Reproductive rights and bodily autonomy matter in their own right. Everyone should be able to decide whether and when to have children and to access the information, healthcare and voluntary family planning services they choose.

This article discusses Population Matters’ Power to the People report and its case studies of Thailand, Kerala, Rwanda and Costa Rica. It considers what the report says about policy and access to services; no fertility or population outcome is a measure of whether people’s rights have been secured.

Rights-based policy starts from people’s ability to decide freely whether and when to have children. Services should be available without pressure or coercion.

Despite the high profile of horrendous abuses such as the one-child policy and forced sterilisation in India in the 1970s, they are aberrations, not the norm. As the United Nations has put it:  

Some population policies, especially in past decades … sometimes [used] coercion to ensure widespread adoption of family planning practices … However, most national population policies were not coercive.

The reality is very different:  

In most high-fertility countries, governments have put in place policies and programmes that contribute to lowering fertility levels through various mechanisms, including by reducing women’s unmet need for family planning, by raising the minimum legal age at marriage, by integrating family planning and safe motherhood measures into primary health care, or by improving female education and employment opportunities.

United Nations Department of Economic and Social Affairs (UNDESA)

Rights, services and policy

The report examines four historical case studies: Thailand, Kerala, Rwanda and Costa Rica. They are not templates for directing reproductive choices. Access to healthcare, education and voluntary family planning should be supported because they advance rights and wellbeing.

Reproductive rights: how to assess a population policy

Reproductive rights and access to services are the starting point. When a population policy affects contraception, ask how it protects choice and meets people’s needs. The WHO’s human-rights guidance provides a framework for these questions.

• Can people make an informed choice? Look for clear information and decisions free from pressure or coercion.
• Who can access services? Look for availability, affordability and non-discrimination, including barriers affecting underserved groups.
• Are services safe and respectful? Look for quality of care, privacy and confidentiality.
• Can people shape services and challenge failures? Look for participation, monitoring and effective accountability.

Population growth, fertility and age structure remain important for planning healthcare, education and other public services. Demographic effects should be examined separately from whether a policy secures rights and access. A lower fertility rate alone does not establish voluntary choice, better services or the cause of an economic change. The historical country examples below invite these questions; they are not proof that every criterion was met.

Thailand: imagination and dedication 

The story of Thailand’s successful population policy has been told many times but has not yet entered the public consciousness. With a total fertility rate (TFR, broadly equivalent to average family size) of six in 1970 and a population growth rate of 3%, the government launched a population programme to ensure that people could access contraception and take advantage of using it. They improved health facilities and access, education and female empowerment.  

Accompanying their work on these basics was an imaginative and popular communications campaign, led by the charismatic Mechai Viravaidya, also known as Mr Condom. From having police distribute condoms (the “Cops and Rubbers” campaign) to opening the Cabbages and Condoms restaurant chain, Mr Condom put contraception squarely in the public eye. Today, Thailand’s TFR is 1.3, and it has enjoyed economic growth the envy of its neighbours, arising, according to the World Bank, from “a rapid demographic transition as a result of birth control campaigns, rising prosperity and delayed childbearing for education and careers.” 

Kerala: putting it all together 

India has a dark history of population control, and while it has made significant strides in protecting human rights, there are still concerns over its “population control” approach. Those include policies in some individual states discriminating against families with more than two children.

The southern state of Kerala is an exception, however. During the 1950s, Kerala’s population was growing faster than that of any other Indian state, but by 1987 it had become the first state to reach a “replacement level” fertility rate (a measure of generational replacement, not an immediate end to population growth). Kerala took advantage of relatively high levels of female education for the time and achieved such rapid birth rate decline – one of the fastest in South Asia – through early investment in women’s empowerment, healthcare, and non-coercive family planning. 

The state has reaped the benefits. In 1978, when its family planning programme was already well underway, Kerala’s per capita income was only $80, far less than the Indian average. However, after slowing its population growth, Kerala has had a much more rapid decrease in poverty than other Indian states. Today, it is one of India’s richest states and ranks first in human development indicators. 

