Politics|Rwanda Aid Shows Reach and Limits of Clinton Foundation
Women in Rwanda's Eastern Province meeting with representatives of the Clinton Development Initiative to discuss farming techniques.CreditCreditMartina Bacigalupo for The New York Times
Rwanda Aid Shows Reach and Limits of Clinton Foundation
In addition to doing good deeds, the foundation enhances the Clinton brand, never more so than while Hillary Rodham Clinton is running for president.
By Kevin Sack and Sheri Fink
KIGALI, Rwanda — In a resurgent Rwanda, only 21 years past the genocide, the government of President Paul Kagame has deputized a high-profile partner for an array of endeavors across this striving, haunted land: in a banana grove in Kayonza, where subsistence farmers are learning to double their yields; in a teaching hospital in Kigali, where American and Rwandan faculty are training a generation of specialists and nurses; in a sprawling plant in Mukarange, where soybeans are being processed into the country's first domestic cooking oil.
In each instance, the partner has been the Clinton Foundation.
As a microcosm of the foundation's worldwide presence, Rwanda reveals it to be more a nonprofit global consulting firm than a traditional philanthropy, with scattered interests that reflect the darting mind of its namesake, former President Bill Clinton. Here in the hills of central Africa, perhaps as much as anywhere, it enjoys the synergy with the government that the foundation seeks wherever it goes.
Former President Bill Clinton and President Paul Kagame of Rwanda greeting medical students in 2012 in Kigali, Rwanda.CreditEd Ou/Getty Images
Born of a deeply respectful friendship between Mr. Kagame and Mr. Clinton, the partnership has been sustained by a shared conviction that with the right kind of help — the teach-a-man-to-fish kind — developing nations can wean themselves from foreign assistance and take ownership of their futures.
"We're literally going to be in a position to work ourselves out of a job in a lot of parts of Africa in the next few years," Mr. Clinton told the foundation's Clinton Global Initiative meeting in New York last month.
Clearly, the Clinton Foundation functions both to do good deeds and to enhance the Clinton brand, never more so than while Hillary Rodham Clinton is running for president. But from the start, her campaign has been nagged by concerns about how the foundation raises its money. Far less attention has been paid to how that money is spent.
In Rwanda, a review of the foundation's history shows that it has done vital, often pathbreaking work, particularly in health and rural development. But with Mrs. Clinton campaigning as Mr. Kagame faces sharpening criticism about human rights, it also highlights the potential for conflict of interest, the outsize access to power and the delicate global politics that inevitably arise when such work is conducted by a former president whose wife is a former United States senator and secretary of state and a two-time contender for the Democratic presidential nomination.
In 2011, for instance, when Mrs. Clinton was secretary of state, leaders of the foundation's health care arm lobbied her department to shift American aid dollars away from H.I.V. programs in Rwanda in order to fund a training program for health professionals that the foundation helped design. The proposed reallocation, a heavy bureaucratic lift in Washington, was approved over the objection of some State Department technical experts as well as foreign aid contractors that stood to lose money.
Mrs. Clinton had pledged to recuse herself if the Clinton Foundation ever had business before her department, and she steered clear of direct decision making. But mediating the dispute was her chief of staff, Cheryl D. Mills, a longtime counselor to both Clintons who had served for five years on the Clinton Foundation board before going to the State Department. Furthermore, the department's top AIDS official said he had kept Mrs. Clinton apprised of the proposal and sought and received her backing before approving his portion of the deal. She then signed the overall budget that shifted the money.
Mr. Clinton hailed the victory when he came to Kigali in 2012 to inaugurate the program.
"The government of Rwanda had to convince some of the largest donors, especially the U.S. government, to support the plan," he said. "They actually offered, the government of Rwanda did, to give up funding for some existing programs so that the money could be redirected." He then pointedly thanked the State Department, which, he noted, "I happen to think is very well led."
