The Woodrow Wilson Center The Woodrow Wilson Center and Population Action and Population Action

InternationalInternational

Eckhard KleinauJohn Snow, Inc. (JSI)

Odile RandriamananjaraVoahary Salama Association

Fred RosensweigTraining Resources Group (TRG)

May, 2005

Finding Balance:Finding Balance:

Results from a Results from a Population, Population,

Health, Health, EnvironmentEnvironment

Success Story Success Story In MadagascarIn Madagascar

1999-20041999-2004

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Presentation Presentation OutlineOutline

• Background– Madagascar– Voahary Salama

• What isIntegrated PHE

• Evaluation design• Results and

lessons learned• Recommendations

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Length: Entire length of country 2 - 50 km wide

Biological Importance: Biodiversity hotspot, center of global endemism

Hydrological Importance: Critical for the maintenance of watersheds and associated agricultural systems

Rate of Forest Loss: Over past 10 years 1% per year on western side; 2% per year on eastern side

The Forest CorridorThe Forest Corridor

Human Population: 7.8 million in 1975, 18 million in 2005 with 2.9% per year increase; low density along forest corridor

Modern Contraceptive Prevalence Rate:18% nationally; 16% rural; lower along corridor

Under 5 Mortality: 94 deaths/1000LB nationally;120 deaths/1000LB rural

Vaccination Coverage (fully immunized):53% nationally; 49% rural; lower along corridor

Health and Population data from DHS 2003/04

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Rationale for Integrating PHERationale for Integrating PHE

• With high levels of poverty, food shortages and limited knowledge people lack the incentives and skills to conserve natural resources

• Meeting people’s needs and conserving the environment can only be attained by simultaneously implementing interventions in all PHE sectors

• Programmatic integration of PHE results in program outcomes in multiple areas because of synergies that increase program efficiency & effectiveness

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Household Food Security and Livelihood Household Food Security and Livelihood ConceptConcept

Rice Rice cultivaticultivationon

Anti-Anti-erosion erosion measurmeasureses

Fruit Fruit TreesTrees

Plant Plant nurserinurserieses

ReforestatioReforestationn

Off season Off season plantingplanting

Forage CropsForage Crops

Fish Fish cultureculture

BeekeepingBeekeeping

Animal Animal husbandhusbandryry

Vaccination, Vaccination, Diarrheal Diarrheal Disease, MalariaDisease, Malaria

NutritioNutritionn Safe Safe

motherhoodmotherhoodReproductive Reproductive healthhealth PotablPotabl

e e waterwater

Sanitation Sanitation & Hygiene& Hygiene

Sustainable Sustainable use of natural use of natural resourcesresources

Protected Protected ecosysteecosystemsms

Market Market gardengarden

Income generationIncome generationMicrocreditsMicrocreditsCivil society Civil society organizationsorganizations

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Community Centered P-H-E Interventions

WatersheWatershedd

Strategies for Working with Local Strategies for Working with Local CommunitiesCommunities

Champion Champion Community Community

Farmer-to-Farmer-to- Farmer Farmer

Child-to- Child-to- CommunityCommunity

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Partners in Sustainable DevelopmentPartners in Sustainable Development

9 9 NGOsNGOs 160 Communities160 Communities

8 Projects, 3 Donors8 Projects, 3 Donors3 Foundations3 Foundations

Government in 19 Government in 19 CommunesCommunes6 Ministries6 Ministries P

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ServingServing125,000 people in125,000 people in160 communities160 communities

(25% of target(25% of targetpopulation)population)

Fort Dauphin

Moramanga

Fénérive Est

Antananarivo(Voahary Salama)

Fianarantsoa

Betioky

Diégo Suarez

Map

ada

pted

from

©

2000

Dav

id P

arks

and

La

rry

Bar

nes

FundingFunding

• USAID: $1.6 million activity over 5 years

• 50/50 split between HIDN and Population Offices

• Increased level of Mission funding in Y5

• Foundations: Summit ($400k), Packard ($2m)

Program EvaluationProgram Evaluation

• Quasi-experimental design– Two groups: integration and non-integration– Two household surveys: baseline 2001 and impact 2004

• 3 organizational arrangements (4 NGOs in 3 regions)

– Type 1: Integration within 1 NGO (multidisciplinary teams)– Type 2: Integration within 1 NGO (separate H & E teams)– Type 3a: Integration between several NGOs– Type 3b: Integration between several NGOs

• Sample size: 1025 HH (2001), 1278 HH (2004)– Sample in each organizational type (1-3): 256 households– Sample in non-integration group: 256 households

Two Operations Research QuestionsTwo Operations Research Questions

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2. Does the sustainability and effectiveness of Integrated PHE depend on the organizational arrangement?

