“PHE”: Family Planning and Environmental Sustainability in Communities

“PHE”: Family Planning and Environmental Sustainability in Communities

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Although they are too rarely the topic of peer-reviewed research, community-based projects in some developing countries are bringing family planning and environmental sustainability together at the level of people’s lives. Called PHE projects—for “population, health, and environment”—these initiatives integrate environmental and natural resource conservation with family planning and reproductive health. They endeavor to tap ground-level synergies by diversifying livelihoods, engaging women in natural resource management, and strengthening community engagement in sustainable development while also contributing to climate change mitigation and adaptation.

In my experience directing Conservation Through Public Health (CTPH), a non-governmental organization (NGO) that manages such projects, many have shown that it is possible to build social resilience in the face of rapid environmental change—and perhaps even to help prevent some of that change. CTPH is a 12-year-old nonprofit registered in the United States and in Uganda that has been implementing PHE initiatives for eight years, starting with a focus on preventing disease transmission in areas where people, their livestock, and gorillas and other wildlife interface.

We added a family planning component to our work in 2007. CTPH works with the Ugandan Ministry of Health, which set up a structure of Village Health Teams (VHTs), or groups of community volunteers trained to conduct public health outreach at the household level. (In Kenya and other countries, these individuals typically are called community health workers.) By adding a conservation component to the teams’ work, we renamed them Village Health and Conservation Teams, or VHCTs.

The activities that VHCTs promote in communities include peer counseling of couples on reproductive health and family planning service delivery, including injectable Depo-Provera, a popular contraceptive in the region. Activities also include the promotion of hygiene and sanitation; counseling on infectious disease prevention and control as well as on nutrition and sustainable agriculture; and education on the conservation of gorillas and the forests in which they live.

The VHCTs have brought about measurable behavior change in our projects, including an increase (from 20 percent to 60 percent) in the number of users of modern family planning methods, an increase (from 11 percent to 60 percent) in the use of hand-washing facilities, and reduced disease incidences and conflicts between people and gorillas. These trends are monitored and evaluated through monthly data collection. Launched with the support of the U.S. Agency for International Development’s Office of Population and Reproductive Health, the VHCT model is now sustained in part through group livestock income-generating projects within each parish. These were introduced in the first year of the PHE project.

A few years after initiating VHCTs, the concept of Village Saving and Loan Associations —community-managed and -owned microfinance groups—took shape, and these associations now help support our work. The health and conservation models that we have developed at Bwindi Impenetrable National Park, in southwestern Uganda, are being scaled up at Virunga National Park in the Democratic Republic of Congo and at Mount Elgon National Park in Uganda and Kenya. Some support for this comes from the Global Development Network, a network of research and policy institutes associated with the World Bank.

One project partner, Expand Net, studies the science of scaling health interventions and has developed a nine-step approach, with the philosophy of “beginning with the end in mind.” One of the steps is to engage government and community planners. This was applied successfully in a project called The Health of People and the Environment in Lake Victoria Basin (HOPE-LVB).The project also adopted the VHCT model in communities in the freshwater ecosystem of Lake Victoria.

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Bridging both sectors, PHE activities fall somewhere in between in both ease and complexity.

We have found that health interventions are often relatively simple and easy to scale up in most places. Conservation interventions, by contrast, tend to be more complex and tailored toward site-specific demands. Bridging both sectors, PHE activities fall somewhere in between in both ease and complexity. PHE often can apply an asset from one of the two sectors in the other—as, for example, the VHCTs apply health innovations to ongoing work on conservation.

Adding livelihood-diversification initiatives—such as group livestock (cows and goats) enterprises, in the case of CTPH—to the integrated conservation and health model provides modest income to VHCT members, reducing their dependence on the forest for their basic needs. Offering livelihood-related activities also allows the teams to expand their presence and time with community members where CTPH operates. In Madagascar, Blue Ventures has diversified livelihoods by encouraging communities to farm seaweed and sea cucumbers. This allows stocks of endangered octopus to regenerate, while promoting community-based family planning, which improves both food security and conservation.

