Making the Link

POPULATION REFERENCE BUREAU

LINKING POPULATION, HEALTH, AND ENVIRONMENT IN PROVINCE,

by Kathleen Mogelgaard and Kristen P. Patterson

or more than a decade, development practi- Samantha Cameron, Ny Tanintsika tioners and communities in Fianarantsoa Fprovince, Madagascar, have been involved in community-based projects that link family plan- ning, health, and environment efforts.1 Since the early 1990s, a range of approaches that combine family planning and/or health interventions with environment and rural development activities have been implemented throughout , making it one of the richest centers of such programming in Madagascar and the world.2 This brief explores the evolution of cross- sectoral approaches and projects in Fianarantsoa, outlines ongoing challenges to effective project The commune of lies on the eastern side implementation, and highlights opportunities for of the central forest corridor in Fianarantsoa, where forest strengthening and expanding collaboration. It is cover is shrinking by approximately 2 percent per year. based on a review of published literature and project documents, and interviews with over 20 practitioners, technical advisers, and funders in Fianarantsoa and throughout Madagascar, cross- Madagascar and the United States (see Acknowl- sectoral approaches are being incorporated into edgments, page 12). broader development approaches and local planning efforts. And perhaps most significant, a growing Fifteen Years of Cross-Sectoral number of practitioners in the environment and Experience health sectors have indicated in interviews that they Early cross-sectoral initiatives in Fianarantsoa support and promote these initiatives because they province had several goals. Natural resource man- believe that coordination can yield better results and agers recognized that the conservation and manage- provide more benefits to communities than when ment of natural resources could be undermined by the services are provided separately. Furthermore, high fertility rates. Many also believed that address- the experience and dedication of these practitioners ing health needs—among the highest priorities in has positioned them to capitalize on new opportu- communities—would lead to greater trust between nities within the development community and the development partners and the community, and a national political context to refine and expand greater community willingness to participate in cross-sectoral approaches. conservation activities. Health practitioners recog- nized that partnerships with environmental projects Demographic, Socioeconomic, and operating in rural areas could reach previously inac- Ecological Context cessible and underserved constituents. Fianarantsoa is among the poorest of How successful have these projects been over Madagascar’s six provinces and has the second- the past 15 years? Evaluations have demonstrated highest number of people.4 Access to potable progress in reaching new audiences, fostering water, the consumption of water and electricity greater community involvement, and promoting per resident, and the rate of spending per person programmatic efficiency.3 Increasingly in are the lowest among all provinces.5 2 PRB Making the Link 2006

Fianarantsoa’s total fertility rate is higher than rural residents.7 In addition, the crash of the the national average (5.7 children per woman vs. global coffee market in the mid-1990s severely 5.2 nationally) and its contraceptive prevalence affected the livelihoods and long-term food secu- rate is lower (11 percent of women in union in rity of the region’s residents. Fianarantsoa use a modern method of family plan- Furthermore, during the country’s socialist era ning, vs. 18 percent nationally). Children’s health (1975 to 1990), the government promoted a pro- is of particular concern in the province, with infant natalist population growth policy and open access mortality rates, child anemia, stunting, and wast- land rights, which encouraged a population boom ing all slightly higher than the national average.6 and the cultivation of previously unused land.8 In Colonial policies dramatically altered tradi- 1991, the government adopted a national popula- tional cropping and land tenure systems, some of tion policy, which recognized the benefits of and which (such as the production of coffee for need to promote family planning at all levels of export) yielded mixed benefits to Fianarantsoa’s society.9 The country’s politically turbulent transi- tion to democracy in the early 1990s led to a Cross-Sectoral Projects in Communes Along Fianarantsoa’s gradual integration of Madagascar into the global 10 Central Forest Corridor economy. Nevertheless, real per capita income declined almost 50 percent from 1972 to 2002,11 dramatically increasing poverty among rural Malagasy, including those living in Fianarantsoa. Rich ecological diversity is found within the Ambohimiera ■◗ province. Fianarantsoa contains some of the country’s most popular national parks (Isalo, Ranomafana, and Andringitra). In 2005, ■ ■ Tsaratanana Fianarantsoa hosted more tourists than any other Ranomafana ■◗ 12 National Park province. A 500-km long moist forest corridor harbors extraordinary biological diversity, con- Project Ranomafana tributing to Madagascar’s designation as one of Name ■◗ ■ ■ 13 ICDP Androy the world’s “biodiversity hotspots.” This forest (1991–1997) ■ Salohy Soloarivelo Razanajatovo, Ecoregional Initiatives Fianarantsoa provides numerous ecosystem services such as ◗ EHP (2000–2005) watershed protection and soil erosion prevention, ✖ MGHC FIANARANTSOA which support agricultural activities and biodiver- (2002–2005) ◗✖ sity maintenance within and beyond the forest. Champion Commune— Most cross-sectoral activities in Fianarantsoa Cycle 1, Maromiandra have been implemented in and around the central Integrated ✖ (2005–2006) ✖ forest corridor that lies between Ranomafana and Andringitra national parks (see map). This ✖ 280,000-hectare central corridor, measuring 200 ■✖ kilometers long and only 4 to 5 kilometers wide