It is natural to view the Clinton Foundation's work here as an outgrowth of Mr. Clinton's deep regret that the United States stood on the sidelines in 1994, when he was president, as Hutu extremists slaughtered an estimated 500,000 to one million Tutsis and moderate Hutus.
Mr. Kagame led the invading force of Tutsi exiles that quelled the massacre after 100 days, and he has been the country's leader ever since. Mr. Clinton met him in 1998 when the American president came to Kigali to apologize that the international community "did not act quickly enough after the killing began."
Tutsi victims of a Hutu massacre in Rukara in 1994. The death toll there, one of the worst massacre sites, was 800.CreditScott Peterson/Liaison, via Getty Images
Mr. Clinton soon became an outspoken admirer of Mr. Kagame for uniting his shattered nation and producing remarkable gains — with the help of guilt-ridden foreign donors — in economic growth, personal income, life expectancy and education. Like leaders of other nonprofits that work in Rwanda, Mr. Clinton has been impressed by Mr. Kagame's ability to tamp down corruption in one of the world's poorest countries and by his effectiveness in maintaining control and delivering basic improvements. (The Rwandan president famously rid his well-paved highways of litter in part by banning plastic bags.)
Dr. Paul E. Farmer, a co-founder of Partners in Health, a nonprofit medical provider that works closely with the Clinton Foundation in Rwanda and elsewhere, recalled Mr. Clinton stressing that point. "He said: 'I know this guy. He's a G.S.D. guy,'" Dr. Farmer said. "Gets stuff done."
Mr. Clinton and Mr. Kagame have met on each of Mr. Clinton's six postpresidential trips to Rwanda, and Mr. Kagame is a regular at the Clinton Global Initiative annual meeting. At the 2009 session, Mr. Clinton presented him with the foundation's Clinton Global Citizen Award, calling him a "brilliant man" who "freed the heart and the mind of his people."
But on a geopolitical level, the foundation's intertwining with Rwanda has become increasingly awkward as the United Nations, the State Department and members of Congress have accused the Kagame government of disregarding human rights, aiding armed rebels in the neighboring Democratic Republic of Congo and suppressing political opponents and the media, at times violently.
The Clinton-Kagame relationship may experience deeper strains if, as many here anticipate, Mr. Kagame allows the amending of Rwanda's Constitution so he can run for a third seven-year term. That would happen in 2017, potentially the first year of a Hillary Rodham Clinton presidency.
Human rights advocates and opposition leaders argue that Mr. Clinton's continuing embrace helps validate Mr. Kagame and buffers him from international pressure.
"Either he's completely uninformed about what we know about Kagame or he's in total denial," said Filip Reyntjens, a Belgian scholar considered an authority on post-genocide Rwanda.
Neither Mr. Clinton nor Mr. Kagame agreed to speak for this article. But in an interview with the BBC in 2013, when criticism of Mr. Kagame was mounting, Mr. Clinton sounded unmoved. "I suppose I do make more allowances for a government that has produced as much progress as that one has," he said. "There are very few situations that are perfect."
Supporters of President Paul Kagame rallied in Kigali in 2010. His relationship with Bill Clinton may be strained if Mr. Kagame allows the amending of Rwanda's Constitution so he can run for a third seven-year term in 2017.CreditFinbarr O'Reilly/Reuters
Big Projects, Big Money
The Clinton Foundation has had two lives. When it was incorporated as the nonprofit William J. Clinton Presidential Foundation in 1997, more than three years before Mr. Clinton left office, its primary mission was to raise $165 million to build his sleek presidential library in Little Rock, Ark.
After the library opened in 2004, the foundation pivoted to an ever-evolving menu of projects, and to the fund-raising needed to support them. By 2013, it had collected $2.1 billion in revenue, tax filings and financial statements show, with significant donations coming from major corporations, foreign individuals and governments like Saudi Arabia, Kuwait, Australia and Norway.
Such gifts are perfectly legal. But never had those donors had such an opportunity to wield theoretical influence over a top cabinet secretary and prospective president by giving unregulated sums to a spouse's foundation.
