How does a country that has lost 300,000 of its children to genocide consider the proposition of family planning?

It’s a problem with nuances and contradictions that Laura Hoemeke, the director of a family planning and health project in Kigali, Rwanda, considers every day. Hoemeke, whose project is operated by the non-profit Intrahealth, works to expand access to family health services at centers and clinics throughout the small east-central African nation. Intrahealth, based in Chapel Hill, N.C., works throughout the developing world to develop effective health care systems.

“My Rwandan contacts,” Hoemeke says, “tell of women, in the years following the genocide, coming into a clinic and saying, ‘Why are you even talking about this? I just lost three kids.’

“Right now I’d say we’re in between the old and the new in the people’s thinking.”

The “old” is a reference to the months in1994 and 1995 after Rwanda’s convulsive genocide, during which an estimated 500,000 ethnic Tutsis died at the hands of a rival ethnic group, the Hutus, tens of thousands of whom, in turn, were killed by Tutsis. Official estimates put the total death toll at between 800,000 and one million. Of them, an estimated 300,000 were children fifteen or under.

Recently, however, thanks in large part to the country’s current president, Paul Kagame, the prospects for family planning have improved markedly. A year ago this month, Kagame emerged from an annual retreat of top government officials to declare family planning and population issues the government’s number one priority.

As the country works to throw off its past, growing numbers of women and their families–not just the government–believe that family planning can make a difference to their lives. With maternal mortality, infant mortality and unwanted pregnancies all still relatively high– there are both micro and macro reasons why this country is experiencing a family planning renaissance.

On the macro level, observers say the president and his advisors recognize that any attempts to improve economic conditions would be hobbled by the current high fertility rate-approximately 6.2 children per woman in a country of nine million people, already one of the continent’s most densely populated.

“We realize we’re late on this,” Kagame told the New York Times last year, adding that he intended to enact a sweeping program to encourage family planning and cut Rwanda’s birth rate by half.

This receptivity of Rwanda’s leaders to family planning and reproductive health recently prompted the Hewlett Foundation to give Intrahealth a grant for $275,000 to help it support the government on these issues.

The Rwandan work supports two of the central goals of the Foundation’s Population Program: to enhance and protect the reproductive health and rights of individuals and to stabilize global populations in ways that promote social and economic well-being.

A Devastating Setback

The killings and civil war during which they occurred had decimated the country’s health care infrastructure. Many nurses and other health care givers fled; health centers were destroyed. It was nearly six years before the health system began to function again. Even then, Hoemeke says, efforts to resume family planning work were hobbled by a desire on the part of the population to “replace” the children lost and a fear of contraception as a “tool” of genocide.

Today, the challenge of family planning still is complicated by a traditional culture that views more children as better-in the words of an old Rwandan saying, Abana n’umutungo: “Children are your wealth”-and by the country’s large Catholic population.

“The government has voiced a commitment,” Hoemeke asks, ” but how do we support them to act on this commitment and do it in a way that’s sustainable after projects like ours end?”  

Finding a Way Forward

Intrahealth’s answer entails several approaches.

The nonprofit will use some of the Hewlett funding to support the Rwandan minister of health in his efforts to promote family planning, developing his knowledge of the issues by sending him to the United States to confer with leading experts.

The organization also will provide support to an inter-ministerial population committee that Kagame created last year to support family planning and health. The group, which includes representatives from the ministries of youth and culture, finance, education, and agriculture as well as health officials, has met just once since being formed.

“The ministry of education alone could do a huge amount to help,” says Hoemeke. “We can offer the committee resources and help them to create a plan of action. We’re hoping that will start to happen in the next few weeks.”

In the second half of the year, she says, Intrahealth also hopes to help the 30 district mayors and other local officials create reports that President Kagame has requested on a variety of indicators in their districts, including family planning. Currently, she says, many of the mayors don’t know how to make these assessments and are torn between the president’s population goals and the traditional cultural call to have many children.

Finally, Intrahealth hopes to use some of the Hewlett grant to train and support journalists in the country who cover family planning issues. Hoemeke envisions training seminars on the use of statistics as well as field visits to clinics.

“We’re hoping to generate some excitement on the topic,” she says.

Dodging Ghosts and New Hope

At Intrahealth’s offices in North Carolina, Rebecca Kohler, the Director of Program Development, noted that while there is a new beginning in Rwanda, the past in not yet entirely the past.
“There are challenges you do need to face,” she says, “concerns about unfairness. It’s important to have broad-based support at all levels, so this isn’t seen as coming from one part of government.”

But for now, in Kigali, Hoemeke sees an enthusiasm to move forward.

‘There are African countries where I’ve worked where you barely meet the health minister,” she says. “This is the first place I’ve been where the minister of health will call you on a Sunday and say, ‘I just had this idea and can we meet to discuss it?’  

“It’s an intense environment to be in. But it’s why it’s exciting to be here.”