Ambinanindovoka Ambolomadinika in some sections, experienced a 1 percent to 2 per- ✖ cent annual forest cover loss between 1990 and ✖ 2000. Additional losses could further threaten bio- ✖ ◗✖ diversity and the ecosystem services relied upon by Miarinarivo regional communities. Evolution of Cross-Sectoral Andringitra Approaches National Park Approaches linking family planning and other health interventions with natural resource man- agement activities in Fianarantsoa province have evolved and expanded over time. The evolution Population Reference Bureau Population, Health, and Environment in Madagascar 2006 3

of these cross-sectoral efforts can be grouped into the international development community, and three phases (for a detailed account of the projects practitioners successfully solicited support from in these phases, see the Appendix on page 8). private foundations. Two major cross-sectoral Phase 1, 1990-1998. In the first phase, projects, the Environmental Health Project cross-sectoral efforts accompanied Madagascar’s (EHP) and Madagascar Green Healthy adoption of a 15-year National Environmental Communities (MGHC), were started in commu- Action Plan (NEAP). The early years of the nities located along the central forest corridor in NEAP focused on implementing integrated con- Fianarantsoa. servation and development projects (ICDPs) The innovations and successes in the second associated with Madagascar’s national parks, phase generated momentum for communication, including . The outreach, and advocacy to expand these Ranomafana ICDP, initiated in 1991 by the approaches. Unfortunately, the destabilizing Natural Resources Office of the United States effects of the eight-month nationwide political Agency for International Development (USAID) crisis of 2002 disrupted this momentum; practi- mission in Madagascar, included economic and tioners had to focus on maintaining field activi- social development interventions in addition to ties in the context of weakened rural health care biodiversity conservation activities.14 In 1995, services and declining household incomes in USAID Madagascar’s Health Office added a fam- Fianarantsoa.17 Nevertheless, in this phase effec- ily planning component to the project.15 tive tools and organizational partnerships for Individuals involved in the Ranomafana ICDP managing cross-sectoral programming were devel- learned to develop strategies to implement com- oped (see Box 1, page 4). munity-level interventions across sectors, such as Phase 3, 2005-present. As the funding for creating networks of community-based distribu- the second phase’s projects drew to a close in tors of contraceptives in rural areas and designing 2005, a third phase has taken shape. This phase is effective community-based environmental educa- marked by the end of private foundation support tion programs. After the ICDP ended in 1997, for integrated work, and the gradual embedding many of the Malagasy who worked for the ICDP of cross-sectoral initiatives into comprehensive went on to establish or work for NGOs that were development programming. This shift is largely engaged in cross-sectoral projects. supported by USAID Madagascar in the imple- Phase 2, 1998-2005. The second phase mir- mentation of its integrated strategic plan, which rored the changing direction of the NEAP: contains common goals for all of its program Interventions that previously focused on national areas, including its work in the health and natural parks and communities immediately adjacent to resource management sectors. them moved into the broader landscape, encom- Building on the success of the integrated passing ecosystems and communities throughout Champion Community approach, USAID the central forest corridor. In this phase, USAID Madagascar led an extensive scale up of these partners and NGOs developed and implemented efforts from the community level to the com- new models for cross-sectoral projects. One of mune level (equivalent to a county in the United these models, Champion Community, was imple- States) in several communes in Fianarantsoa. In mented widely throughout this phase. This com- implementing the Champion Commune munity involvement approach encouraged project approach, USAID Madagascar and its partners managers to amass a large number of volunteers; aim to link development interventions in natural conduct short, practical trainings; promote small, resource management, public health, economic doable actions; use simple and adaptable tools; development, and good governance (a USAID provide mass media support; and celebrate framework known as Nature, Health, Wealth and achievements.16 Power). Voahary Salama members work with USAID partners and NGOs involved in USAID Madagascar partners in implementing cross-sectoral projects formed the Voahary Champion Commune, and six of the 23 Salama Association in 2000 to share information Champion Commune sites in Fianarantsoa and resources. Their efforts drew the attention of engaged in both health and environmental activi- 4 PRB Making the Link 2006

