent set of responses, and present conclusions and recommendations to USAID and the PHE CAs. The team leader should also have experience with both FP/RH and natural resource management and conservation in order to analyze, synthesize, and determine PHE results B: Technical Expert to analyze, synthesize, and determine results in the FP/RH or NRM technical area. There is a possibility that a USAID NEP will be involved at no extra cost to GH Tech in the Washington DC-based components of this assessment, for example conducting document reviews, interviews, and data Assessment of USAID’s Population and Environment Projects and Programming Options 57 analysis. If this is the case, the team will determine the exact role of the NEP with close consultation and approval of the PHE Technical Advisor. At minimum the combined skill sets of the consultants should include: Consultant Skill Sets Advanced degree and technical expertise in FP/RH Experience in natural resource management, preferably an advanced degree and/or advanced years of experience (10+ years) designing and managing NRM projects. Familiarity with PHE research and field implementation Proven experience in evaluating or assessing PHE projects Familiarity with current USAID PHE CAs, PHE donor community, and PHE community at large. Familiarity with USAID systems and procurement processes Experience evaluating international aid programs, preferably as a team lead Excellent analytical and writing skills An illustrative distribution of LOE is seen below. A final time line with distribution of LOE will be developed in consultation with the Team at initial meeting and Team Planning meeting. Contractor Task Consultant(s) Total Person-Days (for 2 persons) Meeting with USAID PHE TA to discuss SOW A, B 1 Document Review A,B 6 Team Planning Meeting—draft assessment methodology, work plan, and interview schedule, including proposed site visits A, B 4 Develop interview instruments/questionnaires A, B 6 Finalize assessment methodology (including questionnaires), work plan, and interview schedule. Set up all state-side meetings. A 5 Meeting with PHE CAs about assessment A, B 1 Conduct in person, phone, or e-mail interviews with State-side Cooperating Agencies (CA), USAID, Donors and other stakeholders A, B 10 Analyze current PRH PHE projects and investments based on data collected from desk review and interviews A, B 8 Conduct in-depth interviews in 3 PHE sites A, B 46* Prepare 1st draft of report, review with PHE TA A, B 15 Prepare presentations for USAID and external audiences A 3 Deliver presentations to USAID and external audiences A, B 2 Revisions and final reports A 5 Total 112 Total Person-Days: 112 (A—62.5, B—49.5) * Assumes 2 days each for travel to each country, 5 days in country and a final 2 days to travel back to the States. Deliverables Within one week consultants will meet with USAID PHE TA to discuss the SOW and agree on expectations, site visit criteria, and deliverable formats. Within 8 working days, Consultant A will deliver a detailed draft of the work plan which will include a proposed methodology for the assessment, the proposed questionnaires to be used during interviews, a list of State-side interviews, and a timeline for the assessment. Preliminary discussions with PHE partners regarding potential site visits will be required. The Consultants and the PHE TA will meet to discuss draft and finalize. The final work plan should be submitted within 5 working days of receipt of comments on the draft. 58 Assessment of USAID’s Population and Environment Projects and Programming Options Deliverable #1: Draft methodology. USAID will return comments within 5 work days. Deliverable #2: Final methodology and timeline, site visit itineraries. Upon acceptance of methodology and work plan, consultants and USAID will hold a joint meeting with PHE partners to explain the evaluation process, answer questions, and develop detailed plans for site visits. Note: The final choice of site visits will be made in consultation with USAID/Washington, Missions and partners. Criteria for choosing sites will reflect an appropriate balance of activities, partners and the overall technical approach, as well as cost-effectiveness. Implement agreed upon methodology for evaluation, including appropriate document reviews, interviews, and three site visits and associated data analysis. Conduct site visits to 3 sites. Prepare draft report for review by PHE TA and USAID staff. It is expected that 15 working days will be allotted for review. On the basis of the assessment, the consultants will present a report that includes: 1. An evaluation of the current PHE portfolio which answers the key questions in section IV, A and B. 2. Programmatic options for the PHE follow-on. These options will be procurement sensitive and must not be discussed or shared with anyone outside of USAID, including the PHE CAs or others interviewed. The recommendations for the follow-on should be a separate section of the report that can be easily removed. Deliverable #3: Draft report of not more than 35 pages, with additional associated appendices and supporting materials. Incorporate necessary edits and prepare final report and associated presentation materials. Deliver two presentations of findings, one for an internal USAID audience and one to a broader body of PHE partners and community. Deliverable #4: Presentation of findings in PowerPoint format to be delivered in two meetings— one for USAID and one for external audiences. Deliverable #5: Final report of not more than 35 pages, with additional associated appendices and supporting materials; including Executive Summary of not more than 5 pages; Microsoft Word; 11 or 12 point font submitted in 2 paper and electronic copies not more than one week after comments are due. Report must meet all legal USAID formatting requirements. All reports should be sent in electronic format and three hard unbound copies, to facilitate removal of procurement sensitive material, to Heather D‘Agnes, PHE TA, USAID, 1300 Pennsylvania Avenue NW, 3.6.36, Washington DC 20523-3600. Electronic copies should be sent to: Heather D‘Agnes, hdagnes@usaid.gov Assessment of USAID’s Population and Environment Projects and Programming Options 59 ANNEX 4. PHE: A HISTORY OF CONVERGING INTERESTS For more than 50 years, organizations have been providing assistance that integrated elements of natural resource management (NRM), health, and family planning (FP) as components of a set of solutions for households, families and communities. This integrated assistance has continued to address real needs while the concepts, delivery strategies and justifications behind this work have continued to evolve. Even now, depending on one‘s organizational perspective, integrating elements of population, health, and environment (PHE) into development interventions makes sense for different reasons and to achieve different goals. However, these different motivations often converge and this convergence provides an opportunity to address multiple needs simultaneously, with each activity reinforcing the goals of the other. These converging interests have led to integrated PHE activities that yield greater outcomes for all stakeholders than had each worked in isolation. The following text provides a brief history of this evolution of PE and PHE programs, although not limited to USAID-funded PHE activities. Pioneering efforts (Field pilots—WN, ICDPs, Michigan PE Fellows) By the end of the 1950s, World Neighbors (WN), a community development organization, was working in their project sites to address household needs, often providing advice related to FP and NRM. By the mid￾1970s, WN had established a partnership with Nepal‘s International Planned Parenthood Federation affiliate and embarked on a two-year project to determine if demand for FP might increase as local livelihoods improved. The organizations recruited promoters from among beneficiary women and ensured that when women encountered health activities, they often found natural resource activities as well. The program did show positive results, has been replicated in over 50 districts, and serves as a model for effective PHE field integration throughout Nepal as well as across Asia, Africa and Latin America38 . WN programs, holistically addressing household and community needs, continue on the same premise today. Along the way, the organization has documented strategies and techniques in order to provide guidance to others seeking to address PHE in the field. Efforts to integrate multiple elements of development into one program near national parks or protected areas became more popular by the early 1990s. By this time many organizations were involved in integrated conservation and development projects (ICDPs) addressing multiple issues related to conservation in a development context. Often these issues included health goods and services, including reproductive health. Over time, however, these integrated projects often struggled to meet expectations of funding agencies and/or project recipients due to lack of focus, overwhelming absorptive capacity of beneficiaries, and project cost inefficiencies. Even so, while ICDPs didn‘t returned the results hoped for by the conservation community, they reflected an understanding that opportunities exist to link conservation objectives with broader community needs. In hindsight, it appears these projects perhaps attempted too much and, in this way, were unable to effectively deliver on their objectives and lost support. Another attempt to integrate PHE began in the early 1990s with the Michigan Population Fellows Program (PFP), which had started in the early 1980s. The PFP was established to provide early career opportunities to promising professionals in the population field and to provide technical assistance to organizations addressing population-related issues. The leadership of the fellows programs, together with technical staff in USAID‘s Office of Population began considering whether the conservation community may be an important constituent in their efforts to address unmet need for quality FP goods and services, particularly in remote rural areas. With this in mind, the PFP began identifying and placing a limited number of Population-Environment fellows with organizations already working in these settings to address the link between population and environment in the field. 38 This information is reproduced from an unpublished ―History of PHE‖ document written by Bob Engleman and obtained through Heather D‘Agnes. 60 Assessment of USAID’s Population and Environment Projects and Programming Options By the mid-1990s, PE Fellows were initiating some innovative integrated efforts with the conservation community at theoretical and applied levels. These fellow placements appear to have been opportunistic at first, seeking to connect with organizations already addressing this link. Later these placements became more strategic, often coinciding with a PE-focused grant from one of several foundations with an active PE portfolio in the 1990s. In this way, resources from the PFP and USAID played a supportive role to others‘ investments as well as to the strategies developed by those foundations and their partners. By 2001/2002 USAID began to direct its grant-making and PE Fellow placements based on strategy developed by the PRH office. This strategic effort has become increasingly focused over the next six years. Conceptual work (PAI, WWF, ECSP) As the development community was reflecting on the importance of integrated development and the failures of some ICDPs, Population Action International (PAI) was writing about the link between population and environment. PAI became involved in research, publishing, coordination, and advocacy in PHE issues in the early 1990s and quickly became a leading voice for others in the field. In the mid-1990s, PAI began convening meetings in Washington on the reproductive health and natural resource/conservation linkage. These gatherings took place roughly once a year, initially informally, but by the early 2000s became more ambitious, engaging more speakers and attendees. Between 1995 and 2003, PAI published several papers and reports documenting the breadth of activities linking NRM/RH/Conservation and building consensus on the way forward. PAI organized several international gatherings on PHE and built a strong network for advocacy on behalf of those working on this in developing countries. PAI‘s contribution to the field was highlighted in 2001 with the inclusion of PHE funding language into the Foreign Operations appropriations bill, for which PAI led the advocacy effort. Around the same time that PAI began highlighting the PHE links in communities, WWF began investigating its own ability to understand and address these connections within their organization and project sites. This was motivated in large part by a $10-million dollar donation from the Summit