Progress toward the Goal in Rwanda

In addition to marking Spain’s first World Cup victory, this past Sunday was World Population Day. Even though it did not receive the same attention as Andrés Iniesta’s goal in overtime, population is a critical component of global development.In this week’s Lancet, Nick Wadhams highlights a rare success story in family planning in Sub-Saharan Africa. Rwanda is a country of 11 million people, all of whom reside on a piece of land that is slightly smaller than Maryland (whose population is 5.8 million), making it one of the most densely populated countries in the world.In 1994, 800,000 to 1 million Rwandans were murdered in a horrific genocide, leaving 5.5 million people in the country. Since then, the population has doubled, and most outside NGOs, bilateral and multilateral agencies have found it difficult to tell a country that recently lost 20% of its population to control the number of births per woman.So, how did Rwanda, a country with a per capita income of merely US$370, become a success story in family planning? Wadhams offers a handful of explanations in his article—increased access to contraceptives, better education, the introduction of performance-based financing, political will, etc.—and an excellent paper from IntraHealth provides a detailed account of “how a taboo topic became priority number one.”While a variety of reasons and events led to Rwanda’s success (and will hopefully lead to continued successes), I would argue that none was more important than political will.It seems that the government’s earnest interest in population control emerged in 2005 when a presentation to parliament demonstrated the economic benefits of having smaller families, including improved health and education opportunities. Rwanda had recently set out ambitious goals to nearly triple its per capita income to $900 and turn the country into an African center for technology by 2020. The presentation spurred leaders to realize that without limiting the number of people in the country, their goals for poverty reduction, economic development, modernization and becoming a leading country in the region would not be possible. Ongoing research is analyzing the effects of health and demographic change on economic growth, and some exciting new research coming out of Brown University (through the PopPov Research Network) will hopefully convince additional policy makers of the link.In Rwanda’s next iteration of its Economic Development and Poverty Reduction Strategy (2008-2012), family planning took a front seat. Goals included lowering the population growth rate from 2.6% to 2.2% and increasing contraceptive prevalence use to 70% by 2020. Rather than solely preaching abstinence—which wouldn’t be surprising in a country where over 50% of the inhabitants identify with the Catholic Church and 40% of health facilities are religiously affiliated—the government focused on increasing access to and usage of contraceptives.The numbers speak for themselves. In 2000, an estimated 4% of the population used modern birth control. In 2005, the number grew to 10%. Data from 2008 saw the biggest jump of all: contraceptive use went up to 27%. (As Wadhams rightly points out in his article, 27% may not seem significant when compared with developed countries, but the rapid increase in usage over three short years is extraordinary.) Meanwhile, the average number of children per woman decreased from 6.2 in 1992, to 5.8 in 2000, to 5.5 in 2007-2008.In Rwanda, when the government decides to put an issue front and center, people listen. The economic argument may have sold government officials on family planning, but it was the government’s strong commitment to act that ultimately brought about change. When I was living in Rwanda, we used to joke that no matter what the Minister of Health (at the time) was invited to speak about, he inevitably ended up preaching about the importance of family planning.Rwanda’s president, Paul Kagame, has come under scrutiny lately for a lack of democratic norms and poor human rights. While there is certainly reason for criticism and the international community should push for massive improvements as national elections approach in August, Rwanda’s incredible progress in family planning should not be overlooked.