Saving Children's Lives--The Key to Low Fertility

On Friday, my colleague and former PhD student, Magdalena Benza, presented a paper at the PAA meetings on which I was a co-author. Her paper was excellent, focusing on how we can create an urban gradient using satellite imagery, from which we can draw key inferences about fertility levels in different parts of a country. One of the other papers in the session examined causes of the stall in the decline of fertility in Kenya. A key element is the fact that child mortality has not declined enough for couples to feel comfortable about limiting fertility. Indeed, as John Casterline of Ohio State University pointed out in his discussion of the papers in that session, Africa is perhaps the best example in the world of a region where the demographic transition has followed the expected model that fertility declines in direct response to a decline in mortality. The flip side of that, of course, is that if mortality is not dropping quickly, then we cannot expect fertility to be declining.

I thought of that when Debbie Fugate today linked me to a story at BBC News about the success that Rwanda has had in lowering their child mortality rate. To be sure, lowering child mortality has been one of the UN's Millennium Development Goals developed in 2000 as targets for 2015.

And one of the biggest success stories is Rwanda. Between 2000 and 2015, it achieved the highest average annual reduction in both the under-five mortality rate and the maternal mortality ratio in the world. The UN estimates that 590,000 children have been saved.

Dr. Fidele Ngabo, head of the division for maternity, child and community health in Rwanda explained how this came about:

"We had four top killers - malaria, diarrhoea, pneumonia, and malnutrition - diseases which can be treated by simple intervention. So we selected 45,000 community health workers at each village so when the children are sick, instead of spending one or two hours going to a health facility, the community health workers can give the treatment in less than 10 minutes.

"They are elected by the community. The only criteria we give is they can read and write. We give them basic training like how to screen for malaria, how to take temperatures, how to check respiration. For complicated treatment, they are obliged to transfer patients to the health facility."

The workers are not given a regular salary, but are paid for what they achieve. "The most important thing is to bring service closer to the community, that's what people can really learn from our country."

This actually sounds a lot like the "barefoot doctor" program in China that helped bring down death rates in the Chinese countryside several decades ago. At the same time, the story points out that there are new technological elements to this that allow community members to be in close touch with health providers. 

The only problem I have with the story is that it is not clear what the source is for the information on child mortality. According to the Demographic and Health Survey website, there is a survey being conducted at the moment, and maybe these data are pre-release findings from that survey, but that is not stated and the website of the National Institute of Statistics in Rwanda does not have any information about the newest survey. So, here is the story we know about: in 1992, 163 out of 1,000 babies born in Rwanda died before their 5th birthday, and the average woman was having 6.2 children. By 2010 (the most recent survey for which we have data), the child mortality rate was down to 102 out of 1,000 and the TFR was down 4.6. Sadly, both of these numbers are still extremely high.