The foundation's programming is subdivided into "initiatives," "alliances" and "partnerships" aimed at a grab-bag of causes. They include climate change, cooperative farming in Africa, economic growth in Haiti, obesity in the United States, access to lifesaving drugs, youth unemployment, early literacy, women's advocacy, the reduction of preventable disease, the streamlining of developing markets, sustainable health systems and volunteerism.
Much of the essential work takes place in offices — analyzing data, strategizing with governments, developing proposals, negotiating, publicizing, squeezing value from the Clinton name and burnishing it in the process. The Clintons' daughter, Chelsea Clinton, a former McKinsey & Company consultant who wields substantial influence as the foundation's vice chairwoman, stressed measurable outcomes when she joined in 2011, and its publications are thick with data about its reach.
Yet even foundation veterans can have trouble encapsulating the mission. They are conveners, facilitators, implementers, catalysts. "We help transform the world's approach to problems," said Amitabh Desai, the foundation's foreign policy director. "That's how I synthesize it."
Perhaps the foundation may best be understood by what it is not. For the most part, it is not a grant-making organization like the Bill & Melinda Gates Foundation. Its primary mission is not to provide direct humanitarian aid, like CARE or Doctors Without Borders.
At the 2007 meeting of the Clinton Global Initiative, the philanthropist Anne Heyman and her husband, Seth Merrin, committed his company, Liquidnet Holdings, to giving nearly $2 million to help build the Agahozo-Shalom Youth Village in Rwanda for orphans of the genocide and AIDS.CreditMarvi Lacar/Getty Images
It does not live off the wealth of a single benefactor, like the Ford Foundation or Bloomberg Philanthropies. Bill and Hillary Clinton have given the foundation about $5 million over the years, and have directed at least $11 million more of their speaking fees to the group, but that total amounts to less than 10 percent of one year's budget.
Rather, the foundation is a public charity that exploits the star power and connections of its principals to finance its programs year by year. Until 2013, when the foundation began building a modest endowment, it spent nearly every dollar it raised, making it vulnerable to economic swings. Measured by spending — $222.6 million in 2013 — it compares to the American Diabetes Association or the March of Dimes Foundation.
The Clinton Foundation gets good marks from the group Charity Watch for keeping its overhead and fund-raising costs low. But it spends more than a third of its budget on compensation for roughly 2,200 employees in 30 countries. In some of those places, Rwanda included, it is known for sending bright but inexperienced recent graduates to work as technical advisers to government ministries.
A number of top foundation officials have extensive histories with the Clintons, and the Manhattan headquarters, on two high floors of the Time-Life Building, is not without its rough-and-tumble palace intrigue. In recent years, its coffers have been used to pay top political advisers to Mrs. Clinton like Huma Abedin and Sidney Blumenthal.
Executive salaries can be high, but are not excessive for the field, surveys show. A former chief executive, the longtime Clinton counselor Bruce R. Lindsey, earned $412,581 in total compensation in 2012, his last full year in the job, according to tax returns. He is now the paid chairman, while the new president is Donna E. Shalala, Mr. Clinton's secretary of health and human services.
Neither Mr. Clinton nor Chelsea Clinton receives a salary, although transportation and expenses are covered when they travel on foundation business. Mrs. Clinton has been in public office for most of the foundation's life. She joined the board after leaving the State Department in 2013, when the foundation's name was expanded to include hers and Chelsea's, but resigned in April when she announced her candidacy for president.
The foundation may be most widely known for its Clinton Global Initiative, the wonky four-day Davos-on-the-Hudson held each September to coincide with the United Nations General Assembly. World leaders travel across town for panel discussions and awards dinners, with the Clintons taking center stage.
But the distinguishing feature is a parade of philanthropic "commitments to action" made by nonprofit organizations, corporations and governments. Some 3,400 pledges have been made over the past decade, including about 160 that involve Rwanda.
