Family Planning for People & Planet
Where: Lake Victoria Basin
Key Themes: Biodiversity loss, livelihood creation, women’s empowerment, sexual and reproductive health, international collaboration
This case study illustrates the relationship between population and family planning, community health, and natural resource management in the Lake Victoria Basin, the largest lake basin on the African continent. It demonstrates how these three dimensions are shaped by many factors, including human-caused alterations to the lake, lack of access to sexual and reproductive health services, and environmental degradation.
To address these challenges, this case study analyzes the effectiveness of an integrated approach called PHE, which stands for population, health, and environment. Since 2012, Pathfinder International’s Health of People and Environment in the Lake Victoria Basin (HoPE-LVB) has been a flagship PHE project in the region. By increasing education and access to the tools to help with healthy timing and spacing of children (population), sexual and reproductive health and sanitation and hygiene (health), and sustainable fishing and sustainable fishing and agriculture (environment), Pathfinder’s project in Kenya and Uganda has demonstrated why a holistic approach is necessary to deal with the Lake Victoria Basin’s complex suite of problems. With significant emphasis on policymaking, advocacy, and institutionalization of best practices, HoPE-LVB is used as a model for district, national, and regional bodies to adopt multi-sectoral approaches in their work.
Recognize the anthropogenic alterations, past and present, that have affected the Lake Victoria Basin.
Understand the dynamics that led to the introduction and growth of the Nile perch, and its ecological consequences on Lake Victoria.
Understand the feedback loops that exist between population, health, and environment in the Lake Victoria Basin.
Acknowledge the reasons why communities on the shores and islands of Lake Victoria are more vulnerable to the effects of diminishing natural resources and HIV exposure.
Assess why certain PHE approaches have been problematic in the past.
Consider each of the elements of a HoPE-LVB model household and how they contribute to one of the three prongs of PHE.
Recognize the importance of community sensitization and working with already-established groups when undertaking development projects.
Reflect on why improved land use management is key in ensuring the health of people and planet in the Lake Victoria Basin.
Understand why women’s economic empowerment and her ability to access sexual and reproductive health rights is central to Pathfinder’s PHE approach.
Consider what could be done to further scale and institutionalize PHE projects at a national and regional level.
Recognize why integrated development projects are a more effective way to accomplish the United Nations’ Sustainable Development Goals.
In East Africa, the shade of a tree provides an informal meeting place. This afternoon, there is a gathering of a half dozen young mothers. Namakula Edith, a sprightly 47-year-old who looks a decade younger, is the one convening. And today, she’s brought props. Reaching into the brown envelope that serves as her family planning kit, Edith pulls out blister packs of birth control pills and rattles them in the air. But the real fun begins when it’s time to talk condoms. Edith doles out a few to the women sitting tentatively on the benches around her, and searches through her envelope for a slightly more phallic prop. For demonstration purposes, of course — though it draws giggles from the surrounding women and a double take from passing motorbike drivers.
Contraceptive methods and family planning are the main topics of conversation today, but the meeting also touches on the connection between family size, health, and the environment. It’s a concept referred to as Population, Health, Environment (PHE), and Edith finds the approach is best explained with an easy-to-grasp example. In an island village like Seeta where Edith and the women live, it makes sense for that story to start with a fish.
Think of the resources your family needs, Edith says. She means the food, firewood, shelter — everything essential to a family’s basic survival. “If the father brings one fish and he has 10 children, it means the fish will not be enough,” she explains. “If you are many, you use a lot of things.” She goes on: if there are fewer children, then you will need only one piece of fish to provide nutrients for your home, and the rest of the money can go towards education and healthcare. You will have fewer children, but you will be able to support them better, she says. And because there are fewer people at home you will not need to collect as much firewood to cook that fish, so the forest will be better maintained. Making the decision to use family planning to space your children conserves the environment around you. Your fish goes further, and so does your family. While an oversimplification of the connections between family size, health, and natural resource management, these are the first messages Edith uses when talking to her peers about PHE.
Edith and the women live on Bussi Island in the Ugandan portion of Lake Victoria. It’s here where Edith serves as a member of the Village Health Team (VHT), a group of government-hired community volunteers who provide the link between villages and government health clinics. Accessible only via a hour-long motorboat ride from the mainland, Bussi Island is one of four focus areas for the Health of People and Environment in the Lake Victoria Basin (HoPE-LVB) project in Uganda and Kenya. A project of Pathfinder International, a long-running sexual and reproductive health NGO based in the United States, HoPE-LVB is an example of an internationally-funded project that has been proven to support positive behavioural, environmental, and policy changes at regional, national, district, and local levels. And in the case of the project, local gets really personal — into the homes and bedrooms of families across the region.
Just as planetary health examines how human health and the spread of disease are influenced by human-caused environmental change, PHE also looks at the health of people and the environment. It does so with an added focus on population dynamics and the pressure that demographic shifts, within political, economic, and social systems that are not yet able to absorb those shifts, can put on people and their natural resources. With HoPE-LVB, the project provides families with the knowledge, access, and choice to plan for the timing and spacing of their next child, within the framework of a rights-based approach of informed choice and reproductive freedom.
To help with that planning, the “P” dimension of HoPE-LVB includes voluntary family planning and contraceptive information sessions for women and men alike. Health-wise, the project has worked to ensure women have safe pregnancies and deliveries, including promoting safer deliveries in health facilities and, more recently, reducing rates of mother-to-child HIV transmission. The health element also addresses minimizing disease through improved household hygiene and sanitation, and reducing the risk of respiratory conditions and accidents through the construction of energy-efficient clean cookstoves. Finally, the “E” in PHE talks about the importance of, and the best ways to, conserve the environment. That ranges from adopting sustainable fishing and agricultural practices, to diversifying livelihoods as to not over rely on any one natural resource.
While the dimensions of PHE can be defined separately, a key element of this approach is recognizing the feedback loops that exist among all three — how demographic trends and poor access to sexual and reproductive health affect the environment, how the changing environment affects health, and so on and so forth. The goal is to create an integrated solution that considers the complex everyday realities of people, including barriers of poverty, culture, and health access.
Lake Victoria in the Anthropocene
The most notable of the African Great Lakes, Lake Victoria is the largest freshwater lake on the continent. With a surface area of 68,800 square kilometers,[i] Lake Victoria’s shores connect Uganda, Kenya, and Tanzania, and its catchment area is more than twice that size, extending to include the countries of Burundi and Rwanda. Today, the lake basin is an integral part of the economy and culture of all five East African countries. An estimated 44 million people live in the Lake Victoria Basin (LVB), and despite making up less than 10% of the land area, the region is home to a third of the people living below the poverty line in the East African Community (EAC).[ii]
Lake Victoria’s geography presents several pressing environmental and health challenges. In addition to being a transboundary ecosystem with management subject to the political will and cooperation of multiple countries, the people who call the LVB home are also unique. “These are people who do not seem to belong to any country,” explains Doreen Othero, the Regional Programme Coordinator for the Integrated PHE Programme of the Lake Victoria Basin Commission, an institution created by EAC to oversee the sustainable development of the region. “The people living here cross borders, do their business, and then return home.”
That transience is telling of the region’s primary industry: fishing. Along with agriculture, these two industries make up more than 80% of the livelihoods of people living in the LVB.[iii] Home to valuable ecosystems and essential natural resources, along with a rapidly growing population, the LVB faces a number of health, environmental, and economic challenges at the hand of human change.
Nothing new, the anthropogenic threats facing Lake Victoria started decades earlier.
Colonial squabbles and the demise of Lake Victoria’s biodiversity
A small aquarium sits near the Ugandan shores of Lake Victoria. Follow the mechanical whir of the filtration systems and you’ll come across a rectangular room, walls lined with some dozen tanks, each containing a common type of fish found in the nearby waters. The invasive fish species that has forever altered the ecology of the lake sits unassuming in a tank on the left side of the room: the Nile perch (Lates niloticus). While the one in this tank is only about a half-meter long, 200 kilogram fish of up to two-meters in length have been found in the lake.[iv] YouTube videos show fisherman hauling huge Nile perch from their boats, the fish hoisted over their shoulder in a fireman’s carry.
