Authored by Evans A.K. Miriti

Reflecting on the added value of a population, health, and environment (PHE) approach, this technical brief discusses implementation experience stemming from phase one of the Health of People and Environment-Lake Victoria Basin (HoPE-LVB) project. To counter the interconnected, multifaceted challenges that communities living in and around the Lake Victoria Basin face, Pathfinder International—along with Ecological Christian Organization in Uganda, several environmental and health partners in Kenya, the Population Reference Bureau, and ExpandNet—implements the HoPE-LVB project in Uganda and Kenya. With funding from the David and Lucile Packard Foundation, the John D. and Catherine T. MacArthur Foundation, USAID, the Evidence to Action project and the Barr Foundation, the HoPE-LVB project aims to reduce threats to biodiversity conservation and ecosystem degradation in the Lake Victoria Basin while simultaneously increasing access to sexual and reproductive health services. This publication explores project experience from phase one (2011-2014), and offers considerations for implementing a scalable, integrated PHE project.


Communities in and around the Lake Victoria Basin (LVB) experience a number of interconnected challenges, including dependence on shrinking natural resources for survival, widespread poverty, food insecurity, poor sexual and reproductive health and inaccessible health services. At the same time, the LVB ecosystems are facing considerable change. To address these challenges and foster healthy, engaged communities, Pathfinder International is implementing the Health of People and Environment–Lake Victoria Basin (HoPE–LVB) project. The project is implemented in a combination of island, lakeshore, and inland sites in Uganda and Kenya. This article discusses project successes and lessons learned from Phase One of the project.


Stretching across parts of Uganda, Kenya, Tanzania, Rwanda and Burundi, the Lake Victoria Basin is home to approximately 42 million people. (1) Many factors affect the health of these people, driving food insecurity, high maternal mortality rates, and poor sexual and reproductive health. In addition to the Basin’s importance for sustaining life, its ecological value—a network of critical wetlands, 52 key biodiversity areas,(2) and more than 200 species of fish—is also of global significance.(3) Over the last half century, the LVB has seen declining fisheries, poor water quality, deforestation and loss of biodiversity. The underlying drivers of this environmental change include climate change, agriculture, pollution, deforestation, overfishing and increasing industrialization (including both the commercialization of Lake Victoria’s fisheries and growing oil and gas exploration in the region), coupled with weak national enforcement of environmental regulations.(4)

Given the LVB’s significance for both human and environmental health, its condition is a cause for concern. In response to these challenges, the HoPE-LVB project aims to reduce threats to biodiversity conservation, enhance the capacity of local communities to manage natural resources, and improve sexual and reproductive health outcomes. The project catchment area comprises sites located in Uganda’s Mayuge and Wakiso districts, as well as in Kenya’s Siaya and Homa Bay counties.

Problem Diagnosis

In 2011, at the beginning of the HoPE-LVB project, LVB resources—which local communities depend on for survival—were being degraded and health indicators were disproportionately poor in the project catchment area. Taken together, these factors were driving a cycle of increasing insecurity for LVB residents.

Depletion of Natural Resources

More than 80 percent of HoPE-LVB residents rely on fishing and agriculture for food and economic gain.(5) At the start of the HoPE-LVB project, both fishing and agriculture had become increasingly insecure as the LVB had changed over time. For communities dependent on fishing, the introduction of invasive fish species (most notably the Nile perch),(6) extinction of native species, eutrophication and overfishing had contributed to declining fish stock and decreasing fish diversity and size. The dwindling productivity of small-scale fisheries was contrasted with—and partially driven by—Lake Victoria’s thriving commercial fishing industry, which today generates more than $600 million in annual revenue.(7) Mostly an export market, the commercial fishing industry’s profits remained concentrated among a small number of large companies located outside of the LVB, and thus brought little benefit to local communities.(8)

At the same time, communities dependent on farming for security faced declining land productivity, soil loss, and livestock and crop diseases all of which made agriculture an unreliable livelihood. With no alternatives and in the face of pervasive poverty and food insecurity, communities dependent on the LVB for livelihood and security had defaulted to unsustainable fishing and farming practices to survive.(9)

Adverse Health Outcomes

At the start of the project, sexual and reproductive health needs in the basin were great and basin-wide health outcomes were poor. The HoPE-LVB baseline assessment found a significant unmet need for contraception. The baseline assessment also showed that a large proportion of women who had given birth in the previous two years had delivered without the benefit of skilled birth attendants.

