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President Obama's ambitious Global Health Initiative — announced to a receptive international community in 2009 — is faltering as budget constraints and shaky implementation limit the impact of the multibillion-dollar program.

Rwanda's Health Minister, Agnes Binagwaho sits at her desk. (Geoffrey Mulonga/GlobalPost)

In Rwanda, a disconnect in choosing GHI focus

Health official says US imposed sexual violence focus without proper consultation.

KIGALI, Rwanda — Over the last two years, Obama administration officials have been refining the Global Health Initiative (GHI) to better meet the health needs of people living in poverty around the world. They searched for savings, too. They looked for efficiencies. And they talked about helping countries take control of their national health plans.

The last point — countries in the driver’s seat as opposed to donors dictating the way — has been a theme heard often in Washington.

But here in Rwanda, a small east African country now 17 years removed from a genocide that killed an estimated 800,000 people, health officials say that country ownership often takes a back seat in U.S.-funded programs. 

A case in point: The U.S. GHI team in Rwanda chose as one of its key priorities a reduction in gender-based sexual violence. For Rwanda’s top health official, that decision was curious. She said it wasn’t a priority and no one had asked her if that fit in with the national plan. 

Health Minister Agnes Binagwaho told GlobalPost that gender-based violence was “just a little piece” of the ministry’s health programs. A wiser path in fighting gender-based violence, she said, would have been if the United States joined Rwanda in building back the country’s tattered economy. She said more economic equality would, in the end, reduce violence against women.

“Our focal area comes directly from the national gender policy...Rwanda’s national gender policy. So we didn’t make it up”
~Nancy Godfrey, GHI Field Deputy for USAID in Rwanda

“Gender-based violence is not our choice” for a GHI-funded program, Binagwaho said. “It is a matter to educate the population with what happened during the genocide where gender-based violence was used as a weapon of war ... But if you ask us … gender-based violence is about empowering women, educating women, educating boys, empowering boys because in a society where you have equity you have less gender-based violence. The solution is economic empowerment. The focus is economic empowerment.”

U.S. health officials in Kigali said they were only following Rwanda’s lead in their choice of programs.

“To choose gender equality reflected the fact that they’ve done phenomenally well in making it a priority,’’ said Nancy Godfrey, GHI Field Deputy for the U.S. Agency for International Development in Rwanda. “Our focal area comes directly from the national gender policy ... Rwanda’s national gender policy. So we didn’t make it up.”

The tension between Rwanda — considered a star health-care performer over the last decade in sub-Saharan Africa — and the United States is symptomatic of the lingering power imbalance between donor and recipient across the developing world, even with a GHI program designed to empower developing countries. Analysts say the Rwandan example illustrates a sometimes-contentious issue in U.S.-funded health programs everywhere: Who really controls the direction of GHI? If it is the United States, why then, are U.S. officials pushing country ownership?

At heart, the issue is about money and trust. Countries such as Rwanda have been asking the United States to join other donors to pool money in a general fund and then allow the countries to spend the funds on top priorities. In such arrangements, donors often set goals. If the goals aren’t reached, the funding either is reduced or stopped. Binagwaho, the Rwandan health minister, sees the arrangement as kind of a business deal.

“You see what the taxpayer in the U.S., the American Congress, the institutions that support us, want to do is to help us in our development,” Binagwaho said. “The American taxpayer … wants to buy life, health, welfare and education. If we tell them, this amount of money will buy this amount of life, educate this amount of people, give welfare to this amount of people, so that means with clear indicators, and they give us the money and we manage, you will be surprised that we will do more.” The German government is one of the donors that decided to turn over its funding — US$36 million (26 million euros) between 2008 and 2012 — directly to the Rwandan government. 

"The budget support is given … only to selected, well chosen countries,” said Elisabeth Girrbach, Health Coordinator of the German Development Cooperation, and the head of the GIZ health program. "This is due to the relatively good public financial management, the willingness and ownership for development and results and development oriented policy of the Rwandan government.”

In 2010, U.S. GHI