The commitments are supposed to be fresh, but many projects clearly would happen anyway, and the foundation does not back them financially. But for a $20,000 membership fee, invitees gain the Clinton imprimatur and a chance to showcase proposals to an audience of possible funders and partners.
At the 2007 meeting, the philanthropist Anne Heyman and her husband, Seth Merrin, committed his company, Liquidnet Holdings, to giving nearly $2 million to help build the Agahozo-Shalom Youth Village in Rwanda for orphans of the genocide and AIDS. Plans for Ms. Heyman's project were already underway, but the announcement "propelled things forward," said Danielle S. Burenstein, the project's executive director.
The tidy hilltop campus of classrooms and group residences in Rwamagana opened in 2008 and now houses 500 teenagers. In addition to academics, it offers extracurricular training in everything from chicken farming to music production.
A Rwandan factory in Ngoma makes absorbent pads from the fiber of banana trees. The idea for supplying feminine products to developing countries was discussed at a meeting of the Clinton Global Initiative.CreditKevin Sack/The New York Times
At the 2009 meeting, Elizabeth Scharpf, a young Harvard M.B.A., used her time onstage to speak about sanitary pads. She explained how the unaffordability of feminine products in developing countries had consequences for both hygiene and absenteeism, and committed her nonprofit, Sustainable Health Enterprises, to supplying one million women and girls in East Africa with sanitary pads by 2012.
Ms. Scharpf had hoped a financial partner might emerge from the audience. That did not happen. But at dinner the next night, she happened to meet the philanthropist Barry Segal, whose family foundation became an investor. Last year, she opened a modest factory in Ngoma that makes absorbent pads from the fiber of banana trees, an abundant local resource. Only 6,500 girls have been reached so far, but Ms. Scharpf hopes to scale up fast.
After a study last year, the foundation concluded that more than 80 percent of the action commitments had been completed on schedule or were progressing adequately. Although it promotes the commitments and monitors them, it has little power to enforce them.
"We're not trying to shame people if it's not working," said Craig Minassian, the chief communications officer. "We're trying to be constructive."
'Feed the Soil'
Down a rutted road in Kayonza District, past mud houses and stands of cassava, Eugenie Mujawamariya has gathered her neighbors on a hillside around a fallow field. The soil is the color of milk chocolate and crumbles nicely in the hand. Ms. Mujawamariya explains that she is waiting for prices to rise before sowing her latest bounty of soybeans.
Most of her 20 listeners are women wrapped in brightly patterned skirts. They have come to meet the fieldworkers from the Clinton Development Initiative who have been tutoring Ms. Mujawamariya on how to increase yields while also nourishing the land.
Not unlike agricultural extension agents, the Clinton workers have helped Ms. Mujawamariya grow demonstration plots of soybeans and bananas, varying the spacing, seed varieties, mulching and fertilizer. In one plot, bananas hang from trees in clumps the size of grown men.
Agriculture employs nearly three-fourths of Rwanda's 11.3 million people, most on plots of an acre or less. The government aims to change that by forming cooperatives large enough to cultivate cash crops, said Tony Nsanganira, the agriculture minister.
The foundation's 13 development workers, all Rwandans, support that mission by using 60 demonstration plots across the Eastern Province to encourage farmers to substitute exportable crops like soybeans, which enrich the soil, for nitrogen-depleting subsistence crops like maize.
"If you feed the soil, the soil will feed you," Austin Ngwira, a foundation staff member, advised the farmers.
Ms. Mujawamariya said that her fields now yielded far more than her family could eat, and that her income from sales had doubled. "I built a house in the town," she said.
The foundation's work on crop yields is part of a larger effort to exploit the market potential of Rwandan exports like coffee, tea and soybeans. It has helped negotiate cheaper prices for fertilizer and seed, and worked with companies and government agencies to build the country's first coffee and soybean processing plants. Both are operating well below capacity.
