Stakeholder Relationships and Sustainability

GLOBAL DYNAMICS OF SOCIAL POLICY
Stakeholder Relationships
And Sustainability
The Case Of Health Aid To
The Kyrgyz Republic
Gulnaz Isabekova
Global Dynamics
of Social Policy CRC 1342
Global Dynamics of Social Policy
Series Editors
Lorraine Frisina Doetter
University of Bremen
Bremen, Germany
Delia González de Reufels

University of Bremen
Bremen, Germany
Carina Schmitt
Bremen, Germany
Marianne Sandvad Ulriksen

University of Southern Denmark
Odense, Denmark
This open access series welcomes studies on the waves, ruptures and
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prior, simultaneous or anticipated episodes of expansion or contraction
in other countries, areas, and risks. One of the aims of this series is to
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zations, political actors and bodies, and business enterprises. A better
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policy making, social policy outputs, and ultimately the outcomes of
social policy.
Gulnaz Isabekova
Stakeholder
Relationships And
Sustainability
The Case Of Health Aid To The Kyrgyz
Republic
Gulnaz Isabekova
University of Bremen, CRC 1342 “Global Dynamics
of Social Policy” and Research Centre for East European Studies
Bremen, Germany
ISSN 2661-8672 ISSN 2661-8680 (electronic)

Global Dynamics of Social Policy
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To my (grand)mother and brother
Preface
This book came into being as an outcome of my multisectoral work expe-

rience in a nongovernmental organization, private enterprise, and aca-
demia. It began with questions, such as what comes after the end of
external funding and how relationships among stakeholders matter in the
long term. This book aims to expand on these questions in the case of
health aid by building a bridge between political science, public health,
and development studies. In so doing, it contemplates and reflects on the
major issues associated with the long-term sustainability of health aid and
the role of the relationships among stakeholders in this matter. Synergizing
the perspectives and findings from these disciplines, this book aims to
offer a comprehensive analysis of the two phenomena, which may serve
as a basis for further studies and as counsel to decision-makers and pro-
fessionals working in the field.
Bremen, Germany Gulnaz Isabekova
vii
Acknowledgments
This book is a product of the research conducted in the Collaborative

Research Center 1342 “Global Dynamics of Social Policy” at the
University of Bremen. The center is funded by the Deutsche
Forschungsgemeinschaft (DFG, German Research Foundation), Project
no. 374666841—SFB 1342. The APCs for the Open Access publication
were partially funded by the State and University Library Bremen (SuUB).
First of all, I would like to thank Prof. Dr. Heiko Pleines, my
Doktorvater, who has guided me throughout the whole process with his
professionalism, wisdom, trust, and humanity. His dedication to aca-
demia and continuous support to colleagues paved the way to opportuni-
ties and professional growth for many early stage researchers like me. I
would also like to express my gratitude to Prof. Kristina Jönsson and Dr.
Monika Ewa Kaminska for their attentiveness, thoughtful suggestions,
and support in writing and defending my Ph.D. dissertation, which laid
down the basis for this book and commenced with the EU-funded
Innovative Training Network “Caspian”. I am sincerely thankful for your
trust and all the long hours you have spent reading many and, at times,
very long pieces from me.
Furthermore, I am grateful to the representatives of civil society and
state and international organizations that participated in this research,
despite their tight schedules and extensive workload. Your professional
insights provided the empirical depth critical to this research by opening
ix
x Acknowledgments
the perspectives understudied in the academic literature to this point. I

would like to especially thank Venera Toktogonova and the Association
of Village Health Committees for their openness and support during the
data collection process. I will not name other organizations to maintain
the anonymity of research participants; still, I am equally grateful for
their time and support.
I would also like to use this opportunity to express my gratitude to my
mother, Nazgul Isabekova, for her unconditional love and belief in me.
To my big brother, Almaz Isabekov, for his continuous support, invest-
ment in my education, and the strong connection we have had since
childhood. To my grandmother, Aynek Karymshakova, who, born as a
nomad and having experienced many hardships and achievements, always
taught us to strive for knowledge. I am also grateful to all other family
members, including my sister Aigerim, aunt Gulnara, sister-in-law Aliya,
and nieces Perizat, Amira, and Mirana, whom I miss dearly. I am also
thankful to my father, Kubanychbek Isabekov, for his support. His deter-
mination and professional excellence made him a role model to follow.
Furthermore, I am sincerely grateful to all the wonderful people I have
met and collaborated with during this journey. These are my dearest
Natalia Zakharchenko and Ohanna Kirakosyan, for their support with
data collection process. I am also very grateful to Azhara Kazakbaeva for
her support with the transcription of interviews. Separately, I would also
like to thank Dr. Ulla Pape, Dr. Esther Somfalvy, and Dr. Ivan Bakalov
for their encouraging comments and literature suggestions that found
substantial reflection in this book. I am also extremely grateful to multi-
ple friends and colleagues who showed immense support, particularly
during the final stages of the writing process: Nathanael Brown, Anastasia
Stoll, Irina Wiegand, Stas Gorelik, Benjamin Ahlborn, Dörte Kanis, Jan
Matti Dollbaum, Andreas Heinrich, Alesia Kananchuk, Lina Pleines,
Aizhan Imanalieva, Tatia Chihkladze, Liva Stupele, Florian Wittmann,
Liliana Sanchez, Mareike zum Felde, Karolina Kluczewska, Manuela
Putz, Felix Herrmann, Oksana Chorna, and many others. Equally, I am
grateful to all participants of the Research Colloquium of the Dept. of
Politics and Economics, Research Centre for East European Studies
(FSO) at the University of Bremen, for taking their time to comment on
the early drafts of this research.
Acknowledgments xi
Last but not least, I want to express my gratitude to my fiancé, Dario

Landau, for his patience, relentless optimism, and support throughout
these years, including during my trips to community-based organizations
and health care facilities in Kyrgyzstan. Thank you for your understand-
ing and support during the long working hours over these past years. I
am also very thankful to his mother Iris Dorn-Lopez, his brother Luk and
his partner Claudi, and other family members, including Domingos
Lopez and Peter Dorn, for their warmth, support, and creativity in help-
ing arrange space for me to work in even under highly unusual
circumstances.
Praise for Stakeholder Relationships
and Sustainability
“Through extensive and careful empirical research Gulnaz Isabekova is able to

offer a detailed and systematic examination of her cases, which is of high value
not only for students of post-Soviet politics, but also for the broader literature
on development aid, health care and infectious diseases.”
—Heiko Pleines, Prof. of Comparative Politics, Research Centre for
East European Studies at the University of Bremen
Contents
1 I ntroduction 1
1.1 Sustainability and Relationships in Aid: Problems and
Approaches 3
1.2 Research Aims of This Book 7
1.3 Case Selection 10
1.4 Contextual Information on Kyrgyzstan 12
1.5 Data Collection 15
1.6 Book Structure 17
References 18
2 Theorizing
Power, Agents, Structures, and Aid
Relationships 29
2.1 Conceptualization of Power 32
2.2 Conceptualizing Agents and Structures 37
2.3 Project Life Cycle 42
2.4 Uniting Theory and Empirical Findings 42
References 53
3 Sustainability
of Health Assistance 59
3.1 Operationalizing Sustainability 61
3.2 Conceptual Definition 62
xv
xvi Contents
3.3 Factors Influencing the Sustainability of Health Care

Interventions 67
3.4 Summary 76
References 76
4 The
Role of Structural Factors in Selected Health Programs 85
4.1 Aid Predictability 85
4.2 Aid Flexibility 90
4.3 Capacity 94
4.4 Aid Dependency 108
4.5 Summary 116
References117
5 The
“Community Action for Health”: The Project Life
Cycle129
5.1 Initiation 130
5.2 Design 134
5.3 Project Implementation 137
5.4 Project Evaluation 145
References148
6 Sustainability
of the “Community Action for Health”
Project153
6.1 Project Description 153
6.2 Continuity of Project Activities 156
6.3 Maintaining Benefits 163
6.4 Community Capacity-Building 169
6.5 Summary 179
References181
7 Aid
Relationships and Power Dynamics in the
“Community Action for Health” Project187
7.1 Donor–CSOs: The “Empowerment” Approach 188
7.2 Recipient State–CSOs: The “Utilitarian” Approach 195
7.3 Donor–Donor: Unequal Cooperation 200
Contents xvii
7.4 Donor–Recipient State: (Contingent) Equal

Cooperation203
References208
8 The
Global Fund Grants: Project Life Cycle211
8.1 Initiation 212
8.2 Design 213
8.3 Implementation 224
8.4 Monitoring 235
References244
9 Sustainability
of Global Fund Grants255
9.1 Description of Grants 256
9.2 Continuity of Project Activities 258
9.3 Maintaining Benefits 273
9.4 Summary 281
References282
10 Aid
Relationships and Power Dynamics in the Global
Fund Grants293
10.1 Donor–CSOs: “Utilitarian” Approach 294
10.2 Recipient State–CSOs: “Utilitarian” Approach 298
10.3 Donor–Donor: Coordination 302
10.4 Donor–Recipient State: Unequal Cooperation 305
References311
11 “ Missing Link”315

11.1 The “Community Action for Health” Project 316
11.2 The Global Fund Grant to Kyrgyzstan 331
11.3 Cross-Case Causal Inferences 338
11.4 Methodological Limitations 342
References343
xviii Contents
12 Conclusion
and General Implications of This Study347
12.1 Aid Relationships 348
12.2 Sustainability of the Selected Health Projects 354
12.3 The “Missing Link” between Aid Relationships and
Sustainability357
12.4 Further Findings and Limitations of This Research 362
References365
A
ppendix369
I ndex371
Abbreviations
AFEW Kyrgyzstan Public Foundation “AIDS

Foundation East-West in the Kyrgyz Republic”
AIDS Acquired Immunodeficiency Syndrome
ART Antiretroviral Therapy
ARV Antiretrovirals
AVHC/Association of VHCs The Association of Village Health Committees
BMZ The German Federal Ministry for Economic
Cooperation and Development (das
Bundesministerium für wirtschaftliche
Zusammenarbeit und Entwicklung—BMZ)
CAH The “Community Action for Health” Project
CBOs Community-Based Organizations
CCM Country Coordinating Mechanism
CDC The Centers for Disease Control and
Prevention
COVID-19 Coronavirus Disease 2019
CSOs Civil Society Organizations
CSW Commercial Sex Worker
DAC Development Assistance Committee
DFID The United Kingdom’s Department for
International Development
DOTS Directly Observed Treatment Short-course
EECA Eastern Europe and Central Asia
xix
xx Abbreviations
FMC Family Medicine Center

Gavi Vaccine Alliance (formerly known as Global
Alliance for Vaccines and Immunization)
GDF Global Drug Facility
GDP Gross Domestic Product
GHI Global Health Initiative
GIZ German Corporation for International
Cooperation (die Deutsche Gesellschaft für
Internationale Zusammenarbeit)
HIV/AIDS Human Immunodeficiency Virus Infection
and Acquired Immune Deficiency Syndrome
HPU Health Promotion Unit
ICRC International Committee of the Red Cross
KfW German Development Bank (die Kreditanstalt
für Wiederaufbau)
KGS Kyrgyzstani som
KR Kyrgyz Republic
LFA Local Funding Agent
LGBTQ Lesbian, Gay, Bisexual, Trans, Intersex,
and Queer
LSG Local Self-Government
M&E Monitoring and Evaluation
MDR-TB Multidrug-Resistant Tuberculosis
MHIF Mandatory Health Insurance Fund
MoH Ministry of Health
MSF Doctors Without Borders/Médecins Sans
Frontières
MSM Men Who Have Sex with Men
NCPh National Center of Phthisiology Under the
MoH in Kyrgyzstan
NGO Nongovernmental Organization
NSP Needle and Syringe Exchange Program
OECD DAC Organization for Economic Co-operation and
Development’s Development Assistance
Committee
ODA Official Development Assistance
OIG Office of the Inspector General
OSF Open Society Foundation
Abbreviations xxi
OST Opioid Substitution Therapy

PEPFAR President’s Emergency Plan for AIDS Relief
PHC Primary Health Care
PLHIV People Living with HIV/Persons Living
with HIV
PR Primary Recipient of the Global Fund Grants
PRA Participatory Reflection and Action, formerly
known as the Participatory Rural Appraisal
PWID Persons/People Who Inject Drugs
RHC Rayon Health Committees
Republican Center Republican Center for Health Promotion and
Mass Communication under the Ministry
of Health
SDC Swiss Agency for Development and
Cooperation
Sida Swedish International Development
Cooperation Agency
SR Sub-recipient of the Global Fund Grants
SRC Swiss Red Cross
STIs Sexually Transmitted Infections
SWAp Sector Wide Approach
TB Tuberculosis
The Global Fund Global Fund to Fight AIDS, Tuberculosis
and Malaria
UN United Nations
UNAIDS Joint United Nations Programme on
HIV/AIDS
UNDP United Nations Development Programme
UNESCO United Nations Educational, Scientific and
Cultural Organization
UNICEF United Nations Children’s Fund
UNFPA United Nations Population Fund
UNOPS United Nations Office for Project Services
USAID United States Agency for International
Development
VHC Village Health Committee
WHO World Health Organization
List of Diagrams
Diagram 6.1 Chronology of the project (Source: Adapted from

Schueth (2009, p. 11) and complemented with
information from project-related documents) 154
Diagram 8.1 The realm of actors monitoring the Global Fund grants 243
Diagram 11.1 The impact of the donor’s “empowerment” approach
on sustainability 317
Diagram 11.6 The impact of the local self-governments’ “utilitarian”
approach on sustainability 327
Diagram 11.7 The impact of (contingent) equal cooperation on
sustainability328
Diagram 11.8 The impact of the unequal cooperation between
donors on sustainability 330
Diagram 11.9 The impact of the donor’s “utilitarian” approach
toward CSOs on sustainability 332
xxiii
xxiv List of Diagrams
Diagram 11.10 Donor–recipient state: the impact of unequal

cooperation on sustainability 333
Diagram 11.11 Donor–recipient state: the impact of unequal
cooperation on sustainability 334
Diagram 11.12 The impact of coordination among donors on
sustainability337
List of Tables
Table 2.1 Structures and their relevance to agents 38

Table 3.1 Sustainability in empirical terms 62
Table 3.2 Conceptual definition of sustainability 67
Table 3.3 The factors relevant to sustainability 68
Table 7.1 Aid relationships between actors in the “Community
Action for Health” project 188
Table 8.1 Evolution of the Country Coordinating Mechanism in
Kyrgyzstan218
Table 8.2 Principal Recipients of the Global Fund grants to
Kyrgyzstan225
Table 10.1 Relationships between stakeholders involved in the Global
Fund grants to the Kyrgyz Republic 294
xxv
1
Introduction
Health aid, as it is known today, is a relatively new phenomenon. Before

the twentieth century, health assistance was limited mainly to missionar-
ies, who targeted specific geographic areas (Fleßa, 2014). Official devel-
opment assistance (ODA) for health is a more formalized and structured
form of aid. Composed of grants (at least 25% of the total sum) and
concessional loans, ODA is provided for development or welfare pur-
poses on a bilateral (country to country) or multilateral (organization to
country) basis (OECD, 2009a, p. 180). In contrast to its predecessor,
which experiences neither competition among actors nor duplication of
efforts (Fleßa, 2014), ODA for health involves multiple bilateral and
multilateral actors. According to some estimates, there are up to 61 pro-
viders (Knox, 2020, p. 11), each having a specific structure and regula-
tions governing its aid provision and acquisition processes, which may
vary considerably across providers.
Notably, ODA for health grew proportionally to the expansion of
understanding development as a multidimensional concept not limited
to economic growth. First advanced by development theorists and prac-
titioners in the late 1960s, this multidimensional approach to develop-
ment stressed the various aspects of human welfare, including health,
© The Author(s) 2024 1

G. Isabekova, Stakeholder Relationships And Sustainability, Global Dynamics of Social
Policy, https://doi.org/10.1007/978-3-031-31990-7_1
2 G. Isabekova
education, and political freedoms (Schafer et al., 2012). Following this

approach and growing criticism of the economic focus of development
activities (Cornia et al., 1987, 1988), aid to social sectors grew from less
than 10% in 1967 to over 40% of total ODA in 2011 (Addison et al.,
2015, p. 1356). Health aid also increased from approximately 4% in
1975 (WHO, 2002, p. 12) to 14% of total ODA in 2017 (Knox, 2020,
p. 9).1 It either targeted specific diseases (“vertical” approach) or aimed to
strengthen health care systems in general (“horizontal” approach)
(Andrews, 2013, p. 130).
Notably, the “vertical” approach subsumes a large share of health aid.
Between 2009 and 2018, over half of the health aid was allocated to com-
batting diseases, with most spending targeting the control of sexually
transmitted infections (mainly human immunodeficiency virus infection
and acquired immune deficiency syndrome (HIV/AIDS)) and other
infectious diseases, such as malaria and tuberculosis (Knox, 2020). This
distribution is also due to the establishment of global initiatives focusing
on communicable (infectious) diseases. Thus, in the early 2000s, global
health initiatives, such as the Vaccine Alliance (Gavi) and the Global
Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund),
emerged to facilitate rapid expansion of prevention and treatment ser-
vices (Biesma et al., 2009). The establishment of these initiatives was also
consonant with the global health agenda. The focus on disease control as
a global problem corresponded to Goal 6 of the United Nations (UN)
Millennium Development Goals (MDGs) (2000–2015) (UN, 2015).
The MDGs stressed the role of ODA and a global partnership for devel-
opment in achieving the stated objectives, but they also noted a slight
decrease in the aid flows (ibid.). Following the legacy of the MDGs, the
UN Sustainable Development Goals (SDGs) (2015–2030) similarly aim
at ending the epidemics of AIDS, tuberculosis (TB), malaria, and other
infectious diseases by 2030 (Goal 3, Target 3.3) (UN, n.d.).
However, achievement of the SDGs is jeopardized by the funding gap
faced by developing countries (United Nations Development Coordination
1
These data includes members of the Development Assistance Committee and multilateral organi-
zations, which represented 2/3 of the ODA in 2018 (Knox, 2020, p. 9). These estimates do not
include the contributions of “emerging” donors, such as Russia, China, and other countries.
1 Introduction 3
Office and Dag Hammarskjöld Foundation, n.d.). Over the decades,

ODA has been a reliable source of financing for developing countries
(Ahmad et al., 2022), but its share, particularly in certain parts of the
world, is decreasing. Although remaining stable in the case of Sub-Saharan
Africa, health aid to other regions, such as Latin America, the Caribbean,
Eastern Europe, and Central Asia (EECA), has been falling (see Institute
for Health Metrics and Evaluation 2023a). Accordingly, Global Health
Initiatives in these regions also shrank. For instance, allocations of the
Global Fund to Latin America and the Caribbean, Eastern Europe and
Central Asia decreased by approximately half, from 7% to 2.9% and from
8% to 2.6%, respectively, of the total investments (see Global Fund,
2011, 2019). Public funding in aid-recipient countries does not necessar-
ily compensate for reductions in ODA to health, as aid is believed to
neither facilitate nor hinder public spending on health (WHO, 2019).
This decrease in health aid has been further exacerbated by the impli-
cations of the fight against the coronavirus disease of 2019 (COVID-19)
pandemic. Indeed, the pandemic has boosted the total ODA to health by
31% compared to the previous year (Brown et al., 2022). This increase,
explained by aid providers’ allocations to ensure immediate responses to
the pandemic, does not necessarily imply more support for areas beyond
COVID-19. In fact, the diversion of health care workers and facilities
from other areas, often those targeting communicable diseases, decreased
access to prevention and treatment services (Economist, 2022). In these
circumstances, achieving the UN SDG targets on communicable diseases
requires additional funding, a substantial portion of which will aim at
catching up to the achievements made before the pandemic.
1.1 Sustainability and Relationships in Aid:

Problems and Approaches
The reduction in health aid jeopardizes the sustainability of the disease
control activities previously covered by it. For instance, there is evidence
that countries transitioning2 from the Global Fund’s assistance struggle
2
“Transition” is a process of moving away from donor funding, also referred to as “graduation” or
“handover” (Burrows et al., 2016, p. 4).
4 G. Isabekova
with reemerging infectious diseases. A 2017 Open Society Foundation

(OSF) case study of three countries (Macedonia, Montenegro, and
Serbia) suggests service disruptions and an increased HIV burden among
key groups (OSF, 2017). The withdrawal of the Global Fund led to simi-
lar outcomes in other countries. Civil society organizations in Northern
Mexico reported a 60–90% decrease in the distribution of needles and
syringes after Global Fund grant program ended (OSF, 2015). In the
three years following the end of the Global Fund program in Romania,
the rate of HIV positivity among drug users in the country increased
from 3% to 30% (OSF, 2014). According to a recent assessment by
Gotsadze et al. (2019b), most EECA grant-recipient countries transition-
ing from the Global Fund’s grants face medium- or high-level risks to the
continuity of their TB and HIV/AIDS programs after the ending of
Global Fund assistance. The authors stress the problems with weak
human resources, limited state financing and high dependence on exter-
nal assistance (ibid.).
In addition to reductions in health aid, the sustainability of the out-
comes achieved in disease control activities is further challenged by aid
fragmentation. Aid fragmentation refers to “aid that comes in too many
small slices from too many donors, creating unnecessary and wasteful
administrative costs and making it difficult to target aid where it is needed
most” (OECD, 2009b, p. 15). Not specific to health aid but common to
development assistance in general, aid fragmentation has multiple reper-
cussions, such as an increased burden on aid recipients and the duplica-
tion of efforts.
One example is the large number of meetings between aid providers
and recipients. For example, in 2007, Vietnam reported hosting 782
donor missions, each of them demanding “time and attention” from the
recipient government (Lawson, 2013, p. 5). In addition to imposing an
administrative burden, aid fragmentation is conducive to the duplication
of efforts. An extreme example is a case of measles in a little girl in Banda
Aceh, Indonesia, after the 2004 Indian Ocean tsunami. The measles
symptoms, identified by doctors as unusual, were the outcome of three-
fold vaccination by three different organizations (Carbajosa, 2005).
The involvement of aid recipients is equally important to the sustain-
ability of disease control efforts. In the measles case described above,
1 Introduction 5
coordination among the humanitarian organizations themselves was

poor at the time of the disaster, but it was completely ignored in relation
to the national government (Susilo, 2010). Indeed, an extensive number
of missions do not solve the problem of aid fragmentation, nor does their
limited interaction.
This study aims to develop comprehensive analytical frameworks to
provide an exhaustive basis for understanding the various forms of rela-
tionships between actors and sustainability in the context of health devel-
opment assistance. It aims to answer the following research question:
How do relationships among stakeholders affect the sustainability of
health aid?
Multiple parties have sought an answer to this question. Countries
providing and receiving development assistance have started multiple ini-
tiatives to overcome the problems caused by the duplication of efforts,
increase the aid recipient’s ownership,3 and improve the outcomes of
development assistance (OECD, 2012, n.d.). The Sector-Wide Approach
(SWAp) was one such response. It aimed to unite external assistance
under the recipient government’s leadership to support its sectoral policy
or program (Foster & Leavy, 2001). Thus, the SWAp aimed to overcome
the aid fragmentation problem and support the aid recipient’s agency.
Nevertheless, it demonstrated rather “mixed” performance (Peters et al.,
2013, pp. 4–5) and accounted for a small share of aid (Sweeney &
Mortimer, 2015), partly because it was bypassed by major aid providers,
including those targeting specific diseases.
Similarly, the academic literature on development assistance has
equally stressed the inclusion of multiple actors in the aid realization pro-
cess and the importance of increasing aid recipients’ ownership to improve
the sustainability of development assistance (e.g., Jerve et al., 2008;
Kindornay, 2014; Paine-Andrews et al., 2000; Swedlund, 2017). This
discussion of aid recipients’ ownership resulted in a distinction between
two approaches to development assistance. In a “top-down” approach,
assistance was planned by “experts” of donor organizations, whereas a
“bottom-up” approach emphasized aid recipients’ participation in
3
Ownership is defined as “the control of recipients over the process and outcome of aid negotia-
tions” (Whitfield & Fraser, 2010, pp. 342–343).
6 G. Isabekova
defining the objectives and means of development assistance (Kaiser,

2020, pp. 94–95). Andrews (2013) suggests that a concentration on
“lone champions” instead of the “broader engagement” of relevant actors
leads to the failure of reforms promoted by development programs. He
argues that engaging multiple actors is essential for ensuring compliance
with the suggested reforms in the local context, as well as local stakehold-
ers’ commitment to these reforms (ibid.). Following this logic, aid pro-
viders have incorporated some elements of the bottom-up approach in
their top-down development programs by emphasizing the aid recipients’
involvement in their assistance (Kaiser, 2020, p. 101).
Despite the rhetorical embrace, the actual fulfillment of the bottom-
up approach to development assistance has been jeopardized by unequal
power dynamics between providers and recipients of development aid
(see Hinton & Groves, 2004). Furthermore, the project benchmarks and
performance criteria set by donor organizations also affect the terms of
aid-recipient participation (Power et al., 2002). Overall, with whom and
how to interact in development assistance remain unclear. The inclusion
of actors without addressing potential issues related to hierarchy, compat-
ibility, and mutual understanding does not guarantee the desired
outcome.
The academic literature on relationships in development assistance is
scattered, examining selected forms or relationships between actors in
general without nuanced consideration of their types. Some studies have
examined coordination (e.g., Aldasoro et al., 2010; Bigsten & Tengstam,
2015; Bourguignon & Platteau, 2015); others, cooperation (Degnbol-
Martinussen & Engberg-Pedersen, 2003; Torsvik, 2005; Zimmermann
& Smith, 2011) or partnerships (Del Biondo, 2020; Nabyonga Orem
et al., 2013). Other research has focused on understanding aid relation-
ships (Eyben, 2006; Hinton & Groves, 2004) or interactions (Lamothe,
2010; Villanger, 2004). However, the link between studies focusing on
specific forms or the general notion of relationships between actors has
rarely been examined.
Similarly, the meaning of sustainability in the context of development
assistance is unclear due to the fragmentation of relevant literature, as the
majority of studies focus either on systematic literature review or on
empirical analysis of interventions (e.g., case studies), often without
1 Introduction 7
theoretical underpinnings (Proctor et al., 2015). This situation contrib-

utes to conceptual ambiguity (see Giovannoni & Fabietti, 2013; Shigayeva
& Coker, 2015) and inconsistent use of sustainability as a term (Blanchet
et al., 2014; Oberth & Whiteside, 2016). The fragmentation of the lit-
erature and conceptual ambiguity offer limited implications for a broader
understanding of the sustainability of development assistance and the
relevant factors.
1.2 Research Aims of This Book

First, by combining and systematizing the relevant literature, this book
offers an analytical framework for analyzing the relationships between
stakeholders. That is, instead of merely stressing the importance of aid
relationships, this research analyzes the underlying issues related to the
structure of development aid and actors’ roles in it. Highlighting the
multiplicity of stakeholders involved in aid, it examines the relationships
between providers (donor–donor), between providers and the recipient
government (donor–recipient state), and between providers, the recipient
government, and civil society organizations (CSOs; donor–CSO and
recipient state–CSO relationships).
This book aims to synergize the discussion of aid relationships in the
development aid literature with a discussion of power and its sources in
political theory to provide a more refined analytical framework for ana-
lyzing aid relationships (Chap. 2). Differentiating between conventional
and alternative perspectives on relationships and power in development
assistance, it examines recipients’ roles, their potential interdependence,
and the (changing) nature of power throughout the assistance.
The analytical framework, composed of four steps, is intended to pro-
vide an exhaustive basis for this examination. (1) The discussion of power
and its associated terms (resources, consensus/conflict, and interests) pro-
vides a necessary conceptual basis for understanding and differentiating
between the types of power and its attributes. (2) Further discussion of
stakeholders and the context of development aid following the agent-
structure approach expand on the relevance of individual and collective
agency corresponding to abstract categories (e.g., donor, CSO, recipient
8 G. Isabekova
state). This approach also places the frequent issues associated with
inequality among actors, namely, aid dependency, capacity, aid flexibility,
and volatility, into structures that may vary depending on the context/
case but nevertheless remain important to relationships. (3) Analyzing
stakeholders’ roles throughout the project life cycle by differentiating
between the initiation, design, implementation, and evaluation phases is
essential to grasp the roles assigned to each actor empirically. (4) Linking
the empirical insights from step 3 and the conceptual basis for defining
stakeholders, power, and the context in the first two steps leads to a theo-
rization of power dynamics and aid relationships. This step is necessary to
place the empirical cases in a broader theoretical framework. This step
combines the seven ways of creating power suggested by Haugaard (2003)
with the “ideal” types of aid relationships defined by the author of this
book in Chap. 2.
Second, this book offers an equally comprehensive analytical frame-
work for understanding the sustainability of health aid. To operationalize
sustainability in a consistent and comprehensive manner, it elaborates on
the empirical and conceptual definitions of the term. In empirical terms,
it defines “what, how or by whom, how much, and by when” to sustain
(Iwelunmor et al., 2016, p. 2). In conceptual terms, the book aims to
balance donors’ and recipients’ perspectives on sustainability; for this rea-
son, it adopts a broader definition of sustainability as a continuity of
project activities, the maintenance of benefits, and community capacity-
building (Shediac-Rizkallah & Bone, 1998).
This book complements Shediac-Rizkallah and Bone’s (1998) defini-
tion with three further extensions. (1) Acknowledging the relevance of
the analysis of both ongoing and complemented projects, it approaches
state commitment in terms of necessary legislative amendments and
financing as indicative of the sustainability of ongoing initiatives. (2) It
complements the operationalization of community capacity-building
with an adaptation of Laverack’s framework (see Labonte & Laverack,
2001a, 2001b) by focusing on participation, leadership, and resource
mobilization. Furthermore, it introduces an aspect that is absent in two
previous frameworks, namely, the survival of CSOs beyond the period of
1 Introduction 9
development assistance provision. (3) Based on a comprehensive review

of research on the sustainability of health care interventions, it also lists
factors relevant to the latter. These factors are financing, accounting for
the influence of general factors (e.g., political and economic situation in
the aid-recipient country), integration into the local context, and organi-
zational factors relevant to the project and the actors implementing it.
Third, systematic operationalization of the relationships, sustainability,
and related factors in the context of development aid is followed by the
examination of a possible causal link between aid relationships and sus-
tainability. To this end, this book uses the concept of a social mechanism
as “a constellation of entities or activities that are linked to one another in
such a way that they regularly bring about a particular type of outcome”
(Hedström, 2005, p. 11). In addition to providing insights into health
aid in the EECA region, this study aims to contribute to the general lit-
erature by defining the mechanisms through which the interaction
between stakeholders affects the sustainability of health aid. Although
specific, these mechanisms are, to a certain extent, generalizable beyond
the context of the selected health care programs.
In addition to outlining the underlying issues and main features of
social mechanisms, this book emphasizes their role in the formulation of
explanatory theories. Thus, by defining social mechanisms, it aims not
only to show how but also to explain why the interaction among stake-
holders matters to the sustainability of aid. In doing so, it seeks to theo-
rize the relationships between the two phenomena and highlight the
conditions under which these relationships are likely to take place and
shape sustainability by using Rohlfing’s (2012) integrative framework for
case studies and causal inferences.
Overall, comprehensive and concise analytical frameworks, based on
the extensive literature review and findings from the field, allows for a
systematic analysis of sustainability and interaction, including the rele-
vant factors. This mid-range approach extends beyond the alleged univer-
sal paradigms and detailed single-case studies by offering a thorough
analysis of development projects to identify issues and opportunities
applicable to similar initiatives in similar contexts.
10 G. Isabekova
1.3 Case Selection

Empirically, this book focuses on projects pursuing the bottom-up
approach in the developing country context as most favorable for chang-
ing the unequal power dynamics between providers and recipients of
assistance. Known as a “pioneer” of health care reforms (Ancker et al.,
2013), Kyrgyzstan (also referred to as the Kyrgyz Republic) is one of the
few countries worldwide to have fully implemented the SWAp. Presuming
aid providers’ compliance with the national policy and procedures of the
aid-recipient governments, the SWAp provides the most favorable envi-
ronment for altering the conventional power dynamics between donors
and recipient governments. The presence of the SWAp in other regions
also means that the lessons learned from Kyrgyzstan are equally applica-
ble to other countries implementing this approach to health aid.
Another reason for selecting this country context is that Kyrgyzstan is
part of the post-Soviet region—an understudied region in the literature
on development aid. Shortly after the collapse of the Soviet Union in
1991, newly independent countries received significant financial and
technical assistance from international organizations. However, except
for the number of articles discussing the conditions (e.g., Pleines, 2021;
Stubbs et al., 2020), assumptions (Wilkinson, 2014), and implications of
international support (Ancker & Rechel, 2015; Kim et al., 2018), the
post-Soviet region is overlooked in literature on development aid (Leitch,
2016), which largely focuses on Sub-Saharan Africa, Latin America, and
Southeast Asia. This book offers insights into health aid in an overlooked
context based on case studies in Kyrgyzstan.
The two case studies investigated in this book are the Swiss Agency for
Development and Cooperation’s (SDC) “Community Action for Health”
project and the Global Fund grants to Kyrgyzstan.
SDC represents a traditional bilateral donor whose activities in the
health context depend on the geopolitical interests of Switzerland in an
aid-recipient country. Unlike the Global Fund, stationed in Geneva,
SDC has its representations in aid-recipient countries. Although still
accountable to headquarters, these local SDC offices enjoy a relatively
high level of autonomy in their policy dialog with recipient governments,
1 Introduction 11
budget management, and other areas, which provides them with the flex-
ibility to allocate finances according to the recipients’ priorities
(OECD, 2005).
Raising approximately US $4 billion annually (Global Fund, 2023a),
the Global Fund is among the largest financiers of TB, HIV/AIDS, and
malaria programs in the world. It offers grants to countries fulfilling the
eligibility criteria (e.g., income status, burden of disease) based on their
applications, in which countries indicate how they are going to fight the
disease/diseases in question and strengthen their health care systems. As a
multilateral donor organization, the Global Fund represents “a new breed
of players in global health” that uses a “common blueprint or strategy”
across countries to target specific diseases and health challenges (Hanefeld,
2014, p. 54).
Thus, both organizations not only formally acknowledge the impor-
tance of ownership but also provide the possibility for aid recipients to
define the objectives and activities of the assistance offered by them. In so
doing, they embody the “bottom-up” approach to health aid, as their
goals and activities are defined by aid recipients.
In addition, the projects differ in their benchmarks and performance
criteria. The recipients of the Global Fund projects are expected to com-
ply with its regulations and demonstrate a “good” performance to receive
financing continuously. The Community Action for Health project, on
the contrary, does not specify the performance criteria and other regula-
tions with which aid recipients need to comply. In this way, the Global
Fund projects and the SDC’s Community Action for Health project are
vivid examples of the bottom-up approach to health aid with and with-
out donor conditionalities. This difference offers another layer of com-
plexity beneficial to understanding the various facets of the bottom-up
approach in practice.
Analysis at the project level is essential to understanding how power
dynamics and different types of interaction between providers and recipi-
ents of health aid form throughout the project life cycle (i.e., its initia-
tion, design, implementation, and evaluation). The focus on the project
level also facilitates credible and yet feasible analysis of what sustainable
health aid and the relevant factors mean in practice. To ensure the com-
parability of projects, this book focuses on the TB and HIV/AIDS
12 G. Isabekova
activities of the Global Fund projects and the Community Action for
Health project.4 The Global Fund grants refer to eight grants that are
nevertheless being approached as an ongoing long-term project combat-
ting TB and HIV/AIDS because the objectives of the grants are built on
each other. Thus, the administrative division of grants into three- to six-
year-long periods corresponds to the length of financial commitments
offered by the Global Fund. In contrast, the SDC’s Community Action
for Health project lasted for nearly seventeen years. It comprised seven
phases, from an early pilot to countrywide implementation, which were
one continuous project.
1.4 Contextual Information on Kyrgyzstan

Kyrgyzstan (also known as the Kyrgyz Republic) is a lower low-middle-
income (Global Fund, n.d.-a) Central Asian country with a gross domes-
tic product per capita (current US$) of 1275.9 and a population of
6,700,000 as of 2021 (World Bank Group, 2023). With a total size of
199,900 sq. km, the country is administratively divided into seven
regions (oblasts) and 40 districts (rayons) (National Statistical Committee
of the Kyrgyz Republic, 2021).5 The population is young, with a median
age of 27.9 years (ibid.). A large part of the population is ethnic Kyrgyz
(73.8%), followed by Uzbek (14.9%), Russian (5.2%), Dungan (1.1%),
and other ethnic groups (ibid.). It is estimated that over 80% of the pop-
ulation identifies itself as Muslim, followed by Orthodox Christians (7%)
and other religious groups (Usenov, 2022). It should, however, be noted
that the extent of religiosity on the individual level, also among those
considering themselves as Muslims, varies considerably (ibid.).
The political system of Kyrgyzstan can be characterized as a hybrid
regime. The country has been referred to as the “Switzerland of Central
Asia” due to its mountainous landscape (see Dorji, 2012) and the “island
4
Unlike the Global Fund projects, the Community Action for Health project included but was not
limited to activities targeting TB and HIV/AIDS. For more information on the projects, see Chaps.
6 and 9.
5
The 7 regions (Batken, Osh, Jalal-Abad, Talas, Chi, Naryn, and Issykkul) are further divided into
40 districts. The capital of the country is Bishkek.
1 Introduction 13
of democracy” because of its initial democratic aspirations (Anderson,

1999). During the three revolutions in 2005, 2010, and 2020, the politi-
cal system underwent multiple changes, from presidential to parliamen-
tary rule and back to presidential rule. The country used to have a higher
level of freedom of speech than other countries in the region. However,
there are substantial issues with the rights of sexual minorities (as else-
where in the former Soviet Union) and concerns with the growing cen-
sorship of media and civil society organizations.
Kyrgyzstan gained its independence in 1991 after the collapse of the
Soviet Union. Similar to other countries in the region, Kyrgyzstan inher-
ited the Semashko health care system, known for its curative rather than
preventive approach to diseases. This system is also characterized by the
state’s paternalistic role as a financer, provider, and regulator of health
care services. Overall, the government has remained the main actor in
regulating health care systems and defining citizens’ entitlement to ser-
vices (see Isabekova, 2019a). The country has also retained vertical provi-
sion of TB and HIV/AIDS services by specialized state agencies, although
there have been considerable changes and ongoing reforms in this regard.
Following the collapse of the Soviet Union, Kyrgyzstan struggled with
political, social, and economic crises that contributed to the outbreak of
tuberculosis. The country’s gross domestic product (GDP) declined by
half after the collapse of the Soviet Union (Wolfe, 2005, p. 13), impover-
ishing nearly half (43.5%) of the population (UNDP and ILO, 2008,
pp. 25–26). Between 1990 and 2001, the estimated mortality rate related
to TB tripled from 9.1 to 29 per 100,000 population (van den Boom
et al., 2015, p. 2). The number of TB cases grew from 52 to 88 per
100,000 population; although the actual number of cases was at least two
times higher (ibid.). The country also struggled with limited access to
testing and poor infection control in medical facilities (WHO/Europe,
2011). Inadequate treatment contributed to the development of
multidrug-resistant tuberculosis (MDR-TB).
The incidence of HIV (i.e., new cases reported) increased after the dis-
solution of the Soviet Union. Situated along one of the three main drug-
trafficking routes from Afghanistan to Russia and Europe (Government
of KR, 2006), Kyrgyzstan was especially vulnerable to HIV transmission
through the use of injection drugs. In the period 1991–1995, the
14 G. Isabekova
number of persons who injected drugs (PWID) increased by 25% annu-

ally and represented 85% of all new HIV cases (Government of KR,
1997). The first HIV case among Kyrgyz citizens was registered in 1996
(ibid.).6 Improved surveillance and the worsening HIV situation in the
country increased the recorded HIV incidence in the 2000s (Ancker
et al., 2013), although the official statistics still did not reflect the magni-
tude of the problem (International Charitable Organization “East Europe
and Central Asia Union of People Living with HIV,” n.d.). Due to lim-
ited testing (Government of KR, 1997), only a third (approximately
30%) of HIV cases were detected (Mansfeld et al., 2015, p. 1).
Overall, health aid has contributed to the prevention, diagnosis, and
treatment of TB and HIV/AIDS in the EECA (see Acosta et al., 2016).
Nonetheless, despite decreasing ODA to health,7 the region still has the
fastest-growing HIV epidemic and the highest level of MDR-TB in the
world (Global Fund, n.d.-b). Kyrgyzstan is on the World Health
Organization (WHO) list of 27 countries with a high burden of MDR-TB
(WHO, 2015). Fifty-five percent of previously treated patients in the
country had MDR-TB (van den Boom et al., 2015, p. 5). Drug resis-
tance is 2.5 times higher among labor migrants than among the general
population (Babamuradov et al., 2017, p. 1688). A large proportion of
Kyrgyz labor migrants work in Russia and Kazakhstan. While a bilateral
agreement with Kazakhstan improved Kyrgyz labor migrants’ access to
TB services in Kazakhstan (ibid.), their access to health care in Russia
remains limited (see Isabekova, 2019b).
Kyrgyzstan has a concentrated form of the HIV epidemic.8 HIV trans-
mission via intravenous drug injection, initially the prevailing means of
infection (Government of KR, 2006, 2012), declined (European Centre
for Disease Prevention and Control and WHO/Europe, 2019) and was
replaced by heterosexual sex as the main avenue of transmission
6
Fifteen cases of HIV were registered during 1987–1991 among foreign nationals who resided in
the country (Godinho et al., 2005, p. 64).
7
That is, a decrease in the absolute numbers, not per capita. The estimates are based on 2019 US
Dollars (see Institute for Health Metrics and Evaluation, 2023).
8
The HIV epidemic is classified as “concentrated” among the key groups (e.g., people who inject
drugs (PWID), men who have sex with men (MSM), and commercial sex workers (CSWs)) if HIV
prevalence among the general population is less than 1%; otherwise, the HIV epidemic is classified
as “generalized” (see Boily et al., 2015).
1 Introduction 15
(Maytiyeva et al., 2015). Fifty-one percent of HIV incidence in Kyrgyzstan

in 2016 resulted from heterosexual intercourse (Government of KR,
2017). This change in the primary mode of transmission shifted the con-
centrated form of the HIV epidemic from an early to an advanced stage
(see World Bank, 2015).
Although concentrated among the key groups, namely, PWID, men
who have sex with men (MSM), and commercial sex workers (CSWs)
(Government of KR, 2017), HIV infection has been expanding to the
general population. Mother-to-child transmission of HIV is still a prob-
lem (Maytiyeva et al., 2015), along with HIV infection of children
through nosocomial (hospital-acquired) outbreaks. For instance, between
2007 and 2009, 143 children were infected in three hospitals (Ancker
et al., 2013, pp. 70–71). Another issue of equal importance to both
countries is labor migration toward countries with high HIV prevalence.
Labor migrants (mostly seasonal workers) engage in unprotected sex with
casual partners (State Partner 4) and, unaware of their HIV status, infect
their sexual partners back home upon their return (CSO 6). Working in
countries with high HIV/AIDS prevalence (e.g., Russia and Kazakhstan),
labor migrants from Kyrgyzstan are at risk of becoming infected with
HIV (Government of KR, 2006). There are no accurate estimates of HIV
prevalence among this group (Ancker et al., 2013); however, it is esti-
mated that the sexual partners of eight out of twelve HIV-positive preg-
nant women were associated with labor migration (State Partner 4).
1.5 Data Collection

The major sources of data that inform this book are interviews, national
legislation on TB and HIV/AIDS, project-related documents, descriptive
statistics, and academic and gray literature relevant to the subject.
First, during her fieldwork in 2016 and 2018, the author of this book
conducted fifty-two semi-structured interviews with representatives of
donor organizations, state authorities, and civil society organizations
working on TB and HIV/AIDS. The interviews were conducted in
Russian, Kyrgyz, and English. The interviewees were selected based on
their availability and responsiveness; to increase outreach, the author
16 G. Isabekova
collaborated with a research assistant to contact and follow up with the

interviewees. A large proportion of the interview transcription was out-
sourced to an assistant but cross-checked and analyzed by the author
using MaxQDA. The interviews were analyzed with thematic content
analysis: the interview questions were the basis for the initial categoriza-
tion of the interview content, followed by a more detailed content-driven
analysis and categorization based on the content itself (Kuckartz, 2014,
pp. 70–88). This approach ensured the accuracy and comprehensiveness
of the interview analysis.
In addition, the national legislation on TB and HIV/AIDS and
descriptive statistics obtained from the state structures and WHO were
essential to understanding the commitments and contributions of the
donors and the national governments in combatting these diseases. These
sources complemented the interviews by providing official data about the
actors’ commitments.9 Furthermore, this book relied on project-related
documents relevant to the selected health care programs. Information on
the Global Fund grants is available online (see Global Fund, n.d.-c), and
information about the Community Action Health project in Kyrgyzstan
was requested from the Swiss Development Cooperation.10 Finally, anal-
ysis of the selected case studies relied on academic and gray literature on
TB and HIV/AIDS in Kyrgyzstan.
Despite using various sources, this study acknowledges potential prob-
lems of coverage and bias (see Rohlfing, 2012). The use of interviews as
primary sources presents a limited picture of sustainability and interac-
tions that is based on interviewees’ experiences and perspectives. The sec-
ondary sources could be similarly biased by research interest (ibid.) in the
case of the academic literature or organizational interest in the case of the
gray literature. This study seeks to overcome potential issues with selected
coverage and bias by means of triangulation (ibid.).
All interviewees received and signed the “Interview consent form,”
which outlined the objectives of the research, rules for quotations, terms,
and conditions for access to and use of interview material. This form also
9
The author followed the BGN/PCGN transliteration system for referencing Kyrgyz sources and
the ISO9 transliteration system for referencing Russian sources.
10
The author received some information from the SDC about the project, which was supplemented
by the interviews as well as by relevant publications by Dr. Tobias Schütz.
1 Introduction 17
provided the researcher’s contact details to ask further questions or to

request withdrawal from the study at any point. The consent form was
provided before the interview, but the participants were asked to sign the
forms by the end of the interview to ensure their awareness of the infor-
mation they provided. All interviewees included in this study expressed
their consent to participate in the research by signing the “Interview con-
sent form,” agreeing to record their consent, or providing oral consent.
Interviewees who chose the third option explained their reluctance with
the need to confirm their participation in the research and their answers
with higher authorities. By providing unrecorded oral consent, they did
not have to participate in the bureaucratic procedures required to obtain
such consent. An equally important factor was the general reluctance to
sign any document or provide recorded consent, which is common in the
post-Soviet region.11
1.6 Book Structure

The introduction to this book is followed by two analytical chapters
expanding on the theoretical underpinnings of aid relationships and sus-
tainability advanced in this book. Chapter 4 demonstrates the applica-
tion of some of these theoretical considerations by showing how aid
dependency, capacity, aid volatility, and flexibility manifest in the selected
case studies. The following four chapters in turn offer a thorough analysis
of stakeholders’ roles throughout the two health projects as well as an
assessment of the sustainability of these projects. Chapters 7 and 10 fur-
ther discuss the aid relationships formed in these projects by linking the
empirical findings to the theoretical underpinnings. Chapter 11 discusses
11
The average duration of the interviews was approximately an hour. With the respondents’ permis-
sion, most interviews were recorded by the author; in other cases, the author took notes. The author
provided all respondents with a consent form explaining the objectives of the research, the funding,
and the terms and conditions for the use of data. Most respondents signed these agreements,
although in some cases, the consent was recorded instead due to interviewees’ hesitation to sign a
document. All interviewees were anonymized. The interview transcripts are available at the
Research Center for East European Studies at the University of Bremen based on the conditions
defined by the respondents. For more information about the selection process, list of interviewees,
and interview questions, see Isabekova (2023).
18 G. Isabekova
the “missing link” or how stakeholder relationships affect the sustainabil-

ity of health aid. Finally, the conclusion summarizes the major findings
by discussing their implications for the broader academic literature and
health projects.
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2
Theorizing Power, Agents, Structures,
and Aid Relationships
The analysis of relationships between providers and recipients of aid

inevitably leads to the discussion of power. One can identify two
approaches in the development aid literature. The conventional perspec-
tive on power primarily emphasizes inequality among actors and aid pro-
viders’ predominance. In contrast, the alternative perspective highlights
aid recipients’ agency and suggests that inequalities among stakeholders
are not constant.
The conventional perspective builds on the discussion of three
approaches to power in development aid by Eyben (2008, pp. 36–37),
who differentiated between the differences in powers enjoyed by actors,
power distribution as a historical legacy, and power as a “process that
enables and constrains action.” All three approaches outline specific
aspects that sum up to the assumption that inequality among stakehold-
ers is inevitable and is led mainly by donors.
First, the differences in actors’ powers suggest that providers enjoy
more power than recipients. As the source of power, aid provides the
means for donors to hold the recipients accountable (Hinton & Groves,
2004). This accountability, however, works only one way (Renzio, 2006).
There are cases of development aid used by donors as “sanctions” against

30 G. Isabekova
the recipients (Feyissa, 2011, p. 801), but the recipients do not hold
donors responsible for breaking their promises due to the fear of not
receiving assistance (Eyben, 2008).
The second approach views power distribution as an outcome of his-
torical legacy. Unequal settings between the global “north” and the
“south” created the basis for development assistance. The meaning of
“development” traces back to the colonization period, when the initial
ideas of what “development” is and who defines it were established. This
is reflected in, for instance, the underdevelopment of recipients and
donor obligations to bring “progress” into these countries (e.g., Schafer
et al., 2012). “Development,” as defined by donors, was imposed on the
recipients.
The third approach examines power by viewing development aid as the
process that enables and constrains stakeholders’ actions. It suggests that
aid per se implies inequality (Robb, 2004) because it underlies “gift-
giving” and “gift-obligation dynamics” (Hinton & Groves, 2004, p. 12).
Following this approach, inequalities between actors are unlikely to be
changed because development aid defines or even preassigns the roles,
responsibilities, and opportunities of each actor. Overall, the three
approaches above are cornerstones of what I call conventional power
dynamics in aid, characterized by inequality in resources and hierarchi-
cal roles.
The alternative perspective on power is based on another strain of the
literature highlighting the recipients’ roles, the interdependence of the
actors involved in giving and receiving aid, and the changing nature of
power throughout the development assistance process. Accordingly,
recipients may depend on donor assistance, but after receiving it, they
weigh the “pros” and “cons” of the objectives of the aid provider and
decide accordingly. Following this perspective, they are not “passive”
recipients but discuss the terms and conditions of receiving development
aid to maximize “their welfare in the face of budgetary constraints”
(Lamothe, 2010, p. 5). Recipients may change their behavior if the incen-
tives and benefits offered by donors are higher than the costs of required
changes (ibid., p. 19). If not, recipients retain the status quo. Thus, the
reforms anticipated and promoted by development aid take place if the
recipient is committed to them.
2 Theorizing Power, Agents, Structures, and Aid Relationships 31
Furthermore, aid relationships between donors and recipients are char-

acterized by interdependence. Development aid involves actors other
than only the direct providers and recipients of the assistance, such as
parliaments, governments, constituencies, and local municipalities. Both
donors and recipients are accountable for the aid they spend. Although
the level of accountability varies depending on the role of the public and
the political system of the country, it nevertheless ensures the interdepen-
dence of donors and recipients. The actors are mutually dependent
because the recipients need the donors’ financial resources, and the
donors need the recipients’ support to show the “success” of their activi-
ties (Shutt, 2006a, p. 154; Swedlund, 2017, pp. 75–76). This interdepen-
dence outweighs the hierarchies, as both actors are interested in
maximizing the output of the assistance and, therefore, are interested in
interacting with each other.
Last, there is an evolving or changing nature of power at different
stages of the assistance process. Although they exercise more power dur-
ing the allocation process, donors nevertheless have limited influence
over the outcomes of an aid project. As they provide the project finances
(in some cases also ideas), donors are important during reform initiation,
but their role decreases during the implementation stages (Andrews,
2013, pp. 209–210). In contrast, the role and power of the recipient
(state, civil society organizations (CSOs)) increase. Although nonachieve-
ment of the outcomes could result in aid suspension, this is not always
the case, and it could also be justified by domestic politics, the pressure of
constituencies, or reform opponents (Swedlund, 2017, pp. 73–96).
Overall, the agency provided to recipients, stakeholders’ interdepen-
dence, and the evolving nature of power suggest that the inherent
inequalities between donors and recipients underlined in the three inter-
pretations of power are not constant. Following these insights, I suggest a
framework composed of the following four steps that are intended to
provide a comprehensive basis for grasping the aspects highlighted in the
alternative approach:
32 G. Isabekova
1. Inspired by scholars in political theory, the first step commences with

a reflection on the meaning of power and the common terms associ-
ated with it, such as resources, consensus/conflict, and interests. It is
intended to provide a necessary conceptual basis for understanding
the types of power in the context of inequality in development aid. I
intentionally focus on classic political theorists, as they, in my opin-
ion, reflect the aid hierarchy best.
2. This book emphasizes the relevance of both stakeholders and the con-
text in which they interact, which is consonant with the agent-
structure approach to aid relationships. In so doing, the second step
aims to expand on the relevance of individual and collective agency
(e.g., organizational level) of abstract categories, such as “donors,”
“CSOs,” and the “recipient state.” Finally, in terms of structure, this
book focuses on the frequent issues associated with inequality among
actors, namely the recipients’ capacities, their dependency on aid, and
the flexibility and volatility of aid.
3. The third step calls for a project-level analysis differentiating the fol-
lowing phases of the project cycle: initiation, design, implementation,
and evaluation. Empirical analysis at this level offers a detailed yet
standardized analysis of development projects, which is beneficial to
cross-project comparison.
4. The fourth step culminates the analytical framework by linking the
empirical insights from step 3 and the conceptual basis defining stake-
holders, power, and the context in the first two steps to a theorization
of power dynamics and aid relationships. This step is necessary to
understand the empirical cases by placing them in a broader theoreti-
cal framework. I built on the seven ways of creating power by Haugaard
(2003) because they provide a suitable basis for comprehending the
roles and means stakeholders use and the types of power they exercise
in relation to each other.
2.1 Conceptualization of Power

