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Coee andCommunity:CombiningAgribusiness andHealth in RandaBy Irene Kitzantides
Rwanda, the land o a thousand hills, is also the
land o 10 million people, making it the most dense-
ly populated country in Arica. Due to the coun-
trys rapid population growth, around 90 percent o
Rwandans depend on ever-smaller plots o land or their
ood and livelihoods, leading to poverty, soil inertility, and
ood insecurity.
But, ater an amazing recovery rom the devastating genocidethat ended in 1994, Rwanda is now a highly sought-ater
origin or specialty coee. Te Rwandan coee indus-
try holds the key to the countrys rebirth, reconcilia-
tion, and sustainable developmentand also the health
o its citizens. By combining community health edu-
cation and agribusiness development, the Sustaining
Partnerships to enhance Rural Development
(SPREAD) Project seeks to improve both the
lives and livelihoods o Rwandan coee armers
and their amilies.
March 2009
F O C U Son population, environment,and security
J une 2011 Issue
22
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The Legacy of Genocide
Rwanda has experienced a remarkable recovery since
the civil war and genocide devastated the countrys
society, economy, and environment 16 years ago.
Close to one million Rwandans were killed, andone-third o the population was displaced. GDP ell
by hal in a single year, 80 percent o the population
plunged into poverty, and large areas o park, or-
est, and armland were destroyed. Between 100,000
to 250,000 women were raped during this time, the
majority o them inected with HIV (Taxton, 2009).
Te legacy o this tragedy is still apparent: Rwanda
lost a signicant portion o its trained human
resources, suered damage to its already struggling
inrastructure, and must now balance administering
justice and preaching orgiveness. Rwanda currentlyhas an estimated 1.26 million orphans and one o
the worlds largest populations o both child- and
emale-headed households (Manning et al., 2008).
Despite such immense challenges, Rwanda has
made tremendous progress in recent years. Te coun-
try is now regarded as one o the saest in Arica, and
tourists once again ock to visit its native mountain
gorillas and other natural areas. Rwanda boasts rela-
tively low levels o corruption, a unctioning central
state with strong institutions, ambitious government
policies, and one o the highest economic growth
rates in the region (UNDP, 2007). It also strives to
maintain a pro-business environment, leading to sig-
nicant interest on the part o oreign investors.
Population-Environment Challenges
Rwandas economic growth and development are
hampered, however, by its population-environment
challenges. Te country is the size o the U.S. state
o Maryland, but holds roughly double the popula-
tion (around 10.6 million) in 2010. With around
403 people per square kilometer, it is the most
densely populated country in Arica (UNPD, 2011).
Around 71 percent o working adults are classiedas subsistence or unpaid armers, which combined
with high ertility rates, leads to extreme pressure on
already scarce land (World Bank, 2011).
Tese population-environment interactions are
outpacing economic growth, leaving 90 percent o
Rwandans living on less than US$2 per day. At its
current growth rate o 2.9 percent, the population
is projected to reach 15.8 million by 2025, which
will likely intensiy over-cultivation o land and soil
inertility, thus decreasing agricultural production
(UNPD, 2011).
Food insecurity remains a real concern: Te average
plot size or arming is around 0.8 hectares, and more
than a quarter o cultivating households arm less than
0.2 hectares; the Food and Agricultural Organization
estimates that at least 0.9 hectares are required to sat-
isy the nutritional needs o a household.
Youth peer educatorslearn ho todemonstrate condomuse (Photo courtesyThe Norman BorlaugInstitute)
Family planning is very
important, because it hasalloed us to put some o our
money into savings.
Female community member
(Source: Kitzantides, 2010)
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N
UGANDA
BURUNDI
TANZANIA
AkageraNational Park
VolcanoesNational Park
GishwatiNaturalReserve
NyungweNational Park
D.R.C.
