(June 2011)"We are trying to integrate things that should never have been separated to begin with. The health and well-being of the community depends on the health and well- being of the ecosystem and vice versa." Million Belay, MELCA Ethiopia
The "Population, Health, and Environment: Integrated Development for East Africa" conference in 2007 marked the formal beginning of the David and Lucile Packard Foundation's investments in integrated population, health, and environment (PHE) projects in Ethiopia. PHE is an approach to development that recognizes that dealing with complex development priorities, such as poverty alleviation, health needs, and sustainable livelihoods, requires an integrated approach that links these issues. The Packard Foundation's investments in Ethiopia have focused on working with rural development organizations to extend the reach of family planning services by integrating health education and service delivery with livelihood, microfinance, and environment interventions such as clean cook stoves, soil conservation, and sustainable agriculture. Packard has supported six organizations in Ethiopia to implement integrated PHE projects to achieve adolescent sexual and reproductive health, capacity building, and conservation outcomes. In addition, USAID investments in technical assistance and capacity building for PHE have supported the promising work.
Over the last three years grantees have reported many successes and lessons learned. The recently completed informal assessment, "Reflections on Population, Health, and Environment Projects in Ethiopia: The Packard Foundation's First 3 Years Investing in PHE in Ethiopia," shows the way forward for future PHE investments, research, monitoring and evaluation, and capacity building. The assessment recommends improved monitoring and evaluation by local organizations; a long-term strategy for developing in-country capability for technical assistance and capacity building; and investments in research to clarify if, how, and why Ethiopia communities benefit from integrated solutions.
Promising Results Reflect a Need to Fund Monitoring and Evaluation
Many results reported by Packard's Ethiopian PHE grantees are attributed to the integrated PHE approach:
- Increased contraceptive prevalence rate (CPR) of couples.
- Religious leaders' support of family planning increased use of family planning by community members.
- Increased male involvement in family planning.
- Increased female involvement in environmental rehabilitation activities.
- Increased efficiencies with government extension workers, such as saving costs and time.
- Improved parent-child communication.
- Teachers focusing less on multiple youth clubs and more on academic affairs.
These successes represent an opportunity to convince more implementers and donors to support and scale up PHE efforts. Apart from personal interviews with project staff, however, there are little data to support the reported successes. When asked why they are not reporting on PHE-related indicators, grantees indicate they do not have the staff capacity or funds to do so. If funding does not accommodate costs associated with monitoring and following up on activities and proposed outcomes, then they are unable to objectively evaluate the impact of their PHE efforts.
This situation reflects a preference to support the "on the ground" work rather than high-quality monitoring and evaluation such as staffing, capacity building, data collection, and analysis. This preference particularly challenges smaller local organizations that do not already have the staff or funding capacity to carry out meaningful data collection, analysis, documentation, and communication of results. With the potentially exciting results reported by implementing staff, it would be a great loss to not confirm the results of the integrated PHE investments in Ethiopia.
Harvest and Support PHE-Related, In-Country Technical Expertise
Over the past three years, Ethiopia's PHE practitioners attended trainings and workshops and received technical assistance. As a result, Ethiopia is ripe with highly skilled and experienced PHE practitioners from many local organizations. In addition, a local PHE network, PHE Ethiopia Consortium, has been established and has partnered with the global PHE community to facilitate capacity building with Ethiopia's PHE community. This wealth of skills and knowledge needs to be coordinated so that the already trained PHE professionals are drawn upon as technical experts for further training.
Therefore, the assessment's second recommendation is to develop a strategy for creating long-term capacity building and technical assistance support in Ethiopia and to reduce dependence on outside technical experts for building knowledge, skills, and overall PHE-related capacity. A sustainability strategy should tap into their skills and expertise and support existing systems for organizing and linking them with those that need the support. A key step to establishing this in-country capacity includes supporting the PHE Ethiopia Consortium to develop a system for identifying and linking in-country PHE experts with other network members, and building the consortium's capacity to organize and implement trainings on PHE project design, monitoring and evaluation, and other skills.
PHE-Related Research Is Needed
The third key recommendation from the assessment is a call for research to understand if and why an integrated approach is needed for the Ethiopian context. Ethiopia is a focal point for aid and development work focusing on food security, climate change, maternal and child health, youth development, reproductive health, and poverty alleviation. The challenges Ethiopia faces are complex and cross multiple sectors, often justifying an integrated PHE approach. This differs from other countries where PHE is justified more as a means of reaching remote populations more efficiently. There is very little research from Ethiopia, however, that supports the claims that an integrated approach is needed or would be more effective than single-sector efforts. Research focused on understanding how sectors are interdependent within communities would help justify the need for integrating interventions. In addition to the improved monitoring and evaluation, research focused to understand reported results more deeply would greatly benefit the PHE and overall development communities in Ethiopia and around the world. Donors and practitioners should partner with academic and research institutions to complete research that provides insight into why PHE makes sense for Ethiopia's communities and whether the results being reported are actually due to this integrated approach or attributed to other factors within the intervention communities.
The PHE accomplishments in Ethiopia so far are promising, and there is interest in integrated PHE approaches to achieve Ethiopia's development outcomes. In order to capitalize on this interest, however, more investments are needed to improve monitoring and evaluation and develop local expertise. Furthermore, more research is needed to help make the case for an integrated approach in Ethiopia. Through these investments, smaller local organizations will be better positioned to communicate why an integrated approach is needed and how it is effective. Moreover, these investments will ensure that local organizations are capable in assisting others in Ethiopia to design and implement projects that contribute to the achievement of Ethiopia's development goals.
Annie Wallace was a PHE Technical Advisor with USAID's Global Health Fellows program based in the Packard Foundation's Ethiopia office from October 2008 to October 2010. During this time she provided technical assistance to Packard grantees and other Ethiopian organizations implementing PHE projects. She currently resides in Oakland, California, and continues to work with the Packard Foundation's Population and Reproductive Health Program.