WASHINGTON — In 2007, Bill Clinton made a public appeal for an international mission with deep personal resonance: to expand and modernize the piecemeal health care system in Rwanda, the African nation whose tribal genocide in 1994 Clinton feels he should have done more to stop.
But it was not until Hillary Clinton, his wife, became secretary of state that Bill Clinton, working through a Boston-based charity that he leads, was able to help the African nation secure at least $27 million from the State Department to bring his vision closer to reality — a network of care centers fortified with newly trained doctors.
The State Department diverted a portion of US government grant money flowing to nonprofit groups fighting HIV infection in Rwanda, and channeled it to the Rwandan government to build the program envisioned by Clinton’s charity.
The ambitious effort had all the hallmarks of a Bill Clinton plan: lofty goals; prestigious institutions, including Harvard, convened for a noble purpose; and high-level efforts to leverage large sums of money.
But in this instance, because Hillary Clinton was secretary of state and the money for Bill Clinton’s pet project was supplied by US taxpayers, it could raise questions of possible favoritism and political and family influence.
Although she has lauded it publicly, there is no evidence that Hillary Clinton herself intervened in any way for her husband’s plan. But the State Department division that oversees the distribution of emergency funds to combat HIV infection overseas — called PEPFAR — was overseen at the time by a former Clinton White House official with close ties to the former first family and its charitable foundations.
The official, former ambassador Eric Goosby, was subsequently given a spot as board member at the Clinton Foundation, another branch of the Clinton charitable empire based in New York.
The State Department declined to detail the deliberations that led to the reallocation of money to a project publicly championed by Bill Clinton. It defended its actions more generally, calling the Clinton initiative a way to broaden the use of US funds to help developing countries build sustainable clinical capacity.
The program would continue to help people with HIV infections — while also improving all aspects of health care.
“This plan was one that would save lives and improve Rwanda’s care and treatment for HIV/AIDS patients, and it’s on those merits which we based our decision to support it,” said Mark Toner, deputy spokesman at the State Department.
Maura Daley, a spokeswoman for the Boston-based Clinton Health Access Initiative, declined to comment. Hillary Clinton’s presidential campaign also declined to comment. Goosby did not respond to multiple requests for comment.
The Clinton Foundation, and its sprawling network of associated charities, has already caused complications for Hillary Clinton’s presidential ambitions. Large donations from foreign governments and business interests prompted concerns that the foundation was seen as a backdoor way to attempt to influence the secretary of state.
The Globe reported earlier this year that the Boston-based arm of the charity failed to disclose to the State Department vast increases in foreign donations, despite promises Clinton made during her confirmation hearings that such gifts to the foundation would be disclosed.
A wish and a plan
For Bill Clinton, the Rwanda mission carried deeply personal meaning: the former president has said he is haunted by his administration’s failure to intervene in the Rwandan genocide, in which 800,000 people died in a single 100-day period, by some estimates.
‘These people have been through a lot and none of us, most of all me, helped them when they were on the verge of destroying each other.’ -- Bill Clinton
The Clinton Health Access Initiative has had programs in Rwanda to improve the country’s health system since 2002. And through his work in the country, Clinton developed such a close relationship with Rwanda’s health minister, Agnes Binagwaho, that he once quipped to the New York Times: “Obama could replace [then Health and Human Services Secretary Kathleen] Sebelius with her tomorrow, and I’d support it.”
But it was in March of 2007 when Clinton made one of his most compelling pitches, alluding to a lingering sense of guilt about Rwanda.
“These people have been through a lot and none of us, most of all me, helped them when they were on the verge of destroying each other,” Clinton said.
He laid out a proposal for a countrywide effort to improve the quality of health care. The setting was classic Clinton: A gathering of some of the world’s top thinkers and business leaders at the Technology, Entertainment, and Design conference in Monterey, Calif. He was accepting an award and, by tradition, winners give a talk where they outline a wish.