Foundation for the explicit exploration of population-related activities. This money was directed to three countries, Solomon Islands, Congo Basin, and CAR/Cameroon, where WWF saw the opportunity to explore links in a functional way through their field projects. When including FP in other program activities, WWF always partners with an organization with this mandate. This allows WWF to remain focused on their ‗core‘ business of conservation while also ensuring the FP/RH activities are being effectively addressed. Based on organizational experience, WWF published several documents addressing FP, gender, migration and community health issues and how these can be understood and addressed in a conservation context. By 2002, the Sant funds had been invested in these programs and lessons had begun to be applied beyond these initial countries so as USAID‘s funding became available at about that same time, WWF was a natural partner. Due to USAID‘s PHE focus on areas of high biodiversity and interest in specific countries, WWF was able to expand their PHE work to include Kenya, Madagascar, and the Philippines. Activities in these countries, as well as staff at WWF headquarters continue to be funded by USAID and make a significant contribution to the field. Of particular note, WWF‘s Director of Community Conservation has been extremely influential within WWF and among conservation organizations as the conservation field works to actively address population and health issues. Momentum builds39 During the 1990s, many organizations began making the PHE link in the field; some were searching for models to replace ICDPs while others were exploring the link more conceptually. Considerable attention and resources were dedicated to exploring these links with several private foundations actively making PHE grants. With the Packard Foundation‘s approval of its PE Initiative in 2000, the Foundation joined others (Summit, MacArthur, Hewlett, and Turner) that had funded such programs at smaller levels during the mid- 39 Extensive content in this section are drawn from the ―Review of Population, Health and Environment programs supported by the Packard Foundation and USAID.‖ Pielemeier, 2005 Assessment of USAID’s Population and Environment Projects and Programming Options 61 to late-1990s. The Packard PE Initiative, with anticipated funding of $5 million per year, not only provided a major increase in funding for PE initiatives, it significantly increased the number of grantees testing PE field projects and increased the number of overall field sites. The initiative also funded operations research at two PE field projects, provided the opportunity for M&E data to be collected at other sites, established new leadership programs in key U.S. institutions, and increased funding for programs that alerted the American public to global PE issues and the impact of U.S. consumption patterns. Still, this dynamic funding environment was to be short-lived for the PHE field. The stock market decline before and after September 11, 2001 led several foundations to reduce or eliminate funding for PE activities. Factors that influenced these decisions were: a) a preference to focus remaining resources on more traditional, core program themes, rather than cross-program funding; b) the general donor/foundation trend towards a ―results‖ orientation with funding for programs that could provide clear benchmarks for monitoring and evaluation; and, c) a tendency to geographically focus foundation resources (place-based strategies). Summit, MacArthur, Hewlett, and Turner all terminated any explicit PE strategies at about the same time as Packard decided to reduce its program to ―close out‖ grants. Several of these foundations continue to fund ―population‖ and ―environment‖ strategies and programs. They typically do not explicitly encourage ―cross-sectoral‖ programs but are willing to ―let linkages occur naturally‖ in a target geographic area if implementing organizations wish to make a PE linkage. Some foundations also continue to provide broad program-wide funding to family planning and environment organizations; this funding could be used for cross-sectoral purposes. About the same time, a new major funder of PE activities entered the field. The U.S. Foreign Assistance Act of FY2002 directed USAID to use some of its FP funds in ―areas where population growth threatens biodiversity or endangered species.‖ This ―directive‖ has been included in all subsequent foreign aid legislation and USAID‘s Population-Health-Environment Program is providing an average of $3.2 million annually in funding between FY2002–2007. Initially, USAID targeted their resources to projects initiated by Packard or by other foundations, where funding was being withdrawn. This allowed these activities to continue to their logical end, enabling the PHE field to gain the lessons from the PE activities initiated before USAID began funding in this field. Recently, a few foundations have begun to fund PHE activities, albeit with small programs: The Prospect Hill Foundation‘s new strategy encourages PHE in their target areas of Guatemala and Mexico; and the Goldman Fund and the Charles Evans Hughes Foundation are providing some PHE funds to PAI. Despite these additions, with the termination of the Packard PE Initiative, the overall level of PHE funding in 2007 will be substantially lower than in 2000 unless new donors or foundations become intrigued by the PHE approach. However, private investments in PHE by foundations have had a lasting impact on many domestic conservation organizations. Over the past twenty years, many organizations and individuals have provided leadership to the PHE field through research and advocacy. Some of these efforts have been privately funded through foundations or membership dues. For example, a number of U.S.-focused conservation/environment NGOs (e.g. National Wildlife Federation, Sierra Club, National Audubon Society, Izaak Walton League) have participated in advocacy efforts to encourage Congressional funding for global family planning programs. Initially these efforts were stimulated by foundation grants, but they are now typically sustained with the NGO‘s own funds. Other PHE leadership efforts have been affiliated with universities (UC Berkley, University of Tanzania, Mahidol University), international organizations (World Conservation Union, UN), or by USAID. Each organization and perspective has added to the global ‗conversation‘ on PHE and some remain very active. The International Union for Scientific Study of Population (IUSSP) provides a valuable service by continuing to provide much of the funding for the Population-Environment Research Network (PERN)—a network of PE researchers based at Columbia University. Other PERN donors include the International Social Science Council, the MacArthur Foundation and UNFPA. The Woodrow Wilson Center‘s 62 Assessment of USAID’s Population and Environment Projects and Programming Options Environmental Change and Security Project (ECSP) first started addressing PHE under a sub-grant from the Michigan PFP. The ECSP continues to provide a non-partisan forum for discussion of many PHE-related issues and facilitates the creation of networks with others interested in the field. Appropriations Language of 2001 The PHE field changed dramatically over the years 2000–2003 due to economic trends leading foundations to redirect funding elsewhere and to USAID‘s entry as a direct funder of PHE activities. USAID‘s Office of Population and Reproductive Health‘s (PRH) PHE framework is shaped by legislative language originally included in the FY02 Foreign Operations Appropriations bill—and repeated in each subsequent bill— stating that under the Child Survival and Health Programs Fund, ―...$XXX million [be allocated] for family planning/reproductive health, including in areas where population growth threatens biodiversity or endangered species.” This ―directive‖ has been included in all subsequent foreign aid legislation and USAID‘s Population-Environment Program is providing approximately $2–4 million annually in funding. Since 2002 when this language first appeared in legislation, similar language appeared in the Manager‘s Report (technical notes accompanying an appropriation) providing more specific directions. These manager‘s notes have evolved over the ensuing seven years. The first language encouraged USAID to develop ―…goals and indicators that promote cross-sectoral integration on community-based PHE programs‖ and later included instructions to consult with the committee on the goals and indicators. In 2008, the manager‘s report acknowledged USAID‘s leadership in PHE and included language that ―…urges USAID to build upon its past investments in population-health-environment programs by expanding and scaling up projects in communities inhabiting areas rich in biodiversity, particularly in Africa and Asia.‖ This new wording reflects the role USAID has played over the past few years while also validating past (and future) efforts focusing investments in the PHE field on consolidating best practices and investing in countries where priorities overlap. Strategic Focus in Biodiversity Hotspots Based on the Congressional directive, the PHE Strategy, and the cross-cutting nature of PHE, GH/PRH is working to develop relationships across offices and bureaus, and especially with the field, to address PHE linkages in biodiversity hotspots, described by ecologists as the most species-rich and endangered ecoregions on Earth. PHE funding supports selected organizations in facilitating RH service delivery to communities inhabiting hotspot areas. USAID works with other NGO partners to promote, advocate, and disseminate information about the benefits of PHE programming. Funding Objectives and Strategies USAID started funding conservation organizations interested in integrating FP in their initiatives as a way to respond to the Congressional directive and expand FP access in rural areas. This first generation of USAID PE projects were focused on determining if the partnership could work at the implementation level. By 2004, there were a number of successful partnerships, though in most cases the conservation organizations integrated population/FP by partnering with a local organization with this capacity. Recently, USAID determined the resources being invested in PHE were not being effectively reflected in the results of the overall PRH portfolio. As part of an agency-wide effort to capture data on accomplishments, the PRH office enhanced its strategy to address this issue. Their approach was to establish a set of core indicators that all grant recipients would use to track accomplishments and report on in the Performance Management Plan. These indicators included ‗soft‘ targets as well as quantifiable outputs and were established to determine if the portfolio was having an aggregate effect sufficient to the investment. The MEASURE/Evaluation activity funded under the PHE portfolio has provided the basis for tracking output and some impact indicators. Linked Indicators Since the PHE field emerged, monitoring progress and evaluating success have been among the most contentious of management efforts. All the usual difficulties such as unclear definitions, no standard Assessment of USAID’s Population and Environment Projects and Programming Options 63 measurements, and faulty indicators (not measuring what was intended) have plagued efforts to bring consistency to this effort. There have even been efforts to develop linked population-health-environment indicators that would reflect changes in the relationship between PHE variables. While many useful and innovative ideas emerged and provide for a common language of progress in the field, it wasn‘t until the PRH office contracted MEASURE/Evaluation that this was addressed comprehensively. Since 2004, MEASURE staff have been working on PHE indicators, and recently have completed an M&E Handbook for PHE. This handbook and its included definitions were developed to assist both USAID and its implementing partners (and others interested in PHE) to speak the same language and work toward common goals. By developing standardized performance management plans and indicator matrices, results from various CAs can now be readily aggregated to reflect broader portfolio impacts. Managers may soon be able to compare the results in different locations from different CAs or using different approaches. Although much remains to be done to realize the full potential of this management tool, it should be among the most useful for tracking progress in the PHE field. Involved Offices and Their PHE Objectives Presently USAID is the only donor with an explicit PHE program that finances (often co-finances) field projects. Most USAID funds are provided through a program managed by the Bureau for Global Health (BGH). Funding has been provided for field projects in all four of the countries