The effects of Nile perch introduction on Lake Victoria have been well documented by scientists, both abroad and by the ones working in the buildings surrounding this particular aquarium. The aquarium is in the town of Jinja, and those researchers work with the National Fisheries Resources Research Institute (NaFIRRI), a semi-autonomous Ugandan government agency that has long had its finger on the metaphorical pulse of the lake.
Motivations for introducing Nile perch to Lake Victoria were two-fold. They would, however, favor the British colonial forces who, at the time, controlled Uganda, Kenya, and Tanganyika (present day Tanzania). The premise was that Nile Perch would provide ample catch for sport fishing, and that it would serve as a predator for the hundreds of endemic but small haplochromine cichlid species that the British administration had labelled “trash fish.”[v] By preying on the haplochromines, the thought was that the small fish could serve as the primary diet of a species worthy of commercial value.
When the first Nile perch were caught on Tanzanian shores in 1961 — the result of secretive introductions by the Uganda Game and Fisheries Department as early as 1954 — the floodgates opened for a larger-scale, formal introduction of the species. Dozens more Nile perch were introduced from Ugandan and Kenyan shores over the coming years.[vi]
Two decades later, the Nile perch population exploded. “All of a sudden whenever fishermen would cast their nets they were seeing a fish they had never seen before. It took over the space in the lake,” says Winnie Nkalubo, a fisheries biologist with NaFIRRI. The difference in total annual fish catch was notable: the size of the fishery increased from 100,000 tons in the early 1970s to 500,000 tons by 1989.[vii]
Commercial processing factories soon cropped up along the shores of Lake Victoria, introducing a new layer of anthropogenic change: fishing pressures. Those factories were responsible for preparing catches of Nile perch for mass export to Europe and the Middle East — the first time Lake Victoria fish were sold internationally. Until then, the fishery had provided subsistence food for the local and regional markets, and had earlier still been a resource used in pre-colonial bartering systems.[viii][ix] Local fisherfolk initially benefited from the large-scale commercialization that came with the Nile perch boom, selling their catch to factory middlemen while still having enough to feed their families.
Perch and population
The expansion of the Nile Perch market in the 1980s and early 90s attracted a gold rush-style migration to Lake Victoria. “The population pressure pushed fish stocks to the lowest level, but fishers were still in business and had to switch to illegal nets,” Nkalubo says. “There was an open access policy on the lake, so there was no regulation that limited the number of fishermen.”
“In terms of economics, the introduction of the Nile perch was a blessing,” adds Herbert Nakiyende, another of NaFIRRI’s fisheries biologists. By the 1980s, it’s estimated the economic value of the fishery increased fivefold.[x] During that time, people living along the shores of Lake Victoria did benefit from the fishery. It improved incomes, brought infrastructure to the area, and created jobs at new processing factories.
“But for conservationists it was obviously a curse since we had so many extinctions,” Nakiyende expands. It’s estimated that the feasting of Nile perch contributed to a 63% species decline in the lake’s 500 haplochromine cichlids between 1960 and 2010.[xi] Today, memory of those fish is found only at NaFIRRI, in a small building that bears the slightly tragic name “museum.” Inside, jars of formaldehyde-preserved fish are stacked on floor-to-ceiling shelves — species that currently populate Lake Victoria, and the ones that were made extinct by Nile perch.
The economic bubble created by the Nile perch boom soon burst. The European Union slapped export bans on Lake Victoria fish between 1997 and 1999 due to salmonella, cholera, and other hygiene and chemical concerns.[xii] During these bans, some processing factories experienced an estimated 75% reduction in operations.[xiii]
Despite temporary bans, stocks of Nile Perch still began to fall. Fisherfolk who had migrated to the LVB during the boom faced obstacles less supply but the same demand from local and regional markets. Nile perch biomass declined nearly 10 fold from 1.9 million tons in 1999 to 200,000 tons in 2008.[xiv] Since then, the biomass of Nile perch has increased slightly, but only 5% are of breeding size,[xv] keeping fish stocks limited.
With more than 800,000 people relying on the fishery for direct employment and declining stocks, fisherfolk were forced to further rely on illegal fishing methods.[xvi] A decline in fish stock also meant fisherfolk had to go further to reach their catch — a factor that increased the travel of an already transient population. The biodiversity of the lake and its ecosystems were at-risk. While conservation of the lake’s natural resources were key for protecting the livelihoods and food security of the families depending on those resources, it also affected their health.
Fish catch and the rise of HIV
By the 1980s, Nile perch stock wasn’t the only thing on the rise in the Lake Victoria Basin — so too was the prevalence of what was, at the time, a relatively unknown condition: HIV/AIDS.
The first case of AIDS in the Lake Victoria region was reported in 1982 in a fishing village in southwestern Uganda.[xvii] Prevalence of the virus continued to rise in the region, with first cases reported the following year in Tanzania, and the year after that in Kenya.
Isiah Kisiki remembers this time well. Born on Bussi Island in 1974, he’s part of a minority: someone who grew up on the island rather than arriving as a result of the temporary boom in Nile perch supply. He recalls how people started to behave when fish stock declined: “A lot of fishermen started fighting. Prostitution increased, domestic violence, and more drunkenness, too,” he says. When it came to the spread of HIV, Kisiki remembers that many people came to the island looking for a means of survival. “The increase in prevalence was due to a high population competing for very few resources,” he says. Fisherfolk needed to travel further and more frequently to get the same amount of fish, meaning the spread of the disease was more likely among multiple sexual partners and in various parts of the lake. Kisiki says other detrimental environmental effects came with this reduction in fishing success: “Because of the decrease in fish catch, people had little revenue and started to cut trees to burn for cooking and to sell as firewood.”
Just as fishing communities experienced firsthand the tumultuous rise and fall of the Nile perch market, they were — and remain today — one of the groups most vulnerable to the transmission of HIV/AIDS. While 18% of Uganda’s general population was infected at the peak of the infection in 1992, [xviii] epidemiologist and former director of the country’s HIV/AIDS Control Program, Dr. Alex Opio, estimates that prevalence could have been as high as 30% on island and fishing communities during the same period. The first survey to quantify the rate of HIV prevalence in island communities did not happen until 2011, when Opio and his co-authors found the rate to be 22% — more than three times higher than the 6% prevalence found in the general population.[xix]
A reason for the increased occurrence is access to healthcare treatment, coupled with the nature and culture of fishing communities. “It was very apparent that the islands were lacking health facilities,” says Opio. More often than not, fishing communities are serviced by outreach or mobile services, as opposed to a dedicated health post. The frequency of travel by fisherfolk made it more difficult still for HIV awareness messaging to be communicated and treatment offered. “So fishermen had no knowledge or health access if they did contract the disease, making disease rates higher,” Opio says.
High prevalence rates were paired with risk-taking behavior. Fisherfolk, Opio says, don’t live in isolation — they come to an island knowing there’s fish, and they leave their family somewhere else in the country. “Fisherfolk saw that they were getting easy money, and they had a lot of disposable income. They do their fishing at night and by 9 a.m. they’ve sold their catch and have money,” he says. “Then they either go to sleep, drink alcohol, or have affairs with the commercial sex workers who go to the island.”
Compounding that spending culture is the fatalistic attitude held by many fishfolk. “Fisherfolk see their risk of mortality coming from different sources,” Opio explains. “They see people dying of HIV, but they also regularly see other fisherfolk drown. They would say ‘if I can survive the rough waves of water, what about this HIV?’ To them, the risk of dying from infection was much less than the risk of dying while on the lake.” This fatalism translates to a resistance of men in using condoms, as well as a lack of desire to protect natural resources. Survive and catch fish on the lake today — worry about tomorrow, tomorrow. It’s a culture that’s still prevalent in island communities today.
