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Foundations of Success – Population-Health-Environment Conventional Wisdom

Conventional Wisdom on Causal Linkages among Population, Health, and Environment

Interventions and Targets

Prepared by: Caroline Stem

Richard Margoluis Foundations of Success (FOS)

4109 Maryland Avenue Bethesda, MD 20816

Tel (703) 764-8572 [email protected]

Prepared for USAID Healthy People, Healthy Planet Workshop

2004 World Conservation Congress

December 21, 2004


Table of Contents Introduction..................................................................................................................................... 1 What We Did .................................................................................................................................. 1 General Background ....................................................................................................................... 2 Causal Linkages .............................................................................................................................. 3 What You Will See in This Document ........................................................................................... 3

1. Model 1: Health/Population Interventions to Achieve Conservation Outcome ................. 4 Examples:................................................................................................................................ 4 Summary of Model 1 Indicators from the PHE Literature ................................................... 12

2. Model 2: Conservation Interventions to Achieve Health/Population Outcomes.............. 17 Examples:.............................................................................................................................. 17 Summary of Model 2 Indicators from the PHE Literature ................................................... 20

3. Model 3: Conservation or Health/Population Intervention to Directly Achieve Both Conservation and Health/Population Outcomes ....................................................................... 22

Examples:.............................................................................................................................. 23 Summary of Model 3 Indicators from the PHE Literature ................................................... 25

4. Model 4: Operational Linkages ........................................................................................ 26 Examples:.............................................................................................................................. 27 Summary of Model 4 Indicators from the PHE Literature ................................................... 30

Next Steps ..................................................................................................................................... 32 Literature Reviewed...................................................................................................................... 33 List of Chains: Chain 1-1. Generic Model – Health/Population Interventions to Achieve Conservation............... 4 Chain 1-2. General Health: Improving socio-economic situation .................................................. 5 Chain 1-3. General Health: Improving livelihood options ............................................................. 5 Chain 1-4. General Health: Improving livelihood options ............................................................. 6 Chain 1-5. General Health: Addressing immediate concerns......................................................... 6 Chain 1-6. Family Planning and Reproductive Health : Decreasing fertility ................................. 6 Chain 1-7. Family Planning and Reproductive Health : Decreasing fertility ................................. 7 Chain 1-8. Family Planning and Reproductive Health : Decreasing fertility ................................. 7 Chain 1-9. Family Planning and Reproductive Health: Decreasing fertility and improving

nutrition................................................................................................................................... 7 Chain 1-10. Family Planning and Reproductive Health: Empowering women.............................. 8 Chain 1-11. Child Survival: Reducing incentives to expand families ............................................ 8 Chain 1-12. Child Survival: Reducing incentives to expand families ............................................ 8 Chain 1-13. Child Survival: Reducing incentives to expand families ............................................ 9 Chain 1-14. Water and Sanitation: Improving water quality.......................................................... 9 Chain 1-15. Water and Sanitation: Improving animal health ......................................................... 9 Chain 1-16. Water and Sanitation: Improving agricultural productivity...................................... 10 Chain 1-17. Water and Sanitation: Reducing disease incidence................................................... 10 Chain 1-18. Medicinal Plants: Reducing disease incidence ......................................................... 10 Chain 1-19. Malaria Interventions: Improving water habitat ....................................................... 11 Chain 1-20. Malaria Interventions: Reducing disease incidence.................................................. 11


Chain 1-21. HIV/AIDS Interventions: Maintaining healthy populations of conservation workers and advocates ........................................................................................................................ 12

Chain 1-22. HIV/AIDS Interventions: Reducing disease incidence............................................. 12 Chain 2-1. Generic Model – Conservation Interventions to Achieve Health/Population............. 17 Chain 2-2. General Conservation: Improving water quality......................................................... 18 Chain 2-3. General Conservation: Improving water quantity....................................................... 18 Chain 2-4. General Conservation: Improving water quantity....................................................... 18 Chain 2-5. General Conservation: Improving land management ................................................. 19 Chain 2-6. General Conservation: Improving water (irrigation) management............................. 19 Chain 2-7. General Conservation: Protecting biodiversity ........................................................... 19 Chain 2-8. General Conservation: Protecting biodiversity ........................................................... 20 Chain 2-9. General Conservation: Protecting biodiversity ........................................................... 20 Chain 3-1. Generic Model – Conservation or Health/Population Interventions to Achieve Both

Conservation and Health/Population .................................................................................... 23 Chain 3-2. Water and Sanitation: Reducing disease incidence in humans and improving animal

health..................................................................................................................................... 23 Chain 3-3. Water and Sanitation: Improving water quality and reducing disease incidence ....... 24 Chain 3-4. Medicinal Plants: Raising environmental awareness and treating/preventing human

disease ................................................................................................................................... 24 Chain 3-5. Malaria Interventions: Preventing human-animal disease transmission..................... 25 Chain 3-6. HIV/AIDS Interventions: Preventing human-animal disease transmission................ 25 Chain 4-1. Generic Model – Implementation Efficiencies to Achieve Conservation and

Health/Population ................................................................................................................. 27 Chain 4-2. Generic Model – Building Community Goodwill to Achieve Conservation or

Health/Population ................................................................................................................. 27 Chain 4-3. Operational Linkages: Sharing program expenses...................................................... 28 Chain 4-4. Operational Linkages: Expanding target audience ..................................................... 28 Chain 4-5. Operational Linkages: Improving communication ..................................................... 29 Chain 4-6. Operational Linkages: Building trust.......................................................................... 29 Chain 4-7. Operational Linkages: Quid pro quo exchange........................................................... 29