North
Province
West
Province
South
Province
EastProvince
Kigali
10 30
Kilometers
201005
National Parks
Integrated Health/Pyrethrum Zone
Integrated Health/Coee Zone
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Reproductive Health Successes
Despite the tremendous obstacles o small land area,
high population growth, and the legacy o civil war
and genocide, Rwanda has made remarkable progress
in improving its health indicators, particularly thoserelated to reproductive health. Like many Arican
nations, Rwandans ace several barriers to amily
planning, including a traditional pro-birth culture,
religious opposition to contraception, and a lack o
inormation and services available in the rural areas
where the majority o the population lives.
However, thanks to strong government lead-
ership and support rom development partners,
increased access to a variety o contraceptive meth-
ods, and improved health care work orce training,
modern contraceptive prevalence rates made anastounding jump rom 10 percent to 27 percent
between 2005 and 2007 (INSR & ORC Macro,
2006; MOH, NISR, & ICF Macro, 2009). Te
total ertility rate (FR) decreased rom 6.1 to 5.5
in the same time period, while the inant mortal-
ity rate decreased 28 percent and under-5 mortality
rate by 32 percent.
HIV/AIDS rates, though low relative to the
region, are at 3 percent nationally, rising to 7 per-
cent in urban areas (INSR & ORC Macro, 2006).
Condom use remains low to due to cultural taboos
and lack o access, especially in rural areas, and
myths run rampant about side eects o amily plan-
ning. Diarrheal disease, malaria, maternal and child
health, and poor access to basic health services and
inormation in rural areas are still serious concerns.
Te Rwandan government understands the threats
posed by these population, health, and environment
challenges to Rwandas newound security and devel-
opment. Te countrys Vision 2020 plan delineates
the governments commitment to halving the poverty
rate and increasing the per capita GDP rom less than
US$300 to US$900 (UNDP, 2007).In support o this vision, USAID has dedicated
more than $12 million since 2000 to developing
the enormous potential o the specialty coee sec-
tor in Rwanda (USAID, 2010). More than 50,000
Rwandan coee armers have beneted rom the
growth and improvements in the specialty coee sec-
tor, increasing their incomes and improving their lives.
4
RwANDAS COFFEEINDUSTRY
Since 2000, the United States Agency or
International Development (USAID) has commit-
ted $12 million to develop Randas specialty
coee industry.
with this support, the industry has gron rom
zero exports and zero dollars in 2000 to 3,045
metric tons and $11.6 million in export revenue
in 2009making it one o the countrys largest
export earners.
Today, the U.S. and international demand or
Randas orld-renoned specialty coee
exceeds supply. Randan coee has been
eatured as a Black Apron Exclusive byStarbucks and praised as the best o the best
by Green Mountain Coee. In 2008 and 2010,
Randa hosted The Cup o Excellencethe
rst Arican country to host this orld-renoned
coee competition.
http://www.usaid.gov/rw/
http://www.spreadproject.org/speciality_coffee.php
http://www.cupofexcellence.org/
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Rwandan Coffee: Growing aSpecialty Market
Rwandas climate and altitude provides almost per-
ect growing conditions or Arabica coee, a ner
variety that etches a higher price than others. Since1917, Rwanda has exported coee, which has been
a major source o income or its rural population.
However, poor agricultural and processing practices
limited its quality.
But by 2005, this small Arican nation was gen-
erating sales o more than $3.6 million in the spe-
cialty coee market (Chemonics, 2006). USAID
assistance was largely responsible or the industrys
early success; the U.S. development agency invested
in initial easibility studies by industry experts and
provided technical and nancial assistance to con-struct more than 45 coee washing stations and
improve agricultural practices, coee processing,
business development, and management.
Since Rwandan coee armers own such small
parcels o land, which are shared with other
ood crops, the average armer grows only 150-
300 trees, as compared with an average 12,000
trees per small-holder arm in Central America
(Chemonics, 2006). USAID development assis-
tance thus ocused on orming and strengthening
cooperatives, so that armers could together garner
a higher price or their coee. Quality control and
marketing were strengthened by training world-
class coee cuppers (tasters) and establishing
relationships between Rwandan producers and
specialty importers and roasters.
