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RWAMAGANA, Rwanda - The health centre just on the outskirts of town seems to be a community hub: Near the main clinic men, women and children sit around the perimeter of a courtyard waiting to be seen by a health worker. In another room, women waiting for family planning counselling are watching a television show that dramatizes the seriousness of AIDS. Outside, children play, and men on bicycles and motorbikes come and go.

Under the shade of a tree in the yard, Daphrose Nyirasafali, a reproductive health advisor for UNFPA, the United Nations Population Fund, is exhorting the group of about 100 men and women health promoters who will talk to members of their community about family planning and distribute contraceptives. They respond with a cheer.

Later they will head back to their communities. The women, many of them who have worked in the past as traditional birth attendants, will talk to other women about the impact that fewer children can have on the health and well-being of the whole family. They will also help monitor pregnant women for any danger signs and to encourage them to get regular pre-natal checkups. The men will make a special effort talk to husbands about the multiple benefits of smaller families.

Talking about family planning

The outreach effort seems to be very effective, even in this mainly Catholic country, where large families - six children or more -- have traditionally been esteemed and been the norm. Most Rwandan women now say they want between three and four children - and educated women want fewer than three.

Conversations with women outside of the clinic add a human dimension to the numbers.

Josiane, a 30-year-old woman with a two-year-old in her lap, and two more children at home, says she doesn't have the capacity to raise more. "Myself, I'm a farmer and I will do all I can to have my three children educated. My husband was the one who suggested we stop."

Angelique, 20 years old with one baby, says her husband also encouraged her to use contraception. They want two more children, but she's using an injectable to space the next birth - six years in the future, she hopes.

arie Louise has three children and is done with childbearing. She also encourages others to choose smaller families, "because with a lot of children you might not be able to give each one their right to education," she says.

Daphrose, 40, has seven children, and is having a hard time making sure they all have enough to eat. "I wasn't informed when I was younger," she complains. "Now I want no more children, because I'm a farmer and I'm facing school fees." She said that she started using contraception four years ago, after years of having a baby every year or two.

"My body wasn't in a good state then," she said. "I was very skinny - just 50 kilograms." Now she has a fleshed out a bit, and finds that she has much more energy. In fact, she is so energetic and so enthusiastic about family planning that she has become a community mobilizer herself. "Because of my testimony, all my neighbors have come here too," she says proudly.

ocus on husbands

It hasn't always been that way. When the family planning clinic opened in 2001, some women were reluctant to use contraception, according to Chantal Gahonga, the director of the health centre. Working closely with community leaders in the area, she was able to organize outreach to villages, paying particular attention to husbands. "We encouraged them to tell their wives to come. They started to understand that after all, they have the burden of feeding the family."

The health centre she directs offers a wide range of primary health care: a paediatric clinic, laboratory , pharmacy, prenatal clinic where women with HIV can get antiretroviral drugs to protect their babies, vaccinations, voluntary counselling and testing for HIV, tuberculosis testing and treatment, nutritional supplementation and family planning services.

It serves a population of about 53,000 - actually 52,977, according to Ms. Gahonga. Like many health administrators throughout Rwanda, she is in firm command of statistics related to her work. Charts and graphs monitoring the number of clients taking advantage of vaccinations, HIV testing and family planning counselling are posted on the wall behind her desk. She, like other health administrators throughout the country, is held accountable to meeting performance-based benchmarks and indicators.

In the decentralized health system, every manager reports to the next level - from the village to the sector to the district to the province, said Cheikh Fall, the deputy representative for UNFPA in Rwanda. "At every level they sign performance-based contracts. And on a yearly basis, they take two or three days to report in front of the President Kagame and development partners. Even we, as the UN have to report. This is why you see health indicators being improved in an incredible way.

Health indicators on the rise

"It is really innovative and evidence-based approach," he added. "Every report is backed up by data."

As a result of this, and other innovations, all health indicators in Rwanda are dramatically improving. Use of modern contraceptives increased from 10 to 17 per cent in just three years (2005-2008), a remarkable improvement. Skilled attendance at birth rose from 39 to 52 per cent in the same period. The average family size has decreased from 5.8 in the 2000 DHS to 5.5 in an interim survey (2007-2008). The ideal family size, according to the same survey, is now between three and four children. Maternal and infant deaths are decreasing, especially among impoverished women.

Another key innovation is the community-based health insurance system, which means that decent health care is widely available. A few years ago the country instituted Mutell de Sante, a health insurance plan that offers voluntary health insurance for the entire population. It's based on a pooling of resources at the community level. For an annual premium of less than $2 per household, health services are almost free, and 85 per cent of Rwandans participate.

A quiet revolution

Dr. Asha Mohamud, a regional advisor for UNFPA, recently made visited this clinic, as well as a number of other health facilities throughout the country to evaluate progress. She was enthusiastic about what she saw. "We knew that Rwanda was ‘called the Singapore of Africa' due to the fast pace of development, and we saw a quiet revolution is

She pointed to a number of innovative approaches in maternal health-where UNFPA is an important partner. Each maternal death is audited to discover the cause of death, and a similar effort is underway for infants. Traditional birth attendants are officially banned from delivering babies but now often monitor pregnancies, encourage women to get regular antenatal care and educate them about potential problems. Women who take advantage of regular prenatal screening can have free institutional deliveries.

The country is also working hard to reduce HIV, much of which is legacy of the genocide. It is estimated that half a million women were raped, and the genocide sparked massive movements of people across borders. HIV testing is encouraged, and antriretroviral treatment is widely available. Couples are encouraged to get tested for HIV together, and, if one is found to have the virus, to work out strategies to protect the other.

"I have seen the highest number of women accompanied by spouses or partners in one day than in many other health services visited where you see only women or men in some settings!" said Dr. Mohamud. "This offers an opportunity to systematically encourage them to negotiate safe sex."

Learning from Rwanda

She added that after her tour of health facilities, she concluded that "Rwanda as a whole is a demonstration project for many of the strategies that UNFPA promotes."

In an address last summer to a World Health Organization-sponsored meeting of health ministers and delegations, Rwanda's President Paul Kagame challenged other African leaders to also commit to the strategic investments in the health of their people.

"It is not pre-ordained that our continent must remain impoverished, illiterate, and in poor health - and if we can make the noted modest achievements in Rwanda, a country that is by no means rich, we can do better regionally and continentally," the Rwandan leader said.

--- Janet Jensen and Didier Habimana