1. Is integrated PHE more effective and sustainable than unlinked, single-sector approaches?(synergies hypothesis)

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Methodological LimitationsMethodological Limitations

• Sample Size• Quasi-experimental design• Multi-purpose survey instrument• Short intervention period between baseline and

follow-up surveys; and • External events

How Confident Can We Be That How Confident Can We Be That Integration Works?Integration Works?

• Patterns and trends explained by process– Comparing organizational Types– For example, Contraceptive Prevalence Rate

• Test of statistical significance– Mostly for integration & non-integration group totals– 2004 results favoring integration or non-integration

communities at p≤0.05 or p≤0.10 level of significance and power=0.8

– Statistically significant improvement from 2001 to 2004, also at p≤0.05 or p≤0.10

1. Integration is effective

2. Livelihood/food security

3. Anosy region high-need

4. Reach remote populations

5. Good return on investment

Results and Lessons LearnedResults and Lessons Learned- Summary -- Summary -

6. Small doable actions

7. Different mechanisms work

8. Women’s participation

9. Better government services

10. Evaluation real-life synergies

11. Successful integration depends on partners to collaborate

Integration is effectiveIntegration is effectivebecause of synergies of an NGO partnershipbecause of synergies of an NGO partnership

• Good results in each sector compared to programs implemented separately

• 29 out of 44 key PHE indicators resulted in higher outcomes in integration than in non-integration communities(statistically significant)

• Complementarity of interventions

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26.4

15.5

9.9

6.5

12.8

1.4

16.6

14.9

9.4

3.4

11.2

8.11.0

2.2

16.8

11.7

7.6

2.40.0

5.0

10.0

15.0

20.0

25.0

30.0

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2004

2001

Type 1-Integration

Type 2-Integration

Type 2-Non-Int.

Type 3a-Integration

Type 3a-Non-Int.*

Type 3b-Integration

Type 3b-Non-Int.

Total 1-3/Integration

Total 1-3/Non-Integration

Contraceptive Prevalence RateContraceptive Prevalence Rate- All modern methods, All Women 15-49 -- All modern methods, All Women 15-49 -

* Type 3a-Non-int. serves as comparison group for Types 1 and 3a - Integration

Pills(CBD)

Injectable(MOH)

MOH &CBD

Pills(CBD) ?

CBD &MOH MOH

High Access

2001 N = 10032004 N = 1360

47.7

53.4

54.6

51.2

53.3

46.3

54.8

69.5

64.5

62.0

38.1

42.5

38.6

33.7

46.9

52.4

51.9

46.3

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

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2004

2001

Type 1-Integration

Type 2-Integration

Type 2-Non-Int.

Type 3a-Integration

Type 3a-Non-Int.*

Type 3b-Integration

Type 3b-Non-Int.

Total 1-3/Integration

Total 1-3/Non-Integration

Prevalence of Stunting (z<2SD)Prevalence of Stunting (z<2SD)- Height for Age, Children under 5 -- Height for Age, Children under 5 -

* Type 3a-Non-int. serves as comparison group for Types 1 and 3a - Integration

2001 N = 8652004 N = 1132

89

7446

35

42

36

6674

6878

65

44

68

16

70

58

58

42

010203040506070

8090

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2001Type 1-Integration

Type 2-Integration

Type 2-Non-Int.

Type 3a-Integration

Type 3a-Non-Int.*

Type 3b-Integration

Type 3b-Non-Int.