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Introduction This document draws on existing literature regarding population, health, and environment (PHE) to summarize the main conceptual foundations under which practitioners are operating when they link population, health, and environment strategies and outcomes. The document is an initial response to USAID’s interest in identifying global or common indicators for PHE projects. Often, organizations want to jump straight to indicators as a way to show that their projects are effective. Indicators are certainly a key and necessary component to demonstrating project effectiveness. At Foundations of Success, however, we do not believe that identifying the “right” indicators for PHE projects is a simple matter of summarizing indicators in the PHE literature or brainstorming a laundry list of indicators. Rather, we feel it is important to think about indicators in the context of specific projects and consider how the projects intend to affect health or conservation outcomes. Doing so helps narrow down the nearly infinite number of potential indicators to a manageable set that is most relevant to a particular project or intervention. Thus, we have developed this paper as an input to the process of identifying indicators. The purpose of this paper is to summarize the conventional wisdom on how PHE practitioners and scholars believe different PHE interventions will lead to conservation or health outcomes. The document served as background material for those participating in the USAID-sponsored Healthy People, Healthy Planet Workshop at the 2004 World Conservation Congress in Bangkok. The intent was to encourage participants to think about their own experiences using PHE interventions and to identify, modify, or create results (causal) chains that best represent their work. We wanted project managers to think explicitly about cause and effect relationships related to their PHE interventions and to specify the intermediate changes that must occur in order to achieve their conservation or health outcomes. This would help them identify the key factors in the results chains that need to be measured to show predicted changes and identify possible indicators for those factors. This exercise is a first step in a longer process of adaptive management that will help managers determine if their interventions are succeeding and why or why not.

What We Did Working with staff from the Population Reference Bureau, we identified and reviewed key PHE references that included institutional literature (both published and unpublished), project reports, project monitoring and evaluation plans, workshop reports, and academic literature. We did not do an exhaustive literature search but rather tried to focus on known key references. We also limited our search to field-level interventions and did not address policy interventions. In areas where information tended to be lacking (e.g., malaria or HIV/AIDS interventions), we sought out specific sources and also consulted with key informants working in the area. The literature review focused on determining under what causal assumptions people were operating when they were making the case for PHE interventions. Some publications explicitly identified those assumptions, while others laid them out more implicitly. Based on the assumptions in the literature, we created 39 separate results chains that formally specified the


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logic behind various PHE interventions and the desired conservation or health outcomes. We analyzed these chains and the literature to identify four main models of PHE interventions:

1) Health/population interventions to achieve conservation outcomes; 2) Conservation interventions to achieve health/population outcomes; 3) Conservation or health/population interventions to achieve both health/population and

conservation outcomes; and 4) Operational linkages to achieve health/population and/or conservation outcomes.

We developed generic results chains for these four main models and then placed the 39 results chains under the most appropriate model. We also reviewed the literature for PHE indicators, including those that have been proposed as well as those that are actually in use. We drew from this group of indicators to identify potential indicators for the various results chains we developed. Each model includes a summary list of indicators available from the reviewed literature. The information presented here reflects the literature we reviewed. We have not passed judgment on the validity of the assumptions, nor have we proposed new chains that do not have grounding in the literature. Likewise, we have presented only the indicators we found. We do not judge the quality of those indicators nor have we suggested new or different indicators if they were not available in the literature we reviewed.

General Background The PHE literature makes many claims about the links (connections or relationships) between population, health, and the environment and the need to use integrated interventions or projects to achieve conservation and/or health-related outcomes. Despite these claims, there is little evidence of impact from PHE projects. Is this because there is no link among population, health, and environment? Probably not. Rather, we believe that those working in PHE have generally not clearly developed or documented how they believe their PHE interventions will lead to conservation or health outcomes (impacts). As a result, they are not collecting the right type of information that would provide evidence of impact. Moreover, if practitioners do consider how their PHE interventions should lead to conservation or health outcomes, they usually do so after the intervention is fully underway rather than before implementing an intervention. As a result, their interventions are not always the most appropriate for what they are trying to affect. Most evidence of impact from PHE projects is still anecdotal, and few projects look beyond traditional, sectoral indicators to measure their initiative’s success. As one report on a project in Madagascar states, “Evaluations have been more qualitative than quantitative and have produced equivocal results, sometimes showing that vertical programs are more effective. It appears that neither organizations dealing specifically with natural resource management nor those implementing health and population programs have taken a leadership role in addressing this knowledge gap.”1

1 Environmental Health Project. 2002. Integration of health, population and environment programs in Madagascar. Midterm progress report. Activity report 115.


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Causal Linkages As a first step to help practitioners define causal mechanisms underlying PHE projects, we have compiled a series of results chains for different population, health, and conservation interventions and targets. These are simple box and arrow chains that define the underlying causal logic behind various interventions – how people believe that the interventions they use will lead to a desired change. Results chains are an important tool for the monitoring and evaluation process because they provide the basis for showing progress toward goals and objectives. They also help practitioners identify where there may be obstacles that are preventing their interventions from achieving their intended impacts. In this document, we focus on the causal links between health/population interventions and conservation outcomes and vice-versa, as these are relationships that generally have not been clearly defined or documented. We, however, do not attempt to specify the many causal links between conservation interventions and conservation outcomes, or health interventions and health outcomes. These relationships are beyond the scope of this report and, for the most part, already well-documented in the literature for each field. Nevertheless, when developing full results chains for their interventions, practitioners should include these relationships so that they can see if they are making progress from both a sectoral (vertical) and linked (integrated) perspective. To indicate the intentional omission of causal links, we have used ellipses (…) in the models. In many cases, projects will be operating – implicitly or explicitly – under several of these results chains. Moreover, there may be other causal mechanisms or external influences that we have not addressed here. Our intent in preparing this document, however, was to provide a representative – not exhaustive – presentation of the most commonly-mentioned causal relationships in the literature.

What You Will See in This Document In this document, we have described four main models for population, health, and environment interventions and outcomes: 1) Health/population interventions to achieve conservation outcomes; 2) Conservation interventions to achieve health/population outcomes; 3) Conservation or health/population interventions to achieve both health/population and conservation outcomes; and 4) Operational linkages to achieve health/population and/or conservation outcomes. For each model, we provide a general results chain that lays out graphically common assumptions about how an intervention influences various factors to reduce threats and lead to the desired long-term conservation or population/health outcome. The following figure is a generic version of these chains. All chains use the same symbols as shown in this generic model: 1) Hexagon for intervention (the strategy or activity a project is using); 2) Rectangle for the influences on factors, which could include both threats and opportunities; and 3) Circle for long-term outcomes (also commonly referred to as impacts or results) that one is trying to achieve through an intervention or series of interventions.