To a certain extent, the discussion of power in the context of develop-
ment leaves the following two impressions: providers and recipients stand
in opposition to each other, and their powers are inversely related because
if the recipients have more power, donors are presumed to have less
power. These impressions recall the perceptions of power as a “zero-sum
game,” in which more power for one actor equals less for another.
However, this conceptualization of power was criticized by Parsons as
early as the 1960s as inapplicable to all cases (Parsons, 1963).
Correspondingly, scholars such as Arendt (1970, p. 44) viewed power as
“acting in concert” and, therefore, not antagonistic in the relation of one
stakeholder to another. Relying on these insights from scholars in politi-
cal theory, I define the conceptualization and theorization of power that
are essential to defining the types of interaction among stakeholders in
step 4 of the analytical framework.
The analysis of any complex phenomenon is associated with multiple
issues, and power is not an exception (see Dahl, 1957). There are dis-
agreements about its definition, measurement, and nature. While some
scholars defined power as a “circulating medium” (Parsons, 1963, p. 236),
others denied its existence as an independent entity, viewing power as “a
mode of action upon the actions of others” instead (Foucault, 2002,
pp. 341–342). Similarly, the essence of this phenomenon, including its
directions (bilateral vs. unilateral) (Goldhamer & Shilds, 1973), interpre-
tations (power “over,” “to,” and “with”) (Pansardi & Bindi, 2021), and
forms (dispersed or concentrated), remains contested, along with its mea-
surement and feasibility of empirical observations (Dowding, 2017,
p. 4). Overall, there is a tendency toward a multidimensional interpreta-
tion of this phenomenon that involves synthesizing different approaches
(Ledyaev, 2021).
Indeed, the analysis and operationalization of power are inevitably
normative (Lukes, 2005, pp. 37–38). Following the focus of this research
on the implications of relationships among stakeholders on the sustain-
ability of health aid, I approach power as a socially constructed phenom-
enon (Dowding, 2017) and a product of a “set of interacting individuals”
(Barnes, 1988, p. 61). I differentiate between the power “over,” “to,” and
“with” due to their relevance to understanding the power dynamics
between stakeholders. Power over is among the first forms, and is defined
as A having power over B or as relations among controlling and depen-
dent units (see Dahl, 1957). The “power over” form is often associated
with hierarchical relations, whereas the “power to” form closely relates to
34 G. Isabekova
altering these relations. This difference was introduced by Pitkin (1972)

and further reemphasized by feminist scholars such as Allen (1998). The
“power with” form was introduced by Barnes (1988) and is based on the
presumption that power is not attributed to a single entity, which was
further strengthened by Arendt’s (1970, p. 44) view of power as an “act
in concert.” There is still an ongoing discussion about interpretations of
power and the validity of these differentiations (see Pansardi & Bindi,
2021). However, in the context of development aid, these distinctions are
relevant, as they are the key to understanding whether the hierarchy
among stakeholders, as in conventional power dynamics, remained or
was altered in the course of providing aid or was not present at all.
The “power with” form lies at the core of the analytical approach. This
book approaches interaction and sustainability both as an individual and
as a collective endeavor. This approach coincides with the perception that
power is not something that, as Barnes (1988, pp. 61–62) aptly noted,
“radiated from heroic figures; they have glowed with it and illuminated
everyone else.” Individuals or entities may enjoy power, but it is neverthe-
less “embedded” in society (ibid.), and the supportive group enables the
presence and exercise of power (Arendt, 1970). In this way, power is not
attributed to a single entity or an individual but to a broader constella-
tion of stakeholders and structures.
I approach “power with” as an overarching perspective toward the
interaction of all stakeholders and their joint impact on the sustainability
of development aid. However, for precision and practical reasons, I assign
interaction in a dyadic manner by delineating two broader categories of
stakeholders (donor–recipient state, recipient state–CSOs, donor–CSOs,
donor–donor). Identifying the interaction types of all stakeholders at
once would be practically challenging but also possibly analytically mean-
ingless, as this would not allow the precision necessary for grasping the
power dynamics. I acknowledge that both aid relationships and aid sus-
tainability are the outcomes of the “power with” form and not individual
dyadic interaction types defined in this book. However, the dyadic focus
provides a meaningful basis for grasping how the “power with” accumu-
lates and potentially changes, although this discussion falls beyond the
focus of this book.
In addition to this conceptualization of power, the analytical approach

introduced in this book ingrains the following phenomena associated
with power and relevant to defining aid relationships: resources, (in)com-
pliance, and interests.
First, resources are commonly associated with power, with the premise
that more resources imply more power (Hinton & Groves, 2004). These
are not limited to material resources and include knowledge and access to
them. This assumption underlies the unequal relationship among actors
in development aid. Nevertheless, although closely related, resources do
not equate to power (Giddens, 1984, pp. 15–16). The way actors
approach their resources makes a difference, as stakeholders with the
same resources may use them dissimilarly (Dahl, 2005, pp. 273–276).
Accordingly, the empirical analysis in this book shows the relevance of
resources in understanding aid relationships, for instance, in relation to
the incentives that one stakeholder may offer to another. However, it also
demonstrates that the difference in resources does not necessarily equal
hierarchical relationships among actors.
Second, the (in)compliance of stakeholders with the recommenda-
tions and regulations of the other stakeholders is another aspect that is
essential to grasping the power dynamics in aid. Here, I focus on sanc-
tions as a “reprisal for nonconformity with a prior act of power”
(Goldhamer & Shilds, 1973, p. 300), following the act of incompliance
(Parsons, 1963, p. 238). It is important to note that sanctions can be
positive or negative (e.g., Baldwin, 1971), the main difference being if
the change in the situation is for the benefit or disadvantage of the stake-
holder to whom sanctions are applied (see Parsons, 1963). The empirical
analysis in this book mainly showed the presence of negative sanctions
following the act of incompliance. One of the reasons was the visibility of
the conflict. However, this may not always be the case, as conflicts rooted
in contradicting interests may be latent and never realized from the out-
side (Lukes, 2005, pp. 28–29). Similarly, consensus among stakeholders
could be implied and is not always expressed explicitly (Dowding, 2011a).
The empirical analysis was limited to visible conflicts due to the objec-
tions stakeholders expressed in relation to actions taken by the other
stakeholders. Overall, both sanctions and consensus/conflict provided a
useful basis for examining acts of (in)compliance.
36 G. Isabekova
Third, closely associated with power, interests are also essential to

defining and validating aid relationships. Power is often defined in rela-
tion to forcing one to act contrary to one’s interests or the capacities of
stakeholders to realize their interests (see Lukes, 2005). This reference to
power and interests further presumes that power is intentional or in pur-
suit of specific interests. The definition of interests also closely relates to
the costs and benefits that those using and are subject to power face and
gain (see Dahl, 2005). This accords with the underlying idea of why
stakeholders participate in development aid or choose not to do so.
However, scholars disagree about the (un)intentional character of power
(e.g., Allen, 1998), its relation to objectives (Giddens, 1984), and the
ability of stakeholders to comprehend their interests (Lukes, 2005). The
empirical analysis encompassed subsections on stakeholders’ interests in
pursuing a specific aid relationship form. I argue for stakeholders’ abili-
ties to define and voice their interests, noting that the emphasis on the
opposite may unintentionally cause unnecessary victimization of stake-
holders. Indeed, actors vary in their access to information and capacities,
and yet, as the empirical analysis shows, they have pursued their interests
by explaining their compliance with specific aid relationship forms.
I follow the simplistic definition of interests related to the realization
of personal and organizational objectives due to the different levels of
abstraction pursued in the theoretical approach to the operationalization
of actors. Individuals and organizations representing donors and recipi-
ents operate in conditions of uncertainty since they are insecure about
each other’s actions and the amount as well as the duration of develop-
ment assistance (Swedlund, 2017). Furthermore, the complexity of
development assistance, which is related to a multiplicity of actors, inter-
ests, and the areas involved, results in the actors receiving incomplete
information. Therefore, I suggest that stakeholders have limited or
“bounded” rationality in maximizing their personal as well as organiza-
tional interests. “Bounded rationality” means that actors are constrained
in their “information-processing” abilities by risks, uncertainty, limited
awareness of other options, and the “complexity” of the setting, resulting
in an inability to choose “the best course of action” (Simon, 1972,
pp. 162–164).
In addition to rationality, interests relate to actors’ perceptions of what

is “important” and acceptable from their personal and organizational
perspectives, as well as in relation to other stakeholders. The actors’ “men-
tal image of the world” frames their perceptions of and reactions to the
ongoing processes and preferences for certain decisions, or what Scharpf
(1997, p. 62) defined as “subjective preferences.” Personal perception is
also shaped by what is “acceptable and legitimate” from both individual
and organizational perspectives (Campbell, 2004, p. 96). This interrela-
tion between individual preferences and acceptability is vivid, particu-
larly in the cases of politically and culturally salient issues. Equally, the
actors’ choices are guided not only by personal perceptions but also by a
“relational” aspect of the actors to each other (Scharpf, 1997, pp. 69–84),
which emphasizes actors’ responsiveness to ongoing processes and others’
reactions to these processes, which also shape their perceptions. This once
again reemphasizes the assumption that decisions do not take place in
isolation but in the context of not only structural factors but also in rela-
tion to other stakeholders involved.
2.2 Conceptualizing Agents and Structures

Following the long-standing discussion on the roles of actors and the
relevance of the context in development aid, I emphasize the significance
of both actors and structures in understanding power dynamics. This
approach corresponds with a meso-level theorization of power as a con-
ceptual tool for specific purposes advocated by Haugaard (2002).
In this book, actors and stakeholders refer to organizations and occa-
sionally individuals whom I approach as agents that act depending on
incentives provided in the relevant structures and the roles assigned to
these agents (Dowding, 2017, p. 22). An action is defined as changing
“the pre-existing state of affairs or course of events” (Giddens, 1984,
p. 14). I acknowledge the significance of both individual and organiza-
tional levels of analysis but largely keep to the organizational level, except
for cases in which individual actions explicitly emanated from individuals
and their specific backgrounds, contributing to actions beyond the orga-
nizational perspective. This attribution to roles relates to practical
38 G. Isabekova
concerns, namely, “collective” agency is “easier to comprehend” than that

of an individual (Dowding, 2011b, p. 9). Furthermore, I believe that indi-
viduals are shaped by the organizations they represent as well as the roles
they are assigned to, particularly in the context of aid. This assumption
accords with Scharpf (1997, p. 12), who suggested that individuals were
“much less free in their actions” but represent certain entities and act on
behalf of them. Indeed, individuals also pursue personal interests shaped
by their comprehension of reality. The impact of self-interest is specifically
relevant to leadership positions, where individuals have fewer organiza-
tional constraints (ibid., p. 62). However, even with these positions, indi-
viduals are censored by their positions and organizations. In addition to
individual and organizational perspectives, agency in the context of devel-
opment aid closely relates to the roles assigned to “providers” and “recipi-
ents.” Therefore, I link individuals and organizations to broader analytical
entities, donors, recipient states, and civil society organizations.
Structures are equally significant to power dynamics. “Recursively
organized sets of rules and resources” enable and constrain stakeholders
(Dowding, 2011c, p. 10), shaping their action and inaction (Lukes,
2005, p. 26). The structures encompass a number of phenomena, but in
the context of development aid, some are regularly of specific relevance.
For example, although common to development assistance in general,
the inequality between the providers and recipients of aid varies across
cases. I suggest that aid dependency and the capacity of the recipient are
vital to understanding these variations. Furthermore, actors dealing with
development assistance face the problems of aid volatility (uncertainty)
and aid (non) flexibility. Similar to inequality, these phenomena are com-
mon to development aid, although donor policies on these issues vary;
therefore, I attribute these factors to the providers and not the recipients
of assistance (Table 2.1).1
Table 2.1 Structures and their relevance to agents

Recipient Aid dependency Capacity
Donor Aid volatility Aid flexibility
1
For the justification of the relevance of these factors to aid relationships, see Isabekova (2019).
First, aid dependency is critical to understanding the actors receiving

aid. A country (in this framework, a recipient state and a CSO) is aid-
dependent when it cannot “achieve objective X in the absence of aid for
the foreseeable future” (Lensink & White, 1999, p. 13). For example, if
stakeholders are interested in conducting specific reforms, aid depen-
dency means that the recipient cannot implement the reforms without
the donor. Obviously, financial and institutional constraints may prevent
the recipient state or CSOs from implementing the desired reforms or
policies independently. However, we need to distinguish between the
necessity for “additional” support and the “sole” reliance on it. A recipi-
ent country or a CSO seeking donor support in addition to its own
resources is not aid-dependent; however, the country fully relying on the
assistance is aid-dependent. Although reflected in individual actors, aid
dependency remains a structural issue because it is rooted in a broader
country/region/global context beyond these actors.
There are different measurements of aid dependence, but this study
suggests a sector-specific definition. Glennie and Prizzon (2012) propose
a quantitative indicator of dependence, calculated by the ratio of aid to
the gross national income of the recipient country. For civil society orga-
nizations, this could refer to the ratio of “external” funding to the
resources of the organization. These types of indicators are useful for the
general ranking of recipient countries/organizations, but they are not
helpful for understanding the power dynamics within specific sectors, for
example, health care. Generally, a country’s dependence on aid is not
equal to its sectoral dependence. The state may receive a large amount of
aid but no health care aid. The sectoral division of the assistance provides
a more accurate picture, but even in this case, the numbers might be
misleading. For instance, the share of “external” health expenditure as
part of current health expenditure in 2016 in Kyrgyzstan was approxi-
mately 4% (World Bank Group, 2023). One may assume that the coun-
try is relatively “independent” from aid because public (state) and private
(patients) contributions to health care are much higher than those from
donors. However, the empirical chapters in this book demonstrate the
opposite. Although independent at the general level, the country relies on
technical assistance in health care reforms or financing in terms of access
to treatment. Therefore, the analytical framework presented here suggests
40 G. Isabekova
that a more specific sector or subsectoral focus provides a better under-

standing of the aid dependence of recipients.
The second factor relevant to understanding the differences in power
dynamics is capacity. Broadly defined as “the ability of people, organiza-
tions, and society as a whole to manage their affairs successfully” (OECD,
2011, p. 2), capacity in a narrow sense refers to the individual, organiza-
tional, and systems’ abilities/“competencies” to implement their func-
tions (European Centre for Development Policy Management, 2008,
p. 2). Based on these definitions, this chapter operationalizes capacity as
a recipient’s ability to perform its functions and administer its activities
with a focus on the availability of human resources. Human resources are
essential to negotiations, implementation, and the evaluation of develop-
ment assistance. A limited capacity, reflected in an insufficient number of
staff members and their qualification issues, causes communication prob-
lems with donors.
However, again, critical to understanding stakeholders, “capacity” is
still an outcome of broader issues in a given sector or country and is not
limited to an individual actor. Thus, in her interviews with donor repre-
sentatives in Sub-Saharan Africa, Swedlund (2017, pp. 92–93) highlights
the staff shortages and computer literacy problems of the recipient coun-
tries. Limited capacity is related to and caused by a “brain drain” from
public institutions. Qualified staff members are often recruited by donors
offering better remuneration and advancement policies (Swedlund, 2017;
Toornstra & Martin, 2013). Similar issues with staff retention are noticed
in the case of CSOs (Frontera, 2007), although there are differences
within this group. The level of staff rotation in community-based organi-
zations (CBOs), where members work on a voluntary basis, might be
higher than in a nongovernmental organization (NGO), which pays its
employees and provides additional nonfinancial incentives, such as train-
ing and travel.
Third, stakeholders operate in conditions of uncertainty related to aid
appropriation procedures and relatively short development program
durations. Aid volatility varies depending on aid modalities, with budget
support being more predictable than project-based assistance. There is a
general acknowledgment of the need for increased aid predictability (e.g.,

Menocal & Mulley, 2006). Correspondingly, the emphasis on long-term
partnerships in institutional capacity-building in the 2000s, for instance,
contrasts with the ad hoc assistance provided in the 1990s (Leitch, 2016,
p. 195). Nevertheless, donors have different aid appropriation procedures
and opportunities to make commitments before their partners. Bilateral
aid from OECD countries often depends on the annual appropriations
approved by their parliaments on the basis of their governments’ propos-
als (Isabekova, 2019). Multilateral aid, by contrast, depends on the con-
tributions of funding countries and organizations. Overall, making
long-term commitments beyond the scope of the specific project is prob-
lematic in cases of both bilateral and multilateral donors.
Fourth, aid flexibility is equally important to understanding stake-
holders. The flexibility of donors has been emphasized in relation to the
ability to adjust to local priorities and contexts (Hirschhorn et al., 2013).
Strict regulations from the parliament or the government negatively
impact the flexibility of the assistance by assigning it to certain purposes.
Thus, driven by the goals defined by the “central” authorities of donor
agencies and not necessarily by the recipients on the ground, tied aid is
commonly viewed as the opposite of flexibility. However, in addition to
preset objectives, flexibility is also closely related to responsiveness to
changes taking place on the ground. This relates to what Leitch (2016,
p. 215) calls the “institutional factors on the donors side.” For this rea-
son, in addition to adherence to recipients’ priorities, I explore the
decision-making authority held by the field offices of donor organiza-
tions. Authorities delegated to the “field” offices of donor organizations
contribute to the ability to respond to changes on the ground. In con-
trast, a highly centralized organizational structure means the concentra-
tion of decision-making authorities at relevant institutions or headquarters.
As a rule, this affects aid responsiveness due to bureaucratic delays.
Overall, the reflections on the roles of stakeholders as individual and
collective agents and structures in the form of key issues attributed to aid
relationships complement the conceptual definition of power in the first
step. A combination of these two steps offers a valuable guide to the
empirical analysis in the following step.
42 G. Isabekova
2.3 Project Life Cycle

To grasp the power dynamics in development assistance projects, I suggest
a project-level analysis by differentiating the four phases of the assistance,
namely, initiation, design, implementation, and evaluation. These stages
are not consecutive since evaluation, for instance, can take place before,
during, or at the end of the project. However, differentiation into phases
allows for the roles of actors, as well as the division of labor between them,
to be analyzed throughout the assistance process. Following Bachrach and
Baratz (1962), power closely relates to agenda-setting and prioritizing the
issues one wants resolved, irrespective of their relevance to the subject.
Thus, a detailed analysis of project phases allows the analysis of power
dynamics, including but not limited to, agenda-setting and observing
stakeholder participation throughout the project realization process.
2.4 Uniting Theory and Empirical Findings

This step links the empirical insights from step 3 and the conceptual basis
defining stakeholders, power, and the context in the first two steps to a theo-
rization of power dynamics and aid relationships. It builds on the seven ways
of creating power, defined by Haugaard (2003), as it offers a suitable basis
for grasping the “power over” and “power to” forms in aid projects.
His theorization intends to organize and explain the analysis of and
insight into power by scholars such as Parsons, Luhmann, Barnes, Clegg,
Giddens, Bachrach and Baratz, Foucault, Lukes, Weber, Dahl, Mann,
and Poggi (see Haugaard, 2003). In his theorization, Haugaard provides
some structured way of understanding the power dynamics between
stakeholders. His overview was utilized by Shutt (2006b) to analyze aid
relationships, inspiring the inquiry and application of this approach in
this book as well.
The first way of creating power is through social order, which derives
its essence in the predictability assured through the intended reproduc-
tion of meaning accepted and emulated by others (Haugaard, 2003,
pp. 90–91). Two practices are highlighted in this regard, namely, “struc-
turing,” which occurs through attributing a similar meaning to actions
irrespective of time and place, and an agent that intentionally exercises

these actions (ibid.). In development assistance, for instance, individuals
and organizations aim to demonstrate the ownership of aid recipients by
negotiating the objectives and adjusting them accordingly. These actions,
conducted in numerous couloirs, represent the intended reproduction of
this principle. The similarity and impersonalization in the reproduction
of meaning contribute to predictability, the foundation of the social
order, which also requires its broader acceptability, which is ensured by
the second element. The “confirm-structuring” embodies the “public”
and “willing” reproduction of the meaning, pointing to the acceptance
and consensus regarding the meaning (ibid.). Accordingly, the practice
mentioned above is broadly acknowledged and adhered to (more or less)
by various stakeholders in multiple countries and sectors. However, con-
sensus is not always the case, or as Haugaard notes, acceptance does not
preclude conflict, as the social orders taken for granted today may not
have been prevalent but were “fought for” in the past (ibid., 96). Similarly,
ownership and actions regarding aid were not common throughout the
history of aid.
The second way of creating power, that is, structural bias, is closely
connected to the former, as it ensures the predictability and stability of
the social order. Nevertheless, system bias represents a different source for
creating power through structural constraints imposed by one actor upon
another (Haugaard, 2003, p. 94). It is characterized by the process in
which stakeholders or initiatives inconsistent with and aiming to change
the prevalent social order face the “noncollaboration” of those who repro-
duce it (ibid.). Thus, the constraints would ensure stakeholder compli-
ance with the principle of ownership and the unacceptance of those
unwilling to implement it upon receiving assistance. This supports the
premise that structural biases are not necessarily negative but rather
essential to the stability of the social system (Haugaard, 2003, pp. 93–96).
However, constraints do not empower stakeholders to the same extent.
Predictability is ensured at the expense of certain forms of interaction and
power that might have benefited stakeholders disadvantaged by the social
order (ibid.). However, actors comply with constraints for reasons that
are not necessarily “consciously chosen” and could be an outcome of
structural and cultural patterns and other reasons (Lukes, 2005,
44 G. Isabekova
pp. 25–26). In addition to consensus regarding the order, social biases

may also involve conflict in the form of destruction or evasion from sup-
porting the system (Haugaard, 2003, pp. 95–96).
The third way of creating power relates to social consciousness, which
is in the foreground of the reproduction of specific order and biases.
Predictability here derives from stakeholders’ perceptions that specific
meanings are not “arbitrary” and exist “out there in the world” but are
consistent with their interpretations of the matter at stake and the world
in general (Haugaard, 2003, pp. 97–99). Thus, the critical aspect of
reproducing meaning and biases lies in their relation to the actors’ sys-
tems of thought. For instance, gender equality and women’s empower-
ment in development assistance relate to the consciousness of gender
equality in a broader context. Prevalent among members of the
Organization for Economic Co-operation and Development’s
Development Assistance Committee, this explicit emphasis today may
not have been common some time ago or in contexts with different per-
ceptions of gender. Similarly, the reasoning behind some health care
intervention programs relating the cognitive abilities and behaviors of
individuals to their ethnic background would be unthinkable today (see
Morgan, 1993). In this way, changes in the system of thought result in
practices common to the previous system becoming obsolete (Haugaard,
2003, pp. 98–99).
The fourth way of creating power is the relationship between tacit and
discursive knowledge. It is based on Giddens’ (1984, pp. 4–5) differentia-
tion between the “practical” or unconscious knowledge actors use in their
social lives and the “discursive” or conscious knowledge underpinned by
their reflection, rationale, and reasoning. Haugaard (2003, pp. 100–102)
notes that most knowledge in social life is tacit to ensure stakeholders’
comprehension of reality. However, a transformation of this tacit knowl-
edge into discursive knowledge allows distance, evaluation, and recogni-
tion (ibid.). An instance of this transformation could be, for instance,
reflections on the meaning of development, which changed from an ini-
tial economic focus to a broader operationalization of development to
include social, environmental, and other factors. Haugaard notes that
tacit knowledge may benefit those in power, but its transformation into
discursive knowledge may change the order if actors realize that the
reproduction of social structures disadvantaged them (ibid.). Following

the example mentioned above, critical reflections on development, in
combination with the evidence for the noticeable shortcomings of a
solely economic reform focus (see Cornia et al., 1987, 1988), offered
favorable circumstances for targeting social needs neglected before.
The fifth way of creating power, that is, reification, stabilizes existing
power relations and structural reproduction on the premise that they
embody something “more than social constructs” (Haugaard, 2003,
pp. 102–103). This source of power resembles the system of thought but
differs from it in one dimension. Stakeholders conform to structures and
related practices, not because of their relations to actors’ perceptions of
reality but for other reasons. This resemblance and distinction are not
explicitly stated in the theoretical framework but are nevertheless critical
to its valid application. Following Haugaard (2003, pp. 103–105), “non-
arbitrariness” in reification could be based on multiple grounds, includ-
ing religion, nature, truth, and science, with practices incompliant with
existing structures as going against these concepts. For example, health
care programs frequently appeal to science to support their objectives and
activities, which could be a vivid example of reification in practice.
The sixth way of creating power, that is, discipline, is manifested
through socialization aimed at establishing a routine based on practical
consciousness (Haugaard, 2003, pp. 105–106). This, in a way, follows
the logic opposite to the one described in the relationship between tacit
and discursive knowledge. It does not result in predictability but origi-
nates from it (ibid.). The assumption consonant with what Barnes (1988,
p. 58) referred to as social power is at the disposal of those able to judge
and decide upon routines. Haugaard (2003, pp. 106–107) notes that as
a relatively modern phenomenon, this power is based on the premise that
discipline is not arbitrary, and practices inconsistent with it are “irregu-
larities” and foes of the social order. In the context of development assis-
tance, disciplinary power could relate to functions agreed upon and
assigned to stakeholders in projects and the relevant training they received.
However, closely related to stakeholders’ socialization and use of practical
knowledge, disciplinary power is also limited to the extent to which
stakeholders “internalize” the suggested routines (ibid.). These limita-
tions are explicitly discussed in Chap. 8 of this book.
46 G. Isabekova
The seventh way of creating power is coercion, which represents the

last resort measure. Haugaard (2003, pp. 108–109) builds an analogy
with physical power and suggests that it comes into play when other
sources of power fail, approaching coercion as neither an “ultimate” nor
“effective” source of power. This perception is consonant with that of
Arendt (1970), who defined coercion as the weakest form of power, as
well as that of Parsons (1963), who stated that coercion was not equal to
power. Coercion is often discussed in relation to freedom. However, pre-
suming that stakeholders have freedom and make decisions depending
on their interests and structural factors, I approach coercion as an act of
compelling that is contrary to the will and interests of stakeholders.
Although associated with physical power, coercion takes other forms in
stakeholder relationships, as discussed in Chap. 8 of this book.
Overall, the seven ways of creating power help theorize the roles of
stakeholders and their actions in relation to each other, as empirically
discussed in the third step. This theorization is necessary to grasp how the
conceptualization of power, agents, and structures unfolded in selected
cases. More specifically, by defining ways of creating power, I expand on
the types of power, how actors used resources, or whether a conflict/con-
sensus accompanied this process. This theorization is critical to validating
the empirical findings in relation to the type of power (“over/“to”) stake-
holders created.
The type of power is essential to understanding whether an alternative
approach to stakeholder relationships, characterized by interdependence,
recipient agency, and changing power dynamics, occurred. In contrast, it
could also be the case that the conventional approach to stakeholder rela-
tionships, mainly characterized by inequality, took place. However, I
refrain from attributing specific ways of creating power to any of these
two approaches or types of aid relationships discussed in the following
subsection. The discussion of the seven ways clearly showed that the
“power over” or the “power to” forms could equally be produced by some
stakeholders, depending on how they use their resources or whether there
is a conflict/consensus. Nevertheless, the seven ways of creating power
provide a good indication of whether “power over” and/or “power to”
emerged between stakeholders. Assuming that the former is a character-
istic of the conventional approach to stakeholders and their relationships
with each other, I suggest that the types of relationships associated with
inequality have “power over” as the prevailing form. In contrast, aid rela-
tionships associated with equality have “power to” as the prevailing form
of power emerging between actors.
However, given that power may be changing throughout the project
cycle, I acknowledge that in some cases, it could be a combination of the
“power over” and “power to” forms. Here, the roles of stakeholders
throughout the project cycle and the analysis of structures (aid depen-
dency, capacity, aid volatility, and flexibility) may help. If stakeholders
were equally engaged throughout the project life cycle and structures
changed in favor of the aid recipient, the “power to” prevailed; otherwise,
the “power over” form prevailed. Why does this matter? Equal engage-
ment of stakeholders addresses the problem of limited involvement of aid
recipients and aid fragmentation (Chap. 1). It also demonstrates the
recipients’ agency and abilities to raise issues or participate in decision-
making. Structures, in turn, demonstrate whether the context in which
aid relationships took place was favorable to changing the hierarchy
underlined in the conventional approach. I argue that aid volatility and
inflexibility of providers, as well as aid dependency and limited capacity
on recipients’ sides, are favorable to retaining the hierarchy among stake-
holders. In contrast, aid predictability and flexibility, accompanied by
relatively limited aid dependency but necessary capacity, are beneficial for
altering the hierarchy.
I argue that considerations regarding engagement in the project cycle
and structures are case-dependent and not attached to a specific type of
aid relationship. However, inequality and hierarchy are attributed to cer-
tain types, as discussed below.
Aid relationships in this book encompass a variety of relationships
between stakeholders, including noncoordination, coordination, unequal
cooperation encompassing recipient/donor-driven cooperation, and a
“utilitarian approach toward CSOs, and equal forms of cooperation, such
as partnerships, and an “empowerment” approach toward CSOs. I
acknowledge that my findings in this book demonstrate the power
dynamics limited to the time and space covered in the empirical chapters.
However, further theorizing regarding the power dynamics in aid rela-
tionships helps us abstract from project phases to a broader
48 G. Isabekova
conceptualization of stakeholder interaction. Therefore, this section

operationalizes different types of relationships, building on the findings
and filling the gaps in the relevant academic literature and international
agreements. The suggested types of interaction are Weber’s “ideal” types,
which combine the features found and relevant to them in reality but in
a manner that is coherent with each type of interaction (Oxford
Reference, 2023).
First, noncoordination may range from the noninteraction of actors
with each other to the noncompliance of one actor with the priorities of
another. Among donors, this means no exchange of information, result-
ing in unawareness of each other and a subsequent possible duplication
of activities. For interactions between donors and recipient states, nonco-
ordination may refer to a donor(s) pursuing activities without exchang-
ing information with the state or without complying with its priorities.
Regarding the interaction of donors and the recipient state with CSOs,
noncoordination is expressed by the noninvolvement of the latter in
development assistance. Since the coordination of activities is time- and
resource-consuming, noncoordination could be beneficial to actors from
the short-term perspective, as this does not require time and an addi-
tional workload in contrast to coordination or cooperation.
I suggest that noncoordination takes place in cases of inequality
between donors and recipients. The recipient is too aid-dependent to
raise the issue of noncoordination or has no capacity to require/imple-
ment the donors’ compliance with its requirements. Donors, in turn, are
disincentivized by the time and resources needed for coordination to ini-
tiate this voluntarily. These disincentives may further be exacerbated by
limited aid flexibility and certainty. As coordination and cooperation pre-
sume a certain level of adjustment and awareness of aid flows, aid volatil-
ity and inflexibility may be accompanying factors of noncoordination.
Potential incentives for donors to coordinate with each other could relate
to increasing their influence over the recipient. However, as the recipient
is aid-dependent, each donor may already have leverage over it and may
not understand the benefits of coordination.
Second, coordination among stakeholders is expressed by the parallel
implementation of activities with information exchange. It is character-
ized by an agreement on priorities, but actors pursue their activities
toward these priorities without involving each other. This agreement on

priorities entails the recipient’s capacity and/or the donors’ willingness to
engage in coordination. The recipient’s capacity is essential since the
recipient is expected to request and, most importantly, ensure donor
coordination and compliance with its priorities. However, coordination
could also be the outcome of donor initiatives. The reasoning behind the
coordination taking place as a result of the donor’s initiative could be (in
addition to altruistic motives) the donor’s interest in increasing their
influence over the recipient. Thus, the recipient may still be aid-
dependent, but the influence of the individual donor may not be suffi-
cient or as high as in the case of noncoordination.
Coordination is beneficial to both recipients and providers of aid in
the long-term, as it decreases transaction costs. Therefore, similar to
cooperation, coordination has been emphasized in a number of interna-
tional documents (e.g., OECD, n.d.). However, the costs stakeholders
face overshadow its long-term benefits in the short term. Its establish-
ment requires staff involvement and time for negotiations that may take
up to several years (Lawson, 2013). Facing a trade-off between long- and
short-term benefits, the actors may favor the latter.
Third, in the context of development assistance, I define cooperation
as a joint realization of aid, which may take unequal and equal forms. The
former takes place when one of the actors, be it a provider or a recipient,
dominates in the aid realization process, while the latter means that actors
are equally engaged in the process. This equality is not only about the
stakeholders’ responsibilities but is also about their roles and “say” in the
process. Although “equal” and “unequal” labels of cooperation inevitably
recall normative connotations, I approach them as mere variations of
cooperation. Following Weber (1986, pp. 28–29), I acknowledge that
domination, in its general meaning, is an essential component of social
action and can take different forms in regard to how one imposes their
“own will upon the behavior” of others. Dominance in unequal coopera-
tion takes different forms, depending on the stakeholders involved.
Between donors, cooperation means that one donor relies on the oper-
ational procedures of another and complies with its regulations and
approaches. The donor may have a “leading” role due to a larger share of
finances or taking over the responsibility for the outcomes. This
50 G. Isabekova
emergence of the “dominant” actor could be the outcome of other donors

being “less motivated” to compete or “much poorer” (Bueno de Mesquita
& Smith, 2016, p. 2). Cooperation presumes a certain level of flexibility
and certainty necessary for negotiations among stakeholders and relevant
adjustments that are possibly more demanding than that required in
coordination, in which stakeholders agree on priorities and not on opera-
tional procedures and approaches.
In relationships between donors and recipient states, unequal coopera-
tion takes two forms, namely, cooperation driven by donors and their
conditions and aid driven by the recipient state and its priorities. There is
an extensive discussion of conditionality in the development aid litera-
ture concerning the requirements the recipient was expected to fulfill in
economic, political, and other terms (e.g., Crawford & Kacarska, 2019;
Molenaers et al., 2015). This type of interaction is probably characterized
by aid dependency and capacity issues on the recipient’s side that also
define the flexibility and predictability possible and provided by the
donor. Thus, if the recipient is relatively aid-independent and/or has the
capacity, the donor may be forced to be more flexible and predictable to
enforce its conditions.
Another form of unequal cooperation between the donor and the
recipient is when aid is driven by the priorities of the latter, with donors
adjusting their activities accordingly. The idea of the recipient state being
the “driver” of interaction complies with the notion of “ownership,” as
emphasized in the Paris Agenda, by increasing its role in the process and
in achieving assistance results. This type of cooperation presumes high
capacity and relative independence of recipients from external aid,
accompanied by flexibility and predictability of assistance, which may
not be immediately offered but are achieved during the negotiation
process.
In civil society organizations’ interactions with other stakeholders,
unequal cooperation refers to a “utilitarian” approach. This approach was
initially used to discuss community participation in development aid
(Morgan, 2001). The analytical framework presented here extends to
explaining the interaction of CSOs with other actors. Following the “util-
itarian” perspective, communities (in this book CSOs) are involved in
development assistance through “passive means” used to reach the project
objectives (Rasschaert et al., 2014, p. 7). According to the “utilitarian”

perspective, CSOs are dependent on “external” assistance due to their low
capacity and structural barriers (ibid.). These include, for instance, illit-
eracy (Jana et al., 2004), gender-related biases (WHO, 2008), the politi-
cal situation in the country, and poverty (Fawcett et al., 1995). In these
conditions, donors may not have sufficient incentives to offer the predict-
ability and flexibility regarding their assistance. Moreover, even if pro-
vided, CSOs may not be able to negotiate for these characteristics because
of the fear of losing access to funding.
Fourth, equal cooperation takes place when all the actors are involved
in the aid realization process and have an equal say in it. None of the par-
ties dominate aid realization. This notion of equality recalls partnerships
that are founded on equality, trust (Hyden, 2008), nonconditionality
(Abrahamsen, 2004), and shared responsibilities and authority. Trust is
ensured in partnerships in which stakeholders fulfill their commitments
(Del Biondo, 2020); however, this is often problematic, as actors may
break their promises in the face of pressure from their constituencies,
parliaments, and so forth. Ideally, a partnership has no conditions, mean-
ing that stakeholders fulfill their responsibilities voluntarily. However,
conditionality may be inevitable and still be present in a partnership as
long as it applies to all parties. Furthermore, I also define shared respon-
sibilities and authorities that are essential to partnerships, as these provide
a necessary underpinning for equality in the aid realization process.
In general, equal cooperation or partnership rarely takes place in prac-
tice, although there are some exceptions. The most pressing issue for
donors in equal cooperation contexts is the adoption of joint procedures,
which is essential to the joint implementation and evaluation of the assis-
tance. These aspects require lengthy discussions and a high degree of flex-
ibility and predictability. Given the complex structures of donors and
their adherence to their own rules, this might be problematic to imple-
ment in practice. Between donors, equal cooperation seldom occurs
because of “harmonization” issues, although there are exceptions among
medium-sized organizations sharing similar perspectives (see Isabekova,
2019). In the relationships of donors with recipient states, equal coopera-
tion similarly assumes the presence of equality, trust, nonconditionality,
and shared responsibilities between the parties. This is problematic due to
52 G. Isabekova
power dynamics and the inherent inequality between the actors, as dis-
cussed in the beginning of this chapter. The recipients might be reluctant
to participate or criticize the donor because of the fear of donors cutting
funding (Hinton, 2004). As the agenda is still set by donors (Nissanke,
2008), partnerships (or equal cooperation) might be viewed as “little
more than rhetoric” (Abrahamsen, 2004, pp. 1455–1456). Because of
aid dependence and limited capacity, equal cooperation rarely takes place
between recipient countries and their donors.
Finally, the relationship of donors and recipient states with the CSOs’
definition of equal cooperation in the analytical framework presented
here is based on the “empowerment” approach. Similar to the “utilitar-
ian” perspective described in unequal cooperation, this approach was ini-
tially suggested for community involvement (Morgan, 2001, p. 223).
This chapter extends it to cover CSOs. Empowerment is a “process of
gaining influence over conditions that matter to people” (Fawcett et al.,
1995, p. 679). In development aid, CSOs are able to express their con-
cerns, set priorities, and participate in negotiations and the decision-
making process. They equally cooperate with other partners by
participating throughout the assistance process. Following this approach,
CSOs are viewed as the source of initiative rather than “passive” aid recip-
ients (Morgan, 2001, p. 223; Rasschaert et al., 2014, p. 7). However,
there is inherent inequality between donors, recipient states, and CSOs
because of the differences in resources and the structure of development
assistance (see the section on power dynamics). The power dynamics fur-
ther vary among CSOs. CBOs are relatively aid-dependent and require
more capacity-building activities. There is evidence that at the end of a
development project, CBOs will continue its activities if it continues to
receive funding from another donor; otherwise, they will cease or decrease
their activities (Ahluwalia et al., 2010). The dependence of CBOs on
donors is clearly illustrated by the statement of one CBO member in
Central Asia: “getting a grant is similar to receiving money from God”
(Earle et al., 2004, p. 34). In contrast to CBOs, NGOs might also be aid-
dependent but have a relatively higher capacity, although there is varia-
tion between local, national, and international NGOs. An organization
with several branches across the country or in several countries has more
human and financial resources than one operating in a village or a town.
Referring to aid relationships, I intended to synergize the narrow and

general approaches in the international documents and development aid
literature. The classification of the “ideal” types of interactions among
stakeholders presented above serves two purposes. First, it provides the
level of abstraction necessary to observe the link between interaction
among stakeholders and the sustainability of development aid. Second,
this level of abstraction is critical to our comprehension of complex rela-
tionships and learning beyond specific cases. In other words, how cases
are selected for empirical research may help us understand both aid rela-
tionships and their connotations of sustainability in other contexts.
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right holder.
3
Sustainability of Health Assistance
Sustainability is a multidisciplinary and multidimensional phenomenon.

From the 1970s to the 1990s, studies on sustainability and sustainable
development focused on the impact of human activity on the environ-
ment (Giovannoni & Fabietti, 2013). Only in the late 1980s did the
perception of sustainability expand beyond ecology, nature conservation,
and environmental degradation to include the social and economic aspects
of this phenomenon (see Kidd, 1992). The 1987 “Our Common Future”
report of the United Nations (UN) World Commission on Environment
and Development (the Brundtland Report) and the 1992 Earth Summit
in Rio manifested this multidimensionality, contributing to a “three-pil-
lar” (environment, economic, and social) perspective of sustainability (see
Purvis et al., 2019). Although the practical feasibility of this approach
(Károly, 2011) and simultaneous attainment of all three dimensions to
the same extent (Boussemart et al., 2020) remain unsettled, the three-
pillar perspective manifested itself in the UN Sustainable Development
Goals (SDGs 2015–2030). The SDGs, per se, embody the multidiscipli-
narity and multidimensionality of sustainability as a phenomenon.
At the same time, multidisciplinarity is among the main reasons for
the ambiguity of the literature on sustainability. Following the Brundtland
Report (1987), multiple authors discussed the interrelation, (in)

60 G. Isabekova
compatibility, and balanced representation of the three pillars, along with

the indicators and factors relevant to sustainability (e.g., Purvis et al.,
2019). A multiplicity of studies contributed to the establishment of sus-
tainability science—an interdisciplinary field aimed at identifying indica-
tors and methods for sustainability research (Kajikawa, 2008).
Nevertheless, the conceptual and theoretical underpinning behind the
integrated approach toward sustainability remained weak, leading to dif-
ficulties in defining and characterizing sustainability (Purvis et al., 2019).
This opacity is echoed in terminological inconsistency and conceptual
ambiguity observed in the literature on the sustainability of development
assistance to health care.
Sustainability is often used interchangeably with, among other terms,
routinization, institutionalization, adaptability, resilience, and continuity
(Gruen et al., 2008; Kiwanuka et al., 2015). However, if routinization
and institutionalization focus on the standardization and integration of
practices at organizational levels (Pluye et al., 2004; Scheirer & Dearing,
2011), sustainability refers to the integration of a practice or a change in
the system as a whole. Similarly, the adaptability or flexibility of a pro-
gram when faced with situational changes (Shigayeva & Coker, 2015)
and the resilience or ability of the system (or a program) “to maintain”
itself (Mayer, 2008, pp. 278–279) and continuity describe specific char-
acteristics of sustainability but not the term itself. Depending on internal
and external changes and challenges, interventions are likely to be
adjusted or to retain certain features. However, it is not clear which
aspects and to what extent they need to be continued for an intervention
to be “sustainable” (Stirman et al., 2012, p. 10). Thus, all the terms men-
tioned above denote specific parts of sustainability but not the phenom-
enon as a whole.
Terminological inconsistency is an outcome of fragmentation of the
literature on the sustainability of development assistance to health care.
There is a prevalence of case studies contributing to context-specific
knowledge but leaving the question of general implications unanswered.
On reviewing the literature on the sustainability of health care programs
in sub-Saharan Africa, Latin America, and Southeast Asia, it becomes
clear that the research focuses on either systematic literature reviews or
empirical analysis of interventions (i.e., case studies), often without any
3 Sustainability of Health Assistance 61
theoretical underpinning. This fragmentation and underdevelopment of

the literature (Iwelunmor et al., 2016; Stirman et al., 2012) is reflected in
the recommendations for further research on sustainability in health care,
which emphasize, among other issues, the conceptual clarity and neces-
sity for understanding the link between specific characteristics of inter-
ventions and contextual factors to the sustainability of interventions
(Proctor et al., 2015).
A genuine understanding of sustainability and related factors also pre-
supposes the awareness of biases behind this phenomenon. Sustainability
is an “inherently political” phenomenon (Purvis et al., 2019, p. 692),
which has a different meaning for different actors (Morgan, 2001). For
donors, it implies the long-term financial costs of the program being
taken over by the recipient, while for the recipient, sustainability refers to
the freedom to make changes to enable the continuity of a program over
time (Walsh et al., 2012). This dissimilarity in interpretation suggests
that different actors are unlikely to have a similar understanding of what
is sustainable and what is not. However, because of unequal power
dynamics, the definition of sustainability and the factors associated with
it may reflect the interests of stronger groups and not necessarily the
recipients of health aid (see Murphy, 2012). The subsections below
expand on the operational framework, which aims to overcome the ter-
minological and conceptual ambiguity of sustainability in the context of
health aid. Adapting and extending the existing analytical models, it
intends to provide an equitable framework for analyzing various perspec-
tives of sustainability and the factors related to it.
3.1 Operationalizing Sustainability

Sustainability in empirical terms requires identifying a matter of interest,
relevant actors, a timeframe, and the extent of sustainability—in other
words, “what, how or by whom, how much and by when” to sustain
(Iwelunmor et al., 2016, p. 2). This book focuses on development assis-
tance for health care and the roles of multiple stakeholders in ensuring
sustainability, which is not achieved by a single or limited number of
actors (see Chap. 2). As indicated in the introduction to this book, the
62 G. Isabekova
Table 3.1 Sustainability in empirical terms

“What” to be Ongoing and completed health care projects
sustained
“How/by whom” Donors and recipients of the assistance
“By when” Up to the present day
“How much” Emphasis on the continuous and not on the categorical
(yes/no) nature of this phenomenon
majority of health care programs are not sustained beyond the end of
donor financing. Yet, sustainability does not automatically come along
with the end of the financing; it is rather built throughout the realization
of a health care aid. The case studies of health care programs selected for
this book represent completed and ongoing projects (Table 3.1). Both
types of projects are of equal value to understanding the sustainability of
health care aid to the present day. Most data I have collected on selected
projects range from 1991, when the Kyrgyz Republic gained its indepen-
dence, to 2018, when I conducted the second fieldwork. The factual data
were updated in 2022 to reflect the current state of organizations and
selected programs in the face of the global coronavirus disease-19
(COVID-19) pandemic. Therefore, “up to the present day” in this book
denotes the state of play at that specific point in time when data were
collected (see Sztompka, 1993, p. 12). Last, sustainability is a “matter of
degree rather than an all-or-none phenomenon” (Shediac-Rizkallah &
Bone, 1998, p. 96). However, I refrain from assigning weak and strong or
partial and full ranges to sustainability, as these measurements are inher-
ently subjective (see Savaya et al., 2008). Instead, I define sustainability
vis-à-vis the three perspectives described in the following subsection.
3.2 Conceptual Definition

This book adopts Shediac-Rizkallah and Bone’s (1998) conceptualization
of sustainability as maintaining benefits, continuing program activities,
and building the capacity of a recipient community. First, maintaining
benefits refers to services or infrastructure provided within development
assistance (Altman, 1995; Torpey et al., 2010). This book focuses on the
services received by the population targeted by the assistance (i.e., the

project beneficiaries) and, where relevant, on any use of hardware or
infrastructure provided to the beneficiaries, continuing beyond the dura-
tion of the program. Second, in terms of continuity of project activities,
it overviews the activities continued and discontinued by the end of the
project. Self-evident in the cases of completed health care projects, these
two aspects can, however, also be assessed in ongoing development pro-
grams. This book identifies arrangements made by aid recipients to main-
tain the services and continue project activities at their own expense or
through financing from other donors as implications for the sustainabil-
ity of these services and activities beyond the duration of the initial proj-
ect funding. Third, community capacity-building presumes, among other
issues, empowerment of a recipient community through a development
program (see Shediac-Rizkallah & Bone, 1998).
Broad but nevertheless precise, Shediac-Rizkallah and Bone’s (1998)
operationalization of sustainability is cited by multiple authors. However,
studies largely concentrate on one or several of three aspects: mainte-
nance of benefits (e.g., Chambers et al., 2013; Johnson et al., 2004),
continuity of project activities (Cassidy et al., 2006; Schell et al., 2013),
and community capacity-building (Alexander et al., 2003). This book
incorporates all three aspects to characterize the sustainability of develop-
ment assistance for health care. This ensures a comprehensiveness of the
analysis and a balance of donors’ and recipients’ perspectives on this phe-
nomenon. Some authors elaborate further on these three categories.
Scheirer and Dearing (2011), for instance, assess the maintenance of pro-
cedures and policies promoted during project implementation, contin-
ued attention to the problem, and dissemination of program ideas and
activities. Although useful for an in-depth analysis of specific aspects of
the assistance, these indicators may be onerous for assessing the sustain-
ability of development projects as a whole.
This book adheres to the original conceptualization by Shediac-
Rizkallah and Bone (1998), although with further adaptations to resolve
the ambiguity of the third aspect. Not as straightforward as the two oth-
ers, it requires further consideration of nuances related to the operation-
alizations of “community” and “capacity-building.”
64 G. Isabekova
The romanticization of “community” and approaching it as a homoge-

neous unit is opposite to the success of community-oriented programs
(Morgan, 1993, p. 44). Among other qualities, communities have nested
hierarchies and power relations. Therefore, it is important to ask who the
community is and whom it represents (Yeo, 1993). Men and women, the
elderly, and marginalized groups, such as men who have sex with men
and others, all have different social statuses. For instance, the status of
men and the elderly in Central Asia, their access to resources and decision-
making processes, is not comparable to the status of women (Earle et al.,
2004). Without addressing these issues, development programs may sim-
ply reinforce existing hierarchies (Wells et al., 2012) instead of empower-
ing the community as a whole. Acknowledging the hierarchies inherent
in communities, this book focuses on community organizations, includ-
ing community-based organizations (CBOs) and nongovernmental orga-
nizations (NGOs), which target or work with marginalized groups. This
specific focus on community organizations, rather than on communities
as a whole, contributes to and also assures the empirical feasibility of the
assessment of capacity-building.
Capacity-building in this book refers to activities that contribute to
the ability of a community organization to formulate and express its con-
cerns and use internal and external resources to achieve its goals. This
definition combines the operationalization provided by multiple schol-
ars.1 Internal resources in this definition include individual and organiza-
tional assets, such as skills, experience, and associations with other
organizations; external resources refer to the physical assets (e.g.,
hospitals, social service institutions) that the organization can use in its
activities (Mcknight & Kretzmann, 2012). The operationalization of
capacity-building used in this book goes beyond Shediac-Rizkallah and
Bone’s (1998) emphasis on training and its role in supporting the roles of
community members as sources of information and expertise. In so
1
Labonte and Laverack (2001a, p. 115) and Sarriot et al. (2004a, p. 28) described community
capacity as the ability of communities to define, evaluate, and “act on health (or any other) con-
cerns of importance to their members.” In addition, Jackson (2003), Raeburn et al. (2006), and
Goldberg and Bryant (2012) characterized community capacity-building as improving general per-
formance and the ability to achieve the stated goals through establishment of a necessary environ-
ment for it, including planning, needs assessment, and assessment of resources.
doing, it amplifies (expands) the meaning of capacity-building and shifts

the emphasis from health projects to the abilities and agency of commu-
nity organizations.
To measure community organizations’ capacity-building, I adopt the
model suggested by Laverack and focus on participation, leadership, and
resource mobilization.2 The emphasis on these three aspects corresponds
to the agency of community organizations highlighted in the definition
above. Engagement in problem-setting and the ability to influence deci-
sions are inherent to participation (Labonte & Laverack, 2001a), which
is critical to the responsiveness of development programs to local con-
cerns. Although concomitant to participation, leadership refers to the
ability of the community organization to define the problems, suggest
solutions, critically assess the factors contributing to inequalities, and
develop relevant strategies to address them (ibid.). Finally, resource mobi-
lization is instrumental to the first two aspects. However, the ability of an
organization to mobilize resources in addition to its own assets (ibid.)
may take different forms.
This book focuses on development aid, state financing, community
fundraising, and liaisons with other organizations as potential sources for
resource mobilization. Donor funding is a typical source of financing for
community organizations in developing countries. However, reductions
in development assistance and unpredictability of funding flows make
this source of financing unreliable. Inclusion of costs into the national
state budget once the project has ended is another option, for instance,
through state provision of services under social contracting, though bud-
get deficits and government prioritization of other areas not targeted by
community organizations may exclude this possibility. The third option
is a mobilization of resources at the community level, for instance,
through collecting donations and in-kind support, introducing member-
ship fees (Paine-Andrews et al., 2000), or conducting income-generating
activities (Walsh et al., 2012). However, there are some underwater stones
here as well. For example, poverty may increase competition for limited
2
The original source is an unpublished Ph.D. thesis by Laverack (1999), which was expanded fur-
ther by Labonte and Laverack (2001a, 2001b).
66 G. Isabekova
resources (Roussos & Fawcett, 2000) or question the viability of fund-

raising activities at all.
Lastly, mobilization of resources also takes place through association
with organizations that have similar objectives (Paine-Andrews et al.,
2000). In addition to in-kind and political support, these alliances may
contribute to strengthening human resources, also through the improve-
ment of skills (Hirschhorn et al., 2013). Through collaboration with
medical workers, community organizations working in health care may,
for instance, gain supervisory support (Ajayi et al., 2012) and link their
activities to existing health care services (WHO, 2008). However, the
same organizations may be gatekeepers that are protective of their areas
of interest. Thus, medical professionals at times oppose the involvement
of community organizations in health care due to the lack of medical
training and expertise of the latter (Morgan, 2001).
Overall, resource mobilization is one of the most important yet prob-
lematic components of community capacity-building. In addition to the
knowledge and skills of community organizations (Sarriot et al., 2004a),
it also largely depends on the overall political and economic situation in
the relevant region or country. This interplay between organizational
aspects and external factors brings to mind an indicator not included in
the original model for analyzing capacity-building by Laverack (see
Labonte & Laverack, 2001a, 2001b), namely, the survival of community
organizations beyond the duration of the project funding.
Both the continuity of project activities and the maintenance of ben-
efits largely depend on the survival of community organizations. For this
reason, multiple stakeholders raised this issue during my fieldwork in the
Kyrgyz Republic. Participation, leadership, and resource mobilization
contribute to but do not necessarily guarantee the survival of a commu-
nity organization. The organization may take part in the decision-making
process, demonstrate leadership, have multiple sources of funding, and
still discontinue its activities. For this reason, I include the survival of the
organization beyond the duration of project funding as an additional
indicator of community capacity-building (Table 3.2).
Table 3.2 Conceptual definition of sustainability

Maintenance of Continuity of benefits offered to targeted groups after the
benefits end of the project (e.g., services and infrastructure)
Continuity of Continuity of project activities after the end of the project
project activities funding
Community Activities contributing to community organizations’
capacity- capacity-building
building 1. Leadership, or the ability of these organizations to
define the problems, suggest solutions, and critically
reflect on the general issues relevant to their work
2. Mobilization of resources via donor and state
financing, fundraising activities, or liaison with other
organizations
3. Survival of civil society organizations (CSOs) beyond
the end of a donor-financed project
The source: author’s adoption of Shediac-Rizkallah and Bone (1998) and Laverack
(see Labonte & Laverack, 2001a, 2001b). Participation in problem-setting and
the ability to influence decisions are not included in the analysis of community
organizations’ capacity-building process, as it is separately evaluated in the
analysis of stakeholders’ roles throughout the project’s life cycle (Chaps. 5 and 8)
3.3 Factors Influencing the Sustainability

of Health Care Interventions
In addition to the empirical and conceptual definition, the accurate anal-
ysis encompasses the related factors, as sustainability does not materialize
in a vacuum. Rather, it depends on several internal and external factors
that are difficult to predict (Sarriot et al., 2004b). In the case of develop-
ment assistance to health care, internal factors are technical or program-
related elements, such as management, planning, implementation, and
achievement of stated goals (Bossert, 1990; Shigayeva & Coker, 2015).
External factors are the economic and political situations in the recipient
country that shape the system in general, including the number of medi-
cal workers in the country, health care coverage (Iwelunmor et al., 2016),
and political support for specific programs. All these factors contribute to
the uncertainty associated with the sustainability of health care programs.
This section summarizes the main factors associated with this
68 G. Isabekova
Table 3.3 The factors relevant to sustainability

