Contraception Hope Public Health

Discover a Success Story in Africa

Smoking hut in northern Ghana

            Last month I wrote about the 5 countries I have enjoyed visiting in Africa, including citing their amazingly low per capita GDP. Although most of the population growth over the next decades is predicted to occur on that continent, I see some rays of hope.

            There are two places in the world where studies have been done on ways to increase voluntary family planning, along with other important medical research. One is Matlab, Bangladesh and the other is Navrongo, northern Ghana. I had never heard of the Navrongo studies until shortly before visiting there! 

            Both Matlab and Navrongo have shown that community health workers can improve health significantly. In addition to family planning, the Ghanaian studies studied several successful interventions, including vitamin supplementation and mosquito nets treated with an insect repellant. Their family planning research showed that it is possible to increase contraceptive use and slow population growth even in an impoverished, poorly educated population. This is especially important research since Navrongo is close to the Sahel, and the people there are similar to Sahelians in their preference for large families.

            In 1995, the beginning of the Navrongo studies, the average woman had about 5 children. Fifteen years later, in 2010, that number had dropped to a bit over 4, both in the Navrongo control group and in the country as a whole. One of the interventions decreased the fertility further, to 3.7; a significant reduction.  Now, a decade later, the fertility rate for the whole country is 3.7 children per woman. That group was ten years ahead of the rest of the country! This group combined specially trained community health nurses (as opposed to stationing them at a clinic or hospital) and “zurugelu”.

            “Zurugelu” means “togetherness for the common good”, and was male-centered in the past. For a better explanation, I asked one of the investigators who had worked in Navrongo what “zurugelu” meant. Here is Dr. James Phillips’ reply:

“The zurugelu approach is a social engagement strategy that involves merging the organizational system of primary health care provision with the traditional system of social organization and governance.  When gender problems were evident, we attempted to turn patriarchy on end by working with women’s social groups in ways that were traditionally dominated by men.  Social events, termed “durbars”, were traditionally male events that were led by traditional male social leaders.   To build women’s autonomy and roles, we worked with leaders to eventually have women’s convened and women’s led durbars.  We also had gender outreach activities for responding to the needs of women.   As such, the “zurugelu” approach was a gender development strategy.”

(A “durbar” is a meeting of men with their chiefs.)

            It is interesting that neither community health nurses nor zurugelu alone had much effect on fertility. Even though the nurses educated women about family planning and supplied the necessary materials, fertility did not decrease significantly in the regions where they were introduced but didn’t have zurugelu. Nor did zurugelu alone have much effect by itself. It took both working together for the fertility to come down.

            The need for both nurses and zurugelu is a very important observation. The statement has been made frequently that worldwide over 200 million women want to limit their fertility but don’t have access to modern contraception. Since the nurses provided that access, we know that access alone isn’t enough—at least in this group of people. Apparently tradition and paternalism were significant barriers to using contraception. It took zurugelu to change attitudes before people made the most of what family planning was available.

            What difference did zurugelu make? This traditionally male function opened the eyes of men to the needs of women. Furthermore, the Navrongo programs strengthen the roles of women. 

            Now, back to my visit in Ghana. It was dusk as we were driving from Navrongo back to Nalerigu. We passed a straw hut with smoke emerging from its roof.

            “Is it on fire?” I asked.

            “No”, my host replied. “She’s just cooking the evening meal.”

            Although there is much beauty in northern Ghana, and everyone I met was friendly and warm, my impression is that life is difficult. Now that child mortality is a fourth of what it was 50 years ago, people will benefit from smaller families as well as more education.

© Richard Grossman MD, 2022


Catch a Glimpse of Kenya

Image from The Hunter Legacy Film, courtesy of Hunter Sykes

            Years ago I met Dr. Rhodes Moicombo in the little African country, Swaziland (now “Eswatini”). When he learned about my interests, he told me how he had promoted family planning in Kenya.

            Right after medical school, Moicombo worked in a rural area of Kenya that had never had modern healthcare. He understood that he needed to win the respect of his future patients so came up with an idea. Knowing how much Kenyans prize children, he planned a demonstration of his medical skill using the kids. He set up shop under a large tree in the center of town and gave kids candy-flavored worm medicine. Parents were amazed and delighted the next day to find worms in their children’s poop!

            After Moicombo had established trust with his worm medicine, he started talking with the mothers about the advantages of family planning. I don’t know what methods were available to women then, but overall Kenya has been successful in lowering its fertility rate in the past half century.

            Back in the 1960s Kenya was one of the fastest growing countries in the world, with a Total Fertility Rate (the number of children that a woman bore) of about 8. Although much lower now, the TFR is still high at just over 3 children.

            Kenya had their census last year and we are just starting ours. A subscriber to Population Matters!, David Zarembka, has lived in Kenya for many years and his wife is Kenyan. Some of his recent blogs treat the results of the 2019 census.

            There are problems in getting accurate census data in any country, so it’s not surprising that the Kenyan 2009 census was marked by some “irregularities”. One of the purposes of a census is to allocate government funds. Knowing this, some enumerators (census workers) in the 2009 Kenyan census “padded” the numbers, so their region would get more money. There may have been a million “ghost” people who didn’t really exist! The Kenyan government made changes to prevent this sort of fraud in 2019. Enumerators came from outside the community, and a local “elder” accompanied each. The result of last year’s census was significantly lower than expected. There were 47.5 million Kenyans on the night of August 24, 2019.

            Zarembka is optimistic that Kenya’s growth rate is slowing. He writes: “As I look around Kenya… I notice that very few teenagers are now giving birth – one of the prerequisites for a fall in the birth rate.”

           It will be interesting to see what the USA 2020 census will bring. We know that our country’s TFR is less than replacement, but our population will continue to grow due to population momentum and immigration. Even in the USA there are difficulties in getting an accurate count, since there are some groups who want to go under the radar—undocumented migrants are an example.

            Kenya is an example of what can be done to slow population growth. Moicombo was a pioneer in introducing family planning in one area, and recently I met another innovator. Dr. Charles Ochieng is a general physician in Nairobi whose passion is providing vasectomy care. He even offered to do his father’s vasectomy for free, but was turned down. His father already has 7 children with his new wife!

            Because I’m limiting my travel due to concern about climate change, I’ll probably never visit Kenya. However, I just watched a wonderful movie, The Hunter Legacy; perhaps some of you saw it at the Durango Independent Film Festival. In addition to world-class pictures of the beautiful people, scenery and wildlife, it tells important stories. Because of rapidly increasing population, especially in the past, humans have destroyed much of the wildlife. Hundreds of animals were killed in the past to make room for settlements. We have plowed much of the wildlife habitat into agricultural fields and ­­­­­­­poachers continue to the slaughter the animals.

            The Hunter Legacy demonstrates ways of protecting wildlife using armed guards, aerial surveillance and fences to keep animals away from settlements. It also stresses the importance of slowing population growth with family planning and education.

            The movie is about J.A. Hunter, a Scot who lived up to his name as a professional hunter, cleared the land of wildlife for human settlement. The film says this about Mr. Hunter: “J.A. Hunter lived for more than 50 years in East Africa. During that time, he shifted from a focus on hunting towards a belief in conservation as concerns about wildlife populations intensified.”

            The film was made by Hunter Sykes, who lives in Durango. You can view the film at:

© Richard Grossman MD, 2020