A government scheme that ranks health centers by how many women they enroll on birth control is having unexpected consequences, including women being denied other services if they resist.

Health centers are using all possible means at their disposal to force as many women on the list. Our investigation in Muhanga, Ruhango, Nyanza and Ngororero districts, and at one health center in Kigali - confirmed allegations by women in rural areas that they are paying the price so that the health center directors get good grades.

In addition to grades, the health centers also expect gifts in form of additional financial bonuses. Attaining such a feat also comes with good publicity for the health center director. A district whose health center ranks high will always be given as example at local conferences. It also contributes to ranking of district in the national Imihigo (performance contracts).

A health center is a facility at the level of a sector. There are 416 sectors making up Rwanda, but there are 499 health centers - meaning some sectors have more than 1 such facilities. At this center, manned by nurses, patients get basic treatments and birth control.

Before the beginning of every year, district officials require health centres under their jurisdiction to set targets of women they will enroll on birth control. With nearly 300,000 babies born every year (or population of a sector), Rwanda stands out as one of the most densely populated countries. It is also having unbearable strain on the country's meager resources.

The rankings

For 2019, in Muhanga district, Nyabikenke health center topped - attaining 76.9% of their target women coming for birth control. Nyabinoni health center was last in the district at 50.2%.

In Ruhango district, the best health center Kigoma exceeded its target with up to 182%, as the last was Byimana health center with 32.3%. For Nyanza district, Gahombo center emerged top with 92% women showing up for birth control.

However, as our investigation has discovered, behind these numbers is a team of health workers employing all sorts of tricks, some cruel, to have as many women as possible registered as on birth control.

In addition, these rankings are not known to public. We first heard of them from some aggrieved women we interviewed in these districts. Our reporters couldn't get the rankings officially, so were obtained them from sources at the district headquarters. We also had to agree to the women not to reveal their identities, otherwise none was willing to speak.

At Muhanga district's highest ranked health center, we find Chantal who told us: "They refused to immunise my child because I did not accept to be put on birth control when I gave birth."

For Marie Claire, when nurses informed her of need for birth control, she accepted without hesitation. However, while she preferred pills, the nurses required her to take intrauterine device (IUD) known as "agapira".

In Kigali, at Kimisagara health center, we met Rosine. She said: "They brought the Agapira but I refused, pleading they give me pills or injection. They closed the door. It was hurtful and I told them my child is about to reach 4 years and will need to have another baby. They responded that they dont want any more babies born in Kjmisagara sector."

Giselle from.... (Which area) said nurses told her they have to make sure the health center gets a good grade and reward. She told us: "The nurses will everything possible so that the health center gets that agahibazamusyi (reward)."

Different senior officials at Muhanga, Ruhango, Nyanza and Ngororero districts confirmed that awards for 2019 rankings of health centers on birth control are still under preparation. The best facilities get certificate of recognition and yet to be specified financial bonuses, which are known on day of the awards, and by the recipients only.

At Muhanga district, our source said: "For us here, health centers that performed well in 2019 will be reward. The awards are being organized in collaboration with district partners."

Another source at Ruhango district told us: "In Ruhango, the best performing health centers in birth control have been getting bonuses (agahimbazamusyi). But this time, with our partners, we are planning different other rewards."

At health centers, according to the health ministry, women can choose at will whether to take the pills, injection, or the IUD (agapira).

Health Minister warns

The standing instruction is that for to be women given all the information and left to make the decision on their own, said health minister Dr Diane Gashumba, adding: "Medical staff are supposed to monitor the women and if there are any negative side effects, the method is changed. Any medical official doing the contrary risks punishment."

"Birth control is a choice women are encouraged to use. Besides, they are aware of the consequences of having many children whom they cant manage. The role of medical officials is to monitor and change the method if it affects the woman."

"Any medical official going against these regulations will be held to account if identified."

As of 2018, Rwanda's fertility rate was at 4.2 (or at least 4 to 5 children). Though it has significantly dropped from as high as 6 a few years back, it remains extremely high. In the Vision 2050 unveiled at end of 2017, government wants fertility rate to be at 2.3.

To get to this rate, various ways targeting both men like vacectomy, and women birth control, have been vigorously promoted. Some sections of political elite at some point pushed for legislation to put in law how many children each family must have. The project didn't succeed.

Last year, NGOs began pushing for a change in the law to allow girls as young as 15 to access contraceptives. The campaign came amid an explosion of men impregnating underage girls.

However, President Paul Kagame and the Catholic Church have both opposed any such moves. Kagame said in November that it would be like granting state permission to underage sex which is unacceptable, instead calling for tougher laws to discourage men from ever attempting to abuse young girls.

Monsignor Filipo Rukamba, head of the episcopal conference of Rwanda, said in August last year that he did not believe the pills actually work. Teenage pregnancies are "caused by girls loosening themselves,” said Msgr Rukamba.

“Even if they give you those pills, the the only medicine is you. The Bazungu (white people) who spread the contraceptives are themselves having many babies they don’t want, as other abort.”