Financing At the expense of the aid recipient or through a
combination of “innovative” funding methods
Accounting for the • Political and economic situation in the aid-recipient
influence of general country
factors • Health care system, the epidemiological burden of
the disease
• Availability of medical workers
• National priorities
Integration into local Consideration for historical, systemic, and cultural
context specifics, but with the account for the social stigma
and discrimination against specific groups
Organizational factors • Project duration
• Capacity of the organization implementing health
care interventions (managerial, financial, and
structural characteristics of the organization and its
human resources)
phenomenon based on the literature on the sustainability of health care

interventions (Table 3.3). Awareness of these factors is critical to the sus-
tainability of health aid, although the prominence of each of these condi-
tions may depend on a particular project and country setting.
First of all, donors provide the initial financing for projects, but at the
end of the assistance period, or in the best-case scenario, at the beginning,
the question of funding continuity arises. This continuity, as a rule, is
ensured at the expense of aid recipients or through a mixture of funding
mechanisms. A plan for program continuation, including evidence of the
recipient’s contribution or evidence of a combination of the donor’s and
recipients’ funding sources, is often a precondition for assistance (Schell
et al., 2013). This requirement for the recipient’s contribution may
increase the share of domestic funding to the areas targeted by develop-
ment aid. UNAIDS (2015, p. 54) notes that in 2005, development assis-
tance accounted for 69% of all HIV-related spending, but by 2014,
contributions from domestic sources in low- and middle-income coun-
tries represented 57% of all HIV-related expenditure.
However, the recipient’s contribution may not be sufficient to cover
the costs of all health care programs. For instance, in the case of projects
combatting tuberculosis (TB), the course of treatment for drug-resistant
forms of this disease ranges between US $1218 and $6313 per patient
(Laurence et al., 2015; Ormerod, 2005). Depending on the burden of

disease, these costs may be unaffordable to patients and governments in
developing countries. Similarly, a recent study of development assistance
for community health workers by Lu et al. (2020) suggests that in the
context of low-income countries, domestic public spending alone cannot
fully cover national community health worker programs. Nevertheless,
the role of domestic resources remains imperative, notably as aid recipi-
ents transition from external assistance. As development aid to Eastern
Europe, Central Asia, and Latin America is decreasing, national contri-
bution becomes the key subject in sustainability discussions (Burrows
et al., 2016).
Continuous financing of health care programs may also be provided
through a combination of various other funding mechanisms. These are
affordable procurement of medicines via large donors, optimization of
spending, and adoption of “innovative” funding methods (Oberth &
Whiteside, 2016, p. 3). As seen above, the cost of medicines is a key issue.
Procurement via large organizations, such as the Global Drug Facility,
provides access to affordable quality-assured TB medications and diag-
nostics because they purchase large quantities of health products (Stop
TB Partnership, 2019). However, the price per item may be higher for
individual countries since they procure considerably smaller quantities
than these organizations. For this reason, the establishment of procure-
ment mechanisms is essential to the sustainability of health projects
involving diagnostic and treatment services (see Chap. 9). Another option
for assuring additional funding is the optimization of spending on health
care. Yet, given the limited amount of resources and budget deficits of the
countries receiving development assistance, this measure may not guar-
antee significant savings to cover the costs of health care programs.
The third option, introducing “innovative” funding methods, may
take different forms, including specific tax mechanisms, fundraising
activities, and recruitment of volunteers. For example, additional taxa-
tion on mining or cigarette companies for their contribution to the “risky
environment and conditions” for the development of TB could be a sup-
plementary source of financing for TB services (Amo-Adjei, 2013,
pp. 4–5). Similarly, taxes on airlines, formally employed individuals and
companies, and mobile phone usage could increase national spending on
70 G. Isabekova
HIV/AIDS-related services (Oberth & Whiteside, 2016). However, there

is no guarantee that gathered resources are actually going to be used for
public health programs (ibid.). The sustainability of community organi-
zations’ activities is associated with community support, volunteering,
and local fundraising activities (Abdul Azeez & Anbu Selvi, 2019).
Nevertheless, donor financing represents the largest share of funding for
community health workers (see Saint-Firmin et al., 2021), and the actual
contribution of “innovative” funding methods in economically weak
countries remains ambivalent.
Furthermore, the economic, social, and political situation in the recip-
ient country has implications for health care interventions, particularly in
the long-term perspective (Bossert, 1990). During the project implemen-
tation period, these external factors are at best targeted by project imple-
menters. By the end of the program, however, when the implementers
withdraw, the influence of these factors on project outcomes increases.
Economic crises or changes in the ruling party may alter domestic poli-
tics and government priorities, resulting in cuts to health care spending.
Outcomes may also be impacted by issues in the local health care system,
such as a shortage of health care professionals, their burn-out, an increased
number of patients, and poor record-keeping systems (Harpham & Few,
2002; Iwelunmor et al., 2016). The prioritization of a program by the
recipient country is also relevant to the continuity of outcomes. Thus,
prevention programs are less likely to be sustained due to the lack of
immediate visible effect (Shediac-Rizkallah & Bone, 1998). Short-term
visibility of an intervention facilitates continuity of curative (e.g.,
treatment-oriented) programs over prevention programs. Similarly, the
type of activity is also relevant to its continuity. Training programs, for
example, offer continuity of outcomes at a low cost. Trained personnel
disseminate knowledge further, also via “training of trainers” (ibid.,
p. 101). In this regard, Kiwanuka et al. (2015) suggest that training
women may be particularly beneficial since they are more likely to stay in
the community and train others than men. These are only a few examples
of the external factors which are relevant to health care programs.
Although program managers cannot foresee the influence of every possi-
ble aspect, they may nevertheless reflect on known factors during the
project implementation/design phase in order to mitigate their impact by

the end of the project.
Similarly, integration into the local context is essential for the sustain-
ability of health care interventions. Sarriot et al. (2004a, p. 34) note that
sustainability plans are “meaningless” out of context, and they are not
alone in this assessment. A systematic evaluation of 125 studies identifies
compliance with the local context as one of the most important factors
for the sustainability of health care programs (Stirman et al., 2012). The
significance of the context is equally acknowledged by practitioners. A
vivid example thereof is the Paris Declaration on Aid Effectiveness (2005)
and its emphasis on using “country systems and procedures” and “exist-
ing capacities” of the recipient country in development assistance
(OECD, n.d., pp. 4–5). Although difficult to define, the context, in a
general sense, refers to the setting broader than the intervention itself and
the discussion of current politics and actors, including systemic, histori-
cal, and cultural factors (Andrews, 2013).
Systemic, historical, and cultural factors are reflected in institutional
structures and actors’ preferences. Closely interrelated, these factors may
hinder, promote, or contribute to the mixed results of a health care inter-
vention, as demonstrated in the following examples of reforms targeting
primary health care and decreased tea consumption.
Despite the broad acknowledgment and efforts made by domestic and
external actors, funding for primary health care in post-Soviet countries
remains small. In addition to the medical lobby behind hospital care and
political, economic, and social hurdles (Kühlbrandt, 2014), the small
funding also corresponds to the structure of the health care system inher-
ited from the Soviet Union. The Semashko health care system emphasized
a curative approach and little prevention or health care promotion. After
the collapse of the Soviet Union, newly independent countries initiated
multiple reforms to change this system (Isabekova, 2019). Nevertheless,
the emphasis on treatment and curative approaches remained, often at
the expense of prevention (Kazatchkine, 2017).
Furthermore, an interplay of cultural and historical factors may con-
tribute to the mixed outcomes of health care interventions. For example,
excessive tea consumption is a problem in Central Asian countries. The
Swiss health promotion program in the Kyrgyz Republic targeted, among
72 G. Isabekova
other issues, child nutrition by promoting the use of a micronutrient

powder and abstention from black tea consumption during meals.
Although tea consumption among pregnant women and children did
decrease (Schüth et al., 2014), the rate of anemia reduction among chil-
dren was still lower than that in other countries (Lundeen et al., 2010).
One of the main reasons was the continued tea consumption in the pop-
ulation (see Tobias Schüth, 2011).
Overall, the “context” has controversial implications for programs
advocating for changes that are incompliant with mainstream norms. For
example, a local population may be open to some projects but not to oth-
ers. Thus, teachers may be reluctant to introduce sex education based on
the belief that condoms could be perceived as an encouragement to have
sex (Maticka-Tyndale et al., 2010). As Rashed et al. (1997) note, public
attitudes toward bed nets and condoms differ because the first is cultur-
ally acceptable, while the second is not. Cultural values defining indi-
vidual and collective behavior are highly relevant to health care programs
(Airhihenbuwa, 1995). However, certain health care interventions, such
as harm reduction programs—including needle exchange services and
methadone substitution therapy for persons who inject drugs—access to
condoms, sexually transmitted diseases for commercial sex workers and
men who have sex with men, are controversial in the local context of
many countries. Although these programs are also expected to address
the context of the recipient country, the extent of their integration into a
context that discriminates against the groups targeted by these projects
may be limited.
(In)acceptability of specific practices and stigma and discrimination
against certain groups is erroneously associated with the “morality” clause
related to individual behavior, although it may, in fact, be the result of a
reaction to the unknown or mere discrimination of marginalized groups.
HIV/AIDS may be perceived as an outcome of or even a punishment for
“immoral” behavior, not concomitant with “traditional” values, such as
abstinence and fidelity (Hannon, 1990). Similarly, stigma is closely asso-
ciated with degrading moral status (Goffman, 1963), leading to the dis-
crimination of specific groups of the population affected by certain
diseases. There, however, is a difference between persons affected and asso-
ciated with diseases. Among persons living with HIV, commercial sex
workers and men who have sex with men are more marginalized than
children or pregnant women. This discrimination against certain groups
also may materialize in the selectivity of the groups entitled to HIV/
AIDS-related services (Oberth & Whiteside, 2016). For instance, follow-
ing a significant reduction in financing from the Global Fund to Fight
AIDS, Tuberculosis and Malaria (Global Fund), the government may
continue the prevention of mother-to-child transmission of HIV but cut
these services for persons who inject drugs (OSF, 2015).
In both cases, (in)acceptability and stigma, the question of whether
these two are parts of the moral system of a society or merely indicate the
cultural variants remains open. Notably, a cultural variant is selected by
an individual based on its popularity in a given environment, whereas the
moral system encompasses a set of codes of conduct persisting over time
due to its contribution to mutually beneficial social cooperation (Luco,
2014). In addition to the cultural meaning, stigma also may be the result
of a “tactical response to perceived threats, real dangers, and fear of the
unknown” (Yang et al., 2007, p. 1528). Thus, (in)acceptability of specific
practices, stigma, and discrimination against some groups may be the
outcome of cultural biases, response to the unknown, or even oppression
of less powerful, often marginalized groups.
Elaborated analysis of moral systems and cultural biases goes beyond
the scope of this book, but it nevertheless reasserts the necessity for going
beyond the romanticized perspective of a “context.” Thus, integration
into the local context presumes the awareness of power dimensions and
hierarchies and considers perceptions of certain practices in the given
context and beyond. This resonates with the distinction between the code
of conduct followed by an individual or group (“descriptive”) against the
one that, in certain conditions, would be supported by “all rational peo-
ple” (“normative”) (Gert & Gert, 2002). In other words, a practice pur-
sued in a given context does not necessarily represent a widespread norm
or contribute to the benefit of people living in this context. The natural
rights of persons, irrespective of their gender, nationality, or sexual orien-
tation, are elaborated in the United Nations Universal Declaration of
Human Rights (1948), the International Covenant on Civil and Political
Rights (1966), and the International Covenant on Economic, Social, and
Cultural Rights (1966) (see Office of the United Nations High
74 G. Isabekova
Commissioner for Human Rights, 2023a, 2023b). Although the univer-

sal applicability of these documents is part of a continuous discussion,
negative implications of stigma and discrimination on public health are
evident. The social stigma and discrimination against marginalized
groups, such as men who have sex with men and sex workers, jeopardize
their access to health care (Oberth & Whiteside, 2016) and contribute to
high HIV/AIDS prevalence among these groups (UNAIDS, 2014).
Clearly, interventions based on “established values and practices” are
better accepted (Aubel & Samba-Ndure, 1996, pp. 53–54), but what can
be done with others who may not comply with the local but a general
perception of morality? Awareness of stakeholders’ interests and societal
hierarchies and going beyond the abstract notion of culture or context is
the first step. It may be followed by strategies pursued by some commu-
nity organizations that learned to build their discourse of providing access
to HIV treatment to marginalized groups for the benefit of the general
population (see Chap. 8).
In addition to the external factors mentioned above, the sustainability
of health care programs is also influenced by internal factors, and this
section focuses on two of them: the duration of the project and the capac-
ity of the organization implementing it.
The duration of a project is inherent to its sustainability beyond the
period of donor funding. There is a close correlation between time and
change because change is closely related to time, and time is associated
with change (Sztompka, 1993). Changes promoted by health care pro-
grams and their sustainability take time, particularly if these changes con-
tradict the values or habits accepted in the recipient society. Projects with
a duration of three to five years are often referred to as “seed funding” or
“demonstration” projects that are expected to get financing from else-
where by the end of those three to five years (Scheirer, 2005, p. 320).
Nevertheless, both practitioners and researchers agree that, in practice,
most interventions terminate before achieving maturity (Shediac-
Rizkallah & Bone, 1998), and the majority of these “premature” projects
are discontinued after the end of donor funding (Altman, 1995, p. 527).
Nevertheless, donor organizations vary in their approaches to project

duration. Swiss development assistance usually lasts longer than other
average development programs. In contrast, organizations such as the
Global Fund have a three-year project duration with the possibility of
prolonging it; although uncertainty in regard to financing has its implica-
tions on relations between the actors (see Chap. 4).
Another factor inherent to the sustainability of health care interven-
tions is the capacity of the organization implementing the relevant proj-
ect. The OECD (2011, p. 2) defines capacity as the “ability of people,
organizations, and society as a whole to manage their affairs successfully.”
This book focuses on an organizational level. Capacity encompasses the
managerial, financial, and structural characteristics of the organization
and its human resources (Shigayeva & Coker, 2015). These attributes
may suggest that larger organizations with developed structure, network-
ing, and access to resources are preferred over their smaller counterparts.
However, this is not necessarily the case. Although beneficial in some
instances, increased professionalization may be counterproductive in
other instances. Similarly, a large structure also may come with bureau-
cratization and rigidity of the organization, which decreases its flexibility
and responsiveness to the local context. Furthermore, in relation to
human resources, it should be noted that in the context of development
programs, there is a continuous rotation of staff members on both sides,
that is, the donor and the recipients. Human resources are particularly
pressing for recipient state agencies and nongovernmental organizations,
in contrast to donor institutions offering attractive employment condi-
tions and recruiting the most qualified staff in aid-recipient countries
(Swedlund, 2017).
Along with these general features of the organization, another signifi-
cant factor to sustainability is the leadership and commitment of staff
members to the health care program (Scheirer & Dearing, 2011;
Shigayeva & Coker, 2015). Although difficult to measure, the dedication
of staff members of implementing organizations was apparent in the two
case studies covered in this book.
76 G. Isabekova
3.4 Summary
This section discussed the conceptual and empirical ambiguity of sustain-
ability, and listed the factors relevant to it. As a concept, sustainability is
defined in relation to the continuity of project activities once the project
has ended, maintaining benefits offered to the targeted population, and
building the capacity of the recipient community (Shediac-Rizkallah &
Bone, 1998). In addition to conceptualization, this chapter also discussed
the empirical operationalization of sustainability: defining what to sus-
tain, by whom, to what extent, and for how long (Iwelunmor et al., 2016,
p. 2). As sustainability analysis takes place in the context of uncertainty,
this section also presented the factors related to sustainability of health
care interventions, namely financing, accounting for general conditions,
integration into local contexts, and organizational aspects. The impact of
each of these factors is case-specific, though awareness of these conditions
contributes to a better understanding of sustainability in health care
interventions.
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right holder.
4
The Role of Structural Factors
in Selected Health Programs
As noted in Chap. 1, this book specifically focuses on two case studies:

(1) the “Community Action for Health” project, financed by the Swiss
Agency for Development and Cooperation (SDC) (hereinafter the CAH/
Swiss project), and (2) grants from the Global Fund to Fight AIDS,
Tuberculosis and Malaria (the Global Fund) targeting tuberculosis and
HIV/AIDs in the Kyrgyz Republic (hereinafter the Global Fund project/
grants). This chapter elaborates on the case-specific factors relevant to
understanding the interaction and sustainability of these health care
initiatives by focusing on the four factors delineated in the analytical
framework as essential to health care initiatives. These are predictability
and flexibility of assistance on the donors’ sides, and dependency and
capacity on the recipients’ sides (Chap. 2).
4.1 Aid Predictability

In the context of health assistance, aid predictability refers to the dura-
tion that donor organizations can commit themselves, financially or by
other means, to the assistance they offer (Chap. 2). Both SDC and the

86 G. Isabekova
Global Fund acknowledge the significance of aid predictability and com-

mit themselves to improving it. However, the outcomes are diverse due to
the development assistance organizational structure offered by these
two actors.
First, the Swiss Development Cooperation structure allows for multi-
year predictability. The Swiss Parliament adopts the “Dispatch on
International Co-operation” every four years (Federal Department of
Foreign Affairs and State Secretariat for Economic Affairs, 2020). This
document underpins the country’s view of development, such as poverty
reduction and sustainable development (2021–2024), and is not limited
to official development assistance (ibid.). Three organizations are respon-
sible for implementing the Dispatch: (1) the Swiss Agency for
Development and Cooperation, (2) the Human Security Division within
the Federal Department of Foreign Affairs, and (3) the Economic
Cooperation and Development Division of the State Secretariat for
Economic Affairs within the Federal Department of Economic Affairs,
Education and Research (OECD, 2019, pp. 13–14). Nevertheless, the
SDC manages the most significant part of the Dispatch on International
Cooperation program (68%), including technical and financial coopera-
tion and humanitarian assistance (ibid.). The four-year budget planning
of the program, combined with sound forecast information and multi-
year funding agreements, provides the basis for the reliability of Swiss aid
(ibid., p. 18). Moreover, Swiss aid agencies have buffer funds to rely on;
this means that Swiss aid organizations can make four- to five-year com-
mitments, and in the case of the SDC, this extends up to ten years
(OECD, 2009, p. 213). Accordingly, Switzerland offers more predictable
aid from a multiyear perspective.
The “Community Action for Health” Project (CAH) is a vivid example
of the predictability of Swiss development assistance in Kyrgyzstan and
beyond. With the average duration of Swiss projects in Kyrgyzstan being
approximately ten years (see Embassy of Switzerland in KR, 2013), the
CAH lasted for seventeen years (2001–2017). Several interviewees
stressed that this long-term duration was essential to the project perfor-
mance (IO Partner 5) because working with existing structures takes
time, with the first three years spent on building networks (IO Partner 9).
This multiyear predictability is a strong feature of the Swiss Development
4 The Role of Structural Factors in Selected Health Programs 87
Cooperation (OECD, 2014). According to estimates of the Global

Partnership for Effective Development Co-operation (n.d.), which is a
multistakeholder platform aiming to promote the effectiveness of devel-
opment efforts, Swiss aid demonstrates high aid predictability. In 2018,
for instance, Switzerland performed better (70%) than the average bilat-
eral member of the Organization for Economic Co-operation and
Development’s Development Assistance Committee (OECD DAC)
(53.2%) in terms of the medium-term predictability (two to five years) of
its aid (ibid.).
In addition to funding, another significant aspect of predictability in
the CAH was the long-term engagement of the project coordinator.
Invited by the Swiss Red Cross (SRC) to conduct a pilot study on com-
munity involvement in health care in 2001, Dr. Tobias Schütz stayed in
Kyrgyzstan for almost thirteen years. He administered most of the project
process, from its early initiation to countrywide expansion and further
extension of community-based organizations at the national level.
According to one interviewee, the absence of short-term consultants ben-
efited the project (IO Partner 5). Indeed, the project coordinator’s con-
tinuous engagement contributed to building partnerships and uniformity
of principles and approaches throughout the CAH. Notably, the long-
term presence of key staff members is one of the aspects of Swiss aid
appreciated by partner countries as beneficial to collaboration (OECD,
2019). However, thirteen years is probably an exception rather than a
rule to a long-term presence.
Second, the Global Fund encourages the initiative of countries, multi-
lateral and nongovernmental organizations, and private foundations will-
ing to unite their efforts against tuberculosis, human immunodeficiency
virus infection and acquired immune deficiency syndrome (HIV/AIDS),
and malaria worldwide. In this way, the initiative to establish the Global
Fund came from Japan, the European Commission, United Nations
agencies, participants of the African Summit on HIV/AIDS (2001), the
United States, and a number of other stakeholder countries (Global
Fund, n.d.-b). However, one could specifically highlight the role of the
Bill and Melinda Gates Foundation, which provided the “single largest
nongovernment pledge” in the amount of US $100 million in 2001
(ibid., pp. 15–24). Over eighty countries made or pledged contributions
88 G. Isabekova
to the Global Fund, with the Organization for Economic Cooperation

and Development’s Development Assistance Committee (OECD DAC)
members and the European Commission representing, as of the end of
2021, the leading government donors (Global Fund, 2023a).
Similar to Swiss aid, the Global Fund (2023b) offers relatively predict-
able assistance by allocating funding to countries on a three-year basis.
This period corresponds with the replenishment cycle, during which the
governments and organizations supporting the Global Fund (2023c)
pledge their financial contributions. Adopted in 2005, this approach was
intended to provide “more stable and predictable” financing (ibid.).
Benefiting ongoing programs, the three-year period also allowed suffi-
cient time for countries to prepare their applications. In so doing, this
approach aimed to eliminate gaps between calls and inflated costs in
applications prepared on short-term notice observed during the time
when the organization made announcements on an ad hoc basis in the
past (Global Fund, n.d.-b). Additionally, as part of its 2012–2016 strat-
egy, the organization introduced the New Funding Model, which, among
others, stipulated early feedback on proposals, intending to decrease the
waiting time and increase their chances of success (Global Fund, 2013).
The Global Fund has equally aimed to increase the predictability of ongo-
ing projects. Its Rolling Continuation Channel Initiative, for instance,
stipulated up to six years of funding for “high-performing grants,” with
applications reviewed quarterly instead of on an annual basis (Global
Fund, n.d.-b, pp. 37–38). Furthermore, the organization aimed to fur-
ther increase transparency by announcing the eligibility of countries for
grants based on their disease burden in each of the three components
supported by the Global Fund (i.e., tuberculosis, HIV/AIDS, and
malaria) and income classification (Global Fund, n.d.-c). Overall, the
Global Partnership for Effective Development Co-operation (n.d.) esti-
mates that the Global Fund performs better (66.8% in 2016) than the
average vertical program (see Chap. 1 for a definition) (42.8%) in terms
of medium-term predictability of its assistance.
Kyrgyzstan has been a long-term recipient of Global Fund grants. The
country has received tuberculosis (TB) and HIV/AIDS grants since
2004, with the average duration of grants being approximately 4.5 years
(Global Fund, n.d.-a). It should be noted that each grant was built around
the objectives and activities of the former. This approach contributed to
the continuity of efforts in both areas. This continuity and uniformity
laid the foundation for approaching the grants as continuous projects
against tuberculosis and HIV/AIDS, respectively.
Nevertheless, the Global Fund’s financial commitment remains lim-
ited to three years, with financing beyond being dependent on the avail-
ability of funds. The Global Fund’s dependence on financiers was also
visible during the accusations of fraud in the grants. Confirmed in “a very
small number” of countries and activities, reports in the mass media
about fraud have nevertheless contributed to the perception that the
organization lost control over its grant disbursements (Brown &
Griekspoor, 2013, p. 139). In response to these allegations, several coun-
tries announced the halt of their financing, resulting in a seven to eight
billion dollar funding shortfall (The Lancet, 2011). Consequently, at the
25th board meeting in November 2011, the Global Fund suspended the
planned call for new grants but assured financing for ongoing programs
(Moszynski, 2011). It took several measures to address the problems
related to fraud allegations. In addition to replacing several senior manag-
ers, it changed its operational model and emphasized “more risk-based
supervision” in grant implementation (Brown & Griekspoor, 2013,
pp. 139–142).
Overall, both Switzerland and the Global Fund acknowledge and plan
to ensure the predictability of their assistance, which is also reflected in
their performance compared to an average donor. However, lasting for
almost seventeen years, the CAH is a striking example of the predictabil-
ity of Swiss aid, supported by the long-term presence of the project coor-
dinator. Similarly, lasting 4.5 years on average, the Global Fund grants to
Kyrgyzstan demonstrate the commitment and efforts of this organization
to aid predictability. Furthermore, building around the preceding objec-
tives, each grant contributed to the continuity of activities, laying the
foundation for analytically treating them as ongoing projects against
tuberculosis and HIV/AIDS. Nevertheless, the organizational depen-
dency on the replenishment cycles limits its ability to make longer com-
mitments, which will be discussed in the following section.
90 G. Isabekova
4.2 Aid Flexibility

Aid flexibility in this book denotes the stakeholders’ abilities to change
the development assistance and the extent to which this change demands
specific procedures that may indirectly hinder the stakeholders from ini-
tiating this process (Chap. 2). Switzerland and the Global Fund acknowl-
edge and commit to providing flexible assistance consonant with
recipients’ needs and objectives, albeit with differing success.
Flexibility is a strong feature of Swiss aid within and beyond Kyrgyzstan
due to the relevant emphasis and organizational structure. Switzerland
allows flexible programming and budgeting adaptable to changing cir-
cumstances at country and project levels (OECD, 2019). This emphasis
is further supported by the structure of the Swiss development coopera-
tion stipulating decentralization and allowing a certain level of auton-
omy for field offices. Although part of Swiss embassies, the Swiss
Cooperation Offices are still “fairly autonomous” (OECD, 2005, p. 73).
They report directly to headquarters in Geneva, have policy dialogs with
the recipient governments and other donors, and manage local staff and
local budgets (ibid., p. 74). Country directors have some flexibility in
allocating funds according to the priorities annually defined in collabo-
ration with partner countries (ibid., p. 218). This flexibility of Swiss aid
is also reflected in the SDC’s operations in Kyrgyzstan. The organization
is among the three organizations providing budget support to assist in
the realization of the national health care program. It also provides proj-
ect-related health assistance, which benefits from organizational flexibil-
ity, as the CAH shows.
The autonomy of Swiss aid agencies was conducive to the flexibility of
the “Community Action for Health” and its responsiveness to local needs.
Driven by specific objectives of empowering the communities to improve
their health and to support the partnership between the state health care
system and local communities (Schüth, n.d.), the project was neverthe-
less open to local initiatives. As demonstrated in Chap. 5, the CAH tar-
geted the issues and solutions identified by local communities and those
prioritized in national health care. This openness to activities suggests
that although covering all significant areas, the project description and
funding still provided space for introducing alterations. It also permitted

rather unbureaucratic approval of budget changes, including further
adjustments of costs and activities (IO Partner 11). This guaranteed the
project’s responsiveness to the changing circumstances, also in terms of
the needs of community-based organizations and the areas of concern
highlighted by the local community.
At the same time, Swiss aid faces challenges in balancing the different
levels of accountability, which may also affect its flexibility. As demon-
strated above, Switzerland ensures the accountability of its aid to recipi-
ents by providing flexibility and responsiveness to local needs.
Nevertheless, Swiss development organizations, as any others, are primar-
ily accountable to citizens paying taxes for aid or, in practice, the organi-
zations representing these citizens. Switzerland has no political ties to its
aid (OECD, 2019), but there are growing voices about conforming offi-
cial development assistance to national interests. One example thereof is
the political pressure to target irregular migration to Switzerland by link-
ing the assistance to migration policies of recipient countries (ibid.). If
successful, these initiatives will provide political ties to Swiss aid, which
will also affect its flexibility.
However, the link to national interests is not the only pressure on
development assistance, as accountability to taxpayers also presumes the
achievement of stated objectives and the use of funds accordingly. This
may increase the control over finances and, in so doing, restrict the “spon-
taneity” of allocations. One interviewee noted that the control over the
financing and budget specifications in the CAH increased, reducing the
initial flexibility of the initiative (IO Partner 11). Although in need of
further investigation, in the broader context of increasing pressure on the
accountability of aid, this suggestion points to the controversial relation-
ship between accountability and flexibility. In other words, increased
control over the assistance is opposite to its flexibility.
Like Switzerland, the Global Fund commits itself to providing flexible
assistance. The organization recognizes the problem with requesting proj-
ect proposals instead of accepting the existing national strategies or apply-
ing project cycles instead of adjusting themselves to the cycle of the
national program of an aid-recipient country (UNAIDS, 2005a,
pp. 14–15). Accordingly, the Global Fund asks applicants to conform
92 G. Isabekova
their proposals with national strategies (Chap. 8) and allows sending

funding requests at any time during the initial three-year allocation
period to ensure alignment with national budgeting cycles (Global
Fund, 2013).
Nevertheless, as the case of the Global Fund project in Kyrgyzstan
shows, the three-year period does not necessarily comply with the dura-
tion of national health care programs. According to a state representative,
the Global Fund is among the few donors explicitly committing finances.
For this reason, the organization is also explicitly stated as a source of
financing for specific activities (Government of KR, 2017b). Other orga-
nizations may similarly support the national program, but their commit-
ments are not stated anywhere (State Partner 2). Nevertheless, even a
three-year commitment does not cover the entire duration of the national
program. Another interviewee explained that with national programs
(i.e., against TB and HIV/AIDS) being developed for five years, the
funding for the remaining two years remains unknown (State Partner 4).
Furthermore, the allowable changes to approved grants seem insignifi-
cant. The Global Fund attempts to consider recipients’ suggestions and
implement relevant changes (CSO 8) by adjusting to unexpected expen-
ditures, savings, cancelations, and transfer of some activities (IO Partner
20). However, these changes are “typically not substantial” (Vujicic et al.,
2011, p. 2) and remain within 10–15% of the grant’s total amount (IO
Partner 20). More substantial changes, such as providing treatment
instead of prevention, may be problematic (ibid.) and involve additional
bureaucratic hurdles, as suggested by another interviewee (State Partner
4). The respondent noted that the approval might come or not, with dif-
ferent conditions and limitations applied and negotiations lasting
months, particularly in the cases involving medications (ibid.). The inter-
viewee emphasized that these hurdles caused issues in the grant realiza-
tion process, adding that organizational responsiveness also depended on
the individual(s) coordinating the relevant matter, with some being more
open to interpretations than others (ibid.). Indeed, individual perspec-
tives and behavior are significant to aid flexibility, as they are to predict-
ability, as demonstrated in the previous section in the case of the CAH.
Nevertheless, the issues with responsiveness and bureaucratic hurdles

are also related to the organizational structure of the assistance. The
Global Fund aims to ensure the recipients’ ownership over grants by del-
egating the process of its realization to stakeholders present in the recipi-
ent country. The absence of field offices also intends to ensure
organizational neutrality (IO Partner 4). Remaining in continuous com-
munication with recipients, the Global Fund bases its judgments and
decisions on the information provided by (inter)national stakeholders
about the achievements and issues. Nevertheless, this concentration of
decision-making in one place contrasts with decentralization and auton-
omy, contributing to the responsiveness of Swiss aid.
Furthermore, the flexibility of grants, similar to Swiss aid, is contin-
gent upon external factors. Following the allegations of fraud in grants to
multiple countries, the flexibility of projects decreased. The Global Fund
introduced new regulations requiring all grant recipients to submit their
training plans for approval, and it proved difficult to make any changes
to these plans during the implementation process (Benjamin, 2011).
There were also issues with adjusting activities to inflation in the country
(see Ancker & Rechel, 2015a). Overall, the changes introduced after the
fraud allegations intended to demonstrate the organizational ability to
control finances, pointing to the organization’s accountability before its
funders. Once again, the increased control over finances seems to coun-
terpoise aid flexibility.
Overall, Switzerland and the Global Fund emphasize and provide flex-
ibility in their assistance. Both highlight recipients’ ownership by adjust-
ing the activities to changes occurring throughout the project realization
process. Nevertheless, the extent of possible adjustment without bureau-
cratic hurdles is associated with the organizational structure of develop-
ment partners. Thus, decentralization and a certain level of autonomy of
field officers in Swiss aid contrast with concentrated decision-making in
the Global Fund. However, both development partners struggle with bal-
ancing accountability before funders and recipients of their aid.
94 G. Isabekova
4.3 Capacity
Capacity in this book primarily refers to the abilities of organizations to
fulfill their functions and set and achieve the stated objectives before
them (Chap. 2). Accordingly, this section discusses the capacities of civil
society organizations and state institutions addressed in the two case
studies.
First, approaching the operationalization of civil society organizations
in a broader sense, this section discusses the capacities of community-
based organizations (CBOs) involved in the CAH and nongovernmental
organizations (NGOs) participating in the Global Fund grants.
The CBOs established within the framework of this project include
the Village Health Committees, Rayon Health Committees, and the
Association of Village Health Committees.
Village Health Committees (VHCs) carry out preventive and health
promotion activities among their communities in areas identified by com-
munity members as pressing and those targeted by national health care
development programs (Chap. 5). These areas include hypertension, alco-
holism, iodine and iron deficiency, influenza, brucellosis, and others (see
Isabekova, 2021). It should, however, be noted that although they mea-
sure the blood pressure of their fellow villagers or the level of iodine in the
salt sold in the local shop, VHCs do not provide medical services. Instead,
the organizations serve as mediators between health care institutions and
the population by noting health care issues and encouraging their villagers
to refer to medical organizations and get timely treatment (AVHC, 2020).
VHCs are present in all seven regions, and most have official registra-
tion. Recent estimates suggest that there are 1606 VHCs in the country
(AVHC, 2018, pp. 11–12). The organizations are composed of volun-
teers who come mostly from the villages in which they conduct their
activities. The VHC members meet regularly, on average from 1–2 times
per week to 2–3 times a month (Kickbusch, 2003, p. 18). Interviewees
note that although generally proportional to the size of the relevant vil-
lage, the number of volunteers fluctuated throughout the CAH from an
initial 20–30 (CSO 4) down to 5–10 (CSO 7; State Partner 1).
Subsequently, the total number of VHC members ranged from 10,215 in
2010 to 15,566 in 2014 and to 13,267 in 2016 (PIL Research Company,

2017, n.p.).
The Rayon Health Committees (RHCs) are composed of the leaders of
the VHCs. Registered as nonprofit organizations (Schüth et al., 2014),
they serve as a platform for VHCs to meet and discuss the work con-
ducted and activities omitted and decide on the work plan for the next
quarter (AVHC, 2018, pp. 5–6). This platform also serves two other pur-
poses. First, it is used to pass on information from the association to the
VHCs. Furthermore, at the end of quarterly meetings, RHCs report to
the Association of VHCs by sending the following documents: a list of
participants, a work plan, a meeting agenda, and a table of the VHCs’
self-initiatives (ibid.). Since the RHCs have no office space of their own,
their meetings take place on the premises of Family Medicine Centers or
in the offices of the local self-government at the district level, where the
authorities are able or willing to offer space for VHC meetings (CSO 4).
In addition to connecting and reporting functions, RHCs aim to solve
health care issues at the village and district levels and coordinate capacity-
building activities for VHCs (AVHC, n.d.). They are also expected to
support Family Medicine Centers in their health care activities and coor-
dinate the annual assessment of VHCs (ibid., pp. 8–9). According to
recent estimates, there are 58 organizations in total in the country
(AVHC, 2020, p. 3), with the number of RHC members proportional to
the size of the population in the relevant district (rayon) (CSO 4).
The Association of Village Health Committees (hereinafter AVHC or
the Association of VHCs) coordinates and represents Rayon and Village
Health Committees before the state and donor organizations. Established
in 2010 as a voluntary association of RHCs, it aims to promote health
and improve sanitation and hygiene and the living circumstances of the
rural population in Kyrgyzstan (AVHC, 2020, p. 3). The executive body
of the AVHC has two permanent staff members and four staff on short-
term contracts, although the number of staff at any given time largely
depends on the workload since the staff on short-term contracts are
taken on at times of increased workload (CSO 4). In contrast to the
Village and Rayon Health Committees, the staff members of the execu-
tive body of the AVHC members receive a salary. Nevertheless, the
AVHC is a nongovernmental and noncommercial organization whose
96 G. Isabekova
primary responsibility is coordinating health committees and represent-

ing them before the state and donor organizations. Actors willing to
work with health committees contact the Association of VHCs first
(CSO 1). Examples of AVHCs’ collaboration with other actors include
disease prevention and health promotion activities conducted within the
framework of programs funded by the World Bank, the German
Corporation for International Cooperation (die Deutsche Gesellschaft für
Internationale Zusammenarbeit—GIZ), the United States Agency for
International Development (USAID), SDC, and others. With the
Ministry of Health, the AVHC mainly works via the Republican Center
for Health Promotion and Mass Communication under the Ministry of
Health (hereinafter the Republican Center), but it also sought collabora-
tion with the Mandatory Health Insurance Fund on the assessment of
medical services (see Development Policy Institute, 2017).
Notably, the Association of VHCs has essential developmental and
supervisory functions. It seeks collaboration with other actors primarily
to support and strengthen the capacities of RHCs and VHCs. Therefore,
in addition to organizations approaching the organization themselves, it
also looks for potential donors and projects that could support the
community-based organizations by financial means or by training and
other forms of technical assistance (CSO 4). The AVHC also pursues
supervisory activities by collecting the information provided by RHCs
during their quarterly meetings to assess the VHCs’ ongoing work and
initiate supportive measures.
Organizational capacity closely relates to the composition and rotation
of staff members. It should be noted that most CBO members (approxi-
mately 90%) are women (Tobias Schüth, 2011a). The CAH initiated
several studies on the role of gender in VHCs and their activities
(Development Planning Unit, 2010; Walker, 2013), but external evalua-
tors did not find any conclusive impact of gender on CBOs. The project
has also attempted to encourage male participation in the project, par-
ticularly in the areas of brucellosis, alcoholism, and tobacco abuse (SDC,
2014). These attempts also included organizing competitions, such as
“Ülgülüü Ata” (a model Dad in Kyrgyz), where men had to complete
certain tasks and answer questions relating to the VHCs’ work to receive
valuable prizes (PIL Research Company, 2017). The project, however,
did not achieve its intended 70/30% gender representation since male
participation dropped over time (Gotsadze & Murzalieva, 2017). Civil
society representatives interviewed for this research similarly suggested
that just two or three men participated in their activities, though these
men were not members: one worked as a veterinary, one for the local
authorities, and one in social services (CSOs 2 and 5). The majority of
VHC members were women (ibid.).
Extensive labor migration and conventional gender roles in the Kyrgyz
society contribute to the prevalence of women in community-based orga-
nizations. These roles, for instance, include the assumption that a house-
hold’s health is viewed as a woman’s “responsibility” and that women (in
contrast to men) are not associated with a role of breadwinner. Men in
rural areas leave for the cities, go abroad to work in construction, or go to
the mountains to look after the livestock (CSO 5). As the men leave, the
women stay at home to take care of the household. The VHCs’ outreach
activities target the villagers who are at home, and these are mainly
women (Development Planning Unit, 2010). Traditional roles in the
Kyrgyz society also view men as “breadwinners” and women as “caregiv-
ers” in households. My interviewee emphasized the fact that health con-
tinues to be seen as “the responsibility of women” (CSO 1). Men declined
to participate in the CAH due to the unpaid nature of the work and the
inconvenience of discussing health issues, such as female reproductive
health (Development Planning Unit, 2010). Overall, the prevalence of
women, however, was not limited to community-based organizations but
mirrored the general tendency in civil society organizations in Kyrgyzstan
(see the following section).
At the same time, not all women join community-based organizations.
Depending on their age, women enjoy different statuses in society and in
their families. Young women are expected to look after their children and
in-laws and are under the strict supervision of their husbands and in-laws.
Older women, however, have a higher status in society and in their fami-
lies, fewer household responsibilities, and, therefore more time and free-
dom. My interviewee stressed the inability of younger women to participate
in the VHCs despite their willingness due to resistance from their hus-
bands and in-laws (CSO 7). For this reason, the VHC members are mainly
women aged 40–50, who are unwilling to leave their positions in
98 G. Isabekova
community-based organizations (ibid.). The majority of these women are

housewives (CSO 5) and have just secondary school-level education (CSO
2). For this reason, training courses for the VHCs, for instance, were
adjusted accordingly and used simplified terminology (CSO 1). Previous
research on the VHCs was ambiguous about the social status and profes-
sion of VHC candidates (e.g., Kickbusch, 2003). Although this research
cannot generalize the findings gained from a limited number of inter-
views, it nevertheless provides an important insight into the profile of
the VHCs.
Remarkably, there was no issue with high staff turnover in the
community- based organizations. On the contrary, my interviewees
pointed to the opposite problem, the difficulty of cadre renewal. There
are regulations in the statute of the VHCs or the statute of RHCs regard-
ing the length of service of committee members (CSO 4), but some
members are unwilling to step down or to delegate their authorities to
younger counterparts (CSO 4; IO Partner 5). This concern was also
expressed in external evaluations of the project, which stated that the
majority of the VHC members who were interviewed had worked there
for 10–13 years (T. Gotsadze & Murzalieva, 2017, p. 18). In other words,
they were not newcomers to the committee. However, in addition to
their unwillingness to leave, local culture was also a contributing factor in
the age profile of the VHC leaders. The VHCs I interviewed stated that
they were trying to attract younger volunteers, but young women cannot
participate if their husbands or in-laws are against it (CSOs 5 and 7).
These findings confirm the problem of recruitment of new volunteers but
contradict the issue of high staff turnover pointed to in the literature on
community-based organizations (e.g., Ajayi et al., 2012; Sebotsa et al.,
2007; Walsh et al., 2012).
Consequently, VHCs as organizations depend on single leaders. Earle
et al. (2004, pp. 31–32) point out that community-based organizations
in Central Asia are built around a “charismatic, strong leader,” and with
fifteen members registered, only one can actually be active. Similarly, my
interviewees, closely working with the VHCs, noted that the organiza-
tions largely depend on the leader (CSO 4). If a leader left without an
“equally strong” successor, the VHC started “losing its positions” since
the work and initiatives depended on one or two people, with others
“passively” following them (CSO 1). In the long-term perspective, this

dependence on one single leader jeopardizes the capacity of the
community-based organizations.
Overall, community-based organizations demonstrate exceptional
capacities due to their members’ motivation to bring positive changes to
their communities. Interestingly, the social and economic factors in the
country, along with the conventional gender roles, contributed to the
prevalence of women among community-based organizations.
Nevertheless, this section emphasizes the necessity for differentiating the
statuses of women in society (e.g., age), which finds its reflection in the
CBOs’ composition. Interestingly, in contrast to the literature on com-
munity volunteers in health, findings from Kyrgyzstan suggest that orga-
nizations struggle more with recruiting new members than with attrition.
However, difficulties with recruitment further aggravate organizational
dependence on single leaders and increase the vulnerability of organiza-
tional survival from a long-term perspective.
In contrast to the CAH, the Global Fund grants involve NGOs work-
ing on TB and HIV/AIDS. Overall, the political course Kyrgyzstan took
during the initial years after gaining its independence provided a favor-
able environment for civil society development. The global agenda toward
civil society engagement, in combination with the inflow of donor fund-
ing, nourished this situation further, encouraging the establishment and
development of nongovernmental organizations. Once called the “land
of NGOs” (see a quote by Edil Baisalov in Pétric, 2015, p. 49), the coun-
try had, in 2007 alone, more than 14,000 officially registered NGOs
(Ancker et al., 2013). This increase also owes to the Global Fund grants
to the country. Several respondents interviewed for this research noted
that some NGOs were deliberately established to “siphon off” Global
Fund grant money (IO Partner 21), implement the grants, and close
right after the grant completion (IO Partner 3). However, the number of
these “pocket” NGOs seems to have decreased with time under the pres-
sure of other civil society organizations (ibid.) and their “collective action”
(Spicer et al., 2011b, p. 1752).
Local NGOs in Kyrgyzstan have relatively good capacity. Organizations
are known to have a “strong workforce” compared to their counterparts
in state institutions or even civil society organizations in Central Asia
100 G. Isabekova
(G. Murzalieva et al., 2009, pp. 64–69). Like community-based organi-

zations, the NGO sector is dominated by female members (Development
Planning Unit, 2010). Despite some attrition, particularly at the level of
outreach workers (Harmer et al., 2013), core staff members remain in
their positions, contributing to the advantage of NGOs also vis-à-vis state
organizations discussed in the following subsection. However, problems
with organizational skills were reported in areas such as legal protection
for the participants of harm reduction programs (Wolfe, 2005), data col-
lection, and some staff members’ limited understanding of the end goals
of their activities (Murzalieva et al., 2009). Reported among the social
and outreach workers, the last problem could also be the outcome of
frequent staff rotation at this level.
The Global Fund contributed to the NGO’s capacity. The grants
advanced the managerial and administrative capacities and “professional-
ization” of the NGOs (Harmer et al., 2013, pp. 302–304) by organizing
multiple training activities for the organizations implementing the grants
(see UNDP, 2014). The grants also facilitated the recruitment of addi-
tional staff members (Spicer et al., 2011a) and the introduction of new
positions, such as “social workers” and “outreach workers” (G. Murzalieva
et al., 2009, p. 58). In addition, the limits on personnel costs in the
grants resulted in low salary levels and significant staff rotation (ibid.).
The NGOs solved these issues by decreasing the number of outreach
workers and increasing the workload of the existing staff members (ibid.).
Capacities vary across NGOs depending on the area in which they are
working. Smaller organizations have limited resources, fewer skills, and
less knowledge than larger NGOs (Spicer et al., 2011b). Moreover, the
organizations established earlier and those working with multiple part-
ners have gathered sufficient experience and networks to rely on. These
NGOs, as a rule, are less dependent on single funding sources than those
working with few partners (Chap. 9). In addition to size, organizational
abilities seem to vary across areas. Several interviewees noted the higher
capacities of organizations working in HIV/AIDS (State Partner 4) than
those in TB (CSO 6). This difference results from varying opportunities
and emphasis in the two areas.
Tuberculosis was seen as a state realm, with detection and treatment
provided mainly by state medical institutions. HIV, in contrast, involved
NGOs in detecting persons affected by this infection and persuading

them to commence and continue their treatment. This difference in atti-
tudes precipitated the incentives and opportunities for civil society orga-
nizations. Underdeveloped in tuberculosis, NGOs flourished in the area
of HIV. In 2007, for instance, 200 organizations focused on this area
(Ancker & Rechel, 2015b). Although insignificant in relation to the total
number of registered NGOs, this number is still impressive in the con-
text of population size and the burden of disease. NGOs working in HIV
also have a network of organizations with considerable advocacy and
community-mobilization skills, which contributes to their participation
in HIV policy and decision-making processes (Foundation for AIDS
Research, 2015). One interviewee emphasized that there were continu-
ous training, roundtable, and meeting opportunities in HIV, with analo-
gous activities for the organizations working in tuberculosis having
commenced rather recently (CSO 6). Following the growing emphasis
on TB and the decreasing share of external aid for HIV, civil society orga-
nizations seem to have reshaped their profiles and worked accordingly
(CSO 8).
Overall, local NGOs, similar to community-based organizations, have
relatively high capacities. Organizations are dominated by female mem-
bers and face a certain level of attrition, although not necessarily among
the core staff members. The Global Fund has contributed to the increase
in the number of NGO staff and the growth of this sector in the country
in general. Indeed, the organizations also developed in response to the
emphasis and consequent funding and opportunities, which found its
reflection in differences among the organizations working in TB and
HIV/AIDS. As the emphasis is changing, the organizations seem to
reshape their focus accordingly, which may also change the capacities and
number of organizations working in tuberculosis.
Furthermore, similar to other developing countries, Kyrgyzstan faces
the problem of human resources in state organizations, which affects
their abilities to perform their functions. There is a general problem with
high staff turnover (Majtieva et al., 2015), political instability (Ancker
et al., 2013), and the low human resources capacity in government orga-
nizations (Spicer et al., 2011b).
102 G. Isabekova
The Ministry of Health is a natural choice for a state partner for health
care projects, but this book focuses on the organizations subordinate to
the Ministry and directly involved in the selected health care projects.
The Ministry of Health is the major state actor in health, which is respon-
sible for defining and implementing the national policy in this area,
ensuring access to and the quality of health care, and coordinating all
actors in this area (see Government of KR, 2009). Although critical to
health care programs and policies at the national level, the Ministry rarely
participates in health care programs directly, instead via agencies repre-
senting it. For this reason, this section focuses on the capacities of rele-
vant agencies and not the Ministry itself.1
The CAH closely collaborated with the Republican Center for Health
Promotion and Mass Communication under the Ministry of Health
(hereinafter the Republican Center) and its subunits at district and
regional levels, also known as Health Promotion Units. The Republican
Center (2022) is responsible for health promotion and disease preven-
tion. Although recently renamed, it was established as early as 2001 to
separate health promotion and protection services traditionally provided
by the Department of State Sanitary-Epidemiological Surveillance under
the Ministry of Health and its branches (Meimanaliev et al., 2005). The
Republican Center has branches in Bishkek and Osh, as well as at regional
and district levels. The Health Promotion Units (HPUs) at district levels
were piloted and supported within the framework of the CAH (ibid.).
HPUs are part of primary health care (Family Medicine Centers) but
report directly to the Republican Center (Tobias Schüth, 2011a). There
is approximately one HPU per 10 villages or 20,000 people (ibid.). HPUs
support the organizational development of the Village Health Committees
by providing training and monitoring their health care activities (Schüth,
2011b). As of 2017, there were approximately 130 HPUs in the country
(Gotsadze & Murzalieva, 2017).
HPUs are critical to the activities and development of community-
based organizations, but low salaries and extensive workloads jeopardize
HPUs’ ability to perform their functions. HPUs have firsthand
1
For more information on the issues with the Ministry of Health of the Kyrgyz Republic capacities,
see Isabekova and Pleines (2021).
experience working with Village Health Committees by supporting orga-

nizations in their awareness-raising activities and conducting training
areas targeted in national health care programs. HPUs also collaborate
with Rayon Health Committees by jointly conducting awareness-raising
activities and evaluating VHCs’ capacities. At the end of the CAH, many
trainers who had previously worked with the SRC moved to jobs in the
HPUs, which contributed to the continuity of knowledge and experience
of the project (Gotsadze & Murzalieva, 2017). However, one interviewee
emphasized that some positions were unfilled since trainers were unwill-
ing to work for a monthly salary of 6000 KGS (about €64).2 In these
cases, the responsibilities were reassigned to existing medical personnel
already tasked with receiving patients and home visits and would there-
fore have little time to engage with community-based organizations
(State Partner 4). Combining the functions of the HPU with another job
certainly affects the HPU’s abilities to work with the VHCs.
Accordingly, the actual work of HPUs with community-based organi-
zations is contingent upon the motivation and willingness of individual
HPU members. It also depends on Family Medicine Centers (FMC)
employing the HPUs. The interviewee noted that the HPUs collaborated
closely with the VHCs in cases in which the heads of the FMCs were
committed to working with community-based organizations (State
Partner 4). Indeed, support from FMCs is also critical to the evaluation
of VHCs because medical organizations provide transportation and per
diem costs for HPUs to conduct evaluation activities.
Furthermore, local self-government bodies are pivotal to community-
based organizations and their activities. Regulated at the national level by
the Cabinet of Ministers, these are elected (representative) and appointed
(executive) at the local level but are accountable to the President and the
Cabinet of Ministers (Government of KR, 2021).3 The sizes of local self-
governance bodies differ. The executive bodies are set by the Cabinet of
Ministers, whereas the representative bodies are proportional to the sizes
of related constituencies (ibid.). The local self-governance bodies have
2
The exchange rate, as of March 17, 2023, was applied throughout this book.
3
On October 12, 2021, the President of the Kyrgyz Republic dissolved the Cabinet of Ministers
(see Gunkel, 2021).
104 G. Isabekova
critical responsibilities in their domain. The organizations are responsible

for drafting, approving, and implementing the local budgets and for
social and economic development of their constituencies, including issues
with access to potable water, sanitation, waste disposal, and other matters
(ibid.). Major sources of funding for these purposes come from public
finances received from higher levels and finances obtained from local
taxes (Tobias Schüth, 2011a).
Nevertheless, the financial and administrative capacities of local self-
government bodies are case dependent. One interviewee reported that
the financial capacity of the local self-governments varies throughout the
country, and yet, most are subsidized by the national government (State
Partner 9). In addition to the budget deficit, administrative capacities are
further hindered by the unstable political situation in the country, caus-
ing rapid turnover among local authority officials. In this regard, several
interviewees aptly noticed that representatives of local self-governments
change as if “one is changing dresses” (CSO 2). As soon as the village
health committee starts collaborating with a state official, (s)he is replaced
by a new one (CSO 7). This high turnover of state officials has a negative
impact on collaboration with community-based organizations (ibid.).
Indeed, the financial and administrative capacities are case-dependent,
and a more general overview of this matter requires a comprehensive
analysis of rotations in local self-government bodies throughout the
country. However, frequent changes of state officials at the national level
support the assumptions made by the interviewees.
CAH also involved representatives of family group practices and
feldsher-midwife (akusher) points, which are the first points of contact
with the health care system in rural areas (Meimanaliev et al., 2005).
These organizations supported the VHCs during the initial stages of the
project, also in terms of the analysis of population health (Tobias Schüth,
2011a). This collaboration has also continued beyond the project dura-
tion, vividly demonstrated by joint activities on infectious and noncom-
municable diseases (AVHC, 2022). Their capacities are reviewed in the
following subsection, as the role of medical professionals is equally sig-
nificant to the Global Fund grants.
In contrast to CAH, the Global Fund grants essentially collaborate
with the agencies responsible for tuberculosis and HIV/AIDS services.
These are the National Center of Phthisiology (NCPh) and the Republican
AIDS Center. Both organizations represent a broader network of vertical
services focusing on and responsible for preventing and treating related
diseases.
Tuberculosis services in the country include NCPh at the national and
tertiary levels, regional and city tuberculosis clinics and centers at second-
ary levels, and tuberculosis cabinets in family medicine centers at primary
care levels (Ministry of Health of KR, 2013). NCPh is responsible for the
diagnosis, treatment, research, and coordination related to tuberculosis
services throughout the country (Government of KR, 2014). The organi-
zation dates back to the Kyrgyz Scientific Institute for Tuberculosis
Research, established in 1957 (NCPh, 2022).
HIV services in Kyrgyzstan include the Republican AIDS Center
(2021a), its regional units, and the center in the capital Bishkek. HIV
testing is provided by 34 labs, including 7 in the regional AIDS centers,
24 in district and city hospitals, and 3 in the medical organizations at the
republic level (ibid.). Treatment is available in AIDS centers and family
medicine centers in all seven regions of the country (ibid.). The AIDS
centers were established in 1989 following the first cases of HIV in the
country (Republican AIDS Center, 2021b). The Republican AIDS
Center is responsible for coordinating HIV-related services, including
detection and treatment, as well as monitoring the HIV situation in the
country (ibid.).
Despite the broader outreach, multiple factors, including political
instability, staff rotation, and excessive workload, limit the state institu-
tions’ capacity. Frequent changes in decision-makers (Majtieva et al.,
2015) and staff rotation have paralyzed state agencies and ministries,
affecting their ability to carry out their functions (Spicer et al., 2011b).
Furthermore, the Global Fund grants increased the number of staff mem-
bers of Sub-Recipient NGOs, but the number of employees in state agen-
cies involved in the grants remained the same (Center for Health System
Development et al., n.d., p. 19). In this way, the tasks related to the
grants were distributed among the existing staff members of the
Republican AIDS Center and the National Center of Phthisiology.
However, the limited capacities of NCPh and the Republican AIDS
Center also prevented them from remaining Primary Recipients of the
106 G. Isabekova
Global Fund grants. Misappropriation and mismanagement of grants

lead to the transfer of the Primary Recipient functions to the United
Nations Development Programme (UNDP) (see Chap. 8).
Limited evaluation of training efforts and the broader structural issues
in the country jeopardize the outcome of capacity-building activities.
Donor organizations are criticized for neglecting the capacity problem in
state institutions (UNAIDS, 2005b). However, multiple organizations,
including the Soros Foundation Kyrgyzstan, the United Kingdom’s
Department for International Development (DFID),4 U.S. Agency for
International Development (USAID), the World Health Organization
(WHO) (Manukyan & Burrows, 2010), and the Global Fund (UNDP,
2015a), provided training to state officials.
Yet, the coverage and intensity of training remain unclear, as there is
no system tracking the number of seminars and their attendees (Murzalieva
et al., 2009). The capacity-building activities are also jeopardized by staff
rotation at the ministries and agencies. As a respondent interviewed for
this book noted, capacity-building presupposed having people in relevant
positions. However, this was difficult because of high staff turnover, the
brain drain from state agencies to donor organizations, and the appoint-
ment of relatives and friends instead of candidates with the necessary
qualifications (IO Partner 4). This way, capacity-building activities seem
to be trapped in a vicious cycle that can be broken only after solving
broader issues related to political instability, staff appointment proce-
dures, and low salaries.
In addition to the managerial level, the capacity of state organizations
closely relates to the availability of health workers. Primary health care
(PHC) workers are critical to health promotion and disease prevention
activities. The reforms in the health care system since the early indepen-
dence toward strengthening PHC and reducing the capacities of second-
ary and tertiary care levels also reemphasized its broader significance.
Commencing in tuberculosis earlier, the tendency toward moving away
from the vertical service provision toward its integration into PHC is also
growing in HIV.
4
In 2020, it was replaced by the Foreign, Commonwealth and Development Office.
Nevertheless, the capacities of both PHC workers and those working

in specialized services are uneven due to staff attrition and geographic
inequity in distribution. There are a sufficient number of medical gradu-
ates in the country, but most prefer specialization over general practice.
There are 700 family medicine centers in the country employing approxi-
mately 2000 family doctors, although at least 3000 are needed for the
growing size of the population (Bengard, 2021). Most PHC workers are
of retirement age, and there are problems attracting new cadres (ibid.).
Low salary levels and limited incentives at the PHC level are among the
few reasons. Furthermore, the distribution of PHC workers in urban and
rural areas remains unequal. These issues affect TB and HIV, particularly
given the risks of nosocomial infections associated with these services.
The availability of medical professionals is also affected by larger issues in
the country and beyond, including extensive internal and external migra-
tion and limited incentives for attracting new and retaining existing
health care workers.
Despite government efforts, the salaries of medical workers remain
low. According to the Republican AIDS Center, the salaries of a nurse
and a doctor were 4000 and 7500 KGS monthly (approximately €43 and
€80), respectively (Government of KR, 2017a). The situation was similar
in tuberculosis. According to an interviewee, the base rate salaries were
approximately 2500 for nurses and 6000 KGS for doctors (approximately
€27 and €64 Euro) (Health Worker 1). The final salaries in tuberculosis
also depended on the number of successfully treated patients who added
to additional payments for nurses and doctors. However, an interviewee
noted that with all bonuses, salaries amounted to 10,000 KGS (€107)
(ibid.). In this way, the suggested salaries of medical workers in tubercu-
losis and HIV were lower than the average salary at the country level for
2017 and 2018 (National Statistical Committee of KR, 2023). The gov-
ernment initiated a number of reforms to offer additional incentives in
PHC and the health care sector in general. In 2018, it introduced a pay-
ment system stipulating additional payments to doctors’ and nurses’ base
rate salaries depending on their work experience and work performance
(Kudrâvceva, 2018). In 2022, the government initiated an increase in the
base salary levels, as a result of which monthly salaries of medical person-
nel increased to 9000–15,000 KGS (€97–161) (Today.kg, 2022). Despite
108 G. Isabekova
these increases, the monthly salaries of medical workers remain below the
national average (see National Statistical Committee of KR, 2023).
Overall, the capacities of state organizations involved in the
“Community Action for Health” and the Global Fund grants are signifi-
cantly affected by the general economic and political situation in the
country. In contrast to civil society organizations, state institutions are
particularly disadvantaged by frequent rotation and unequal distribution
of staff members. Development organizations have attempted to support
capacities by organizing training activities. However, their outcomes
remain unclear. Similarly, salary rates remain below the national level
despite government efforts. All these factors result in capacity issues that
continue to prevent state organizations from exercising their functions to
the full extent.
4.4 Aid Dependency