communes in areas of high biodiversity or ecologi- Box 1 cal sensitivity, and are often beyond the network Promising Results of Cross-Sectoral Projects During Phase 2 of passable roads, telephone lines, and even radio broadcast coverage. During the peak of the rainy While the precise “value-added” of providing health and environment inter- season (January through April), many of the exist- ventions in a coordinated fashion rather than separately is difficult to quanti- ing roads in the most remote areas become fy, a recent review of the David and Lucile Packard Foundation and USAID Washington-funded population-environment and population-health-envi- impassable, making field visits and in-person tech- ronment projects (including the Environmental Health Project and nical assistance difficult. Unpredictable and severe Madagascar Green Health Communities) reported promising results. weather, such as the cyclones in 2000 that were The assessment specifically noted the effectiveness of the integrated particularly devastating in Fianarantsoa, worsen an Champion Community approach in mobilizing communities to achieve already weak transportation network. The lack of clearly defined, cross-sectoral results within a one-year period. In addition, transport and communication networks perpetu- there is evidence that cross-sectoral approaches encourage efficiency in ates the distrust of outsiders—including govern- obtaining multiple objectives. ment agency officials and development The assessment found that these projects bring three major advantages practitioners—common in the central forest corri- to family planning efforts: dor region.18 Furthermore, multiple political juris- ■ Greater access to and interaction with men; dictions create additional communication and ■ Greater access to and interaction with adolescent boys; and coordination challenges, because the central forest ■ Positive changes in the community perception of women and in corridor lies within five separate government women’s self-perception when they have access to credit. Régions, each with distinct development plans and authorities. Equally compelling advantages for conservation efforts were also noted: ■ Greater female involvement in natural resources management; Turnover of Funding Cycles ■ Increased participation of adolescents; and NGO practitioners in Fianarantsoa are con- ■ Providing an “entry point” by offering health services, thus building cerned about the current funding structures for trust within the community. cross-sectoral projects. While efforts are under- way to engage new funders, including govern- SOURCE: John Pielemeier, “Lessons From the First Generation of Integrated Population, Health, and Environment Projects” (Population Reference Bureau, www.prb.org, accessed Sept. 20, 2006). ment agencies at the national and provincial levels, cross-sectoral projects in Fianarantsoa have thus far been supported by private founda- tions and USAID. Presently, USAID is the sole funder for these efforts in the province. Funding ties in the first phase of the project (2005 to cycles from USAID tend to be four to five years 2006). One commune’s experience is highlighted long, and while funding and staffing within in Box 2, page 5. USAID Madagascar have remained remarkably consistent, each cycle brings in new partners Challenges of Project Implementation with different work styles and leaders, as well as Throughout all three phases, cross-sectoral modified goals, objectives, and strategies, espe- approaches have adapted in response to the chal- cially at the field level. The transition can bring lenges and obstacles inherent in carrying out fresh perspectives, but can also bring a loss of community-based development programming in momentum and institutional knowledge, since remote areas. In interviews, practitioners noted new partners sometimes need up to a year to the most common ongoing challenges they become fully operational. encounter when implementing cross-sectoral pro- jects in the central forest corridor: Limited Government Capacity The government of Madagascar has traditionally Transportation, Communication, and Cultural been unable to ensure adequate staffing and regu- Isolation lar provision of medical supplies to remote health The target communities for most cross-sectoral clinics such as those in the central Ranomafana- projects in Fianarantsoa are remote, underserved Andringitra forest corridor. The transfer of gov- Population Reference Bureau Population, Health, and Environment in Madagascar 2006 5

ernment personnel also can adversely affect a pro- The Way Forward: Strengthening ject’s success: Medical personnel in rural health Cross-Sectoral Collaboration clinics are regularly relocated (at times unpre- The third phase of cross-sectoral programming in dictably) due to personnel reallocations at the dis- Fianarantsoa offers practitioners valuable opportu- trict level or in response to personal requests for nities to address ongoing challenges by capitalizing reassignment. Thus, a project’s success can be on the experience and lessons learned from the derailed when health clinic staff who have first two phases. New initiatives promoted by received project training and who work well with USAID and other international development community health volunteers (such as communi- ty-based distributors of contraceptives and treated mosquito bed nets) are relocated. Also, in the Box 2 environment sector, cross-sectoral projects often Champion Commune Approach in Tsaratanana operate in rural communities where the govern- Kristen P. Patterson, SantéNet ment does not provide rural agricultural exten- sion services.

Limited NGO Capacity Civil society in Madagascar remains in the early stages of development compared to many other developing countries. Some NGOs involved in cross-sectoral work in Fianarantsoa, while dili- gent and committed to working in rural areas, do not have long-established histories or clear missions. In some cases, NGOs are established when a donor needs a local partner to imple- ment a project. The number of staff may grow or downsize depending on funding. Such fluc- tuations can limit an NGO’s ability to develop Community members are involved in setting their own environmental and the institutional knowledge and experience health goals as part of the Champion Commune approach in Tsaratanana. needed to operate effectively in difficult field environments. Association Ainga receives funding from both health and environment/ rural development partners of USAID Madagascar. This funding allows Lack of Uniform Measures of Success them to implement the Champion Commune approach in two communes For some practitioners, the lack of a common on the eastern side of the Ranomafana-Andringitra forest corridor. Eight results framework (with specific goals, objec- months into the project, the commune of Tsaratanana had embraced the tives, activities, and indicators) for cross-sectoral cross-sectoral model. In May 2006, the committee of local leaders that projects has hampered coordination of project oversees the coordination of Champion Commune in Tsaratanana cited design and implementation. While population the following compelling advantages of simultaneously implementing and health interventions are typically evaluated health and environment interventions: using common maternal and child health indica- ■ Even if people use family planning to have healthier children, unless tors (such as contraceptive prevalence rate or they are able to grow nutritionally good food, their family’s health childhood vaccination coverage), no such set of won’t improve. indicators exists yet for environmental interven- ■ Improved agricultural techniques that don’t rely on herbicides and tions. This lack of a commonly accepted suite of pesticides are better for the environment and for families. environment indicators adds to the time and ■ Protecting the surrounding area adjacent to water sources helps the discussion needed to design effective programs, environment and provides cleaner water for human consumption. ■ determine activities, and develop budgets. One cannot separate the two: Healthy people and a healthy enviro- Comparing success across projects is also more ment go hand in hand! difficult because activities—particularly in the SOURCE: Meeting of Champion Commune Committee, Tsaratanana (May 9, 2006). environment sector—are not standardized. 6 PRB Making the Link 2006