Healthy people, healthy planet
While it may be more straightforward to understand how the health of Lake Victoria’s ecosystems affect the health of people who depend on those natural resources, the same is true of the reverse. A 2017 paper authored by Dr. Kathryn Fiorella and her Cornell University research group quantified how human health and wellbeing in the Kenyan portion of Lake Victoria influences the capacity of people to sustainably manage their natural resources.
The findings directly contradict a common hypothesis around health and the environment: that sick people will reduce their environmental impact. “By this logic, ill people reduce the time and effort that they put into extractive livelihoods and, thereby, their impact on natural resources,”[xx] the paper reads. If correct, this conventional hypothesis would mean sick fisherfolk would withdraw from their fishing activities and stay home, reducing their fish catch and allowing time for the lake to recover.
Fiorella and her team’s research found otherwise. When fishers were sick, they were less likely to be participating in fishing. Yet for those individuals still fishing, the large majority, the study demonstrated that when people experience poorer mental and physical health, there was no effect on the total hours fished by month, nights spent away, or income per hour fishing. Poor physical health did, however, influence the choices people made around fishing methods. Fisherfolk with poor physical health were 69% more likely to use an illegal methods focused on inshore fishing areas — locations requiring less travel and ones with smaller, easier-to-catch fish. Illegal methods include using fine mesh monofilament nets to catch younger fish. Sick people were still fishing, but they were doing so in even less sustainable ways.
“In contrast, methods used by physically healthy fishers require fishers to reach deep water or fish overnight to target the more sustainable mature Nile perch and dagaa fisheries,” Fiorella and her team write.
Gender Dynamics in the Lake Victoria Fishery
A 2015 paper authored by Dr. Kathryn Fiorella and her research group investigates how declining fish catch affects men and women who exchange sex to access fish in Lake Victoria in Kenya.
Whereas periods of high catch means fish is plentiful and can be purchased using money alone, a declining stock means women have to compete for catch using non-cash methods. This has affected jaboya relationships — the Luo word used to describe fish-for-sex. Transactional sex relationships like jaboya, are distinct from sex work; participants define these relationships differently. They are often with a regular partner and include other benefits such as housing and emotional support.[i] Jaboya transactions typically involve a woman exchanging sex with a man in order to gain preferential access to purchase the fish he has caught. While women are conventionally excluded from the Nile perch economy, and standard prices are set by fishery managers, the possibility of fish-for-sex transactions introduces the opportunity for a non-monetary bargaining chip. It’s notable that jaboya relationships have existed for several generations due to the transient nature of the fishing industry, though exchanges are now being altered by fluctuations in Nile perch and dagaa catch.
These transactions are among the many factors that have contributed to higher-than-average HIV rates in the Lake Victoria Basin.
Lake Victoria’s fishery is male-dominated, but it’s not only the health of men that affects natural resource management, nor is it only men who are impacted by the negative side effects. Illegal fishing practices and the unsustainable management of the fishery can lead to increased vulnerability for women (see textbox 1). Poor health is just one point in a cycle that leads to destructive fishing practices. As illustrated in appendix 1, those practices can then impact family food security and livelihoods — less fish means less for families to eat, and an increased reliance on other natural resource-based livelihoods such as charcoal-making and farming. If done unsustainably, those activities can lead to deforestation or damaging agricultural practices. That natural resource degradation and food insecurity can then increase illness, which again fuels the cycle of poor health and poor natural resource management.
The introduction of the Nile perch and the subsequent declining fish stocks exacerbate the inequitable gender dynamics that exist in Lake Victoria’s fishery. Traditionally, men are the ones who fish, selling their catch at the shore to women who manage the processing, transportation, and sale of those fish. The role of women in the fishery shifted after the introduction of the Nile perch with the rise of larger packaging plants to prepare the fish for international export. To this day, women are primarily excluded from the more lucrative Nile perch market and instead take on the responsibility of drying and trading dagaa, a small, sardine-sized fish that has become populous in the lake, and locally trading and processing undersized Nile perch.
Finally, physical health and wellbeing hinges on gender equity: women having increased rights within the supply chain of the fishery (see textbox 1), and also having control over their reproductive health (the ability to access contraception, avoid diseases, and safely plan for and deliver children). Removing the element of choice when it comes to a woman’s sexual and reproductive health rights, and limited bargaining power within economic systems, has a negative impact on her welfare. That, in turn, has a similar impact as a sick fisherman: poor natural resource management.
As demonstrated by Fiorella’s research, the feedback loops that exist around the environment and human health are complex. Natural resource management and conservation cannot be done without considering the health and wellbeing of the people who rely so heavily on the services provisioned by those ecosystems. Any project that wanted to improve the outcomes of one would have no choice but to integrate the other. This was the environment in which the HoPE-LVB project began.
The Need for an Integrated Solution
The Lake Victoria Basin has long been shaped by changing demographics and population pressures. Even before the Nile perch boom of the 1980s, the LVB had a higher population density than the rest of the continent. As of 2015, an estimated 246 people inhabit every square kilometer of lakeside areas of Uganda, Kenya, and Tanzania, compared to 45 people per square kilometer in 1960.[xxi] It’s notable that in the case of Tanzania and Kenya, the population density in lakeside areas is two to three times higher than the density of the country at-large.[xxii] These demographic trends can be attributed to two key factors: an influx of in-migration to the fishery, particularly following the Nile perch boom, and birth rates that surpass national averages.
The result is 44 million people whose lives and livelihoods are intertwined with and dependent on a finite set of resources. While addressing in-migration to the region could be one way to mitigate natural resource pressures, Pathfinder International is taking a rights-based approach to improving sexual and reproductive health. By increasing sexual and reproductive health access and contraceptive choices of women and families in the region as part of a broader PHE approach, the organization is ensuring couples have children when they want to have children. The premise is that by offering more comprehensive sexual and reproductive health services, families are able to have the number of children they choose, improve their health and wellbeing, and live within the means of what the natural environment can sustainably support.
Pathfinder and PHE
‘Integration’ is a word that comes up often among the Pathfinder International team, both internationally and in its offices in Uganda and Kenya. In this case, integration involves project objectives to conserve Lake Victoria’s natural resources, maintain the health and wellbeing of the people who live on its shores, and provide families the knowledge and access to sexual and reproductive health services. Add on combatting traditional gender roles, advocating for greater healthcare access, women’s economic empowerment, and institutionalizing it all at various levels of government, and you have Pathfinder International’s Health of People and Environment in the Lake Victoria Basin (HoPE-LVB) PHE project. If it sounds complicated, it’s because it is — but Pathfinder’s belief is that complexity is the only way to address complexity.
PHE and Planetary Health
Sono Aibe says she sees planetary health as a broad umbrella under which she hopes issues of health of people and the environment can be discussed. “Initially when we were trying to join the conversation around planetary health it seemed skewed heavily towards climate scientists and more abstract issues that were very macro-level,” she says. There was also concern about the “P” controversy: that PHE would bring up the contentious topic of addressing demographic trends in developing countries that are threatening remaining areas of high biodiversity and endangered wildlife habitats, all the while upholding all individuals’ reproductive rights.
Ultimately, the two approaches are working towards similar messaging: that integrated solutions and multi-sectoral collaboration are the best way to achieve the Sustainable Development Goals — the aspirational global goals created by the United Nations General Assembly in 2015.
This concept of integration is one Sono Aibe, Pathfinder’s Senior Program Advisor, has been thinking about since her public health career started in 1988. One of her first projects involved creating an integrated reproductive health, environmental sanitation, and maternal health project in the Philippines, a country long considered a leader in integrated PHE approaches. “Having come from that background made me a proponent for taking a broader view of sexual and reproductive health because women’s lives are complex, and their problems are intertwined,” says Aibe. While it would be possible to dedicate entire projects solely to natural resource management, family planning, or health, the premise is that it takes addressing all three to target the root causes of a region’s challenges.