Aid dependency in this book refers to the abilities of organizations to
perform their functions and achieve their objectives in the absence of
external aid (Chap. 2). This book focuses on the provision of services, be
it health promotion, disease prevention, or treatment, by examining
dependency in relation to technical (e.g., expertise) and financial
assistance.
First, in terms of state organizations, aid dependency varied across the
two cases studied in this book. The objectives and activities of the CAH
echoed the ideas enunciated in the national programs. Community
involvement and strengthening PHC were in the foreground of both
“Manas” (1996–2000) and “Manas Taalimi” (2006–2010) (Government
of KR, 2006; WHO/Europe and UNDP, 1997). Although commencing
as a pilot project in selected districts, the CAH demonstrated the ability
of the rural population to take responsibility for its own health, which
was essential to the abovementioned reform programs.
The governmental commitment to learning was also evident in the
division of health promotion from public health. The Ministry trans-
ferred the relevant responsibilities to the newly established Republic
Center for Health Promotion and, in so doing, moved away from the
system inherited from the Soviet Union, in which the Sanitary

Epidemiological Service was responsible for both (Schüth, 2011a). The
Semashko health care system generally emphasized treatment over preven-
tion, with limited efforts targeted at health promotion. The newly estab-
lished institution had no prior experience working with communities.
Therefore, the Republican Center for Health promotion closely collabo-
rated with the CAH, supporting its capacity for health promotion and
working with communities. Notably, HPUs had limited prior experience
in these areas. Specifically established by the Ministry of Health for the
expansion of the CAH initiative, they were intended to strengthen the
abilities of PHC workers to cooperate with communities (ibid.). HPUs
received extensive training within the framework of the CAH (ibid.).
Equivalently, primary health care workers had neither prior knowledge
nor experience in engaging with community-based organizations. The
paternalistic health care system inherited from the Soviet Union pre-
cluded citizen participation (Ferge, 1998) and treated patients as passive
service recipients (Field, 1988). Working with community organizations
was never a part of the PHC activities before the CAH (Schüth, 2011a).
Preventive activities were conventionally limited to individual consulta-
tions with patients during their visits or home visits of medical workers
to specific groups of the population, such as pregnant women, those with
newborns, and those with chronic diseases (ibid.). Therefore, the PHC
workers equally received extensive training in the project.
It should be noted that the compelling expertise in community
capacity-building the CAH offered was further strengthened with the
project collaboration with primary health care and public health initia-
tives. The Vaccine Alliance (Gavi), United Nations Children’s Fund
(UNICEF), USAID, Global Fund, World Bank, and Aga Khan
Foundation are among the organizations with which the SRC collabo-
rated within the framework of the CAH. Among others, cooperation
with Gavi supported the immunization program in the country
(Akkazieva et al., 2009), and work with UNICEF (2016) and other part-
ners launched the Gulazyk program for the distribution of micronutrient
sprinkles. USAID was critical to the CAH in multiple aspects (also coun-
trywide expansion) within the framework of its programs implemented
between 1994 and 2009 on reforming and strengthening primary health
110 G. Isabekova
care in Central Asia (see Abt Associates Inc., 2015). The Global Fund
supported disease prevention, and the World Bank (n.d.), in turn, pro-
vided access to potable water and sanitation systems in rural areas.
However, the closest in design was the community-based health care ini-
tiative in fifty villages by the Aga Khan Foundation, which adjusted its
activities to match the CAH (Schüth, 2011b, p. 31). This coordination
benefited community capacity-building efforts in health by reducing
project activity duplications and contradictions. Integration with other
projects has also strengthened the position of the CAH.
Overall, limited prior experience and knowledge in health promotion
and community engagement left the Ministry of Health and its institu-
tions dependent on the knowledge and skills the project offered. The
CAH demonstrated the very outcomes of communities taking responsi-
bility for their own health, which the state organizations were interested
in. Thus, although not necessarily dependent on financial terms, the
recipient state depended on the donor’s technical expertise.
In contrast to CAH, the aid dependency in the Global Fund grants is
related mainly to financing. Donor organizations finance a large share of
tuberculosis and HIV/AIDS programs in Kyrgyzstan. At its peak, in
2007, donors provided 94% (297.8 million KGS or €3,193,395) and the
state approximately 6% (20.3 million KGS or €217,683) of total expen-
ditures on HIV/AIDS services (G. Murzalieva et al., 2009, p. 18). The
share of donor contributions decreased with time, but it still represents
more than half of HIV-related funding.5 Multiple donor organizations
participate in TB and HIV/AIDS programs in Kyrgyzstan. The German
Development Bank (die Kreditanstalt für Wiederaufbau—KfW) finances
laboratory construction, and GIZ provides technical assistance in the
area of reproductive health. The International Committee of the Red
Cross and Doctors Without Borders cover TB services in prison. The
President’s Emergency Plan for AIDS Relief (PEPFAR) and USAID
5
The data on the share of external financing is inconsistent: the UNDP (2015a, p. 56) suggests that
international financing to HIV/AIDS was 62% in 2012, 66% in 2013, and approximately 56% in
2014. A state representative, however, in her presentation during the SWAp, notes that external
financing to health care was 71% in 2012, 76% in 2013, and 57% in 2014 (Majtieva et al.,
2015, p. 20).
finance TB and HIV programs in the civilian sector, along with an HIV
grant from the Russian Federation.
Despite the multiplicity of donors, the Global Fund remained the
leading financier of TB and HIV/AIDS programs in the country. In
2004–2006, it covered 69% of all HIV/AIDS-related services, with other
donors and the government providing the remainder of the financing
(Gulgun Murzalieva et al., 2007, p. 31). Representing over half of the
external assistance, the Global Fund finances HIV treatment and nearly
all HIV prevention programs among the key groups (e.g., men who have
sex with men, commercial sex workers, persons who inject drugs, and
others) (Majtieva et al., 2015). Similarly, in the area of TB, the Global
Fund covered medications against drug-resistant forms of TB, laboratory
supplies, co-payments to health care workers, and other expenses (State
Partner 9). In this way, the Global Fund remained the principal financier
of TB and HIV services in the country.
In contrast, multiple organizations provide technical assistance in TB
and HIV/AIDS. The interviewees specifically emphasized the Joint
United Nations Programme on HIV/AIDS (UNAIDS), World Health
Organization (WHO), KfW, World Bank, and USAID’s contributions to
the development of regulatory documents, management of health care,
and building the capacity of state organizations (State Partner 10 and
Academic Partner 2; IO Partner 3). Similarly, Global Fund grants stipu-
late training and capacity-building activities for medical personnel
involved in TB and HIV/AIDS services. Therefore, the state officials
interviewed for this research suggested that technical assistance was
among the “most significant” benefits development organizations offered
(State Partner 3) and that without it, the country would end up establish-
ing ineffective and cumbersome systems (State Partner 6). Studies on
health aid to Kyrgyzstan similarly highlight donors’ contributions to
strengthening laboratory services, establishing sentinel surveillance sys-
tems (Wolfe et al., 2008), and revising HIV/AIDS-related legislation
(Ancker & Rechel, 2015b).
Despite the significance of all development partners, one could specifi-
cally highlight the role of the two United Nations agencies, namely, the
WHO and UNAIDS, as primus inter pares in health. Their recommenda-
tions are equally followed by the state, civil society, and donor
112 G. Isabekova
organizations. The Global Fund itself complies with the WHO standards
(e.g., Global Fund, 2009) and the UNAIDS (2005a) suggestions. In this
regard, Kaasch (2015) notes that although insignificant in terms of
financing, the WHO has established itself as a standard setter and a lead-
ing actor in the area of health. Similar conclusions could also be made
regarding UNAIDS, which specifically maintained its expertise in the
area of HIV.
Overall, the Ministry of Health and state agencies on TB and HIV/
AIDS collaborate with multiple donors, but they still heavily rely on the
financing provided by the Global Fund. However, in technical assistance,
the Global Fund, like other donors, conforms to the standards and regu-
lations of other partners that established themselves as standard and norm
setters for TB and HIV/AIDS.
As noted in the previous section on capacity, civil society organizations
refer to CBOs in CAH and NGOs in the Global Fund grants. The CAH
initiated community engagement in health care and facilitated the mobi-
lization of community members to join the VHCs. However, newly
established, these organizations had neither the experience nor the
resources to pursue their objectives. The literature on grassroots organiza-
tions suggests that illiteracy (Jana et al., 2004), gender-related biases
(WHO, 2008), political situation, and poverty (Morgan, 2001) all make
communities dependent on external aid. According to UNESCO (2023)
estimates, over 99% of the population in Kyrgyzstan is literate.6 Moreover,
members of the Village and Rayon Health Committees faced and over-
came multiple issues, including gender-biased treatment from their com-
munities and local authorities, frequent rotation of local self-governments,
and resource mobilization hardships (Chaps. 5 and 6).
Nevertheless, similar to the recipient state, communities did not have
prior knowledge or skills to participate in the health care system. Through
technical and financial assistance, the project intended to build the
capacities of community-based organizations throughout the project, but
this extensive support has unintentionally contributed to the dependence
of community-based organizations on the donor. The CAH was the only
project providing comprehensive coverage of the Village and Rayon
6
As of March 2023, the relevant data is available until 2019.
Health Committees throughout the country. Other donors just engaged

with VHCs from specific regions and in certain areas that were compliant
with their project objectives. Although continued donor assistance was
not the only factor relevant to community capacity-building, the end of
the CAH in 2017 exposed community-based organizations to a certain
level of uncertainty about their future (Chap. 6).
At the same time, although providing significant technical and finan-
cial support at an organizational level, the CAH offered only minor
financial incentives to the community volunteers. The project may have
covered travel and per diem costs related to health promotion activities.
However, the members of community-based organizations did not
receive salaries from the SRC. One interviewee pointed out that the CAH
would have been able to pay salaries, and initially, volunteers did request
payment for their work (CSO 4). However, no salaries were paid to sup-
port the continuity of organizations and activities beyond the project,
which was also explained to community members and accepted by them
(ibid.).
Not everyone stayed, but those who remained were not driven by
financial gains but by the willingness to bring positive changes to their
communities. Several interviewees noted that those who joined
community-based organizations for financial reasons soon resigned (CSO
5). As a result, very few VHC members sought financial gains or declined
to conduct certain activities because they were volunteers (CSO 1).
Instead, as unpaid volunteers, the community volunteers implemented
the project-related activities because of their willingness to bring changes
to their communities. Seeing the outcomes of activities generated enthu-
siasm among the volunteers and a belief that they could “bring some-
thing good” to their villages through their work (CSO 5). In this way, the
incentives offered by the SRC supported but did not define the VHCs’
willingness to carry out their activities.
As unpaid volunteers, the VHC members could discontinue their
activities without any financial consequences to themselves. This finan-
cial independence at an individual level evened out the organizations’
dependence on the project because the SRC also depended on the VHC
members’ willingness to work. As volunteers, the community members
were able to decide whether to continue their work or not. As one of the
114 G. Isabekova
interviewees noted, no one could point to them, saying, “you should

work,” and only those with “initiatives in their hearts” continued (CSO
4). In this way, the SRC (implementing) and the SDC (financing the
CAH) depended on the community members’ willingness to work. The
lack of financial incentives limited the leverage of development partners
over community volunteers.
Civil society organizations’ aid-dependency dynamics differed in the
Global Fund grants. NGOs working in TB and HIV/AIDS areas depend
on external aid. This dependency is evident in the interruption of services
during disruptions in external funding. The delays in Global Fund financ-
ing affected NGOs’ service delivery (Harmer et al., 2013). To address the
short-term breaks, the organizations involved volunteers; however, the
long-term interruptions in 2007–2008 caused the termination of activities
and staff turnover due to the disruption of salary payments (Spicer et al.,
2011a). Some activities, such as diagnostic and treatment services to com-
mercial sex workers, resumed only after the Global Fund restarted its
financing (Murzalieva et al., 2009). Several donor organizations commit-
ted their resources to cover the financial gap and address the issue of
NGOs’ service interruptions. The Soros Foundation Kyrgyzstan and the
UNDP provided “emergency coverage” during funding disruptions in
2004 (Wolfe, 2005, pp. 23–24). The UNDP has also used its own resources
for staff recruitment, procurement of condoms, methadone, and the
“emergency stock” of antiretroviral medications during the delays in the
HIV grant of the Global Fund (2011–2016) (Grant Performance. Report
External Print Version. Kyrgyzstan KGZ-910-G07-T, 2016, p. 31). In
doing so, the UNDP ensured a continuous supply of medications (ibid.)
and provision of other services stipulated in the grants. However, in con-
trast to the UNDP, local NGOs do not have sufficient financing to cover
these costs, even temporarily, during financial interruptions.
However, financial dependency varies across organizations. Those with
multiple sources of financing were less affected by the delays (Murzalieva
et al., 2009) compared with those solely dependent on Global Fund
grants. Accordingly, the perspective of the NGOs interviewed for this
research on the continuity of their activities beyond the Global Fund
grants varied. While some were optimistic about their continuance (CSO
6), others acknowledged the inability to implement the initiatives on
their own (CSO 8) and that the breadth of their activities depended on
donors (CSO 9).
In terms of technical assistance, NGOs received multiple but inconsis-
tent training opportunities from donors. The Soros Foundation, UN
agencies (Godinho et al., 2005), USAID, Global Fund, and other actors
offered technical assistance to NGOs. The Global Fund financed the
seminars on social support, strategic planning and fundraising, account-
ing and document management (see UNDP, 2015b, 2015c), and other
areas. However, assessing dependency in terms of technical assistance is
challenging, as neither donors, recipient states, nor civil society organiza-
tions have a broad understanding of all training activities conducted in
the areas of TB and HIV/AIDS. Accordingly, the impact, selection crite-
ria, and compliance of training with the needs of targeted groups are
unclear (G. Murzalieva et al., 2009). An NGO representative interviewed
for this research suggests that the selection criteria for participants are
guided by their rotation and not the NGOs’ specialization. However, the
rotation does not contribute to the institutional memory of organiza-
tions, which would be enhanced by the more consistent and continuous
support of fewer organizations for a longer period (CSO 8).
Overall, both community-based organizations and NGOs depend on
external assistance. However, in the case of the former, this dependency
was evened out because the community volunteers were unpaid by the
project and could halt the activities at any time without any financial
losses. In this situation, the donor depended on the willingness of com-
munity members to continue their activities. In the case of the latter, the
dependency remained. On its own, financial benefits are natural to eco-
nomic interaction. However, in the context of development assistance,
they may unintentionally strengthen the conventional “gift-giving” and
“gift-receiving” dynamics between stakeholders (see Hinton &
Groves, 2004).
116 G. Isabekova
4.5 Summary
This chapter explored the structural factors relevant to both interactions
between stakeholders and the sustainability of health projects. Focusing
on the actors relevant to the selected cases, it examined the predictability
and flexibility of aid on the sides of donors, as well as capacities and aid
dependencies on the sides of recipients.
1. The chapter has vividly demonstrated that despite the acknowledg-

ments of and commitments to ensuring predictable aid, Switzerland
and the Global Fund varied considerably in their achievements.
Although performing better than the average bilateral partner or a
vertical health care program, the two actors nevertheless provided
varying predictability due to their development cooperation structure.
Indeed, Switzerland has performed better by offering a longer dura-
tion of assistance than does the Global Fund.
2. The comparative overview of the two actors has equally demonstrated
their commitment to providing flexibility. Both put a great emphasis
on the recipient’s ownership. Accordingly, the Global Fund finances
the proposals developed by applicants and is in accordance with their
national strategies. Switzerland, in turn, places great value in defining
the objectives in collaboration with partner countries. Correspondingly,
the decentralization and autonomy of field offices provide the space
for adjusting the activities to local needs and priorities. Driven by
similar objectives, the Global Fund focused on concentrated decision-
making with the rest of the activities performed in recipient countries.
However, this concentration hinders the flexibility of assistance by
affecting the responsiveness to changes occurring in the applicant
countries. Another hindering factor is accountability before finan-
ciers, which equally affected the Global Fund and Swiss aid, having to
balance accountability toward the funders and recipients of aid.
3. The capacities of state organizations involved in both health initiatives
are extensively constrained by the political and economic instability in
the country, causing frequent staff rotation, limited institutionaliza-
tion, and a limited range of incentives available to state employees.
Notably, these factors seem to have an equally annihilatory impact at

both the decision-making and service-provision levels. Interestingly,
their effect on civil society organizations was less and uneven. The
economic situation in the country facilitated migration, which, com-
bined with conventional gender roles in households and society, con-
tributed to the recruitment and retention of women in
community-based organizations. Nevertheless, not all women join
organizations that seem to depend on single leaders. Similarly, domi-
nated by women, the NGO sector has also demonstrated a relatively
strong capacity, particularly in comparison to state institutions.
However, the capacities greatly vary across the organizations and sec-
tors, with the organizations in HIV performing better than those in TB.
4. The broader political and economic instability in the country has con-
tributed equally to the dependency of national actors on external aid.
At the same time, the dependency on technical assistance observed in
the CAH contrasts with the dependency on financial support offered
in the Global Fund grants. Certainly, the organization provides sub-
stantial technical support to all stakeholders involved in its grants.
However, the significance of this support in relation to financing
seems smaller, particularly in the context of other technical partners.
Having limited funding to offer, these have established themselves as
arbiters of standards and norms equally followed by other develop-
ment partners and state and civil society organizations. In the case of
civil society, nonpayment of community volunteers evened out the
dependencies of CBOs on donors, which did not occur in NGOs,
whose activities remain financially dependent on donors.
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right holder.
5
The “Community Action for Health”:
The Project Life Cycle
This chapter discusses the interaction among the principal actors over the
life cycle of the “Community Action for Health” (CAH) project by
grouping them into the following analytical categories.
First, the recipient state refers to the Ministry of Health, represented by
the Republican Centre for Health Promotion and Mass Communication
under the Ministry of Health (hereinafter the Republican Center) and its
subunits, and primary health care workers who participated in the proj-
ect and collaborated with community-based organizations. It also encom-
passed local self-governments at the village, city, and district levels, which
are directly accountable to the President of the Kyrgyz Republic and the
Cabinet of Ministers. Community-based organizations at the district
level work with authorities at this level, but for those at the village level,
the local self-governance bodies at the village level are of particular impor-
tance. These are local councils (ayyl kengesh) elected by local communi-
ties, with the size of these councils being proportional to the size of the
related constituency (Government of KR, 2021). A structure of an execu-
tive body (ayyl ökmötü) is defined by the Cabinet of Ministers at the
national level, but the head of the executive body at the district level
appoints the head of ayyl ökmötü (ibid.).

130 G. Isabekova
Second, civil society organizations are community-based organizations

(CBOs) established within the framework of the CAH project. These
include the Village Health Committees (VHCs) in a village, Rayon
Health Committees in a district, and the Association of VHCs at the
national level.
Third, donors denote the Swiss Agency for Development and Cooperation
(SDC), which financed the CAH, and the Swiss Red Cross (SRC), which
implemented it. I conceptualize each as a “donor” because the SRC was the
key actor working with CBOs, and in so doing performed the role of the
“donor” on the ground. However, a number of other development organi-
zations supported CAH. The Swedish International Development
Cooperation Agency (Sida) and the United States Agency for International
Development (USAID) joined the project at a later stage and were essential
to the expansion of the initiative throughout the country. The list of other
international organizations contributing to the project includes the
Liechtenstein Development Service (Schüth et al., 2014a), the German
Internationale Zusammenarbeit—GIZ), the United Nations Children’s
Fund (UNICEF), the World Bank, the Soros Foundation, the Global Fund
to Fight AIDS, Tuberculosis and Malaria (the Global Fund), the Interchurch
Organization for Development Cooperation, the Asian Development
Bank, and the World Health Organization (WHO), among others (www.
cah.kg n.d.). Nevertheless, Sida and USAID remained the major donors
(in addition to the SDC), since the contributions of other organizations
were limited to specific project activities complying with the areas targeted
by those organizations.
5.1 Initiation
The initiation of the “Community Action for Health” project coincided
and corresponded with the country’s transition from the Soviet-style
Semashko health care system. The government aimed to optimize health
care spending and emphasize citizens’ responsibility for their health, as
opposed to the idea of health care being a state responsibility, which was
in the foreground of the previous system. First, as part of optimization
5 The “Community Action for Health”: The Project Life Cycle 131
reforms, the national health care reform program “Manas” (1996–2005)

intended to address the majority of health care issues at the primary
health care (PHC) level and decrease the number of referrals to secondary
(or hospital) care (Government of KR 1995). Accordingly, the govern-
ment aimed to increase public funding to PHC and cut the number of
hospital beds per capita to decrease the maintenance and utility costs
spent on health care facilities and secondary care. A state representative
interviewed for this research estimated that in one district of the Naryn
region, for instance, just two or three facilities were retained out of twenty,
with the rest being demolished (State Partner 1). Second, the “Manas”
program emphasized people’s responsibility for their own health
(Government of KR 1995). The government propagated the idea of citi-
zens taking preventive measures to improve their health instead of
depending on the health care system (State Partner 1). In so doing, it
attempted to delegate at least part of its responsibility for health to the
population.
The CAH project was in line with the health care reform agenda at
that time, but it is not clear who initiated the project. According to
Gotsadze and Murzalieva (2017, p. vi), the Ministry of Health approached
SDC in the early 2000s to design a program for health promotion in
rural areas. In other words, the Ministry was the one who initiated the
project. However, the CAH also may have been the outcome of a donor
initiative. Indeed, the national program “Manas” highlighted the respon-
sibilities of the population for their own health (Government of KR
1995), but it did not stipulate any means for citizens to express their
wishes and concerns about the reform process. The CAH, on the con-
trary, stressed the role of the local population in defining the issues to be
targeted by the program. This emphasis on the involvement of groups
targeted by health care programs in the decision-making process (SRC
n.d.) and the empowerment of communities (SDC 2003) corresponded
to the objectives of the organizations financing and implementing the
project.
The CAH occurred in the second phase of the Kyrgyz–Swiss Health
Reform Support Project. Following the request from the Ministry of
Health, the first fifteen months of this initiative, from January 2000 to
March 2001, were dedicated to the renovation of two remote hospitals in
132 G. Isabekova
the Naryn region (Schüth 2011b). However, as the agreement between

the SDC and the Ministry stipulated supporting health care reform in
the Naryn region as a whole, the SRC planned to increase the scope of
activities in the second phase of the project, which commenced in the
summer of 2000 (ibid.). The organization invited the SRC for this pur-
pose. This choice was not surprising since Swiss development agencies
tend to provide a large part of the development assistance through Swiss
nongovernmental organizations (OECD 2014). The increase in the scope
of activities materialized through the involvement of communities in the
planning, implementation, and evaluation phases of the project, corre-
sponding to the principles of the SDC and SRC (Schüth 2011b). To
identify the priorities of the population in health care reforms, the SRC
invited a project coordinator, Dr. Tobias Schüth, to conduct a qualitative
study among the communities.
The initiative on community involvement in health care reforms com-
menced with an appraisal of people’s views on health care services and
their priorities for reforms. The appraisal was conducted in the At-Bashi
and Ak-Talaa districts of the Naryn region. The study covered district
centers and three villages of various distances from the center (Schüth
2000), and used the Participatory Reflection and Action approach, for-
merly known as Participatory Rural Appraisal (PRA). PRA encompasses
approaches and methods that “enable local (rural and urban) people to
express, enhance, share and analyze their knowledge of life and condi-
tions, to plan and to act” (Chambers 1994, p. 1253). By using this
approach, the SRC intended to understand communities’ perceptions
through their analysis of problems and solutions. The SRC trained a
study team of eight members, which also included representatives of dif-
ferent state departments (Schüth 2000). To cover various community
groups, the organization engaged volunteers to conduct separate inter-
views with vulnerable groups, such as the poorest households, pregnant
women, mothers with young children, and people with disabilities (ibid.,
pp. 16–19).
The communities were asked about the most pressing diseases, their
priorities in health care, and their awareness of the “Manas” health care
reform program. The most frequent diseases identified by people were
brucellosis, anemia (mainly in women), high blood pressure, dental
diseases, goiter, and liver disease (Schüth 2000). People’s priorities in

health reforms related to access and quality of health care. This included
the availability of specialized health care services and ambulances in
remote areas, higher salaries for medical staff, combatting bribery at dis-
trict hospitals, and so forth (ibid., p. 8). The appraisal demonstrated
uneven access to health care, dependent on the social status of a house-
hold. Traditional healers were the first point of contact for the villagers,
though better-off households also used health facilities at the district level
(ibid., p.7). In general, the villagers spent less on health care than the resi-
dents of districts did. Overall, the respondents “had heard” about the
“Manas” health care reform program and were willing to learn more
about family group practices and eligibility for the health insurance
scheme (ibid., pp. 8–9, 47–48). People were even ready to pay a small
amount of money for the health brochures (ibid.). In general, the initial
study demonstrated the interest of communities in the health care reform
program and their readiness to participate in health promotion.
Notably, the recipient state participated in the initial appraisal of the
population’s concerns and priorities (e.g., the PRA sessions), which was
essential to state interaction with community members. The study team
of eight members, trained by the SRC, included representatives of differ-
ent state departments (Schüth 2000). The state actors worked with com-
munities in defining their concerns. The participation of the recipient
state in the appraisal was key to its interaction with communities. The
SRC also encouraged community members to present the results of the
initial study to the Ministry of Health in Bishkek, which was “well
received” by the Ministry (Schüth 2011b, p. 24).
It should be noted that the Swiss actors (SDC and SRC) were the only
donors involved in initiating the CAH, possibly due to the general divi-
sion of labor among the donors in the country, a result of the sector-wide
approach (SWAp) to health care in the country (see Chap. 1). Formalized
in 2005, the SWAp has been in use in Kyrgyzstan since 1996 (see
Isabekova and Pleines 2021). For this reason, the fact that the Swiss actors
were the only donors working in the area of community engagement in
health care reforms also may be the outcome of negotiations taking place
in the SWAp.
134 G. Isabekova
Overall, the initiation phase suggests that the CAH may have equally
been a donor initiative and an initiative of the recipient state. The initia-
tion of this project coincided with the transition from the Semashko
health care system. This transition was consistent with the interests of the
recipient state, which, in the face of social and economic crises in the
country, was willing to delegate part of its responsibilities to citizens.
However, the project emphasized community engagement in the
decision-making process, which was consonant with the principles of the
SDC and SRC. Although the source of the initiative is ambiguous, the
CAH nevertheless addressed pressing issues of the local population,
which also was reflected in their interest and readiness to collaborate with
the project.
5.2 Design
The design of the project was developed in collaboration with commu-
nity members. The CAH commenced in the Jumgal district of the Naryn
region. Selection of this region complied with the renovation of hospitals
(IO Partner 11), which took place in the same area. Another reason for
the selection of this region was poverty. My interviewees note that the
project commenced at a time of extreme impoverishment (CSO 7), and
the Naryn region was among the poorest in the country (IO Partner 5).
The CAH pursued two overarching goals, namely, supporting the com-
munities in taking action for their health and building the partnership
between the state health care system and communities (Schüth n.d.).
These goals were further divided into smaller objectives and project activ-
ities, jointly identified by the SRC and communities in the PRA sessions.
The PRA sessions followed the principle of “nondominance.” In a nut-
shell, this principle meant respectful behavior, which aimed to provide a
space for the actors to express themselves and be heard by another party.
This respectful behavior intended to overcome conventionally unequal
roles between the providers and recipients of aid by emphasizing the fun-
damental equality of all stakeholders involved in development assistance
(Schüth 2011b). The sessions stressed the expertise of local people and
noninterference in the discussions. The emphasis was on local people as
the ones “who know” and the project team being the ones “who learn
from the people” (ibid., pp. 23–24). The SRC and the primary health
care staff aimed to encourage the discussions without “guiding” them.
Noninterference in the discussions meant “accepting people’s views with-
out judging them as right or wrong” (ibid.).
Dr. Tobias Schüth, a project coordinator invited by the SRC, stressed
the role of nondominance in relationships among the actors throughout
the project cycle. Both the SRC and state representatives engaged in the
project complied with this principle. The project recruited staff members
who “were good with people, behaved in a good way, and were quick to
pick up things” (IO Partner 11). The SRC also trained and involved the
local primary health care staff in the PRA. A former state official inter-
viewed for this study emphasized the collaboration of the Ministry of
Health and the SRC in forming health committees in the Jumgal district
(State Partner 1). The involvement of state institutions was critical for the
further nationwide rollout of the program because the recipient state, and
not the SRC, conducted the PRA sessions beyond the pilot districts. No
other donor organization participated in the initial design of the CAH, as
USAID and Sida joined the project at later stages.
The PRA sessions were intended to define those diseases that were of
pressing concern to communities and to the community perspective on
how to stay healthy (IO Partner 11). The sessions took place in every vil-
lage and involved approximately 50–80% of households (Schüth 2011a,
p. 147). A PHC representative gathered approximately ten people from a
neighborhood and supported them during their analysis using the PRA
approach (ibid.). Since most of the PRA participants were women (as
they were the ones at home), separate sessions were organized for men to
consider their opinions (ibid.). The outcomes of the survey varied across
the regions but generally included goiter, alcohol consumption, anemia,
hypertension, brucellosis, and so forth (see Isabekova 2021). In addition
to listing problems, the PRA participants also brainstormed and listed
their ideas on “what do you need to stay healthy in this village?” (Schüth
2011b, p. 32). They compiled a list of determinants of health, which
included broader issues, such as the lack of public baths or access to pota-
ble water. The facilitator (e.g., the SRC or primary health care staff) com-
pared this list to the elements of primary health care outlined in the
136 G. Isabekova
Alma-Ata Declaration (1978) (see WHO/Europe n.d.), which encour-

aged the participants since their list often contained most of or even went
beyond the elements outlined in the declaration (Schüth 2011b).
In addition to defining the problems and potential solutions, the PRA
sessions were used to mobilize community members. The participants
were asked to nominate trustworthy, “active and community-minded”
people from their neighborhoods (Schüth et al., 2014a, pp. 5–6) to
become members of the VHCs, which intended to take action on the
problems and determinants of health. My interviewee noted that the
project, in a way, identified “people respected and influential in villages”
(CSO 2). Nomination and election to the VHCs by village residents con-
tributed to the recognition of candidates by the local population, which
was essential to the subsequent implementation of the project.
Importantly, the selection of the VHC members took place via secret vot-
ing of PRA participants to ensure the election of persons willing to work
and not merely influential in their communities (Tobias Schüth 2011a,
p. 151). During a public vote, people were often willing “to be seen” to
vote for persons influential in their communities (ibid.).
The CAH was built around close collaboration with local communi-
ties. During the initial stages, project staff members lived in the local
communities (Schüth 2011a). This has allowed continuous interaction
with community volunteers. The interviewees noted that the project
members incorporated the perspectives of local communities into ideas
by asking for feedback from community members and adjusting these
ideas accordingly (IO Partner 11). Thus, the decision could have been
made in the morning and changed in the evening if the initial idea did
not work out (IO Partner 5). This interaction allowed further adjust-
ments of activities to the lives of community volunteers. As one inter-
viewee noted, while present on site, the project workers did not limit
themselves to the “usual” working hours but to the time the community
members could spare between their daily responsibilities. The interviewee
highlighted that this flexibility and immersion into the context discerned
the differences with other projects following the “usual” working hours
and visiting community members on an occasional basis (IO Partner 5).
Overall, this section demonstrated a close collaboration among com-
munity representatives, the SRC, and PHC workers commissioned by
the Ministry of Health to support the initiative. The following country-

wide rollout of this project involved the health promotion units (HPUs)
established by the Ministry of Health. The expansion also has involved
the USAID representatives that funded the Jalal-Abad and Issy- Kul
regions. The countrywide extension of the project is elaborated on in the
following section.
5.3 Project Implementation

Multiple stakeholders participated in implementing the “Community
Action for Health” in Kyrgyzstan. Nevertheless, close collaboration
among the donor, state PHC, and community-based organizations was a
distinctive characteristic of this project. The health-related activities in
the project included three components: essential research, awareness-
raising, and data collection for monitoring and further research
(Schüth 2011a).
First, the essential research conducted and analyzed by the VHCs was
intended to provide deeper insights into community problems and fur-
ther encourage the CBO members to work with them (Schüth 2011a,
p. 151). A participant interviewed for this research notes that following
the PRA seminar, its participants surveyed the local population by visit-
ing “every second house” (CSO 2). In addition, they attempted to orga-
nize general meetings by gathering people “from every street.” However,
the participant admits that convincing people to attend these meetings
was “difficult.” The interviewee notes that surveying the local population
and disseminating the information about the CAH in a way demon-
strated the abilities of those nominated to become VHC members to
reach out to the local population (ibid.).
Second, the awareness-raising was conducted within the project,
mainly by providing information materials, although at times individual
consultations and explanations aimed at behavioral and lifestyle changes
(Schüth 2011a). The VHCs targeted a broad spectrum of health care
issues (see Isabekova 2021). These included decreasing alcohol consump-
tion, controlling brucellosis, anemia, tuberculosis (TB), smoking, hyper-
tension, sexual–reproductive health (Schueth 2009), promoting “safe
138 G. Isabekova
nutrition” (iodized salt, fortified flour, meat consumption), and increas-

ing awareness of childhood diseases such as diarrhea, influenza, acute
respiratory infection, and others (PIL Research Company 2017). Most of
these issues were identified by the village population in the surveys con-
ducted by the VHCs during the project design. In addition to survey
results, the VHCs also targeted priority areas highlighted in the national
health care program.
Following the focus of this research on TB and HIV/AIDS, I will
describe the VHCs’ activities in regard to these diseases. TB was not one
of the priority areas defined by the population (Schüth et al., 2014a,
p. 19), but it was among the issues targeted by the VHCs, also due to the
problem of drug-resistant tuberculosis in the country. Kyrgyzstan, similar
to other countries in the post-Soviet region, has a high prevalence of the
multidrug-resistant form of tuberculosis, particularly among previously
treated patients (Isabekova, 2019b). The absence of tuberculosis among
the issues prioritized by the communities may relate to its prevalence in
urban, rather than rural, areas (ibid.). The “Manas” (1996–2006), “Manas
taalimi” (2006–2012), and “Den Sooluk” (2012–2018) health care reform
programs listed TB among their priority areas (Government of KR 2006,
2012; WHO/Europe and UNDP 1997). Therefore, the inclusion of TB
in the areas targeted by the VHCs made their work compliant with
national health care policy. The VHCs received leaflets on the importance
of treatment continuity and its completion, as well as nondiscrimination
against patients with TB (Schüth et al., 2014a, p. 20). First piloted in
Chui and Issyk-Kul regions, these dissemination campaigns were
expanded to the country as a whole in 2013 (ibid.).
In contrast, HIV/AIDS was, in a way, among the issues prioritized by
the villagers and the national health care programs. Reproductive tract
infections were among the priorities listed by people in all oblasts (Schüth
et al., 2014a, p. 19). HIV/AIDS also was among the priority areas listed
in the national health care reform programs “Manas” (1996–2006),
“Manas taalimi” (2006–2012), and “Den Sooluk” (2012–2018)
(Government of KR 2006, 2012; WHO/Europe and UNDP 1997).
Correspondingly, the VHCs implemented campaigns to raise awareness
of sexually transmitted infections, including HIV/AIDs, in collaboration
with the SRC, other donors, and local actors. Working with school
parliaments (a body composed of pupils elected by pupils to represent

their interests before the school administration) and teachers, the VHCs
circulated an educational course called “The road to safety” for students
of the 9th–11th grades. This course used DVDs on sexual and reproduc-
tive health, developed in the framework of CAH’s collaboration with
GIZ (Schüth et al., 2014a, p. 19). To target the working-age population,
the VHCs visited local businesses (CSO 2) and conducted seminars with
potential labor migrants—the youth—due to a large amount of labor
migration to Russia and Kazakhstan. For instance, in the city of Osh, in
the south of the country, the VHCs informed migrant workers about TB,
HIV/AIDS, and treatment possibilities as part of CAH’s collaboration
with a global nongovernmental organization—the Interchurch
Organization for Development Cooperation (Schüth et al., 2014a, p. 25).
Thus, in contrast to the VHCs’ activities for TB, the awareness-raising
campaigns for HIV/AIDS complied with the priorities of both the local
population and the national health care program.
Third, data collection and monitoring took place at a district level,
based on the essential research conducted by the VHCs during their work
with target groups or selected research (Schüth 2011a). The data com-
piled at the district level were further sent to the Republican Center and
supporting health care projects at regional and national levels (ibid.). The
information exchange also was intended to inform both state and donor
organizations about the VHCs’ findings and to compare the coherence of
priorities with those identified at the community level.
It should be noted that the SRC supported the VHCs in their activities
by providing technical and financial assistance for dissemination cam-
paigns, organizational capacity, and resource mobilization. The SRC
offered training courses in a number of areas, but I focused only on those
indicated in the project-related documents and mentioned by my
interviewees.
First, the VHCs learned how to work with the population and orga-
nize seminars. During the dissemination campaigns, the VHC members
gathered the villagers to inform them about preventive measures and
health promotion. In this regard, the VHCs followed the principle of
nondominance promoted by the SRC. A VHC representative interviewed
for this research noted that training pertained to building relationships
140 G. Isabekova
with others and identifying issues. According to her, becoming a VHC

member implied “understanding the work” and finding “a common lan-
guage with people.” Therefore, “giving orders to others” by pointing at
the information they “should learn” about the diseases relevant to them
was “not right” (CSO 5). The VHCs used the principle of nondominance
during the seminars to build a dialogue between medical workers and the
population groups affected by the various diseases. They also followed
this principle in relation to each other, irrespective of their position in the
VHC, be it a head or a member of the organization.
Through their close work with communities, the VHCs, unlike the
state health care workers, were familiar with the health issues of specific
households. By offering blood pressure checks, for example, the CBOs
were aware of members of the community who had hypertension (CSOs
2 and 5). The VHCs prepared coffee breaks and gathered local health care
workers and people affected by the different diseases (CSO 5) to increase
awareness of danger signs, symptoms, and preventive measures against
specific diseases, such as hypertension, anemia, diabetes, and others.
It should be noted that medical personnel were not always supportive
of the VHCs’ work. There were occasions when health care workers did
not perceive community-based organizations as equals or even competed
with them. However, this attitude changed due to the support the VHCs
provided to primary health care professionals in outreaching the local
population and the joint implementation of health promotion cam-
paigns. This change also is demonstrated by medical and community-
based organizations congratulating each other on their professional days,
namely, September 9 for the VHCs and July 2 for medical professionals
(AVHC 2022).
Similarly, the attitude of local self-government bodies has transformed
from an initial disinterest to cooperation. My interviewees recalled the
initial detachment of local authorities toward the VHCs and their activi-
ties (CSO 5) and questions of why VHC members “needed this” (CSO
1). According to one, there also were remarks hinting at a superior posi-
tion of authorities over community-based organizations, such as “some
five women are running around, are those the VHCs?” (CSO 4). However,
this attitude changed during the joint implementation of activities. The
CAH forethoughtfully offered small grants to which VHCs could apply
jointly with local authorities. This collaboration strengthened further

within the framework of the project implemented by the Development
Policy Institute, which sought to enhance the partnership between the
state and VHCs through their joint realization of initiatives (AVHC
2017a). The cooperation also has continued beyond donor assistance.
The VHCs I interviewed in one of the northern regions participated in
the meetings and the joint committees of the local authorities on social
issues, for example, working with poor households (CSO 5). According
to the local authority representative in this region, this collaboration had
been going on for 4–5 years, and the authority had provided a Certificate
of Merit to the VHC member in appreciation of her work (State
Partner 12).
In addition to the joint implementation, the attitude of local self-
governments toward community-based organizations changed as the
authorities realized the potential of community-based organizations
(CSO 1). The VHCs work closely with the local population and are
aware of their concerns and their living circumstances (CSO 4). This
contributes to the expertise of community-based organizations, which is
valuable to the local authorities. One VHC representative from another
region I visited noted that not a single activity organized by the local
authorities took place without the VHC. The interviewee noted that in
recent years, authorities often asked for support in mobilizing the local
population on the grounds that people’s attitude toward the VHCs was
“positive,” in contrast to their attitude toward the authorities (CSO 2).
Engaging with the VHCs is essential for the work of local authorities
since the VHCs have not only the capacity for dissemination activities
but also a certain status in their communities.
Secondly, during the first two or three years after their formation, the
community-based organizations received training on bookkeeping and
budgeting, and were given office equipment, which intended to improve
their organizational capacity (Schueth 2009). The CBOs learned essen-
tial budgeting skills to calculate the current financial balance of their
organization, and plan their activities accordingly. The SRC also explained
how to write appeals to local self-government and enclose the relevant
attachments (CSO 5). The VHCs obtained their office spaces from local
authorities or medical organizations (CSOs 2 and 5); however,
142 G. Isabekova
maintenance of these offices and the relevant equipment were provided

by the SRC. During my fieldwork, the VHCs presented me their books,
receipts for activity-related expenses, as well as the equipment and furni-
ture provided by the SRC, including table, chairs, PCs, printers, and so
on (CSO 5).
Thirdly, the CBOs received training on how to write grant applica-
tions, and financing to mobilize their resources. My interviewee stressed
that the SRC provided not only guidance on how to write proposals, but
also the opportunity to work on relevant issues. Another community
member interviewed for this research noted that members were unaware
of how to write project applications, but trainers elaborated on the writ-
ing process. She added: “they explained to us [the application process]…
taught us like children. Other projects do not do that” (CSO 7).
In addition, the SRC offered small grants and materials for the VHCs
to top up their organizational budget. The VHCs applied for these grants
to address the problems highlighted by communities in the initial survey.
These grants were used to build public baths, feldsher-midwife (akusher)
points (primary health care facility in rural areas), repair water pipes
(Health Worker 3; State Partner 1), and support vulnerable households.
Poor families received chickens, roosters, chicken feed (CSO 7), and
chicken coops built by the VHCs (Schüth et al., 2014a, p. 25). The
VHCs used their small grants to build public baths and establish social
enterprises, such as sewing workshops and hairdressers, which contrib-
uted to the organizational funds of these community-based organiza-
tions.1 Overall, mobilization of resources was emphasized throughout the
CAH. The SRC provided project-related materials, such as gloves to pre-
vent brucellosis, quality seeds to plant beetroot, carrots, tomatoes, and so
forth to combat anemia, that were sold by the VHCs to the local popula-
tion (CSO 4). At the end of the CAH, the SRC announced another
round of small grants, namely 25,000 Kyrgyzstani som (KGS) (around
€268)2 to be provided to the VHCs based on their project applications
(CSO 2). These grants were intended to ensure an additional financial
1
For more details, see the section on income-generation in the chapter on sustainability of
the CAH.
2
basis for the VHCs to continue their activities beyond the end of the
project (CSO 4). In general, the SRC’s technical and financial support
was essential for the VHCs’ organizational capacity. Yet this assistance
complemented, rather than dominated, the project implementation,
because it targeted the issues identified by communities themselves.
It should be noted that the donor did not conduct the training activi-
ties alone. The Ministry of Health supported the VHCs after it became
acquainted with the VHC members and their work. During the pilot
phase of the CAH in fifteen villages in the Jumgal district of the Naryn
region, the VHCs organized a campaign against goiter, where they pro-
moted the usage of iodized salt, and checked iodine in the salt sold by
local retailers (see Isabekova 2021). This campaign caught the Ministry’s
attention and contributed to its acknowledgment of the initiative (Schüth
2011b). The VHC member I interviewed notes that the Ministry’s sup-
port was dependent on the “success” of the project. If the initiative
“worked out,” the Ministry wanted to retain the VHCs to disseminate
the information among the population; if it didn’t, the community-based
organizations (CBOs) would be discontinued (CSO 2). According to
project-related documents, this acquaintance was decisive, since “no
amount of explanation can be as convincing as an hour spent with a
VHC” (Schueth 2009, p. 47; Schüth 2011b, p. 49). Equally significant
was the support of individual persons, including the Minister of Health
at that time, Tilek Meimanaliev, who supported community engage-
ment, despite the relatively modest attention to this matter in the national
health care program (Schüth 2011a).
The recipient state actively participated in training activities, particu-
larly after the countrywide expansion of the CAH. The Ministry of
Health included the CAH in the national health care program and
requested its countrywide extension. The SRC, in turn, asked the Ministry
to provide health care staff for this purpose and offered calculations on
the number of staff needed. The Ministry agreed and promised to estab-
lish HPUs in regions in which donors funded the expansion of the
“Jumgal model” (IO Partner 11). Notably, the HPUs are part of the
health care system and are accountable to the Republic Center for Health
Promotion under the Ministry of Health. The HPUs received extensive
training on how to work with communities from the SRC before taking
144 G. Isabekova
over the training of PHC workers on the PRA approach. They equally
took over training the VHCs on how to work as an independent civil
society organization and conduct health-related activities (Schüth 2011a).
The HPUs were selected and worked in compliance with the principle
of nondominance. People with a “bossy attitude” were “avoided” during
the selection process (Schüth 2011b, p. 48). The SRC trained the HPUs
on the PRA tools (Schueth 2009, p. 22) and in the principle of nondomi-
nance. The HPU representative interviewed for this research emphasized
that medical professionals should not “give orders to common people,”
and instead of acting as “teachers,” they should be “equal” to people refer-
ring to them (CSO 5). The interviewee noted that the HPUs had already
learned about the nondominance principle at the beginning of the proj-
ect (ibid.). This timely training contributed to the HPUs’ roles as “facili-
tators” of the PRA sessions and training activities that support but do not
overlook the community initiative.
Following the endorsement by the Minister for Health, USAID and
Sida joined the project implementation to support its national rollout.
The Ministry of Health’s inclusion of the “Jumgal model” in the national
health care program (Schüth 2011b, p. 26) and a promise to provide the
HPUs for the countrywide extension of the program encouraged other
donors to support the initiative (IO Partner 11). Two organizations were
critical to this expansion. First, the USAID covered Jalal-Abad and Issyk-
Kul regions as part of its ongoing “Zdravplus” (2000–2005) and
“ZdravPlus II” (2005–2009) projects (Dominis et al. 2018), which aimed
to improve the quality of health care services in Kyrgyzstan, Kazakhstan,
Uzbekistan, Tajikistan, and Turkmenistan (Abt Associates 2023). Health
promotion by community members corresponded to community and
population health—one of the four major components of these projects
(Cleland et al. 2008). Second, Sida financed the SRC to include the
Batken, Osh, and Chui regions (Schüth 2011b). Between 2006 and
2011, Sida was among the core financiers of the Sector-Wide Approach
to health care (Sida 2008). Because of the joint financing from Sida and
the SDC, the project changed its name in 2006 from the Kyrgyz Swiss
Health Project to the Kyrgyz, Swiss, Swedish Health Project (Development
Planning Unit 2010). With the Swiss organizations (i.e., SRC and SDC)
taking over the expansion in the Naryn and Talas regions (IO Partner
11), the organizations ensured the countrywide extension of the program.
Despite the differences in engagement, both USAID and Sida fol-
lowed the leadership of the SRC. USAID implemented the extension
itself as part of its ongoing project, while Sida cofinanced the
SRC. However, compliance with the Swiss model (IO Partner 5), or the
SRC approach in the Jumgal district, was “part of the deal” (IO Partner
11). This was ensured throughout the extension process. The SRC train-
ers accompanied USAID and trained its staff on project implementation
and monitoring (ibid.). In the case of Sida, no issues arose in terms of the
differences in approaches, since it simply transferred finances without any
direct involvement in the project implementation. As my interviewee
noted, one “did not even notice that there was different money” (ibid.).
The SRC reported on how the funds were used, and Sida visited the proj-
ect sites. However, although it was cofinancing, Sida basically accepted
the Swiss actors’ approach to project implementation and monitoring
(ibid.). In this way, despite their differences in engagement in the CAH,
both donors, USAID and Sida, followed the Swiss actors’ approach to
project implementation.
Overall, the project implementation phase shows that participation
and support of the Ministry of Health intensified further as the project
recommended itself as the “Jumgal model.” It also allowed the country-
wide expansion of the project, encouraging other donors to commit
themselves. Notably, both Sida and USAID followed the SRC’s approach
in the CAH.
5.4 Project Evaluation