actors, changes in Madagascar’s governance struc- Commune approach, in particular, has attracted ture, and efforts to share information and best the interest of bilateral donors. USAID partners practices among local and international practition- in Fianarantsoa are working to place U.S. Peace ers offer new platforms to refine and expand cross- Corps volunteers in Champion Commune sites, sectoral approaches. noting the past contributions of volunteers in the health, environment, and education sectors. The Ecoregional Alliance and Local Planning European Union has also shown interest in sup- Committee porting the good governance component of In 2004, USAID Madagascar formed the Champion Commune. Fianarantsoa Ecoregional Alliance, a consortium of National development initiatives also represent USAID-funded partners. Members of the alliance new opportunities for collaboration. Building represent the four pillars of Nature, Health, upon water resource management and sanitation Wealth, and Power (natural resource management, activities undertaken by cross-sectoral projects, public health, economic development, and good government entities, and national and internation- governance), and meetings are used to promote al NGOs in Fianarantsoa, representatives of the cross-sectoral thinking and programming.19 The Ministry of Energy and Mines, the U.S. Peace Fianarantsoa Ecoregional Alliance collaborates Corps, and USAID’s health and environment part- closely with the Comité Multi-local de Planification ners collaborated to establish a Fianarantsoa-based (Local Planning Committee), a Malagasy consulta- WASH (Water, Sanitation, and Hygiene) tive body that advocates for interventions around Committee in 2006. The provincial committee (a the central Ranomafana-Andringitra forest corri- coordinating body for more than 30 water, sanita- dor in Fianarantsoa. tion, and hygiene organizations) helped create Creative cross-sectoral approaches have been committees in four of the five Régions in the initiated as a result of the alliance. For example, in province, and the original provincial committee early 2006, members collaborated with the now solely represents the Région. European Union-funded Andrew Lees Trust to Regional government representatives as well as establish contracts with five radio stations in the national NGO staff serve on the board of the central Ranomafana-Andringitra forest corridor to Haute Matsiatra committee, contributing to the broadcast information about health-environment sustainability of the effort to provide improved linkages. More recently, alliance members strate- water, sanitation and hygiene in the region. As gized to foster stronger cross-sectoral collaboration communication and coordination increases during the second phase of Champion Commune. through such mechanisms as these regional com- The alliance also provides members with new mittees, there will be more opportunities to engage ideas for their own work: the Madagascar Program new actors. Office of the World Wide Fund for Nature (WWF), an alliance member, is implementing Decentralized Decisionmaking and Funding activities such as transfer of forest management In 1996, the Malagasy government began an incre- and installations of potable water systems in select mental process of government decentralization. In communes located in the southern forest corridor 1998, each government ministry installed a in Fianarantsoa, and hopes to secure funding for a Direction Inter-Régional representative at the provin- health component. Notably, WWF and other cial level. In 2004, the government created new environmental NGOs involved in the alliance, sub-provincial government units, or Régions. such as Conservation International, are interested Regional development plans were elaborated for in using the Champion Commune approach in Fianarantsoa’s five Régions in 2005, with input from their work in Fianarantsoa. the communal development plans of most of Fianarantsoa’s communes.20 Engagement of Other Development Actors By involving local government, Champion In addition to the work of the Ecoregional Commune complements the decentralization Alliance, opportunities exist for engaging addi- process by supporting communes’ identification tional development actors. The Champion of priority activities and development indicators. Population Reference Bureau Population, Health, and Environment in Madagascar 2006 7