Gender norms in the area also impacted natural resource use. A larger share of household chores such as cooking and gathering wood fell to women and girls.

Inadequate Response to Needs

Community members in the basin area reported feeling systematic abandonmnent by local government authorities and the health system at the start of the project. Communities reported that they rarely received government support and that none of the health facilities in the basin met a minimum standared of care for maternal and newborn health, contraceptive or youth-friendly services. Community-based village health teams or community health workers were inactive at the start of the project and outreach services to the community were rare.

On the environmental protection side, what local mechanisms to mitigate degradation and uphold sustainable practices did exist were largely ineffective at the start of the project. Community actors charged with promoting sustainable practices, such as village environmental committees, sub-county council members, and district environmental and natural resource officers lacked the capacity and support to carry out their work.

All these pressures and lack of support or response in the basin had served to disempower communities, suppress stewardship, exacerbate environmental degradation and drive poor sexual and reproductive health outcomes.

The HoPE-LVB Project

The Health of People and the Environment in the Lake Victoria Basin (HoPE-LVB) project assembled a multi-sector team to implement an integrated population, health and environment (PHE) strategy in the region. Working with local stakeholders, the project team examined and then addressed threats to biodiversity conservation and ecosystem degradation in the LVB while simultaneously increasing access to family planning and reproductive health services. By integrating the delivery of reproductive health, livelihood, and conservation education and services in these communities, HoPE-LVB is improving reproductive health and natural resource management in the basin more successfully than programs focused exclusively on reproductive health or the environment.

HoPE-LVB works at individual, community and structural levels to implement actions.

Individual Level

At the individual level, the project takes on the cycle of increasing insecurity by fostering opportunities for people to realize and then act upon their own agency across both the environmental and health domains. The project works to lessen the effects of poverty and counter adverse gender norms.  The project team trained and supported individuals to lead discussions about the HoPE-LVB approach and advocate for environmental regulations through a network of PHE champions and model households that were selected by the community. These model households are trained using an integrated curriculum and then promote healthy behaviors and sustainable natural resource use through group and one-on-one peer education sessions, as well as advocacy at multiple levels.

During Phase One of the project, a total of 233 PHE champions were established (126 in Uganda and 107 in Kenya).

The project also supports individuals and households to diversify their sources of livelihoods and transition away from sole reliance on fishing and farming. The construction and sale of energy efficient stoves, tree nurseries, and beekeeping all emerged as attractive alternative livelihoods throughout the project.

During Phase One of the project, community groups constructed 7383 energy efficient stoves (4544 in Uganda and 2839 in Kenya) and planted a total of 258,977 trees (240, 884 in Uganda and 18,093 in Kenya). The sale of stoves and trees resulted in profits exceeding $10,000 and community groups have invested this money in other income-generating activities such as poultry keeping and construction of water harvesting tanks.

To foster gender equality, the project works to increase the social capital of women and girls by creatting opportunities for women-led groups to initiate income-generating activities and by supporting networks of peer groups to foster greater social support for health-seeking behavior. The project also uses BMUs and other traditionally male community-based groups to engage men in sexual and reproductive health.

At the end of the project's first year, a routine review of data revealed that from July to September 2012, 31 male PHE champions had been selected and 12 female champions. This prompted the project to assess what other project interventions might be inadvertently perpetuating inequality and to identify the underlying factors that contribute to gender equality in the basin. The outcomes resulted in more intentional gender-aware programming and more equitable distribution of training and income generation opportunities.

Community Level

At the community level, the project builds the capacity of a diverse range of community based resource groups—Beach Management Units (BMUs), Village Health Teams (VHTs), Community Health Workers (CHWs), women's groups, youth groups, farmers' groups, and savings and loan groups—to promote positive health and environmental practices. The project works with relevant government authorities to increase availability of services at the community level and to support community-based mechanisms that are already in place for sustainable natural resource management.