The CAH, similar to other development projects, went through a num-
ber of evaluations by external parties (e.g., Gotsadze and Murzalieva
2017; Kickbusch 2003). Both USAID and Sida also conducted an exter-
nal evaluation of their contribution to the expansion of the Jumgal model
(e.g., by hiring consultants). USAID conducted an external evaluation of
its activities within the framework of the “ZdravPlus” program. Similarly,
Sida assessed the use of financing by the SRC.
146 G. Isabekova
However, in addition to external assessments, the project developed

annual evaluations of its activities by the project participants themselves.
For this purpose, the project coordinator adapted Labonte and Laverack’s
(2001a, 2001b) framework for community capacity-building. This
framework stresses participation, leadership, organizational structure,
problem assessment, resource mobilization, “asking why,” links with oth-
ers, the role of outside agents, and program management (all categories
listed verbatim) (Labonte and Laverack 2001a, p. 117). The original
framework was adapted into 25 indicators (IO Partner 11) and further
elaborated into clarifying questions, including those related to organiza-
tional abilities and essential accounting, conflict resolution, and sources
of regular income (Schüth 2011a, p. 163). These indicators and questions
aimed to ensure the evaluation of the CBO activities by the CBOs them-
selves and the organizations working with them.
The project evaluation emphasizes the roles of the state and commu-
nity representatives in the assessment. The annual evaluation commences
with the VHC members’ reflection on the abovementioned indicators.
The CBO members additionally fill out their “happiness” and “work-
load” indices. Following this “internal” self-assessment, the HPUs and
Rayon Health Committees conduct the “external” evaluation of CBOs
(IO Partner 11). Both assessments matter to the validity of evaluation
outcomes. The “internal” evaluation demonstrates the VHC members’
perception of and satisfaction with their work. The “external” assessment,
in turn, shows the perspectives of organizations having firsthand experi-
ence with the VHCs. HPUs provide the training necessary for organiza-
tional development and connect CBOs to the national health care system.
They are the ones having continuous contact with the CBOs and are
aware of their organizational issues. Additional involvement of the Rayon
Health Committees, composed of the VHC leaders, contributes to the
validity of the CBO assessment by both state and civil society representa-
tives. As one interviewee noted, one could claim many achievements on
paper. However, during the actual visits to organizations, the VHC lead-
ers witness the outcomes of the organizational work (CSO 2).
Both “internal” and “external” assessments are based on the same set of
indicators. These include organizational membership, VHCs’ abilities for
collective decision-making and conducting activities, documentation
quality, and attracting new members (AVHC 2018). The indicators also
stipulate conducting formal events and essential accounting according to
the VHCs’ regulations (adopted by the Association of VHCs), engage-
ment, and connections to authorities and other associations and organi-
zations at a local level (ibid.). Another indicator signified and regularly
monitored by the Association of VHCs is self-initiatives that, in addition
to VHC funds, also can be conducted at the expense of local authorities
and third-party funding sources (AVHC 2017a). Self-initiatives may
include fundraising for health funds, support to the poor, community
care, improving the environment in villages, organizational development,
activities related to health, and participating in improving the village
infrastructure (AVHC 2018). Overall, this similarity of assessment crite-
ria ensures the consistency of internal and external evaluations (IO
Partner 11).
One should specifically emphasize the roles of the Association of
VHCs and Rayon Health Committees (RHCs) in the evaluation process,
particularly after the end of the CAH. The evaluation of RHCs closely
relates to their support for Village Health Committees. The organizations
are expected to conduct at least four regional meetings funded by the
organizations themselves, four self-initiatives on improving health deter-
minants at a district level, monitoring health funds, and monitoring
activities targeted at VHC development (AVHC 2018). The RHCs also
are integral to the supervisory functions of the Association of VHCs. By
the end of the quarterly meetings at a regional level, RHCs report to the
AVHC a list of participants, meeting protocol, working plan, and a com-
plete table with self-initiatives (ibid., pp. 15–16). This reporting is critical
for the AVHCs’ overview of the organizations and their activities. Delayed
reporting because of nonparticipation of VHCs at regional meetings or
the inability of RHCs to report the activities on time distorted the assess-
ment of the actual situation (AVHC 2018). Therefore, as a corrective
measure, the Association of VHCs asked the Rayon Health Committees
to fill the tables on VHCs’ activities right after the meeting and send the
data to the AVHC immediately after the meeting via email or WhatsApp
(ibid.).
Indeed, there have been multiple issues with evaluation, particularly
since the end of the CAH. There were cases of HPUs not conducting the
148 G. Isabekova
evaluation due to a lack of funding for transportation and per diem costs,
although at large, the Family Medicine Centers provided the necessary
funding (AVHC 2017b). The Association of VHCs discusses these issues
directly with the Republican Center (ibid.), and it also intends to improve
the mechanisms for collecting and streamlining HPU reports (AVHC
2017a). The attrition of medical professionals additionally challenges the
evaluation process. However, foresightedly, the Association, in collabora-
tion with donors, developed a training film for RHCs and HPUs on the
assessment of VHCs (ibid.). This was intended to ensure the awareness of
evaluation criteria and approaches irrespective of rotation in personnel.
However, in the long run, the evaluation criteria are likely to evolve fur-
ther. There also was a discussion on changing the self-assessment indica-
tors as the organizations and their activities evolved further (AVHC
2018). These are only a few of the issues the Association of VHCs and
organizations and members in the network face.
Nevertheless, the “Community Action for Health” project was remark-
able in the sense that, in addition to the evaluation of project activities by
external parties, it stipulated an opportunity for both state and commu-
nity representatives to participate in the evaluation process. Although the
SRC adapted the assessment criteria based on the academic analytical
framework, these were the very HPUs, VHCs, and Rayon Health
Committees that assessed the work and organizational capacity of the
community-based organizations. This has changed the roles of the VHCs
and HPUs from mere “subjects” of evaluation to actors assessing their
own performance. It also laid down the basis for the Association of VHCs
and its network members to continue evaluating their activities beyond
the duration of the CAH.
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right holder.
6
Sustainability of the “Community
Action for Health” Project
This chapter introduces the “Community Action for Health” project in

Kyrgyzstan and discusses the sustainability of this project. It commences
with an overview of the project and its objectives. The following sections
focus on the analysis of project sustainability as the long-term continuity
of project activities, maintenance of benefits, and community capacity-
building once the project has officially ended (Shediac-Rizkallah & Bone,
1998). The chapter also examines how factors relevant to the sustainabil-
ity of health care interventions, principally funding, and account for the
influence of general conditions, including political, economic, sociocul-
tural, and organizational factors, unfold in this project.
6.1 Project Description

The “Community Action for Health” lasted for almost 17 years and had
an overall budget of 24,500,000 Swiss francs (around €24,736,2361)
(Gotsadze & Murzalieva, 2017, vi). The project was implemented in
1

154 G. Isabekova
2002
2001
Establishment of Establishment of
Pilot program in
Village Health Rayon Health
Jumgal Rayon of
Committees in the Committees
Naryn Oblast
pilot district
2005
Acknowledgment by the 2006
Country-wide
Minister of Health and Sida and USAID
extension of the
inclusion into the joining CAH as core
program
national health reform donors
program
2010
Establishment of the 2017
Association of
Village Health End of the project
Committees
Diagram 6.1 Chronology of the project (Source: Adapted from Schueth (2009,
p. 11) and complemented with information from project-related documents)
seven phases (ibid.). It started off with a pilot project, which covered 16
villages in the Jumgal rayon of Naryn oblast (Schueth, 2009, p. 10). After
its acknowledgment by the Minister of Health, who also referred to com-
munity engagement with the health care system as the “Jumgal model”
(IO Partner 11), the project was included in the national health care
reform program, “Manas Taalimi” (2006–2010) (Government of KR,
2006). The project was then expanded throughout the country, which
was also made possible with assistance from the United States Agency for
International Development (USAID) and the Swedish International
Development Cooperation Agency (Sida) (see Diagram 6.1).
The “Community Action for Health” Project (CAH) was set up to
empower2 Kyrgyz communities through their engagement in health care.
Previously known as the Kyrgyz-Swiss Health Reform Support Project
(Schüth, 2000, p. 7), and the Kyrgyz-Swiss-Swedish Health Project
(Jamangulova et al., n.d.), the project commenced by renovating five
2
Here empower meaning “enabling communities to increase control over their lives” (WHO, 2023).
6 Sustainability of the “Community Action for Health” Project 155
hospitals in Kyrgyzstan, before beginning its work in the community

(SDC, 2008, pp. 1–2). As part of its collaboration with local communi-
ties, it had two goals: to “enable rural communities to act on their own
for the improvement of their health” and to support the state health care
system “to work in partnership with communities for improving health”
(Schüth, n.d., n.p.). First, “acting on their own” means the emancipation
of communities, which, following Kessler and Renggli’s definition
(2011), implies the participation of local communities in the health care
system by defining the services those communities need and taking
responsibility for their own health care. Second, the project was also
intended to facilitate the collaboration of communities with Kyrgyz state
institutions in this regard.
The emphasis of the project on communities and their engagement
with health care provision echoes the ideas laid out in the Ottawa Charter
for Health Promotion (1986) and the Alma-Ata Declaration (1978). The
Charter stressed health as being the responsibility of individuals and
communities, rather than just being the responsibility of the health sector
alone (WHO/Europe, 1986). The Declaration went further by calling for
the eradication of health inequalities, both between countries, and within
countries, through the participation of individuals and communities in
health care (WHO/Europe, n.d.-a). These international documents—the
Ottawa Charter and the Alma-Ata Declaration—were referred to specifi-
cally in several of the documents setting out the CAH project (see
Kickbusch, 2003; Schüth et al., 2005). Thus, in addition to increasing
communities’ control over their health (WHO, 2023), “empowerment”
in the project also implied overcoming health inequalities within the
country, a goal which was also reflected in the project’s focus on rural areas.
The “Community Action for Health” project has been positively evalu-
ated by academics and practitioners for its achievements in disease pre-
vention and health promotion. According to the Swiss Tropical and
Public Health Institute, preventive activities pursued by the project saved
about US $3 million in patient travel and treatment costs, and around
US $1.5 million in loss of income by patients who would otherwise have
been unable to work (Schüth et al., 2014, p. 11). These preventive activi-
ties, together with health promotion, are believed to have contributed to
improved public (Gotsadze & Murzalieva, 2017) and hypertension
156 G. Isabekova
(WHO/Europe, n.d.-b), as well as a decrease in the incidence of brucel-

losis (Schüth et al., 2014) and goiter (Schueth, 2009), decreased infant
and maternal mortality, and decreased mortality from cardiovascular dis-
eases (Gotsadze & Murzalieva, 2017). The project has been positively
evaluated by representatives of the Government of Kyrgyzstan, local
Kyrgyz communities, and external experts (see Ibraimova et al., 2011;
Kickbusch, 2003; Maier & Martin-Moreno, 2011). Moreover, the CAH
is referred to as a “good example” of collaboration between rural com-
munities and their state health care system (Kessler & Renggli, 2011,
p. 24), with “good practices” and “documented knowledge” of this proj-
ect being beneficial to countries willing to adopt a similar model (Gotsadze
& Murzalieva, 2017, p. 5).
6.2 Continuity of Project Activities

The “Community Action for Health” targeted wider community con-
cerns including, but not limited to, tuberculosis (TB) and human immu-
nodeficiency virus infection and acquired immune deficiency syndrome
(HIV/AIDS). However, to ensure comparability with another case
selected for this book, sustainability refers to the continuity of project
activities and benefits related to TB and HIV/AIDS and community
capacity-building. This section discusses the continuity of project activi-
ties by elaborating on the types of activities (“what”) and the extent of
their continuity (“to what extent”) (Scheirer & Dearing, 2011, p. 2062).
As previously noted, the Village Health Committees (VHCs) largely pro-
vided awareness-raising and health promotion in their villages but no
medical services. The discussion also incorporates the factors critical to
the continuity of activities, such as the sociocultural, economic, and
political context in the country.
First of all, regarding the types of activities (“what”), my fieldwork in
Kyrgyzstan in 2018 substantiated the continuity of TB-related services.
The interviewees reported that there had been a continuity of awareness-
raising activities for TB (State Partner 12; CSO 5), including dissemina-
tion campaigns in streets or schools (CSO 7). Each VHC decided on the
timing of the activities by themselves. While some of the VHCs had a
specific day for their campaign (CSO 5), others defined a longer time
period and suggested that campaigns to fight TB should not be limited to
one day, but should rather last up to a month. Overall, the campaigns
had broad involvement, including representatives of local self-government,
health care workers, school pupils, local residents, and others.
TB activities pursued multiple objectives. Community-based organi-
zations intended to raise awareness among the population about the
transmission of the disease and tackle discrimination and stigmatization
against people with TB. A VHC representative noted widespread dis-
crimination against persons with TB, driven by a misconception that this
disease was not treatable. The VHCs informed the population that it was
an airborne disease and not transmitted through the shared use of towels
and dishes, as many believed (CSO 2). The organizations also aimed to
prevent TB by raising population awareness of the symptoms of the dis-
ease and the need to refer cases to a health care facility. By stressing that
no one is safe from TB and that it can be treated, the VHCs also intended
to overcome the discrimination TB patients have to suffer from their
family members and neighbors (ibid.).
Still, the awareness of TB and its treatment, as well as discrimination
against persons affected by it, continued to be relevant in 2022. The
Association of VHCs (AVHC) emphasizes the importance of treatment
and that the treatment is provided for free (AVHC, 2022). The VHCs
continue their awareness-raising activities. For instance, in Arkalyk vil-
lage of the Jalal-Abad region, a VHC member used the break cotton
pickers take after harvesting to bring information related to TB, social
and behavior change, and other matters out into the open (ibid.). A VHC
in Suusamyr village in the Chui region conducted a campaign among
pupils of grades 5–11 by providing books, notebooks, and pens as rewards
for active participation (ibid.). Similarly, discrimination and stigmatiza-
tion of TB patients remained relevant, also reflected by a seminar that
included representatives of local self-governments and police workers of
two villages in the Chatkal district of the Jalal-Abad region (ibid.). On
March 24, VHCs annually celebrate the World TB Day.
Similarly, the fieldwork demonstrated continuity of activities targeting
HIV/AIDS (CSO 5). The VHCs organized seminars in schools, round-
tables, and community walks to raise awareness (ibid.). As with the
158 G. Isabekova
activities targeting TB, some VHCs chose a specific day for these activi-
ties (CSO 7), while others stipulated a longer duration, with the cam-
paigns being conducted over the period of a week or even a month (VHC
activities related to HIV/AIDS in 2019. Reports from Batken, Chui,
Issyk-Kul, Naryn, Osh, n.d.). Similar to TB, these activities had a broad
coverage, including representatives from local self-government and from
the health care facilities in the village and at district levels (CSO 5; State
Partner 12), as well as the local population, school pupils, and so on.
The main goal of these activities was to increase awareness among the
population about HIV prevention and discrimination against persons
living with HIV (PLHIV). However, the attitude of Kyrgyz society
toward sexually transmitted diseases remains conservative and moralistic.
In this regard, one of the project-related documents reports a case of a
man coming forward during the PRA seminar to ask for information
about syphilis. However, as elderly residents of the same village
approached, the man fell silent (Schüth, 2000, p. 25).
The population’s awareness of HIV transmission avenues, preventive
measures, and nondiscrimination of persons living with HIV remained
relevant. VHCs annually commemorate World AIDS Day (December
01). In 2019, the organizations organized a number of activities in col-
laboration with Rayon Health Committees, Health Promotion Units,
primary health care workers, local self-governments, mass media, and
other representatives. The awareness-raising activities included contests at
schools, seminars by medical professionals (also for school teachers,
pupils, and their parents), roundtables, processions of pupils, school per-
formances, flashmobs, Q&A sessions, and essay-writing contests (VHC
activities related to HIV/AIDS in 2019. Reports from Batken, Chui,
Issyk-Kul, Naryn, Osh, n.d.). With support from other actors, the VHCs
also organized walking campaigns and hung posters on HIV/AIDS in
public spaces, public transportation, and bus stops (ibid.). In addition to
increasing the awareness of the epidemiological situation via various
media outlets, the activities touched upon themes such as “HIV is not
transmitted through friendship” or “say no to drugs” (ibid., n.p.).
Similar to the smaller Village Health Committees, Rayon Health
Committees have continued their awareness-raising activities in TB and
HIV/AIDS. They have also continued supporting the VHCs in their
organizational development and activities (AVHC, 2017b). This conti-

nuity of activities both at the district and at the village level suggests that
the TB and HIV/AIDS campaigns did not cease immediately after the
end of the project in 2017. Still, the simple fact of the continuity of
activities does not tell us much about their extent. This topic will be dis-
cussed in the following subsection.
Furthermore, regarding the extent of their continuity (“to what
extent”), the number of general activities implemented by the VHCs
fluctuated throughout the project. One development partner noted that
the VHCs had around sixteen different areas of activity at one particular
moment in time, which caused the “burn-out” of VHC members (IO
Partner 5). In this regard, the decision was taken to highlight certain key
areas, leaving other areas up to the VHCs’ discretion (ibid.). This was
intended to ease the workload of volunteers. The community-based orga-
nizations also used this momentum to reshuffle their objectives. One
VHC member who was interviewed stated that since 2013 the organiza-
tion had started to discontinue campaigns that had achieved their goals.
These included activities targeting alcohol abuse, iodine deficiency, and
brucellosis. As of 2018, the interviewee stressed that the organization was
currently focusing on five or six activities (including TB and HIV/AIDS),
but had the relevant material to revive the discontinued campaigns, if
necessary (CSO 5). This availability of multiple brochures on various
health care issues was also evident during my visit to the offices of
other VHCs.
Still, a certain level of letup in activities seems to have accompanied the
end of the project. For example, in response to my question about the
changes since the end of the CAH, several interviewees pointed to a gen-
eral “slowing down” in the VHC’s work. One emphasized that the work-
load decreased without funding, and with the decrease in the frequency
of meetings, some VHC members wondered if they were “unemployed”
now (CSO 4). Indeed, some volunteers seem to have perceived their
work in the CAH as employment. Therefore, the end of the project
brought a sense of uncertainty about the future of their activities.
One important indicator was the number of meetings between VHC
members. One interviewee noted that these meetings, also taking place
through tea gatherings, were crucial to bonding between members and
160 G. Isabekova
their discussions of ongoing issues and future plans (CSO 4). It should be
noted that the number of meetings among Rayon Health Committees
(RHCs) also fell from 393 in 2014 to 275 in 2018 (AVHC, 2018).
Devoted to a specific topic suggested by the Association of VHCs or
Health Promotion Units (HPUs), these meetings are also used to discuss
the outcomes, opportunities, and issues in the VHCs’ work (AVHC,
2017b). They were also used to discuss the yearly report, the work plan,
and activities targeted at the VHCs’ organizational development
(AVHC, 2022).
Still, the community-based organizations continued their activities. As
of 2021–2022, the VHCs were implementing campaigns on multiple
issues, including noncommunicable diseases, healthy nutrition, non-
smoking, physical activity, clean water, handwashing, and awareness of
breast cancer symptoms (AVHC, 2022). Similarly, despite the decrease in
the number of meetings, the RHCs increased the share of meetings
funded entirely on their own (without third-party funding). Thus, if in
2014, 74 out of 393 meetings were self-funded, in 2018, 209 out of 275
meetings were financed entirely by the RHCs (AVHC, 2018). As one
interviewee acknowledged, the range of activities may not have been as
extensive as before, and there was an overall “slowing down,” but the
community-based organizations continued their work (CSO 7).
The collaboration with donor organizations supported the continuity
of some, but not all areas. The CAH coordinated its campaigns with
other donor organizations throughout the entire duration of the project.
Some examples thereof are awareness-raising activities conducted in col-
laboration with the German Corporation for International Cooperation
(die Deutsche Gesellschaft für Internationale Zusammenarbeit—GIZ) and
the Interchurch Organisation for Development Cooperation or comple-
mentarity ensured through the USAID funding the RHC meetings
(Gotsadze & Murzalieva, 2017). After 2017, the Association of VHCs
continued working with the World Bank, USAID, GIZ, SDC, and the
United Nations (UN) agencies. Though beneficial to the capacities of the
Village and Rayon Health Committees, the projects implemented by
these organizations did not necessarily target infectious diseases. For
example, the GIZ project pursued the incorporation of community pri-
orities in its socioeconomic development plans (Development Policy
Institute, 2016). The World Bank initiative aimed to strengthen the

capacities of Village Health Committees to collaborate with local self-
governments (Independent Auditor’s Report, 2018). The joint project of
four UN agencies (the UN Women, the Food and Agricultural
Organization, the World Food Programme, and the International Fund
for Agricultural Development) focused on providing economic opportu-
nities for women in rural areas (AVHC, 2022). The SDC initiative, in its
turn, focused on the management and prevention of noncommunicable
diseases (SDC, the Federal Department of Foreign Affairs, n.d.-a).
In the Kyrgyz Republic, USAID is among the few organizations,
except for the Global Fund to Fight AIDS, Tuberculosis and Malaria
(discussed in this book), focusing on TB and HIV/AIDS. The AVHC has
collaborated with several of its initiatives, including “Defeat Tuberculosis”
(2014–2019) and “Cure Tuberculosis” (2019–2024). The former
involved RHCs and VHCs in selected regions, with main activities tar-
geted at raising the population’s awareness of ambulatory treatment, non-
discrimination, and protecting the interests of TB patients (AVHC,
2018). The latter closely involves the AVHC and the Rayon and Village
Health Committees in five regions, and the Kara-Suu district of the Osh
region. Activities range from raising the population’s awareness of TB
treatment opportunities and the nondiscrimination of persons affected
by this disease (AVHC, 2022), to fundraising and advocacy, to financially
assisting TB patients from vulnerable groups (JSI Research & Training
Institute, 2020).
Yet the activities also continued beyond the donor-funded areas. These
include, for instance, the VHCs’ annual countrywide awareness-raising
campaigns dedicated to International TB Day (March 24) (AVHC,
2022). The scale of activities varies. Yet, delineating the campaigns sup-
ported by a development partner or conducted at the expense of the
VHC is tricky, especially since the “Cure TB” project expanded its cam-
paigns throughout the country in 2021. The activities are inextricably
related, complementing each other. There are, for instance, cases in which
the development partner provided the leaflets, but the VHCs organized
and conducted the walking campaigns or seminars at their own expense.
Notably, the VHCs conduct TB activities also at their own organizational
expense (AVHC, 2017b) but mostly in collaboration with other actors,
162 G. Isabekova
such as representatives of local self-governments, HPUs, RHCs, medical

workers, school administrations, and others.
In contrast to TB, USAID’s involvement in HIV/AIDS activities is
somewhat limited. The organization instead collaborates with local
NGOs having access to and working with targeted groups, such as
PLHIV and intravenous drug users (see USAID, 2019). Due to stigma,
discrimination, and anonymity concerns, these groups are closed to the
state health care system and presumably to community-based organiza-
tions working on broader issues. This may explain the financier’s inclina-
tion toward NGOs specializing in and closely working with persons
affected by HIV/AIDS. In this way, the community-based organizations
continued the awareness-raising activities mainly at their own expense.
The lack of donor support is also reflected in the limited availability of
information materials in different languages during the awareness-raising
campaigns in 2019 (VHC activities related to HIV/AIDS in 2019.
Reports from Batken, Chui, Issyk-Kul, Naryn, Osh, n.d.).
In these circumstances, state support proved critical to the continuity
of HIV/AIDS-related activities. Decrees of the Ministry of Health and
local state administrations on HIV/AIDS prevention were the basis for
medical professionals and representatives of local self-governments to
organize and support the campaigns (VHC activities related to HIV/
AIDS in 2019. Reports from Batken, Chui, Issyk-Kul, Naryn, Osh, n.d.).
As of 2019, the scale of activities varied across the country, ranging from
small seminars to large-scale campaigns involving up to 900 participants
(ibid.). The extensive involvement of actors allowed a broad range of
activities, including printing articles in local newspapers and broadcast-
ing videos (ibid.). Thus, similar to TB, VHCs organized HIV/AIDS-
related activities in collaboration with a wide range of actors, including
Rayon Health Committees, the Republic Center, HPUs, regional AIDS
centers, mass media representatives, medical professionals, pupils, reli-
gious leaders, and others (ibid.).
Overall, the community-based organizations continued their activities
despite the end of the project. The presence of a donor organization in a
relevant field, such as USAID in TB, did surely strengthen the campaigns
by providing additional resources. However, the awareness-raising in the
areas not covered by donors, such as HIV/AIDS, has continued mainly at
the expense of community-based organizations. Notably, state support

proved to be critical to these campaigns. However, state support is also
changeable, which impacts the maintenance of benefits (discussed in the
following subsection).
6.3 Maintaining Benefits

The VHCs’ activities in relation to TB and HIV/AIDS largely relate to
dissemination campaigns. Therefore, the benefits maintained refer to the
information received by the communities in regard to these two diseases.
This assumes, however, not just the existence of the information activities
but also the quality of the information.
One of the ways to look at the quality of the information provided by
the VHCs is to look at the external evaluation of project activities both
during the project and at the end of it.
The external assessment of the VHC activities on TB is inconclusive.
Becoming a “tradition” among the VHCs (PIL Research Company,
2017), the information activities for TB improved the population’s aware-
ness of the disease. Randomized cluster surveys show greater awareness of
TB indicators in the areas with VHCs than in the areas without (Schüth
et al., 2014), which has also been confirmed by the external evaluation of
the project (Gotsadze & Murzalieva, 2017). At the same time, another
assessment found that increased awareness of the disease and its symp-
toms did not necessarily influence people’s knowledge of TB treatment,
and discriminatory attitudes toward people with TB remained (PIL
Research Company, 2017). Though contributing to improved popula-
tion awareness about the disease, the activities seem to have had limited
effect in regard to treatment of the disease and discrimination against
patients with TB.
The VHCs’ activities also contributed to public awareness of HIV/
AIDS. The VHCs surveyed school pupils from the 9th grade from the
districts of Naryn, Talas, Chui, Batken, and Osh regions (five schools per
district were covered), before and after the training course on HIV/
AIDS. The surveys demonstrated increased awareness of HIV prevention
among the pupils as a result of the training course conducted by the
164 G. Isabekova
VHCs (Schüth et al., 2014, p. 19). Similarly, the external evaluations of

the project pointed to increased population awareness of HIV transmis-
sion, preventive measures (Gotsadze & Murzalieva, 2017), and increased
awareness of sexually transmitted diseases (PIL Research Company,
2017). However, the impact of activities on stigma and discrimination
against PLHIV is unclear.
Overall, the evaluations conducted both within the project and by
external actors point to the contribution of the VHCs’ information activ-
ities to increasing population awareness of the two diseases. Yet these
assessments alone are not sufficient to evaluate the quality of informa-
tion. I propose looking at the training received by the VHCs as another
way to estimate the maintenance of benefits. VHC members are volun-
teers, and the majority of them have no medical education. For this rea-
son, the quality of information they provide closely relates to their
training.
The primary source of training for the VHCs was the Swiss Red Cross
(SRC), which gradually transferred this function to the Health Promotion
Units (HPUs). This transfer took place during the rollout of the program
from the initial pilot districts to the country as a whole. The HPUs are
essential to the VHCs’ training. A development partner closely working
with the community-based organizations supported this assumption,
suggesting that the quality of, or problems with, HPUs inevitably reflected
upon VHCs (IO Partner 11). Indeed, the HPUs continuously train the
VHCs by visiting them in the villages. Therefore, they have firsthand
knowledge of the issues faced by community-based organizations, as well
as the opportunities to address them.
However, the frequency of HPU visits and the scope of training areas
have decreased over time. During the period of operation of the CAH,
the SRC covered the relevant travel costs for HPU staff to travel to the
villages. After the project ended, the Ministry of Health took over the
financing but decreased the frequency of visits. Previously monthly visits
changed to quarterly (CSO 4). The Ministry of Health also limited the
scope of training to four areas prioritized by the national health care pro-
gram “Den Sooluk” (2012–2018), namely hypertension, HIV/AIDS,
tuberculosis, and mother and child care (IO Partner 5). Explicit prioriti-
zation of TB and HIV/AIDS was beneficial to the continuity of training
by state-funded HPUs. Albeit with decreased frequency, these activities

nevertheless contributed to the uniformity of the information received
and provided by the VHCs, and their compliance with the state health
care program.
Still, the quality of training largely depends on staff availability and
motivation. One interviewee noted that the organizational decline of
VHCs was, to a certain extent, expected without the CAH but also
dependent on HPUs and broader issues, such as the availability of quali-
fied medical professionals in the country (IO Partner 11). By the end of
the CAH, some trainers continued their work with community-based
organizations in HPU roles. However, as elsewhere, low salaries and lim-
ited motivation contribute to the high rotation of medical professionals
and inequity between urban and rural areas.
Furthermore, with the adoption of the “Healthy Person—Prosperous
Country” program (2019–2030), Kyrgyzstan’s priorities changed toward
a systemic and away from its previous area-specific approach to health
care. In contrast to “Den Sooluk” (2012–2018), which, along with other
activities, targeted the four areas mentioned above, this program pursues
a systemic approach to the health care system and reforms instead.
Priority directions of the new program are public health, further strength-
ening primary health care, improving and rationalizing the hospital sec-
tor, developing emergency medical care and lab services, and improving
the regulations of and access to medicines and medical devices
(Government of KR, 2018a). It also intends to ensure strategic manage-
ment of the health care system, target the problems with human resources
in this sector, develop E-Health and health financing, and ensure the
successful realization of stated objectives (ibid.). In contrast to “Den
Sooluk,” it does not explicitly prioritize TB or HIV/AIDS, but rather
integrates them into the public health and primary health care areas of
the program (ibid.).
Despite the aforementioned changes, community-based organizations
are still central to the Kyrgyz health care system. The systemic approach
of the “Healthy Person—Prosperous Country” (2019–2030) program
envisions a broad engagement of stakeholders and community-based
organizations. In addition to emphasizing citizens’ responsibilities for
their own health, the new program also intends to increase awareness of
166 G. Isabekova
the right to quality health care and modernize the planning and organiza-
tion of health care according to the population’s needs (Government of
KR, 2018a). VHCs are indispensable to achieving these objectives. Not
explicitly prioritizing TB and HIV/AIDS, the program still offers dis-
tance learning modules on organizational development and public health
and training activities on population needs assessment for health care
(ibid.). However, the actual implementation of training activities largely
depends on the availability of funding.
Furthermore, along with state institutions, donor organizations pro-
vide training to VHCs within the scope of their activities. For example,
the World Bank-funded project (2014–2017) implemented by the
Development Policy Institute aimed to build the capacities of VHCs and
AVHC in identifying social determinants of health and working with
local authorities to solve them (Development Policy Institute, 2014). It
also allowed VHCs to expand their activities in unexplored areas, such as
participating in the formation of local budgets at a village level. The
emphasis on the role of the PRA in defining social determinants of health
has also allowed the VHCs and the AVHC to then use this approach later
to assess health care quality (see Development Policy Institute, 2017).
Despite the wide range of benefits offered by this initiative, its coverage
was limited to 30 pilot villages (Development Policy Institute, 2014). In
addition to geographic coverage, the scope of activities may also be related
to specific areas. The SDC-funded project on the “Effective Management
and Prevention of Non-communicable Diseases” targeted Chui, Naryn,
Issyk-Kul, and Talas regions in the first phase (2017–2022), and Batken,
Osh, and Jalalabad regions and two cities, Bishkek and Osh, in the sec-
ond phase (2022–2026) (SDC, the Federal Department of Foreign
Affairs, n.d.-a, n.d.-b).
As noted above, USAID’s “Cure TB” program is among the few proj-
ects with countrywide coverage and a focus on TB. In collaboration with
the AVHC and the Republican Health Promotion Center, this project
offered a series of trainings for HPUs, which, in turn, conducted semi-
nars for VHCs to increase awareness of TB, reduce stigma and discrimi-
nation, and support adherence to treatment (JSI Research & Training
Institute, 2021). Initially, the project covered only Talas, Naryn Chui,
and Jalal-Abad, but in 2021 it expanded to the Batken region and the
Kara-Suu district of the Osh region (ibid.). To date, USAID’s “Cure TB”
program seems to be the main source of training for HPUs and VHCs in
the area of TB.
Despite the fluctuations in development assistance, the AVHC serves
as a stabilizing factor by coordinating training activities. Through its
coordinating role and direct engagement in initiatives, the Association of
VHCs keeps an overview of development assistance provided to VHCs,
including a record of organizations covered and excluded from aid. This
perspective is essential to quality assurance and equity among community-
based organizations, as the AVHC uses health projects to support and
expand the training offered to VHCs. For instance, during the
Development Policy Institute, the VHCs outside the piloted areas also
expressed their interest in learning more about collaboration with local
self-government bodies (AVHC, 2017b). In response, the Association
developed a strategy for sharing experiences within the network. The
Rayon and Village Health Committees discussed this strategy further,
along with funding options and mechanisms for methodological sup-
port, during the RHC meetings (ibid.). Based on these discussions, the
AVHC stipulated funding for experience-sharing within the network
depending on the willingness of RHCs and VHCs and their financial
capacities (ibid.). As a result, the coverage of training activities expanded
beyond those piloted in the project. The VHCs from piloted areas con-
ducted 1–2 seminars in areas not covered by aid, the organizers taking
over small tea and coffee breaks, and the visiting CBOs covering com-
muting costs (ibid.).
Overall, both state and donor support are critical to maintaining ben-
efits. However, the Association of VHCs and its network organizations
and members demonstrated a remarkable initiative in extending training
programs beyond their initial scope. In so doing, they contributed to the
equality of awareness-raising activities in regions not covered by aid.
Certainly, the shift in government priorities toward a systemic approach
affects TB and HIV/AIDS, which had been explicitly prioritized in the
previous health care program. Still, the maintenance of benefits also
depends on the availability of training material, as discussed below.
168 G. Isabekova
In addition to training, dissemination campaigns presume the avail-

ability of relevant leaflets and other supporting material, which had pre-
viously been ensured by the CAH. VHCs interviewed for this research
used the leaflets they accumulated during their work with the SRC and
other international organizations (CSO 2). However, replenishment of
these stocks is uneven.
Indeed, training material and handouts provided within the frame-
work of the “Cure TB” project ensure access to updated information on
TB, also in the context of the COVID-19 pandemic (see JSI Research &
Training Institute, 2021). The project supported the preparation of infor-
mation in Kyrgyz and Russian, online and in the form of postcards and
videos (AVHC, 2020). There has been an increased use of social net-
works, such as Facebook, Odnoklassniki, and Instagram, among the
AVHC and the VHC members that, for instance, follow the relevant
pages of the Association (JSI Research & Training Institute, 2020). The
project also supported the development of methodological handouts for
conducting seminars (on- and offline formats) and booklets for volun-
teers providing extensive and brief information on TB and its prevention
(AVHC, 2020). This support ensures access to updated information
across the VHCs, which contributes to the uniformity of the information
provided.
The situation with HIV/AIDS is different. Due to the lack of an ongo-
ing project with countrywide coverage, the information provided by
community-based organizations is limited to content from previous proj-
ects. The AVHC aims to increase public awareness of HIV via its social
media posts. Yet, a more systematic approach to and the broader avail-
ability of information on treatment options, preventive measures, and
risks of HIV in the context of the global pandemic would be desirable,
certainly benefiting the efforts of community-based organizations.
Overall, a closer look at training provided within the areas of TB and
HIV/AIDS vividly demonstrates the changing agenda and differing
stakeholder involvement, which also contributes to inequity in terms of
access to training and supporting materials.
6.4 Community Capacity-Building

Survival of civil society organizations (CSOs) beyond the end of a donor-
financed project is a key indicator of community capacity-building.
Therefore, in this section, I examine the extent to which community-
based organizations set up under the CAH continue to exist beyond the
end of the project, and I look at their leadership and mobilization of
resources (see Labonte & Laverack, 2001a, 2001b).
In 2018, the Association of VHCs conducted a “mapping” of the
VHCs and RHCs to identify the number of VHCs still operating and
those who discontinued their work or needed additional support. In so
doing, the Association intended to support “quality” over “quantity” of
community-based organizations (CSO 4). The mapping showed some
attrition, but most of the VHCs, and all of the RHCs continued their
work. As of 2020, the AVHC (2020, p. 3) reported that there were 58
RHCs and over 1500 VHCs in the country. Following these results, the
AVHC organized a general meeting of its members to discuss the VHCs’
self-evaluation outcomes and strengthen the VHCs in need of assistance
(ibid.). Participants divided themselves into groups and worked on own
initiatives, support to the poor, reanimation of organizations, and VHCs’
connections to other actors as part of the VHCs’ and RHCs’ work plans
(ibid.). The processes and issues encountered during this activity would
require research on their own.
As noted above, there has been some attrition of members and organi-
zations. However, most VHCs have continued to exist after the end of
the project. In response to my question about organizational perfor-
mance, my interviewee, closely working with the VHCs, noted that the
majority of “weak” organizations were in close proximity to the capital.
The interviewee stressed that in contrast to their rural counterparts,
members of these organizations had little time and did not have such
close communication with local residents (CSO 4). This corresponds to
the findings in the literature about the strength of social bonding (e.g.,
Agnitsch et al., 2006) and the persistence of community-based organiza-
tions in rural areas in contrast to urban settings (Gryboski et al., 2006).
170 G. Isabekova
Indeed, the survival of community-based organizations depends on

several factors, including the leadership of its members (see Labonte &
Laverack, 2001a, 2001b). My interviewees similarly stressed the impor-
tance of leadership of VHCs (IO Partner 5) and the ability of its mem-
bers to express and formulate their concerns (IO Partner 11). In this
section, I elaborate on the issues the VHCs faced in their work, the solu-
tions they developed, and the strategies they used to overcome the struc-
tural inequalities.
During their work, the VHCs came across a number of issues, includ-
ing mistrust from the local population and the local authorities. There
were cases of people throwing away the health information brochures
provided by the VHCs (CSO 2) and actually chasing the VHC members
out of the seminars (CSO 5). There were also negative remarks toward
the members, most of whom were women. There were claims that these
women had “nothing else to do” but were “just fishwives running around
the streets”3 (CSO 2). A similar misunderstanding was common among
representatives of local authorities. My interviewees recalled disinterest
on the part of local authority officials (CSOs 4 and 5). At times, the
remarks were also related to gender, with individual government repre-
sentatives pointing to the VHC members to “go and look after husband
and children” and not to “interfere” in matters that did not concern them
(CSO 1).
However, not all VHCs continued their work under these circum-
stances. One interviewee noted that only people capable of saying, “no,
you sit and listen to what I say,” remained in the VHCs (CSO 1). The
interviewee noted that those remaining had to be (using a Kyrgyz saying
to describe it) “barking dogs”4 in order to be resilient to the “attitude” of
others (ibid.). It should be noted that the VHCs interviewed for this
research were those who continued their work despite resistance from the
local population and local authorities. These women continued to
advocate for their ideas and developed their own strategies to overcome
the structural barriers.
3
Translated from Kyrgyz, “fishwives” is the closest expression in meaning to the original Kyrgyz
expression “dankyldagan ayaldar,” which refers to noisy or shouting women.
4
Translated by meaning, original is “azhyldagan ayaldar.”
First, the VHCs used “existing resources” for their dissemination cam-
paigns. They targeted public gathering places and asked people for “five
minutes” to share their information with them (CSO 2). In addition to
visiting schools and local organizations, the VHC members also attended
celebrations and visited communal grazing areas.5 The VHC members
used all available means to conduct their awareness-raising activities. One
interviewee, for instance, told me that she could not find a place for the
seminar after the representatives of the local self-governments ignored her
request. However, on the way back, the VHC member saw a young
woman hanging her laundry outside and paid attention to her yard as she
approached and noticed that it was “large and clean.” The interviewee
asked for permission to host her event in the woman’s yard, and was
granted a permit to conduct a seminar for the local community on
sanitary-hygiene issues there. The VHC member recalled that this semi-
nar turned out to be even larger than expected as neighbors and other
people from the street came in response to her and the woman’s invita-
tions to attend it (CSO 5).
Second, VHC members tried to “popularize” health care practices by
following these practices themselves. Their adherence raised the interest
of other people in the village. One VHC noted that as members started
practicing what they called for, neighbors began to wonder why the per-
son was “so obsessed” with a specific practice, for instance, cleaning the
yard (CSO 5). This curiosity developed into interest, which was the exact
objective of VHCs. But beyond this interest, the VHC practices also
brought tangible results. The same interviewee emphasized that the
CBOs contributed to halting the problem of alcohol abuse, which was a
pressing problem in the 1990s. The VHC members persuaded people not
to bring alcohol to funerals. They followed this practice and pointed out
that alcohol consumption at funerals was inappropriate, also during their
conversations with community members at tea gatherings after burials
(ibid.). In this way, adherence to certain practices went hand in hand
with information dissemination.
5
In rural areas of Kyrgyzstan people take their cattle out to the mountains by giving their cattle to
shepherds who carry out large-scale herding in the mountains in spring-summer period.
172 G. Isabekova
Third, the VHCs sought solutions for socially significant issues.

Sometimes, these issues included those not initially anticipated in the
work plan. For example, another VHC member interviewed for this
research recalled a problem the members encountered during their dis-
semination campaign. One community they visited shared its concern
with the dump on their street. The volunteers supported the local popu-
lation in writing the relevant petition to the local self-government, which
the local population had not considered before. As a result, the landfill
was closed, and another one was opened elsewhere. The interviewee
brightly concluded that though headed to a neighboring community for
one reason, the VHCs were able to support it in solving a separate issue
that was pressing to them (CSO 5).
Fourth, the VHCs pursued own initiatives on matters relevant to local
communities. In contrast to socially significant issues, these initiatives
were not limited to problems raised by local communities, but included
support to its members and opportunities for community development.
As part of the support to community members, the VHCs continued to
assist vulnerable groups, including the poor and those facing catastrophic
health expenditures (see Isabekova, 2021). The organizations also regu-
larly commemorate Victory Day (May 9) and International Children’s
Day (June 1) by arranging presents and organizing events for war veter-
ans and children, particularly those from vulnerable households (AVHC,
2022). In addition, the organizations sought further development of
their villages in collaboration with other stakeholders. With small grants
provided during the CAH, the VHCs cooperated with local self-
government institutions and local sponsors to realize the projects. These
included constructing a mini-football field with changing room and
shower facilities, building a bus stop, maintaining bridges in emergency
conditions, renovating and equipping a kindergarten, and renovating a
local medical center (AVHC, 2017a).
By the end of the CAH, the AVHC intended to support the own ini-
tiatives that varied across organizations. In the case of VHCs, the number
of initiatives fluctuated over the course of the project. Though growing
between 2014 and 2016, the number fell by half in 2018 to 1254 (AVHC,
2018, p. 19). In contrast, own initiatives organized by Rayon Health
Committees increased over time. Thus, if in 2017, only five organizations
implemented over four initiatives, by 2018, twenty-seven organizations

did (AVHC, 2018, p. 16). The number of organizations that did not
implement own initiatives decreased from 14 to 1 over the same period
(ibid.). It should, however, be noted that in the case of VHCs the low
number was related to not only the actual work but also logistical issues.
The organizations not participating in regional meetings failed to pass on
the information at the RHC level, which in turn delayed reporting to the
AVHC (2018, p. 19). As a result, some organizations were not included
in the statistics of the Association of VHCs. As a corrective measure, the
Association of VHCs asked the Rayon Health Committees to fill out
tables on VHCs’ activities and send this data to the AVHC immediately
after the meeting via Google Forms or WhatsApp (ibid.).
The abovementioned are only a few examples of the strategies used by
the VHCs to overcome structural barriers and gender-biased attitudes in
their society. They used existing resources for their dissemination cam-
paigns, popularized practices by following these themselves, sought solu-
tions to local issues, and raised initiatives in regard to the matters relevant
to the development of their communities.
It should be noted that the misunderstanding from the local popula-
tion and disinterest on the part of the local authorities gradually changed
into appreciation and the inclusion of the VHCs into decision-making
processes (CSOs 2 and 5; State Partner 12). This appreciation is also
reflected in the cases of individual VHC members receiving a medal for
distinguished labor (“emgek kaarmandygy”) from local organizations, or
the broader fact that September 9 is now celebrated as the “Day of Village
Health Committees,” with organizations receiving congratulations from
local authorities and medical institutions (AVHC, 2022). I do not make
countrywide generalizations about the strategies the VHCs used to over-
come the social barriers, as, in fact, not everyone did overcome them.
However, the VHCs I interviewed in the north of the country demon-
strated their leadership through their ability to define problems, suggest
solutions, and develop various strategies to overcome gender-biased atti-
tudes in their local society.
Finally, mobilization of resources via donor or state financing and fun-
draising is an essential component of sustainability, as it relates closely to
the continuity of civil society organizations and their activities beyond
174 G. Isabekova
the end of the donor-funded project. In this section, I examine resource

mobilization through donors, fundraising, and income-generation activi-
ties conducted by community-based organizations and state support.
First of all, in terms of donor financing, donor organizations cover
specific geographic locations or issues relevant to project objectives. For
instance, the World Bank-financed “Sustainable Rural Water Supply and
Sanitation Development Project” (2016–2025) operates in Osh, Chui,
and Issyk-Kul oblasts and provides training of trainers to the VHCs on
water quality, handwashing and hygiene, improvement of sanitation
facilities, and food hygiene (World Bank, 2016). As part of the USAID-
funded “SPRING Project” (2014–2016), the VHCs disseminated infor-
mation on nutrition and hygiene among pregnant and lactating women
and parents of children under two years of age in Jalalabad and Naryn
regions (USAID, 2021). There are indeed countrywide initiatives, such as
the USAID-funded “Cure TB” or the SDC-financed “Effective
Management and Prevention of non-communicable Diseases” projects.
The former expanded countrywide in 2021 (SDC, the Federal Department
of Foreign Affairs, n.d.-a), while the latter focused on a select number of
regions in each phase of the project to ensure countrywide coverage
(SDC, the Federal Department of Foreign Affairs, n.d.-b, p. 2). Despite
their countrywide coverage, both focused on areas relevant to project
objectives (i.e., infectious or noncommunicable diseases). One inter-
viewee similarly referred to the uneven coverage of donor assistance, with
some providing training but not financing (CSO 4). None covered the
broad spectrum of activities, including those identified by VHCs and not
necessarily prioritized by the project, as the CAH had done.
What happens to activities or VHCs not covered by donors? They
remain the sole responsibility of the community-based organizations. In
2018, I interviewed one VHC representative who stated that they had no
collaboration with any donor organization at the time of our conversa-
tion (CSO 2). Yet the VHC continued its activities, and the interviewee
stressed that other VHCs did the same and did not necessarily wait for
development projects (ibid.). Although non-generalizable, this finding
suggests some continuity of community-based organizations without
donor support. One could specifically emphasize the role of the
Association of VHCs, which serves as a stabilizing factor, also in
coordinating the project implemented by donors and experience-sharing

activities to VHCs not covered by donor activities. As seen from the map-
ping exercise, the AVHC has also been critical in identifying and organiz-
ing support for VHCs in need of assistance.
Second, fundraising is another option for the VHCs’ resource mobili-
zation. One of the VHC members showed me photos of the fundraising
campaign the organization organized for a villager in need of surgery,
namely a sports competition which raised around 27,000 Kyrgyzstani
som (KGS, national currency of Kyrgyzstan), which is around €290
(CSO 2). The organizations also use other methods in addition to com-
munity fundraising for a specific purpose. Some organizations introduce
membership fees to replenish their budget. The fees vary, but are rela-
tively small, about 5–20 KGS (approximately 5–21 Euro cents) (CSO 4).
However, poverty and unemployment in rural areas hinder the VHCs’
fundraising possibilities. For this reason, during the CAH, the VHCs
received small grants in the amount of 25,000 KGS (around €268) based
on their project applications (CSO 2). A VHC noted that in 2017, a
commission was formed among the representatives of the rayon adminis-
tration (ibid.). Its aim was to evaluate the VHCs and redistribute the
financing previously received from the SRC. The commission visited
each village, checked the documentation, VHCs’ activities, fundraising,
and links to local institutions, and so on. As a result of this assessment,
eleven organizations received small grants for two years, and the VHCs
nominated for the first four places received additional rewards (ibid.).
Third, community-based organizations mobilize resources through
social entrepreneurship and by using their organizational funds for
income generation, though not all initiatives were “successful.” During
the CAH, the VHCs used the small grants provided by the SRC to solve
community problems and establish small social enterprises. Public baths
(banya) were built to address sanitation problems. VHCs provided free
entrance to vulnerable groups in the population, including the elderly
and people with disabilities. In addition to covering the maintenance
costs, the entrance fees to the public baths supplemented the VHC’s bud-
get/fund (CSO 5). Community-based organizations also established sew-
ing workshops and hairdressers. In addition to providing employment for
the local population, these enterprises brought in 150 KGS (around
176 G. Isabekova
€1.6) to the VHC’s budget on a quarterly basis (ibid.). However, not all
of these initiatives were successful. The majority of public baths in the
district I visited were in need of an overhaul, and the VHCs I interviewed
were negotiating their transfer to the ownership of the local self-
government, as the entrance fees for the public baths did not cover the
amount needed for the overhaul (ibid.). In addition to social entrepre-
neurship, the VHCs also used their organizational funds to generate
additional income. Some increased their funding by lending funds to
VHC members at low interest rates (CSO 2). Others invested in cattle
breeding, which was unsuccessful (CSO 7).
VHCs were not alone in their struggles. Rayon Health Committees
similarly received stimulus grants within the framework of the CAH to
generate additional income for organizational support. However, not all
organizations benefited from this income, the amount of which also
turned out to be less than expected. For instance, in 2014, fourteen
RHCs received these grants, and nine of them managed to receive addi-
tional income in 2015; among twenty-nine organizations receiving grants
in 2015, only six received extra income in 2016 (AVHC, 2017a,
pp. 18–19). As a result, the total amount of revenue obtained through
grants was considerably lower than expected due to internal as well as
external factors. Internal factors were related to the organizations’ abili-
ties to maintain income-generating activities, decision-making in crises,
and their skills in financial management, further investment, account-
ability, and taxation (ibid.). External factors included the low level of
income, lack of marketing, and falling cattle prices, among others (ibid.).
As noted above, further capacity-building may be desirable for both
VHCs and RHCs in the areas of social entrepreneurship and income
generation. My interviewees noted that “good” leadership was critical to
the size of the organizational budget (CSO 4), and yet the community-
based organizations were “not ready for business,” and despite their will-
ingness to invest, they were unsure how to (CSO 7). Similarly, external
evaluations of the CAH suggest that although the VHCs gained fundrais-
ing and strategic planning skills during the CAH, these may not be
enough for them to work independently (PIL Research Company, 2017)
beyond the end of the project. At this point, the Association of VHCs
continues exploring investment opportunities at the national level to
support community-based organizations at both village and district lev-

els. However, further training in social entrepreneurship and income gen-
eration would undoubtedly benefit the organizations by allowing effective
use of existing resources and more effective sourcing of further resources.
The fourth source of resource mobilization is state support. National
authorities, including the Ministry of Health, the Republican Center for
Health Promotion, and regional and district administrations, largely sup-
port the continuity of activities in the areas prioritized in the national
health care program. Examples include HIV/AIDS and tuberculosis
activities which benefited from the Ministry of Health and state admin-
istrations’ decrees, in turn stipulating the organization of relevant activi-
ties by medical professionals and by extension supporting the
community-based organizations. In addition, the Ministry and the
Republican Center for Health Promotion were also critical to the con-
tinuous training of community-based organizations provided by Health
Promotion Units, thus contributing to the maintenance of benefits (i.e.,
quality and uniformity of health promotion information provided by
VHCs). The acknowledgment and support at the national level are also
critical to the capacity of community-based organizations. Thus, inclu-
sion in the national health care program allows the CBOs to develop
additional skills. For instance, the ongoing “Healthy Person—Prosperous
Country” (2019–2030) program stipulates the development and imple-
mentation of remote training modules for VHCs also in areas of organi-
zational development (Government of KR, 2018b).
However, as part of resource mobilization, I focus on local self-
government institutions that are somewhat unexplored and yet vital to
the Village and Rayon Health Committees. The local self-government
institutions provide administrative support to community-based organi-
zations. My interviewees referred to meeting rooms the local authorities
provided for the VHCs to gather and conduct their seminars and other
awareness-raising activities (CSOs 4 and 5; State Partner 12). There are
also cases of VHCs receiving office spaces from local authorities for their
exceptional work and contribution to local development (e.g., AVHC,
2022). The VHCs often conduct maintenance work at the expense of
their organizations. However, the availability of a fixed location for their
activities and organizations indeed contributes to their capacity.
178 G. Isabekova
Community-based organizations may also receive financial assistance

from local authorities, though the amounts in question are rather small
due to budget deficits within state organizations. One interviewee esti-
mated that the financial support to VHCs might range between 2000
and 5000 KGS (around €21–54) in the case of “poorer” and up to 10,000
KGS (about €107) in the case of “well-off” local authorities (CSO 2). A
more accurate assessment of financial assistance would undoubtedly
require access to local budgets and their countrywide comparison.
However, another community-based organization representative simi-
larly corroborated the small share of financial support. The interviewee
emphasized that the eagerness of VHCs to work with donors also relates
to the “little money” local self-governments had, which was not sufficient
to meet the population’s needs (CSO 7). In this way, although offering
administrative support, the local authorities can provide only limited
financing to the VHCs and their activities.
It should, however, be noted that the state support both at national
and local levels is also contingent on the support of individual officials to
community-based organizations and their work. The significance of state
support and understanding was emphasized already during the CAH. The
project-related documents reported changing attitudes of officials, also at
the level of the Ministry of Health, after their acquaintance with the
VHCs and their work (Schüth, 2011). Yet, awareness does not always
equal support for the VHCs, as there were cases of individual candidates
for political positions attempting to involve the VHCs in their election
campaigns. Driven by their own agenda, they do not necessarily consider
the interests or organizational development of CBOs. One of my inter-
viewees noted that the presence of (former) VHC members among local
authorities contributes to those authorities’ understanding of and sup-
port for the VHCs’ work (CSO 5).
Notably, the Association of VHCs endorses the political aspirations of
its members. In 2016, for instance, it prepared guidelines for trainers and
brochures to support the VHC members running for election to local
councils (jergiliktüü kengeshter) (AVHC, 2017a, pp. 15–16). The AVHC
conducted 12 seminars at the regional level throughout the country for
candidates to enhance their capacity and ability to participate in political
processes and advance their leadership skills (ibid.). Out of 325 VHC
members trained, 45 obtained seats in local councils, with two-thirds of

them being women (ibid.). It should be noted that in addition to strength-
ening the skills of the individual CBO members, these training activities
were beneficial to the local self-governance institutions’ understanding of
health issues and their affinity toward the VHCs’ work.
Still, the unstable economic and political situation in the country con-
tributes to the frequent rotation of state officials. In these circumstances,
relying on state officials or, in fact, also relying on the changing agenda of
donor organizations does not seem sensible.
In addition to country-specific problems, the global COVID-19 pan-
demic constituted an unanticipated challenge, which, however, ended up
demonstrating the relevance of community-based organizations in
Kyrgyzstan. The volunteers had to halt their activities during the state of
emergency declared in the country. Similarly, the HPUs had to cancel the
training activities planned for the Village and Rayon Health Committees
(AVHC, 2020). The pandemic has profoundly impacted community-
based organizations and their work. Indeed, the seminars were renewed
by online means in the second quarter of 2020, and the HPUs actively
used social media (e.g., WhatsApp) to communicate with volunteers and
share information (ibid., pp. 13–15). However, a better understanding of
capacity-building, continuity of activities, and maintenance of benefits
during (and, at some point, after) the pandemic require further research.
Though challenging, the pandemic has also demonstrated the relevance
of community-based organizations. In collaboration with local medical
workers, Village and Rayon Health Committees organized awareness-
raising activities on protective measures and campaigns calling for people
to vaccinate against COVID-19 (AVHC, 2022). Similarly, the Association
of VHCs continued sharing information on vaccination and the virus,
also in relation to TB, on its social media pages (ibid.).
6.5 Summary
This chapter evaluated the sustainability of the “Community Action for
Health” project by focusing on the continuity of activities after the end of
the project, maintenance of benefits received by the targeted population,
and community capacity-building.
180 G. Isabekova
First, it demonstrated that community-based organizations continued

their activities, also in TB and HIV/AIDS, after the end of the project.
However, there has been a general “slow-down,” further amplified by the
lack of donor assistance covering all aspects of VHCs’ work throughout
the country.
Second, in terms of maintenance of benefits, since the external assess-
ment of the VHCs’ activities and their impact on TB and HIV/AIDS was
inconclusive, I used training as the assurance for the quality of the infor-
mation disseminated by the VHCs. Most assistance focused and pro-
vided training on either specific issues or geographic areas and thus was
incomparable to the CAH, which encompassed all initiatives and activi-
ties of health committees throughout the country. The community-based
organizations continued receiving TB and HIV/AIDS-related training
from the Health Promotion Units. However, the change in the national
health care strategy from a disease-specific toward a systemic approach
also affected the training offered to RHCs and VHCs. Still, the organiza-
tions continued their activities and demonstrated exceptional learning
and training skills by sharing their experience and skills within the net-
work. The coordinative and developmental roles of the Association of
VHCs were crucial to this effort, though the leaflets and other materials
used for the dissemination campaigns still primarily come from donors.
Third, as part of community capacity-building, despite some attrition,
most of the organizations continued their survival beyond the end of the
CAH. The organizations mobilize resources via donor funding, fundrais-
ing, social entrepreneurship, and state support, all of which are challeng-
ing in an environment of poverty, unemployment, and limited
skills/training in the relevant area. Overall, the VHCs demonstrated lead-
ership and continued their activities beyond the end of the development
project. At the same time, there are a number of internal factors (men-
tioned here in the chapter) and external factors (the political, economic,
and sociocultural situation in the country, the global pandemic) which
challenge the sustainability of the community-based organizations,
VHCs, and their activities in the area of TB, HIV/AIDS, and beyond.
Overall, the detailed analysis provided in this chapter demonstrated
both issues and opportunities associated with the sustainability of health
aid. Indeed, the CAH is a “success story,” demonstrating the long-term
sustainability of the activities and organizations initially supported by the

project beyond the duration of donor funding. The resilience of
community-based organizations and activities to (un)anticipated chal-
lenges, including the global COVID-19 pandemic, is extraordinary. This
resilience also suggests that members of community-based organizations
not only overcome obstacles, but also seek opportunities for their activi-
ties and places for their organizations in these very challenges. Still, this
chapter also enlisted multiple issues in this regard, including the contin-
gency of the long-term sustainability of health projects on the broader
political, economic, and social situation in the country. In so doing, it
showed that the sustainability of health aid is not a categorical “yes/no”
matter, but a complex phenomenon requiring a fine-grained analysis of
each of its three dimensions and related factors.
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right holder.
7
Aid Relationships and Power Dynamics
in the “Community Action for Health”
Project
This chapter discusses the types of relationships between the actors in the
“Community Action for Health” (CAH) project in Kyrgyzstan based on
the findings from previous chapters. It builds around the findings regard-
ing stakeholders’ roles throughout the project realization process described
in Chap. 5. It also considers the evolution of structural factors, including
aid predictability and flexibility of providers, as well as the capacities and
aid dependency on the recipients’ sides, presented in Chap. 4. These two
chapters constitute the basis for applying the analytical framework about
power dynamics in relationships among stakeholders elaborated in Chap.
2. Informed by the findings and analytical frameworks laid down in these
chapters, this chapter defines the following types of aid relationships
(Table 7.1). It also elaborates on the impetuses these aggregated analytical
categories of actors may have for pursuing the selected types.