PHE projects typically engage health workers for education and service delivery in conservation as well as in reproductive health. Organizations such as FHI 360 and the Green Belt Movement tested the concept of using environment workers to promote integrated health and conservation. The success of this innovation was attributed to the fact that the tree-planting volunteers delivering PHE messages had already gained the trust of the community through successful work on natural resources conservation.

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Conservation and public health workers alike capitalize on each other’s community networks and allegiances to promote PHE.


Conservation and public health workers alike capitalize on each other’s community networks and allegiances to promote PHE. Conservation organizations can expand family planning services to remote locations where they work that often have scarce health services. Similarly, health organizations can implement PHE where conservation organizations have already built trust with the community. This has been the case with the HOPE-LVB project implemented by both health and conservation organizations in Uganda and Kenya. The same is true of projects in Madagascar and Nepal.

In Tanzania, surveys demonstrated that communities gained more support for conservation not only through education, but also because health services were brought closer to them, an outcome that PHE projects aim to achieve. Certain interventions are seen as demonstrating core principles of PHE, such as the promotion of energy-efficient cook stoves in projects in Nepal. This intervention combines in a single device benefits to personal health (less pollution risk to respiratory systems) and environmental sustainability (reduced use of wood and other biomass to cook meals). VHCTs are promoting the stoves in Bwindi Impenetrable National Park, an important home to critically endangered mountain gorillas, and to households in Lake Victoria Basin.

To date, there have been very few studies that quantitatively demonstrate the cost-effectiveness of PHE. In the Philippines, at least, operational research suggested greater impacts on both fertility and the sustainability of fisheries from integrated conservation and health activities, as opposed to those with activities in just one of the two sectors. Other ways of measuring the value added by PHE need to be developed that are less costly and that allow for examination and analysis of data retrospectively.

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Documentation of the evidence that PHE results in benefits for both health and the environment is particularly important for engaging policymakers and governments.


Documentation of the evidence that PHE results in benefits for both health and the environment is particularly important for engaging policymakers and governments. Historically, PHE projects have been developed by NGOs in Madagascar, Tanzania, Uganda, Nepal, the Philippines, India, and other countries. In East Africa, however, advocacy efforts by PHE working groups and/or networks have led to an exciting new development: A multinational government agency, the East African Community, has developed a five-year strategic PHE plan for all five partner states (Burundi, Kenya, Rwanda, Tanzania, and Uganda).

This is a significant policy development that offers greater hope than ever for institutional sustainability. The advocacy role that NGOs have played in East Africa is now evolving from showcasing tested pilot projects to developing sustainable PHE interventions that the government can scale up. Similar developments are offering hope for both scaling up and improving the sustainability of PHE work in Nepal.

NGOs in both East Africa and southern Asia will continue to catalyze cross-sectoral responses for complex development issues such as the linkage of family planning, environmental sustainability, and development. And, we can hope, more researchers will demonstrate the evidence that this approach to development is both cost-effective and catalytic in improving lives and sustaining health and well-being.


CTPH Founder and CEO Dr. Gladys Kalema-Zikusoka educating the community on conservation and public health: Photo by Charles Capel

Dr. Gladys Kalema-Zikusoka is founder and chief executive officer of Conservation Through Public Health, www.ctph.org. She is a member of the FPESA network of collaborating research assessors. Photo by Charles Capel.


Banner photo: Members of a cooperative group that raise goats, as an income generating activity. The group also gathers regularly to discuss sexual reproductive health, and family planning options. June 12, 2014 in Kwale, Kenya. (Photo by Jonathan Torgovnik/Reportage by Getty Images).

This article is excerpted from the upcoming report of the findings of the Family Planning and Environmental Sustainability Assessment. 



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