The approach engages commune leaders and Timeline of Cross-Sectoral Approaches in Fianarantsoa community members in ways that can facilitate effective and sustainable cross-sectoral program- 1991-1997 Ranomafana Integrated Conservation and Development ming, particularly as communal development Project plans are further elaborated and implemented. ■ Supported by USAID Madagascar The Ministry of Decentralization and Regional ■ Partners: APPROPOP/Management Sciences for Health; Planning plans to establish pilot Centres d’Appui Cornell International Institute for Food, Agriculture, and aux Communes (Communal Support Centers) to Development; Institute for the Conservation of Tropical assist selected communes in implementing their Environments; North Carolina State University development goals in 2007. The Malagasy government is working closely 1997-2000 University of Michigan Population-Environment Fellow with the World Bank and the European Union to based in Fianarantsoa put in place Fonds de Développement Locales (local ■ Supported by USAID Washington ■ development funds), which will help support Hosted by APPROPOP/Management Sciences for Health, then regional and communal development plans in Jereo Salama Isika/John Snow, Inc. ■ Fianarantsoa and throughout Madagascar. Once Collaborated with Landscape Development Interventions/ Chemonics International Inc. local development funds are in place, decentraliza- tion will offer interested local governments a way 2000-2005 Environmental Health Project to dedicate funds for long-term, cross-sectoral ini- ■ Supported by USAID Washington tiatives in their development plans. ■ Fianarantsoa-based partners: Association Ainga; Madagascar Institute for the Conservation of Tropical Environments Building a Community of Practice (MICET); Ny Tanintsika As the breadth of experience in cross-sectoral programming grows, capturing and sharing infor- 2000 Voahary Salama formed mation about best practices and lessons learned ■ Supported by the Summit Foundation and USAID Washington will become increasingly important. Improved ■ Fianarantsoa-based members: MICET (founding member in telecommunications in the province will bring 2000); Ny Tanintsika (joined in 2002); Association Ainga valuable online resources to practitioners for col- (joined in 2003) laboration and capacity building. For instance, the USAID Washington-funded FRAME pro- 2002-2005 Madagascar Green Healthy Communities gram’s website helps build online knowledge- ■ Supported by the Packard Foundation (via JSI Research & sharing networks among natural resources Training Institute, Inc.) management professionals for the natural ■ Fianarantsoa-based partners: Association Ainga; Jereo Salama resource management community.21 In addition, Isika/John Snow, Inc.; Landscape Development Interventions/ USAID Washington’s Global Health Bureau sup- Chemonics International Inc.; MICET; Ny Tanintsika; Supporting ports and manages a web-based clearinghouse of Service for the Management of the Environment (SAGE) population-health-environment tools and infor- mation, designed to assist field practitioners and 2005 Champion Commune launched ■ others interested in cross-sectoral approaches.22 Supported by USAID Madagascar (primarily via SantéNet/ While the activities of the Voahary Salama Chemonics International Inc. and Ecoregional Initiatives/ Development Alternatives, Inc.) Association have slowed somewhat in the mid- ■ Fianarantsoa-based cross-sectoral partners: Association Ainga; 2000s as the association transfers from a USAID- MICET; Ny Tanintsika funded project to an independent Malagasy association, Voahary Salama could, with adequate 2005-2007 University of Michigan/Public Health Institute Population funding and support, continue to serve as a con- Environment Fellow based in Fianarantsoa vener of interested and experienced parties. The ■ Supported by USAID Washington association could play an expanded role in pro- ■ Hosted by SantéNet/Chemonics International Inc. moting the Champion Commune approach— ■ Collaborates with Ecoregional Initiatives/Development particularly by leveraging the decentralization Alternatives, Inc. process to develop and implement local develop- 8 PRB Making the Link 2006

ment plans, build capacity, and maintain an years focused on the implementation of integrat- information clearinghouse on cross-sectoral ed conservation and development projects approaches in Fianarantsoa and throughout (ICDPs) associated with Madagascar’s national Madagascar. parks. These projects coupled biodiversity con- servation efforts with social and economic devel- Building Leadership and opment interventions throughout Madagascar, Sustainability and within this context efforts began to explicitly How successful have partnerships been between the link family planning and health services to con- health and environment sectors in Fianarantsoa servation interventions. The Natural Resources province? The outcomes have been shaped by a Office of USAID Madagascar funded an ICDP combination of persistent challenges and incremen- around Ranomafana National Park that included tal but meaningful accomplishments, not unlike park management, ecological monitoring, biodi- most development work initiated in the province versity research, community-based natural over the past 15 years. The assessments and experi- resources management, community health, eco- ence of cross-sectoral projects in Fianarantsoa have nomic development, and education and eco- shown that humans and the environment can bene- tourism interventions. In keeping with USAID fit from efforts to link interventions in health and Madagascar’s strategic plan at the time and its environment in rural areas. One of the most com- goal of “balancing population growth and natur- pelling results is the development of a community al resource use,” the USAID Madagascar Health of dedicated practitioners who promote continued Office added a family planning component in interventions in the rural central Ranomafana- 1995, making it the first population-health-envi- Andringitra forest corridor. ronment project in the province. These practitioners are beginning to capital- Cross-sectoral programming received another ize on a suite of new opportunities for expanded boost in 1997 with the arrival of a University of programming. Recent efforts by USAID Michigan Population-Environment (PE) Fellow, Madagascar and its partners to mainstream cross- funded by USAID Washington, who played a sectoral efforts within broader development plan- critical role in helping to manage grants made to ning efforts are beginning to bear fruit, and NGOs to implement the family planning com- could lead to increased sustainability of these ponent of the Ranomafana ICDP.23 The presence approaches. Documenting these experiences and of an early-career professional who was dedicated sharing information on effective tools and to advancing cross-sectoral approaches helped to approaches is critical as these efforts continue to build interest, capacity, and momentum for inte- evolve and strengthen. Madagascar, and grated programming among development practi- Fianarantsoa province in particular, has the tioners in Fianarantsoa. potential to continue to be a leader in advancing cross-sectoral approaches in support of sustain- Phase 2, 1998 to 2005: Population-Health- able human development. Environment Integration Coordination Among USAID Health and Environment Partners. Even though no formal APPENDIX cross-sectoral project existed in the early years of Three Phases of Cross-Sectoral Phase 2, USAID Madagascar’s health and envi- Approaches in Fianarantsoa Province ronment partners worked together to implement their respective activities in remote communities Phase 1, 1990 to 1998: Cross-Sectoral near the biodiverse forest corridor, and they rec- Initiatives Around National Parks ognized the benefits of sharing information and resources. In 1990, the government of Madagascar adopted In 1997, a USAID child survival health part- a 15-year National Environmental Action Plan ner and the Ministry of Health developed and (NEAP)—the first in Africa. The NEAP’s early piloted a new approach for community engage- Population Reference Bureau Population, Health, and Environment in Madagascar 2006 9