188 G. Isabekova
Table 7.1 Aid relationships between actors in the “Community Action for
Health” project
Type of
Actors Reference relationships
The Swiss actors—community-based Donor–civil “Empowerment”
organizations (CBOs) society approach
organization
Ministry of Health/Health Promotion Recipient “Utilitarian”
Units/local authorities—CBOs state– approach
community
The Swiss actors—the United States Donor–donor Unequal
Agency for International cooperation
Development (USAID) and the
Swedish International Development
Cooperation Agency (Sida)
The Swiss actors—Ministry of Health/ Donor–recipient (Contingent) Equal
Health Promotion Units state cooperation
7.1 Donor–CSOs:
The “Empowerment” Approach
I conceive of the relationships between the donor and civil society organi-
zations (CSOs), which in the case of the CAH mainly refer to community-
based organizations (CBOs), as an “empowerment” approach because of
the equal participation of both actors throughout the project, structural
factors favorable to this approach, and altered power dynamics between
the provider and the recipient of the assistance.
First, in the CAH, both the “donor” and CBOs participated equally
throughout the project. Ideally, the “empowerment” approach presumes
the active role of CSOs throughout the period of the development assis-
tance, but their role may vary in practice. The Swiss Red Cross (SRC)
dominated the initiation phase of the project by suggesting the idea of
community involvement in health care and establishing the Village Health
Committees (VHCs) for this purpose. Furthermore, it was the SRC and
not the participants themselves who suggested the Participatory Reflection
and Action (PRA) approach and developed the assessment criteria used by
the project participants. Yet, the SRC largely pursued a supportive role by
offering relevant technical and financial support, following the needs and
demands of the community-based organizations and the issues they
7 Aid Relationships and Power Dynamics in the “Community… 189
encountered. It also initiated a process of annual self-assessment for the

VHCs and the Health Promotion Units (HPUs) to emphasize their role in
evaluating the project, something more commonly conducted by external
consultants.
The community members played an equally significant role in the proj-
ect. Their interest and agreement to participate in the initiative were essen-
tial to the advancement of the CAH beyond the pilot areas. Thus, in the
following stages of the project—design and implementation—the VHCs
took the leading role in the project by defining the issues of importance to
them and implementing their solutions. These roles were consonant with
the idea of empowerment as the “process of gaining influence over [the]
conditions that matter to people” (Fawcett et al., 1995, p. 679), presum-
ing the abilities of community-based organizations to express their con-
cerns, set priorities, and participate in negotiations and decision-making
process. By defining the issues and taking initiatives into their own hands,
the CBOs were the source of initiative for the project and not merely its
“passive” recipients (Rasschaert et al., 2014, p. 7).
However, the project initiation by an external actor, which also sug-
gested the approaches followed by communities (e.g., PRA approach and
assessment criteria), contrasts with the definition of the “empowerment”
approach in ideal terms, which presumes the active role of civil society
organizations throughout the development assistance. Yet, structural
issues, such as illiteracy (Jana et al., 2004), gender-related biases (WHO,
2008), the political situation, and poverty (Fawcett et al., 1995), prevent
civil society organizations from taking this active role throughout the
assistance. Thus, the domination of the SRC in the initiation and evalua-
tion phases points to structural issues hindering the ability of community
members to initiate a project such as the CAH or suggest an assessment
framework for their activities.
Yet, in the case of the CAH, these issues cannot be put down to illiter-
acy or economic hardships, as most of the population in the country (over
99%) is literate (UNESCO Institute for Statistics, 2023), and the organi-
zations thrived in spite of the economic issues at the local and national
levels. I argue that the structural issues stemmed from path dependency
from the Semashko health care system inherited from the Soviet Union,
which foresaw little space for public participation and initiative in health.
190 G. Isabekova
Despite the formal changes, both state and population continued living in
practice within the old, paternalistic health care system, and therefore had
limited perspectives on possible alternatives. My reasoning largely matches
the analysis of health projects in Costa Rica by Morgan (1993, pp. 5, 15),
who suggested that the “induced” or “sponsored” community participa-
tion could also be an outcome of a lack of citizen involvement in health
projects.
Second, in addition to the equal involvement of VHCs throughout the
project life cycle, the “empowerment” approach toward the CBOs was
possible due to favorable structural factors. Remarkably, conventional
gender roles in society contributed to the participation and retention of
women in VHCs. These roles, for instance, include the assumption that a
household’s health is viewed as a woman’s “responsibility” and that women
(in contrast to men) are not associated with a role of breadwinner. The
capacity of CBOs was further assured by the outstanding leadership of
members who continued pursuing the organizational objectives amid mis-
understandings from other community members or local authorities.
Furthermore, the volunteer status of VHC members altered the hierarchy
between the donor and CBOs by making the donor dependent on the
willingness of community members to engage in the project, and, in so
doing, evening out the aid dependency of CBOs on the donor. Certainly,
the community-based organization members did receive minor incentives
for taking part in the project, such as reimbursement of any project-related
travel costs, training courses, seminars, and coffee breaks. However, these
incentives were not the reason for community engagement—the reason
was their willingness to work.
Equally, the flexibility and predictability of the Swiss aid assured the
responsiveness and longevity of the project, providing a sense of security
to stakeholders involved in this initiative and offering the time necessary
to establish and build the capacities of community-based organizations.
Flexibility and responsiveness were the foundation for the active roles of
communities in the initiative. In total, the capacities of CBOs, the mutual
dependence of stakeholders on each other’s willingness to work, along
with the predictability and flexibility of aid resulted in circumstances in
which hierarchic relations between the provider and recipient of aid ren-
dered themselves irrelevant.
Third, the altered power dynamics are another reason for defining the
relationships of the “donor” with CBOs as an empowerment approach.
Despite the dominance of the financier in specific phases, the relation-
ships between the SRC and CBOs were characterized by the existence of
the “power to,” qualifying it as the “empowerment” approach. The “power
to” manifested itself through a combination of the systems of thought and
transformation of tacit knowledge into discursive, which empowered
communities by attributing a decisive role to them, and a supportive one
to the donor.
The systems of thought on the relationship with community members
advanced by the SRC created the “power to” empower the CBOs.
Following Haugaard (2003, pp. 107–108), the systemic biases and spe-
cific meanings “do not simply exist out there,” but are rather supported by
knowledge based on the “particular interpretative horizons.” This way,
stakeholders use and promote specific interpretations to create power for
themselves or other actors. In the case of the CAH, the Village Health
Committees benefited from the social consciousness the SRC and the
project coordinator endorsed in relation to the role of communities in
health, resulting in their decision-making and expert roles.
The SRC and the project coordinator advocated for the decisive role of
communities in defining the issues targeted by project activities, which
found its reflection in the active participation of community members in
the initiation and design phases of the CAH. As demonstrated in Chap. 5,
community members surveyed households and mobilized the local popu-
lation to determine the pressing health care problems. The community
members also brainstormed possible solutions to these problems. As a
result, the issues targeted by the CAH were defined by the communities
themselves and not induced by a donor. The SRC aimed to provide com-
munity members, who later joined the VHCs, the space to discuss the
issues at hand and suggest possible solutions. This space presumed the
altered roles: the donor and state representatives involved in the project
were the ones listening, and the community members were the ones who
spoke (Schüth, 2011b). This attitude, in combination with the nondomi-
nance approach, emboldened community members by placing them in
the position of experts, those who knew the local needs and potential
solutions.
192 G. Isabekova
By assigning the expertise to CBOs, the SRC altered the conventional

perspective of donors, including their staff members and external consul-
tants, as those who share their expertise with local people. In so doing, the
staff members aimed to overcome the tradition of subordination of local
expertise and knowledge to their international counterparts (Sending,
2015). This decisive role and the expertise of communities were supported
by the transformation of tacit knowledge into its discursive form. Following
Haugaard (2003, p. 108), stakeholders may be supportive of the existing
social structure due to tacit knowledge rooted in practical consciousness,
but changing this knowledge into a discursive form may “empower the
powerless,” who would use this knowledge to question the existing order.
In the case of the CAH, this transformation of practical or tacit knowledge
into discursive knowledge occurred throughout the project cycle.
During the initiation and design phases, the supportive role of facilita-
tors, composed of both SRC and state representatives, included providing
a space for discussions and encouraging community initiatives. Positioning
the local communities as “those who know,” the facilitators not only lis-
tened to, but actually encouraged the discussions. One of these encourage-
ment tools was, for instance, comparing the community members’
brainstorming on “how to stay healthy” to the Alma-Ata declaration on
Primary Healthcare (1978) (Schüth, 2011b, p. 32). In addition to encour-
aging the community members, this comparison reaffirmed their position
as “experts.” This way, practical consciousness based on the tacit knowl-
edge of the brainstorming exercise during the PRA sessions turned into
discursive knowledge resulting from the community members’ realization
of their roles. The discursive knowledge complemented the formalized sys-
tems of thought, advancing the expertise of communities and their deci-
sive roles in community health.
This realization about the roles of the local community and community-
based organizations in health care continued during the implementation
and evaluation phases. The VHC members used the means and knowledge
obtained during the seminars to target the issues outlined by their com-
munities. By applying this practical knowledge, the VHC members also
realized their roles in targeting these problems and changing lives in their
communities, which contributed to their willingness to continue their
work. Despite the local self-governance representatives being adamant
about the purpose of CBOs and their work, particularly at the beginning
of the project, the community members proceeded with their activities
(Chap. 5). I argue that it was the transformation of tacit knowledge into
discursive that emboldened community members in their work. Self-
reflection during evaluation, endorsed in the community capacity-build-
ing indicators adopted by the SRC, continued to emphasize the roles of
VHCs also during the evaluation phase. Notably, the same tacit knowl-
edge could have disempowered community members had it been used to
support the existing hierarchies between the “donor” and CBOs.
This transformation of knowledge was supported by the systems of
thought through which the SRC took the supportive, rather than leading,
role in the project. As vividly demonstrated in the implementation phase,
it provided necessary means and training to VHCs. Notably, the SRC
could have also used these resources differently to increase its “power over”
the community-based organizations, but it chose to advance the VHCs’
position instead and create the “power to.” This points to an important
distinction between power and resources. The presence of resources does
not automatically equal power, as power is about using resources. As Dahl
(2005, pp. 273–276) noted, actors may use the same resources
differently.
The SRC used the resources to highlight the nondomination principle,
which was equally critical during the implementation process as it was
during the design and initiation phases. My interviewee suggested that the
project implementation involved and emphasized the importance of all
participants and their contributions (IO Partner 5). The emphasis on non-
dominance was particularly strong in the case of communities. The VHC
representative endorsed the project coordinator’s idea. The interviewee
reflected that VHC members had differing levels of education, but were
asked not to correct each other. Neither the SRC nor other VHC mem-
bers corrected anyone who misspelled, for instance, while writing on the
board. CBO members corrected the spellings later in their own notes,
based on the protocols they received from training facilitators at the end
of the seminar (CSO 5). This seemingly simple yet introspective idea
nourished community participation and prevented possible building of
hierarchy based on educational level.
194 G. Isabekova
Overall, a combination of a system of thought and transformation of

tacit knowledge into its discursive form laid the foundation for changing
the conventional power dynamics, characterized by “power over,” to aid
recipients’ “power to.” These altered power dynamics, in combination
with the favorable structural factors and the equal engagement of an aid
provider and recipient throughout the project, contributed to the forma-
tion of the “empowerment” approach of the Swiss actors toward
community-based organizations in the CAH.
Why were the community members interested in cooperating with the
SRC? I suggest two reasons for this, namely motivation for change and the
opportunity for self-development. The interviewees noted that commu-
nity members joining the VHCs were interested in “changing something,”
“not just existence” (CSO 1) but rather bringing “at least something good
for the village” (CSO 5). This motivation to bring positive changes to their
communities is the primary reason behind the VHCs’ relationships with
the SRC and with all other donors and state organizations.
Furthermore, the willingness to bring changes is related to another rea-
son driving the community members, namely self-realization. Interviewees
closely working with VHCs remarked/observed that having “some author-
ity” motivated them to learn (CSO 1), and members often say that “instead
of doing nothing, better work for free, everyone needs health” (CSO 4).
The motivations of VHC members outlined in the testimony of the sec-
ond interviewee suggest that women do not perceive their household work
as labor. Still, outside their households, women in rural areas often have
limited opportunities to participate in decision-making processes. A VHC
representative opined that participation in the CAH offered opportunities
for training and meetings at district, regional, and national levels for
women that rarely left their village (CSO 5). These women were eager to
take advantage of the knowledge and skills the project offered. According
to another VHC representative, as a result of their work with the VHCs,
many women were elected onto the local council (kenesh), got jobs in local
government institutions (aiyl okmotu), or became nurses at primary health
care facilities or cooks in schools (CSO 2). Thus, engagement in the proj-
ect offered knowledge and skills women used to advance themselves.
What were the reasons for the SRC to engage with the community and
pursue their “empowerment” approach? Community involvement in the
CAH was paramount, since the goal of the project was to contribute to
community capacity-building. Besides, the emphasis on community par-

ticipation was consonant with the principles of the Swiss Agency for
Development and Cooperation (SDC) and SRC, which financed and
implemented the project, respectively. Still, instead of approaching com-
munity members as “free labor” (Earle et al., 2004) for project objectives,
SRC approached them from an “empowerment” perspective. This was due
to the project coordinator, Dr. Schüth. Having previously worked on a
similar participatory community development project in Bangladesh
(Schüth, 2011b), the project coordinator stressed the principle of “non-
dominance” among SRC team members, the community, and state
representatives.
The role of the project coordinator brings to light the significance of an
individual, among other things, in understanding the outcomes of the
organizational work. His background and perspective on community
engagement were decisive to the “empowerment” approach pursued by
the SRC in the CAH. Through his work, he established a close relation-
ship with the communities. As one of the external evaluators noticed:
“Indeed, it seems as if some villages will soon have little boys called Tobias”
(Kickbusch, 2003, p. 13). The project coordinator spent thirteen years in
the country and administered most of the CAH, leaving shortly before its
completion. The VHC members were “upset” when the project coordina-
tor was leaving the country, as they “considered him as their own son”
(CSO 4). The community-based organizations interviewed for this
research expressed their appreciation of the project coordinator’s work and
efforts (CSOs 2 and 7), emphasizing that “his work will never be forgot-
ten” and the VHCs will not cease in their efforts (CSO 5).
7.2 Recipient State–CSOs:

The “Utilitarian” Approach
The Ministry of Health, the HPUs, and local self-governments (LSGs)
had a “utilitarian” approach toward community-based organizations, with
collaboration primarily driven by promoting their own agendas rather
than supporting VHCs and approaching them as equal partners.
196 G. Isabekova
Notably, stakeholders’ roles during the project and structural factors did
not point to a “utilitarian” approach. Both actors participated equally
throughout the project realization process (Chap. 5), which could have
been the basis for equal aid relationships. Similarly, the impact of struc-
tural factors on aid relationships was rather mixed. State organizations
were not providers of aid during the CAH, but the continuous training
and facilities they provided may suggest their roles as providers after the
end of the project. In this sense, the recipient state offered limited flexibil-
ity in its assistance, which was largely limited to the areas the state itself
prioritized (e.g., training), or the areas it could offer within the confines of
its limited budget (e.g., office spaces or some funding). Political and eco-
nomic instability in the country has also hindered the predictability of
state support, though the areas prioritized in the national health care pro-
grams, such as “Den Sooluk” (2012–2018), were somewhat “secure” for
the duration of the program. In terms of capacity and dependency, com-
munity-based organizations demonstrated exceptional leadership, endur-
ance, and independence, contrasting with the frequent staff rotation and
aid dependency on the side of the recipient state. These mixed outcomes
from structural factors, in combination with the stakeholders’ roles
throughout the project, are open to interpretation.
The “utilitarian” approach owes to the power dynamics formed between
stakeholders. The recipient state exercised two forms of power in relation
to CBOs, namely the “power to” and “power over.” The former occurred
due to social consciousness, whereas the latter was contingent on the (non)
transformation of tacit knowledge into its discursive form.
The recipient state provided the “power to” to CBOs through systems
of thought. As noted in the project cycle, the government emphasized
prevention over treatment and citizens’ responsibilities for their own
health. This idea, in a way, constrained the role of the state in health by
providing a window of opportunity for community participation. Indeed,
the idea of CAH was broader than state activities driven by retrenchment,
but still the project complied with the state agenda. The systemic bias
toward community participation in the project was based on the interpre-
tative horizon advocated by the government, which provided power to
population involvement in health (Haugaard, 2003, pp. 107–108). The
VHCs, supported by the SRC and HPUs, used this opportunity to define
and implement community initiatives in health. Similarly, the commu-

nity-based organizations received acknowledgment and support through
governmental decree, which solicited LSGs to collaborate with commu-
nity-based organizations. The VHCs used this opportunity to expand and
legitimate their activities through cooperation with local authorities.
The relationship between the tacit and discursive knowledge was deci-
sive in creating the recipient state’s “power over” community-based orga-
nizations, at the expense of supporting CBOs’ “power to.” Following
Haugaard (2003, p. 108), the use of knowledge driven by practical con-
sciousness results in the “power over,” whereas its transformation and
internalization into discursive knowledge create the “power to.” The non-
dominance principle, which contributed to the SRC’s empowerment
approach toward CBOs (see the previous section), equally resulted in the
relationship of CBOs with the recipient state being characterized by the
“power to” and not “power over” VHCs.
However, the outcome was contingent on state actors’ internalization of
the nondominance principle beyond their mere compliance with this idea
due to donor recommendations. This process scales down to an individual
perception of this principle, emphasizing the relevance of and the differ-
ence between the analysis of actors at individual and organizational levels.
At an individual level, support from the key employees from the Ministry
was critical to the countrywide roll-out of the CAH, as these individuals
advocated for increased community participation in health (see Schüth,
2011a). Similarly, VHC training, particularly at the end of the donor
funding in the CAH, largely depended on the HPUs working with them,
or rather their individual commitments to community empowerment.
This significance of individual perspectives is also traceable to LSGs. As
one interviewee noted, the community members manage to achieve more
in locations where the LSGs support the VHCs’ work (CSO 5).
Emphasizing this significance of internalization of the norm at the indi-
vidual level, this book makes no generalizations, but it highlights that in
cases when this internalization occurs, the state actors pursue the “empow-
erment” approach toward community members, and where it does not,
the “utilitarian.”
198 G. Isabekova
Without internalization of the norm and transformation in a discursive

form at an individual level, tacit knowledge will result in state organiza-
tions exercising “power over” the CBOs.
The Ministry of Health’s agenda, not that of the communities, pre-
vailed in the relationships between these actors. One vivid example of
ministerial agenda guidance can be found in the cutting of the number of
training areas after the end of CAH. During the project, the HPUs pro-
vided a broad range of training to the VHCs in the areas relevant to their
work. After the end of the CAH, training shrunk to four areas prioritized
by the national health care program: TB, HIV/AIDS, cardiovascular dis-
eases, and mother and child health. The VHCs received no training out-
side these four areas, even though other issues might have been equally
important to their communities or to their organizational capacity. In this
regard, an interviewee closely working with the VHCs claimed that the
Ministry “used” the CBOs to achieve its indicators on preventive activities
without “acknowledging” the VHCs or their work. This way, although
reporting on the engagement of VHCs, the Ministry does not provide
institutional support for the VHCs’ organizational capacity (CSO 1).
This cooperation, following the approach/agenda of the recipient state
rather than that of communities, qualifies the relationships between the
Ministry and the VHCs as a “utilitarian” approach toward the CBOs. The
CBOs were “passive” recipients (Rasschaert et al., 2014, p. 7) of training
courses and a “means” of implementation (Morgan, 2001, p. 221) for the
Ministry, which was guided by its own agenda rather than the agenda of
the VHCs. This style of relationships is drastically different from the
“empowerment” approach of the SRC toward the VHCs, where the com-
munity-based organizations expressed their concerns and set priorities,
acting as the key decision-makers.
Without the transformation of tacit knowledge into discursive, HPUs
pursued a “utilitarian” approach toward community-based organizations.
As part of primary health care, the HPUs have an increased workload,
which, combined with low salaries, may contribute to pro forma rather
than actual work with communities unless an individual HPU member
decides otherwise (see Chap. 6). The “empowerment” approach toward
CBOs also depends on the extent to which individual medical profession-
als internalize the principle of nondominance or maintain the hierarchical
doctor-patient relations consonant with the Semashko health care system

inherited from the Soviet Union. The project cycle offered a glimpse into
issues, including the protective attitude of medical professionals question-
ing the exercise of VHCs and their activities in health. Thus, at an organi-
zational level, HPUs may have limited incentives for pursuing the
community empowerment approach.
Overall, the recipient state’s “utilitarian” approach toward CBOs is pri-
marily an outcome of power dynamics between these stakeholders.
Interestingly, all other things being equal, internalization of the empower-
ment and nondominance norm at the individual level seems to be decisive
in transforming the tacit knowledge into a discursive form, and thus creat-
ing the “power to” in place of “power over.”
Correspondingly, the relationships between the LSGs and community-
based organizations depended on the extent to which the former consid-
ered CBOs equal to them or merely instrumentalized VHCs for the sake
of their own objectives. Engaging with the VHCs is essential for the work
of the local authorities since the VHCs not only have the capacity for dis-
semination activities, but also have a certain status in their communities.
One interviewee noted that not a single activity organized by the LSGs
takes place without the VHC, which also helps the local authorities mobi-
lize the local population (CSO 2). The community-based organizations
express their concerns and participate in the LSGs’ decision-making pro-
cesses. However, their ability to set priorities on the agendas of the local
authorities remains unclear. The VHC involvement in meetings seems to
be limited to supporting the activities of the local self-government. In
these circumstances, the VHCs remain the “means” of implementation
(Morgan, 2001, p. 221), which qualifies the relationships between the two
actors as a “utilitarian” approach on the part of the local self-government
toward the community-based organizations.
What are the actors’ interests in the “utilitarian” approach? Through
cooperation with the VHCs, the Ministry of Health improves the perfor-
mance of the national health care program by increasing the awareness of
the population about the diseases relevant to the four areas prioritized in
the program. Through the VHCs, the Ministry has the possibility to out-
source disease prevention measures and health promotion activities from
overloaded and understaffed primary health care personnel to the
200 G. Isabekova
population itself. For the VHCs, the HPUs have remained the main
source of training since the end of the CAH. Although they are not receiv-
ing training in other areas, the VHCs continue to improve their knowl-
edge of the prevalence and prevention of the four diseases prioritized in
the national health care program, which contributes to their expertise in
disease prevention and health promotion. These reasons explain both the
VHCs’ and the Ministry of Health’s interest in pursuing a “utilitarian”
approach to the CSOs. HPUs, in their turn, engaged with the VHCs as
part of their responsibilities.
Surely, the VHCs could have also benefited HPUs by providing out-
reach to local communities. Equally, the local authorities have a limited
capacity for outreach among the community members in their villages
(CSO 1). Therefore, the VHCs served as mediators between the recipient
state and the local population. For the VHCs, collaboration with local
self-governments offers limited financial incentives due to the budget defi-
cit, but does provide administrative support for community activities.
Notably, the VHCs were not financially dependent on any institution rep-
resenting the recipient state.
7.3 Donor–Donor: Unequal Cooperation

In terms of structural factors, there is no explicit hierarchy in the relation-
ship among donors, in contrast to donor–recipient relations. The unequal
cooperation between donors formed primarily as a result of uneven
involvement in the project and power dynamics.
Donor participation in the CAH was uneven. Absent during the initia-
tion and design period, USAID and Sida joined the project during the
implementation phase to support the countrywide roll-out of this initia-
tive. Yet, the two donors had different forms of engagement: while USAID
implemented the program activities in collaboration with the SRC train-
ers, Sida financed the SRC activities in the agreed areas without direct
participation in the project. Despite this difference, both donors complied
with the SRC’s approach to communities, including the principle of “non-
dominance” and evaluation of the VHCs and their work according to the
criteria developed by the SRC. Thus, both implementation and evaluation
phases were primarily guided by the SRC, with two actors following its
framework.
This inequality also found its reflection in the power dynamics between
the three donors, which combined attributes of both “power over” and
“power to.” In this context, the former is related to the preeminent posi-
tion of some organizations, whereas the latter concerns the ability of orga-
nizations to work with each other.
First, the SRC exercised “power over” two other organizations through
what Haugaard (2003, p. 108) called “reification.” Reification occurs if
stakeholders reinforce power relations because these relations are based on
more than “simply arbitrary convention” (ibid.). In the case of the CAH,
the reification concerns the “evidence-based” nature of arguments in favor
of the SRC’s approach. Though not explicitly focused on community
engagement in health, the SRC has nevertheless demonstrated the effec-
tiveness of its approach. These kinds of achievements supported the evi-
dence for the “Jumgal model” (see Chap. 5) and contributed to USAID
and Sida’s compliance with the SRC’s approach, including the nondomi-
nance principle, during the design and implementation phases as the proj-
ect expanded beyond the selected regions.
Second, the “power to” was a result of the social order related to the
ownership of the recipient country and harmonization among donors. It
facilitated the collaboration between development partners guided by the
global agenda on aid effectiveness. The principles of “ownership” and
“harmonization” that would become almost synonymous with effective
aid were accentuated in the Paris Declaration on Aid Effectiveness (2005)
and the following Accra Agenda for Action (2008) (see S. Brown, 2020).
The significance of these two principles is vividly demonstrated by the
support USAID and Sida offered following the Ministry of Health’s call
for the expansion of the Jumgal model. The project life cycle vividly dem-
onstrates that the commitment of the recipient state to provide Health
Promotion Units encouraged donors to support the CAH. This response
is consonant with the principle of “ownership” recalled in the Paris
Declaration (OECD, n.d.). Similarly, a rapprochement between develop-
ment organizations during the evaluation phase helped avoid duplica-
tions. Donors continued monitored project achievements, also by
involving external consultants. Yet they seem to have agreed to retain the
202 G. Isabekova
community capacity-building criteria developed by the SRC as the key

approach to evaluating the VHCs and their activities in health.
At the same time, the social order has also contributed to the SRC’s
“power over” other organizations due to its awareness of the areas the
recipient state was willing to expand. The idea of community participa-
tion in health has been discussed since the 1950s and culminated in the
1970s with the adoption of the Alma-Ata declaration (1978) (Morgan,
1993). This social order on community participation in health contrib-
uted to the emphasis on empowering local community members and
community-based organizations. This bias has also allowed the SRC to
implement the project and encouraged two other donors to join its expan-
sion process in their efforts to contribute to the reform of the Kyrgyz
health care system. Implemented in combination with reification, the
“power over” created through social order was still different. Thus, in con-
trast to the evidence-based rationale of reification, the power here was an
outcome of development organizations following the global agenda on
community participation.
In both cases of social order creating the “power over” and the “power
to,” development organizations confirmed the meaning of community
participation in health and the recipient state’s ownership over the assis-
tance. Both endorsed the Jumgal model, resulting in development organi-
zations supporting the CAH as the initiative pursued by the Ministry of
Health and giving the leading role to the SRC based on its experience and
expertise on the desired topics.
Why did these three donor organizations engage in unequal coopera-
tion? USAID and Sida agreed to unequal cooperation because of the
SRC’s expertise in community involvement. Overall, donors vary in their
capacities, in their awareness of the context in recipient countries, and in
other characteristics; however, the power dynamics between the donors
are relatively equal (Chap. 2). A “dominant” donor only emerges if the
other donors are “less motivated” or “financially less able” to compete
(Bueno de Mesquita & Smith, 2016, p. 2). The leading role of the SRC in
the CAH was related not to funding, but rather to its expertise in com-
munity involvement, which was also acknowledged by the Ministry of
Health. Developing community capacity was the main area of activity for
neither USAID nor Sida. Implementing the “ZdravPlus” (2000–2005)
and “ZdravPlus II” (2005–2009) projects in five Central Asian countries

(Abt Associates, 2023), USAID capitalized on primary health care devel-
opment. As the core financier of the Sector-Wide Approach, Sida aimed to
support health care reforms in Kyrgyzstan. In this way, the development
of community capacity was only part of USAID and Sida’s activities,
which may explain their interest in going along with the SRC’s approach
instead of developing a new one. For the SRC, USAID and Sida involve-
ment provided the necessary finance for the countrywide expansion of the
pilot program.
7.4 Donor–Recipient State: (Contingent)

Equal Cooperation
Both stakeholders participated throughout the project realization process.
However, the formation of the type of aid relationships between them
largely depended on the structural factors and power dynamics.
The relations between the SRC and the Ministry of Health, including
the HPUs,1 combined both the “power to” and the “power over.” The SRC
supported the ministerial social order, creating the “power to,” but reifica-
tion contributed to the SRC’s “power over” the Ministry. Yet, the relation-
ships between stakeholders also largely depended on the transformation of
knowledge state representatives received from the SRC.
The Ministry of Health advocated for a new social order in which the
population, and not only the state, was responsible for health. Following
Haugaard (2003, p. 91), the social order creates power through predict-
ability emerging from actors’ “structuring” and “confirm-structuring”
specific meanings. In other words, the social order is built on predictabil-
ity assured through actors acting in compliance with ideas that support
this social order (Haugaard, 2003, p. 90). The project life cycle and, more
specifically, the initiation phase of the CAH vividly demonstrated the shift
in the governmental agenda toward delegating part of the state’s
1
I do not include the local self-governments here as they did not directly work with the SRC. Affected
by the decrees from the government, they have worked with CBOs but had only limited interaction
with the SDC and SRC.
204 G. Isabekova
responsibilities for health care to its citizens. The Ministry conducted

reforms according to the social order of increased population responsibil-
ity for its health (see Government of KR, 2006; WHO/Europe and
UNDP, 1997). The government commenced optimization reforms in the
hospital sector to increase primary health care funding. This emphasis on
prevention over treatment and individual responsibility over health was
also consistent with the Alma-Ata Declaration (1978) and the Ottawa
Charter for Health Promotion (1986). The Charter highlighted that
health was the responsibility of an individual and community, and not just
one of the health sector alone (WHO/Europe, 1986). The Declaration
stressed primary health care and called for the participation of individuals
and communities in health care to overcome health inequalities within
and between countries (WHO/Europe, n.d.).
The CAH was consonant with the social order the Ministry advocated
for. The CAH aimed to “enable rural communities to act on their own for
the improvement of their health” and support the state health care system
“to work in partnership with communities for improving their health”
(Kessler & Renggli, 2011, p. 24). These objectives were in harmony with
the state agenda and international documents mentioned above. Through
its objectives and activities, the CAH confirmed the social order promoted
by the Ministry. The VHCs’ activities allowed a nationwide expansion of
awareness-raising campaigns and subsequent prevention of diseases sig-
nificantly affecting the population, also according to the national health
care strategies. In addition to cost-saving (see Chap. 6), these activities
supported overloaded medical professionals in primary health care and
expanded the coverage of prevention activities to rural areas, in which
access to health care is particularly pressing.
However, in contrast to the state initiative, the project stipulated
broader community participation in, and not only responsibility over,
health. Having its roots in these international declarations, the state
reforms were still driven by efficiency concerns. As one state official
engaged in reforms at that time noted, several hospitals were demolished
to reduce the excessive spending on maintenance, because they took up
most of the public health financing (State Partner 1). Though highlighting
responsibility, the state documents did not indicate the participation of
communities or populations in health (e.g., Government of KR, 2006).
The CAH, in contrast, foresaw community participation in health. This

difference in framing was crucial to community engagement and subse-
quent agenda-setting in health. This way, the community members and
organizations were not mere implementers of state or donor-defined
objectives, but also had the opportunity to define their own agenda.
In addition to supporting the Ministry’s social order (the “power to”
mentioned above), the SRC also had the “power over” the Ministry
through reification. As discussed in donor–donor relationships in this
chapter, the “Jumgal model” was a demonstration of the effectiveness of
community participation in health. It demonstrated the effectiveness of
the SRC’s nondominance approach and became evidence in favor of it.
This “evidence-based” rationale was the basis for reification, a situation in
which stakeholders reinforce power relations, even if these relations are
unequal, based on the belief that these relations rest on more than “simply
arbitrary convention,” in this case referring to science as the source of rei-
fication (Haugaard, 2003, pp. 104–105). It is important to remember
that though consistent with the state agenda, the CAH went beyond it. In
addition to targeting priority areas in the national health care program,
the VHCs also pursued their own objectives (e.g., capacity-building) and
problems their communities defined as significant. Thus, though support-
ive of state medicine, these activities also increased requests community-
based organizations sent to state institutions, including the local
self-governance organizations (see Chap. 5), which may not be ideal in the
circumstance of a budget deficit.
Combined with reification, the tacit knowledge created the SRCs’
“power over,” though its transition to discursive also contributed to the
“power to.” The Ministry followed the SRC’s approach in the project imple-
mentation and evaluation phases. Trained according to the principle of
nondominance, the HPUs trained the VHCs accordingly and evaluated
the VHCs using the community capacity-building criteria developed by
the SRC. In so doing, the Ministry and HPUs “confirm-structured” the
systems of thought on community participation advocated by the SRC. On
the level of “practical consciousness,” the knowledge the HPUs received
from the SRC contributed to unequal power relations in which the recipi-
ent state followed the approach suggested by a donor. However, a transition
of this knowledge into a “discursive form” empowered the HPUs and the
206 G. Isabekova
Ministry (Haugaard, 2003, p. 108). Accordingly, the HPUs did not apply
this knowledge following donor recommendations or regulations from the
Ministry. Instead, the HPU representative applied this knowledge due to
personal vision or motivation. This perspective is likely behind the state-
ment of an HPU representative, who noted that medical professionals
“should not be teachers” but rather “equal to” the population they treat
(CSO 5). Resulting from a personal vision or motivation and not incul-
cated from outside, the knowledge becomes discursive and enables the
HPUs to build relations with communities. This significance of a personal
perspective was also vivid at the end of the project, as the HPUs continued
training community-based organizations without the SRC’s support.
Overall, the relations between the SRC and the Ministry of Health,
including the HPUs, combined both the “power to” and the “power over.”
However, the transition of tacit knowledge into discursive was critical to
equal cooperation between the donor and recipient state. Thus, if the state
representatives applied the knowledge based on personal vision and com-
mitment and not following the regulations from “outside,” this knowledge
became discursive and empowered the recipient state instead of the donor.
Notably, the structural conditions, including predictability and flexibil-
ity of aid, capacity, and aid dependence of state institutions, did not have
definite implications on the type of relationships formed between the
actors. On the one hand, the Swiss aid was predictable and flexible,
reflected in the duration of the CAH (thirteen years) and adjustment to
the “wishes” of the Ministry of Health at the beginning of the project. On
the other hand, the capacity of the recipient state, on the part of both the
Ministry and the HPUs, remained somewhat limited (see Chap. 4). The
state institutions also relied on the SRC’s expertise in working with com-
munities due to the lack of prior experience in this area. Thus, the struc-
tural factors could have contributed to both equal and unequal forms of
aid relationships.
What was the Ministry of Health’s interest in pursuing equal coopera-
tion, which was contingent upon knowledge transformation? The Ministry
intended to strengthen primary health care in the country and get citizens
to take more responsibility for their own health, which is also reflected in
the national health care reform programs. However, the Ministry had lim-
ited interaction with the population and no previous experience in
working with communities. Acknowledging the success of the “Jumgal

model,” the Ministry requested the nationwide roll-out of this program
and agreed to provide the HPUs for this purpose, following the SRC’s
request. The ministerial decision to establish the HPUs is remarkable,
given the budget deficit in the country (and particularly in health care).
This may, however, also have been a response to the SRC’s flexibility and
responsiveness to ministerial requests, particularly at the beginning of the
project. Notably, the renovation of hospitals exclusively had not been part
of the SRC or the SDC’s vision (Schüth, 2011b, p. 23), and yet, despite
this, the donor had supported the maintenance works in the Naryn region
as demanded by the Ministry.
To understand the Ministry of Health’s interest in committing itself to
the CAH, it is also important to consider the relationships between the
Ministry and the SDC, which financed the project. The SDC is one of the
three donors, along with the German Development Bank and the World
Bank, providing financial assistance for health care in Kyrgyzstan. The
relationship of the Ministry with the donors, particularly with those pro-
viding the financial assistance, is unequal (see Isabekova & Pleines, 2021).
According to a development partner, budgetary assistance allows develop-
ment partners to promote their “parallel” projects (IO Partner 9) or the
projects implemented along with the budget assistance. This way, the posi-
tion of the SDC may have been a foreground for the Ministry to include
the CAH in the Sector-Wide Approach. This inclusion contributed to
coordination among development organizations and “more efficient use of
available resources in support of the CAH model” (Gotsadze & Murzalieva,
2017, pp. 13–14).
Why did the SRC pursue equal cooperation? The main reason behind
the SRC’s interaction with the Ministry of Health and the HPUs was the
sustainability of the CAH beyond the period of donor funding, which
required the acknowledgment and commitment of the Ministry to the
project activities. Another reason was the idea of “ownership,” which
intended to show the engagement of the recipient state and its ownership
over the project, following the social order described in the “donor–donor”
section of this chapter. Similar reasons guided stakeholders in the grants
provided by the Global Fund to Fight AIDS, Tuberculosis and Malaria
(see Chap. 10) to be introduced in the following chapter.
208 G. Isabekova
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right holder.
8
The Global Fund Grants: Project
Life Cycle
The Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global
Fund) delegates the realization of its project in Kyrgyzstan to the relevant
national actors involved in tuberculosis (TB) and human immunodefi-
ciency virus infection and acquired immune deficiency syndrome (HIV/
AIDS) programs. However, external development actors are equally rel-
evant since the Global Fund project is implemented in parallel with other
health aid provided to the country. These actors are grouped into the
following three analytical categories:
First, the recipient state refers to the Ministry of Health, represented by

the National Center of Phthisiology and the Republican AIDS Center.
Second, civil society organizations (CSOs) are the local nongovernmental
organizations (NGOs) receiving the Global Fund grants, but not the
community-based organizations, as in the case of the “Community
Action for Health” project in Kyrgyzstan.
Third, donors denotes the Global Fund and other international organiza-
tions working on TB and HIV/AIDS, such as the United States Agency
for International Development (USAID); World Health Organization
(WHO); German Development Bank (die Kreditanstalt für

212 G. Isabekova
Wiederaufbau—KfW); Joint United Nations Programme on HIV/

AIDS (UNAIDS); United Nations Population Fund (UNFPA); and
United Nations Educational, Scientific and Cultural Organization
(UNESCO).
In addition to these three analytical categories, the grants involve the

Local Fund Agent (LFA) and the United Nations Development
Programme (UNDP). LFA involvement is a standard part of all Global
Fund financing, being responsible for validating the information pro-
vided by grant recipients. The UNDP is not on the list of donors, but
rather became the first-line recipient of the Global Fund grants after the
misappropriation of funds by the official(s) of the state organization. The
following subsections expand on the roles of these national and interna-
tional actors throughout the project cycle (i.e., the initiation, design,
implementation, and monitoring phases).
8.1 Initiation
This phase is critical to understanding who stands behind the objectives
targeted by health aid. According to Andrews (2013), ideally, assistance is
driven by the pressing problems of the aid recipient and not by the objec-
tives imposed by donors from outside. This section discusses whether TB
and HIV/AIDS were perceived as significant issues in Kyrgyzstan before
the assistance from the Global Fund.
Indeed, the problem of HIV/AIDS and TB was recognized as pressing
in Kyrgyzstan long before the country received the Global Fund grant. To
address the increasing HIV incidence in the country, the government
initiated the National Program on Prevention of HIV and Sexually
Transmitted Infections (STIs) (1997–2000). It restated the country’s
commitment to the Paris Declaration (1994) by recognizing the threat of
the AIDS pandemic and the need to fight against HIV/AIDS (WHO,
1995). This program prioritized the prevention of Sexually Transmitted
Infections (STIs), including HIV, through awareness-raising activities,
improved blood donor screening, and distribution of condoms
(Government of KR, 1997). However, it also acknowledged insufficient
financing for health care and noted that even a small number of HIV
8 The Global Fund Grants: Project Life Cycle 213
cases represented a burden on the state budget (ibid.). Correspondingly,

the national program highlighted the contributions of the UNDP,
UNFPA, UNAIDS, UNESCO, and WHO to HIV/AIDS-related activi-
ties (ibid.). International development organizations were equally signifi-
cant to the National Tuberculosis Program (1996–2000), which aimed to
develop an affordable solution to the growing number of TB cases in the
country. In addition to vaccinating newborns and children and identify-
ing the sources of infection, this program intended to standardize chemo-
therapy treatment (Government of KR, 1995). The country adopted the
WHO-recommended Directly Observed Treatment Short course
(DOTS). A countrywide roll-out of the DOTS was possible due to the
WHO’s technical assistance and a continuous supply of medications
from the German government. Still, problems with limited financing and
a disparity between the activities and the TB epidemic in the country
remained (Government of KR, 1995, 2008).
As seen above, TB and HIV/AIDS-related activities were present in
the country before the Global Fund. The presence of these activities,
despite their insufficient funding, hints at the political commitment of
the government to combat the two diseases. Furthermore, its collabora-
tion with multiple donor organizations points to the fact that the state
initiative was in place long before the arrival of the first Global Fund
grants to the country in 2004.
8.2 Design
The design phase expands on stakeholders’ roles in defining the content
of grant applications and their participation in the application process.
This section discusses the compliance of grant applications with national
programs; how recommendations and requirements of the Global Fund
still shape the content of grants; and elaborates on the roles of national
and international stakeholders in drafting the country’s applications to
the Global Fund.
First of all, in terms of the content, the grant applications are conso-
nant with the health care objectives of recipient countries in the areas
targeted by the Global Fund. A close overview of project activities and
national TB and HIV/AIDS programs of the Kyrgyz Republic
214 G. Isabekova
demonstrates adherence of activities to national goals. My interviewees

support this observation (State Partners 4 and 9) and note that compli-
ance with national strategies is the foremost evaluation criterion for the
applications (IO Partner 4). Nevertheless, this adherence focuses on dis-
eases targeted by the Global Fund (TB, HIV/AIDS, and malaria) and not
necessarily on those causing the most deaths on the local level.
To illustrate, non-communicable diseases, such as ischemic heart dis-
ease and stroke, were the leading causes of death in the Kyrgyz Republic
between 2009 and 2019 (Institute for Health Metrics and Evaluation,
2023). TB, by contrast, ranked 10th in 2009 and 16th in 2019, and
HIV/AIDS was not among the most common causes of death (ibid.).
One state official noted that, despite the clarity of this data, cardiovascu-
lar diseases received the least funding in the national health care program
(2012–2018), whereas TB and HIV/AIDS received the most (State
Partner 6). In fairness, it should be noted that the ranking mentioned
above may be an outcome of the Global Fund grants improving the
detection and treatment of the two diseases and, in doing so, extended
the lives of persons affected by TB and HIV/AIDS—the relative fall in
TB as a cause of death over the period 2009–2019 being one piece of
evidence for this argument. Still, the extensive funding for two diseases
alludes to the role of the organizational mandate in shaping grant appli-
cations. In this regard, a state representative notes that “technical specifi-
cations are developed by the donor, and all the rest is adjusted to its tune”
(State Partner 4).
The Global Fund’s requirements and recommendations also consider-
ably shape the grant applications. Recommendations are not binding,
but requirements are implicitly put forward via the explicit conditions
the applicant is expected to meet to receive or continue receiving the
grants.1 Joint application and “dual-track financing” could be typical
1
I will not focus on technical specifications, such as the provisions of the procurement plan (see
Grant Performance. Report External Print Version. Kyrgyzstan KGZ-910-G07-T, 2016), submis-
sion of policies and procedures to evaluate them (Grant Performance Report External Print Version.
Kyrgyzstan KGZ-607-G04-T, 2012), and appointment of an “independent auditor” to evaluate
the program (Grant Performance Report External Print Version. Kyrgyzstan KGZ-202-G01-H-00,
2011), provision of updated plans on monitoring and evaluation (Grant Performance. Report
External Print Version. Kyrgyzstan KGZ-910-G07-T, 2016), and others. For more information on
these, see the documents related to the Global Fund grants to Kyrgyzstan.
instances of recommendations, whereas the incorporation of human

rights, co-financing, and the Country Coordinating Mechanism (CCM)
serves as illustrative examples of the Global Fund’s requirements.
However, in this regard, an interviewee notes that applicants, including
Kyrgyzstan, equally follow both recommendations and requirements,
though the former are not binding (IO Partner 20).
Kyrgyzstan submitted a joint application for two diseases. The Global
Fund introduced the submission of joint applications as part of its New
Funding Model (2012–2016) in order to facilitate dialogue and decision-
making between the disease programs and ensure greater synergy and
strategic use of funding (Global Fund, n.d.-c). The new scheme was
designed exclusively for those countries with high TB-HIV coinfection
rates, and encouraged those ineligible for further financing to submit
joint applications for diseases (ibid.). Thus, in addition to applicants
transitioning from the Global Fund grants (ibid.), joint proposals were
relevant to many countries in Sub-Saharan Africa, where, for instance,
nearly half of TB patients were HIV-positive in 2012 (Nelson, n.d., p. 4).
Kyrgyzstan was neither transitioning from the grants nor did it have high
TB-HIV coinfection rates. In 2012, for instance, only 2.2% of TB cases
were found to be HIV-positive (Global Fund, 2014, p. 8). Still, the coun-
try submitted a joint TB/HIV application in 2015 for the first time since
it received the Global Fund grants. This fact corresponds to the country’s
acquiescence to recommendations, suggested by the interviewee in the
previous paragraph.
The country has also incorporated “dual-track financing” in the grant
implementation process (see the section on “Implementation”). According
to this approach, the Global Fund streams financing via “two tracks”—
state and non-state actors—to strengthen the role of civil society and the
private sector in grants (Global Fund, 2015, p. 3).2 It encourages the
CCM to use this approach to financing each disease and asks for an
2
Involvement of the private sector in grant implementation in Kyrgyzstan is somewhat limited.
According to UNDP (2015a, p. 38), eight private pharmacies, eight NGOs, and thirty-two state
health care facilities offered HIV prevention, care, and support services to persons who inject drugs.
Private sector involvement in the Global Fund grants included testing and treatment services by
client-friendly clinics and a private family group practice in Issyk-Kul region, and a few other
instances (Murzalieva et al., 2007, p. 41).
216 G. Isabekova
explanation if the CCM do not apply this approach (ibid.). Yet, unlike
the CCM, dual-track financing is not a requirement, although my inter-
viewees’ perceptions of it varied: some saw it as a recommendation based
on international practice (CSO 8), and others approached it as a condi-
tion for financing (State Partner 2).
Despite the country’s compliance with both recommendations, this
book differentiates between recommendations and requirements to dis-
tinguish their (non-)binding nature. Though possibly increasing the
chances for funding, the recommendations are not preconditions for
financing, unlike the Global Fund requirements discussed below.
First, the applicants are expected to incorporate human rights into
their grant applications. The Global Fund denies supporting programs
violating human rights (“Local Fund Agent manual. Section G—Global
Fund essentials,” 2014, p. 18). It asks applicants to target human rights
and gender constraints on health care services (Global Fund, 2016a) and
stipulates additional financing, also known as “catalytic investments,” for
this purpose. In the case of Kyrgyzstan, the catalytic investments in the
amount of US $1 million focused on eliminating human rights con-
straints on HIV-related health care services (Global Fund, 2023b). The
country took several steps to address human rights issues among groups
vulnerable to HIV, including men who have sex with men (MSM), com-
mercial sex workers (CSWs), persons who inject drugs (PWIDs), and
others. The Government of the Kyrgyz Republic decriminalized sex
between men and voluntary adult sex work and introduced changes to
the law on possession and use of drugs (Ancker et al., 2017). Although
these changes cannot be attributed to the Global Fund alone, they never-
theless constitute changes corresponding to the human rights perspective
in the country’s applications to the Global Fund. Thus, the country’s
joint HIV/TB proposal for 2017–2019 aimed to eliminate the “legal bar-
riers to human rights-oriented services” (Zardiashvili & Garmaise, 2017,
n.p.). Similarly, the country’s previous applications stipulated training of
law enforcement officers on stigma, discrimination, and HIV/AIDS pre-
vention (see UNDP, 2015b).
Another example of Global Fund regulations followed by the appli-
cants is co-financing or a domestic contribution by the grant recipient
country in the form of government revenues, loans, health insurance, and
others to the areas supported by the Global Fund (2016a, p. 12). The
goal of this scheme is to demonstrate that the Global Fund grants are
complementary to (Brown & Griekspoor, 2013) but do not replace state
funding to relevant areas (Vujicic et al., 2011). Applicants are allowed to
waive this requirement upon the provision of a detailed plan on how they
intend to catch up with co-financing in the future (Global Fund, 2016a).
The Global Fund negotiates the share of cofinancing with each appli-
cant individually, but sets general thresholds depending on income
groups. Lower low-middle-income countries such as Kyrgyzstan are
expected to cover at least 50% of financing for disease programs and pro-
gressively absorb the key program costs (Global Fund, 2016a, pp. 5, 16).
Notably, 15% of grant disbursements are conditional on the fulfillment
of this requirement (ibid.). In compliance with co-financing (State
Partners 2 and 9), the country planned to increase the share of state fund-
ing for TB and HIV. More specifically, national stakeholders developed
detailed plans, also known as roadmaps, to gradually transfer donor-
funded services in these two areas to the state budget. My interviewees
note that the cofinancing increased the state funding for TB and HIV/
AIDS (CSO 3; IO Partner 3) and that without this condition, the gov-
ernment “would not even move a centimeter to look [for money] in its
budget” (CSO 8). In this way, the country followed this explicit regula-
tion from the Global Fund, similar to the accounting for human rights in
grant applications.
Third, the most salient yet implicit requirement grant applicants,
including Kyrgyzstan, comply with is the CCM. Applicants are expected
to have a unit to supervise the planning, implementation, and use of
grant resources (Global Fund, 2008, p. 9). Although not explicitly asking
for the establishment of the CCM, the Global Fund accepts applications
without CCM only in “exceptional circumstances,” that is, from coun-
tries in conflict or without a legitimate government and those facing
natural disasters and other emergencies (Global Fund, 2018, p. 21).
Established during the country’s first application to the Global Fund, the
CCM in Kyrgyzstan has 23 members (nine CSOs, nine state, and five
donor representatives) (Committee on TB and HIV under the
Government of KR, 2023) and 23 alternates (State Partner 10 and
Academic Partner 2). Alternates are primarily recipients of Global Fund
218 G. Isabekova
grants. In contrast to members, they have observer status, which pre-

cludes them from voting or participating in grant monitoring due to
conflicts of interest. CCM meetings are case-dependent, but their fre-
quency increases during the development of grant applications (IO
Partner 3).
The CCM in Kyrgyzstan underwent multiple changes because of a
narrow focus on three diseases and duplication of existing institutions.
The CCM added to at least three coordinating platforms the country had
before the application to the Global Fund (see Table 8.1). In 2005, these
platforms merged into the Country Multisectoral Coordinating
Committee to fight HIV/AIDS, Tuberculosis, and Malaria (Murzalieva
et al., 2007, p. 22). It engaged representatives of state agencies and min-
istries, international organizations, CSOs, and persons living with HIV
(Government of KR, 2006) and dealt with the Global Fund grants exclu-
sively (State Partner 2).
However, in 2007, the responsibilities of the Committee expanded to
over 40 infectious human and animal diseases (Ancker et al., 2013,
Table 8.1 Evolution of the Country Coordinating Mechanism in Kyrgyzstan