where Packard‘s PE program has been operating: Philippines, Madagascar, Tanzania, and Mexico. More importantly, USAID funding has gone where the Packard programs were taking root and interest was strong. In addition, funds have been provided to Kenya, Cambodia, and DRC and will be provided soon in Nepal. USAID monies for field projects have been transferred via grants to implementing PVO/NGOs such as WWF, CI, JGI and Pro￾Peten, Path/Philippines, and Save the Children or transferred via the centrally-funded Environmental Health Program (EHP). USAID/Washington program managers encourage USAID missions to add their own funds to those provided by the BGH, and four USAID missions have done so. USAID PE funds also helped finance the Michigan Population-Environment Fellows program and a series of ―Environmental Security‖ workshops and presentations organized by the Woodrow Wilson Center in Washington, DC. Over the past few years, funding for USAID‘s environment and population sectors have both declined. Unless a stronger case is made for PHE‘s relative effectiveness as a mechanism that can help in the achievement of broad PRH goals, funding for PHE might disappear. However, since USAID‘s population and health offices are also looking for project models with the proven capacity to reach rural areas and ―scale up,‖ PHE may yet be able to provide a strong return on investment. The USAID environment office, on the other hand, is not yet convinced that PE projects would meet their program objectives better than more traditional environment and biodiversity programs. In the absence of the Congressional directive, it is unlikely that USAID Central Bureau would have funded PE in the first place, and funding for these integrated programs may remain dependent on this directive for some time. Finally, as noted in other sections of this report, several NGOs have accepted the value of PE programs and have internalized the PE approach in their strategic approach to field projects whether they use their own funding or solicit funds from other sources. World Neighbors, for example, now includes FP activities in ―the way it works‖ and addresses broader rural poverty issues worldwide. The Jane Goodall Institute is expanding its programs to the DRC using a PE framework. ProNatura/Chiapas and some other host-country NGOs with PE experience also state that they plan to include PE in their standard operating practice and in their solicitations for funding. With USAID support, WWF and CI now see PHE as ―part of the fabric of what we do‖ in remote ―hotspots,‖ and other major PVOs such as the Wildlife Conservation Society and CARE are experimenting with PHE projects. Just as this history has been in important factor in shaping USAID‘s current PHE strategy, USAID‘s future PHE investments will be critically important in shaping the field‘s continuing evolution. 64 Assessment of USAID’s Population and Environment Projects and Programming Options ANNEX 5. IMPACT OF USAID/WASHINGTON PORTFOLIO IN KEY COUNTRIES 1. THE PHILIPPINES PHE Activities and Impact of PRH/PHE funds in the Philippines: In 2001 two large pioneering PHE projects were funded in the Philippines by the Packard Foundation: 1) Integrated Population and Coastal Resource Management (IPOPCORM) designed and implemented at 12 sites on three islands (Bohol, Cebu and Palawan) by PATH Philippines; and 2) Population, Environment and Development (PESCODEV), designed and implemented at 11 sites by the West Visayas office of SAVE/Philippines. Both have been completed and are viewed as successful pilots. USAID/ GH/PRH provided timely, supplemental funding for both projects: (1) $863,000 in FY2002 to support expansion of the IPOPCORM project, and later a total of $240,000 in FYs 2005–FY2007 to support data collection and analyses; and (2) $200,000 in bridge funding in FY 2002 for the PESCODEV project between two Packard grants.40 In sites where PHE has been initiated by both projects, FP and CRM activities are reportedly being sustained with local government funding. However, no major donor funds have been provided for replication and some experienced PHE staff from SAVE and PATH are no longer working on active PHE projects. Some PHE project replication is occurring, without major donor funding, within neighboring LGUs (nine LGUs that neighbor the PESCODEV project sites copied the approach with funding from two small donors), and PFPI has strong local support to expand their PHE program throughout the Visayas ecosystem. Some mayors that have hosted and supported PHE activities have aggressively encouraged their peers, at Mayors Association meetings, to undertake similar integrated projects on their own. Both PESCODEV and IPOPCORM sites have hosted visits from several interested LGUs (including 25 people from the WWF-Roxas project) and have also been sites for international visitors; but they are unlikely to continue to host such visits without some compensation for their time. PFPI has been invited to present the PHE model at an upcoming League of Municipalities conference. Two USAID/Washington-funded PHE pilots, initiated in 2003, are providing information on additional PHE models: (1) The Conservation International Sierra Madre project is implementing a PHE program in an upland NRM setting in a threatened ecosystem in northern Luzon; and (2) World Wildlife Fund is implementing a PHE program in Palawan where a RH component has been added to an ongoing CRM program. Both pilots have the potential for scale-up into contiguous areas. WWF/P is hoping to find resources to fund program expansion from seven to all 31 of the barangays in Roxas. CI/Philippines, however, does not plan to continue its program focus in the Sierra Madre region in the absence of major funding and intends to continue supporting PHE via policy-level interventions. Aside from funding the two pilots and providing support for the IPOPCORM and PESCODEV projects, the USAID/Washington PHE portfolio has supported PHE activities in the Philippines through a major PRB advocacy effort (see below), and by providing two Population-Environment Fellows who have supported the SAVE, PATH and CI PHE programs. In the Philippines, a few additional pilot PHE projects are being tested with UNFPA, AusAid and other donor funding and SAVE-Australia is reportedly interested in funding PHE activities in Palawan. The PHE integrated approach has also been tried in urban settings of Manila and as part of disaster relief and mitigation programs. PHE lessons have been disseminated through national PHE conferences, funded largely by Packard with PRB technical support and a 3rd National PHE Conference is scheduled for March, 2008. The PHE model 40 This compares with a total Packard Foundation funding for these projects of $395 million for IPOPCORM and $800,000 for PESCODEV. Assessment of USAID’s Population and Environment Projects and Programming Options 65 will also be disseminated in December 2007 at a conference in Mindanao, where high levels of donor funding are available due to security concerns. A very impressive PHE Network, chaired by the Philippine Legislators‘ Committee on Population and Development Foundation, Inc., has been established with strong assistance from USAID-funded PRB advocacy and leadership training activities, and Packard Foundation funding for operational costs. This network is now being formalized with an Operations Manual. The Network is well structured with three regional sub-groups (Manila, Mindanao and one more) and has agreed on three primary objectives (advocacy, research and information exchange). The network has effectively used the bi-annual national conferences to transfer lessons learned, build broader membership and gain consensus and support for future objectives. The PHE network has had impact on several levels: Gaining support for national legislation that encourages access to family planning as part of broader food security or poverty alleviation objectives Developing consensus on the need for FP as an essential ingredient of livelihood and development efforts Providing a platform for local government leaders and NGOs to explain their successful PHE activities to a broader audience, including the private sector Transferring lessons learned, PHE program methodologies and other materials Providing a unique venue for Pop/Health and Environment organizations to come together to discuss and sometimes advocate on broader issues Present Status of PHE in the Philippines Integration of PHE into Institutional Portfolios of PVOs and Government: The national offices of WWF and CI express support for PHE and have provided basic backstopping for the Washington-funded PHE field projects. Still, neither has actively marketed the PHE concept to gain additional funding nor used its own funds for PHE (with the important exception of CI providing staff time as the lead institution for the 3rd National PHE Conference). CI/Philippines has been a pioneer for CI worldwide in producing the PVOs first comprehensive strategy for addressing ―Wellbeing41‖, as part of biodiversity protection programs. CI/P sees PHE as one element of its new Livelihoods Strategy for which it has recently published a. WWF/P leadership is waiting for the results of the Palawan project before including PHE within its ―marketing‖ to donors. USAID/Philippines has limited its role in PHE to being an observer with the exception of a small PHE component that was included in the environment office‘s FISH project. A mid-term evaluation indicated that FISH‘s PHE component is working successfully. PHE Network members and surveyed practitioners feel that USAID/Manila is extremely difficult to work with and has shown almost no interest in their successful models. Most network members prefer to work with USAID/Washington. The USAID Mission‘s health office apparently has no vehicle with which provide operational funding for scaling up successful PHE models. Although it directs some of its program attention to working with LGUs, mostly providing technical assistance and training, the health office does not appear interested in trying to make a connection with Filipino technical specialists with successful PHE experience. The environment office appears to be more willing to use its funds for integrated projects, but has no money available for new projects. The Packard Foundation has provided: (1) the bulk of PHE funding for initial pilot projects that have largely proved successful; (2) funding support for the operations of the PHE Network thru 2010; (3) leadership training for several key Filipinos at the Beahrs Environmental Leadership Program at the University of California-Berkeley; and (4) funds for training media personnel in PHE. However, the 41 Framework and Strategy for Human Well-being (complete) 66 Assessment of USAID’s Population and Environment Projects and Programming Options Foundation has announced that it will not include the Philippines in its new Population program strategy and will phase out FP assistance to the Philippines by 2010. Despite its successful pilot PESCODEV project, SAVE/Philippines has decided not to include PHE as an explicit sub-component of its new country strategy. It will encourage integration of the PHE concept into its ―core‖ child sponsorship activities. This decision flows from a strategic review which determined that PHE was not likely to bring in new funds. However, SAVE appears open to building on its positive PHE reputation if donor funds become available. The PATH Foundation of the Philippines, which designed and implemented the ―gold standard‖ IPOPCORM program, has not located funding for program expansion or replication and may soon have to move its very strong PHE technical staff onto other priority activities where funds are available. 2. MADAGASCAR PHE Activities in Madagascar: USAID has been the major initiating force for testing PHE programs in Madagascar. Since the USAID Mission environment and health programs began to grow in 1995,FP interventions were encouraged in conjunction with three Mission-funded ICDPs focusing on villages around new national parks as the first phase of a three-phase, 15-year, multi-donor Environment Program–EP1. Mission management and influential technical staff strongly encouraged linkages between sectoral programs arguing for a holistic approach to rural development around protected areas and elsewhere in rural Madagascar. Some small foundation resources (Summit, MacArthur) were provided initially for PE programs. When the Packard foundation visited Madagascar in 2001, a USAID health contractor, JSI, provided them with a proposal to fund a major PE program in key biodiversity areas. Packard accepted and funded the proposal as a five-year Green and Healthy Communities program. The program operated in 100 communities in 33 communes reaching a population of 88,000. Unlike previous USAID-funded projects, the Packard program, which ended in 2005, also supported income generation activities. The Packard funding coincided with the decision to change the country‘s environmental focus from ICDPs to much larger ―landscape‖ areas because the ICDPs were not operating at sufficient scale to ensure biodiversity conservation. In 2002, another major PHE program was initiated with USAID HIDN and PRH funding through the EHP project. This program, with water as the theme for linking forest conservation with improved health and FP practices, was geographically focused in two USAID-supported landscapes. The EHP program also supported the establishment of a coordinating agency in 2000 for PHE activities, Voahary Salama (VS), meaning ―Human health and all that is natural.