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Figure 1. Generic Results (Causal) Chain

1. Model 1: Health/Population Interventions to Achieve Conservation Outcome

PHE interventions that fall under Model 1 involve a health or population intervention that is assumed to improve conservation directly or indirectly, through improving health (Chain 1-1). In the following paragraphs, we provide examples of specific population or health interventions and how practitioners assume that these interventions will lead to improved conservation. Chain 1-1. Generic Model – Health/Population Interventions to Achieve Conservation

Examples:

General health: Improving socio-economic situation Although different population and health interventions can lead to conservation through different causal mechanisms, all have in common the causal links stemming from improved health: an improved socio-economic situation, greater livelihood options, and the ability to consider other needs now that the most immediate health needs have been met. To avoid repetitious discussions of these links under each separate health intervention, we have summarized these main general causal relationships here and in the following two sections. One argument for using health interventions to achieve conservation is that healthy people are better able to participate in all aspects of society, including the productive sector. As a result, they are presumably better able to provide for themselves and, as indicated in Chain 1-2, their improved socio-economic situation will reduce poverty. It is assumed they will then extract fewer resources because their basic needs are already met. This will reduce resource degradation and result in conservation. A reduction in poverty is also likely to discourage migration to other areas because the family’s home offers the economic opportunities to be able to sustain them.


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As a result, less land is cleared for new settlements and fewer resources are needed or extracted from these areas, ultimately reducing degradation and improving conservation. Chain 1-2. General Health: Improving socio-economic situation

General health: Improving livelihood options A similar, but slightly different justification is that improved health offers more livelihood options, including more environmentally-friendly employment opportunities. Thus, people are able to decrease their involvement in environmentally-destructive practices and reduce resource extraction and degradation. Chain 1-3. General Health: Improving livelihood options

Likewise, the improved opportunities at home make them less likely to migrate to other areas that may be fragile, overpopulated, and/or unsuitable for the land management practices they are accustomed to using. The migration prevented reduces the opening up of new areas and associated resource use and extraction, thus reducing degradation and improving conservation.


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Chain 1-4. General Health: Improving livelihood options

General health: Addressing immediate concerns Conventional wisdom throughout the health, development, and environment literature is that people cannot begin to think about environmental issues when they have much more immediate needs, such as health care and feeding their families. Thus, by improving health (as shown in Chain 1-5), people have time to think about less immediate concerns, like the environment. If they are concerned about the environment, they will be likely to reduce their resource use and extraction, leading to reduced degradation and improved conservation. Chain 1-5. General Health: Addressing immediate concerns

Family planning and reproductive health: Decreasing fertility The quintessential population-environment relationship is outlined in Chain 1-6. The basic premise is that family planning and reproductive health services help families reduce their size, which, at a broader level, leads to lower fertility rates. With fewer people, there will be less demand on the earth’s resources, and the environment will be better off. Many practitioners, however, have chosen not to emphasize this link in their field work, as it is less meaningful to the people in their target area because the scale is too large and the immediate benefits to families are not very clear. Chain 1-6. Family Planning and Reproductive Health : Decreasing fertility

Instead, practitioners have chosen to focus on links that are directly relevant to people on the ground, such as those elaborated in the following chains. Essentially, family planning provides direct benefits to families because it can help them limit their family size, allowing them to


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provide more resources and a better quality of life to a smaller family unit. Ultimately, this reduces stress on the family and poverty overall. The assumption is then that if people are not as poor, they will not need to exploit their resources as much, they will not be motivated to move to and clear new areas, and their overall resource exploitation will decrease, thus reducing degradation and improving conservation. Chain 1-7. Family Planning and Reproductive Health : Decreasing fertility

Chain 1-8. Family Planning and Reproductive Health : Decreasing fertility

There is also an indirect link in this relationship that operates through a link between more resources being available to a smaller family unit and improved nutrition and health (Chain 1-9). The general relationships between improved health and improved conservation are detailed in the general health interventions section. Chain 1-9. Family Planning and Reproductive Health: Decreasing fertility and improving nutrition2

Family planning and reproductive health: Empowering women Another rationale behind family planning and reproductive health services as conservation interventions is that when women have access to these services, they are empowered to manage their own child bearing and that sense of empowerment transfers to other aspects of their lives, including natural resource management. The belief is that if they feel more empowered, they will take more responsibility for caring for their resources, and this will lead to less or better resource use and reduced degradation.

2 This chain could also arguably fit under Model 3 because of the early and direct impact on health outcomes. We have put it here, however, because improving health is a necessary condition for improving conservation, so the link to conservation is less direct than other examples under Model 3.


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Chain 1-10. Family Planning and Reproductive Health: Empowering women

Child survival: Reducing family size PHE interventions to improve child survival and conservation are generally based on the premise that couples will be less inclined to have extra children if they can be sure that those they have will survive into adulthood. The causal relationships (depicted in the figures below) are similar to those under family planning and reproductive health in that through child survival interventions, family sizes and fertility rates decline. The changes that follow these declines in family size are the same, regardless of the intervention that caused the decline. Chain 1-11. Child Survival: Reducing incentives to expand families

Chain 1-12. Child Survival: Reducing incentives to expand families


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Chain 1-13. Child Survival: Reducing incentives to expand families3

Child survivalintervention

Reduceexpansion of

family

Fewer peopleto support

More resources(incl. food)available to

family

Improvenutrition

Improve childsurvival rates

Improvedconservation

Improvedhealth

Note: Refer to general health interventions chains for common causal links between improved health & improved conservation

...

Water and sanitation: Improving water quality There is a very direct and simple relationship between water and sanitation interventions and improved conservation. Essentially water and sanitation interventions improve the quality of natural water bodies and, therefore, conservation, because domestic wastes are not entering these water bodies. Chain 1-14. Water and Sanitation: Improving water quality


Water &sanitation

interventions

Improve qualityof natural water

bodies

Reducedomestic wastereaching water

bodies

Water and sanitation: Improving animal health Similar to the relationship described above, the improved quality of natural water bodies also provides a more hospitable environment for aquatic organisms, thus improving their health and abundance as well as the health and abundance of other animals that feed off of these organisms or the water itself. This improved animal health leads to improved conservation. Chain 1-15. Water and Sanitation: Improving animal health

Water and sanitation: Improving agricultural productivity PHE practitioners also reason that water and sanitation interventions improve conservation less directly by increasing water flows, which improves agricultural productivity and increases food resources available to a family. This helps families improve their nutrition and health, and this 3 As with Chain 1-9, this chain could possibly go under Model 3 because of the early and direct impact on health outcomes. We have put it under Model 1 because improving health is a necessary condition for improving conservation. Thus, the link to conservation is less direct than other examples under Model 3.