A soybean processing factory in Rwanda.CreditMartina Bacigalupo for The New York Times
"Now that the businesses are creating demand, a lot of what we do is creating production to meet that demand, to help the farmers take advantage," said Walker Morris, chief executive of the Clinton Development Initiative.
Those projects began 10 years ago when Sir Tom Hunter, a Scottish billionaire entrepreneur, found himself sitting beside Mr. Clinton at a dinner. The men did not know each other, but each had a foundation. The talk turned to Africa, which Mr. Hunter had never visited, and before long Mr. Clinton had invited his new friend to travel with him there.
Soon after, Mr. Hunter appeared at the Clinton Global Initiative to commit $100 million over 10 years to development projects in Rwanda and Malawi. It seemed like a beautiful marriage — Mr. Hunter's money and Mr. Clinton's connections — but the partnership soon stalled when Mr. Hunter took a beating in the financial crisis.
"We never stopped, but we had to scale back," Mr. Hunter said. He has spent about $25 million so far, he said.
To maintain momentum, the Clinton Foundation formed its own development program in 2010 and recruited new donors. The government of the Netherlands provided $3 million to support the agricultural work in Rwanda.
Battling AIDS
In 2002, as Bill Clinton contemplated his next act, he received an impassioned letter from his former presidential policy adviser, Ira C. Magaziner, a friend since their days as Rhodes scholars. The two had just met in Barcelona, Spain, with the leaders of several AIDS-ravaged nations, including Mr. Kagame, and heard how hundreds of thousands of people were dying because they could not afford antiretroviral drugs.
Mr. Magaziner, a business consultant whose White House portfolio included the failed Clinton health reform plan, urged the former president to tackle the problem. He volunteered to direct the effort without pay and to donate $1 million as seed money.
"If we succeed at this, we can help save millions of lives," Mr. Magaziner wrote. "We will help accomplish something that is as significant as your best accomplishments as president."
Today, Mr. Magaziner's Boston-based Clinton Health Access Initiative, which became a separate legal entity in 2010, is by far the largest component of the Clinton philanthropic world, accounting for two-thirds of its budget and employees. Mr. Magaziner, who began taking a salary in 2008, now makes roughly $350,000 as chief executive, according to a spokeswoman.
In Rwanda, as in many poor countries, the health initiative is credited with negotiating down the price of AIDS treatment and testing. By pooling guaranteed orders from low-income countries, thus ensuring large markets for manufacturers, it helped lower the annual cost of H.I.V. drug treatment in Rwanda to $139 from more than $500.
Such intervention to improve access for the poor became the hallmark of scores of subsequent deals that lowered prices on vaccines, diagnostic equipment and medicines for diseases like tuberculosis and malaria. The next targets for Rwanda are costly hepatitis drugs.
With 30 employees, the health initiative's presence here is small compared with its presence in other African countries, but its relationship with the government stretches back more than a decade. At the invitation of the Health Ministry, it has helped organize the country's H.I.V. response, structure its community health system, build hospitals, monitor health spending, design vaccination programs and plan construction of a baby-food factory.
"They don't do the real job, but they help you to do your job where you have gaps," said Dr. Agnes Binagwaho, Rwanda's health minister.
Among the closest collaborations between the government and the Clinton Health Access Initiative has been "human resources for health," a medical training program aimed at creating 400 specialized physicians and upgrading the credentials of 5,000 nurses and midwives in seven years.
Ira C. Magaziner briefing journalists about the work of the Clinton Foundation on a flight to Lesotho in 2006.CreditEvelyn Hockstein for The New York Times
When the concept was hatched five years ago, Rwanda had made huge strides in extending life expectancy. AIDS deaths had fallen sharply, and access to H.I.V. drugs had markedly increased. Dr. Binagwaho anticipated that many Rwandans, including AIDS patients on antiretroviral drugs, would develop other life-threatening illnesses that the country was ill equipped to treat without specialized care.