‖ EHP also funded a major operations research study designed to determine whether the integrated PHE approach led to better results than in a stand-alone environment or health interventions, and how best to implement these programs. VS was meant to serve as platform for bringing together implementing organizations, government entities and donors embracing a common PHE vision. Initially VS NGOs worked in over 120 communities in 35 communes. A unifying concept among VS members was the importance of work at the community level. Different strategies for effectively linking the PHE domains and engaging stakeholder at the community level were tested and/or promoted by VS and its members. Since 2002, three Michigan PE Fellows have served in Madagascar, initially working with rural NGOs that were, for the first time, implementing PHE programs. The initial fellow helped manage USAID population support to ICDPs and was instrumental in pointing out the need for a Malagasy institution such as VS. The second supported NGOs in the eastern region but also worked part time with VS. The third built institutional capacity of 3 VS member NGOs in the central-south and maintained integration as a focus of the Ecoregional Alliance in that region. During the tenure of the third fellow, the USAID Mission requested a more senior fellow to assist with PHE in the Mission. A Johns Hopkins Fellow, co-funded with PRH/PHE and mission funds, was assigned to work with the Mission and also with VS. Among other benefits of her Assessment of USAID’s Population and Environment Projects and Programming Options 67 tenure in Madagascar, this fellow is the author of a very insightful and well researched 2007 report: ―Population Environment Scale Up: Madagascar Case Study,‖ funded with WWF PHE funds. Historical elements of this chapter draw heavily on this report. PRB visited Madagascar in 2002 using PHE funding to determine whether it might play a role in capacity building and advocacy, as it was doing in the Philippines. Perhaps because EHP was already supporting VS, PRB did not elect to work in Madagascar, which was a major loss in retrospect. USAID funding encouraged the expansion of PHE models in Madagascar. Using new PHE grant funds provided in 2002, both WWF and CI chose to place one of their three pilot sites in remote areas of Madagascar—WWF in the southeast in the Spiny Forest and CI in the east along the Zahamena corridor. In 2005, PHE provided funding to the Wildlife Conservation Society (WCS) for a new PHE activity with CARE field support around a new, and very remote, protected area. The grant was part of the USAID Mission‘s novel ―Extra Mile‖ program which funded attempts to meet FP needs in remote areas and to explore other innovative approaches to FP. With the addition of WCS, each of the three major U.S.-based environmental organizations now working in Madagascar is presently testing PHE pilot programs. USAID Mission funds have continued to encourage integrated programming that includes FP and conservation, in novel ways: (a) establishing a major new initiative in 2005, the EcoRegional Alliance that strongly encouraged USAID sector program CAs to work in a coordinated fashion in target regions (The guiding philosophy of this approach was based on the Nature-Wealth-Power theme used elsewhere in Africa, but expanded to Madagascar to add Health: NWHP); (b) encouraging PL480 Title II grantees to include FP in their food security programs; and (c) providing modest health sector funding through VS, helping to keep the institution alive after EHP operational support had terminated. With the completion of the Packard ―Green and Healthy Communities‖ program, other donor funding for PHE in Madagascar has been scarce, although new proposals are being generated. Only UNESCO has funded small pilot programs. CARE now believes that it may have funding for a continuation and expansion of the CI program in the Zahamena area and is preparing a project proposal with CI and VS. WWF would like to continue and expand its Spiny Forest PHE program, but has not yet found a funding source. Despite the presence of major WB, GEF, European Union, and bilateral donor funds focused on poverty alleviation and environment, none of these funds have yet been used for PE or PHE programs. Almost all donor funds are channeled through central ministries. Donor staff in Madagascar are mostly unaware of the PHE programs that have been piloted in the country. Impact of PRH/PHE funds: The USAID/Madagascar office believes that these funds have been ―hugely helpful‖ in encouraging and supporting integrated initiatives in Madagascar. The EHP program provided steady support to establish VS. Unfortunately, this new organization has been only marginally effective in: advocating for donor funding, providing technical support to PHE programs run by its member organizations, and providing a visible platform for information exchange between PHE programs. To survive financially, VS has partially reinvented itself as locus for donor funds destined to be used by member Malagasy NGOs working on community-based Malaria and HIV-AIDS programs, and as a national representative of civil society in ECOSOC and other international fora. PRH/PHE funds have encouraged WWF, CI, and WCS to test PHE programs for the first time in Madagascar. The initial programs have provided an opportunity for greater depth of understanding among these conservation actors regarding strategies for partnering with local NGOs and overcoming logistical challenges in multisectoral programs. Each of these local offices of these international PVOs indicate a desire to continue and expand their PHE programs, as a way of gaining the trust and support of local communities around protected areas and, ideally, as part of a 68 Assessment of USAID’s Population and Environment Projects and Programming Options broader package of health and livelihood activities. However, none of the programs has yet begun to ―market‖ PHE or FP as they search for funds for Madagascar. The EHP and Packard funded PHE programs both provided sites to test the expanded use of a community mobilization concept—Champion Communities—from a health/FP only tool to a broader tool that encourages communities to make progress in other sectors. Under the performance-based program, a community receives a blue star when it meets its own annual health objectives and a green star when meeting its environment/livelihood objectives. USAID/Madagascar is now attempting to scale up and broaden the use of this mobilization tool in 22 counties (communes) with funding provided by two USAID programs: SanteNet (health/FP) and ERI (environment/livelihoods). This scaled-up program, called the Champion Commune program, includes a gray star for education, yellow star for economic growth, and a white star when all of the four stars have been obtained. Scaling up this expanded program to the commune level reportedly is facing significant operational challenges; but meanwhile the use of the original Champion Community mobilization tool is spreading to a number of donor projects in Madagascar. Stimulated by EHP funds, the use of water as an integrating theme for linking the conservation of forests to community health and livelihoods has taken root in Madagascar. A new EHP tranch of $1.0 million for community water projects has recently been authorized for Madagascar with VS as the coordinating agency. These funds are not, however, specifically directed towards PHE project areas. The USAID Mission has also successfully tested integration of FP into Title II food security programs. The PE Fellows program has been quite valuable in providing extra support to CAs as they developed rural PHE programs and later in trying to strengthen VS and provide a locus for PHE attention within the USAID Mission. Presently with no PHE fellow stationed in Madagascar, there is no single ―point person‖ and source of technical support for PHE in the country. Present Status of PHE in Madagascar: Over the past seven years, Madagascar has been the home for perhaps 50 community-based PHE programs (funded by Packard, EHP, USAID/Madagascar, and PRH/PHE). Most have been deemed successful; reportedly, several completed programs have sustained the PHE interventions introduced by the projects. Many of these programs have been less integrated than the IPOPCORM and PESCODEV models in the Philippines. Population, health, and environment interventions have often been simultaneous, but not necessarily integrated (e.g. not delivered by one field agent or volunteer, not presented within an integrated PHE framework, or not presented to both sexes together). This partially reflects the more traditional nature of Malagasy rural society, especially in quite remote areas, as well as the operational difficulties of funding two to three sector programs through the same CA. International as well as Malagasy NGOs believe that for these remote areas, health is an excellent entry point (with FP as one of several components), and can provide quick visible results, but this must be accompanied by livelihood interventions that directly address poverty. Environmental and governance interventions are seen as more long term in nature and often should be introduced gradually as part of sequenced program. Use of PE or PHE as a program title is not viewed as advantageous by most actors in Madagascar and is seen by some as an impediment to broad acceptance of the concept of a ―comprehensive‖ or ―integrated‖ program. The PHE concept might be repackaged to emphasize poverty alleviation, or as a means to achieve equity in service provision (e.g. the ―Extra Mile‖ concept). The demand for PHE-type programs is expanding with strong Presidential leadership for FP and ensuring that health and livelihood support is provided to communities impacted by the tripling of the country‘s Assessment of USAID’s Population and Environment Projects and Programming Options 69 protected area network. FP commodities are in very strong demand, even in rural areas and the MOH recognizes that NGOs can help lengthen the supply line of FP commodities and train CHWs in remote areas. The initial scaling up of the successful Champion Commune program is still in its teething stages and is unproven. Scale-up is occurring simultaneously in two forms: moving from communities to larger communes, and moving from a health only or health/environment sector program to a four-sector program in 12 communes where environment, livelihoods, DG and education are included. Central government support for multisectoral or integrated programs remains fragmented with MOH reportedly being very supportive, but with little central direction provided to field agents by the Environment Ministry of the Decentralization Ministry. Regional and Commune officials have not been as visibly committed to PHE as their colleagues in the Philippines. Also the communal and regional planning process, that could include PHE programs in an integrated fashion, are just being introduced in rural Madagascar. Finally, while there is growing donor and international NGO interest in PHE and integrated programming in Madagascar, funding is scarce, and is effectively limited to USAID (Washington or Madagascar) sources. In sum, there is now considerable potential for scale-up, but the potential has not been fully realized. 3. OTHER LOCATIONS PHE/PRH investments to-date have been concentrated in only a few countries, appropriately, so that implementing institutions could learn from and build off each other‘s work, and national networks could be created. A few initial PRH investments were made in Central America (Guatemala Pro-Peten) and Bolivia, but like the Packard Foundation, USAID decided that the expanding presence of national FP programs throughout most Latin American countries made PHE unnecessary. East Africa (Kenya, Uganda) and Asia (Cambodia, Nepal) have been the sites for some Cluster 2 and 3 PRH investments. The recent PRB-led workshop for PHE in East Africa revealed strong regional interest in more effective ways to bring FP, health, and livelihood/conservation activities to remote communities where government services have not reached. However, PRH has not had adequate funding to encourage a concentrated number of PHE project sites and network building in East Africa nor in other countries or regions. 