Rwanda: from trauma to empowerment 

Rwanda, the most densely populated country in Africa, had one of the world’s highest fertility rates in the 1980s, with each woman having on average 8.5 children in her reproductive life. Reducing population growth with the primary aim of promoting economic development and reducing poverty became a key government target. 

In 1994, however, the Rwandan genocide took place, with a million people murdered, in a country with a population of just eight million. Following the genocide and an exodus of millions of refugees, fertility rose amid social chaos and reluctance to see population shrink further. In 2003, the country’s National Policy for Sustainable Development identified the importance of addressing population growth as part of a holistic programme for sustainable development, including ensuring universal education for all children, and equal economic opportunity for men and women.  

Between 2000 and 2010, “ideal family size” in Rwanda dropped from 4.9 to 3.3, while between 2005 and 2020, contraceptive use among married women increased from 17% to 64%. Its TFR of 3.7 is the lowest in the region. Child and maternal mortality have dropped significantly, and Rwanda was one of only two countries in sub-Saharan Africa to achieve the Millennium Development Goals for health. 

There is much work still to do. Many local health facilities are church-provided, and, in turn, often reluctant to embrace family planning and hostile to abortion. A 2022 bill to allow girls between 15 and 18 to legally access contraception was rejected in parliament.  

Despite the obstacles, and the challenges remaining for this tiny country, categorised as among the world’s Least Developed, the achievements have been remarkable.

Costa Rica: paving the way for progress 

In the past 60 years, Costa Rica has undergone a remarkable transformation. Its GDP per capita grew from $380 to over $12,000, life expectancy climbed from 60 to 80 years, and the fertility rate fell from nearly seven to less than two. Costa Ricans now enjoy much higher standards of education and one of the world’s most effective primary healthcare systems. Nature, too, is flourishing: after years of intensive logging, Costa Rica became the first country to reverse deforestation, and now leads the world in renewable energy use. 

In the early 1960s, forestry professor Henry Tschinkel and his colleague Alberto González noticed a link between Costa Rica’s rapid deforestation and the extremely high unmet need for contraceptives among Costa Rican women. Convinced that slowing population growth would simultaneously lift families out of poverty while also relieving pressure on Costa Rica’s natural resources, González founded the Costa Rican Demographic Association to start promoting and providing family planning services.  

Despite never articulating an explicit population policy, the Costa Rican government also played a critical role. Through its family planning programme, the government made contraceptives much more accessible, particularly to rural and low-income communities. Local churches helped distribute contraceptives while minister Padre Carlo hosted a radio show called Dialogo, in which he challenged the cultural hesitancy to discuss sex and promoted contraceptive usage. 

Through mass communication and home visits – particularly important in rural areas – nurses, social workers, and priests explained to couples that having fewer children would enable them to save more money and enjoy more leisure time. Costa Rica now has Latin America’s highest rates of contraception usage – 84% – and one of the region’s lowest birth rates. 

Costa Rica’s progress in demographic terms is remarkable, but that should not obscure remaining challenges. Socially and economically, progress has stalled in some respects, with inequalities continuing to impact on the health and rights of the most vulnerable.  

While it would be a mistake to ignore its remaining and significant problems, in a 2021 evaluation, Costa Rica ranked as the 16^th happiest place on Earth. Like every country, Costa Rica’s story is multi-faceted, and no one factor has driven the gains it has made. It nevertheless serves as an excellent example of how addressing population growth paves the way for women, children, and nature to flourish.   

The picture today 

These examples are far from the only ones, with countries from South Korea to Bhutan to Kenya having made great strides, as the report describes.  

According to the UN’s 2021 World population policies report, in 2019, nearly three quarters of governments had policies related to fertility: 69 governments to lower it (including in half of all developing countries), 55 to raise it and 19 focused on maintaining existing levels.  

Reproductive rights and bodily autonomy must guide every policy that affects people’s choices about having children. Voluntary family planning, healthcare and education support people’s rights and wellbeing in their own right. Demographic change may follow, but it is never a target. Policies should also address barriers and inequalities that shape access to services.

Read more about reproductive rights and voluntary family planning.