ment and behavior change. In 1998, a USAID est corridor, all of which were designed to com- comprehensive health partner joined the effort, plement and reinforce the lack of government adopting the new approach, expanding it, and infrastructure in the remote area.25 naming it “Champion Community.” Champion For its field-supported activities, EHP used Community differed from ICDPs in that commu- the integrated Champion Community approach. nities set their health goals. Notably, with the sup- Community members helped set a range of health port of the USAID comprehensive health partner, and environmental goals, such as reductions in cross-sectoral projects such as the Environmental infant mortality, improved nutrition, agricultural Health Project and Madagascar Green Healthy intensification, and alternatives to slash and burn Communities (see below) later adopted the agriculture. Community members monitored Champion Community approach and added nat- results and publicly celebrated the achievement of ural resource management components to existing self-identified targets. health activities, creating a tool for integrated The project ended in 2005, and project man- population-health-environment (PHE) initiatives. agers concluded that the use of local NGOs (rather Voahary Salama Association. In 2000, indi- than international NGOs) was cost-effective; that viduals from several organizations that had been better results can be achieved in areas where govern- involved in ICDPs and other cross-sectoral activ- ment services are stronger, such as health clinics ities in Fianarantsoa and across Madagascar that are adequately staffed and receive regular provi- formed the Voahary Salama (“Healthy Nature”) sions of contraceptives and immunizations; and Association. Voahary Salama is a consortium of that the organizational implementation model (for funding, technical, and implementing partners example, two NGOs from different sectors collabo- dedicated to promoting sustainable natural rating vs. one NGO training their staff in multiple resource management and addressing the health sectors) is not as important as the capacity and and livelihood needs of communities living commitment of the NGO.26 around biodiverse forest corridors in Madagascar. Madagascar Green Healthy Communities. In The PE fellow based in Fianarantsoa and the 2002, USAID Madagascar health and environment Tany Meva Foundation helped Voahary Salama partners and Voahary Salama received funding from secure funding from the U.S.-based Summit the David and Lucile Packard Foundation to imple- Foundation. Voahary Salama combined this with ment PHE activities in rural zones under a project funding provided by the USAID Madagascar called Madagascar Green Healthy Community health partner to support organizational develop- (MGHC).27 MGHC used the integrated ment and capacity building for the cross-sectoral Champion Community approach, and adopted work of member organizations.24 other proven community education and mobiliza- Environmental Health Project. Momentum tion approaches such as “Child to Community” (an for cross-sectoral approaches continued to build approach that motivates children to achieve goals later in 2000, when Madagascar was selected as a and share their knowledge with their community) site for the Environmental Health Project (EHP). and “Farmer to Farmer” exchanges (where farmers Funded by USAID Washington, the project teach other farmers about health behaviors and included an operational research component to agriculture techniques). The MGHC pilot phase test whether linked health and environment was implemented in two communes (13 villages) interventions were more effective than single-sec- on the eastern side of the central Ranomafana- tor programs, and to measure the effectiveness of Andringitra forest corridor, and then scaled up to various integrated organizational implementation work in partnership with four NGOs and two models. In addition, later in its project cycle, USAID Madagascar partners in more than 100 vil- EHP funded select Voahary Salama member lages in eight communes adjacent to the central for- NGOs to implement coordinated activities in the est corridor.28 health and environment sector, such as installing Like EHP, MGHC ended in 2005. Based on potable water systems, increasing vaccination their experience, MGHC project managers con- coverage, and promoting reforestation in several cluded that integrated population, health, and communes adjacent to Fianarantsoa’s central for- environment programs can produce better results 10 PRB Making the Link 2006

than single-sector programs, and felt that adding a integration between single-sector programs microcredit program helped foster greater commu- among USAID missions worldwide, these shared nity engagement.29 During this period, EHP and goals help to drive deeper communication and MGHC focused their cross-sectoral projects in collaboration among the sector-specific USAID sections of the central forest corridor most vulner- programs. able to being cut. EHP and MGHC had their NHWP and Champion Commune. In own goals and objectives, but worked together to mid-2005, USAID Madagascar adopted Nature, support the larger vision of Voahary Salama and Health, Wealth, and Power (NHWP)—a frame- to reinforce the capacities of its members in work linking natural resource management, pub- implementing PHE programs in the field. lic health, economic development, and good Growing International Interest. During governance.31 The NHWP model seeks to sup- this phase, cross-sectoral approaches in port interventions in at least these four general Fianarantsoa and elsewhere in Madagascar gener- sectors to meet minimum development needs of ated international interest. Supported by the communes around biodiverse areas. U.S.-based Population Reference Bureau and In keeping with the NHWP framework, Voahary Salama, Fianarantsoa-based NGO lead- USAID Madagascar health partners have used ers were trained on improving their skills to previous achievements of the Champion communicate their cross-sectoral work. Community approach and collaborated with The cross-sectoral efforts of EHP, MGHC, other USAID partners in an extensive scale-up of and Voahary Salama were highlighted in interna- the approach from the community level to the tional venues such as the Global Health Council commune level in Fianarantsoa and three other annual conference and the Woodrow Wilson provinces in Madagascar. Champion Commune Center in Washington, D.C.; and a documentary is implemented at a higher level of government, video produced by U.S.-based Population Action ensuring greater geographic coverage than work- International that featured the work of Voahary ing at the community level, and providing a Salama. By the end of this phase, many in the foundation for good governance through its international development community saw development of community capacity for priority- Madagascar as a leader in this emerging field. setting and development planning. During the first cycle of Champion Commune Phase 3, 2005 to Present: Scale-Up and (2005 to 2006), Malagasy and international Expansion of Cross-Sectoral Initiatives NGOs implemented the health component in 23 communes in Fianarantsoa. In six of these com- Integrated USAID Strategic Plan. The ground- munes, Voahary Salama member NGOs concur- work for this third phase was laid in 2002, when rently implemented the health and environment USAID Madagascar built upon goals from its components of Champion Commune. Another PE previous strategic plan and adopted an integrated Fellow, based in Fianarantsoa from 2005 to 2007, strategic plan for its 2003-2008 funding cycle.30 is supporting the Fianarantsoa-based Voahary The integrated strategic plan was designed to Salama member NGOs as they implement the establish several goals that would be shared health and environment components of Champion between all four USAID Madagascar program Commune. areas. For instance, the goals “Demand for Family Planning and Health Services and Products in Priority Conservation Areas Increased,” “Water Resource Management for Agriculture and Households Improved,” and “High Nutritional Value Agricultural Products Increased” are shared by the Health, Population, and Nutrition program as well as the Environment and Rural Development program. As one of the only strategic plans with targeted Population Reference Bureau Population, Health, and Environment in Madagascar 2006 11