70 Assessment of USAID’s Population and Environment Projects and Programming Options ANNEX 6. SUMMARY OF OPERATIONS RESEARCH RESULTS There are two USAID-supported PHE endeavors that have included operations research (OR) components. These efforts represent important attempts to empirically explore the hypothesis that integration yields added value as compared to single sector approaches to health or environment interventions. The first, as reviewed in the body of this report, is PATH Foundation Philippine‘s IPOPCORM project. Second, the Packard Foundation-funded Madagascar Green Healthy Communities project was closely linked to Voahary Salama, a Malagasy PE umbrella organization that carried out OR in project areas with financial and technical support from USAID‘s Environmental Health Project (EHP). PFPI’s IPOPCORM Project: PRH/PHE provided funds to support, at various times, efforts within IPOPCORM including OR. IPOPCORM used a quasi-experimental evaluation design to test for synergies between RH, NRM, and food security. The specific hypothesis stated that food security would be achieved more quickly when marine resource management and RH management are implemented together (D‘Agnes et al. 2005). To provide comparative data, some study target areas had only RH activities, others had only CRM, and others had both RH and CRM in an integrated fashion. A control region was also identified in which there were no IPOPCORM interventions. All of the areas were poor with coastal populations located in geographically remote, high priority, marine ecosystems. Demographic and socioeconomic surveys were undertaken in 2001 and 2004, while behavioral monitoring surveys were undertaken annually from 2002. Biophysical data on corals, reef fish, sea grass, and mangroves were collected in 2001 and 2004 to gauge the status of marine habitats and resources. The most current OR results also incorporate data generated by PATH Foundation Philippines‘ (PFPI‘s) behavioral monitoring surveys (BMS) among the same study populations since 2002. Thus far, analyses have basically examined changes across individual biophysical and socio-demographic indicators across the study period. On social-economic outcomes, a comparative analysis of results documented in the 2001 and 2004 data collection demonstrates that incomes increased across all study households, regardless of type of intervention (Magbanua, D‘Agnes and Castro 2007). On health outcomes, results published in 2007 suggest that malnutrition in pre-school children declined, suggesting improvements in food security at the level of the household in the integrated and RH-only sites, with greater impact in the RH-only site. On reproductive outcomes, in the experimental site where the integrated approach was being applied, youth fertility declined by three percentage points (from 14.8% in 2001 to 11.8% in 2004), whereas it increased or remained the same in the non-integrated and control sites (Magbanua, D‘Agnes and Castro 2007). Unfortunately, CPR data are not yet available, as errors were found in the datasets, suggesting the 2004 CPR under-represents the true CPR in the OR sites. Results are forthcoming (Magbanua, D‘Agnes and Castro 2007). On environmental outcomes, a comparative analysis of results documented in the 2001 and 2004 rounds of biophysical surveys conducted in the four study municipalities suggest statistically significant differences across the study period and positive trends for reef benthos, reef fish, sea grass and mangroves. CRM as a stand-alone intervention did not yield positive biophysical results (Magbanua, D‘Agnes and Castro 2007). Overall, early IPOPCORM results provide some support of the value-added hypothesis; although they are non-definitive results given the lack of CPR data and the need for multivariate modeling due to data contamination resultant of outside interventions (see below). Additional analyses are underway. VS/EHP: This program used a research design similar to the PATH research described above. The five￾year Madagascar EHP was designed to establish an evidence base for integrated PHE projects. Specifically, the project aimed to ―determine if activities implemented in an integrated manner achieved better results than if the activities were implemented separately‖ (Kleinau, Randriamananjara, and Rosensweig 2005). Assessment of USAID’s Population and Environment Projects and Programming Options 71 Using a quasi-experimental design, the analyses used data from a group of 56 ―integration communities‖ where PHE activities were carried out compared with 29 ―non-integration communities‖ that either had no project support or had single-sector interventions. A baseline survey was conducted in March/April 2001 and a follow-up in March/April 2004. According to project documents, the integrated PHE program built on existing program resources and amplified the impact by supporting communities, linking different partners‘ messages and services, sharing resources for fieldwork and evaluation, and cross-training field agents from different sectors. EHP also argues that integrated programs can be very effective at relatively low costs and that the ―gold standard‖ model of integration, as well as collaboration across multiple NGOs are equally efficient (EHP 2004). The conclusion on program type is based on results from 35 indicators as measured across three types of interventions; many of the results were quite positive with integrated programs outperforming non￾integrated programs for 22 of these 35 indicators (EHP 2004a). On key PHE outcomes, EHP summaries of their analyses note that PHE integration yielded increases in CPR (from 12% to 17%), immunization coverage (from 48% to 68%), access to safe water (from 19% to 24%) and basic sanitation (from 52% to 55%). Even so, health indicators such as malnutrition and diarrhea prevalence remained high, with poverty and natural disasters from cyclones as important contributing factors. On environmental outcomes, the practice of destructive NRM methods (slash and burn) decreased from 55% to 25% (EHP 2004b). Based on preliminary analyses, EHP argues that that the following conclusions are significant (EHP 2005:76): The integration of health, population and NRM programs can achieve good results in each sector compared to programs implemented separately because of complementarities of interventions and programmatic synergies Local NGOs offer a good return on investment. At a cost of only $100,000 to $200,000 per year, they achieved results for some key indicators such as CPR or reforestation that compare favorably to larger donor investments in relative terms. Different mechanisms can successfully implement Integrated PHE. Organizational management (Type 1, 2 or 3 organization structures) is not as important as capacity and commitment. Community-centered PHE fosters participation, especially by women. Better government services make a difference and NGOs depend on it. Examples are government provision of contraceptives and immunization services. Conclusion: Throughout this assessment‘s data collection, respondents across a variety of geographic settings, and representing various PHE constituencies, noted the importance of evidence-based program and policy development. As such, these two attempts at OR are critically important to the PHE field and researchers should be encouraged to finalize and disseminate research results. The final analyses should make best use of the available data, including multivariate analyses as feasible, and should ultimately be subject to scientific peer review and published in scientific outlets. This process will enhance the credibility of the results and offer the most substantial contribution to the PHE field. In addition to the actual empirical results, the PATH and EHP projects represent important contributions in lessons learned with regard to designing and implementing PHE field-based research. These lessons should also be published and widely disseminated. Key to lessons learned is the complexity of OR in such remote locations with dynamic socio-demographic-economic characteristics. Indeed, undertaking quasi￾experimental field-based research is quite difficult due to the inability to truly ―control‖ comparison sites. As an example, and as noted in the body of this report, other NGOs became active in IPOPCORM‘s no￾intervention comparison site, thereby negating any insight to be gained from comparing trends across 72 Assessment of USAID’s Population and Environment Projects and Programming Options intervention/non-intervention settings. In addition, the RH-only site experienced some marine development that affected its biophysical setting. The CRM-only site was plagued by a lack of municipal support for law enforcement, thereby resulting in negative environmental effects due to the use of cyanide and compressors in fishing. These various factors combined to undermine the effectiveness of the research design. Further, efforts at PHE OR have been hampered by the remoteness of the study sites (e.g., ocean travel to some IPOPCORM sites is sometimes impossible during seven months of the year). In addition to issues related to data contamination and access, OR problems may arise because not enough input/intervention is being provided to effect the amount of change required to measure statistically and programmatically significant difference; regardless of the amount of input, the amount of time passed is inadequate for change to become evident; and/or the indicators used are not sufficiently sensitive to measure the change that is occurring (Pielemeier 2005:22). Still, although cross-site may be difficult and/or impossible due to various complications, examination of trends within the integrated site provides an important opportunity to explore program impact with regard to health and environmental benefits. In addition, multivariate analyses may allow greater use of available data. In conclusion, the need for evidence remains strong and, although past OR models ultimately became unfeasible within remote PHE settings. Future effort should be made to develop more streamlined research designs that include collection of qualitative data on perceived program benefits as discerned through in￾depth interviews with implementers as well as beneficiaries. Although simpler designs may lack some empirical strength, they do offer the potential to provide the evidence base desperately needed by the PHE field. References Magbanua, F., D‘Agnes, L., and Joan Castro. 2007. Integrated Coastal Management Matters. IPOPCORM Monograph Series No. 4. PATH Foundation Philippines, Inc., Makati City, Philippines Environmental Health Project (EHP). 2004a. Healthy People in a Healthy Environment: Integrating Population, Health and the Environment in Madagascar. EHP Brief. No. 25 July 2004. http://pdf.usaid.gov/pdf_docs/PNADB077.pdf Environmental Health Project (EHP). 2004b. Integration of Health, Population and Environment Programs in Madagascar. Midterm Progress Report. Activity Report 115. Environmental Health Project (EHP). 2005. ―Impact of an Integrated Population, Health and Environment Program. Page 76, Final Report, May. Kleinau, E., Randriamananjara, O., and Rosenweig, F. 2005. Healthy People in a Healthy Environment: Impact of an Integrated Population, Health, and Environment Program in Madagascar. Washington, D.C./USAID: Environmental Health Project. Pielemeier, J. 2005. Review of Population-Health-Environment Programs Supported by the Packard Foundation and USAID. http://www.ehproject.org/PDF/phe/ll-packard2.pdf Assessment of USAID’s Population and Environment Projects and Programming Options 73 ANNEX 7. ROSTER OF PE FELLOWS P/E Fellows from 2002–present Name Organization Country Fellowship dates Kathleen Dowd-Gailey Pronatura Mexico 2/01–4/03 James Hutchins CARE Tanzania 12/00–3/03 Robert Layng Save the Children Philippines 10/00–10/02 Jennifer Talbot USAID Madagascar 7/00–8/04 Ben Piper The Nature Conservancy USA 6/00–6/02 Caryl Feldacker Management Sciences for Health Brazil 2/03–11/04 Carol Boender Conservation International USA 9/02–12/04 Anthony Kolb Medecins sans Frontiers Uzbekistan 7/01–5/04 Kirk Riutta Conservation International Philippines 6/01–8/03 Dorsey Burger TNC Ecuador 3/01–5/03 Heather D’Agnes USAID USA 11/05–present Bill Fischelis Save the Children & CI Philippines 5/05– resent Kristen Patterson SanteNet Madagascar 3/05–8/06 Stacy Fehlenberg JGI Tanzania 2/05–8/06 Cara Honzak WWF USA 7/04–9/06 Kathleen Mogelgaard PRB USA 6/04–7/06 Lynne Gaffikin USAID Madagascar 2004-2006 Ericka Moerkerken Pro-Peten Guatemala 2/04–/06 74 Assessment of USAID’s Population and Environment Projects and Programming Options ANNEX 8. BUDGET TABLES PRH/PHE Funding Obligations FY2002–2007 ($ thousands) Recipient 2002 2003 2004 2005 2006 2007 TOTAL by Org. CI 675 400 350 450 600 400 2,800 WWF 300 400 325 450 475 1,950 WWC 190 472 625 502 200 490 2,479 PRB 257 330 320 202 272 1,381 Pro-Peten (through M&L) 150 125 275 PE Fellows42 1,280 1,220 1,440 990 1,260 6,190 Population Leadership Program /PHI 350 555 905 Env. Health IQC 100 145 60 305 MEASURE/Evaluation 100 175 75 125 475 JGI 400 275 175 95 945 Madagascar—WCS 35 35 PATH/IPOPCORM 763 100 60 80 1,003 CATALYST 22 22 SAVE Phil/PESCODEV 100 200 EHP 290 150 440 ProSalud 18 18 TOTAL by YEAR 3,338 2,949 4,120 3,237 3,202 2,552 19,398 (NOTE: All figures are in thousands of dollars) 42 The PE Fellows program was funded through the University of Michigan until 2007. The FY2007 funding was channeled through the Global Health Fellows Program. Assessment of USAID’s Population and Environment Projects and Programming Options 75 ANNEX 9. PHE STRATEGIC FRAMEWORK (October, 2006) G 1.1 Improved outcomes in FP, health, biodiversity and NRM. 1.2 Demonstrate instances of value added where FP, RH health, NRM, biodiversity, and/or environmental threat reduction activities are linked in priority biodiversity areas. 