In Rwanda, a disconnect in choosing GHI focus

By Gregory Branch 

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.

“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 funding totaled $161 million, which accounted for roughly three-quarters of all U.S. assistance to Rwanda. Of the $161 million, the Centers for Disease Control and Prevention (CDC) contributed roughly half of its budget — nearly $20 million — directly to Rwanda’s government’s coffers. USAID, in contrast, cannot turn over its funding directly to a foreign government because of restrictions from federal regulations.

Still, despite the disagreement over the gender-violence focus, Binagwaho said she loves GHI — at least in theory. Her opinion carries weight. She has been a significant international player in global health for more than a decade, working closely on issues related to HIV/AIDS, children, and other issues, and a frequent featured speaker at global health events. She is also a senior lecturer Harvard Medical School’s Department of Global Health and Social Medicine.

GHI “means that we put together the support from USAID, the support from CDC and support from the US government in one framework,” she said. “Before it was separated, (and the U.S. agencies were) not necessarily talking to each other. … (Now) we just do it in a better coordinated manner.”

Rwanda has already amassed a strong track record.

By 2010, Rwanda was successfully treating 85 percent of its tuberculosis patients — meeting GHI goals even before GHI began. Another GHI goal was to reduce malaria deaths by half; Rwanda has cut malaria deaths by more than half since 2005. GHI calls, by 2015, for 85 percent of all pregnant women to be tested for HIV before giving birth and 85 percent of HIV-positive pregnant women to receive anti-retroviral (ARV) medicine to prevent mother-to-child transmission of the virus; last year, Rwanda tested 99 percent of all pregnant women for HIV. Seventy-three percent of those that were HIV-positive, received the AIDS drugs.

“There’s been incredible progress made in HIV, in TB, in malaria, in family planning and reproductive health,” said Pratima Raghunathan, CDC’s country director in Rwanda. “Preliminary results of Rwanda’s 2010 demographic and health survey demonstrates for all the world to see that they have really done an incredible job with their health sector.”

Raghunathan said that GHI’s focus now is on “the gaps that remain. … Gender is an area where they’ve made progress but they still have a ways to go and I think they would acknowledge that as well.” 

When you look at the numbers, Rwanda has made significant strides on gender issues. Women make up 56 percent of parliament, making Rwanda a leader in the representation of women in governance. 30 percent of the president’s cabinet are women. Women also have strong representation in the judiciary. Numbers don’t always reflect the full story of a society, at the individual level, many issues remain, and gender based violence is preeminent among them. 

To that end, the U.S. GHI team in Rwanda plans to increase the number of counseling centers for the victims of domestic and sexual violence, providing both technical and financial support. In 2009, the Rwanda National Police Health Services, along with the United Nations and the Imbuto Foundation, founded the Isange One Stop Center, for sexual and gender based violence. Starting in 2010, U.S. government funding helped train staff and paid for a manual for survivors of sexual violence. 

Isange’s services are free for survivors of domestic abuse (including children) and sexual and gender-based violence. It provides “one-stop” services — protection from further violence, criminal investigation, medical and psycho-social care, legal advice, support for and collection of forensic evidence and operates a toll-free hotline for those in need of assistance.

Two women, who are the face of the struggle against sexual and gender based violence, waited at the center, which is part of the Kacyiru Police Hospital in Kigali. One, 16 years old and pregnant, was raped by a neighbor; the other, 25 years old with a two-year-old daughter, was frequently beaten and sexually abused by her husband. “If I complained, he would send me outside, naked!” said the 25-year-old mother. She says it has been a struggle, but she has faith that she can get better through the help of the center.

Jacqueline Mukamwezi, a clinical psychologist with Isange explains, “Some women can’t afford to have their husbands out of the home. The men work and bring in the money. They just want the beatings, the violence to stop … we offer them protection.” The Ministry of Health is helping to plan the expansion of the Isange centers, after accepting the U.S. plan to focus on gender-based violence and gender equality.

Though Health Minister Binagwaho accepts the GHI focus, she still believes she knows best how to spend American taxpayer dollars. “I want more trust,” she said. “It’s all a concept of new development. If we do good for our population and we can do more with your money, let’s trust us and let’s do it.”