by The Lancet
http://rnanews.com/national/3774-can-rwanda-control-its-exploding-population-/
Thursday, 15 July 2010 07:56

Kigali: Rwanda’s Government has put slowing the country’s population growth rate at the centre of its Vision 2020 plan for the future. The scientific journal, The Lancet, reports on the problems and progress so far.

Not ghosts, babies!: Experts say there is no way the country can make economic progress without starting with controlling how many children are born every other time

Rwanda is a place where the notion that people could control how many children they had was once so alien that parents would name their children Harerimana, or God will raise him. It is not uncommon in this predominantly Catholic country for people to have more than ten brothers and sisters. So when Jannette Mukagisagara, a 44-year-old mother of five children, says “when you have fewer children you can feed them, clothe them and even educate them”, it is exactly what the Rwandan Government wants to hear.

A large family was once a sign of status and wealth, and more children meant more farmhands. As a result, the 11 million people in Rwanda are some of the most densely packed in the world, and the 90% of Rwandans who rely on agriculture to survive are forced to work tiny plots of land. The population has now doubled since 1995, the year after the Rwandan genocide, and will do so again in 25 years if population growth rates are unchanged. The situation has forced the government to look for new ways to lower the population growth rate: a goal that it has made central to its Vision 2020 plan for the future. That includes increasing per person gross domestic product to US$900, up from its current $330, and lowering maternal mortality rates from 750 per 100 000 births to 200 per 100 000. It also wants every child to go to primary school, and lower the population growth rate from 2•6% to 2•2%.

There has been a measure of success. The UN Population Fund (UNFPA) estimates that 27% of Rwandans use contraceptives—a small proportion perhaps, but far higher than even a few years ago. “Certainly within Africa, it’s really a shining star”, said Karen Hardee, vice president of research at Population Action International in Washington, DC, USA. “27% pales in comparison to the developed world, but when you think they were at 10% in 2005 and went to 27% in 2008, that’s extraordinary, unusally rapid growth.”

The high take-up of contraceptives in Rwanda is even more impressive considering the influence of the Catholic Church in the country. Although there has been a softening of the church’s stance towards contraception in Rwanda. Church leaders these days say explicitly that they will stay out of politics, and also argue that they understand the population pressure the country is now under. They might not allow church hospital staff to dispense birth control, but they do let them tell people where they can get it. “We are not against but also do not provide the services”, said Sister Xaverime Mwemera, medical chief of staff at the Kiziguro hospital. “The Government must respect the doctrine but this hospital must function within a democratic country.” Most Rwandan women have no trouble reconciling their faith with the reality of life on the ground. “The Pope cannot raise my children”, said Daphrose Nyrasafali, reproductive health programme officer at the UNFPA in Rwanda.

The government’s most effective way around the church’s refusal to provide contraceptives in its own hospitals has been to open what it calls secondary health clinics just down the road from Catholic-run hospitals. No matter how remote, these clinics are always stocked with contraceptives and, for at least a few days a week, have someone to staff the place and to hand out the contraceptives free of charge.

In a dimly lit room, complete with rickety examination table and posters urging people to “know the truth”, 30-year-old nurse Donat Murego staffs Kiziguro’s own secondary health clinic. “Before, women couldn’t find a place to get these [contraceptive] methods because the hospital was not providing them”, Murego says. “The church just treats people, believes they are responsible for their own choices, and all the people should have only those children they can raise.” Part of Murego’s job is dispelling myths about contraception. Hence the posters and a stack of pamphlets that debunk several myths, among them that using contraception will make women fat or unable to conceive in the future, or that condoms do not stop the spread of sexually transmitted diseases. Places like this clinic benefit financially from bringing in more women. Clinics that record more visitors get more government funding in a system known as performance-based financing.

However bold the government’s plan, it still has a long way to go. For all the talk of sensitisation and awareness-raising, it is still clear that women face huge challenges to using contraception: their own husbands. For many men a large family is still seen as a status symbol. Some also believe that birth control makes women too tired to do the chores, or uninterested in sex, or means they will not be able to conceive once they get off contraception. According to the government and various NGOs, women tend to prefer injectable contraceptives because they are both easy (one injection every 3 months), and, perhaps more importantly, husbands cannot detect them.

Barnabe Karenzi is Jeannette Mukagisagara’s husband. He says he is now a believer in family planning, but suggests his friends are less sure. “Other husbands do not meet me because they don’t want their wives to do the same”, he says. And he admits there was a time when he thought of demanding that his wife stop taking birth control. “In 2004, there was a period when she was feeling dizzy”, he recalls. “If I hadn’t been a good husband I would have stopped her.”

Population control might seem like an inappropriate topic to broach in a country that saw 800 000 people killed in the 1994 genocide, but the intense competition for land and resources brought on by overcrowding was an important contributing factor to the conflict. The genocide wreaked havoc on government efforts to control the birth rate in many, often unpredictable ways. Before the genocide, 13% of the population had access to birth control; that fell to 4% in the aftermath. Doctors and nurses who could teach people to use family planning—or insert and remove contraceptive implants or intrauterine devices—were killed. Sometimes people lost children or other relatives, and wanted to have more children as soon as possible. “After the genocide, imagine a man who lost all of his children—he must be able to make children again”, said Nyrasafali. “It was very sensitive and it was not easy to talk about it in public.”

Whether the approach taken by Rwanda can serve as a template for others in the region is not clear. Undoubtedly, Rwanda’s small size can work in its favour; it only takes a few health centres to serve the population, because no population is too remote. Implementing the same policies would be far more difficult in a country such as Kenya, with four times the population spread over a far larger territory. And Uganda, Rwanda’s neighbour, has faltered in the fight against HIV/AIDS. Prevalence of the virus is believed to be rising again, and no one quite knows why, although some experts believe it is because people no longer see HIV/AIDS as a serious threat.

Political will is also a factor in Rwanda’s success. President Paul Kagame exerts such control over the country that there is little political opposition that can stand in his way, especially since the Catholic Church took a back seat in domestic politics. “Rwanda’s a really good example of the impact that a political leader can have on setting the policy and setting the tone”, said Hardee. That is clear about an hour west of Kiziguro at the Rwamagana District Hospital, where doctors acting on government orders are keeping far more detailed medical records so officials can understand better what ailments their patients suffer from. Avite Mutaganzwa, a doctor at the hospital, echoes Hardee’s thoughts on the benefits of strong leadership. “One of the strengths is political will from the president down to the community,” he says.

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