HEAL Cross-Cutting Module            
Picture of mountains in Bolivia
© Julie Larsen Maher, WCS

Cross-Cutting Syntheses, Cross-Site Learning and Tools

Introduction to Cross-Cutting Team Research and Management Functions

Collectively, this portfolio of projects represents a unique opportunity to have far greater impacts on conservation and public health practice and policy than any single project could achieve alone. To realize these added benefits, a Cross-Cutting HEAL Module that will both provide management support to the multiple HEAL projects and ensure that synthetic lessons learned are captured and shared is being developed. This cross-cutting initiative will ask over-arching questions about the role that nature plays in human health, questions that cannot be adequately answered solely by individual research projects. For example, a) under what ecological, socio-economic, and market conditions are the “services” provided by nature important, or not, for supporting human health; b) under what conditions might nature conservation be a cost-effective public health investment; c) under what geographic and socioeconomic conditions, in terms of equity, are health-related services derived from nature likely to be the only ones sustainably available, and d) how can the results from these case studies be generalized to inform conservation decisions and policies elsewhere? Answers to these questions will help the HEAL team develop policy messages on the role and value of nature in sustaining human health, and will be disseminated via scientific papers and non-technical communications tools targeting a range of important audiences.

Synthetic Research Questions and Approach

The synthetic research will consist of two main components: an economic analysis of nature as a “provider” of health services; and, closely related to this, the development of production functions that will allow the HEAL team to better quantify and predict the relationship between changes in ecological condition and the health benefits of conservation. Data collected across projects should be sufficiently comparable to enable these more generalized analyses.

Economic Assessment of Conservation Approaches to Addressing Health Challenges

Depletion or loss of nature’s services results from land-use changes, unsustainable extraction and shifts in land and resource tenure. These, in turn, may adversely impact human health through a number of direct and indirect pathways including changes in food sources that affect nutrition, and increased exposure to both biotic and abiotic causes of disease, among others. The portfolio of research studies described in this proposal aims to shed light on these relationships. For this information to be incorporated into health decision-making (or conservation planning), however, the research findings need to be further translated into standard metrics that also consider cost as well as equity implications.

Health economic studies are designed to identify the “optimal” use of resources in the health sector. An optimal strategy includes how to maximize the health gains from resource investments. Optimization also refers to ensuring equity in terms of the distribution of health gains. Cost-effectiveness analyses (CEA) are increasingly being used as a means for assessing the relative merits of alternative health interventions in terms of how efficiently they achieve specified health outcomes. To date, however, CEAs have mostly compared interventions delivered as products or services by the health sector. Many health interventions are actually preventive and are affected by changes in other areas such as societal conditions and the environment.  The lack of CEAs focusing on preventive activities means that the relative merit of environmental “interventions” is not generally being evaluated. The Economic Assessment cross-cutting research activity aims to fill this very important information gap by investigating the effectiveness of conservation as an “intervention” producing health gains, taking into account its associated costs.

There are a number of challenges inherent in such a study, including the reality that the health benefits of conservation may not be realized until the distant future, and that some of the health benefits may be more indirect, e.g., livelihood security which affects health through psychological and economic pathways. In addition, conservation may yield health impact by ensuring that health gains made through traditional health interventions (e.g., improved water and sanitation) are not undermined. Questions of scale provide another challenge, in terms of the fact that there may be local and / or very distant beneficiaries to a particular conservation intervention. Furthermore, the impact of environmental interventions, when actually evaluated in terms of cost-effectiveness, has been plagued by a lack of reliable data and non-generalizability of data between settings.  The HEAL portfolio of studies described herein specifically addresses these issues. Other challenges related to this research will be addressed through careful consideration of: the pathways through which health benefits are gained; the multitude of sectors investing in and with a vested interest in avoiding environmental degradation; and how costs averted can be adequately incorporated along with appropriate “discounting” rates given the potential long-term timeframe for impact. To compare across projects, HEAL collaborators will identify common metrics for the health outcome(s), such as disability adjusted life years (DALY’s). 

The analysis will assume a societal perspective and will incorporate the cost-effectiveness of traditional approaches to addressing the health issue (e.g., distribution of bed nets for malaria prevention) for comparative purposes. The team will also identify an acceptable comparator standard by which the absolute cost-effectiveness of conservation action in the project area can be assessed. It may be that traditional health interventions, in theory, would prove to be more cost-effective, if available. However, for numerous reasons, they may not be available. This speaks to the important issue of inequities in health which can be particularly problematic in remote rural areas where, not coincidentally, intact ecosystems still remain. Conservation in these areas may constitute not only a cost-effective intervention, according to a comparator standard, but also one of the only interventions ensuring health currently available.  Adding together the health and non-health benefits of conservation to the “tally” may considerably strengthen the argument in favor of conservation action over alternative uses of remaining natural ecosystems (“water, carbon, and health”). 

The design phase of this research will begin in year one, with on-the-ground data collection undertaken in the latter part of year 1 and years 2-4, and analysis and write-up of results being completed in year 5. The outcomes of this work will include: 1) a cost-effectiveness analysis of conservation as a health intervention, taking equity issues into account; and 2) a decision tree for public health practitioners and land-use managers on the conditions under which conservation can be used as a cost-effective method to provide health services and/or augment other public health interventions. Work on production functions (discussed below) is also relevant here.

From Case Studies to General Tools

The five modules included in this proposal are designed to provide a series of discrete entry points for examining the relationships between natural systems and human health. To widen their impact, however, the team will need to move towards synthesizing the learning from case studies into general principles and tools.  Such tools will allow the team to apply the growing knowledge of ecosystem / health linkages far beyond this constellation of case studies.