She enlisted the Clinton group to help draft a proposal to import 100 faculty members a year from top American universities to pair with Rwandan counterparts, enabling the University of Rwanda's medical college to double admissions. The Clinton team helped put the program into effect for the first year and a half.
It fell to Mr. Magaziner and his group to recruit 13 universities and persuade them to work for an exceptionally low 7 percent administrative rate. Even so, the plan called for $150 million in foreign investment paid directly to the Rwandan government, of which nearly half would be used to cover salaries of American doctors and nurses. Knowing that Washington would not provide new funding, Dr. Binagwaho asked the Clinton team to advocate cuts in existing AIDS programs that were supported by the United States.
Mr. Magaziner already had his own complaints about waste and duplication in the programs. "She started the conversation, but I must say I piled on," he said.
They took an ax to more than 40 line items, including a Columbia University program to help medical workers identify rape victims and a Johns Hopkins-affiliated project to encourage circumcision as an H.I.V. prevention measure. Other programs that were cut promoted abstinence and monogamy or supported pediatric AIDS care at Kigali's teaching hospital.
Dr. Binagwaho then implored the Clinton group to "use your advocacy power" to win approval for the reallocation in Washington. In a letter written at Mr. Magaziner's urging, she assured Dr. Eric P. Goosby, who directed the President's Emergency Plan for AIDS Relief at the State Department, that the cuts would have "virtually no negative impact" on H.I.V. services. Any gaps, she wrote, could be filled by Rwanda.
But there was concern at State because taxpayer money originally intended for H.I.V. treatment and prevention would be used instead for training by specialists ranging from pediatricians and obstetricians to neuroradiologists and plastic surgeons. Technical experts in the United States Embassy in Kigali were fiercely defending the existing H.I.V. projects that were targeted. Others believed the money should be redirected to countries with more extensive AIDS epidemics.
Deeply frustrated by the resistance, Mr. Magaziner and Dr. Binagwaho appealed to top officials at the State Department, the Agency for International Development and the Centers for Disease Control and Prevention. Mr. Magaziner said he had written a letter to Ms. Mills, Secretary Clinton's chief of staff, and met with her, Dr. Goosby and Dr. Rajiv Shah, then the director of the development agency.
Mr. Magaziner said he had kept Mr. Clinton informed about the Rwanda proposal as chairman of the health initiative's board, and said the former president had offered helpful advice. But Mr. Magaziner said he had not communicated directly with Mrs. Clinton.
Mrs. Clinton's policy in such situations called for recusal. Before being sworn in, she wrote an ethics letter to department lawyers pledging that "I will not participate personally and substantially in any particular matter involving specific parties in which the William J. Clinton Foundation (or the Clinton Global Initiative) is a party or represents a party."
Ms. Mills, although a Clinton Foundation board member from 2004 to 2009, did not face similar restraints and reviewed the proposal.
Ms. Mills returned to her unpaid seat on the foundation board after leaving the State Department in 2013. Dr. Goosby left the same year and also accepted an unpaid seat on the board.
Despite Mrs. Clinton's self-imposed restriction, Dr. Goosby said he felt it necessary to brief her on the proposed reallocation. He said he had sought her blessing and found her "very supportive."
"It was a divergence from the way the program was traditionally managed," he said. "We had to get approval from not just the secretary of state but also the White House. It was a big deal."
Dr. Shah said he had found supporting the Rwanda proposal "a tough judgment," but it aligned with his and Mrs. Clinton's broader interests in encouraging self-sufficiency in developing nations and attacking what they viewed as contractors' inflated overhead charges.
In a statement, a spokesman for the Clinton campaign, Nick Merrill, said, "Elevating the role of global aid and development was at the core of Secretary Clinton's 'smart power' approach to foreign policy." In Rwanda, he said, "the U.S. government invested in on-the-ground training and programs with partners who could make lasting impact. That was the bottom line, and to suggest otherwise is off base."
Ms. Mills did not comment for this article.
