A health center offering family planning services in Rwanda, supported by Partners In Health/Inshuti Mu Buzima.

“There are few places in the world where the full pressure of population growth is felt as strongly as in tiny, landlocked Rwanda,” write PIH’s Antoinette Habinshuti and Josh Ruxin of Columbia University in an article published in the June 29 issue of Nature. “Its politicians and citizens are keenly aware that their country is nearing a population crisis.”

The small nation is smaller than the state of Maryland but has almost twice as many people — over 11 million compared to 5.7 million. Women in Rwanda have an average of five to six children, giving it the sixteenth highest fertility rate in the world.

The article, "Crowd Control in Rwanda," details how Africa's most densely peopled mainland nation is working to head off this population crisis — focusing on a national family planning strategy — and why other countries should take note.

“The situation in Rwanda is forcing reality and political pragmatism together more rapidly than in neighboring countries. The choices are stark: restrict population growth or remain in poverty, without the capacity to support either a growing population or an emergent economy,” write Ruxin, who is also the founder and director of the Access Project, with Habinshuti, who is the deputy country director of PIH’s Rwandan sister organization Inshuti Mu Buzima. “The lesson from Rwanda for other nations is that without coordinated efforts… population growth will swallow up a country's potential.”

Ruxin and Habinshuti offer a simple recipe, based on lessons learned from Bangladesh, Ghana, and elsewhere: grow the economy, educate girls and women, and offer free contraceptives in every health center and through every community health worker. “That will get you 90 percent of the way,” they write.

This is more easily said than done. While policies focusing on educating girls and women, and pushing for prosperity are widely accepted both nationally and internationally, making contraception freely and widely available has historically faced opposition from local religious and political institutions. For example, Habinshuti and Ruxin note that the Catholic Church manages about half of the health centers in Rwanda and refuses to provide contraceptives on site, even to men with HIV. 


A woman receiving an in Depo-Provera, a contraceptive injection. Access to contraceptives is one of the family planning services offered at health centers supported by PIH/IMB in Rwanda.

But public discourse and political will are changing in Rwanda. For example, some government and partner programs have set up discrete family-planning centers just outside the doors of Catholic facilities. And politicians and church leaders now often speak of kubyara aba ushoboye kurera — “giving birth to those you are able to raise fairly,” say Ruxin and Habinshuti. “Rwanda is determined to do what works.”

However, Family planning remains a low priority for many international donors. Between 1994 and 2007, family-planning aid dropped from 30% to 12% of overall aid, according to the Worldwatch Institute. Habinshuti and Ruxin strongly advocate for reversing this trend. “Family planning is cheap,” they write. “ The UN estimates that for every dollar invested there is a threefold economic return.”

Read Ruxin and Habinshuti’s full article.