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improved health leads to improved conservation, as further detailed in the section on general health interventions to achieve conservation. Chain 1-16. Water and Sanitation: Improving agricultural productivity

Water and sanitation: Reducing disease incidence Water and sanitation interventions also help people improve their hygiene practices, which reduces disease incidence and improves people’s health, and ultimately improves conservation Chain 1-17. Water and Sanitation: Reducing disease incidence

Water &sanitation

interventions

Reduceincidencediseases

Improvehygienepractices



Improvedhealth ...

Medicinal plants: Reducing disease incidence Similarly, medicinal plant harvesting and cultivation are believed to affect conservation through improving the health of local people. The plants provide alternatives for treating or preventing disease and help reduce disease incidence. A healthy population is able to better care for its environment for several reasons, as noted under the general health interventions discussed earlier in this section. Thus, conservation is ultimately achieved. Chain 1-18. Medicinal Plants: Reducing disease incidence

Reduced diseaseincidence

Medicinal plantharvesting &

cultivation

Plants used totreat or prevent

disease



Improvedhealth ...

Malaria prevention: Improving water habitat One strategy to prevent malaria is to improve irrigation systems so that standing pools of water, where malarial mosquitoes can breed, are eliminated. By improving irrigation systems and reducing overall water usage, this anti-malarial intervention can also increase stream flows, improving the quality of natural water bodies, which serve as important habitat for aquatic


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organisms. This leads to the improved health and abundance of these aquatic organisms, as well as the animals that feed upon them, thus improving animal health and conservation overall. Chain 1-19. Malaria Interventions: Improving water habitat

The PHE literature also makes reference to environmental management as a way to reduce malaria. In addition to improved irrigation schemes, this includes primarily filling in or draining standing pools of water. We do not see this necessarily as a contribution to conservation. In fact, some anti-malarial environmental interventions involve altering wetland habitat important for other animals. For this reason, we have not included a results chain depicting this relationship.

Malaria prevention: Reducing disease incidence Another way PHE practitioners believe malarial prevention may lead to improved conservation is through its effect on improving health. Successful interventions will help reduce the incidence of malaria and improve the health of local populations. If these populations are healthy, they will be more able to contribute to improving conservation in the ways discussed in the general health interventions section. Chain 1-20. Malaria Interventions: Reducing disease incidence

HIV/AIDS prevention: Maintaining healthy populations of conservation workers and advocates In places like Africa, the AIDS epidemic has had a devastating impact on several sectors of society. The continent is quickly losing its work force, and conservation workers are not immune to this trend. Some conservation practitioners reason that HIV/AIDS interventions can help reverse this trend by reducing disease incidence, including among conservation staff and advocates. If these countries can hold on to those people who have been moving conservation forward, they will be able to maintain their conservation programs and advocacy, thus improving conservation.


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Chain 1-21. HIV/AIDS Interventions: Maintaining healthy populations of conservation workers and advocates

HIV/AIDS prevention: Reducing disease incidence PHE workers also promote HIV/AIDS interventions because they believe that by reducing the incidence of HIV/AIDS, health will improve and, ultimately, conservation will improve – as described in the general health interventions section above. Chain 1-22. HIV/AIDS Interventions: Reducing disease incidence

Summary of Model 1 Indicators from the PHE Literature Most PHE publications we reviewed do not present potential indicators in relation to the causal mechanisms the interventions are designed to affect. Some publications, however, do discuss indicators and the need to identify appropriate, relevant indicators for PHE work. In Table 1, we present a summary of indicators we found in the PHE literature that could be used for the various factors found in the chains under Model 1. Table 1. Indicators from PHE Literature related to Model 1

Factor* Indicators

Ability to think about less immediate concerns

Awareness of plants’ medicinal importance

Decrease # mosquitoes carrying malaria

Decrease total fertility rates Total fertility rate

Contraceptive prevalence rate

Decrease use of environmentally destructive practices # poaching incidents

Deforestation rate

# apprehensions for illegal fishing/logging

Discourage migration to fragile areas # men/women migrating seasonally

Migration into regions in/near critical ecosystems

Migration out of regions in/near critical ecosystems

Urban population growth

Rural population growth


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Factor* Indicators

Fewer people to feed & support

Improve agricultural productivity Adoption rate of new agricultural techniques

Yield per hectare

# new production practices implemented

Amount of production for subsistence consumption

Amount of production for market

Improve animal health # endemic species (including bird, plant, mammal, reptile, amphibian)

Improve child survival Infant mortality rate

Under five mortality rate

% of alive births under 2.5 kg

% fully immunized infants (12-23 months)

Children’s complete vaccination coverage rate

% infants exclusively breastfed

Proportion of children under 5 with normal height for age

Proportion of children without diarrhea

Low birth-weight newborns

Improve conservation Will vary by conservation target defined by project (e.g., population in numbers of key indicator species, hectares of habitat preserved)

Improve health & abundance of aquatic organisms # change in fish abundance/coral cover

Improve (human) health Will vary by health target defined by project (e.g., mortality rate, morbidity rate)

Improve hygiene practices # families practicing proper garbage disposal

# families using latrine

Improve irrigation & agricultural management Adoption rate of new production techniques

Adoption rate of new agricultural techniques

Total surface area cultivated by slash & burn

Proportion of households admitting use of slash & burn practices

# households adopting new environmental conservation techniques

Square meters of land protected by soil and water conservation

# farmers using soil conservation

# farmers using green manure

# irrigation systems installed

# communities or families with access to irrigation

Improve livelihood options

Improve maternal & child health Maternal mortality rate

Infant mortality rate

Under five mortality rate


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Factor* Indicators

% of alive births under 2.5 kg

% fully immunized infants (12-23 months)

