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Focus Media (Kigali)

Rwanda: Political Will Essential for Success of Family Planning

Sam Ruburika

24 August 2008

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opinion

In the 1994 genocide, people often lost nearly their entire family. Others might have seen their children die due to awful conditions in refugee camps. How do you

"How a taboo topic became priority number one". It is the fitting subtitle to the report "Family planning in Rwanda," recently released by IntraHealth.

"The family planning story in Rwanda is one of gain and loss, followed by rebuilding to regain lost ground and then achieving even greater progress," the report notes. It makes the experience probably all the more interesting, and a good example of how a coordinated effort can overcome many obstacles.

Family planning was certainly not advanced before the genocide. Indeed, in 1992 only 13% of married women were using modern contraceptive methods. Then came the genocide, which obliterated whatever achievements that had been made.

Already, there were (and are) social and cultural barriers in Rwandan society that make family planning a difficult package to sell. "The culture had always been strongly pro-natalist," the IntraHealth report points out. "A traditional wedding toast encourages newly married couples, 'Be fruitful, may you have many sons and daughters'."

Moreover, the stance of the predominant Catholic Church on contraception did not make matters easier.

The aftermath of the genocide only added more obstacles. In the first place, with all the human loss, family planning was not an easy matter to talk about. "The government was shy to talk about family planning because so many families had lost loved ones," a USAID staff member says in the report.

Furthermore, the country's health system needed to be reconstructed, which is hardly an appropriate context to pay much attention to family planning.

It is therefore no surprise that it was estimated that in 2000, only 4% of married women used modern contraceptives. Yet by 2005, this had increased to 10%. And the latest estimates, for early 2008, indicate that the rate has almost tripled, reaching 27%.

Poverty reduction

So how was it achieved?

"When asked about the main keys to success, most people talked first about the political will behind family planning," IntraHealth says, also quoting the Minster of Health who remarked that "family planning is priority number one-not just talking about it, but implementing it."

This strong commitment can be explained by the fact that the government has recognized that family planning is necessary for poverty reduction and the development of the country, which is only reinforced by the fact that Rwanda is the most densely populated nation in Africa, with 355 people per square kilometer, compared to an average of 32 per square kilometer in sub-Saharan Africa.

What also played an important role, according to many interviewees, was the impact of the RAPID model in driving home the link between population growth and economic development, and the need for family planning in order to achieve poverty reduction.

RAPID projects the social and economic consequences of high fertility and rapid population growth for such sectors as labor, education, health, urbanization and agriculture. This model is used to raise policymakers' awareness of the importance of fertility and population growth as factors in social and economic development.

It puts a positive spin on things by talking about the advantages of having smaller families in terms of improved health and education opportunities.

In addition, family planning was seen as an essential way to reduce high levels of infant and maternal mortality, both of which had increased after the genocide.

This shift from family planning being a political taboo to becoming a priority issue, is also reflected in the country's socioeconomic master-plans.

Whereas the first Poverty Reduction Strategy Paper (2002-2005) did not even mention family planning, it became a prominent issue in the Economic Development and Poverty Reduction Strategy, 2008-2012 (EDPRS).

Coordination

There were also factors that made that this political goodwill of the central government quickly translated in action in the field. One of them was cultural: "People have a high propensity to listen to authority. [...] There is a high level of obeying what the government says," one interviewee is quoted as saying in the IntraHealth report.

The government's drive for decentralization also made it easier to get the message-and the action-down to the grassroots. However, the report points out that decentralization also carries a danger, in the sense that implementation of family planning policies might be done at different speeds in different areas.

"The biggest challenge now is harmonizing and having national coverage because we are not going at the same pace," an IntraHealth International staff member says.

This is why coordination is very important, all the more so given that Rwanda has a large number of partners working on family planning and reproductive health.

According to the report, "coordination has ensured that all districts are receiving assistance in strengthening family planning service delivery and has led to standardized training and IEC tools [Information, Education, and Communication]."

Yet there is still room for improvement, the IntraHealth report notes. "While there are various mechanisms for coordination, and a number of policies in place, there is a lack of a strong central focal point for family planning within the government to ensure coordination and effectively share lessons and identify gaps."

It has to be noted, though, that efforts are underway to revitalize an inter-ministerial committee which was set up in 2007; yet it met only once and then stalled.

Motivating providers

Both clients and providers of family planning services, the report says, talked about the importance of trust-trust that services will be available, appropriate and confidential. Essential steps in improving quality so that such trust is developed include ensuring that methods are there and that providers are trained.

Also important is the question of motivation, especially on the part of local authorities. According to IntraHealth, "there have been a number of innovative methods of providing motivation and incentives for performance, including performance-based financing, performance-based contracts and District Incentive Funds."

So far these methods have worked, the report says, but the question is whether they can be sustained on the long term. "Motivation produces results-but it can be expensive. These projects should include exploration of how to transition to more sustainable systems of motivation over time," according to the report.

Obviously, there are still challenges to overcome.

The main ones, mentioned in the report, are scaling up successful initiatives nationally; improving use of data for decision making; mobilizing resources for commodities (with increasing demand, it will become more of a challenge to cover the costs of contraception); addressing the continuing opposition from the Catholic Church; removing 'small' barriers (e.g. women being denied services if they are not menstruating, or being required to obtain husband's consent); developing and conducting a national-level awareness campaign on family planning that addresses myths and misperceptions about methods and their side effects and other barriers to family planning use; including sexual and reproductive health education in schools; strengthening integration of family planning and HIV.

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