1.3 Instances of national, regional, and int’l forums, networks, coalitions, or communities of practice formed around PHE. 1.4 Evidence that PHE issues have gained the attention of policymakers or other key audiences 1.5 Key actionable findings, success stories, and experiences identified, generated, and summarized and their lessons learned. 1.6 Development of tools, procedures & models for scale up, replication, or sustainability of PHE programs. 2.1 Number of policy briefs written, articles published, websites created, and other written communication circulated to support and improve understanding of PHE linkages. 2.2 Number of papers presented at key int’l conferences for health, environment or development 2.3 Number and types of outreach activities organized 2.4 Target and new audiences reached with products from 1.5, 1.6, 2.1, and/or 2.3. 3.1 Instances of TA provided for developing and funding PHE programs 3.2 Instances where organizations use PHE program development tools and PHE training materials 3.3 Number of USAID Missions adopting PHE in their strategies. 3.4 Number of PHE implementation models replicated in new countries or geographic areas. 3.5 Number of PHE programs scaled￾up. GH SO 1: Advance and support voluntary family planning and reproductive health programs worldwide. E AT/NRM SO: Improved human well-being through healthy ecosystems and sustainable resource management PHE Strategic Objective: Advance and support links between population, health, and environment sectors worldwide Primary Impact Indicators: 1. # of PHE policies implemented 2. # of new PHE partnerships formed 3. Dollar value of resources allocated and leveraged for PHE programs IR1 Global leadership demonstrated in influencing the worldwide PHE agenda and other organization’s programs IR2 Knowledge generated, communicated, and disseminated to improve understanding of PE linkages in new and primary audiences IR3 Support provided to the field to strengthen their institutional capacity to implement effective and sustainable PHE programs 76 Assessment of USAID’s Population and Environment Projects and Programming Options ANNEX 10. FUTURE DIRECTIONS FOR USAID PHE FUNDING A. PRINCIPAL BARRIERS AND OPPORTUNITIES FOR EXPANDING PHE ACTIVITIES Barriers: The principal barriers facing the PHE field relate to inadequate funding, linked to the complexity of integrated efforts; the limited evidence base for the program model; and the growing but still limited capacity to implement PHE field programs. These barriers are related to the need for additional advocacy to expand the PHE funding base. Advocacy is also needed within USAID/Washington, as well as with missions where population pressures have a negative impact on environmental conditions. The inflexibility in the use of FP and HIDN funds to meet the multisectoral needs of field projects is also a barrier. Funding: There remains an absence of major donor/foundation funding for both the scale-up of successful PHE models and for testing PHE in new locales. Of course, the complexity of integrated programs is partial reason for this absence. Cross-sector efforts are difficult to structure, fund, and manage at greater scale, as donors and often central governments find PHE bureaucratically unwieldy. USAID‘s sectoral ―stovepipes‖ also make it an unwieldy donor for PHE. Implementers working on integrated programming find it difficult to deal with budgets that support only particular program components, especially if these components are not perceived as top priority by local communities. Evidence Base: Complexity and ―stovepipes‖ also make it difficult for PHE programs to demonstrate ―added value.‖ The cross-sectoral nature of PHE demands cross-sector impact measurements but measuring the value of integration, per se, is substantially more challenging. Also, sectoral ―stovepipes‖ mean that different organizations place greater value on measurements of relevance to that particular sector (e.g., CPR for those with RH focus, coral density for those with environment focus). Operations research has, thus far, proven difficult to design and manage given the ever-changing nature of the socio-economic settings in which these programs operate. It has also been difficult for implementers to engage academic researchers in collaborative PHE research efforts. Although PHE programs appear potentially sustainable in regions with decentralized and effective local government structures, additional effort is needed to understand routes to sustainability in bringing FP to remote regions where local governments have less capacity to reach these communities with services. There is some concern that the ―PHE‖ label is limiting in that it inhibits recognition, and potentially collaboration, with others engaged in similar integrated efforts. PHE advocates have not yet made a major effort to demonstrate results that could fit these programs into a larger donor focus on equity, poverty alleviation, food security, or conflict mitigation. Capacity: A great deal has PHE leadership and technical capacity has been fostered in specific focus PHE countries, especially in the Philippines, as well as via the PE Fellows programs. The PRH leadership portfolio has produced high-quality manuals and analyses and collected best practices. However, there remains a strong need to build and maintain leadership and ―champions‖ for PHE and integrated programming. The field remains too dependent upon a handful of central organizations and individuals and, in this way, is vulnerable to loss of important human capital as these organizations/individuals move on to other topics and/or professional opportunities. Opportunities: With the strong support of the PRH/PHE program (and the Packard Foundation PE program), much of the stage is now set for a major expansion of PHE or PHE-like activities that could provide FP services to remote and underserved populations. Assessment of USAID’s Population and Environment Projects and Programming Options 77 1. Very successful ―gold standard‖ PHE field projects and the Philippines PHE Network are available as models for future programs with both field and policy components. 2. Several International Environment PVOs have learned the value of PHE and are increasingly including FP and health as common components of their new remote area livelihood or human wellbeing programs. 3. PHE programs have developed successful IEC materials and methodologies for encouraging youth and men to accept family planning services. 4. The IR2 ―consolidation phase‖ has helped produce and make available a basic library of how to design, implement, and evaluate PHE projects using successful methodologies and IEC materials from previous projects. 5. The continued decentralization of government authorities and services in developing countries provides opportunities, similar to the Philippines, for county and district-level planning and funding to include PHE activities. Local governments in the Philippines have also demonstrated that PHE projects can be sustained at modest cost using local government funds. 6. PHE programs may represent an effective approach for efficiently providing multisectoral services to remote areas as part of ―equity‖ focused programs. 7. PHE programs may also represent an effective approach for efficiently providing multisectoral services to remote areas as part of environment-focused landscape, corridor programs. PHE multi￾sectoral approaches could potentially be used for a new phase of integrated conservation and development programs (ICDPs) or ―climate change‖ programs. 8. On capacity, identify ongoing, successful efforts to build capacity and ―champions‖ such as the Beahrs Environmental Leadership Program. Also tap in to existing networks to build community such as the ―Population Environment Research Network.‖ 9. Ongoing data collection efforts such as through Demographic and Health Surveys or national surveys may help provide evidence of the impact of PHE programs. 10. PHE programs provide an opportunity to foster south-south collaboration and learning, using technical capacity from the Philippines and Madagascar. 11. Finally, PHE may represent precisely the type of programming that could facilitate cross-office collaboration within USAID and act as a model for other USAID regional and community-based programs. B. RECOMMENDED STRATEGY FOR PRH/PHE The following strategic recommendations are based on the assumption of a five-year strategy and program horizon, and also the assumption that PRH/PHE will continue to provide funding levels similar to the previous strategy period (average $3.2 million/year). It is further assumed that GH program guidance will continue to focus on three core areas: funding field activities and research that fosters innovative approaches to addressing key issues/problems; developing research, tools and communication to promote technical leadership; and providing support to USAID Missions and others by building capacity and providing technical assistance. In general, it is suggested that PHE efforts are most appropriate: In, or near, threatened ecological or biodiversity ―hotspots‖ and protected areas and where there is heavy pressure on the local ecological setting and/or natural resource base by local communities due, in part, to high population densities demographic, health, and/or poverty indicators are relatively worse than regional/national indicators government services are unavailable or insufficient to meet local needs. 78 Assessment of USAID’s Population and Environment Projects and Programming Options C. PRIORITY LOCATIONS The following analysis, prepared by WWF, demonstrates the intersection of rapid population growth trends, population pressure and threats to regions of important biodiversity.43 Conservation International has carried out somewhat similar analyses that show the relationship of population pressure to their ―biodiversity hotspots.‖44 Several of the WWF and CI ―Priority Places‖ and ―Hotspots‖ coincide with new PRH priority countries, former PRH priority countries in Asia where there remains significant unmet need for FP in remote areas, and Congressional interest in PHE expansion/scale-up in Asia and Africa. Population Trends in WWF-US Priority Places Due to Fertility and Migration (May 2007*) WWF-US Priority Places Population Growth Rate (through 2015) (2) Projected Doubling Time (years) (2) Population 2000 (1) Projected Population 2005 (1) Projected Population 2015 (1) Amazon and Guianas 2.2 32 23,259,308 26,062,234 32,299,980 Amur-Heilong -0.4 N/A 64,779,920 64,967,264 61,071,984 Bering Sea -3.1 N/A 420,993 357,850 264,631 Borneo and Sumatra 1.4 49 41,923,736 45,221,760 51,808,508 Chihuahuan Desert 1.3 52 17,628,256 19,003,480 21,541,764 Coastal East Africa 1.9 36 30,975,114 34,134,760 41,413,844 Congo Basin 2.9 25 25,484,444 29,406,422 39,109,092 Coral Triangle 1.0 67 138,056,752 146,596,016 161,546,784 Eastern Himalayas 1.7 40 39,202,700 43,060,484 50,846,748 Galapagos 4.4 16 18,832 23,753 36,492 Gulf of California 1.0 69 7,488,066 7,962,561 8,719,471 Madagascar 2.7 26 15,781,927 18,186,030 23,801,400 Mekong 1.2 56 75,280,256 80,668,752 90,731,992 Mesoamerican Reef 2.3 30 9,165,508 10,406,618 12,975,752 Namibia 2.9 24 448,531 512,876 692,232 Northern Great Plains 0.7 104 1,342,971 1,406,352 1,483,980 U.S. Southeast Rivers 0.8 88 10,941,353 11,518,566 12,313,608 Southern Chile 0.7 95 4,966,885 5,190,146 5,542,643 Yangtze 1.2 60 421,270,464 433,158,432 500,932,416 Key Shading indicates that doubling time is less than 50 years. Italics Italics indicates that WWF currently has a population project in that place. 43 The Population Growth Rate used for the Coral Triangle (Philippines, Indonesia, Malaysia) is much lower than national estimates and should be used with caution. 