Children’s complete vaccination coverage rate

% infants exclusively breastfed



# prenatal visits during last pregnancy

Low birth-weight newborns

Improve natural resource management Adoption rate of new production techniques






# farmers using soil conservation

# farmers using green manure

# communities with successful mangrove management system

Improve nutrition % households with underweight preschoolers

% of human population that is under-nourished

Proportion households claiming year-round sufficient food production


Improve quality of natural water bodies Access to potable water

Percentage of population with access to safe water

# communities, people, or families with access to safe drinking water

Improve socio-economics % of households with additional income

% households better off than 5 years ago

Wealth index (e.g., see EHP Activity Report 115 for Madagascar)

Household educational level

House quality index (EHP report)

# bedrooms

Ownership of luxury item

Ownership of at least one cow

Access to arable land ≥ 250 acres

Increase concern for environment Demand for environmental information

Increase employment opportunities in environmentally


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Factor* Indicators

friendly sectors

Increase or maintain stream flows

Increase space between births

Increase water flows Water stress

Average annual internal water resources available per capita


Less resource extraction/use # poaching incidents

Deforestation rate


Length of time & distance walked fetching fuelwood

Maintain conservation programs & advocacy

More resources available to family % of households with additional income

% households better off than 5 years ago

Wealth index (e.g., see EHP Activity Report 115 for Madagascar)

Household educational level

House quality index (EHP report)

# bedrooms

Ownership of luxury item

Ownership of at least one cow

Access to arable land ≥ 250 acres

Plants used to treat or prevent disease

Reduce clearing of new areas Deforestation rate

Forest cover

Cropland per capita

Reduce degradation Deforestation rate

Forest cover

Cropland per capita


% preserved areas

% cultivated areas

Hectares reforested

Reduce demand/need for resources Length of time & distance walked fetching fuelwood

Reduce disease incidence Prevalence of diarrhea


Reduce disease transmission between animals

Reduce domestic wastes reaching water bodies # of families practicing proper garbage disposal

# of families using latrines

Reduce expansion of family (family size) Total fertility rate


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Factor* Indicators


Couple years of protection

# new family planning acceptors

# continuing family planning acceptors

% youth (15-24) reporting unintended pregnancy

# children desired

Reduce family size Total fertility rate


Couple years of protection

# new family planning acceptors

# continuing family planning acceptors

% youth (15-24) reporting unintended pregnancy

# children desired

Reduce human-animal disease transmission

Reduce incidence diseases Prevalence of acute respiratory infections

Reduce incidence of HIV/AIDS in humans

Reduce incidence water-borne diseases Prevalence of diarrhea


Reduce loss of conservation staff & advocates

Reduce malaria incidence

Reduce poverty Poverty rate

Gross domestic product per capita

(see also socio-economic indicators)

Reduce quantity of water used for agriculture Square meters of land protected by soil and water conservation

Slow population growth Population growth rate – natural increase

In-migration rate

Out-migration rate

Urban population growth

Rural population growth

Total population

Population density

View health as dependent upon biodiversity

Women empowered to manage child-bearing Perceived level of self-esteem

Perceived level of empowerment

Women more able to manage other areas of lives Perceived level of self-esteem

Perceived level of empowerment

* The factors listed indicate the desired direction of the relationships. Technically, however, the actual variables would not show direction (e.g., the variable would be “health status,” not “improved health” or “agricultural yields,” not “improve agricultural yields.”)


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2. Model 2: Conservation Interventions to Achieve Health/Population Outcomes

The main emphasis of this review is on how population and health interventions can help achieve conservation goals. This emphasis reflects the fact that most of the interventions used are population/health interventions to achieve conservation goals. Nevertheless, it is important to recognize that the relationship between population, health, and the environment is more circular, rather than linear. Population and health interventions can have a positive influence on the environment. Likewise, conservation interventions lead not only to a healthy environment, but also to healthier families and populations. In this section we explain some of the general mechanisms behind this relationship, as presented in the PHE literature. Specifically, those include: improving water quality, improving resource (land and water) management, and protecting biodiversity. As in the general health interventions discussion, we do not discuss the causal mechanisms between conservation interventions and conservation outcomes. We assume these are well documented in the conservation literature and, thus, we focus on the less-documented relationships between conservation interventions and population or health outcomes. Practitioners developing results chains, however, would want to be more specific about how their conservation interventions lead to both conservation and health outcomes. We use ellipses (…) to indicate where we have omitted a more detailed portrayal of causal relationships. As shown in Chain 2-1, the general relationship for Model 2 is that a PHE project uses a conservation intervention that contributes to improving conservation, and this improvement in conservation then leads to an improvement in human health. Chain 2-1. Generic Model – Conservation Interventions to Achieve Health/Population


ConservationIntervention

Improvedhealth

Examples:

General Conservation: Improving water quality and quantity One of the most conceptually clear relationships between biodiversity health and human health can be seen in the impact from clean water services provided by healthy ecosystems. Humans need water to survive and to function, and a healthy ecosystem helps guarantee that water of sufficient quality and quantity reaches populations downstream. Chain 2-2 shows that conservation interventions can lead to improved water quality, which reduces the incidence of water-borne diseases among humans. This can have a direct impact on health, but it also affects health indirectly through improved nutrition and an improved socio-economic situation that allows people to invest in health care.


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Chain 2-2. General Conservation: Improving water quality

Healthy ecosystems can also increase the amount of water available to downstream users. Chain 2-3 shows that more water will lead to improved agricultural yields, improved nutrition, and an improved socio-economic situation, all of which ultimately results in improved health. Chain 2-3. General Conservation: Improving water quantity

Likewise, water conservation interventions increase the quantity available for domestic use and sanitation. This improves hygiene, reduces the incidence of disease transmission, and improves nutrition, socio-economic status, and health. Chain 2-4. General Conservation: Improving water quantity

General Conservation: Improving resource management Conservation interventions often promote best management practices. Here, we present a chain for a conservation intervention to improve land management, although this could easily be adapted for other areas, such as fisheries. In essence, as shown in the figure below, conservation-oriented interventions such as agroforestry practices are designed to improve the


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way the land is managed for conservation as well as for production. The assumption is that this leads to improved agricultural yields which will increase incomes and also provide more food for a family and, therefore, improve nutrition. Improved nutrition leads directly to improved health, while improved socio-economic status provides a family with additional resources, some of which can now be invested in health care – an investment that will lead to improved health. Chain 2-5. General Conservation: Improving land management