The National Multisectoral Coordinating Committee for The Sector-Wide
HIV/AIDS Prevention (1997) Approach (SWAp)
The UN Thematic Group on HIV/AIDS (1996–2001) to Health care
The Coordinating Committee for Prevention of Drug (preparations
and Alcohol Abuse (2001) commenced 1996;
The Country Coordinating Committee on Prevention of SWAp formalized
STIs, HIV/AIDS and Tuberculosis (2002) 2005)
Country Multisectoral Coordinating Committee to Fight
HIV/AIDS, Tuberculosis and Malaria (2005)
The Multisectoral Country Coordination Committee on
Socially Significant and Especially Dangerous
Communicable Diseases (2007)
The Country Coordination The Coordination
Committee (2011) Council of Public
Health (2014)
Integration of the Country Coordination Committee into
the Coordination Council of Public Health under the
Government of the Kyrgyz Republic (2017)
This table was compiled by the author based on Murzalieva et al. (2007, 2009),
and other sources
pp. 75–76). Though aimed at enlarging the Committee’s competence

beyond malaria, TB, and HIV/AIDS, this change jeopardized its ability
to supervise the grants (Manukyan & Burrows, 2010) and resulted in the
delegation of responsibility over three diseases to the Country
Coordination Committee under the Ministry of Health. Yet, the
Committee had limited impact beyond the supervision of grants. It did
not participate in developing and evaluating national policies relevant to
the three diseases (Ancker & Rechel, 2015b). Furthermore, grant-related
issues required broader engagement of stakeholders. For instance, irre-
spective of the decision taken at the level of the Ministry of Health, dis-
crimination against sex workers and prosecution of drug users by police
forces continued due to their accountability to the Ministry of Internal
Affairs and not the Ministry of Health (State Partner 4). The following
reform aimed to address these issues.
Integration into the Country Coordination Council for Public Health
under the Government of the Kyrgyz Republic elevated the authority of
the Committee and partially addressed the issues with duplication of
existing institutions. This integration guaranteed a high level of authority
for the Committee’s decisions (CSO 8) and compliance of stakeholders
beyond the Ministry of Health (State Partner 4). The Council involves all
relevant ministries and stakeholders, including the Parliament, under the
chairmanship of the vice prime minister responsible for social affairs
(WHO/Europe, 2019). This merger also aimed to reduce the duplication
of organizational mandates (Government of KR, 2017a).
Similar to the Committee, the Council sought to coordinate the actors,
though not only in the areas of three diseases but rather for Kyrgyz public
health in general. Its functions include developing and implementing
public health policy, monitoring and evaluating public health programs,
and coordinating actors working in this area (Government of KR, 2014).
It aimed to address the shortcomings of state stewardship in health care
observed in the Sector-Wide Approach (SWAp) to health care imple-
mented in Kyrgyzstan. Covering health care systems as a whole, the
SWAp still faces multiple issues, including the limited capacity of the
Ministry of Health and oversight of development organizations to pro-
vide the relevant support (see Isabekova & Pleines, 2021). Before incor-
porating the Committee into the Council, the Government of the Kyrgyz
220 G. Isabekova
Republic, with financial assistance from the Global Fund and SDC
(Health Focus, 2020), initiated a study that ascertained the feasibility of
integrating the Committee into the SWAp (Global Fund Office of the
Inspector General, 2016). However, the decision was taken in favor of
the Council due to, among other reasons, the limited representation (IO
Partner 4) and participation of civil society organizations in SWAp (see
Isabekova & Pleines, 2021).
During the process of applications, the CCM is intended to serve as an
inclusive platform for stakeholders working in TB and HIV/AIDS.3 It
aims to facilitate the collaboration between stakeholders (Spicer et al.,
2011a) and provide a broader representation of all relevant actors, includ-
ing people affected by the diseases and representatives of the private sec-
tor, academia (IO Partner 20), international development organizations,
state institutions, and civil society (State Partner 9). Civil society repre-
sentation is one of the critical aspects of the CCM: grant applicants are
expected to provide evidence for CCM membership of persons affected
by diseases or their representation by NGOs and individuals advocating
for their interests (Global Fund, 2018). Notably, delegate representation
may be waived by the Global Fund’s Secretariat to protect key popula-
tions (Global Fund, n.d.-c, p. 7), for instance, if direct participation of
persons affected by diseases, and subsequent disclosure of their status or
sexual orientation, may subject them to discrimination and criminaliza-
tion. In any case, national civil society should compose at least 40% of
the CCM, and CCM leadership (e.g., chair and vice-chairs) should be
elected from state and non-state actors on a rotational basis (Global
Fund, n.d.-c, p. 9).
However, the design of grant proposals in Kyrgyzstan shows that the
ideal scenario does not always play out. One state representative notes
that, in comparison to neighboring countries where CSOs have “no
voice,” the Kyrgyz state institutions take their opinions into account
(State Partner 2). However, the literature on civil society organizations
and development programs in Kyrgyzstan still points to the “tokenistic”
participation of NGOs (Spicer et al., 2011b, p. 1752) and persons living
with HIV (Ancker et al., 2013). Outnumbered by state representatives
3
Kyrgyzstan was declared malaria-free in 2006.
(Harmer et al., 2013), civil society members have limited resources of

their own to take part in meetings, and there are, in fact, no “effective
mechanisms” in the CCM to support their participation (Spicer et al.,
2011a, p. 10; Spicer et al., 2011b, p. 1752). This unequal distribution of
powers between the state and civil society organizations urged CCM
reforms in Kyrgyzstan (Manukyan & Burrows, 2010), particularly after
the Global Fund’s rejection of the country’s application.
CCM reforms addressed insufficient civil society representation and
participation in designing the grant applications. By 2014, the CCM
included two persons living with HIV, one affected by TB, one by coin-
fection of TB and HIV, two persons who inject drugs, one commercial
sex worker, and one MSM (UNAIDS, 2015a, p. 20). Despite this increase
in numbers, civil society participation in the decision-making process
remained limited. For instance, most civil society organization represen-
tatives had difficulties understanding the proposals written in English.
Due to the lack of documents in Russian and Kyrgyz, CSOs had a lim-
ited understanding of the country’s application to the Global Fund
(Global Fund, 2016b). Following the Global Fund’s rejection of the HIV
proposal due to its noncompliance with the CCM eligibility criteria in
2014, the CCM members applied for the Community, Rights, and
Gender Special Initiative of the Global Fund (ibid). This initiative cov-
ered extensive consultations with and capacity-building activities for
CSOs, based on findings from situation analysis and review of the coun-
try’s HIV proposal (ibid, pp. 12–15). Interviews with multiple stakehold-
ers, including the state, NGOs, and international organizations, identified
issues that were targeted during the capacity-building activities (ibid.),
contributing to the improved participation of civil society in the follow-
ing grant applications as well (Zardiashvili & Garmaise, 2017).
In addition to the Global Fund, multiple donor organizations support
national stakeholders in designing the applications. The organizations
providing technical assistance are the Stop TB Partnership, USAID,
UNAIDS, WHO, BACKUP Health,4 and others (Global Fund, 2023b).
4
The initiative implemented by the German Corporation for International Cooperation (die
Deutsche Gesellschaft für Internationale Zusammenarbeit—GIZ) and funded by the German Federal
Ministry for Economic Cooperation and Development (das Bundesministerium für wirtschaftliche
Zusammenarbeit und Entwicklung—BMZ).
222 G. Isabekova
A few individual examples of this assistance include the UNAIDS,

USAID, and the United Kingdom’s Department for International
Development (DFID)5 support to the state agencies and NGOs in pre-
paring the country’s HIV proposal and making the relevant budget calcu-
lations (Manukyan & Burrows, 2010). The WHO, in its turn, provided
an evaluation of the HIV situation in the country to support the govern-
ment in defining the priority areas for the HIV proposal (Mansfeld et al.,
2015, p. 8).
Similar assistance was provided in the areas of TB. The German
Internationale Zusammenarbeit—GIZ), for instance, offered training to
national stakeholders on the development of a joint TB/HIV proposal
(2018–2020) to the Global Fund (AFEW Kyrgyzstan, n.d.). In addition
to technical assistance, donors support national actors in coordinating
each other’s activities. They use the CCM to inform about their plans,
available budget (IO Partner 3), “preferences,” and prospective projects
(State Partner 10 and Academic Partner 2). This coordination’s purpose is
twofold. To avoid duplication of activities, the country’s proposals to the
Global Fund focus on the areas which are not covered by donors and are
consistent with the mandate of the Global Fund. Donor organizations
and the national government aim to cover the remaining areas (i.e., those
excluded from the country’s applications), though within the limits of the
financial possibilities and interests of each donor (State Partners 4 and 9).
These depend on organizational structure, earmarking, and geopolitical
interests that vary across donors and considerably limit the flexibility of
their assistance.
Overall, designing Kyrgyzstan’s applications to the Global Fund proj-
ect involves a large number of national and international actors working
on TB and HIV/AIDS in Kyrgyzstan. Donor organizations participate in
the country’s proposal to the Global Fund by providing their technical
assistance and taking over those areas not included in the proposal or
state budget. Overall, the country’s applications to the Global Fund com-
ply with national health care programs.
5
DFID was replaced by Foreign, Commonwealth and Development Office in 2020.
The grant applications are intended to cover the needs of all stakehold-
ers in targeted areas. By providing a platform for civil society organiza-
tions and the persons affected by the relevant diseases, the Global Fund
supports the representation of groups often excluded from decision-
making. This support is demonstrated by the Global Fund’s requirement
to establish the relevant platform, rejection of proposals not complying
with the civil society representation requirement, and provision of addi-
tional financing to strengthen the capacity of local CSOs. All these pos-
sibilities elevated the participation of often underrepresented and
vulnerable stakeholders in Kyrgyzstan. Their engagement in drafting the
grant applications in Kyrgyzstan was also intended to ensure that the
applications were consonant with the needs and interests of target groups
and not only with the aims of the recipient government and donor
organizations.
However, the design phase also shows that civil society representation
and its actual participation are still in their infancy. Hence, limited capac-
ity and awareness of grant regulations hinder CSOs from fully participat-
ing and discussing the country’s proposals. The Global Fund’s assistance
provided considerable support in this regard, but this was nevertheless
limited to a one-time event, and does not represent the regular activity
available to CSOs. The mature engagement of civil society is further hin-
dered by state organizations that reckon with this requirement, mainly
pro forma, to receive donor financing.
Along with promoting civil society representation and participation in
designing country proposals, the CCM, along with other recommenda-
tions and requirements, demonstrated the pertinence of the Global Fund
and its mandate in defining the content of the applications. The evolu-
tion of the CCM vividly showed that the country complied with require-
ments and recommendations, even if it meant duplicating existing
institutions. Multiple changes in the CCM structure allude to the
dilemma between ensuring the supervision of grants and integrating the
platform into the broader context of infectious diseases and health care in
general. Evidence suggests that Kyrgyzstan is not alone in these struggles:
an audit of 50 sample CCMs in recipient countries showed that they all
“partially or entirely” duplicated existing structures (Global Fund Office
224 G. Isabekova
of the Inspector General, 2016, p. 13). This supports the assumption

about the significance of the Global Fund recommendations and regula-
tions to grant applicants.
8.3 Implementation
The Global Fund delegates implementation of its projects to the Principal
Recipients (PRs) and Sub-Recipients (SRs) of its grants. Both are nomi-
nated by the CCM and approved by the Global Fund. Grant recipients
could equally be state or nongovernmental organizations, as long as they
have programmatic, financial, and management capacities (see Global
Fund, 2015). Great emphasis is placed on PRs, responsible for assessing
SRs, concluding contracts with them, and achieving the indicators stated
in the grant agreement with the Global Fund. The PR also provides a
procurement plan, reports on prices and quality of health products, coor-
dinates with partners, and fulfills other functions (see Grant Performance
Report External Print Version. Kyrgyzstan KGZ-202-G01-H-00, 2011;
Grant Performance Report External Print Version. Kyrgyzstan KGZ-H-
UNDP, 2016).
Not all actors are capable of accomplishing these responsibilities in a
timely manner. Nine to sixteen months may pass from the commence-
ment of a project until the arrival of the procured products (Global Fund
n.d.-c, p. 31). Delays in tasks may cause disruptions in treatment or other
services stipulated by grants. Ideally, the grant recipients are local public,
private sector, or civil society organizations, although in “exceptional cir-
cumstances” (e.g., conflict, currency risks), the Global Fund may tempo-
rarily approve the nomination of a multilateral organization or an
international NGO (Global Fund n.d.-c, p. 2). These organizations are
then required to provide a capacity-building plan and a timeline for
transferring their PR functions to national actors (ibid.).
In Kyrgyzstan, the Principal Recipients of the grants changed from
government institutions to international nongovernmental and multilat-
eral organizations in 2011 (Table 8.2). The following subsections discuss
the reasons behind this transfer of PR functions that are also relevant to
understanding the relations between the Global Fund, the state institu-
tions, and the NGOs involved in the grant implementation process.
Table 8.2 Principal Recipients of the Global Fund grants to Kyrgyzstan

Period Principal Recipient Area
2004–2011 National Center of Phthisiology TB
2004–2009 Republican AIDS Center HIV
2011–2015 Project HOPE TB
2011-present UNDP TB and HIV
Sources: The documents related to the Global Fund grants to Kyrgyzstan see
Global Fund (n.d.-c)
Initially, the Principal Recipients of the first Global Fund grants to

Kyrgyzstan were the National Center of Phthisiology (for TB) and the
Republican AIDS Center (for HIV grants). Implementation of both
grants was initially rated “strong” (Global Fund 2006a, p. 2, 2006b,
p. 2). My interviewees note that both agencies procured health products
according to the World Bank procedures (IO Partner 21), but the loop-
holes in the National Procurement Law still provided room for corrup-
tion schemes (State Partner 7). During the TB grant period (2007–2012),
the Global Fund hinted at management issues and agreed to continue its
funding primarily due to the engagement of the UNDP in building the
capacity of the two state agencies (Grant Performance Report External
Print Version. Kyrgyzstan KGZ-607-G04-T, 2012). Yet an anonymous
call to Global Fund headquarters about the financial violations taking
place in the country (IO Partners 11 and 21) resulted in a visit of its
Audit Unit, which took place between November and December 2009
(Global Fund Office of the Inspector General, 2012). It found “signifi-
cant financial irregularities” in the implementation process and urged an
investigation into this matter (Global Fund Office of the Inspector
General, 2013, p. 3).
This investigation, conducted by the Global Fund between February
2010 and August 2012, found multiple violations in the grant imple-
mentation process. There were violations in medical supply procurement
(IO Partner 21), unauthorized cash advances, and transfers to unauthor-
ized entities (Global Fund Office of the Inspector General, 2013).
Preposterous justifications for the misuse of funds included the construc-
tion of a fish pond fencing to serve fish to TB patients (IO Partner 21).
The head of the National Center of Phthisiology also used grant finances
to buy a vehicle for his wife (Global Fund Office of the Inspector General,
226 G. Isabekova
2013, p. 3), with “maintenance costs” exceeding the value of the vehicle
itself (IO Partner 21). Three out of four Sub-Recipient NGOs had family
ties to the head of the National Center of Phthisiology, and one of these
NGOs was used to misuse finances (Global Fund Office of the Inspector
General, 2013, p. 3). Similar issues were found in the grant implemented
by the Republican AIDS Center. My interviewees suggest that the initial
amount of misused finances identified during the audit reached several
million USD, but the state agencies provided supportive documentation
in their own defense (State Partner 4; IO Partner 21). However, US
$120,974 remained accounted for (Friends of the Global Fight Against
AIDS, Tuberculosis and Malaria, 2018). Despite the National Center of
Phthisiology’s disagreement with the investigation results (Global Fund
Office of the Inspector General, 2013, p. 68), the General Prosecutor’s
Office of the Kyrgyz Republic opened a criminal case on suspected mis-
use of position (Office of the Attorney General of KR, 2012). The head
of the National Center of Phthisiology passed away before the investiga-
tions were concluded.
The Global Fund repeatedly asked the Ministry of Health to return
finances that were unaccounted for. The Minister of Health neither
replied to the Global Fund requests (Kasmalieva, 2015) nor returned the
finances, referring to the budget deficit (Bengard, 2017). Notably,
Kyrgyzstan was not the only case of grant mismanagement. “Misuse” of
the grants was identified in Cameroon, Djibouti, Haiti, Mali, Mauritania,
and Zambia (Benjamin, 2011, p. 3). In response, the High-Level
Independent Review Panel on Fiduciary Controls and Oversight
Mechanisms of the Global Fund to Fight AIDS, Tuberculosis and Malaria
developed a report. Its recommendations included strengthening the
capacity of the CSOs to ensure their supervisory roles as well as a closer
evaluation of training activities in the grants. In Kyrgyzstan, the Global
Fund neither discontinued the grants nor contacted the supranational
authorities, as it usually does in corruption cases (see Global Fund, 2018).
Instead, it took a disciplinary measure by deducting US $241,948 or
“two dollars for every dollar that the Global Fund sought to recover”
from the following grant to the country in 2017 (Friends of the Global
Fight Against AIDS, Tuberculosis and Malaria, 2018).
After the mismanagement of finances by the state agency, the UNDP

became the main recipient of Global Fund grants in Kyrgyzstan. It con-
tracted with 33 local NGOs to work with persons living HIV, persons
who inject drugs, commercial sex workers, men who have sex, and others
(see UNDP, 2015a, pp. 34–47; 60–61). The organization also cooperates
with state institutions, such as the National Center of Phthisiology, the
Republican AIDS Center, the State Service for the Execution of
Punishment, the Republican Center for Narcology, the Republican
Center for Dermatovenereology, and others (UNDP, 2014). Notably,
before assuming this new role, the UNDP implemented TB and HIV
grants along with these state agencies and Project HOPE. The Global
Fund rated the performance of these two organizations as “excellent,”
“exceeding expectations,” “meeting expectations,” and “adequate” (Grant
Performance. Report External Print Version. Kyrgyzstan KGZ-910-
G07-T, 2016, pp. 19–28; Grant Performance Report External Print
Version. Kyrgyzstan KGZ-H-UNDP, 2016, p. 36). Yet, the nomination
of UNDP by the CCM and its approval by the Global Fund was not
random. Globally, the UNDPs are Primary Recipients of 31 Global Fund
grants in 18 countries (UNDP, 2018). In Kyrgyzstan, the organization
has worked on HIV issues since 1997 (Manukyan & Burrows, 2010). In
other words, the UNDP received Primary Recipient status due to demon-
strated country-based expertise and extensive experience with grants.
Still, both state and non-state actors were concerned with the transfer
of PR functions to the UNDP. In 2015, the local NGOs appealed to the
President, and the Parliament of the country, threatening to discontinue
their activities if the national actors did not reconsider this transfer, which
purportedly was not agreed with the CSOs (Ismanov, 2015). Similarly,
the state actors criticized the transfer of PR functions to the UNDP, refer-
ring to the high administrative costs and loss of the country’s ownership
over the grants. According to state officials, about 20% of the grant funds
were spent on administrative management due to the high salaries of
foreign managers and project coordinators (State Partner 9), although
state institutions could complete the same work (even with “good sala-
ries“) for one-ninth the cost, or about 2% of the grant value6 (State
Partner 2). Validating these estimates was not feasible within the
6
Estimates are made by the author, based on approximate numbers provided by interviewees.
228 G. Isabekova
framework of this research: administrative expenditures are not visible in

the Global Fund reports (e.g., Grant Performance Report External Print
Version. Kyrgyzstan KGZ-H-UNDP, 2016), and the UNDP representa-
tives in Kyrgyzstan (PR) did not answer research requests on multiple
occasions. According to a news agency report, the total administrative
costs were about US $3 million (Èrkebaeva, 2017).
In addition to increasing management expenses, the transfer of the PR
functions to the UNDP allegedly jeopardized the country’s ownership of
the grants. Several interviewees emphasized the ownership of state insti-
tutions over the finances provided to the country (CSO 3; State Partner
9). Others noted that even though frequently argued by the Ministry of
Health (State Partner 14), this notion of ownership does not prioritize
the interests of the population affected by the diseases (IO Partner 4).
This discussion raised the pertinent question of whether the recipient
state’s ownership over the grants represented the “country” and the inter-
ests of the population affected by the diseases.
In response to the allegations mentioned above, the UNDP pointed to
grant savings and the small number of NGOs that signed the petition
against it. The organization reported US $1.7 million in savings achieved
through changing the suppliers and contractors previously involved
through the state agencies (Eurasianet, 2012). Although more expensive,
the UNDP represented a “safe” option for the Global Fund (IO Partner
20), notably due to the reliability of its procurement procedures.
According to an anonymous “UN source” interviewed by an indepen-
dent news organization, the costs of 13 essential items in the grants were
300% higher during the period of grant implementation by the state
organizations (Eurasianet, 2012). Thus, despite the seemingly higher
administrative costs, the UNDP assured the effective use of finances. In
response to the CSO petition, the UNDP emphasized the small number
of NGOs that signed the appeal, which merely attempted to “discredit”
the organization’s work (Ismanov, 2015). Yet, the small number of signa-
tures could also relate to CSOs’ aid dependency. Spicer et al. (2011b,
p. 1752) note that the NGOs in Kyrgyzstan refrained from criticizing the
PR (a state agency) due to the fear of not receiving further financing. This
observation could, however, be equally relevant to the NGOs’ relation-
ship with PRs in general and not limited to the state PR.
Following the grant agreement, the UNDP committed itself to build-

ing the capacity of national actors. The replacement of NGOs previously
involved in the grants implemented by the state agencies caused “serious
protests,” and in response, the new PR offered capacity-building activities
to the excluded organizations to support their potential future return to
grant activities (Grant Performance Report External Print Version.
Kyrgyzstan KGZ-H-UNDP, 2016, p. 6). Twenty-one CSOs received
training on quality of services, HIV prevention, adherence to treatment,
and other areas (Grant Performance Report External Print Version.
Kyrgyzstan KGZ-H-UNDP, 2016, p. 32). The UNDP has equally com-
mitted itself to building the capacity of state agencies and gradually trans-
ferring its PR functions to them (IO Partner 3).
Nevertheless, the Global Fund grants remained with a multilateral
organization. Government organizations repeatedly emphasized their
willingness to resume their roles as PRs (CSO 9; IO Partner 4), and in
2014, the CCM voted in favor of this resumption. To enable this, the
Ministry of Health had to fulfill several conditions, namely, to develop
the necessary mechanisms for contracting the local NGOs and to register
the medications currently procured by the UNDP as humanitarian assis-
tance (Minus Virus, 2017). The Ministry was also expected to provide
timely reporting and financial management within the grants. The Global
Fund and USAID provided US $600,000 to establish the Project
Implementation Group under the Ministry of Health to support it in
these tasks. However, there were multiple inefficiencies in its work. For
instance, a supervisor of this group, appointed by the Minister of Health,
ended up sending personal acquaintances for training abroad (ibid.). The
Ministry also once delayed its report to the UNDP for two months, sub-
sequently delaying for six months the payout of financial incentives for
adherence to treatment for persons living with HIV for six months (ibid.).
One and a half years after its establishment, the Project Implementation
Group did not achieve all of the agreed goals, fulfilling eight of eleven
indicators (Bengard, 2017). The Global Fund evaluated the Ministry as
not yet ready to take over the PR functions (State Partners 4 and 9). The
Ministry of Health continued negotiating the transfer of PR functions
and reductions in the UNDP’s administrative costs (Èrkebaeva, 2017).
230 G. Isabekova
There are in theory no restrictions on the types of organizations receiv-

ing the grants, but the Global Fund’s requirements for grant implementa-
tion in practice result in the selection of organizations with specific
qualifications. Following the Global Fund requirements, the UNDP has
also developed a transition plan to transfer PR responsibilities to the
national stakeholders. However, a state official noted that the donor pro-
cedures do not specify the period within which the organization is
expected to transfer PR functions to national actors (State Partner 4).
During both field trips to Kyrgyzstan in 2016 and 2018, multiple inter-
viewees expected the near-term transfer of PR functions to state organiza-
tions. Yet, to this day, the UNDP remains the PR of grants.
It should be noted that regardless of other actors taking over the PR
functions, local NGOs remained Sub-Recipients of the Global Fund
grants. NGOs’ interaction with the donor is limited to meetings with the
portfolio manager of the Global Fund. There are no statistics about the
frequency of these meetings, but in 2014 alone, the portfolio manager
visited Kyrgyzstan at least three times (UNDP, 2015b, 2015c).
Encompassing multiple actors, including the Primary and Sub-Recipients
of grants, members of the Parliament, and others, these meetings are used
to discuss the issues and achievements in the grant implementation pro-
cess, the administrative, financial, and management systems of the Global
Fund, and other matters (ibid.). The portfolio manager also answers
questions and explains the changes (if any) in the Global Fund policies
and regulations (ibid.). Still, the interaction between the local NGOs and
the financiers beyond these meetings remains limited. In contrast, the
financier seems to have continuous communication with the PR of the
grants (IO Partner 4), which is the main point of contact for the
local NGOs.
Still, the Global Fund and PR have hierarchical relations with local
NGOs. According to one NGO representative interviewed for this
research, donors greatly vary in their approach toward NGOs. She
pointed to hierarchical relations in the Global Fund grants and stated
that during the interaction with donors and project managers, the SR was
frequently reminded of grant objectives and indicators that prevailed over
the changes and suggestions made by the NGO (CSO 6). The inter-
viewee noted that as “implementers,” they were well aware of their
“functions” and target groups, and their inability to go beyond these

(ibid.). The interviewee contrasted this experience with her work on
another health project. There, project managers “listened to” and consid-
ered the NGO’s suggestions because, working on the ground, they had
first-hand knowledge on how to improve the situation (ibid.). The inter-
viewee was “astonished” by the appreciation and respect she experienced
in this project, which aimed to introduce, not reject, the NGO’s sug-
gested changes (ibid.). This interviewee’s perspective is not generalizable,
but it does echo certain issues raised in the literature on health aid to
Kyrgyzstan.
Multiple studies point to the limited flexibility of donor organizations.
According to Benjamin (2011), the Global Fund assessment criteria focus
on input and output indicators but leave little space for qualitative infor-
mation. Yet this openness to suggestions is essential to the responsiveness
of health assistance to local needs. For instance, multiple studies note
increased emphasis on prevention (Murzalieva et al., 2009) but not advo-
cacy in health care programs (Harmer et al., 2013; Spicer et al., 2011b).
However, this may not reflect the priorities of target groups, such as com-
mercial sex workers, who consider police harassment as their most signifi-
cant problem (Ancker & Rechel, 2015a). Some interviewees in the study
by Burrows et al. (2018) go even further by partially relating the increased
violence and hostility toward the groups vulnerable to HIV to the reduc-
tions in donor funding and its growing emphasis on testing and treat-
ment instead of advocacy for human rights. Designed by local stakeholders,
the Global Fund grants ideally target issues identified by them. Yet, fur-
ther openness to suggestions by local implementers would ensure the
responsiveness of the assistance to the changing realities on the ground.
Local NGOs implemented the grants in collaboration with state agen-
cies—former PRs of the Global Fund grants. Joint project implementa-
tion by state organizations and NGOs was possible due to the “dual-track
financing” of the Global Fund, which contributed to collaboration
between these actors. According to Harmer et al. (2013), this coopera-
tion laid down the basis for overcoming the stereotypes actors had of each
other. Yet, the sections below show multiple issues encountered during
the joint implementation, which may not have overcome these stereo-
types but did become the basis for collaboration beyond the grants.
232 G. Isabekova
State and civil society organizations found common ground for col-
laboration. The actors jointly develop the clinical protocols, organize
round tables (State Partner 4), and implement harm reduction programs
(Murzalieva et al., 2009) and awareness-raising activities throughout the
country (CSO 3). State organizations largely provide the treatment of TB
and HIV/AIDS, and NGOs complement these activities by reaching out
to groups vulnerable to HIV out of reach to the state health care system
(e.g., PWIDs, CSWs, MSM, and others). NGOs primarily work on dis-
ease prevention, the distribution of information materials, outreach, and
care for the abovementioned population groups (Ancker et al., 2013).
The state officials interviewed for this research claimed a “quite good”
relationship and close collaboration with NGOs (State Partners 2 and 4).
A civil society representative emphasized the significance of working with
state officials, but stressed the importance of “speaking the language of
state officials” by highlighting the general benefits of the services to the
city and population instead of talking about the patients’ needs (CSO 6).
This framing seems to have contributed to the changing attitudes of state
officials toward groups vulnerable to HIV and to their readiness to make
the relevant changes (ibid.).
Still, tensions, particularly regarding the role of NGOs and their exper-
tise in health, remained. Spicer et al. (2011b, pp. 1751–1752) note that
state officials merely tolerate the CSOs’ advocacy work and essentially
perceive them as “helpers” rather than (equal) partners. The authors con-
clude that state institutions are not ready to consider NGOs’ opinions
and are cautious of their growing influence on social policy (ibid.,
p. 1754). Indeed, often overloaded with a large number of patients,
health care workers have limited capacity to work with groups vulnerable
to TB and HIV that tend to avoid state health care systems due to the fear
of stigma, discrimination, and anonymity concerns. NGO social workers
commonly come from the groups they are working with, which contrib-
utes to the trust between the social workers and these groups (CSO 6). By
filling in the gaps in the state health care system (Semerik et al., 2014),
NGOs, in a way, take over some state responsibilities (Ancker & Rechel,
2015a). However, their expertise in working with vulnerable groups is
not necessarily acknowledged by state officials. One interviewee pointed
to the discussions in the Ministry of Health regarding the abilities and
qualifications of NGO employees to deal with health care issues without

having relevant medical education (State Partner 4). This finding corre-
sponds to the statements of the former Minister of Health (2014–2018),
who portrayed the Ministry of Health as the primary actor in health care
and advocated for ministerial control over NGO financing and activities
in this field (Majdan.kg, 2018).
Nevertheless, the collaboration between the NGO and state organiza-
tions continued, particularly in preparing for the country’s transition
from Global Fund grants. The government adopted a “roadmap,” in
which it committed to increasing its share of HIV-related financing to
80% during the 2017 to 2021 period (State Partner 2). The Ministry of
Health “worked closely” with the NGOs on the development of a road-
map, demonstrating the gradual transition of the activities currently
financed by donors to the state budget (ibid.). My interviewees empha-
sized civil society organizations’ role, including active lobbying efforts, in
increasing state financing for HIV (State Partner 4). In addition to justi-
fying the relevance of the roadmap before the Ministry of Finance (State
Partner 2), CSOs advocated for increased funding and their role in moni-
toring the use of HIV-related resources. These activities found their reflec-
tion in the national program (see Government of KR, 2017a, 2017b),
hinting at future collaboration between state and civil society actors.
Similar to the relationship between the recipient state and CSOs, lim-
ited financing seems to have intensified the coordination among donors.
The Global Fund pays particular attention to coordination with American
institutions, such as USAID, the Centers for Disease Control and
Prevention (CDC), and the President’s Emergency Plan for AIDS Relief
(PEPFAR) (IO Partner 20). Still, interviewees noted that coordination
among donors intensified mainly due to decreased financing (IO Partner
3; State Partner 2). According to state officials, previously, a project ben-
eficiary may have received the same service from three organizations
(State Partner 2), but de-duplication was finally achieved in the recent
National HIV Program (2017–2021) (State Partner 4). Yet a civil society
representative notes that donor coordination intensified only due to a
“catastrophic shortage of finances”:
234 G. Isabekova
The money was so little that if you take it here, [a gap] opens there, [if] you take
it there [a gap] opens here. For this reason, they are now endlessly meeting to
review [the spending] and to try to cover these holes. (CSO 8)
In addition to complementarity concerns, donor coordination during

implementation is driven by attempts to de-duplicate efforts. Though
expected to prevent the duplication of donor activities (IO Partner 20),
the CCM may always not be able to coordinate the donors or have a
complete picture of the programs implemented in the country (IO
Partner 4). A single health care worker may simultaneously have contrac-
tual agreements with multiple donor organizations (Semerik et al., 2014).
Data gathering in these circumstances is exceptionally challenging (see
the following section on monitoring). Therefore, the Global Fund addi-
tionally meets with the relevant donor organizations, also during the vis-
its of the portfolio manager to a grant-recipient country (see UNDP,
2015b). Through coordination with major partners, the Global Fund
avoids the duplication of efforts and substantial gaps in aid-recipient
countries (IO Partner 20) to ensure the continuity of services.
Overall, the roles of actors and their relations to each other during
implementation demonstrated multiple differences to those of the design
stage, except for the relations between the Global Fund and other donors
remaining equal and driven by coordination of efforts to avoid duplica-
tion and gaps in services. However, there were considerable changes in
state/civil society organization, donor/CSO, and donor/recipient state
relations.
First, the relationship between the CSOs and state agencies imple-
menting the Global Fund grants remained strained but equal. The vision
of individual ministers on the mandate of the Ministry of Health and its
prerogative to supervise and control all organizations working in health
care complemented the general discourse about the inefficient use of
finances by NGOs. The purely medical perception of health care by indi-
vidual state authorities has led to additional questioning of the expertise
of NGOs and their ability to work with target groups. Common to the
post-Soviet region, this perspective is not unique to Kyrgyzstan. Despite
these concerns, actors still continued jointly implementing the grants
and lobbying for future financing. In contrast to the design phase, the
local NGOs were not outnumbered by state organizations and seemed

contested but equal partners here.
Second, relations of the Global Fund with the local NGOs were hier-
archical. Despite its contribution to civil society participation in the
implementation of grants, the financier seems to provide little space for
SRs’ suggestions. With their roles defined and little space for change,
local NGOs are seen merely as implementers of grant activities. This
approach is different from the promotion of active participation of NGOs
in drafting the country’s applications we observed in the design phase.
Third, though complying with the Global Fund’s decisions, state orga-
nizations demonstrated some resistance during the implementation
phase, in contrast to the acceptance without reservations we observed
during the design stage. State organizations complied with the Global
Fund’s decision to keep the UNDP as the PR, as the Ministry of Health
could not demonstrate its ability to do so. Still, organizations repeatedly
requested the transfer of functions to state institutions and discussed the
potential cost-saving in administration by returning the administration
of grants to state organizations. Moreover, in response to the Global
Fund’s repeated request to return the unaccounted-for finances, the
Ministry of Health neither acknowledged the inquiries nor returned the
missing finances. Unable to obtain finances from the recipient state, the
donor cut this amount from its follow-up grant. Though the theoretical
assumption about changing power assumes high provider leverage at the
beginning of the grant process, this particular finding suggests an increased
role of the recipient state in the project implementation phase, as well.
8.4 Monitoring
The Global Fund outsources project monitoring to the Local Fund Agent,
the Principal Recipient, and the Country Coordinating Mechanism7:
7
In addition to these actors, the Global Fund (2003) involves an external auditor that conducts an
independent audit of the grants and reports back to the Principal Recipient, Local Fund Agent, and
the CCM. This section, however, focuses on the role of the national and international actors work-
ing on TB and HIV/AIDS in Kyrgyzstan. For more information about the auditor, see Global
Fund (2019).
236 G. Isabekova
The Country Coordinating Mechanism is expected to have “strategic

oversight” over the grants (IO Partner 4), but this ability depends on the
CCM’s capacity to do so. The Oversight Committee of the CCM con-
ducts field trips to observe the implementation of the Global Fund proj-
ect (UNAIDS, 2015b) and discusses the Primary Recipients’ progress
with programmatic, procurement, and financial indicators (UNDP,
2015a). For this, CCM members are expected to be aware of Global
Fund policies and procedures, as well as the financial, procurement, and
implementation details of the grant operation process (Sands, 2019). Yet,
a study of 50 CCMs (including the one in Kyrgyzstan) found their over-
sight function “weak,” with a need for further improvements (Global
Fund Office of the Inspector General, 2016, p. 11). The Kyrgyz CCM
received technical and financial assistance from multiple donors, includ-
ing the European Union, DFID, PEPFAR, USAID, and others
(Manukyan & Burrows, 2010). Nevertheless, the CCM’s ability to moni-
tor the grants remained relatively weak. Studies on health care aid to
Kyrgyzstan point to lack of work plans, problems with analytical work
(ibid. p. 14), and CCM members’ unawareness of their functions (Spicer
et al., 2010, pp. 11–12). These issues culminated in the CCM’s inability
to oversee the Global Fund grants, resulting in the mismanagement of
finances discussed in the “Implementation” section.
The Local Fund Agent (LFA) monitors the grant implementation pro-
cess by the PR and SRs and reports directly to the Global Fund.8 Known
as the “eyes and ears” of the Global Fund (IO Partner 21), the LFA par-
ticipates in the CCM meetings, but its interaction with grant implement-
ers remains somewhat limited to ensure the neutrality of its assessment
reports. More specifically, the LFA verifies the prices, quantities, and sala-
ries indicated in the programmatic and financial reports of the Primary
Recipient (IO Partners 4, 20 and 21). In addition to desk research, it also
conducts field trips to evaluate the service coverage and the end receipt of
procured goods by grant beneficiaries. In Kyrgyzstan, for instance, there
were instances in which commercial sex workers had to pay for the con-
doms they were entitled to receive for free, and cases where condoms
procured within the grants and marked “the Global Fund, not for sale”
8
For more information on LFA selection, see Global Fund (2007).
were sold in local kiosks (IO Partner 21). Based on these accounts, the
LFA reports to the Global Fund with suggestions for further grant-related
disbursements (Global Fund, 2007). The LFA monitoring results are
critical to the continuity of the grants.
In contrast to the LFA, the Principal Recipient participates in design-
ing and implementing the grants, but also monitors the achievement of
indicators and takes corrective actions to address the relevant issues. The
PR visits the Sub-Recipients of grants to meet grant beneficiaries and
identify and solve issues, including those related to the quality of reported
data, patient adherence to treatment, and other aspects relevant to the
grant indicators (e.g., UNDP, 2015b, 2015d, 2015e). During these meet-
ings, the PR also validates the programmatic and financial data reported
by the SRs. There are concerns that the local NGOs misrepresent and
manipulate data in their reports (Ancker & Rechel, 2015a). There are no
statistics about the frequency of PR visits to Sub-Recipient NGOs, but in
2014 alone, the UNDP conducted 63 field trips to the SRs (UNDP,
2014, p. 21). Based on the monitoring and SRs’ reports, the PR submits
programmatic and financial reports to the Global Fund, the LFA, and the
CCM (Global Fund, 2003) on a quarterly to biannual basis (Grant
Performance. Report External Print Version. Kyrgyzstan KGZ-910-
G07-T, 2016; Grant Performance Report External Print Version.
Kyrgyzstan KGZ-H-UNDP, 2016). These reports aim to demonstrate
the progress against the indicators stated in the grant agreement, which is
essential to continuous financing from the Global Fund.
Overall, the Sub-Recipients, including state and civil society organiza-
tions, provide data for monitoring activities but do not participate other-
wise to avoid conflicts of interest. Still, state and civil society organizations
monitor each other’s activities.9
State and civil society organizations share information about each oth-
er’s activities, except for data on NGO financing. CSOs participate in
SWAp meetings in which the Ministry of Health reports about achieve-
ments and issues in the national health care program (see Isabekova &
Pleines, 2021). A state official interviewed for this research emphasized
9
In addition, the organizations have their own monitoring to assess the achievement of stated
indicators, which is not discussed here.
238 G. Isabekova
NGOs’ reciprocal responsiveness, openness, and readiness to provide the

requested material (State Partner 2). However, actors’ access to financial
information on each other varied. If necessary, the CSOs could request
the information, also in terms of public financing, from the relevant min-
istries (CSO 8). In contrast, government organizations had no right to
scrutinize NGO funding until 2021. The former Minister of Health
(2014–2018) accused NGOs of receiving almost half of the Global Fund
grants but not reporting on their use of funding (Malyševa, 2018). The
state official interviewed for this research similarly resented having no
right to access the funding information, noting that NGOs are “only
accountable to those who finance them” (State Partner 2). Similar con-
cerns were raised in the literature on health aid to Kyrgyzstan, suggesting
that local NGOs are accountable to donor organizations that finance and
monitor their activities (Spicer et al., 2010) but not project beneficiaries
or the government (Ancker et al., 2013; Ancker & Rechel, 2015a).
State organizations are mistrustful of the use of finances by local
NGOs. Government organizations perceive CSOs as “foreign agents”
and “grant eaters” (CSO 8) rather than equal partners (Murzalieva et al.,
2009, p. 55). Exacerbated by the limited access to the data on NGO
financing, these accusations are based on two main reasons:
First, there is alleged disproportionality of payments for services pro-
vided by NGOs. Several interviewees noted that the salary rates of gov-
ernment officials were not consistent with their workload (State Partner
10 and Academic Partner 2), and that NGO staff received higher salaries
compared to health care workers (State Partner 2). To be fair, in addition
to their routine workload, state officials may indeed have additional tasks
related to health aid provided by donor organizations. The intensive
workload, in combination with low salaries, contributes to understaffing
and high staff turnover rates, also in the Ministry of Health (see Isabekova
& Pleines, 2021). Health care workers in public facilities face similar
issues (see the subsection below).
NGOs justified the proportionality of payment to services by referring
to the “difficult cases” they take over from the state health care system and
the irregular working hours these require. In contrast to general practitio-
ners providing health care services to the general population, NGOs have
a small number of patients. Yet these are the “most difficult” cases,
including patients with addiction problems (drugs or alcohol) (CSO 8),

as well as the homeless (State Partner 4). As a rule, these patients avoid
state health care facilities and require more time for care. Therefore, the
costs of finding, persuading, and supporting these patients are not com-
parable to the costs of patients willingly coming to health care facilities
(ibid.). The latter will, as a rule, adhere to treatment, but the former
require the continuous engagement of health care professionals to do so.
A civil society representative in this regard notes that, in contrast to state
employees, NGO staff have irregular working hours depending on the
project needs and the groups they are targeting (CSO 8).
Second, the mistrust toward NGOs is also driven by the perception
that the state institutions “should control” health aid. One former
Minister of Health repeatedly restated the role of the state in all matters
of citizens’ health (Malyševa, 2018) and emphasized that the Ministry of
Health had the authority to “control any organization working in health
care independently of its form of ownership” (Majdan.kg, 2018). Another
state official noted that the Minister’s concern over NGO accountability
mainly refers to finances because all NGO activities and indicators fully
comply with the national health care program (State Partner 4). In any
case, the discourse about governmental control over health assistance
contributed to continuous discussions about the role of the government
in scrutinizing NGOs, resulting in the amendments to the Law of the
Kyrgyz Republic “On non-profit organizations.” Since June 26, 2021,
NGOs are required to report on sources of their financing and the use of
these funds (Government of KR, 2021).
Regarding content, the Global Fund aims to coordinate its monitoring
activities and indicators with the grant-recipient government and other
donor organizations.
First, the Global Fund integrates the monitoring of its grants into
national systems by aligning its monitoring requirements with the moni-
toring and evaluation (M&E) system of a grant-recipient country. The
organization asks project implementers to provide national rather than
grant-specific M&E to demonstrate the project impact, coverage, and
outcome indicators (“Local Fund Agent manual. Section G—Global
Fund essentials,” 2014). In doing so, it encourages the use of data already
gathered by government institutions. State agencies and ministries
240 G. Isabekova
routinely collect and report the information related to the realization of

national health care programs to the Ministry of Health (see Majtieva
et al., 2015). The PR is free to use this data as long as it clearly demon-
strates the indicators and objectives stated in the project. Further excep-
tions to the use of the national M&E are the cases with no national
system or in which the system is not relevant to the Global Fund grants
(“Local Fund Agent manual. Section G—Global Fund essentials,” 2014).
The use of national indicators is also intended to strengthen the
national M&E systems, though this support is in practice limited to the
areas relevant to the grants. The applicants are also encouraged to include
support for the national M&E systems in project proposals. The Global
Fund may provide assistance in the amount of 5–10% of the total grant
financing for data systems, registration, analytical skill development, and
other purposes (“Local Fund Agent manual. Section G—Global Fund
essentials,” 2014, p. 8). In the context of low- and middle-income coun-
tries, this assistance may be pivotal to strengthening the national systems.
In Kyrgyzstan, for instance, this support resulted in a unified database
with common indicators, data collection, and analytical mechanisms
(Ancker & Rechel, 2015a). The Government planned to further increase
the funding for the national M&E and provide continuous training to
specialists. However, in the face of budget deficits, the national system
remained “weak” and largely dependent on donor funding (see
Government of KR, 2017b, n.p. Majtieva et al., 2015, p. 29).
Second, the Global Fund aims to coordinate its monitoring require-
ments and activities with other donor organizations to avoid duplica-
tions. Still, its emphasis on the visibility of its contribution jeopardizes
these attempts. To decrease the burden on grant recipients having to
report to multiple donors using different indicators, the organization
negotiates the list of common indicators with the WHO, USAID,
PEPFAR, and other actors (“Local Fund Agent manual. Section G—
Global Fund essentials,” 2014). Furthermore, suppose the Global Fund
contributes to the national program by pooling its finances together with
other donors: in that case, the Primary Recipient of grants may provide a
single audit report with all other donors, as long as this audit explicitly
indicates the Global Fund’s contribution (Global Fund, 2019, p. 12).
However, as a rule, the organization does not merge its finances with
other donors due to the difficulties with tracking and validating the use
of its resources (IO Partner 20). This notion of transparency hinders the
Global Fund’s attempts to coordinate its monitoring activities with
other donors.
Donor visibility and tracking requirements contribute to counting
irregularities in the NGO sector. In Kyrgyzstan, there have been cases of
double-counting of the target groups due to the multiplicity of donor
approaches to the registration of project beneficiaries (Murzalieva et al.,
2009). These irregularities in counting may artificially inflate the number
of people covered by the services and contribute to inaccurate estimation
of the size of the groups targeted by projects (e.g., commercial sex work-
ers, persons living with HIV, and others). Local NGOs register their cli-
ents (e.g., project beneficiaries) by using a universal identification code,
but the organizations do not share these data with each other and mainly
concentrate on collecting the data requested by donors (ibid.). In other
words, a person may have received analogous services from multiple
NGOs that registered him/her in parallel to each other. As neither NGOs
nor donor organizations comprehensively share the reporting data with
each other, this double-counting may remain hidden in reports submit-
ted to, and later by, development organizations.
Limited coordination among donors in terms of their monitoring
requirements overwhelms civil society organizations, having to deal with
various, at times contradictory criteria. After the misappropriation of
grant disbursements in multiple countries, including Kyrgyzstan, the
Global Fund introduced several changes in its financial reporting require-
ments. The increased control over finances resulted in the grant recipients
spending extensive time and effort on reporting, which affected their
grant implementation functions (Benjamin, 2011). Ancker and Rechel
(2015a) went even further, suggesting that the NGOs spent more time
reporting on projects than actually implementing them. This was true
particularly for those that received financing from multiple organiza-
tions, and therefore had to comply with various project cycles, reporting
forms, indicators, and other requirements of each donor (ibid.). The
authors noted that the NGOs felt “torn” between the multiplicity of
donor requirements that at times contradicted each other. For instance,
the Global Fund stipulated 100% coverage of the groups vulnerable to
242 G. Isabekova
HIV, while the United Nations General Assembly Special Session on

HIV/AIDS defined a 60% target (ibid.). Still, the organizations were
expected to fulfill the indicators to continue receiving finances.
In the government sector, donor visibility and tracking requirements
caused problems with quantifying and forecasting demand for medica-
tions. The vivid examples hereof were documented in relation to TB
medications. There were problems with forecasting and quantifying the
drugs in Kyrgyzstan (Manukyan & Burrows, 2010) because the medica-
tions are stored, recorded, and reported in separate registers according to
their sources of supply (van den Boom et al., 2015). The WHO study
suggests the presence of nine registers in one health facility, which made
the accurate review of the total quantity of the relevant medications
impossible, and due to the lack of a unified electronic database, the per-
sonnel in this health institution recorded and reported the quantities by
hand (ibid.). Unfortunately, this example is not limited to a single facility.
According to a development partner interviewed for this research project,
it took almost a year to monitor the overall stock of medications in the
country due to the “parallel reporting systems” used by health facilities
(IO Partner 4). Overall, donor visibility and tracking requirements
increase the burden on health care workers already overwhelmed with
routine tasks and responsibilities. It also complicates the quantification
and forecasting of medications, in doing so jeopardizing the continuity of
treatment.
Overall, donor coordination of monitoring activities remains limited.
One state representative notes that organizations do not duplicate each
other in terms of their objectives and geographic coverage, but their
monitoring visits often repeat each other’s efforts. The interviewee
reported receiving multiple invitations from various donors to joint
monitoring visits to the same area. The state representative agreed to par-
ticipate in some cases but not in others (State Partner 3).
Similar to implementation, the Global Fund delegates monitoring of
its project to local stakeholders in Kyrgyzstan. The Country Coordinating
Mechanism, Local Fund Agent, and Primary Recipient complement each
other and provide comprehensive coverage of stakeholders (see Diagram
8.1). As Sub-Recipients of grants, the state agencies and local NGOs do
not directly participate in the monitoring process to avoid conflicts of
Country
Coordinating
Mechanism oversees
the grant
implementation
process
Local Fund Agent
monitors primary
and sub-recipients
of grants
Principal
recipient
monitors the sub-
recipients of
grants
Diagram 8.1 The realm of actors monitoring the Global Fund grants
interest. Instead, they end up monitoring each other. As in the imple-

mentation phase, NGOs’ use of financing remains an issue between the
state and civil society organizations.
The Global Fund attempts to coordinate its monitoring with the
national M&E system and evaluation activities of other donors. It aligns
its monitoring plans with the national programs on TB and HIV/AIDS
and contributes to the development of the national M&E system. Though
considerable in some areas, this support obviously failed to solve
Kyrgyzstan’s systemic issues related to staff capacity and budget deficit.
Moreover, this support also seems to primarily facilitate the alignment of
national systems with grant indicators.
The Global Fund attempts to coordinate its monitoring activities with
other donors, but its requirement for the visibility of its contribution
hinders these efforts. Other donors have similar issues, demonstrated by
the presence of nine registers in one health facility. The actors vest differ-
ent interests and standards in their M&E, but until donor commitments
to harmonize this area materialize, aid recipients continue bearing most
of the related costs (Holzscheiter et al., 2012). In Kyrgyzstan, the multi-
plicity of donor requirements not only increased the burden on the state
and civil society organizations, but also affected their abilities to forecast
need for medications and record the project beneficiaries.
244 G. Isabekova
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254 G. Isabekova
the permitted use, you will need to obtain permission directly from the
copyright holder.
9
Sustainability of Global Fund Grants
The grants of the Global Fund to Fight AIDS, Tuberculosis and Malaria
(the Global Fund) provided to the Kyrgyz Republic are still ongoing, but
the country is preparing to transition from its assistance. This chapter
discusses the sustainability of Global Fund grants provided to the coun-
try by expanding on the continuity of project activities, maintenance of
benefits, and community capacity building within the grants. As dis-
cussed in Chap. 3, within ongoing projects, the continuity of project
activities and maintenance of benefits received by the targeted population
refer to the services taken over by a donor, recipient state, or civil society
organization. Community capacity building, in its turn, implies the lead-
ership of civil society organizations, their ability to continue their work
and mobilize the necessary resources for it. In addition to discussing the
three components of sustainability, this chapter also examines the signifi-
cance of the factors relevant to these components, such as the commit-
ment of the recipient state, quality of services, and financing. This chapter
commences with a description of the grants and major activities stipu-
lated by them.