44Conservation International (Larry Gorenfo) prepared a somewhat similar table for their ―Footprints‖ coffee table-sized book, that indicates the population density in 2005 and projected to 2015 at each of their 38 global hotspots. Assessment of USAID’s Population and Environment Projects and Programming Options 79 In the above table, for each priority place that includes marine ecoregions, the populations living in watershed areas that drain directly into the relevant marine ecoregions have been included as part of that priority place (with the exception of the Coral Triangle, for which a unique approach was taken in collaboration with the Priority Place leader). More details about methodology and background will be made available once this analysis is published, projected for Spring 2008. D. LONG-TERM ―GOALS‖ FOR THE PRH/PHE PROGRAM: 1. FP services are available in most ‗hotspots‖ where population pressure is a major threat to biodiversity and the environment. 2. PHE scale-up has occurred in at least two ecosystems or landscapes. 3. PHE and other integrated methods of providing FP services in remote regions are fine-tuned and readily available to donors and implementing agencies. 4. Increased and diversified donor, foundation, and private-sector funding is available to support PHE and similar programs. 5. Many international environment PVOs accept and integrate FP as an important component of their recommended remote-area community support programs. 6. PHE program design, M&E, training and partnership manuals, working papers, and research results are disseminated widely and updated as needed. 7. A cadre of experienced PHE professionals, including from developing countries, are available to provide technical support to new and/or continuing efforts. 8. Research has been undertaken to measure the added value of integrated programming, with results published in both organizational materials and in scientific outlets. 9. PHE becomes an efficient ―stovepipe-breaking‖ model for cross-sectoral USAID-funded activities that reach remote communities. 10. PHE activities have been chosen and designed, in part, to help achieve new PRH strategic objectives (13 priority countries and 6 programmatic priorities). Proposed Portfolio: Priorities for the next five years should include: scale-up of successful PHE models, as suggested in the 2008 House report; a major advocacy effort to attract new funding for PHE or PHE-like programs; consolidation of sustainable PHE networks, including local advocacy capacity, in the Philippines and Madagascar; broad dissemination and use of recently developed learning materials; support for research to examine the value-added hypothesis; and use of PHE as a model effort to break through USAID funding stovepipes in order to provide more effective support for community-based and regional development programs. A summary of recommendations follows, with additional activity-specific detail below. IR1: Field Activities 1. Provide tailored support to meet the needs of PHE movements in three lead countries/regions: the Philippines, Madagascar, and East Africa (country- and region-specific activity recommendations outlined below). 2. Provide GDA funding for several sites as part of an innovative WWF partnership with Johnson and Johnson. Encourage and foster additional GDA opportunities. 3. Encourage innovative approaches to providing FP to remote communities through a new small grant mechanism similar to Child Survival Grants, managed by a new CA (see below). The 80 Assessment of USAID’s Population and Environment Projects and Programming Options objectives would include encouraging other PVOs (e.g., CARE) and NGOS to experiment with the PHE concept. 4. Experiment with including FP in selected USAID Title II food security programs. IR2: Develop research, tools and communication to promote technical leadership. 1. Continue to fund PRB to support PHE coalitions, advocacy networks, training workshops for practitioners and political leaders, media training, and national conferences. Support for a pilot research funding program would enhance linkages with the academic community and provide support for modest, but important, inquiry into the added value of integrated PHE efforts. 2. Provide tailored support to the Wilson Center to expand outreach activities to the potential funding agencies, academia, and developing world audiences. Support to bring a graduate student or post￾doctoral researcher to act as a bridge the academic community would enhance ECSP‘s contributions to PHE in this area. 3. Given the ongoing need for central leadership in PHE, competitively select a new CA that will provide both technical leadership and technical support for PHE activities worldwide. Key functions could include support for and expansion of the Environment Policy Working Group to include health and FP organizations; provision of STTA to missions and implementing CAs; undertaking a major PHE advocacy effort to attract new funding; increased involvement of academic researchers in PHE efforts to explore scientific argument for added value; determining future informational needs of the PHE community and working to fulfill those needs; designing and managing a small-grant program (similar to Child Survival grants); and developing and managing a virtual community of those interested and engaged in PHE activities, including CA staff (including field staff), donors and potential donors, academics, and Mission staff. Depending on the composition of the CA partnership, some of the PRB and WWIC activities might also be funded via this mechanism. IR3: Providing support to USAID missions and others by building capacity and providing technical assistance. 1. Maintain a ―retainer‖ relationship with MEASURE/Evaluation to respond to USAID mission or CA requests for PHE technical support. 2. Maintain a mid-level or senior advisor in PRH/PHE who can provide supplemental TA to USAID missions. Ensure that PHE competency is also available in EGAT (Environment team) and HIDN (water team, possibly others). 3. Consider placing a long-term PHE advisor at REDSO/EA to provide technical support for new PHE activities and the regional EA network, as well as Madagascar. Assessment of USAID’s Population and Environment Projects and Programming Options 81 E. BALLPARK BUDGET ESTIMATES (ASSUMING $3.0 MILLION/YEAR) FY08 FY09 FY10 FY11 FY12 Total IR1 6.8 WWF GDA 0.5 0.5 0.5 0.5 0.5 PATH Scale-up 0.5 0.5 0.4 0.2 - Madagascar 0.2 0.3 0.4 0.4 0.3 Grants fund 0.2 0.3 0.2 0.2 0.2 IR2 5.25 RFP45 0.6 0.7 0.7 0.7 0.4 PRB 0.25 0.25 0.25 0.2 0.2 WWIC 0.2 0.2 0.2 0.2 0.2 IR3 2.95 Fellows 0.6 0.6 0.4 0.4 0.4 MEASURE 0.15 0.1 0.1 0.1 0.1 Total 3.2 3.45 3.15 2.9 2.3 15.0 F. COUNTRY-SPECIFIC RECOMMENDATIONS The Philippines: Encourage consolidation, advocacy and PHE program expansion in collaboration with USAID/Philippines. PHE Prognosis: The Philippines has by far the best base to replicate and scale up successful PHE models. All of the prerequisites for scaling up CRM PHE activities are in place. The PHE Network remains strong and very dedicated. Continued Packard funding for the PHE Network, the 2008 conference and possibly for some small scaling up activities are much needed and welcomed, but Packard cannot be counted on to provide any major new infusion of funds into PHE in the Philippines. Excitement about the successful PHE pilot projects and the network activities is beginning to wane in the absence of major new PHE support. Additional LGUs may be interested in trying to replicate the PHE models and probably will be able to do so if TA from experienced PHE practitioners were available and site visits to successful locations occur (this TA would have to be donor funded). The next few years may lead to a mushrooming of local PHE efforts. However, if they do not occur soon, the energy of the PHE movement is likely to dissipate and the movement may flag and potentially disappear. In this context, USAID PRH/PHE funding should support scale-up and learning from the successful Filipino PHE models. Some specific activities might include: Provide modest funding to encourage other donor funding for the scale up of IPOPCORM through the Danagon Ecosystem. Provide funding for site visits and learning exchanges to encourage LGU and provincial replication of successful PHE projects (could be funded via the Philippines PHE Network). Assist the USAID mission in determining how best to integrate PHE as an element of its municipal government health program (TA). Assist the USAID mission in determining how to include PHE in next phase of its CRM program (TA). 45 RPF includes activities directed towards both IR2 and IR3 objectives. 82 Assessment of USAID’s Population and Environment Projects and Programming Options Madagascar: Encourage consolidation, advocacy and PHE program expansion in collaboration with USAID/Madagascar. The absence of an effective coordinator/support mechanism is striking. Almost all organizations involved with PHE indicate the need to visit other field sites, learn from previous PHE experience, exchange technical and operational lessons learned, and benefit from IEC and other written materials developed by previous PHE projects. In addition, there is no effective advocacy process to introduce the PHE concept to other donors and the central government. Two steps that should be considered are to organize the first national PHE conference for Madagascar as a first step in creating a more effective PHE network and to communicate PHE results to the government of Madagascar and potential donors, and to either attempt to strengthen VS as a coordinating body or develop another approach to program interchange and coordination, working through another institution. Assistance to VS might include guaranteed operational funding for several years (such as Packard support to the Philippines‘ PHE Network), funding a full time PHE coordinator (new staff member) and through a mentoring relationship with PRB or the Philippine‘s PHE network; providing funding for site visits, learning exchanges, and training of trainers to encourage district and communal replication of successful PHE projects. Consider funding second-stage field projects, building on WWF, CI, and WCS experience with more significant cost-sharing and a clear plan on how the institution would market the PHE concept if the program were successful. Position these second-stage projects as opportunities to learn new approaches to services in remote areas, such as use of CHWs to provide FP injections, CHW delivery of health-related commodities (FP, malaria, safe water, etc), and addressing the needs of youth. As part of Madagascar President‘s Durban Initiative, encourage USAID leadership in an expanded national program to provide integrated services (including FP) to populations in/around newly designated National Parks. Repackage the concept of PHE either as 1) a program focused on equity providing services and support to remote areas—―The Extra Mile‖ program, or 2) as a program focused on poverty alleviation and ―safeguards‖ (WB terminology) in remote areas. Such a repackaging may enhance appeal to a wider variety of offices within the mission. Encourage a major scale-up of PHE-related water programs in ERI program areas using EHP funds. Help resolve teething issues related to scale-up of Champion Community program to a Champion Commune program (technical assistance). Consider placing a new PHE fellow in Madagascar or hiring a part-time Malagasy ―point person‖ for PHE activities. Encourage communes to include PHE programs in their development plans, (and position them for funding from the WB and the European Union) by including PHE planning methodologies in the assistance offered by new Commune Support Centers. Test a new integrated PHE focus on youth in remote communities. None of the environment programs have yet focused on youth. SanteNet programs, which work through networks of scouts, sports teams, and schools could be expanded to deliver ―stewardship‖ programs that focus on stewardship of one‘s body and one‘s environment. East Africa: Provide modest but timely support for PHE program start-up Provide institutional support for start-up of the East Africa PHE network following recent regional conference in Addis Ababa. Consider placing a PHE Tech Advisor with REDSO/EA (perhaps part-time) to provide support to the PHE network and to assist USAID missions with PHE planning, project design and support. Assessment of USAID’s Population and Environment Projects and Programming Options 83 G. ACTIVITY-SPECIFIC RECOMMENDATIONS Woodrow Wilson Center SSPHERe program ECSP and its staff represent a cornerstone of the PHE community in the DC area and continued support would facilitate moving PHE forward. Even so, future ECSP efforts should be part of a larger PHE strategy, with the strategy shaped by the broader community of implementing organizations, scholars, and other engaged constituencies as represented by the PHE Working Group (noted above). On