Likewise, some conservation best management techniques promote improved irrigation systems that reduce the amount of water used for irrigation purposes, thus reducing standing pools where vectors breed. The decrease in breeding sites reduces the spread of vector borne diseases, resulting in improved health. Chain 2-6. General Conservation: Improving water (irrigation) management

General Conservation: Protecting biodiversity Conservation interventions oriented toward protecting biodiversity increase the natural resources available, providing local communities with more opportunities for sustainable harvesting. It is assumed these communities will improve their socio-economic situation from the increased income related to sustainable harvesting and thus have more money to invest in health care which will help them to improve their health. Chain 2-7. General Conservation: Protecting biodiversity


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Protecting biodiversity also increases or maintains the natural source of many traditional remedies which can be used to treat or prevent illness and help improve the health of local populations. Chain 2-8. General Conservation: Protecting biodiversity

Finally, protecting wild plants and animals increases the availability of wild foods which can supplement the diets of local populations and improve both their nutrition and health. Chain 2-9. General Conservation: Protecting biodiversity

Summary of Model 2 Indicators from the PHE Literature Table 2 presents a summary of indicators we found in the PHE literature that could be used for the various factors found in the chains under Model 2. Table 2. Indicators from PHE Literature related to Model 2

Factor* Indicators

Greater natural resource availability Total reforested surfaces # trees planted # planted trees surviving for set minimum time Length of time & distance walked fetching fuelwood

Improve agricultural yields Amount of production for subsistence consumption Amount of production for market Crop yields per hectare % households with additional agricultural production Proportion households claiming year-round sufficient food production


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Factor* Indicators

Improve capacity to absorb nutrients

Improve health Will vary by health target defined by project (e.g., mortality rate, morbidity rate)

Improve hygiene # families practicing proper garbage disposal # families using latrines

Improve irrigation systems Square meters of land protected by soil and water conservation

# irrigation systems installed

# communities or families with access to irrigation

Improve land management # farmers using soil conservation # farmers using green manure Square meters of land protected by soil & water conservation Number & size of areas under improve management Cropland per capita Adoption rate of new production techniques






Improve nutrition % households with underweight preschoolers % of human population that is under-nourished Proportion households claiming year-round sufficient food production Proportion of children under 5 with normal height for age

Improve socio-economics % of households with additional income % households better off than 5 years ago Wealth index (e.g., see EHP Activity Report 115 for Madagascar) Household educational level House quality index (EHP report) # bedrooms Ownership of luxury item Ownership of at least one cow Access to arable land ≥ 250 acres


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Factor* Indicators

Improve water quality Access to potable water Percentage of population with access to safe water # communities, people, or families with access to safe drinking water Proportion of children without diarrhea # drinking water systems installed

Improve water quantity Length of time and distance walked fetching water

Increase availability of traditional medicines

Increase availability of wild foods

More resources available for & invested in health care

# clinic visits # pregnant women receiving prenatal care % households with young children purchasing & actively using child health & mother cards

More water for domestic use & sanitation Length of time and distance walked fetching water # communities, people, or families with access to safe drinking water

Potential for sustainable harvesting

Protect biodiversity (plants & animals) # poaching incidents Species counts Protection status of forest Hectares of forest cover planted

Reduce incidence disease transmission

Reduce incidence water-borne diseases Prevalence of diarrhea Proportion of children without diarrhea

Reduce vector breeding sites

Reduce vector-borne diseases

Reduce water run-off/wasted Square meters of land protected by soil and water conservation

Use of plants to treat/prevent illness

3. Model 3: Conservation or Health/Population Intervention to Directly Achieve Both Conservation and Health/Population Outcomes

The third general model that PHE practitioners are using involves a conservation or a population/health intervention that has a direct impact on both improving health and improving


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conservation. In Models 1 and 2, both health and conservation may be improved through a PHE intervention. The main distinction between those models and Model 3, however, is that, in Models 1 and 2, the achievement of one outcome (e.g., improved health) is a requisite intermediate result for achieving the other outcome (e.g., improved conservation). In Model 3, a population/health or an environment intervention influences both health and conservation outcomes directly, independent of any relationship between health and conservation outcomes. As show in Chain 3-1, the generic relationship for Model 3 is that a PHE project uses either a conservation or a health/population intervention. That intervention leads to improvements in intermediate health and conservation outcomes and ultimately results in both improved health and improved conservation. Chain 3-1. Generic Model – Conservation or Health/Population Interventions to Achieve Both Conservation and Health/Population

Improvementstoward health &

conservation

Conservation orHealth/PopIntervention

Improvedhealth


Examples:

Water and sanitation: Reducing disease incidence in humans and improving animal health As discussed earlier in Chain 1-15, improved water quality can improve animal health through improving the quality of water bodies and the health and abundance of aquatic organisms. The following chain shows that improved water quality also can have a less direct impact on animal health by reducing the incidence of water-borne diseases among humans and animals and reducing the possibility of disease transmission to or between animals. This improves animal health and conservation in general. Chain 3-2. Water and Sanitation: Reducing disease incidence in humans and improving animal health


Water &sanitation

interventions

Improve animalhealth

Reducedisease

transmission to/betw. animals

Reduceincidence

water-bornediseases


bodies


bodies

Improved(human)health


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Likewise, a minor variation in the above chain emphasizes that improving the quality of natural water bodies also has a direct impact on improving conservation. Chain 3-3. Water and Sanitation: Improving water quality and reducing disease incidence

Water &sanitation

interventions

Reduceincidence

water-bornediseases


bodies


Improvedhealth



bodies

Medicinal Plants: Raising environmental awareness and treating/preventing human disease Medicinal plant harvesting and cultivation help raise awareness of plants’ medicinal importance because people see their value as a resource for treating or preventing disease. People receive a direct benefit of improved health, and they begin to see a clear connection between their health and biodiversity health. If they want to maintain natural stocks of that plant, they realize they need to protect their environment and reduce or improve resource extraction or use, which will help reduce degradation and improve conservation. Chain 3-4. Medicinal Plants: Raising environmental awareness and treating/preventing human disease

Malaria Interventions: Preventing human-animal disease transmission Malarial interventions can lead to direct improvements in human health through a reduced incidence of malaria in humans. That reduced incidence in humans also leads to a reduction in possibilities of transferring malaria from humans to animals. The logic then holds that animal health improves, and conservation is achieved.