He described how the Clinton Health Access Initiative had helped poor countries around the world negotiate better deals for HIV-fighting drugs. But those countries lack effective health care systems to distribute the drugs and make sure people keep taking them, he said.
“My wish is that TED assist us in our work and help us to build a high-quality rural health system in a poor country, Rwanda, that can be a model for Africa, and indeed, for any poor country anywhere in the world,” Clinton said, as images of Mother Teresa, Mahatma Gandhi, and Charles Darwin were projected behind him.
It would take four more years for the vision he sketched out to expand to a more aggressive plan for Rwanda. In 2011, the Clinton Health Access Initiative received a grant from the private nonprofit ELMA Foundation to help Rwanda’s Ministry of Health write its proposal to the US government.
Under the proposal, Rwanda, using State Department funds, would pay prestigious American universities to send medical specialists into rural areas of Rwanda to train Rwandan health care workers. Participating institutions included Harvard Medical School, Boston Children’s Hospital, Brigham and Women’s Hospital, Massachusetts General Hospital, Brown University, and the Yale School of Medicine, among others.
The proposal went to Clinton’s State Department — more specifically the office tasked with distributing hundreds of millions of money to combat HIV infections abroad, the President’s Emergency Plan for AIDS Relief Office, or PEPFAR.
Even though the office had just approved a five-year plan for Rwanda, it was willing to make a change and put more focus on training local health care workers, according to the State Department.
In February 2012, the State Department approved Rwanda’s Human Resources for Health plan and agreed to move $23.5 million in PEPFAR funds to it, along with $3.8 million in other aid funding.
Launching the new project meant other priorities needed to be defunded. The State Department said only that “certain technical assistance and training activities” were curtailed to make way for the new Clinton-backed programming.
When the program launched in July 2012, Bill Clinton along with his daughter Chelsea traveled to Rwanda’s Rwamagana School of Nursing and Midwifery. They posed for photos with Rwandan President Paul Kagame and Binagwaho, the minister of health — and Clinton called it “the largest medical education project ever undertaken with foreign assistance.”
He was buoyant a few months later when Kagame and Binagwaho came to a meeting of the Clinton Global Initiative in New York, where Clinton celebrated the project.
“This is a huge deal,” Clinton said. “When I get done with all this, if you want me to come to Rwanda and clean bedpans for you, I’d be glad to do it.”
He summed up its unprecedented nature: “This has never been done in my lifetime” and added, “I want to make full disclosure here: my Health Access Initiative had the honor of helping to work on this commitment for an extended period of time.”
He thanked the head of the charity, Ira Magaziner, by name, along with “all the people who worked with me through the [Rwandan] health minister for negotiating this.”
Goosby, the US global AIDS coordinator, was listed as “featured attendee” at the meeting and was personally thanked there by Bill Clinton. Then Clinton thanked “the secretary of state” — his wife — for making it happen.
Without mentioning her husband’s interest, Hillary Clinton specifically cited the Rwanda program in a 2012 speech to the United Nations the same week. She lauded it as an example of the State Department prodding a poor country to take on more responsibility programs to fight HIV infection.
She said Rwanda had taken over the management of treatment programs at 70 facilities’’ to “free up resources’’ for training health care workers.
By December 2013, the Clinton Health Access Initiative ended its involvement in the program and fully turned over its management to the Rwandan government, according to its annual report.
After the foundation pulled back, the State Department continued funding Rwanda’s Human Resources for Health program. By 2015, it had put roughly $60 million toward the initiative. That’s about 12 percent of the total PEPFAR money earmarked for Rwanda over the last five years, according to the State Department.
What started as Bill Clinton’s idea for something new at the intersection of international aid, public policy, and academics was described in detail in a 2013 report in the New England Journal of Medicine.
The 20 authors included boldface names such as Magaziner and Harvard professor Paul Farmer — the founder of Partners in Health who is on the Clinton Health Access Initiative's board of directors and whose work in developing countries provided the model.
The authors thanked a list of top officials from universities and government whose “leadership made these efforts possible.”
The final name on the thank-you list: Hillary Clinton.