seminars, the WWIC offers an excellent forum with the potential to be very influential. As such, seminars should be strategically defined and targeted at particular audiences. An excellent example is the forthcoming series exploring the ―Future of PHE‖ from multiple perspectives (e.g., environmental organizations, population organizations, potential donors). Seminar participants and audiences should be geographically broadened. ECSP staff could potentially reach out to other DC-region organizations that bring in relevant speakers to explore the potential for cross￾fertilization. In particular, the contributions of ECSP seminars and publications could be enhanced by greater connection to PHE field activities. AID/W should keep ECSP staff informed of DC visits by mission staff and program implementers. In addition, field reporting could be facilitated through a requirement that each PE fellow offer one presentation and submit one publication for ECSP dissemination. On audiences, additional, targeted promotion of available webcasts might increase identification of interested parties beyond the DC-region. On connections to the academic community, it would be useful to have a graduate student or post-doctoral position within ECSP designed to both undertake PHE-related research and act as a ―bridge‖ to the scholarly community by reviewing relevant research, developing ECSP publications based on this work, and perhaps communicating with the academic community as to their needs/desires with regard to PHE information. ECSP staff are presently too overstretched to focus on increasing these connections although the organization‘s contributions to PHE could be greatly enhanced by strengthening relationships with a broader array of researchers. Publications are of high quality but it is recommended that future efforts in outreach be more strategically situated within a broader effort to advocate for PHE. As an example, if aiming to target academic audiences, seminars and/or specific publications educating the research community as to available data, potential material for curricula. Population Reference Bureau PRB is another cornerstone within the PHE community and the organization‘s commitment to replace the Technical Director is a sign of its commitment to the topic. Continued support is recommended to facilitate moving PHE forward. Even so, as with ECSP, future PRB efforts should be part of a larger PHE strategy, with the strategy shaped by the PHE Working Group. It remains to be seen if the new Technical Director will have the skills and desire to continue to focus PRB PHE efforts on hands-on workshops and training. These are key contributions of PRB to PHE and their continuance should be encouraged. Successful models of workshops and training should continue, with a focus on key geographic regions of interest (especially East Africa and Madagascar). Future training should also carefully draw on existing lessons to enable learning from the many case studies, evaluations, and tools/guides developing within the PHE community of present. Other future workshops should be informed by a comprehensive training needs assessment. As noted above, within PRB, PHE work is somewhat different in that it includes more applied efforts (workshops, coalition building, etc.) in addition to PRB-style research syntheses. This distinction could be a 84 Assessment of USAID’s Population and Environment Projects and Programming Options strength (i.e., opportunity to tap into different funding sources) or a limitation (i.e., potential to be seen as organizational mission drift). Within PRB, efforts should continue to build synergies between PHE and other PRB materials. As an example, the PHE team incorporated several PHE indicators in the 2006 World Population Data Sheet and region-specific press releases were developed from a PHE angle. This demonstrates potential to adapt and disseminate other PRB materials to include PHE messages of relevance to USAID missions and other developing country audiences. PRB PHE team members should be key contributors to a DC-based PHE Working Group, and the organization may indeed be well-suited to act as a key. This would position PRB to more effectively build upon the extensive network of participants from many countries who have been trained on PHE over the past seven years. There also exists an opportunity to link these ‗alumni‘ on real-time discussion of PHE topics through a blog or other web-based communication technology. PRB‘s PHE team should endeavor to enhance links with the academic community through targeted mailings of PHE materials, regular review of key academic outlets, and increased representation at key professional meetings. The development of a pilot research funding initiative would greatly facilitate this connection with the academic community as well as engage more scholars in PHE-related research. CDM (co-funded with HIDN) All of the functions now included in the PHE task order for CDM should be transferred to the new CA that specializes in PHE activities (see above). If this recommendation is not adopted, the following recommendations would apply to a continuing CDM task order. Identification of a new Technical Coordinator for the TO is an important component of moving PHE forward. As noted, the IQC/PHE Task Order is essential to the current PHE portfolio as the community finds itself in need of documentation, outreach/dissemination of that documentation, as well as Technical Assistance. The Technical Coordinator of TO activities should have PHE expertise and be in the DC region in order to best facilitate dialogue and outreach. The individual within this position should also possess leadership skills and be able to frequently travel internationally. The TO should facilitate development and implementation of PHE network within the DC-area, but including global representation. As noted by one PE fellow, ―The next step is to develop forums, virtual and real, for real dialogue and reflection regarding [key] questions, analytic (versus PR-oriented) pieces that can contribute and inform the dialogue, and unified responses to these questions from a body that is accepted as representing the interests and future of PHE.‖ The TO must continue to strategically identify activities needed by PHE community and work with the PHE network to fulfill those needs. One area of potential TL is facilitation of the development of joint IEC tools, and documentation as to how to engage donors would also be useful. The technical coordinator should also play a central role in PHE advocacy and fundraising, in collaboration with other members of the PHE network. PATH Foundation Philippines/IPOPCORM Operational Research Given the ongoing need for evidence of value-added, IPOPCORM should be encouraged to distribute existing publications and look to publishing in other venues (e.g., academic outlets, through PRB) results and lessons learned in order to best inform future efforts to empirically examine PHE impacts. WWF-leadership WWF is a key PHE actor, both with regard to implementation and the provision of Technical Leadership to the PHE community. Continued support both for field and learning activities would certainly be recommended to facilitate moving PHE forward. Assessment of USAID’s Population and Environment Projects and Programming Options 85 MEASURE/Evaluation The organization is well positioned to respond to the technical needs of PHE implementers, and MEASURE/Evaluation should work closely with the new CA to ensure identification of priority technical needs of the PHE community, and the most efficient means of responding to those needs. MEASURE could also continue to improve and promote the effective use of the Guide through dissemination, STTA, and capacity building for PHE grant recipients. Making presentations for national PHE Networks and at regional events Assisting PHE CAs develop PMPs and establish survey tools for data collection Strengthen the capacity of PHE grant recipients ( especially Environment PVOs) to measure and track health/FP results Testing the guide and its indicators Developing a survey or rapid assessment tool for collection of data (baseline or subsequent data) Population-Environment Fellows program As the PHE program has grown and expanded geographically, there have been increasing requests from USAID missions and from CAs for STTA. These requests have been filled by the PHE Technical Advisor and by experienced consultants provided through the CDM Task Order. This has been effective at accomplishing several things: Experienced PHE practitioners and thinkers continue to participate in and invest in the future of the PHE field Provides a bridging mechanism between sectors and allows specialized talent to contribute when needed (bolstering quality and results integrity) Responds to needs when they arise by connecting a leading thinker/practitioner to help address the identified need Maintain and advance collected lessons in the small and dynamic PHE field by sending those with the most experience to address issues that come up However, the need for STTA could also be a reaction to the significant decline in PE Fellows. In order to bring new personnel into the PHE field and expand the number of qualified PHE technical staff in overseas settings, USAID should consider increasing the number of PE fellows (beyond two per year) or by providing other opportunities for technical participation in PHE by junior-level professionals through scholarships, research grants or other support mechanisms. Other options for providing STTA would be to increasingly draw upon senior and mid-level technical specialists from the Philippines and Madagascar, thereby encouraging south-south exchanges and cross-country learning. PHE Fellows can continue to play a core technical role and this can be enhanced through: Designating the development of PE Fellow descriptions to a PHE Advisory body, rather than GHFP Re-establishing a network of PHE fellows, including current and past participants Considering cross-site visits for PE fellows Designing and supporting activities to enhance PHE employment possibilities post-fellowship Providing support for PE Fellows to make presentations to national/regional PHE Networks, and the Wilson Center Ensuring that PE Fellows in the field incorporate the M&E toolkit into CA‘s activities (testing indicators, data quality, testing survey tools, etc.) 86 Assessment of USAID’s Population and Environment Projects and Programming Options Encouraging the PE Fellows to develop, analyze, and summarize results of applied research in their field sites for dissemination through the network and publication in scientific outlets USAID PHE Technical Advisor Continue to maintain close relationships with CAs and continue to bridge field and leadership IRs Work closely with the PHE Working Group to develop a PHE strategy, acknowledging that the community must extend beyond USAID Identify others to provide high-quality PHE TA in the field Continue to build and enhance relationships with other donors, including those supporting applied programs as well as applied research Continue to build and enhance relationships with other sectors such as those engaged in efforts related to poverty reduction, equity, livelihoods, and food security H. WHAT APPROACHES SHOULD BE REPLICATED IN FUTURE PRH-FUNDED PHE PROJECTS? Every PHE implementing organization and official stresses that the design of future PHE projects MUST be context-specific and site-specific. Nevertheless, some successful approaches and tools that should be considered for adaptation include: A variety of community mobilization techniques such as Champion Community and Appreciative Community Mobilization can be used successfully to bring results within two to three years. The CDB franchising arrangement with DKT established by IPOPCORM has been easy to sustain. Improved partnership models have been identified and used that include written agreements on roles and responsibilities, counterpart contributions that each partner will bring to the effort, joint project design and development of M&E systems, etc. (see WWF partnership analysis for additional best practices). IEC messages that are provided to a couple or to groups of men and women gathered together (e.g. Family Planning Action Sessions, Family Budgeting Sessions) Use of food security, or another relevant local ―hook,‖ as a common organizing theme (IPOPCORM) Successful use of boats to transport MOH workers to coastal villages in Kiunga Pilot efforts/scale up in policy-enabling settings where fiscally-enabled LGUs have greater potential to sustain projects Efforts in very remote locations where an engaged NGO enables access For more information, please visit http://www.ghtechproject.com/resources/ Global Health Technical Assistance Project 1250 Eye St., NW, Suite 1100 Washington, DC 20005 Tel: (202) 521-1900 Fax: (202) 521-1901 www.ghtechproject.com