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Chain 3-5. Malaria Interventions: Preventing human-animal disease transmission

Reducehuman to

animal diseasetransmission

Malariaintervention

Reducemalaria

incidence inhumans


Improveanimal health


HIV/AIDS Interventions: Preventing human-animal disease transmission The same general logic for malarial interventions holds for HIV/AIDS interventions and infectious disease interventions in general – namely, that animal health can improve by reducing disease incidence in humans. The reduced incidence of disease in humans leads to a direct improvement in human health, as well as reduces the opportunities for animals to be exposed to diseases transmittable by humans. Animal health would improve as a result, ultimately leading to improved conservation. Chain 3-6. HIV/AIDS Interventions: Preventing human-animal disease transmission

Reducehuman to

animal diseasetransmission

HIV/AIDSintervention

Reduce HIV/AIDS

incidence inhumans


Improveanimal health



Factor* Indicators

Awareness of plants’ medicinal importance

Improve animal health # endemic species (including bird, plant, mammal, reptile, amphibian)


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Factor* Indicators


Improve (human) health Will vary by health target defined by project (e.g., mortality rate, morbidity rate)

Improve quality of natural water bodies Access to potable water


# communities, people, or families with access to safe drinking water

Increase concern for environment Demand for environmental information

Less resource extraction/use # poaching incidents

Deforestation rate


Plants used to treat or prevent disease

Reduce degradation Deforestation rate

Forest cover

Cropland per capita


% preserved areas

% cultivated areas

Hectares reforested

Reduce disease transmission to/between animals

Reduce domestic waste reaching water bodies # of families practicing proper garbage disposal

# of families using latrines

Reduce HIV/AIDS incidence in humans

Reduce human to animal disease transmission

Reduce incidence water-borne diseases Prevalence of diarrhea


Reduce malaria incidence in humans

View health as dependent upon biodiversity

4. Model 4: Operational Linkages Many project documents refer to the benefits of linking population, health, and environment interventions from a programmatic standpoint. They claim that linking these interventions helps make programs more efficient and garner community goodwill. In reality, this could be said of linking just about any development interventions. These sorts of operational linkages are not unique to population, health, and environment initiatives. Nevertheless, because these links are


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so often cited in the literature, we felt it was important to present the hypothesized causal mechanisms behind these operational linkages. One of the frequently-mentioned rationales behind linking PHE interventions and targets is that doing so makes good programmatic sense. It helps make programs more efficient because they are able to simultaneously share operating expenses, expand target audiences, and improve communication between programs. All of these are seen as bringing important benefits that could not be achieved through traditional vertical approaches. Chain 4-1 provides a generic representation of this type of relationship. By combining conservation and population/health interventions, organizations or programs are able to share their efforts and costs. As a result, they are able to improve their efficiency and achieve both their desired health and conservation outcomes. Chain 4-1. Generic Model – Implementation Efficiencies to Achieve Conservation and Health/Population

The PHE literature also mentions that PHE interventions can help build community goodwill because projects are able to provide services that communities request or need. By meeting peoples’ needs, PHE projects are able to build trust. This trust helps secure community or individual engagement in conservation or health/population projects, which ultimately leads to improvements in conservation or health. Chain 4-2. Generic Model – Building Community Goodwill to Achieve Conservation or Health/Population

Engagement inconservation or

health/population

Intervention tosatisfy community

needs


or health

Improvedgoodwill/trust

Examples:

Operational linkages: Sharing program expenses Much of the PHE literature argues that linking PHE interventions makes good economic sense. If programs can carry out their activities jointly, they can share many of the fixed operational costs (e.g., infrastructure, staff time, field travel, etc.) and reduce costs overall to both programs. This frees up resources to invest in additional activities, which allows the programs to expand


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their reach. With an expanded reach, more people are aware of PHE issues and more people will participate in PHE interventions. Those who participate in these interventions will be able to both improve their health and the health of the environment that surrounds them. Chain 4-3. Operational Linkages: Sharing program expenses

Operational linkages: Expanding target audience A related argument is that carrying out PHE activities jointly allows programs to expand their target audience. This may be through reduced costs and increased resources, as described above. It may also happen when a program with little experience working in one area is able to partner with another program that has an in-depth knowledge of and an established presence and trust within a community. The new program can take advantage of the established partner’s relationship with the community and more easily tap into that target audience, thus expanding their programmatic reach and expanding the number of people aware of and participating in PHE activities. These PHE activities will presumably lead to improvements in health and conservation, as discussed in the results chains from earlier sections. Chain 4-4. Operational Linkages: Expanding target audience

Operational Linkages: Improving communication Carrying out joint PHE activities can also contribute to programmatic efficiency by improving communication and information sharing between programs. This helps improve coordination and collaboration, and partners will take on greater responsibility of being the “eyes and ears” for one another. They will be able let one another know of opportunities, as well as any potential problems – information that will help partners expand the reach of their program and ultimately increase participation in PHE activities.


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Chain 4-5. Operational Linkages: Improving communication

Operational Linkages: Building trust Many conservation organizations find it difficult to promote their agendas in communities where conservation is not the number one priority. They find that they must also help communities address important, immediate needs if they wish to get them to participate in conservation interventions. Essentially, they need to show that they are interested in community wellbeing in order for communities to accept their conservation projects. Once the community accepts and trusts the project, they will participate in the conservation interventions and will become more committed to conservation. As a result they will use few resources or use them more wisely, leading to reduced degradation and improved conservation. Chain 4-6. Operational Linkages: Building trust

Operational Linkages: Quid pro quo exchange A quid pro quo exchange is similar to the trust-building mechanism but is less focused on building commitment to conservation. Instead, this is more of a barter arrangement where a conservation organization might provide a community with social or health services to help meet their needs. In exchange, the community agrees to participate in conservation interventions that will reduce or improve their resource use, thus reducing degradation and improving conservation. Chain 4-7. Operational Linkages: Quid pro quo exchange