The SPREAD Story: A HolisticApproach to Development
Since 2006, the SPREAD (Sustaining Partnerships
to enhance Rural Enterprise and Agribusiness
Development) Project, a cooperative agreementbetween USAID and exas A & M University, has
ocused primarily on urthering the development
o Rwandas specialty coee sector. In addition,
SPREAD has expanded its eorts to include some
technical assistance or other high-value agricultural
commodities, such as pyrethrum (used to produce
a natural insecticide) and birds-eye chili pepper.
But Rwandas arming amilies need more
than simply increased incomes to improve their
lives: they also need better health care and servic-
es, as well as education about preventive health
practices and issues like alcohol abuse that can
aect household health. USAID recognized that
the coee sector provides an ideal opportunity
to reach a sizable segment o the population that
may otherwise be overlooked. SPREAD pools
unding or economic growth, HIV/AIDS pre-
vention, and amily planning and maternal and
child health promotion, as well as support rom
the U.S. and UK specialty coee industries, to
combine its agribusiness eorts with an innova-
tive community health component.Tis unique example o integrated programming
is inspired by the population, health and environ-
ment (PHE) approach to development, which aims
to solve development problems in a holistic ashion
and build synergies across sectors that are tradition-
ally siloed. In the past, PHE projects have ocused
on integrating environmental conservation or natu-
Coee armer,Southern Province(Photo courtesyNick Fraser,.nickraser.org)
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ral resource management programs with commu-
nity health eorts; the SPREAD project is one o aew that are emphasizing agricultural and economic
development, which some argue would be a pro-
ductive avenue or expanding the approach (see,
e.g., Clarke, 2010).
SPREADs Evolution
Integrating community health into the existing
SPREAD program was designed to take advantage
o a number o potential co-benets and synergies:
First, as revenues rom coee increase, armerscould spend more money on amily health ser-
vices, education, hygiene, and nutritional needs.
Second, SPREADs existing community engage-
ment structure (the coee cooperatives) provided a
ready mechanism or rapidly disseminating health
inormation and services at the community level.
Tird, meeting the armers health needs not only
helps achieve the overall goal o improving arm-
ers lives and livelihoods, but could also increase
buy-in rom the cooperative members, thus
improving cooperative development and coee
quality (DAgnes, 2007).
Rather than re-invent the wheel, SPREAD built
on existing resources, such as training, program strate-
gies, educational materials, and human resources rom
the Ministry o Health (MINISANE), Population
Services International (PSI), the International Planned
Parenthood Federation in Rwanda (ARBEF), and
community health services.
Starting in January 2008, SPREAD:
rained and mentored existing coee extensionagents (animateurs de cae) to become health edu-
cators, who reached armers primarily through
small-group education sessions and reerrals to
local health services;
Created a new system o both Youth and Adult
Peer Educators;
Facilitated the sales o PSIs Prudence con-
doms and Sur Eau drinking water purication
solution via cooperative ofces, coee-washing
stations during harvest season, and community-based distribution by coee extension agents and
Peer Educators;
Female coeearmers listen to aneducation sessionby cooperativehealth agents (Photocourtesy Nick Fraser,.nickraser.org)
The big lesson I learned
is that you cannot achieve
your coee production
objectives at 100 percentithout addressing the
health o the armers.
Cooperative leader
(Source: Kitzantides, 2010)
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About the AuthorIrene Kitzantides as a Population, Health and Environment Advisor ith
the USAID Global Health Felloship Program, based at the SPREAD Project in
Butare, Randa rom 2008 to 2010. Previously, she served as a natural resourcemanagement/environmental education volunteer ith the Peace Corps in the
Casamance region o Senegal, west Arica. She holds a Masters in Public Health
rom the University o washington in community-oriented public health practice,
and a bachelors degree in anthropology rom the University o Virginia.
7
Combining health ith
cooperative activities is a good
idea, because SPREAD is looking
at saving the entire person and
his/her amily.