The HoPE-LVB project used its integrated PHE curriculum to train 792 community group members (337 in Uganda and 455 in Kenya) on sustainable agriculture and fishing practices; alternative livelihoods; gender; maternal health; and healthy timing and spacing of pregnancies.

The project also supported monthly outreach services during which facility-based health workers provided health education and information, contraception, immunizations, HIV testing and counseling and referrals for further care.

Structure Level

At the structural level, the project strengthens health and natural resource management systems, and works toward institutionalizing the integrated PHE approach across sectors. Because many potential avenues for remedying environmental degradation (most notably, broad-based oversight and regulation of industry) require cross-border action and collaboration, the HoPE-LVB project also supports regional efforts for greater enforcement of existing environmental regulations. Finally, cognizant that sustainable, long-term solutions to the LVB’s challenges must demonstrate scalability, the project partnered with ExpandNet (10) to systematically test the viability of the integrated approach throughout the project’s first phase (2011–2014) in order to inform scale-up in its second phase (2014-2017).

In collaboration with government trainers and using the Ministry of Health curriculum, the project facilitated training for 28 health workers across both countries. By the end of Phase One, facilities have broadened the contraceptive method mix available, with the number of methods offered in Ugandan project-supported facilities increasing from four to eight and the Kenyan facilities increasing from five to six.

In order to institutionalize the project's integrated approach, the HoPE-LVB team worked with relevant government authorities to establish a cross-ministerial steering committee comprising health, environmental, and youth stakeholders. This team is responsible for the oversight of HoPE-LVB interventions and advocated with local policymakers to pass bylaws to further project actions.

To learn more about the successes of Phase One of the HoPE-LVB project, including testimonials from the people they have helped, visit: is external)


Text source: Pathfinder International. Sustaining Health, Rights, and the Environment in the Lake Victoria Basin. Watertown, MA: Pathfinder International, 2015.


1. J. Bremmer, D. Lopez-Carr, A. Zvoleff, and N. Pricope, Using new methods and data to assess and address population, fertility, and environment links in the Lake Victoria Basin, IUSSP International Population Conference, 2013.

2. Key biodiversity areas are “globally significant sites for biodiversity conservation.” Identification of these sites is based on diversity of amphibians, birds, butterflies, crabs, fish, mammals, mollusks, dragonflies, plants, and reptiles. (The John D. and Catherine T. MacArthur Foundation’s Conservation and Sustainable Development Program).

3. MacArthur Foundation and Birdlife International, Conservation Strategy for the Great Lakes Region of East and Central Africa, retrieved from " is external)".

4. MacArthur Foundation and Birdlife International, Conservation Strategy for the Great Lakes Region of East and Central Africa, retrieved from " is external)"

5. Bremmer, et al., 2013.

6. Although the Nile perch was introduced into Lake Victoria relatively recently (in the 1950s), its effect on the fish ecosystem has been stark, resulting in the decimation of several hundred native fish species and fueling commercialization of the lake’s fisheries.

7. M. Njiru, et al., “An overview of the current status of Lake Victoria fishery: Opportunities, challenges and management strategies” Lakes & Reservoirs: Research & Management, 2008: Vol13, Iss.1: 1-12.

8. K. Geheb, S. Kalloch, M. Medard, AT Nyapendi, “Nile perch and the hungry of Lake Victoria: Gender, status and food in an East African fishery” Food Policy, 2008: Vol 33(1): 85-98.

9. Resulting practices include the use of illegal gillnets, capture of juvenile fsh, slash and burn agriculture, farming along the lakeshores, cutting trees for charcoal, and over-cultivation of land.

10. ExpandNet is a network of professionals working toward advancing the science and practice of scale up. HoPE-LVB was the first project to systematically apply the ExpandNet methodology for scale. See Beginning with sustainable scale up in mind: Initial results from a population, health and environment project in East Africa for more details on this process