By the time Aibe was hired in 2009, Pathfinder had already tested the waters of combining environmental and health programming. Whether it was an HIV-focused project with a livelihood or agricultural component, or integrating HIV education and family planning, Aibe says she had an inkling that PHE programming was something Pathfinder could take on.
What came next wasn’t easy. “There definitely was pushback in the sense that people thought [PHE] would be a mission creep. They envisioned us having to work with environmental groups, share resources, and learn about conservation terminology and monitoring indicators. There was this whole anxiety around going into a completely non-health sector,” Aibe recalls.
Another reason for Pathfinder’s apprehension was that the “P” element of PHE approaches has historically attracted controversy. “Some environmental groups still talk about problems of environmental degradation being because developing countries are growing too fast,” Aibe says. “That’s a very harmful narrative for what we’re trying to advocate for, which is reproductive health and rights, and the fact that a woman has to be given a full basket of choices and accurate information to make a decision about the number of children she wants. So there was this nervousness of ‘are we going to be working with groups promoting the value of smaller families, which is diametrically opposed to the universal access to sexual and reproductive health and reproductive rights that we stand for.’” Aibe says she firmly believed the challenges of cross-sectoral work could be overcome by working with African communities to hear how people articulated the linkages.
A PHE Approach in Madagascar
A well-studied Population, Health, and Environment initiative is the work of Blue Ventures in Madagascar. Blue Ventures was founded as a marine conservation organization in 2003. Its first intervention was working with fishing communities to temporarily close a small area of their fishing ground to octopus fishing — octopus is a marine species that recovers rapidly with protection. Through the temporary closure and resulting recovery of octopus populations in these sites, Blue Ventures demonstrated to communities that they could generate quick profit by protecting their marine areas for a short period of time. It made a business case for locally-led conservation.
“Rather than international companies coming in and telling people who have fished off these coasts for generations that they can’t fish anymore, we’re turning this on its head — making marine management pay for coastal communities,” says Vik Mohan, Blue Venture’s Medical Director. “Protecting fisheries means better income for people, so they want to protect those areas.” Similar to HoPE-LVB’s advocacy towards community by-laws, this protection involved the creation of local regulations using dina, the name for customary Malagasy laws.
Blue Venture’s family planning and maternal health program was introduced in 2007 in response to community members highlighting their unmet health needs — especially those linked to reproductive health. Maternal and child health was poor and couples were having more children than they wanted. Women and men were seeing the connection between their family size and depleting fish stocks. Today family planning and other maternal health services are offered either by community support workers or through strengthened government-led clinics. Blue Ventures also partners with international organizations like Marie Stopes, USAID, and Population Services International to improve access to health services for the communities it serves.
For more information: Blue Ventures (www.blueventures.org)
Just as Aibe faced challenges in introducing the PHE concept to Pathfinder International, the country teams faced their own unique start-up obstacles with HoPE-LVB — namely, the need to work with so many sectors. “For a sexual and reproductive health or maternal child health project we’re basically working with the Ministry of Health and a few partners here and there,” says Dorah Taranta, the Project Manager for HoPE-LVB in Uganda. According to Taranta, the PHE project was the equivalent of the organization getting out of its comfort zone and needing to find partners in sectors beyond health. That meant reaching out to ministries of all backgrounds: water and environment, agriculture, education, gender, and others. “So the scope kept expanding, and with HoPE being the first PHE project for us, it was really a learning project. You have all these activities and objectives based on the funding proposal, but then we had to fit in and achieve everything. Many times we came back to the drawing board to say ‘what did we do right and what went wrong. Are we really doing integration or are we still different sectors working in the same room?’”
At the start of the project, Taranta says there was a “whole shopping list” of indicators — nearly 35 points the team had outlined to measure the impact of the project. The challenge was creating indicators that considered integration: how family planning lessons were being used in farming. How energy efficient cookstoves affected health and the environment. “It was about bringing best practices from one sector into the other and looking at how one affected the other,” Taranta says. “Then we had to make sure the communities also understood it this way.”
These integration needs meant HoPE-LVB was perpetually a work in progress. Partners from various sectors were brought on board and dropped if things weren’t working; donors and their demands changed from phase to phase. “That calls for a lot of patience, especially if you’re leading a project. You are like this small punching bag where everyone is saying ‘we asked you for this,’” Taranta laughs. “It’s complex, but very interesting work.”
Meanwhile, committing to integration on paper was one thing — actually doing it was another. For HoPE-LVB, the focal point of that integration happens in the homes.
A model household approach
Drive a motorbike along the red dirt roads of Bussi Island and you start to recognize some key differences between households. A few of those features are spotted from the road: a rubbish pit sitting at the edge of the property, a dish drying rack, a garden containing various crops and fruit trees, the size of which provide ample shade for homeowners and their guests. On Bussi Island and the other three lakeside regions where HoPE-LVB operates, homes with these features are most likely model households — living demonstration sites that illustrate the project’s PHE interventions.
The model household concept is nothing new, and has existed in past PHE projects, as well as other global health and development work. What Pathfinder staff say is different is that the positive behaviors exhibited in HoPE-LVB model households protect both health and natural resource management, while being tailored to the needs of Lake Victoria communities. “In PHE you need to look at what ecosystem you’re conserving, what are the health issues of the people living around there, and what are the demographic issues in that area,” says Taranta. Only then can a project address the unique integrated pressures faced by that community.
A home visit is the best way to see a model household in action. Namuyaba Margaret and her husband, Kayemba Taddeo, sit on wobbly blue plastic chairs in the shade of their generously sized mango tree. Margaret and Taddeo are one of four original model households in Gombe Village on Bussi Island, and the couple live with their five children who range in age from six to 17-years-old. The eldest, Helen, is kneeling off to the side, scrubbing aggressively at the family’s laundry. Home visits are nothing new for the couple — one requirement of becoming a model household is an agreement to talk and tour neighbors and other officials so they can learn about the benefit of integrated PHE activities. The integrated nature of the model household was what originally appealed to the couple: “other projects came with only one intervention, but HoPE came with three: PHE,” Taddeo says.
At Margaret and Taddeo’s, the PHE activities are hard to overlook. Taddeo walks behind the red brick structure that serves as the couple’s one-room home. Onions, tomatoes, and collard greens that go by the local name sukuma grow in the shade of a banana tree. These kitchen gardens are a feature of every model household, and ensure families have access to a healthy source of vegetables, quite literally right in their backyard. Beyond the kitchen garden is a small shack, its walls made of worn wooden slats. Inside is the energy efficient cookstove where Margaret prepares the family’s meals. Training to build these cookstoves is offered by the HoPE project. Whereas cooking would typically be done over an open fire with less efficient means of burning wood, these clean cookstoves require only two to three branches per meal. The construction of this particular stove funnels smoke outside the small cooking space, reducing the risk of respiratory disease caused by smoke inhalation[xxiii] and the opportunity for cooking pots to spill on unsupervised children. This more efficient stove is also used by families to boil drinking water.
Outside the cooking area is a dish drying rack raised from the ground for sanitation purposes, and beyond that, a latrine located an appropriate distance from the home. Latrines are challenging to build in the sandy soils of Bussi Island, but HoPE-LVB links families like Margaret and Taddeo with government funding and other NGOs that focus on that specific infrastructure.
While a latrine and other features of a model household require families to invest some of their savings, a USAID external review of HoPE-LVB noted that “some of the most important PHE outcomes are the least costly, with some requiring no up-front capital expenditure whatsoever. This is a valuable lesson of high applicability to other potential PHE sites.”[xxiv] One example is a low-cost innovation found outside Margaret and Taddeo’s latrine. It’s called a tippy-tap, and it’s fashioned from an old jerry can, a piece of string, and a small stick. Taddeo steps gingerly on the stick and the string tips the bottle, enabling family members to wash their hands without touching a dirty surface.