References (Fianarantsoa, Madagascar: Landscape Development 1 The term “environment” is used by current practitioners in Interventions, 1999). Madagascar to mean biodiversity conservation, natural 19 Fianarantsoa Ecoregional Alliance members include: ERI; resources management, and sustainable land use planning BAMEX; SantéNet; MIARO/WWF; MIARO/CI; JariAla; through improved forest management and agricultural prac- Title II/CRS; ANGAP; Ministry of Environment, Water, and tices. The term is not equated simply with “conservation.” Forests; and CMP. 2 Practitioners in Fianarantsoa province use a variety of terms 20 Sous-préfectures, the foundational units for the central gov- to describe these projects, including complementary, integrat- ernment that were demarcated in the 1960s and 1970s, were ed, PHE or HPE (population, health and environment), and renamed Districts in 2005. Development plans have not yet CBPE (community-based population and environment). been elaborated at the District level. 3 John Pielemeier, “Lessons From the First Generation of 21 The FRAME website can be accessed at www.frameweb.org Integrated Population, Health, and Environment Projects,” 22 USAID’s Population, Health, and Environment informa- Population Reference Bureau website, accessed online at tion clearinghouse can be accessed at www.ehproject.org/ www.prb.org, on Sept. 20, 2006. ehkm/phe.html 4 Institut National de la Statistique (INSTAT) and ORC 23 Established in 1984, the Population Fellows Programs were Macro, Enquête Démographique et de Santé, Madagascar 2003- funded by USAID Washington and managed by the 2004: Rapport de Synthèse (Calverton, MD: INSTAT and University of Michigan until September 2006. The programs ORC Macro, 2005). are now part of the Global Health Fellows Programs, also 5 INSTAT, Tableau de Bord Social: Fianarantsoa (: funded by USAID Washington, and managed by the Public Ministere de l’Economie, des Finances et du Budget, 2003). Health Institute. 6 INSTAT and ORC Macro, Enquête Démographique et de 24 The Summit Foundation lost the majority of its assets after Santé, Madagascar 2003-2004. the stock market crash of September 2001, and renegotiated 7 Madagascar was a French colony from 1895 to 1960. all of their multiyear grants, including Tany Meva. Summit 8 Karen S. Freudenberger, Livelihoods Without Livestock: A arranged for USAID Washington to cover the remaining por- Study of Community and Household Resource Management in tion of the grant in October 2002. the Village of Andaladranovao, Madagascar (Fianarantsoa, 25 Personal communication with Association Ainga; MICET, Madagascar: Landscape Development Interventions, 1998). and Ny Tanintsika; and Eckhard Kleinau, Odile 9 Dan Whyner, “Collaborating for More Effective Population- Randriamananjara, and Fred Rosensweig, Healthy People in a Environment Interventions: The Experience of the Healthy Environment: Impact of an Integrated Health, APPROPOP Project and its Environmental Partners in Population, and Environment Program in Madagascar Madagascar,” University of Michigan Population-Environment (Washington, DC: Environmental Health Project Final Fellows Newsletter (Winter 1999/2000); and personal commu- Report, May 2005). nication with Lisa Gaylord, Mamy Randriambololona, and 26 Kleinau, Randriamananjara, and Rosensweig, Healthy Yvette Ribaira. People in a Healthy Environment. 10 Joanna Durbin, Koto Bernard, and Mark Fenn, “The Role 27 Madagascar Green Healthy Communities (MGHC) project of Socioeconomic Factors in Loss of Malagasy Biodiversity,” management was designed to pass from JSI Research and in The Natural History of Madagascar, ed. Steven M. Training Institute, Inc., to Voahary Salama in year three Goodman and Jonathan P. Benstead (Chicago and London: (2004) of the project. The transfer of management responsi- University of Chicago Press, 2003); and USAID Madagascar, bilities never occurred, which resulted in the implementation Madagascar Integrated Strategic Plan FY 2003-2008 of two “parallel” PHE projects in Madagascar in the early (November 2002). 2000s (MGHC and EHP). Also, MGHC was conceived as a 11 USAID Madagascar. Madagascar Integrated Strategic Plan grant project with multiple four-year cycles. The Packard FY 2003-2008. Foundation cut back on its programs after depreciation of its 12 Comité Multi-local de Planification (CMP) PE3 meeting stock in September 2001, and discontinued funding the PHE notes, March 6, 2006. project in Madagascar after the initial four-year cycle. 13 To qualify as a biodiversity hotspot, a region contains at 28 Madagascar Green Healthy Communities, Contrat de least 1,500 species of vascular plants (greater than 0.5 percent Subvention, Programme LDI, “Fast-track activities” (February of the world’s total) as endemics, and has lost at least 70 per- 2002); Yvette Ribaira, Madagascar Green Healthy Communities cent of its original habitat. For more information, see Annual Report (September 2002–August 2003); and Conservation International’s website, accessed online at Madagascar Green Healthy Communities Annual Report www.biodiversityhotspots.org/xp/Hotspots, on July 5, 2006. (September 2003–August 2004). 14 Now known as the Environment/Rural Development Office. 29 Yvette Ribaira, Madagascar Green Healthy Communities 15 Now known as the Health, Population, and Nutrition Office. Final Report (January 2002–September 2005). 16 Jereo Salama Isika Final Report (2003). 30 A second University of Michigan PE Fellow, based in 17 The results of the presidential elections of December 2001 Moramanga and Antananarivo, contributed significantly to were disputed by the two candidates, which led to an eight- the development of USAID Madagascar’s first programmati- month political crisis during which the losing candidate’s sup- cally integrated strategic plan. porters bombed and blockaded major transport routes around 31 USAID Madagascar added a health component to USAID the country. The crisis was resolved in July 2002. Washington’s Nature, Wealth, and Power framework. For 18 Whyner, “Collaborating for More Effective Population- more information, see USAID, Nature, Wealth, and Power: Environment Interventions”; and Karen S. Freudenberger, Emerging Best Practices for Revitalizing Rural Africa Flight to the Forest: A Study of Community and Household (Washington DC: USAID, 2004). Resource Management in the Commune of Ikongo, Madagascar 12 PRB Making the Link 2006