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Factor* Indicators

Commitment to conservation

Community agrees to quid pro quo exchange

Community trusts/accepts conservation project Community image of project Community respect for extension agents Community acceptance/perception of host agency Community acceptance/perception of host agency activities Perceptions/receptivity to organization’s work by communities Level of trust/confidence within communities

Expand reach of each program # projects or initiatives started as result of formal or informal idea exchange # people in target audience # new activities initiated

Improve communication & information exchange between programs

Frequency of communication Sharing of data & institutional knowledge of target area


Improve health Will vary by health target defined by project (e.g., mortality rate, morbidity rate)

Increase coordination & collaboration Demand for partnerships from other organizations Expansion of linked programs to other regions Partners’ level of participation in areas outside their expertise Level of coordination in typically sectoral agencies Participation by other institutions in PHE initiative Sharing of data and institutional knowledge of target area Projects started as result of formal or informal idea exchange


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Factor* Indicators

Less resource use/extraction # poaching incidents Deforestation rate # apprehensions for illegal fishing/logging Length of time & distance walked fetching fuelwood

More people aware of P,H, &/or E issues # community members with adequate knowledge of PHE links Demand for information on PHE issues Changes in knowledge or attitudes regarding PHE issues

More people participating in P,H, &/or E issues # new family planning acceptors citing environment as one of the reasons for family planning # people participating in PHE activities (& from what groups) Adoption of promoted services (compare to sectoral)

More resources available for other activities # new activities initiated

Participation in conservation interventions Proportion of households with members participating in community groups (in this case, should be conservation groups or projects)

Partners act as “eyes & ears” for one another # people reached through referrals from partner staff Projects started as result of formal or informal idea exchange

Project shows interest in community wellbeing

Reduce costs Money saved, as compared to sectoral approach

Reduce degradation Deforestation rate Forest cover Cropland per capita Length of time & distance walked fetching fuelwood % preserved areas % cultivated areas Hectares reforested

Share operational expenses Money saved, compared to sectoral approach

Take advantage of established knowledge of & trust within community

Tap into target audience of two or more programs

# people reached through referrals from partner staff


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Next Steps In this paper, we have drawn on the existing PHE literature to present numerous results chains that represent general relationships behind strategies to link population, health, and environment. We have done this to stimulate thought among participants in the Bangkok Healthy People, Healthy Planet Workshop about the specific PHE interventions they are using and what causal assumptions underlie these interventions. Workshop participants should use this reference document as a starting point to develop more detailed and specific results chains that represent what they are doing in their sites and to start identifying indicators that could be used to measure each factor in the chain to show progress toward the final conservation (and health) goals.


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Literature Reviewed Ali, R. (2004). Conservation and health: A case study in Borneo. Cultural Survival Quarterly

(28.2).

Ali, R. (No Date). The Orangutan Rainforest Health Initiative: Linking health and conservation in Borneo and Sumatra. Powerpoint presentation.

Anderson, G. W., L. Gaffikin, et al. (2004). Assessment of the Lake Tanganyika Catchment, Reforestation and Education (TACARE) project, Jane Goodall Institute.

Carr, D. L. (2004). "Proximate population factors and deforestation in tropical agricultural frontiers." Population and environment 25 (6): 585-612.

Castro, J. R., L. A. D'Agnes, et al. (2004). Mainstreaming reproductive health and integrated coastal management in local governance: The Philippines experience. Makati City, Philippines, PATH Foudnation Philippines Inc. (PFPI).

Engelman, R. (1998). Plan and conserve: A source book on linking population and environmental services in communities. Washington, DC, Population Action International.

Engelman, R. and P. LeRoy (1995). Conserving land: Population and sustainable food production. Washington, DC, Population Action International.

Environmental Health Project (2001). Linking health, population, and the environment in Madagascar. EHP Brief (2).

Environmental Health Project (2002). Integration of health, population, and environment programs in Madagascar: Midterm progress report. Washington, DC, Environmental Health Project.

Environmental Health Project (2004). Healthy people in a healthy environment: Integrating population, health and the environment in Madagascar. EHP Brief(25).

Gardner-Outlaw, T. and R. Engelman (1999). Forest futures: Population, consumption, and wood resources. Washington, DC, Population Action International.

Kleinau, E. and J. Talbot (2003). When the whole is greater than the sum of its parts: Integrated indicators for population-environment programs. PECS News Spring.

Lalasz, R. (2003). Conservation, population, and health: A conversation with Jane Goodall. ECSP Report (9): 161-166.

Layng, R. (2002). PESCO-DEV M&E Plan. Philippines.

Lindsay, S. W., T. G. Egwang, et al. (2004). Community-based environmental management program for malaria control in Kampala and Jinja, Uganda. Washington, DC, Environmental Health Project.

Margoluis, R., S. Myers, et al. (2001). An ounce of prevention: Making the link between health and conservation. Washington, DC, Biodiversity Support Program.

Population-Environment Fellows Program (1995). Observations and insights on integrated development activities: Proceedings of the first Population-Environment Fellows Workshop. Population-Environment Fellows Workshop, Ann Arbor, MI, University of Michigan.


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Population-Environment Fellows Program (1996). Integrating population and environment: Experiences from the field. Population-Environment Fellows Workshop, Quito, Ecuador, University of Michigan.

Ribaira, Y. (2003). Performance monitoring plan 2002-2005: Monitoring and evaluation of health-population-environment programmes, Madagascar Green Health Communities Project.

Stem, C. (1997). The Population-Environment Fellows Program: Documenting results. Ann Arbor, MI, Population-Environment Fellows Program, University of Michigan.

Sutherland, E. G., D. L. Carr, et al. (2004). "Fertility and the environment in a natural resource dependent economy: Evidence from Petén, Guatemala." Población y salud en Mesoamérica 2 (1).

Vogel, C. G. and R. Engelman (1999). Forging the link: Emerging accounts of population and environment work in communities. Washington, DC, Population Action International.

WWF (2002). Living in balance: Population, consumption, and the planet. Washington, D.C., WWF.

WWF Conservation Strategies Unit (2002). Conservation on a crowded planet: A population sourcebook for conservation practitioners. Washington, D.C., WWF.

WWF Conservation Strategies Unit (2002). Mapping the connections: The population-environment lessons from Madagascar. Washington, DC, WWF.

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