Access to clean cookstoves and improved household water, sanitation, and hygiene (WASH) standards are part of the “H” element of this PHE approach. The HoPE-LVB project’s baseline study found that just 41% of people had access to a protected drinking water source, with the lake being the main source of usable water for activities like drinking, washing, and cooking. This improvement was also seen in non-model households, with nearly half reporting an improvement in WASH.[xxv] This reduces the risk of water-borne diseases in households.
Other interventions were low-cost because they related to behavior shifts rather than the creation of new infrastructure. “Before, people were only focused on earning money and didn’t know what was good for their families,” explains Jackie Nakajubi, one of two HoPE-LVB field staff in Uganda. Nakajubi focuses on health and family planning while her counterpart, Stellah Mbatudde, covers environmental conservation. “People would fish and sell everything because of the amount of money they could make. Then as a family they would choose to eat vegetables. As a project we tried to ask them to start with themselves first, including when it came to eating fish,” Mbatudde explains.
Changing perceptions of sexual and reproductive health
The features of a model household aren’t all visible, particularly those involving key behavioral shifts around family planning. “We used to think about planning our family but didn’t know how,” Margaret says. We would hear the rumors about family planning, like that if I used contraception I’d give birth to a child with a defective brain. This scared us off, but the education we got from HoPE helped shed those fears.” Margaret now takes birth control in the form of an implant, and the couple has chosen to not have a child since 2013 when they first became a model household.
Margaret is not alone in her contraception fears. Back under the tree in Seeta Village where Village Health Team (VHT) member Edith has finished demonstrating how to properly fit a condom over her phallic wooden prop, she’s just opened the session to questions.
“Is it true birth control will sit undissolved on my stomach and cause a tumor?” asks one woman. Edith swiftly pops one of the pills from its blister pack and puts it in a cup of water. Moments later she passes it around, pointing out that the pill has dissolved into the liquid. The women nod their heads. Just as model households demonstrate the visible benefits that PHE can bring to a home, education around family planning also requires the same level of learning by example.
Edith says the continued use of contraception relies on these regular educational campaigns. “You go to church once, but you need to keep preaching the gospel,” she explains. “So yes, I have trained these women on family planning before, but I need to continue training them. For example you can’t teach all four to five methods in one go, so each session needs to focus on a different method.” Speaking of church — the highly religious nature of communities in Kenya and Uganda presented just another barrier for the project to overcome.
Improving access and building healthcare demand
Beyond debunking misconceptions, HoPE-LVB has also made it easier for community members to access family planning methods. Almost half of pregnant women surveyed during the project’s baseline study said they would have preferred to get pregnant later or not at all.[xxvi]
That data also found that less than 1% of respondents received their contraceptives from a community-based clinic or outreach service, meaning they had to travel to a public health center, often accessible only by motorbike or, on smaller islands, by traveling to the nearest large island. Despite contraception being free at these centers, the cost of reaching them often restricted access. This high cost was compounded by the fact that husbands would often not allow for women to make solo clinic visits.
While one approach to these challenges may have been to open a series of HoPE-LVB health facilities to dole out contraception, the project prefers to build the capacity of existing community groups, and advocate for better services to be offered by government health facilities for long-term sustainability and country ownership.
In her role as a VHT member, Edith is one of the community members who has received capacity training through HoPE-LVB. Outreach volunteers hired by the government with minimal training, VHTs bridge the gap between the community and public health facility. But in isolated island communities like Bussi, VHT members are often the only public health professional women can see. To build the capacity of VHTs, Pathfinder offered 10-days of family planning training when the project began. Following that training, VHTs can distribute condoms and provide birth control to women who have already been given the medication by a trained health worker. They’re also trained to offer follow-up and support — listen to a woman’s concerns during contraception use or pregnancy and refer to a health worker when needed.
Advocacy-wise, the project wanted to provide families more contraceptive choice and guaranteed access. With short-acting methods of contraception already being provided for free by the government — though with the previously mentioned access limitations — phase II of HoPE-LVB advocated at the district and national government level for long-acting and permanent methods of contraception. That includes intrauterine contraceptive devices (IUCDs) and implants for women, and vasectomies for men. By successfully getting long-acting methods of contraception added to the list of free offerings, and increasing contraception access through outreach services, HoPE-LVB has offered thousands of Couple Years of Protection (CYP)[xxvii] to families in Uganda and Kenya, and has had more than 118,000 visits for contraception between 2012 and 2017.[xxviii] The project also improved the health information management systems in each country to prevent government health clinics from running out of stock. Not solely used to help couples plan pregnancies, contraceptive use has also been linked to reduced maternal mortality and lessened risk of developing certain cancers.[xxix]
Pathfinder staff acknowledge these outcomes would not have been possible if not for working with already-established government-formed groups like the Village Health Teams. Partnering with existing groups was also a strategic decision. “These groups have a common goal as to why they’re together, so it’s easier than picking individuals and forming a group here and there,” says Stellah Mbatudde, the conservation field officer in Uganda. “If you form a group, it dissolves at the end of the project, so we worked with existing ones for sustainability.” It was also a matter of trust. Despite being Ugandan, project staff Jackie and Stellah were at first seen as outsiders from the capital city. “When people get someone of their own giving them testimony about family planning or fishing then they understand it better,” says Jackie Nakajubi.
That community sensitization and working with existing groups is the way HoPE-LVB took on one of its most challenging PHE integrations: deconstructing the traditional gender roles in which couples divided natural resource management and sexual and reproductive health.
Rewriting gender norms
Given that Lake Victoria is the world’s largest freshwater fishery, Kyanjazi landing site on Bussi Island is remarkably quiet. A half dozen narrow wooden boats have been pulled onto the shore, paint peeling and faded in the equatorial sun. Fisherman stand around, cigarettes dangling as they untangle fishing nets and repair their boats. A man in knee-high rubber boots navigates his motorbike over loose red sand. In the distance, a shrill piglet squeal competes with the sound of a hand saw. It’s early in the morning, and yet the final packing preparations are already being done on the catch of the day. Taddwa Lawrensio picks up two foot-long Tilapia, his fingers pressing into the gelatinous eye sockets. Today, the catch collected from this particular landing site is small. A large woven basket mounted on the back of a motorbike is all that’s needed to carry the fish to another landing site where they’ll be sold on Uganda’s mainland.
Lawrensio is the chairman of Kyanjazi’s Beach Management Unit (BMU). BMUs were created by the government in 2006 with the goal of curbing illegal fishing activity, protecting fish breeding zones, and training fisherfolk on sustainable practices. Like the VHT members, the HoPE-LVB project also works with BMUs on natural resource management and, more unexpectedly, topics of family planning. By adopting this approach, the project offers positive reinforcement to the idea that women should have a stake in natural resources and that men can do the same when it comes to sexual and reproductive health and family planning. Untangling these deeply entrenched gender norms is called a “gender transformative approach.”
“Usually men would say these topics are for women,” Stellah Mbatudde explains. Not only was family planning classified as a female-only topic, but men say there was also misinformation. “As fishermen we were not using family planning. We thought people were telling us not to give birth,” says Lawrensio, staring out at the water. “Now we know it’s just timely spacing. After the training we were taught to use condoms and how to protect our lives. Now we know women should go to safe delivery services which prevents our children from getting HIV. HoPE-LVB also works with BMUs to provide boat fuel so women in need of specialized delivery services can easily reach mainland hospitals.
Project success wouldn’t be possible without buy-in from both men and women. “For community level change, women are important pillars, but if you’re not talking to men you won’t change things because of the paternalistic nature of our societies,” said one Pathfinder team member. Following phase II of the project, model households in Kenya were 20% more likely to discuss the number and spacing of children, and in Uganda, it was a 34% increase difference between model households and non-model households. Three quarters of families only started having these conversations during HoPE-LVB.[xxx]
Once men understand the importance of sexual and reproductive health, they become a pathway in which women are referred to health services. While in the past, health center visits may have come through referral from a VHT member, HoPE-LVB has created health referral champions in men and other non-traditional groups. Referrals from BMU groups increased 43-fold between the start of the project in 2012 and midway through 2014. Similarly, referrals from farmer groups rose from 156 referrals at the beginning of the project to 614 referrals in the same two years.[xxxi] More recently, a September 2018 internal review of phase I and II of HoPE-LVB found that the number of women delivering babies in healthcare facilities greatly increased, as did HIV testing and immunization for children under five. Focus groups conducted by the project suggest that bringing sexual and reproductive health messages to non-traditional groups such as BMUs contributed to this increase in service use.
