_Regina McNwmara_ **_et al._** _8_ It may be neither possible or necessary to assemble elsewhere the numerous organizations and consultants that were involved in the creation of this family planning service. The cost in U.S. dollars was high; probably over half a million in three years for the ACNM part alone (in Ghana and in the U.S.). Yet the funds and technical assistance provided to the GRMA, the coordinating role played by ACNM, and the adroitness of the GRMA in managing relationships with five agencies while guarding its autonomy were undoubtedly factors responsible for a successful launching of a family planning service program with excellent potential for long term influence on Ghanaian attitudes and Practices. The experience gained is guiding replication of the program in Nigeria and Uganda, n',o countries where private maternities are also common.

The effects of this program, which adds about ')OO service delivery sites throughout a country that has approximately two and a half million women of reproductive age, are not likely to be seen immediately in national prevalence or total fertility rates. Nonetheless, by expanding the scope of professionals who are already established in their communities, it has put in place (with good prospects for continuation) a private sector piece that was missing from the national program.

# III. The Rwanda Community Project

# _Background_

Rwanda has two extraordinary demographic problems; a population of about seven million on 26.3 thousand square kilometers (270 persons per sq. km.) and an annual rate of population increase of about 3.5 percent. The 1988 total fertility rate, estimated at 8.0, was the world's highest (World Bank, 1990, Table 27). Rwanda is also one of the least urbanized countries; worldwide, its 7 percent urban population is exceeded by all nations except its neighbor, Burundi, and Bhutan (World Bank, 1990, Table 31). Subsistence crops comprise 95 percent of agricultural production; and these are raised on a rugged land mass with steep slopes.

The area was part of German East Africa until the League of Nations awarded it to Belgium as a mandate after World War I. It attained political independence in 1962. The Hutu group (a Bantu people) constitute 84 percent of the population and nearly 100 percent of the leadership; 15 percent of Rwandans are Tutsi (Europa Publications, 1986). This is a tightly structured society, organized from the highest levels of government to the ten regions, the communes within regions, and the cellules within communes.

The rate of population increase was recognized as a problem in the colonial era and after independence in several five-year plans that proposed internal and external migration, expansion of arable lands, and agricultural improvements. The second-five year plan (1977-198 1) recognized overpopulation as a major obstacle to development, and proposed research on family planning, training and service delivery (Emmanuel, 1988). The third development plan (1982-1986) was more specific; it proposed to maintain the growth rate at 3.7 percent per year while the conditions for a rapid decline after 1986 were to be put in place. Raising age at first birth and limiting births among women over age 40 were priorities. Pronouncements of the presidept, and the politfical party, Mouvement Revolutionnaire National pour le Developpement (MRNO), have called for action by the State and non-governmental organizations, especially by religious groups.