Mr. Magaziner said he did not see it as a conflict to lobby Mrs. Clinton's department. Given the foundation's work on global health, he said, it would have been unfair to restrict its right to advocate just because Mrs. Clinton had become secretary of state. He stressed that his group had received no government funding for its work on the project; it was supported instead by the private ELMA Foundation, which focuses on alleviating child poverty in Africa.
"That was the line we drew, that we should not be favored and not be discriminated against," Mr. Magaziner said. "And we should not take a penny, so we couldn't be accused of feathering our nest."
An American pediatrician, left, during a radiology teaching session with Rwandan pediatrics residents in Kigali in August.CreditMartina Bacigalupo for The New York Times
Dr. Binagwaho and many of the program's participants consider it a striking success.
"I used to recruit like four residents every year," said Dr. Stephen Rulisa, the head of obstetrics and gynecology at the university. "When the program started I can recruit like 15."
But the program has had a rocky start. Higher-than-expected administrative costs, red tape and late reimbursements by Rwanda to universities prompted one of the biggest partners, Duke University, to drop out this year. Institutions have struggled to recruit appropriately skilled and experienced American faculty who could stay for a year and have resorted to hiring contractors previously unaffiliated with the universities. Overwhelmed by the added workload, some Rwandan professors have decamped for private practice.
In June, at the behest of the Health Ministry, Mr. Magaziner convened an all-day meeting in New York to hear the universities' complaints. The Clinton group, which was no longer involved in carrying out the program, brought a senior employee out of retirement to do damage control and lead a midcourse review.
To the shock of some, the foundation also unveiled plans for an even more ambitious version of the program in Liberia, where the Ebola epidemic has devastated all levels of care.
"It floored people," said Dr. Cliff O'Callahan, a Connecticut pediatrician who taught for a year in Rwanda as contractor for Yale. "Why in the world would you start it in Liberia or anywhere else if you don't have proof of your first experiment?"
Bill and Chelsea Clinton had visited Liberia the previous month, and discussed the proposal in a meeting with President Ellen Johnson Sirleaf, who had expressed support for its goals. Chelsea Clinton said she had appealed to the World Bank and United States officials to repurpose Ebola-response funds for the health work force training program.
"This can't be a one-off," Mr. Clinton said during a forum with Ms. Sirleaf at this year's Clinton Global Initiative. "It's a wonderful story."
The World Bank is working with the Liberian government to tailor the proposal to Liberia's post-Ebola needs. "Some of the ambitiousness of the C.H.A.I. plan was brought into check," said Dr. Timothy G. Evans, the World Bank's senior director for health, referring to the Clinton health initiative.
Dr. Deborah L. Birx, who is Dr. Goosby's successor as global AIDS coordinator, said her office would assess whether the medical training program in Rwanda was the most appropriate use of taxpayer dollars.
"It will be important to see if having subspecialists results in a better outcome for H.I.V.-positive patients," she said.
In the only formal review to date, monitors with the Centers for Disease Control and Prevention described the program in 2014 as "not well aligned" with the government's goal of battling the AIDS epidemic.
Former President Bill Clinton with Hillary Rodham Clinton and their daughter, Chelsea, at the Clinton Global Initiative meeting in 2011.CreditDaniel Berehulak/Getty Images
Clinton's Rwanda Pledge
In the two decades since the Rwandan genocide, historians and journalists have documented that Bill Clinton's administration missed or ignored warnings of the looming cataclysm and led efforts to withdraw United Nations peacekeepers as the rampage took root.
In a 2007 speech, Mr. Clinton spoke transparently of his desire to make things right. "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," he said. "We're undoing that now."
The Clinton-Kagame relationship is friendly enough that three years ago Mrs. Clinton's State Department discussed using her husband as a back channel to the Rwandan leader. Shortly before Mr. Clinton flew to Rwanda, Ambassador Johnnie Carson, then the assistant secretary of state for African affairs, emailed Ms. Mills that it "would be useful" if Mr. Clinton encouraged Mr. Kagame to defuse tensions with the Democratic Republic of Congo.