While Lawrensio received family planning training through his role with the BMU, HoPE-LVB recognized the need to start these challenging conversations in comfortable settings. That’s where the project’s campfire outreach sessions came in. Fire blazing and maize roasting, men would slowly approach the gathering and bring up topics of conversation — including questions about family planning that were then addressed by health workers in attendance. By pairing natural resource management information with messages about healthy timing and the spacing of pregnancies, an internal evaluation found boys and men in communities showed increased knowledge about family planning.[xxxii] And they were willing to talk about it with their friends and wives, too.
Education and social acceptability are two ways to increase access to maternal healthcare for women. Another is empowering women with greater agency, and raising the status of women within their communities and homes — something that has proven to have a positive impact both on families and the environment.
One of these women is Namudu Annet who, at 38-years-old, holds many titles in her village on Bussi Island: model household, leader of a young mother’s group, BMU member, and mother of seven. Annet says the negative stereotypes that exist around the role of women are beginning to change. So too are the places where women are allowed to speak up — while there were some female BMU members before HoPE-LVB started, she says a woman’s place was still very much within the home.
Annet hasn’t always felt a sense of empowerment. Pregnant with her first child at the age of 16, she was expelled from her family’s home. “I was seen as an outcast and a waste in my family,” Annet says. “The boy who got me pregnant couldn’t look after me, and so I was a burden to his family and turned into a housemaid.” That relationship didn’t work out, and Annet moved to Bussi Island 18 years ago with her current husband.
Many of HoPE-LVB’s interventions empower women with the dignity and skills that Annet didn’t have as a young mom. Women get skills training for free, and then apply those skills to create a sustainable income-generating activity. “We gather young mothers together and teach them to immunize their children and other skills, like how to build clean cookstoves, make mandazi (a fried bread snack), and soap. That income means they don’t have to depend on their husbands,” she says. The scale of these income generating activities is notable: by the end of HoPE-LVB phase II, more than 25,000 energy efficient cookstoves had been built by women in Uganda and Kenya.[xxxiii]
“When our husbands realized we could bring income into the family, they started respecting us more,” says Annet. The USAID review of HoPE-LVB supports this claim — it found that the majority of respondents from Uganda and Kenya say their relationship with their partner had improved as a result of income-generating activities.[xxxiv]
A woman’s access to sexual and reproductive health and rights is explicitly tied to her ability to work. Studies have shown that female participation in the labor force among women aged 25 to 39-years-old can decline by 10 to 15% with every additional child.[xxxv] On the opposite end of the spectrum, research into the value of HoPE-LVB’s PHE integration found that women who earned additional income “frequently invested in sustainable income-generating activities, such as tree nursery management or beekeeping, in addition to other investments such as school fees.”[xxxvi]
Also connected to ability to work is bargaining power within the home — something which, as discussed in textbox 1, was shown to be diminished through declining fish stocks and fish-for-sex transactions. Following HoPE-LVB, women have more freedom to become engaged in natural resource management and men become more invested in sexual and reproductive health and supporting the health of their wives. But the question remained: did these integrations work?
Family planning for health and the environment
Educating people to consider — and value — the connection between population, health, and natural resource management is one of the key objectives in HoPE-LVB’s theory of change.
Research supports and quantifies the effectiveness of the project’s integrated efforts. A 2018 paper authored by Samuel Sellers for Environmental Conservation looks specifically at HoPE-LVB’s four sites, and Pathfinder’s hypothesis that a PHE approach could be used to deconstruct established gender roles, increase income, save family time, and improve community cooperation — each a factor that would improve conservation and health outcomes.
Here’s an example from Sellers’ research on how PHE integration helped prompt a shift to sustainable livelihoods — something especially important since a large percentage of Uganda and Kenya’s populations are youth of working age.
Following the first 2.5 years of the program (2011-2014), HoPE-LVB model households reported having more time because of the project’s interventions. That increased time came through three pathways: people needed to care for fewer children because of their ability to use family planning to space their pregnancies; were sick less often because of increased access to healthcare; and because they had to spend less time collecting firewood for energy efficient cookstoves. “This time was often devoted to livelihood activities such as beekeeping, tree planting, or gardening, all of which the project has provided training in and, in some cases, capital equipment for, and most of which are likely to have positive or at least neutral conservation outcomes,” Sellers writes. In other words, more free time translated to reduced pressure on vulnerable natural resources like firewood and fisheries.
One of HoPE-LVB’s other project hypotheses was that improved natural resource management would lead to people recognizing the benefits that come with a healthier lake or reforestation. As a result, the thought was that couples may reconsider their family size in order to reduce strain on the environment. While Sellers found people were starting to understand this connection between birth rates and environmental sustainability, no family had specifically chosen not to have a child because of it.
Interestingly, ideas of family planning have changed the way fisherfolk look at the resources provided by Lake Victoria. “When you don’t illegally fish, it gives some time for the young fish to grow which means they’ll be bigger and able to breed other fish later. It connects to family planning — we now plan for the lake,” explains Lawrensio, the head of the Beach Management Unit.
Annet, the mother of seven, says she also uses concepts of family planning in her garden. A cluster of matooke trees grows around the back of her house. It is here that Annet says people are able to first grasp the concept of PHE. “The more matooke trees you have growing next to one another, the smaller the bunch of bananas they produce,” she explains. “So you need to thin your banana plantation to get a bigger bunch. This is the same with family planning — if you have a smaller family then they’re healthier because of it.”
While this community-level change demonstrated by Lawrensio and Annet is a key part of local-level advocacy, a goal of HoPE-LVB was to make sure these changes remained once the project ended — and that they could be used to inspire new PHE projects across the region.
Institutionalizing a PHE Approach
In Kenya’s capital city of Nairobi, the jacaranda trees are flowering, distinctive purple blooms arching over the roadway. It’s down a road like this where Pathfinder International’s Kenyan office sits. Inside the boardroom, surrounded by stacks of folders and papers, is Pamela Onduso, the organization’s Youth, Advocacy, and Partnership Advisor in Kenya. An expert in reproductive health and family planning, Onduso has worked with Pathfinder for more than 25 years.
Onduso is responsible for grappling with the inevitability that accompanies any international development project, including HoPE-LVB: what happens when funding finishes and the project ends? Knowing such a future was on the horizon, the Pathfinder team built HoPE-LVB with sustainability and scalability in mind. This meant finding ways to get policymakers at all levels to understand PHE and adopt its integrated development practices in policies and programs.
To that end, Pathfinder partnered with ExpandNet, a global network of public health professionals and scientists who develop strategies to scale public health solutions. ExpandNet has worked with the HoPE-LVB team from the beginning to plan, implement, and expand the PHE approach to benefit more people and support long-lasting policymaking.
At the start of the project, that meant planning for expansion before any level of success was demonstrated. Community, district, national, and regional stakeholders were briefed about the project early on, told about the proposed model household interventions, and asked about their own pressing needs and obstacles.
This participatory exercise shaped the project.[xxxvii] For example, the decision was made to offer environmental conservation activities to district and county officials in addition to project communities, something that subsequently boosted project buy-in and the approval of new local by-laws. Building for scalability (anticipating to expand the project to new communities and add more model households) also helped HoPE-LVB grow to a larger geographic area during phase II, though the approach had to be tweaked to different local contexts and settlement patterns. By the end of phase II, there were 1,583 active model households across Kenya and Uganda.