The Cross-Cutting Module partners include the University of Vermont’s (UVM) Gund Institute of Ecological Economics ( as well as Natural Capital Project (NatCap- within which UVM is also a partner-(, who play a role in helping generalize key findings within the framework of their InVEST tool. NatCap is a unique university-NGO partnership (principal partners being The Nature Conservancy, Stanford University, WWF, and the University of Minnesota) focused on quantifying ecosystem services, connecting this information to specific conservation issues, and mainstreaming consideration of ecosystem services within resource decisions of all kinds. NatCap’s principal product to date has been InVEST, a free and open-source software tool that maps the sources of ecosystem services, traces their flows to people, and estimates their economic value. In the broad area of ecosystem services, NatCap has led the transition from case studies to syntheses and general tools. The Program works actively in over a dozen field projects to test and improve InVEST, and the software has been downloaded over 2,000 times to date. Other tools, such as ARIES, are also being evaluated for use in the HEAL context.

The goal here is to begin this same transition for ecosystems and human health, even as key demonstration projects are developed. To do so, two specific areas of collaboration involving the University of Vermont’s Gund Institute of Ecological Economics and the Natural Capital Project, are getting underway. A team member focused on applying InVEST and other models to the specific place-based research has been brought on. This post-doctoral modeling expert is working with both the Cross-Cutting Module and the HEAL core (place-based) module teams. One of her tasks is to distill a simple, general model from what the HEAL team and wider research community is learning and to develop it into an InVEST module for more widespread use. This is the same basic approach NatCap has taken to develop each of the 10 InVEST modules currently available. The two most promising HEAL modules for inclusion in InVEST are those investigating 1) cardiorespiratory illness resulting from forest fires, and 2) wild foods and nutrition. Both present clear “production functions” linking changes in ecosystems through well-studied mechanisms to human health, and both are relatively amenable to generalization.  The team will evaluate this choice adaptively over time, however, in consultation with HEAL core module teams in order to make a final determination.

Second, the team will work to broaden existing InVEST modules to report changes in health outcomes, in addition to the existing biophysical and economic results. For example, InVEST’s water purification module currently reports outcomes in terms of reduced pollutant concentrations by wetlands and other vegetation, and the economic value of that reduction. Many users have expressed interest in health measures as well, such as access to potable water and incidence of diarrheal disease. Funding permitting, an additional post-doctoral researcher, trained in public health and modeling, will be hired to work with the InVEST modeling team to develop simple but defensible health-related outputs. The several water-related HEAL modules appear most suitable for this extension (e.g., water purification, water provision for drinking, sediment retention). The team again, however, will begin by scoping possibilities and prioritizing modules for which there is demand for health outcome information and a likelihood of sufficient data to support it. 

Structure of the HEAL Cross-Cutting Management Team

The cross-cutting management team will serve three functions: 1) they will work directly with HEAL consortium staff around the world to support their work and ensure that their results get disseminated widely to appropriate audiences at local, national, regional, and international levels; 2) they will work across projects to generate synthetic results and disseminate them to relevant audiences at regional and international scales; and 3) they will serve as the monitoring and evaluation team for the life of the project, in terms of ensuring on-time and on-budget delivery of quality products and the maintenance of the highest ethical standards across the program portfolio.  All projects will of course comply with U.S. and relevant international standards for work with human subjects, under appropriate IRB approvals as required.

This team will consist of a Director, Deputy Director, Program Manager, and four post-doctoral researchers.  Specific consultancies will also be undertaken as needed, including (for example) on health equity issues, international health policy, and applied economics.


The Director of the Consortium will be responsible for overall management: overseeing the reporting across all of the projects and catalyzing policy-related actions; coordinating outreach; and directing communications.  The Director will be in regular communication with all of the HEAL project leads and the program’s funders.

Deputy Director

The Deputy Director will be responsible for working closely with the Director to write reports and policy documents; organize HEAL consortium and donor workshops; ensure synthetic research across project components is being completed and progressing according to agreed timelines; and work with the Program Manager to disseminate updates and lessons-learned emerging from individual projects.

Program Manager

The Program Manager will be responsible for managing the overall project budget; ensuring semi-annual financial reports are submitted by all HEAL project leads and submitted as necessary to donors; and establishing and managing the HEAL web-site and a dynamic collaborative work-space for HEAL projects to share data, information, and approaches. The Program Manager will also be responsible for other administrative tasks as needed, such as circulating a bi-annual newsletter.

Post-Doctoral Fellows (Cross-Cutting Synthetic Analyses)

Four post-doctoral fellows will be hired as part of the cross-cutting team to work with individual HEAL module staff on economic analyses and development of production functions.

Economic Analysis

A post-doctoral fellow will assist with the development of a cost effectiveness model consistent with the HEAL consortium’s philosophy and objectives, and with individual field site realities. The fellow will travel at least once per year to each field site to ensure that the cost data collection tools are understood and are sensible for the local context, and that local staff are adequately trained to utilize them effectively. The fellow will work with each module’s principal investigator and team to contribute to sensitivity analyses and interpretation of model findings to ensure consistency with HEAL objectives.

Developing General Production Functions in InVEST

Two post-doctoral researchers will be hired to work with NatCap and HEAL teams to develop general production functions and to incorporate them into InVEST. 

Extending Existing InVEST Modules to Report Health Outcomes

One post-doctoral researcher will be hired to work with core NatCap scientists at Stanford, extending existing InVEST modules to report health-related variables.

Funding Status   

Partially funded- additional resources needed.

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