Emails obtained through public records requests by the conservative research group Citizens United show that Ms. Mills forwarded the note to Mr. Desai at the Clinton Foundation. Neither Mr. Carson nor foundation officials would comment on what had come of it. A State Department spokesman said it was not uncommon to use former presidents for high-level diplomacy.
Mr. Carson said that Rwanda rarely appeared on Secretary Clinton's radar but that she did not pull punches when it did. The day after Mr. Clinton's 2012 appearance in Rwanda, the State Department announced a small cut in military aid to protest Rwanda's support for Congolese rebels.
"In no way did she impede or interrupt or attempt to soften or contradict," said Mr. Carson, who recommended the action to Mrs. Clinton. "She did ask pertinent, direct and tough questions."
The State Department's concerns about Mr. Kagame have only worsened since. Among them are the murder and attempted assassination of prominent Rwandan exiles that, according to department officials, "appear to be politically motivated." Shortly after his former intelligence chief was found strangled in a Johannesburg hotel room last year, Mr. Kagame denied involvement but warned — at a national prayer breakfast — that anyone who betrays Rwanda "will face the consequences." His government suspended BBC broadcasts in the local Kinyarwanda language in 2014 to protest a documentary hostile to Mr. Kagame.
Mr. Clinton's unqualified praise for Mr. Kagame places him at odds with the Obama administration's impatience with Africa's "big men," who cling to power for decades.
In early September, the State Department announced its opposition to any change in Rwanda's presidential two-term limit. Two months earlier, while visiting Africa, President Obama warned without singling out Mr. Kagame that "when a leader tries to change the rules in the middle of the game just to stay in office, it risks instability and strife."
In response, Mr. Kagame's spokeswoman, Stephanie Nyombayire, posted on Twitter that "irony doesn't even begin to describe the act of giving lessons on how not be a 'big man' while condescendingly lecturing an entire continent."
Paul Kagame, the president of Rwanda, at the annual Clinton Global Initiative meeting in New York in 2011.CreditRamin Talaie/Bloomberg, via Getty Images
Many of Mr. Kagame's loudest critics worry that a second President Clinton might go soft on him because of the foundation's ties to his government.
"I am very concerned," said Theogene Rudasingwa, Mr. Kagame's former chief of staff, who now lives in Washington, D.C. "She might gently criticize, but they will not break the relationship just because Kagame has decided to be president for life."
Clinton Foundation officials said that notwithstanding Mrs. Clinton's State Department position and White House ambitions, it would be self-defeating for a global philanthropy to not work in impoverished countries with suspect human rights records.
"There are lots of countries in the world that are complicated and it's not our role to pass judgment," said Mr. Desai, the foundation's foreign policy director. "The ethos we have here, and it comes from him, is that there are plenty of other people who are focused on those issues, including the United Nations and the State Department, and our job is to focus on health care and agriculture."
Still, foundation officials said they might "have to recalibrate" their relationship with Rwanda if more serious evidence emerged. "It doesn't seem like we've gotten there yet," Mr. Desai said.
For the time being, the Kagame government is pleased that Mr. Clinton continues to attest to its progress. Some outsiders, Dr. Binagwaho said, resist accepting that it could happen here, in "a black country in the middle of Africa."
"People say to me: 'Propaganda! Propaganda! Impossible that you do that,'" she said. "They don't consider us capable. So it's good that somebody that has run the world just tells the world that it's true."
Correction: Oct. 26, 2015
Because of an editing error, a picture caption last Monday with the continuation of an article about the Clinton Foundation's partnership with Rwanda, which has resulted in both pathbreaking work and the potential for conflicts of interest, misstated the year of a meeting of the Clinton Global Initiative, the annual four-day gathering of world leaders, in some editions. It was 2011, not 2001.
Kevin Sack reported from Rwanda, and Sheri Fink from New York.
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