Next came the creation of PHE steering committees in the two Ugandan districts and two Kenyan counties where HoPE-LVB works. Committee members come from multi-sectoral ministries whose work links to PHE efforts. Onduso says those steering committees have been key to earning acceptance at a level of governance that sits between community decision-making and national policy. “Everyone can see the problem, but you can’t begin to break it down and see how your different perspectives and resources can contribute to a solution until someone brings you together,” Onduso reflects on the value of those steering committees.
When it comes to engaging these various levels of government, adoption isn’t immediate. On the contrary, Onduso is the first to explain that advocating for PHE and sexual and reproductive health is a fine art.
Just as HoPE-LVB has certain tactics to effectively engage communities, there are also best practices when it comes to advocating among government officials — especially when it comes to potentially controversial topics. That means that while Pathfinder International frames the project as a “rights-based approach” to sexual and reproductive health, that same language needs tailoring for national government officials in Kenya and Uganda. “As much as I would like to say ‘rights,’ I don’t when I’m doing policymaking with high-level government officials,” Onduso says. “That opens a Pandora’s Box because they want to know about which rights: abortion, LGBTQ… It’s very sensitive.” Instead, Onduso uses language like ‘contraception,’ and ‘healthy timing and spacing.’ “I mean the same thing, but you have to be very careful how you frame it so the governments don’t blacklist us,” she adds. Knowing which messaging to use has been key in making PHE advocacy a success.
Strategic partnerships have also helped. From 2015, HoPE-LVB has had a Memorandum of Understanding with the Lake Victoria Basin Commission (LVBC), the body that oversees management of the region on behalf of the five East African Community (EAC) countries. “We use evidence from HoPE-LVB to advocate to change policies in each of the relevant ministries, and now there is an EAC PHE Strategic Plan,” says Doreen Othero, the Regional Programme Coordinator for the Integrated PHE Programme at the LVBC. “Without that evidence we would not have convinced our ministers.”
Projects precede policy
Project evidence has also helped Andrew Tiondi, a bureaucrat with Uganda’s National Population Council, and Coordinator of the country’s National PHE Network. Like Onduso, he has the unenviable role of convincing government officials in various ministries and jurisdictions to work together in adopting a multi-sectoral approach to solving some of the country’s development challenges. Coming from a fishing community in northern Uganda, Tiondi understands some of the natural resource management challenges villages face. But not all policymakers have the benefit of that firsthand experience, and concepts like family planning and improved latrines can go over the heads of bureaucrats sitting in a bustling capital city. That’s where field visits to the model households come in.
Once government officials see the model households in action, they get it, Tiondi says. “The PHE model households address important issues the government is grappling with: preventative health by having basic sanitation interventions in place, health and nutrition, and the fact that Uganda’s population is increasing but its land and resources are constant,” Tiondi says of those visits. Ultimately, there are mutual benefits to be gained from HoPE-LVB cooperating with the national government, and vice versa. For the government, the project’s community-level interventions help reach every household in a way larger national or district-level programs may struggle, particularly in rural and isolated fishing communities. From HoPE-LVB’s perspective, support from national government leaders is needed to work with district level staff in departments like community development, culture, and health.
The next policymaking step is for Uganda and Kenya to finish their national PHE strategies. Once finalized, government PHE champions like Tiondi can work to weave PHE values into specific ministerial policies related to health, water, environment, and beyond. It may seem like a lot of paperwork, but these similarly named policy pieces are needed to institutionalize the value of integration and advocate for greater budget allocations for PHE projects. “Some officials are still cagey about the multi-sectoral approach, and questions arise about how we will pool resources,” Tiondi says. “But they’re not looking at the bigger picture. As a government you may not be able to deliver an outcome because you need other players to play a role in that delivery.”
As with any initiative, more funding is needed to support PHE integration across the Lake Victoria Basin. Pathfinder and its collaborators still struggle with single sector funding: “everyone always looks at which budget PHE activities should come from — Conservation? Health? Planning?” says Dorah Taranta, HoPE-LVB’s Uganda Project Manager. “Each sector has its allocations and key activities.” Meanwhile, Doreen Othero of the Lake Victoria Basin Commission remains hopeful that the PHE integration efforts started by HoPE-LVB can be continued, even without donor funding. “That has been my main worry, and I’ve told Pathfinder many times that they need to build capacity of the people who will be here beyond the project life cycle,” she says.
There are some positive signs of financial support in Uganda. The national government has pledged 4 billion Ugandan shillings (about US $1.5 million) to start PHE model households in the Mount Elgon region of Kenya and Uganda. The area bears similarities to the Lake Victoria Basin: large family sizes and environmental degradation, though in mountainside communities. “While several LVBC environmental programs have been implemented in this area before, it was realized that there was the need to pay attention to the link between environmental challenges in the basin and community health issues,” Othero says. “Previous challenges were addressed vertically: per sector, and in silos.”
Ultimately, Pathfinder International is confident HoPE-LVB has demonstrated that a PHE approach is needed — and possible — across multiple complex ecosystems, socioeconomic backgrounds, and geographies. “In the past people thought PHE was a little boutique project,” says Sono Aibe, the Pathfinder International Senior Advisor who first led the way for the organization’s PHE efforts. “Thankfully, I think Pathfinder was able to fill that gap, demonstrating scalability, institutionalization, and the advocacy for new policies.”
Appendix 1 shows the cycle that exists between human health, fishing patterns, food insecurity, and poverty. This cycle illustrates some of the interconnected challenges faced by people who live in Lake Victoria’s fishing communities. Research another scenario where health could affect the way people manage their natural resources, and create an illustration similar to the one of Dr. Kathryn Fiorella and her team.
 Dagaa (Rastrineobola argentea) is the Kiswahili name for the small, sardine-like fish found in Lake Victoria. Fisheries researchers attribute the rise in dagaa biomass to the decline in Nile perch stock, as dagaa was released from competitive pressure with the demise of the cichilds. Food preference-wise, dagaa is considered less valuable than Nile perch or Tilapia, as there exists a culture of eating larger table fish. The dagaa fishery could, however, be a way to make the lake’s fishery more gender equitable, as women play a larger role in the harvest, drying, and selling of dagaa versus traditional Nile perch.
 The African continent has a population density of 36 people per square kilometer. A shift from rural to urban environments, in addition to high birth rates, has, however, meant that Africa’s most populated cities have dramatically higher population densities. Take Cairo, Egypt (population: 19.5 million, population density: 19,376 people per square kilometer) and Kinshasa, Democratic Republic of Congo (population: 9.4 million, population density: 19,900 people per square kilometer).
 In Uganda, Population Research Bureau data says women of childbearing age give birth to an average of 5.4 children, and that number sits at 3.9 children per woman in Kenya — both substantially higher than the global average of 2.4 children per woman.
 “[R]eproductive rights…rest on the recognition of the basic rights of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health.” - UN International Conference on Population and Development, Programme of Action, Para 7.3, 1994.
 The HoPE-LVB project works in two sites in Uganda and two sites in Kenya. In Uganda, it is Wakiso District (home to Bussi Island) and Mayuge District; in Kenya, the project operates in Siaya County and Homa Bay County.
 The HoPE-LVB baseline study found that 81% of households in the Uganda and Kenya sites relied on firewood as their main source of cooking fuel.
 Another case study in this anthology looks at how land use management and dam construction in the Senegal River Basin in West Africa has affected the spread of schistosomiasis in the region.
[i] “Lake Victoria Map And Map Of Lake Victoria Depth Size History Information Page.” World Atlas. July 12, 2016; https://www.worldatlas.com/aatlas/infopage/lakevictoria.htm
[ii] http://documents.worldbank.org/curated/en/537691468202150422/pdf/PID-Appraisal-Print-P153466-03-23-2015-1427143505609.pdf The East Africa Community is made up of six countries: Tanzania, Kenya, Uganda, Burundi, Rwanda, and South Sudan.