Community health orker
(Source: Kitzantides, 2010)
Coordinated with local health centers to con-
duct mobile voluntary counseling and testing
or HIV, amily planning clinics, and intestinal
parasite treatment at convenient locations dur-
ing harvest season;
Integrated health messages into the weekly coee
talk-show produced by the National University
o Rwandas (NUR) Radio Salus, Imbere Heza,
supported by Coee Lieline;
Facilitated the creation o community theater
groups and competitions, or both youth and
adults, that conveyed messages about improv-
ing community health and agribusiness develop-
ment; and,
Established demonstration gardens and held
training sessions on improving household nutri-
tion with kitchen gardens.
Smaller-scale activities include supplying sae
drinking water and portable hand-washing equip-
ment to promote hygiene at coee-washing stations
and ofces; and helping two o the target coopera-
tives ulll air trade requirements through provision
o First Aid training and supplies. SPREAD also
leveraged the strengths o its local partners, working
with Aricares mobile cinema equipment to show
HIV prevention lms and with UK-based Health
Unlimited to acilitate community theater troupes.
SPREADs Success
Te health program provided its integrated ser-
vices to three coee cooperatives and one pri-
vately owned enterprise in the southern districts
o Rwanda, totaling around 11,000 coee arm-
ers, plus their amilies and neighbors as no one
is turned away. As o May 2010, SPREAD had
achieved impressive results:
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Challenges and Constraints
Integrating a sound community health program into
an already established agribusiness project is not with-
out challenges. Te overall project was structurally
separated into three programs: coee quality, coop-erative development, research, and community health.
Limited resources and high demands across all three
programs meant collaboration ell on the shoulders o
already overstretched sta, and this eort was made
even more difcult when program sta were located at
three dierent sites throughout the country with lim-
ited telecommunication networks.
Each o the unding streams had its own set o
required indicators or reporting to donors and, at
times, separate systems and points o contact, which
produced a high volume o reporting requirements.Monitoring and evaluation o integrated bench-
marks received less attention than it should have,
again due to the twin constraints o little time,
small sta, and ew resources.
Recommendations and LessonsLearned
My experience with integrating health services into
the SPREAD program leads me to oer the ollow-
ing recommendations:
Farming amilies need more than simply increased
incomes to improve their lives and livelihoods;
although more ormal study is required, project
data and qualitative input rom stakeholders sug-
gest it is easible, cost-eective, and worthwhile
or agribusinesses to combine health outreach
with cooperative extension activities.
Although coee arming cooperatives may not
be deemed high risk or HIV or other dis-
eases, the members still have high unmet need
or basic health inormation and services, andperhaps a greater likelihood o improving their
lives and livelihoods.
Funders could raise the bar o integrated
approaches by investing in evaluation, recogniz-
ing and replicating best practices, and building
the capacity o implementing partners. Funders
should be exible enough to allow implement-
ers to appropriately target interventions to best
meet local needs, which should be reected in
appropriate project rameworks and measures. Project designers and managers should include
time in the design and planning phases to think
through and articulate the overall goal, objec-
tives, and strategies, so that integration makes
operational and conceptual sense:
Look beyond unding prescriptions: Spend
time getting to know the cross-cutting issues
at play in the community, such as youth
development, gender, money management,
and alcoholall o which could impact both
health and agribusiness development.
Determine which activities make sense to inte-
grate: What new activities need to happen to
ensure optimal synergy, and what can be derived
rom other partners?
Consider structuring programs horizontally
rather than vertically: For example, a commu-
nity outreach program could be responsible or
both agribusiness and health education objec-
tives, rather than having separate agribusiness
and health teams.
Design integrated program plans, results rame-
work, and monitoring and evaluation plans and
indicators; dedicate sta and unds or appropri-
ate monitoring and evaluation; and collect base-
line data to allow or true measures o program
outcomes and impact.
9
Men are no sensitive to the
problems o overpopulation and
come together ith their ives to
plan births together.
Cooperative health agent
(Source: Kitzantides, 2010)
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Engage with the community partners and local
health ofcials and centers to align with govern-
mental goals, build on one anothers strengths,
and reduce duplicative service delivery.