Total 1-3/Integration

Total 1-3/Non-Integration

Tree Planting: EucalyptusTree Planting: Eucalyptus- All households -- All households -

* Type 3a-Non-int. serves as comparison group for Types 1 and 3a - Integration

2001 N = 9852004 N = 857

PHE must be seen in the context of PHE must be seen in the context of livelihood and food security, but is hardest livelihood and food security, but is hardest

to doto do• Half of the villages are only

connected by dirt track or foot path

• 40% of villages are 5-15 km away from the nearest market

• 4 in 5 households live well below the poverty line

• 3 in 4 households do not produce enough food to last an entire year

• NGOs and other partners have promoted cottage industry and income generation

• Data indicate that these activities are still at a small scale

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20.8

13.3

44.2

11.0

36.2

18.5

20.3

25.715.8

9.7

15.5

14.4

30.7

16.2

21.9

15.5

27.5

14.9

0.05.0

10.015.020.025.030.035.040.045.0

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2001

Type 1-Integration

Type 2-Integration

Type 2-Non-Int.

Type 3a-Integration

Type 3a-Non-Int.*

Type 3b-Integration

Type 3b-Non-Int.

Total 1-3/Integration

Total 1-3/Non-Integration

Food Security for an Entire YearFood Security for an Entire Year- All households -- All households -

* Type 3a-Non-int. serves as comparison group for Types 1 and 3a - Integration

2001 N = 9502004 N = 1148

37

29

46

31

35

15

48

3227

18

27

20

36

36

37

27

32

24

0

10

20

30

40

50

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2001Type 1-Integration

Type 2-Integration

Type 2-Non-Int.

Type 3a-Integration

Type 3a-Non-Int.*

Type 3b-Integration

Type 3b-Non-Int.

Total 1-3/Integration

Total 1-3/Non-Integration

Participation in Agricultural TrainingParticipation in Agricultural Training- All households -- All households -

* Type 3a-Non-int. serves as comparison group for Types 1 and 3a - Integration

2001 N = 9852004 N = 1271

Different mechanisms can successfully Different mechanisms can successfully implement Integrated PHEimplement Integrated PHE

• Integrated PHE program designed as a natural experiment

• Comparing three different organizational arrangements:– multidisciplinary teams within one

organization (the gold standard)– different health and environment

teams within the same organization

– field agents from different sector specific organizations—health, agriculture, environment working together

• All produced positive outcomes in some areas

• Differences explained by:– Available resources– Organizational capacity– Program focus– Cultural & economic situation RR776655443322 8811LLLL 99 1010 1111

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51.5

15.7

53.7

48.5

60.5

33.3

78.1

19.7

91.4

30.1

39.0

20.3

46.4

11.8

51.8

22.5

65.1

24.2

0.0

20.0

40.0

60.0

80.0

100.0

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20

01

20

04Type 1-Integration

Type 2-Integration

Type 2-Non-Int.

Type 3a-Integration

Type 3a-Non-Int.*

Type 3b-Integration

Type 3b-Non-Int.

Total 1-3/Integration

Total 1-3/Non-Integration

Use of Slash and Burn AgricultureUse of Slash and Burn Agriculture- All households -- All households -

* Type 3a-Non-int. serves as comparison group for Types 1 and 3a - Integration

2001 N = 9502004 N = 1147

Community-centered PHE fosters Community-centered PHE fosters participation, especially by womenparticipation, especially by women

• In integration communities women are more engaged in community groups and mobilization efforts

• Includes groups that are traditionally dominated by men such as farmers’ associations

• Women’s participation increased by 4 percent in integration communities to 33 percent

• It decreased by 5 percent in the non-integration group to 26 percent

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ChallengesChallenges• Does the integration of PHE

improve health and livelihood?

– Evidence shows that we are on the right track

– Achieving health and socioeconomic impact and measuring the impact is still the long-term focus

• Can development activities conserve ecosystems and biodiversity?

– Requires longer implementation and new evaluation methods

• Need more reliable environmental indicators and measurement tools

– Direct observation, visual impact evaluation

RecommendationsRecommendations

3. Proof that sustainable development and conservation of biodiversity are compatible

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1. Improve technical aspects of PHE integration

2. BuildVS and NGO organizational capacity