[iii] Bremner, Jason, et al. “Using New Methods and Data to Assess and Address Population, Fertility, and Environment links in the Lake Victoria Basin.” XXVII IUSSP International Population Conference. August 26-31, 2013; “https://iussp.org/sites/default/files/event_call_for_papers/IUSSP_paper_JBremner_etal_0.pdf
[iv] Ogutu-Ohwayo, Richard. “Management of the Nile perch, Lates niloticus fishery in Lake Victoria in light of the changes in its life history characteristics.” African Journal of Ecology 42:4. January 7, 2005; https://doi.org/10.1111/j.1365-2028.2004.00527.x
[v] Pringle, Robert M. “The Origins of the Nile Perch in Lake Victoria.” BioScience 55:9. September 1, 2005; https://doi.org/10.1641/0006-3568(2005)055[0780:TOOTNP]2.0.CO;2
[vi] Pringle, Robert M.
[vii] Pringle, Robert M. “The Nile Perch in Lake Victoria: Local Responses and Adaptations.” Africa. November 2005; https://www.researchgate.net/publication/250227017 [viii] Pringle, Robert M.
[ix] Downing, Andrea S., et al. “Was Lates Late? A Null Model for the Nile Perch Boom in Lake Victoria.” PLOS ONE. October 18, 2013; https://doi.org/10.1371/journal.pone.0076847
[x] Reynolds, J. Eric, et al. “Thirty years on: the development of the Nile perch fishery in Lake Victoria.” The Impact of Species Changes in African Lakes. 1995; https://doi.org/10.1007/978-94-011-0563-7_10
[xi] “Lake Victoria.” International Union for the Conservation of Nature (IUCN). 2018; https://www.iucn.org/theme/species/our-work/freshwater-biodiversity/what-we-do/lake-victoria
[xii] Njiru, M., et al. “An overview of the current status of Lake Victoria fishery: Opportunities, challenges and management strategies.” Lakes & Reservoirs Research & Management 13:1. January 22, 2008; https://doi.org/10.1111/j.1440-1770.2007.00358.x
[xiii] Njiru, M., et al.
[xiv] Turyaheebwa, Nicholas. “Perception on fishery trends in Lake Victoria.” Norwegian College of Fishery Science. https://munin.uit.no/bitstream/handle/10037/7140/thesis.pdf?sequence=2
[xv] LVFO Secretariat. “Fisheries Management Plan III (FMP III) for Lake Victoria Fisheries 2016 - 2010.” East African Community. http://www.lvfo.org/sites/default/files/Final%20FMP%20III%202016%20to%202020_0.pdf
[xvi] Njiru, M., et al.
[xvii] Opio, Alex, et al. “HIV Infection in Fishing Communities of Lake Victoria Basin of Uganda – A Cross-Sectional Sero-Behavioral Survey.” PLOS ONE. August 5, 2013; https://doi.org/10.1371/journal.pone.0070770
[xviii] Yebra, Gonzalo, et al. “Analysis of the history and spread of HIV-1 in Uganda using phylodynamics.” Journal of General Virology. July 2015; https://dx.doi.org/10.1099%2Fvir.0.000107
[xix] Opio, Alex, et al.
[xx] Fiorella, Kathryn J., et al. “Human health alters the sustainability of fishing practices in East Africa.” PNAS. April 4, 2017; https://doi.org/10.1073/pnas.1613260114
[xxi] “Lake Victoria Falling Water Levels Concern for Growing Population.” United Nations Environmental Programme Division of Early Warning & Assessment. https://na.unep.net/atlas/africaLakes/downloads/posters/Lake_Victoria.pdf
[xxii] World Bank
[xxiii] “The Issues.” Global Alliance for Clean Cookstoves. http://carbonfinanceforcookstoves.org/about-cookstoves/introduction/
[xxiv] Lopez-Carr, David, et al. “Health of the People and Environment in the Lake Victoria Basin (HoPE-LVB) Project Evaluation.” USAID, p. x; http://ghpro.dexisonline.com/sites/default/files/350%20HoPE-LVB%20Report%20Final_with%20annexes_4-25-18.pdf
[xxv] Aibe, Sono, et al. “Health of People and the Environment Lake Victoria Basin Project Baseline Study Synthesis Report.” Pathfinder International. 2013; https://www.pathfinder.org/wp-content/uploads/2016/09/Health-of-People-and-the-Environment-Lake-Victoria-Basin-Project-Baseline-Study-Synthesis-Report-1.pdf
[xxvi] Aibe, Sono, et al.
[xxvii] “Couple Year of Protection.” John Hopkins Bloomberg School of Public Health. https://www.k4health.org/sites/default/files/Couple%20Year%20Protection.pdf
[xxviii] “Health of People and Environment in the Lake Victoria Basin.” Pathfinder International. 2018; https://www.pathfinder.org/projects/hope-lvb/
[xxix] Kavanaugh, Megan L., et al. “Contraception and Beyond: The Health Benefits of Services Provided at Family Planning Centers.” Guttmacher Institute. July 2013; https://www.guttmacher.org/sites/default/files/report_pdf/health-benefits.pdf
[xxx] Aibe, Sono. “Scaling-up the Population, Health, and Environment Approach in the Lake Victoria Basin: A Review of the Results from Phases I and II of the HoPE-LVB Project.” Pathfinder International. September 2018; https://www.researchgate.net/publication/327780767_Scaling-up_the_Population_Health_and_Environment_Approach_in_the_Lake-Victoria_Basin_A_Review_of_the_Results_from_Phases_I_and_II_of_the_HoPE-LVB_project
[xxxi] “Sustaining Health, Rights, and the Environment in the Lake Victoria Basin.” Pathfinder International. June 2015; https://www.pathfinder.org/wp-content/uploads/2016/09/Sustaining_Rights_2015PHE.pdf
[xxxii] Aibe, Sono. 2018.
[xxxiii] Aibe, Sono. 2018.
[xxxiv] Lopex-Carr, David, et al.
[xxxv] Sundaram, Preethi. “Sexual and reproductive health and rights – the key to gender equality and women’s empowerment.” International Planned Parenthood Federation. February 2015; https://www.ippf.org/sites/default/files/2020_gender_equality_report_web.pdf
[xxxvi] Sellers, Samuel. “Does Doing More Result in Doing Better? Exploring Synergies in an Integrated Population, Health and Environment Project in East Africa.” Environmental Conservation. September 14, 2018; https://doi.org/10.1017/S037689291800022X
[xxxvii] Omimo, Antony, et al. “Applying ExpandNet’s Systematic Approach to Scaling Up in an Integrated Population, Health and Environment Project in East Africa.” Social Sciences 7:1. January 2, 2018; https://www.mdpi.com/2076-0760/7/1/8/htm
[i] Fiorella, Kathryn J., et al. “Transactional Fish-for-Sex Relationships Amid Declining Fish Access in Kenya.” World Development. October 2015; https://doi.org/10.1016/j.worlddev.2015.05.015
[i] Ochumba, Peter B.O., et al. “Observations on blue‐green algal blooms in the open waters of Lake Victoria, Kenya.” African Journal of Ecology. March 1989; https://doi.org/10.1111/j.1365-2028.1989.tb00925.x
[ii] Goldschmidt, Tijs, et a. “Cascading Effects of the Introduced Nile Perch on the Detritivorous/Phytoplanktivorous Species in the Sublittoral Areas of Lake Victoria.” Conservation Biology. September 1993; https://doi.org/10.1046/j.1523-1739.1993.07030686.x
[iii] Anderson, Donald M., et al. “Harmful Algal Blooms and Eutrophication: Nutrient Sources, Composition, and Consequences.” Estuaries. August 2002; https://www.whoi.edu/cms/files/Anderson_etal_2002_Estuaries_29903.pdf
[iv] Slootweg, R. “Prey Selection by Molluscivorous Cichlids Foraging on a Schistosomiasis Vector Snail, Biomphalaria glabrata.” Oecologia 74:2. 1987; https://www.jstor.org/stable/4218454
[v] “Water Hyacinth Re-invades Lake Victoria.” NASA Earth Observatory. December 2006; https://earthobservatory.nasa.gov/images/7426/water-hyacinth-re-invades-lake-victoria