Te community-based, peer-to-peer approach isan invaluable way to reach armers with behav-
ior change communication, and strong support,
mentoring, and supervision o community out-
reach agents and peer educators is essential to
maintaining their job satisaction and ensuring
the quality and consistency o their outreach.
References
Chemonics International. (2006, April).Assessing
USAIDs investments in Rwandas cofee sector.
Available online athttp://pd.usaid.gov/pd_docs/
PNADG793.pd
Clarke, Gib. (2010, September). Helping hands: A
livelihood approach to population, health, and envi-
ronment programs(Focus Issue 20). Washington
DC: Woodrow Wilson Center. Available online at
http://www.wilsoncenter.org/topics/pubs/ECSP_
Focus_20_Clarke.pd
DAgnes, Heather. (2007). SPREAD integration rec-
ommendation report. Unpublished manuscript.
Institut National de la Statistique du Rwanda (INSR)
& ORC Macro. (2006, July). Rwanda demographicand health survey 2005. Calverton, MD: INSR &
ORC Macro. Available online at http://www.mea-
suredhs.com/pubs/pub_details.cm?ID=594
Kitzantides, Irene. (2010, May). USAID SPREAD
Project: Integrated community health program mid-
term program evaluation.Available online at http://
www.k4health.org/system/les/sites%252Fdeault%
252Fles%252FSPREAD_Health_Eval_Final.pd
Manning, Judy, Kamden Homann, & Jessica
Forest. (2008, September). Rwanda community
health needs assessment. Kigali, Rwanda: USAID/
Washington.
Ministry o Health (MOH) [Rwanda], National
Institute o Statistics o Rwanda (NISR), & ICFMacro. (2009, April). Rwanda interim demographic
and health survey 2007-08. Calverton, MD: MOH,
NISR, & ICF Macro. Available online at http://
www.measuredhs.com/pubs/pd/FR215/FR215.pd
Population Reerence Bureau. (2010). Datasheet.
Available online at http://www.prb.org/Datander/
opic/Bar.aspx?sort=v&order=d&variable=107
Taxton, Melissa. (2009, February). Integrating
population, health and environment in Rwanda.
Washington, DC: Population Reerence Bureau.
Available online at http://www.prb.org/pd09/phe-rwanda.pd
UN Development Programme. (2007). urning Vision
2020 into reality: From recovery to sustainable human
development. National human development report,
Rwanda 2007. Kigali, Rwanda: UNDP Rwanda.
Available online at http://hdr.undp.org/en/reports/
national/arica/rwanda/name,3322,en.html
UN Population Division. (2011). World population
prospects: Te 2010 revision. Available online at
http://esa.un.org/unpd/wpp/index.htm
USAID. (2010, June). Cofee in Rwanda.Available
online at http://www.usaid.gov/rw/our_work/pro-
grams/coee.html
World Bank. (2011, April). Rwanda economic update:
Seeds or higher growth (Spring Edition). Kigali,
Rwanda: World Bank. Available online at http://
siteresources.worldbank.org/INRWANDA/
Resources/Rwanda_Economic_Rwanda_Update_
Spring_Edition_April_2011.pd
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This report is made possible by the generous support o the American people through the United States Agencyor International Developments (USAID) Oce o Population and Reproductive Health. The contents are theresponsibility o the woodro wilson International Center or Scholars and do not necessarily refect the vies oUSAID or the United States Government. Vies expressed in this report are not necessarily those o the Centerssta, ellos, trustees, advisory groups, or any individuals or programs that provide assistance to the Center.
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PUBLIC MEMBERS: James H. Billington, Librarian o Congress; Hillary R. Clinton, Secretary, U.S. Department
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PRIVATE CITIZEN MEMBERS: Timothy Broas, John T. Casteen, III, Charles Cobb, Jr., Thelma Duggin,Carlos M. Gutierrez, Susan Hutchison, Barry S. Jackson.
The heavily cultivatehills o RandasSouthern Province(Photo courtesyNick Fraser,.nickraser.org
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