Acknowledgments Kathleen Mogelgaard, Population, Health, and Environment PRB’s Population, Health, and Environment Program works to Fellow with the Population Reference Bureau; and Kristen P. improve people’s lives around the world by helping decisionmakers Patterson, Population and Environment Program Officer for understand and address the consequences of population and envi- SantéNet Fianarantsoa, prepared this brief. Thanks are due to ronment interactions for human and environmental well-being. the many professionals who committed their time and shared their knowledge and institutional memory in order to help For more information on the PHE program, please write to us make this document as thorough as possible. Special [email protected]. thanks are due to our interviewees: Wendy Benazerga, The Population Reference Bureau informs people around the Samantha Cameron, Mark Freudenberger, Lynne Gaffikin, world about population, health, and the environment, and empow- Lisa Gaylord, Philippe LeMay, Michael Park, Voahanginirina Ramanandafy, Zoelimalala Ramanase, Odile ers them to use that information to advance the well-being of cur- Randriamananjara, Mamy Randriambololona, Johanesa rent and future generations. For more information, including Rasolofonirina, Tiana Razafimahatatra, Diamondra membership and publications, please contact PRB or visit our web- Razaivaovololoniaina, Yvette Ribaira, and Elaine Rossi in site: www.prb.org. Madagascar; and Roger-Mark De Souza, Janet Edmond, Peter Gottert, Nancy Harris, Tom Outlaw, John Pielemeier, Jennifer Talbot, and Dan Whyner. Thanks also to Erica Policy Briefs in PRB’s “Making the Link” Series: Brewster, Heather D’Agnes, Karen Schoonmaker Freudenberger, Rachel Nugent, Suzanne Petroni, Daniela Linking Population, Health, and Environment in Fianarantsoa Raik, Salohy Soloarivelo Razanajatovo, Melissa Thaxton, and Frank Zinn for their valuable assistance and helpful insights. Province, Madagascar (2006) Funding for this policy brief was provided by the U.S. Agency for International Development under the BRIDGE Breaking New Ground in the Philippines: Opportunities to Improve project (No. GPO-A-00-03-00004-00) and the University of Human and Environmental Well-Being (2004) Michigan Population Fellows Programs.

© November 2006, Population Reference Bureau. All Ripple Effects: Population and Coastal Regions (2003) rights reserved. Women, Men, and Environmental Change: The Gender Dimensions of Environmental Policies and Programs (2002)

Children’s Environmental Health: Risks and Remedies (2002)

Finding the Balance: Population and Water Scarcity in the Middle East and North Africa (2002)

Healthy People Need Healthy Forests—Population and Deforestation (2001)

All publications are available on PRB’s website: www.prb.org/ environment

POPULATION REFERENCE BUREAU 1875 Connecticut Ave., NW, Suite 520, Washington, DC 20009 USA Tel.: 202-483-1100 | Fax: 202-328-3937 Website: www.prb.org | E-mail: [email protected]

PRINTED WITH SOY INK TM