256 G. Isabekova
9.1 Description of Grants

The Global Fund is among the largest financiers of activities targeting
tuberculosis (TB), human immunodeficiency virus infection, and
acquired immunodeficiency syndrome (HIV/AIDS) problems world-
wide. In the Kyrgyz Republic, it covered the costs of antiretroviral ther-
apy (ART), treatment of TB and HIV/AIDS coinfection, prevention of
mother-to-child transmission of HIV (Ancker et al., 2013), TB medica-
tions, laboratory reagents, and more (State Partner 9). The organization
also provided equipment and staff training to support health systems
strengthening in the country (Murzalieva et al., 2009).
The Global Fund provided multiple grants to facilitate TB control in
the country.1 The first grant (2004–2009) aimed to prevent the disease by
training medical specialists, providing treatment and detection of TB,
increasing the awareness of TB in the civilian and penitentiary sectors,
and other activities (Grant Performance Report External Print Version.
Kyrgyzstan KGZ-202-G01-H-00, 2011). The following grant
(2007–2012) provided training to health care workers, social support2 to
TB patients, and quality control in the labs to integrate TB services into
primary health care (PHC) (Grant Performance Report External Print
Version. Kyrgyzstan KGZ-607-G04-T, 2012). It also offered directly
observed treatment short-course (DOTS) for both drug-susceptible and
drug-resistant forms of TB for the patients in prisons (ibid.). The third
grant (2011–2015) intended to increase TB detection and treatment in
the country by implementing drug-resistance surveillance and improving
the regulatory basis for service delivery (Grant Performance. Report
External Print Version. Kyrgyzstan KGZ-910-G07-T, 2016). It stipu-
lated social support for TB patients, training of medical workers and the
Village Health Committees, and other activities (ibid.). The following
grant (2011–2016) intended to consolidate the DOTS framework by
improving the detection and treatment of all forms of TB, providing
quality control in the labs, training TB specialists, and so on (Grant
1
For more information on the list of grants included in the analysis, see Appendix 1.
2
This includes psychological support as well as financial and in-kind benefits (reimbursement of
travel costs, food and hygiene parcels, etc.).
9 Sustainability of Global Fund Grants 257
Performance Report External Print Version. Kyrgyzstan KGZ-S10-

G08-T, 2016). Kyrgyzstan was also among the eleven countries benefit-
ing from the TB Regional Eastern Europe and Central Asia Project on
Strengthening Health Systems for Effective TB and drug-resistant TB
Control, financed by the Global Fund. This grant aimed to reduce
TB-related stigma and discrimination, promote people-centered outpa-
tient care, and facilitate the participation of persons affected by this dis-
ease in the decision-making process (Amanzholov et al., 2018). The
Kyrgyz NGO “Association of AIDS Service NGOs of the Kyrgyz Republic
Anti-Aids” promoted outpatient TB care among the decision-makers, the
general public, and health care professionals (ibid.).
In parallel with TB grants, the Global Fund also provided grants to
control HIV/AIDS in the country. The first grant (2004–2009) focused
on HIV prevention among the general population and the groups most
vulnerable to this disease, including commercial sex workers (CSWs),
persons who inject drugs (PWID), men who have sex with men (MSM),
and others (Global Fund, 2006a). The grant stipulated a wide range of
activities, such as establishing needle-exchange points, providing metha-
done treatment and antiretroviral therapy (ART), HIV prevention and
counseling, training for journalists and health care workers, and other
activities (Grant Performance Report External Print Version. Kyrgyzstan
KGZ-202-G01-H-00, 2011). The following grant (2011–2016) aimed
to achieve universal access to prevention, diagnosis, and treatment, par-
ticularly among vulnerable groups (Grant Performance Report External
Print Version. Kyrgyzstan KGZ-H-UNDP, 2016). It stipulated HIV pre-
vention, ART, training of health care workers, and capacity building of
communities affected by the disease (ibid.).3 In 2016, the country
received a joint grant for TB and HIV/AIDS (2016–2023) aimed at uni-
versal access to TB and HIV diagnostics, treatment, and care (UNDP,
2023). In addition to TB and HIV/AIDS prevention, testing, and treat-
ment, this grant emphasized treating coinfection of these two diseases
(Grant Performance Report External Print Version: Kyrgyzstan
3
Communities/community organizations/community-based organizations in the Global Fund
grants refer to persons affected by TB and HIV/AIDS and the organizations working with them.
This operationalization used by the Global Fund is different from the one presented in relation to
the “Community Action for Health” project, in which communities are persons living in the
same area.
258 G. Isabekova
KGZ-C-UNDP, 2016) and achieving sustainability of the national pro-

grams targeting them (UNDP, 2023).
9.2 Continuity of Project Activities

This section discusses the continuity of grant activities by elaborating on
the types (what) and the extent of activities related to the treatment and
prevention of TB and HIV/AIDS. It also discusses the factors relevant to
the continuity of activities, namely, the formal character of state support,
financing, the epidemiological situation in the country, and the quality of
services.
Regarding HIV/AIDS, I focus on grant activities related to prevention
(testing, condom distribution, needle- and syringe-exchange program,
opioid substitution therapy) and treatment services (ART and treatment
of sexually transmitted infections).
First, the Global Fund grants increased the breadth of prevention
activities. The grants contributed to the establishment of testing services
at NGOs and state health care facilities. This included the provision of
consent-based testing for pregnant women and children under five at
health care facilities (Murzalieva et al., 2009) and the establishment of
rapid saliva-based HIV testing at nongovernmental organizations
(NGOs) for the groups unwilling to receive the services at state health
care facilities. As of 2015, 20 NGOs and 63 state health care institutions
provided saliva and capillary blood-based HIV testing free of charge
(Mansfeld et al., 2015, pp. 9, 16). As a result, the amount of HIV testing
in the country increased (European Centre for Disease Prevention and
Control and WHO/Europe, 2019). The number of HIV tests in 2020
alone reached 32,299 (Global Fund, n.d.-b). There are concerns that this
increase is primarily attributed to extensive testing among pregnant
women, not of the groups most vulnerable to HIV (Mansfeld et al.,
2015; Semerik et al., 2014). Nevertheless, in 2020, HIV tests taken
among MSM, CWS, and PWIDs cumulatively represented 82% of the
total number of HIV tests (Global Fund, n.d.-b). Therefore, the plausi-
bility of concerns about insufficient testing among vulnerable groups
requires further research.
Second, the grants contributed to condom distribution among the

groups most vulnerable to HIV, but the availability and use of condoms
in the country remained limited. In 2014 alone, about 1.5 million con-
doms were distributed at the expense of the Global Fund grants. Yet,
these condoms had a “supplemental” character, and they did not meet
the needs of grant beneficiaries (UNDP, 2015d, p. 4). The availability of
condoms in prison settings also remained limited (Burrows et al., 2018).
Unmet needs contributed to the irregular use of condoms. For example,
a survey conducted within the framework of the Global Fund grants
showed that the CSWs did not use condoms with their regular sexual
partners or if a client paid extra (UNDP, 2015d).
Third, the Global Fund expanded the needle and syringe exchange
program (NSP) in the country, but the coverage of this program remained
limited due to the criminalization of drug use. Kyrgyzstan introduced the
NSP in 1999 with the support of the Soros Foundation Kyrgyzstan, the
United Nations Development Programme (UNDP), and Joint United
Nations Programme on HIV/AIDS (UNAIDS) (Wolfe, 2005). By the
end of 2004, the program covered twelve prisons and two large cities—
Bishkek and Osh (ibid.). The Global Fund grants expanded the NSP
further by including all pre-trial detention centers, open prisons, and ten
large and ten small cities into the program (Murzalieva et al., 2009). As
of 2015, there were 31 state and 15 nongovernmental organizations and
eight pharmacies offering NSP services to the population (Foundation
for AIDS Research, 2015, p. 18). In 2014 alone, seven million syringes
and needles were distributed at the expense of the grants (UNAIDS, 2015).
Nevertheless, the NSP services covered only 36% of PWID (Grant
Performance Report External Print Version. Kyrgyzstan KGZ-202-
G01-H-00, 2011, p. 24). Despite the high demand (Murzalieva et al.,
2009), the actual use of services was limited due to the criminalization of
PWID for possession of used syringes (Spicer et al., 2011a). There were
cases in which police officers confiscated NSP supplies of outreach work-
ers (Wolfe, 2005),4 arrested them for carrying needles (Mansfeld et al.,
2015), and asked for bribes (Spicer et al., 2011a) and/or information
4
Outreach workers are the NGO employees providing HIV testing, NSP, and other services to the
groups most vulnerable to HIV.
260 G. Isabekova
about the grant beneficiaries using the NSP services (Murzalieva et al.,
2009). Police officers’ activities contributed to the high attrition of out-
reach workers (ibid.) and the distribution of new syringes without
exchanging the old ones (Spicer et al., 2011a). Despite the countrywide
expansion, the actual use of NSP services by persons who inject drugs
remained limited.
Similarly, the use of opioid substitution therapy (OST) services
remained limited due to the harassment of and discrimination against
persons who inject drugs. Kyrgyzstan is among the few post-Soviet coun-
tries offering methadone maintenance treatment to opiate addicts (Wolfe,
2005). The Global Fund expanded the maintenance therapy, which was
initially financed by the Soros Foundation and the UNDP (ibid.), by
ensuring continuous financing and supply of methadone (Murzalieva
et al., 2009). Between 2008 and 2015, the number of health care facili-
ties providing OST in civil and penitentiary sectors more than doubled,
increasing from 13 to 31 (Subata et al., 2016, pp. 1–4).
Still, methadone remains “an extremely controlled substance” (Wolfe,
2005, pp. 46–47), since possession of drugs is illegal and may result in a
fine or imprisonment of up to four years (Foundation for AIDS Research,
2015). PWID willing to receive the OST are required to undergo regis-
tration at narcological centers (ibid.) and come to health care facilities on
a daily basis for the therapy (Mansfeld et al., 2015). The coverage of OST
services remains low (18% of all PWID) due to the negative attitude of
medical staff, policy-makers, and some PWID toward these services
(ibid., pp. 33–34) as well as social disapproval (Semerik et al., 2014).
There are also cases of harassment (Subata et al., 2016), detention (Spicer
et al., 2011a), and police officers’ use of withdrawal syndrome to torture
the PWID receiving the OST services (Foundation for AIDS
Research, 2015).
Overall, the Global Fund grants contributed to the expansion of HIV
prevention activities, such as HIV testing, condom distribution, NSP,
and OST, in the Kyrgyz Republic. But the outreach of these activities,
particularly among the groups most vulnerable to HIV, seems unclear.
In addition to preventive services, the Global Fund grants contributed
to the treatment of sexually transmitted infections (STIs) and the intro-
duction of antiretroviral therapy in Kyrgyzstan, though the ART
coverage and patients’ adherence to it are still low. The Global Fund also
contributed to the introduction of ART in 2005, which was not previ-
ously available in the country (Murzalieva et al., 2009). The National
AIDS centers offered limited immune monitoring to persons living with
HIV (Wolfe, 2005). The Global Fund supported the revision of clinical
protocols on HIV treatment and the provision of relevant training to
medical workers (Murzalieva et al., 2009). ART is provided by all AIDS
centers and 76 PHC facilities throughout the country (UNDP, 2015a,
p. 29). In 2020, 4435 persons received ART (Global Fund, n.d.-b).
100% of pregnant women with HIV and 72% of children born to them
receive ART (Grant Performance Report External Print Version:
Kyrgyzstan KGZ-C-UNDP, 2016, p. 25), yet only half of registered HIV
cases are covered by the therapy (Government of KR, 2017a). Persons
living with HIV (PLHIV) often reject the treatment (UNDP, 2015a) due
to its side effects, potential interruption of drug supplies, and mispercep-
tion of ART as a “new drug trial” (Murzalieva et al., 2009, p. 82). In
addition to limited coverage, there are issues with poor knowledge of
PHC workers about the therapy (Mansfeld et al., 2015), stigma around
and discrimination against PLHIV (Murzalieva et al., 2009), patients’
non-adherence to treatment (Semerik et al., 2014) and development of
acquired antiretroviral drug resistance (Masikini & Mpondo, 2015).
Similar to prevention, the outreach of treatment activities remains an
issue, often due to factors lying beyond grant activities.
Along with targeting HIV/AIDS, the Global Fund grants contributed
to TB prevention in Kyrgyzstan by improving lab services, training health
care workers, and increasing the awareness of the population about this
disease. The grants stipulated equipment (Grant Performance Report
External Print Version. Kyrgyzstan KGZ-202-G02-T-00, 2011) and
quality assurance measures in the labs, including improved lab safety,
appropriate collection and analysis of specimens (Grant Performance
Report External Print Version. Kyrgyzstan KGZ-607-G04-T, 2012;
Grant Performance Report External Print Version. Kyrgyzstan KGZ-
S10-G08-T, 2016), and training for lab technicians (Grant Performance
Report External Print Version. Kyrgyzstan KGZ-202-G02-T-00, 2011).
The grants aimed to improve TB detection at PHC facilities by providing
the relevant training to general practitioners (Grant Performance Report
262 G. Isabekova
External Print Version. Kyrgyzstan KGZ-607-G04-T, 2012; Grant

G08-T, 2016). Similar activities were initiated in the health care facilities
in prisons to improve the identification of TB patients among detainees.
These activities contributed to the detection of about 1700 new smear-
positive TB cases annually (Grant Performance Report External Print
Version. Kyrgyzstan KGZ-202-G02-T-00, 2011; Grant Performance
Report External Print Version. Kyrgyzstan KGZ-607-G04-T, 2012). The
grants also covered information and educational campaigns on TB among
the population through media outlets, schools, and detention centers
(Grant Performance Report External Print Version. Kyrgyzstan KGZ-202-
G02-T-00, 2011). It should, however, be noted that awareness-raising
activities fighting against the stigmatization of and discrimination against
TB patients were not explicitly stated in the grants.
In addition to prevention, the Global Fund grants contributed to the
consolidation of the DOTS throughout the country. The grants stipu-
lated the expansion of DOTS (against drug-susceptible TB) and DOTS-
plus (against drug-resistant forms) in the civilian and penitentiary sectors
(Grant Performance Report External Print Version. Kyrgyzstan KGZ-607-
G04-T, 2012; Grant Performance Report External Print Version.
Kyrgyzstan KGZ-S10-G08-T, 2016). The Global Fund guaranteed a
continuous supply of TB medications, restructured storage facilities
(Government of KR, 2013), and provided training to TB specialists on
storage, quantification, and forecasting of drugs. It also financed the
establishment and refurbishment of PHC service delivery points (Grant
Performance Report External Print Version. Kyrgyzstan KGZ-607-
G04-T, 2012). This integration of TB services into primary health care
facilities contributed to the development and availability of outpatient
care throughout the country. In addition to achieving timely detection
and quality treatment (ibid.), the grants aimed to increase patients’ adher-
ence to TB treatment through counseling and follow-up of patients by
NGO volunteers and medical workers (Grant Performance Report
External Print Version. Kyrgyzstan KGZ-202-G02-T-00, 2011; Grant
G08-T, 2016). In 2020, 4435 individuals with TB received treatment
(Global Fund, n.d.-b).
Regarding the extent of activities (“to what extent”), TB and HIV/

AIDS programs vary in their readiness to transition to purely state-budget
funding. The following sub-sections take a closer look at the factors
affecting the government’s compliance with its commitment to continue
TB and HIV/AIDS-related services beyond the duration of the grants.
HIV prevention activities largely depend on the Global Fund, but the
government took multiple steps to take over the financing. The initial
state contribution to HIV prevention was insignificant. It included some
parts of lab services (Gulgun Murzalieva et al., 2007), operation and
maintenance costs of health care facilities, and medical workers’ salaries
(Maytiyeva et al., 2015). State financing did not extend to HIV preven-
tion among vulnerable groups (International Charitable Organization
“East Europe and Central Asia Union of People Living with HIV,” n.d.,
p. 13). Condom distribution, NSP, and OST relied entirely upon the
Global Fund (see Mansfeld et al., 2015), also illustrated by the interrup-
tion of services and supplies during the delays of grant disbursements
(Murzalieva et al., 2009; Semerik et al., 2014). However, following the
Global Fund’s request to gradually transfer the grant activities to domes-
tic or “alternative” sources of financing (Global Fund, n.d.-a, pp. 13–14),
the government started increasing its contribution to HIV.
The government’s commitments to HIV/AIDS services are outlined in
related state programs. However, as of the beginning of December 2022,
the Draft Programme of the Kyrgyz Republic on Combating HIV
Infection for 2022–2026 was still not available. Therefore, in addition to
interviews with stakeholders conducted in 2016 and 2018 (see Chap. 1),
the analysis is based on the previous national program (2017–2021) and
recent sustainability assessments provided by organizations such as the
Eurasian Harm Reduction Association.
It should be noted that the government took extensive responsibility to
increase its contribution to HIV prevention and treatment. In terms of
preventive activities, the National HIV Program for 2017–2021 stipu-
lated increased state financing for methadone (from 50 to 100%) and
distribution of condoms among the groups vulnerable to HIV to cover at
least half of their needs (Government of KR, 2017b). In terms of treat-
ment, the Kyrgyz government has committed itself to providing ART
and STI treatment to groups vulnerable to HIV and ART to HIV-positive
264 G. Isabekova
pregnant women and children born to them (ibid.). Overall, the govern-
ment aimed to increase the number of individuals on ART fourfold (from
2109 to 8644) and achieve adherence to treatment for no less than
12 months for 90% of patients on ART (ibid.).
Among the sources of financing, the government defined the contribu-
tions of national and local authorities. Thus, the Mandatory Health
Insurance Fund (MHIF) and the Ministry of Health were responsible for
procuring methadone (Government of KR, 2017a). Similarly, the local
self-governments in the Osh and Chui regions contributed to HIV pre-
vention services in their areas by providing 20% of necessary funding (by
agreement) (Government of KR, 2017b). In addition, the program stipu-
lated an increase in financing for antiretroviral (ARV) drugs and test sys-
tems from 10% to 50% between 2018 and 2020 (Government of
KR, 2017a).
However, despite multiple sources of financing, the program was
accompanied by a considerable budget deficit (33%) (Eurasian Harm
Reduction Association, 2021, pp. 21–22) due to a substantial decrease in
Global Fund grants. Nevertheless, despite the reductions by almost half,
Global Fund grants represented 48% of funding, followed by the state
budget (23%), the President’s Emergency Plan for AIDS Relief (PEPFAR)
(15%), and other donors (13%) (ibid.). The state acknowledged that
insufficient financing due to reductions in and possible termination of
Global Fund grants and other donors’ assistance might jeopardize HIV
services in the country (Government of KR, 2017a).
The state fulfilled its commitments but with mixed results. Eurasian
Harm Reduction Association (2021) assessment indicates considerable
progress in HIV diagnosis and treatment, human rights, and related bar-
riers. This included improvement in HIV-related incidence and morbid-
ity, awareness of HIV status (also among vulnerable groups), and the
share of PLHIV on ART who have suppressed viral loads at the end of
the reporting period (Eurasian Harm Reduction Association, 2021). The
assessment also demonstrated improvements in reducing the stigma and
discrimination against groups vulnerable to HIV and improved coverage
of HIV prevention services (ibid., pp. 33–48). However, the achieve-
ments in other areas were less impressive. For example, the awareness of
HIV status among CSWs and the share of CSWs receiving ART remained
low, and the use of opioid agonist therapy in vulnerable groups decreased
(ibid.). In this regard, the assessment notes that despite the improve-
ments, stigma and discrimination continue to jeopardize access to health,
vividly demonstrated by low coverage of treatment and prevention ser-
vices, particularly among some groups (e.g., CSWs) (ibid.).
It should be noted that the government lived up to its financial com-
mitments. It increased the funding for TB and HIV by 169 million KGS
(around €1,812,236) in 2017–2020 and committed itself to providing
an additional 280 million KGS (€3,002,521) for the 2021–2023 period
(Eurasian Harm Reduction Association, 2021, pp. 23–25).5 HIV
expenses represented 80 million in additional funding, which allowed for
the procurement of some ARV drugs, payments to medical professionals,
and social contracting (ibid.). However, despite the considerable increase,
state funding is insufficient to purchase second-line ARV drugs, rapid
tests, and CD4 tests used to assess viral load (ibid.). Moreover, prevention
services in vulnerable groups are still largely financed by donors (Eurasian
Harm Reduction Association, 2021, p. 61).
As in the case of HIV/AIDS, the government committed itself to tak-
ing over TB activities. It should be noted that the government lived up to
its financial commitments. It increased the funding for TB and HIV by
169 million KGS (€1,812,235) in 2017–2020 and committed itself to
providing an additional 280 million KGS (€3,002,521) for the
2021–2023 period (Eurasian Harm Reduction Association, 2021,
pp. 23–25). HIV expenses represented 80 million in additional funding,
which allowed for the procurement of some ARV drugs, payments to
medical professionals, and social contracting (ibid.). However, despite
the considerable increase, state funding is insufficient to purchase second-
line ARV drugs, rapid tests, and CD4 tests used to assess viral load (ibid.).
Moreover, prevention services in vulnerable groups are still largely
financed by donors (Eurasian Harm Reduction Association, 2021, p. 61).
As in the case of HIV/AIDS, the government committed itself to tak-
ing over TB activities. In its strategy for Eastern Europe and Central Asia,
the Global Fund explicitly asked countries to take over the provision of
first-line medications for drug-susceptible TB by 2017 and develop a
5
266 G. Isabekova
plan for a similar transition of second-line drugs for MDR-TB (WHO/

Europe, 2014). Since 2015, the government of Kyrgyzstan has fully
financed first-line medications (State Partner 9), and it plans to increase
its contribution to second-line drugs to 20% in 2023 (Global Fund
Office of the Inspector General, 2022, p. 4).
In addition to medications, the Global Fund (n.d.-a, p. 10) also expects
grant-recipient countries to transfer the costs of laboratory reagents and
consumables, maintenance of equipment, and services to domestic or
“alternative” sources of funding. As of 2015, TB diagnostics were “almost
exclusively” financed by the Global Fund (Mansfeld et al., 2015, p. 9),
which also covered laboratory supplies, equipment (van den Boom et al.,
2015), co-payments to specialists working with hazardous materials and
other costs (State Partner 9). The government intends to increase its con-
tribution to these areas as well, but fulfilling these commitments in the
context of a budget deficit is challenging. Thus, the financial gap in the
national health care reform program (2019–2030) is approximately 45%
or approximately 2.3 billion KGS (approximately € 24,663,564), with
the optimization and redirection of resources ensuring 57 million KGS
(about €611,227); the rest is foreseen from other sources (Government of
KR, 2018).
The country initiated optimization reforms to ensure additional
financing. The TB Roadmap for 2016–2025 aims to decrease unneces-
sary hospitalizations by 5–8% annually, reduce bed capacities by 60%
compared to 2015, and increase coverage with full ambulatory treatment
by 60% by 2025 (Ministry of Health of KR, n.d.). These reforms mainly
target problems related to excessive hospitalization (also among patients
whose TB diagnosis is not confirmed) to reduce the length of hospital
stay, which could last up to two to three months (ibid.). A savings of
137.7 million KGS (approximately €1,476,597) resulting from these
reforms are to be spent on PHC strengthening, procurement of medica-
tions, laboratory supplies, and reagents, and improving the conditions of
buildings (ibid.). Nevertheless, the Government of Kyrgyzstan (2017a)
acknowledged that these savings were insufficient to meet the country’s
TB needs. Thus, procurement of second-line medications, laboratory
maintenance, and supplies remain dependent on external support.
Despite explicit commitments and reforms initiated by the govern-

ment, there is skepticism regarding the actual fulfillment of its obliga-
tions. My interviewees noted that the country was “unique” in the sense
that there were many “good” laws and decrees that nevertheless fizzled
out with time (CSO 3). They questioned the actual implementation of
the “written promises” (State Partner 4) and suggested that many docu-
ments were not further realized (State Partner 6). Studies by Ancker and
Rechel (2015a, 2015b) similarly suggest a “declaratory manner” of state
policies, targeting donors rather than actually guaranteeing the contin-
ued implementation of the programs.
I suggest that the actual implementation of commitments depends on
two factors, namely, national priorities and the choices of decision-
makers. TB and HIV were explicitly prioritized and delineated in previ-
ous national health care reform programs (2005–2018), but the new
program, “Healthy People, Prosperous Country” (2019–2030), incorpo-
rates these two into broader priority areas, such as public health and pri-
mary health care. Indeed, improvements in other areas highlighted in the
program, including laboratory services, access to medications, human
resources, information systems, eHealth, and an increase in state financ-
ing, equally benefit TB and HIV (Government of KR, 2018). The pro-
gram pursues an interdisciplinary approach to health and intends to take
this perspective to a new level by harmonizing legislation, engaging a
broad spectrum of stakeholders, and emphasizing their responsibilities in
health (ibid.). The program still targets TB and HIV but in an inte-
grated manner.
This comprehensive and non-disease-specific focus nevertheless has
implications for prioritization. For instance, the new program defines the
following TB- and HIV-related indicators: the percentage of patients suc-
cessfully completing TB treatment at the PHC level and the number of
HIV notifications and TB prevalence per 100,000 people (Government
of KR, 2018). “Den Sooluk” delineated TB and HIV and defined six
indicators (three for each) (Government of KR, 2012). Indeed, this pro-
gram aimed to strengthen the health care system by targeting key barri-
ers, including public health, financing, and stewardship, but it still
delineated cardiovascular disease, mother and child health, TB, and HIV
as “core services” (ibid.). Surely, indicators in the new program hint at the
268 G. Isabekova
prioritization of these diseases but in the context of broader health care

reforms. This difference in the approaches of the two programs also relates
to broader changes beyond the country (Chap. 12).
In addition to national priorities, the continuity of the project activi-
ties, among others, depends on the decision-makers’ personal interests
and beliefs. Increased state financing of health care programs requires an
“active position” of the Ministry of Health and the relevant state agencies
(IO Partner 3). However, the leaders, often political appointees, may not
necessarily be committed to TB and HIV/AIDS or other services (IO
Partner 4). On the contrary, some members of the parliament and gov-
ernment seem to have “a detrimental or disruptive effect” on the HIV/
AIDS policies due to their “moral” beliefs and conventional positions
toward CSWs, MSM, and PWID (Ancker & Rechel, 2015b, pp. 8–16).
Although legal commitments hint at the government’s intention to
continue HIV/AIDS and TB services, the extent and depth of these ser-
vices depend on other factors. Among others, there are procurement costs
and opportunities, the epidemiological situation, the political environ-
ment in the country, the availability of trained personnel, and other fac-
tors (e.g., the COVID-19 pandemic).
First, the continuity of services is conducive to procurement costs and
opportunities. Accordingly, the low costs of methadone (approximately
US $0.10 per day (Subata et al., 2016)) and condoms (approximately US
$0.18 per unit (Stover et al., 2011)) may be advantageous to their conti-
nuity beyond the duration of the Global Fund grants. However, the lim-
ited state contribution to HIV prevention for vulnerable groups hints at
the relevance of other factors, such as prioritization or stigma and dis-
crimination against these groups (Chap. 3). Nevertheless, costs matter,
particularly in the context of limited financial capacity, and vivid exam-
ples thereof are ARV and TB medications. ART is a lifelong therapy, and
the annual cost of ARV drugs per patient ranges between US $490 for
first- and US $1520 for second-line medications (Stover et al., 2011,
p. 3). According to state partners interviewed for this research, the esti-
mated costs of a single course of TB treatment in Kyrgyzstan vary from
US $50–107 for drug-susceptible (State Partner 9) and US $4–15,000
for multi- and extensively drug-resistant TB per patient (State Partner 6).
In this way, although taking over first-line treatment, the government
may find it challenging to finance second-line medications against drug-

resistant strains of TB/HIV.
Surely, treatment costs are changing following scientific progress. A
state interviewee hoped that the emergence of generic drugs and license
expiration of some items might contribute to the affordability of medica-
tions (State Partner 2). As of 2019, ARVs are included in the list of essen-
tial medicines intended to ensure their accessibility (UNAIDS, 2020)
due to the state control of the prices of items on this list. Moreover, prices
for ARVs are gradually falling, and there are several alternatives to ART,
including preexposure prophylaxis products offered by pharmaceutical
companies and charities, as well as the potential use of mRNA vaccines
against HIV (Economist, 2022b). Following the COVID-19 pandemic,
there are also plans to commence trials of TB mRNA vaccines (Economist,
2022a). Trail results may provide alternatives to existing treatment regi-
mens for TB and HIV.
Procurement opportunities are inherent to medication costs and treat-
ment outcomes by ensuring the continuous supply of medications neces-
sary for quality treatment. Kyrgyzstan procures TB and HIV/AIDS-related
products via the voluntary pooled procurement mechanisms of the
Global Fund and the Global Drug Facility (GDF), which allow aggrega-
tion of orders and negotiation of better prices and delivery conditions
(Gotsadze et al., 2019). Upon its transition from the Global Fund grants,
the country is expected to procure health products on its own. However,
individual country procurement will result in an increase in prices (ibid.).
It may also result in situations in which manufacturers are not interested
in supplying health care products to the country due to the small size of
the order. One of my interviewees recalled the “bitter experience” of
Kazakhstan, which encountered a drastic increase in prices after the
country’s transition from the Global Fund grants (State Partner 2). To
avoid this situation and allow the continued procurement via interna-
tional organizations, the government actors initiated relevant amend-
ments to the national legislation (ibid.).
In addition to access to international procurement mechanisms, pro-
curement of health products beyond the duration of Global Fund grants
requires their registration in the country. Most of the grant-recipient
countries (including Kyrgyzstan) used one-time waivers for the drugs
270 G. Isabekova
procured via the Global Fund (Gotsadze et al., 2019) by qualifying them
as “humanitarian assistance.” By contrast, the medications purchased at
the expense of the state budget must be registered in the country. As of
2018, most of the medications used for ART and treatment of multidrug-
resistant (MDR-TB) and extensively drug-resistant tuberculosis
(XDR-TB) were not registered in the country (Mandel, 2018). In other
words, their procurement by the government was not possible. Accelerated
registration of medications has improved since then (see Eurasian Harm
Reduction Association, 2021). One interviewee, however, expressed con-
cerns that the country may switch to drugs with treatment outcomes
different from those provided in the grants (IO Partner 4). As the situa-
tion evolves, procurement requires closer consideration and research on
its own.
Second, in addition to the use of certified medications, the quality of
TB and HIV/AIDS services depends on the availability of qualified med-
ical workers. To improve the quality of services, the Global Fund financed
multiple training seminars on infection control, quality of lab services,
management of medical waste (UNDP, 2015e), and HIV prevention.
The seminars also targeted health workforce management by providing
training on electronic spreadsheets, management of payments to medical
workers, and other areas (UNDP, 2015c). Yet, the long-term impact of
these training activities is jeopardized by high staff rotation. A health care
professional interviewed for this research suggests that training of one lab
specialist takes around six months and costs KGS 36,000 (about €386
Euro). However, after a year, this specialist leaves the state hospital to
work in a private lab due to the better salary rates offered there (Health
worker 1). Therefore, the long-term impact of training activities on the
qualifications/competencies of health care personnel involved in the TB
and HIV/AIDS programs remains unclear due to the structural problems
in the health care system (Chap. 4).
Third, the continuity of services also relates to the epidemiological
situation in the country. Despite coverage issues, there is a growing
demand for HIV and TB treatment. After a nosocomial outbreak of HIV
in the south of the country, the procurement of antiretroviral medica-
tions in Global Fund grants changed from an annual to biannual basis
(Murzalieva et al., 2009). Correspondingly, the number of people on
ART has doubled annually since 2011 (Mansfeld et al., 2015). Similarly,
there is a growing demand for TB treatment, particularly in the context
of the drug-resistant forms of this disease (Chap. 1). There is a consider-
able financial gap in the treatment of drug-resistant TB (WHO/Europe,
2011), and even donor financing cannot meet the increasing demand for
treatment. The Global Fund grants and Doctors Without Borders/Médecins
Sans Frontières (MSF) covered 609 out of 1136 cases of multidrug and 36
out of 60 cases of extensively drug-resistant TB (van den Boom et al.,
2015, p. 88). All savings in the grants have been used to provide treat-
ment, but the Global Fund could still not cover the existing needs of the
National TB Control Program, much less meet the growing demand for
treatment of drug-resistant forms of tuberculosis (see UNDP, 2013).
Predicting changes in the epidemiological situation in the country goes
beyond the scope of this research. However, financial struggles in meet-
ing the growing demand for treatment suggest grim perspectives for the
continuity of services.
Fourth, the epidemiological situation is closely related to other factors.
For instance, the COVID-19 pandemic was an unexpected challenge
that strained the health care system and led to a diversion of resources
(e.g., facilities, health personnel, and finances) from other diseases (Davis
et al., 2021). Health care providers and civil society volunteers demon-
strated unprecedented solidarity, dedication, and commitment in tack-
ling the pandemic. The Global Fund, along with the World Bank, the
German Federal Ministry for Economic Cooperation and Development
(das Bundesministerium für wirtschaftliche Zusammenarbeit und
Entwicklung—BMZ), and others, supported the country in its immedi-
ate response to COVID-19.
Global Fund grants adapted to the unexpected situation by providing
a range of services to mitigate the impact of the pandemic. These included
mobile brigades, online services, video supervision, and opening centers
and shelters for individuals to continue their TB and HIV-related treat-
ments (see UNDP, 2020a). The grants also supported medical workers
who were at the forefront of the epidemic and worked for long hours and
often without access to protective equipment.
Although it reduced deaths, the lockdown imposed by the Kyrgyz gov-
ernment from March 24 to May 10, 2020, caused a decrease in testing
272 G. Isabekova
and prevention and limited access to care for both TB and HIV services
(Alliance for Public Health et al., 2021). The medication supply was
uninterrupted, and the share of outpatient services increased, but mobil-
ity restrictions affected health care-seeking habits for both diseases (ibid.).
The medium- and long-term consequences of disruptions caused by the
pandemic remain to be seen. The country has no catch-up plan against
the impact of the pandemic on health (Global Fund Office of the
Inspector General, 2022). However, at the global level, COVID-19 set
back the global achievements made in TB and HIV/AIDS in recent
decades (Economist, 2022a, 2022b). Reductions in global TB and AIDS-
related funding combined with the ongoing pandemic clearly jeopardize
the continuity of TB and HIV/AIDS services. How much the Global
Fund manages to raise in its seventh round and how it distributes these
finances remain to be seen.
To summarize, this section analyzed the continuity of the Global Fund
project activities after the country’s transition by elaborating on the types
(what) and the extent of the services currently provided within the grants.
As demonstrated above, the Global Fund increased the geographic cover-
age and the type of HIV/AIDS services in Kyrgyzstan by contributing to
HIV testing, distribution of condoms, opioid substitution therapy, nee-
dle and syringe exchange program, and antiretroviral therapy. The Global
Fund has similarly contributed to the prevention and treatment of tuber-
culosis by ensuring the countrywide availability of MDR-TB treatment.
Nevertheless, reaching out to the groups affected by TB and HIV/AIDS
and patient adherence to treatment remained problematic.
The government, in turn, demonstrated its commitment to continu-
ing TB and HIV services by increasing its financial contribution and
indicating its responsibilities in relevant legislation. Following skepticism
that some interviewees and related studies expressed, this section listed
factors critical to fulfilling commitments. These included changes in
national health care priorities, the choices of decision-makers, medica-
tion prices and procurement, health personnel availability, the country’s
epidemiological situation, and the COVID-19 pandemic. The continu-
ity of services in the long-term also depends on how these factors evolve.
9.3 Maintaining Benefits

In addition to diagnosis and treatment, Global Fund grants provided
incentives to patients and health care workers to increase patient adher-
ence to treatment. This section discusses the types of incentives and the
maintenance of patient and health care workers’ benefits beyond the
duration of the Global Fund grants to Kyrgyzstan.
First, the benefits for patients with TB included reimbursement of
travel expenses (UNDP, 2014) and provision of hygiene and food parcels
(Government of KR, 2013). Because of stigma and discrimination related
to TB and confidentiality concerns, patients often prefer to receive their
treatment in health care facilities outside their area of residence. The
Global Fund reimburses all travel expenses a patient incurs on the way to
examination and treatment (UNDP, 2014). Furthermore, patients
received food and hygiene parcels to incentivize treatment adherence. For
those in inpatient care, these parcels included butter, condensed milk,
black tea, sugar, biscuits, laundry and toilet soaps, shampoo, toothpaste,
and toilet paper (UNDP, 2013). The patients in outpatient care received
vegetable oil, rice, pasta, grain sugar, black tea, washing powder, toilet,
and laundry soaps (ibid.). These parcels could be received by TB patients
themselves or their family members. A CSO representative, who distrib-
uted these parcels, noted that there were only seven rejections during the
five years. Generally, people accepted these parcels as a contribution to
the family budget since TB patients could not work for the duration of
their treatment. An interviewee notes that the low number of rejections
vividly demonstrates the economic hardships encountered by TB patients
and the population in general (CSO 3).
Later, the hygiene and food parcels were replaced with vouchers and
money transfers. The national actors implementing the Global Fund
grants concluded an agreement with supermarkets and provided training
to their staff members on how to work with the vouchers issued within
the framework of the grants. The vouchers intended to provide a more
“client-oriented approach,” which allowed the patients to choose the nec-
essary food and hygiene items. The patients received the change if the
amount of purchase was less than or paid extra if it exceeded the value of
274 G. Isabekova
the voucher (CSO 9). The vouchers were later replaced with money
transfers, which patients received for their adherence to treatment after
being confirmed by a health care worker providing the DOTS (CSOs 3
and 9). Monthly money transfers ranged from 1300 KGS (about €14) for
patients with drug-susceptible to 1800 KGS (€19) for patients with drug-
resistant TB (Health Worker 1). The decrease in the amount of the Global
Fund grants to Kyrgyzstan also affected the patient benefits. Since 2018,
only patients with drug-resistant TB receive money transfers (ibid.),
though reimbursement of travel expenses has remained available to all TB
patients.
Second, patients with HIV/AIDS were entitled to reimbursement of
their travel expenses related to treatment and examination. They also
received psychological and peer-to-peer support from the NGOs imple-
menting HIV-prevention activities. These NGOs supported persons liv-
ing with HIV in administrative and legal issues related to obtaining
identity documentation, applying for social benefits, and others (CSO 6).
Adults are entitled to disability pensions, depending on their clinical stage,
although the amounts remain low (not just for HIV) and insufficient to
cover actual needs (ibid.). Children with HIV are entitled to monthly
motivational payments of 1000 KGS (approximately €11) (see UNDP,
2021a). In 2019, for instance, 80% of registered HIV-positive children
received monthly support (UNAIDS, 2020). However, there is still a
problem with the coverage of support activities due to rejections from
PLHIV. The main reason is the fear of their status becoming known dur-
ing the preparation and request of documents necessary for receiving these
benefits (ibid.). A few activists, such as Baktygul Shukurova, disclose their
HIV status to draw attention to this problem (Akipress.org, 2017).
Third, in addition to patient benefits, the Global Fund grants stipu-
lated additional incentives for health care workers working in TB and
HIV/AIDS. In TB, medical workers receive bonuses for the achievement
of the “favorable treatment outcome,” sputum conversion at the six-
month point after the initiation of treatment (UNDP, 2015b). According
to a health care worker interviewed for this research, 12,000 KGS (about
€129) is awarded for the successful treatment of a patient with drug-
susceptible and 24,000 KGS (around €257) for a patient with drug-
resistant TB (Health Worker 1). The interviewee noted that the bonuses
were divided between the health care workers participating in the treat-
ment. Seventy-five percent is provided to a nurse supervising the patient,
15% to a head doctor, and the rest is awarded to the director and deputy
director of the family group practice, the coordinating TB specialist, and
others (ibid.). Similar co-payments are stipulated for health care workers
in HIV/AIDS. For instance, a narcologist, nurse, and social worker are
entitled to base salary and additional payments for every patient enrolled
in methadone substitution therapy. A narcologist/nurse receives US $50
base monthly salary and an additional US $3 for each patient, while a
social worker receives US $80 monthly and an additional US $2 per
patient, respectively (UNDP, 2015d).
It should be noted that support for key groups was further reempha-
sized during the COVID-19 pandemic. For instance, 480 children with
HIV received tablets to continue their school education during the pan-
demic (UNDP, 2021b). A total of 2577 individuals from vulnerable
groups, including PLHIV, patients with TB, and those in precarious life
situations, received food parcels (ibid.). In addition, the grants continued
providing shelter opportunities, stipulating the provision of meals for
vulnerable groups (ibid.). Training activities intended to inform the
LGBTQ community and NGOs about COVID-19 and their rights,
including access to health care and other issues, were conducted
(UNDP, 2020b).
My interviewees emphasize that the discontinuity of some benefits was
clear from the beginning, but the grants continued providing them to
facilitate the fight against the two diseases (IO Partner 20). Nevertheless,
some activities, such as the outpatient treatment of drug-resistant TB,
may evolve into a “time-bomb” if the state or another donor will not take
over the patient benefits to ensure their adherence to treatment (State
Partner 10 and Academic Partner 2).
The Global Fund (n.d.-a) stipulates a gradual transition of expenses for
human resources and social support from grants to the state budget.
Some interviewees were skeptical in this regard. One noted that the dis-
continuity of some benefits was clear from the beginning, but the grants
continued providing them to facilitate the fight against the two diseases
(IO Partner 20). Another warned that some activities, such as outpatient
treatment of drug-resistant TB, might evolve into a “time bomb” if the
276 G. Isabekova
state or another donor would not take over patient benefits to ensure
their adherence to treatment (State Partner 10 and Academic Partner 2).
Overall, the state committed itself to continuing the reimbursement of
travel expenses, provision of social support to children with HIV, and
financial incentives for health care workers. However, budget deficits,
stigma, and discrimination against individuals affected by TB and HIV
jeopardize the actual implementation of these commitments. Thus, local
self-governments are expected to cover the travel costs of TB and HIV
patients residing in their area (State Partner 6). However, as the majority
of regions are subsidized by the national government (State Partner 9),
local self-governments’ ability to fulfill this function is unclear. In addi-
tion to travel expenses, the national government committed itself to pro-
viding social support to 90% of children with HIV (Government of KR,
2017b). Since 2020, the government has stipulated a lump-sum cash
compensation in cases of nosocomial HIV infection. Individuals who are
18 or parents of children under this age are entitled to compensation in
an amount not less than 1000 calculation indices (Government of KR,
2005). Yet, stigmatization and discrimination of persons living with HIV,
bureaucracy, and unawareness about the entitlements hinder access to
these benefits (Murzalieva et al., 2009). The national government has also
stipulated co-payments to primary health care workers, particularly
nurses providing DOTS, to ensure the patients’ adherence to TB treat-
ment (Health Worker 1). Currently, the nurses’ monthly salary of 12,000
KGS (around €129) is below the average national wage rate of 16,427
KGS (about €176), and nurses have no incentives to follow-up on
patients defaulting from treatment (IO Partner 17).
Overall, the Global Fund provided multiple benefits to patients and
health care workers to facilitate the prevention and treatment of TB and
HIV/AIDS. These benefits included the reimbursement of travel expenses,
provision of hygiene and food parcels, vouchers and money transfers, and
co-payments to medical workers involved in TB and HIV/AIDS services.
However, the majority of these benefits are unlikely to be maintained
beyond the duration of the grants. The government has committed itself
to reimbursing the travel expenses incurred by patients on their way to
TB and HIV/AIDS-related services. It has also promised to provide social
support to 90% of children with HIV and pensions to adults with HIV
(as discussed above). Nevertheless, the budget deficit jeopardizes the

actual implementation of these commitments. In addition, due to stigma
and discrimination, individuals with TB and HIV reject state support
due to the fear of exposure.
9.3.1 Community Capacity Building
This section examines the survival of the NGOs involved in the Global
Fund grants, their leadership, and resource mobilization beyond the
duration of the grants.
First of all, in terms of survival, a decrease in the Global Fund grants
affects the NGOs working in TB and HIV/AIDS, although to different
extents. NGOs compete for the “scarce resources” (Spicer et al., 2011b,
p. 1753) and some organizations currently working in the Global Fund
grants will have problems with finding alternative sources of funding
(Zardiashvili & Garmaise, 2017). Yet, the decrease in donor financing
will have a differentiated impact on NGOs.
The organizations (including those involved in the Global Fund grants)
vary greatly in their human resources and work experience. For instance,
“AIDS Foundation East-West in the Kyrgyz Republic” (“AFEW-
Kyrgyzstan”) (n.d.) registered itself as a local Kyrgyz NGO in 2015, but
it commenced its work in the country already in 2004 as part of the
projects financed by AFEW-International. The organization inherited
the standard operating procedures of the international organization,
which ensured its strong capacity in comparison to other local NGOs
(CSO 3). Another organization, “Socium,” commenced its activities in
1996 as a public association working on social development and adapta-
tion of individuals with drug and alcohol addiction (CSO 8). Similar to
“AFEW-Kyrgyzstan” (2023), “Socium” collaborated with multiple
donors, such as the Soros Foundation Kyrgyzstan, the Global Fund,
USAID, UNAIDS, and others. This cooperation and long-term experi-
ence ensured the relative independence of these NGOs from the Global
Fund grants.
However, smaller grant recipients largely depend on the Global Fund
(Nasakt, 2015). These organizations concentrate on specific groups
278 G. Isabekova
particularly vulnerable to HIV/AIDS, such as MSM, CSWs, and

PWID. This specialization contributed to the selection of NGOs receiv-
ing Global Fund grant funding, as the financier typically differentiates
between the vulnerable groups and assigns organizations to work with
each of them. However, in the long-term perspective, this narrow special-
ization negatively affects the organizations’ abilities to adjust to the
changing environment of development assistance. For this reason, larger
NGOs with multiple sources of financing are likely to survive, in contrast
to smaller organizations working with specific groups and dependent on
a single donor (IO Partner 4).
Furthermore, the leadership of the NGOs working in the Global Fund
grants remains unclear due to their dependence on donor financing and
the limited training provided within the grants. Leadership can be defined
as the organizations’ ability to define the problems, suggest solutions, and
critically reflect on the general issues relevant to their work. In the NGOs’
case, it closely relates to their ability to advocate for the issues pressing to
them and the groups of the population they aim to represent. The studies
on NGOs working in TB and HIV/AIDS in Kyrgyzstan note that the
organizations generally refrain from criticizing the donors (Murzalieva
et al., 2009) and acting independently from them (Ancker & Rechel,
2015b) due to fear of losing financing (Spicer et al., 2011b). Smaller NGOs
solely dependent on the Global Fund seem to be particularly vulnerable in
this regard (Harmer et al., 2013) and less likely to criticize the donor.
It should also be noted that the Global Fund stipulates limited support
of the NGOs’ advocacy work. Relevant in the early 2000s, the advocacy
for treatment and human rights does not seem to be relevant to the donor
anymore (IO Partner 20). An NGO representative also notes that most
of the training activities targeted service provision (CSO 8). Mainly
focusing on prevention (Murzalieva et al., 2009) and treatment, the
Global Fund grants devote limited attention (Harmer et al., 2013) and
resources to advocacy for the rights of the persons affected by the diseases
(Spicer et al., 2011b). Burrows et al. (2018) go further by linking the
increase in violence and hostility toward vulnerable groups to the reduc-
tions in external funding for advocacy. The general dependence of the
organizations on donor financing and the limited support for advocacy
within the Global Fund grants do not stimulate leadership among the
NGOs involved in the grants. However, a more specific estimation

requires a closer look at individual NGOs, since the quality of their lead-
ership greatly varies depending on the size and experience of organiza-
tions and their access (or lack thereof ) to multiple sources of financing.
Equally, mobilization of resources via donor and state financing or
fundraising is an essential component of sustainability, as it closely relates
to the continuity of civil society organizations and their activities beyond
the individual donor-funded projects. As mentioned above, the NGOs
involved in the Global Fund grants greatly vary in terms of their access to
alternative sources of financing. Therefore, instead of discussing the
mobilization of resources by individual NGOs, this subsection focuses
on social contracting, a source of financing for all NGOs developed as a
result of the Global Fund grants to the country.
The Global Fund (n.d.-a) asks grant-recipient countries to develop
social contracting to secure financing for NGOs and their activities in TB
and HIV/AIDS after the end of the grant period. Social contracting pre-
sumes NGO contracting by government agencies. The Government of the
Kyrgyz Republic (2017b) committed itself to developing the normative
legal basis necessary for social contracting by the end of 2021. Seminars for
representatives of state and nongovernmental organizations offered within
the grants intended to support these aspirations (see UNDP, 2021c).
Overall, by integrating social contracting into its legislation, the govern-
ment aimed to continue the work of the NGOs with vulnerable groups
through its integration with primary health care (Government of KR,
2017a). UNAIDS (2020, p. 6) notes that three million KGS (€32,170)
were used to pilot social contracting projects on support and care to
PLHIV. However, the issues and achievements in this process require fur-
ther research, particularly in the face of challenges presented by COVID-19.
It is important to note that the introduction of social contracting will
have further implications for the services provided by NGO social work-
ers and the accountability of NGOs. First, as one interviewee noted,
unlike the psychological and peer-to-peer support in the Global Fund
grants, which targeted individuals affected by TB and HIV, an NGO
social worker contracted by the government is expected to cover all
patients with “socially significant diseases,” including but not limited to
TB and HIV/AIDS (State Partner 2). This will affect the quality and
280 G. Isabekova
quantity of consultations provided to each patient. Furthermore, accord-

ing to the same interviewee, the breadth of services offered by a social
worker (e.g., peer-to-peer support, follow-up, and outreach to target
groups) will also decrease, as the government cannot maintain the breadth
of services offered through Global Fund grants (ibid.). In addition, an
interviewee added that social contracting would result in NGOs’ account-
ability to the government for the services financed by it (ibid.). This may
have further implications for NGOs’ ability to criticize the government,
as in the case of NGOs and donor organizations.
At the same time, the feasibility of social contracting in practice
remains to be seen. Indeed, social contracting may be the only opportu-
nity (other than donor financing) to continue the services provided by
NGOs (State Partner 2). “Unavoidable” and “possibly good,” social con-
tracting is probably something that the civil society organizations strived
for (CSO 6). For the government, social contracting offers the possibility
to involve knowledgeable and experienced social workers, and for NGOs,
it promises some security in the context of decreasing donor funding
(ibid.). Nevertheless, not all NGO employees may be willing to partici-
pate in social contracting due to salary differences. A state representative
interviewed for this research suggests that project coordinators in NGOs
may earn around US $500–600 per month, while a family doctor might
earn about US $150 (State Partner 6). This difference in salary, along
with accountability to the government, may affect the NGO employees’
willingness to conclude social contracting with state institutions.
Overall, the Global Fund has contributed to community capacity
building in multiple ways. It increased the number of NGOs and facili-
tated the development of social contracting to guarantee the NGOs’
access to state financing after the country’s transition from the Global
Fund grants. These benefits notwithstanding, the increased number of
NGOs and the scarcity of resources resulted in competition among the
organizations and their dependence on donor financing. The NGOs
working with the Global Fund grants seem to restrain themselves from
criticizing the donor or the primary recipients of the grants due to the
fear of losing access to financing. This dependency, along with the limited
focus of the Global Fund on advocacy work, discouraged the leadership
of civil society organizations from working with the grants.
9.4 Summary
The COVID-19 pandemic demonstrated an unprecedented challenge to
the sustainability of grant activities. With its medium- and long-term
implications still to be seen, the impact of the pandemic on each dimen-
sion of sustainability requires further research. Although it reflected on
some initial implications, this chapter was nevertheless bound to provide
a more general analysis over a longer time period. This chapter reviewed
the sustainability of the Global Fund project in Kyrgyzstan by focusing
on the continuity of activities, maintenance of benefits, and community
capacity building beyond the duration of the project.
First, the Global Fund increased the type and geographic coverage of
preventive and treatment services related to TB and HIV/AIDS. More
specifically, it consolidated HIV testing and TB detection, and expanded
access to opioid substitution therapy and needle-exchange programs. The
Global Fund introduced antiretroviral therapy, previously inaccessible to
persons living with HIV. It has also contributed to the provision and
expansion of treatment of multi- and extensive drug-resistant forms of
tuberculosis in Kyrgyzstan. Despite these improvements, the Global
Fund grants neither reached out to all persons most vulnerable to HIV
nor provided treatment to all MDR-TB patients. The author reckons
with these issues as not to give a false impression about the extent of proj-
ect activities financed by the Fund. Since the grants are still ongoing, the
continuity of the Global Fund project remains an open question, which
is also vividly demonstrated by the lack of consensus on this subject
among the stakeholders involved in TB and HIV/AIDS. The government
committed itself to continuing most of the project activities. However,
the actual fulfillment of these commitments largely depends on policy-
makers’ interests and beliefs, further availability of state financing, the
epidemiological situation in the country, access to certified medications,
and trained health care personnel.
Second, the Global Fund provided extensive social support to patients
and health care workers to increase patient adherence to treatment. The
benefits included reimbursement of travel expenses, provision of hygiene
and food parcels, vouchers, monetary incentives, and co-payments.
282 G. Isabekova
Although unequally distributed among the TB and HIV patients, these

benefits supported preventive and treatment activities covered by the
grants. The government has committed itself to taking over the reim-
bursement of travel expenses, co-payments to health care workers, and
social support for children with HIV. However, the actual use of these
benefits is unclear due to lack of awareness of the population about these
entitlements, state bureaucracy, stigma and discrimination, and budget
deficits at the level of local self-governments. The maintenance of benefits
not taken over by the government seems implausible without donor
assistance.
Third, the Global Fund contributed to community capacity building
by ensuring the NGOs’ access to state financing, as well as increasing the
number of NGOs and number of NGO staff. Yet, the limited focus of
the Global Fund on NGO advocacy, along with the civil society organi-
zations’ dependence on the grants, emasculated the leadership of the
NGOs working with the grants. Notably, the transition of the country
from the Global Fund grants will have a differentiated impact on the
survival of civil society organizations, depending on their size, experi-
ence, and collaboration with other actors.
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right holder.
10
Aid Relationships and Power Dynamics
in the Global Fund Grants
This chapter discusses the types of relationships between stakeholders

involved in the Global Fund to Fight AIDS, Tuberculosis and Malaria
(the Global Fund) grants to the Kyrgyz Republic. This discussion builds
on the findings of the previous chapters. Chapter 2 outlined the general
analytical framework used to analyze the relationships between providers
and recipients of aid. It also introduced the analytical categories used to
delineate the stakeholders: “donors” or aid providers, “recipient state” or
state organizations receiving the assistance, and “civil society organiza-
tions” (CSOs) or nongovernmental organizations (NGOs) involved in
health aid. Chapter 4 further elaborated on how the structural factors
relevant to relationships and sustainability, namely, aid predictability and
flexibility on the providers’ side, as well as capacity and dependency on
the recipients’ side, evolved in the Global Fund grants. Chapter 8, in its
turn, disentangled the roles of stakeholders in reference to the abovemen-
tioned analytical categories in initiating, designing, implementing, and
monitoring the grants. Building on the findings of these chapters, this
chapter discusses the power dynamics among stakeholders and defines
the following types of relationships between actors involved in the grants
(Table 10.1).

294 G. Isabekova
Table 10.1 Relationships between stakeholders involved in the Global Fund

grants to the Kyrgyz Republic
Type of
Actors Reference relationships
The Global Fund—grant-recipient Donor–civil society “Utilitarian”
NGOs organizations approach
The Ministry of Health, represented by Recipient state–civil “Utilitarian”
the National Center of Phthisiology, society approach
and organizations
the Republican AIDS Center—NGOs
The Global Fund—other development Donor–donor Coordination
organizations, working in
tuberculosis and HIV/AIDS
The Global Fund—Ministry of Health, Donor–recipient “Unequal”
represented by the National Center state cooperation
of Phthisiology and the Republican
AIDS Center
10.1 Donor–CSOs: “Utilitarian” Approach

I define the relationships between the Global Fund and NGOs as evinc-
ing a “utilitarian” approach because of the equal participation of both
actors throughout the project, structural factors favorable to hierarchical
relations, and power dynamics between these stakeholders.
First, the participation of grant-recipient NGOs through the grant
realization process was uneven. Civil society participation and empower-
ment are at the cornerstone of the Global Fund’s mission, and this
emphasis also found its reflection in the grant design and implementa-
tion phases. The organization was critical to NGOs’ engagement in
designing the grant applications and implementing them on equal terms
with state organizations. However, the NGOs’ involvement in the grant
monitoring process was limited to data provision, filling no decision-
making functions, reaffirming the conventional provider-recipient rela-
tions in which the local NGOs felt that they were relegated to being
themselves mere grant implementers.
Second, the structural factors accommodated hierarchical relations
between stakeholders. The Global Fund strives to provide predictable
10 Aid Relationships and Power Dynamics in the Global Fund… 295
assistance, but the organizational dependence on replenishment cycles,

the guaranteed financing is confined to three years. The organization also
aims to ensure the compliance of its grants with recipient countries’ pri-
orities, among other things by ensuring the broader engagement of stake-
holders in designing the grants. Still, the organizational structures seem
to hinder the adaptability of grants to changes and suggestions, as alluded
to in the case of the limited adjustment to NGO suggestions. Though the
capacities of grant-recipient organizations greatly vary depending on
their size, experience, and the areas they are working in, the services pro-
vided by NGOs appear highly dependent on external assistance.
Though surely case-dependent, a combination of the four structural
factors, together with the NGOs’ limited engagement in the monitoring
process, lay down the basis for power dynamics to unfold the way they did:
The relationship between the financier and local NGOs vividly dem-
onstrates the dilemma presented by, but also the interrelation between
the “power to” and “power over.” The former emerged through structural
bias favoring the roles of NGOs in health aid and the strong organiza-
tional support for it. By contrast, the latter came into being through
social order and discipline favoring the predictability of outcomes over
flexibility in the grant realization process.
The structural bias and constraints promoted by the Global Fund in its
grants created the “power to” for the local NGOs. Following Haugaard
(2003, p. 107), structural biases occur through specific social order,
which creates possibilities that empower or disempower actors through
structural constraints. The Global Fund’s emphasis on civil society par-
ticipation (social order) provided a window of opportunity (empower-
ment) for the local NGOs to participate in the decision-making and
implementation of grants. This social order was further supported by
structural constraints. The Global Fund’s requirements concerning the
establishment of the Country Coordinating Mechanism (CCM) and the
incorporation of a human rights perspective into the grants contributed
to the involvement of local NGOs and persons affected by diseases in
designing the country’s applications.
Similar constraints were applied to the implementation of grants. The
Global Fund facilitated NGOs’ involvement in the project implementa-
tion process through its “dual-track” financing or channeling of funds via
296 G. Isabekova
state and non-state actors. Though arduous, this collaboration between

actors nevertheless set a precedent for joint lobbying for the continuity of
tuberculosis (TB) and human immunodeficiency virus infection and
acquired immune deficiency syndrome (HIV/AIDS) services beyond the
duration of the grants.
Notably, the deference to the abovementioned structural bias was
backed up by sanctions. The Global Fund rejected the country’s HIV pro-
posal due to the noncompliance of the Country Coordinating Mechanism
Country with the “minimum requirements” of civil society representa-
tion. This gatekeeping action signaled national stakeholders to take this
requirement seriously in order to access the grants. The Global Fund
financing available for the capacity building offered means for “correcting”
this situation and ensuring sufficient civil society participation in drafting
the country’s grant applications. This access to additional financing repre-
sented what Baldwin (1971, p. 23) would call a “positive sanction” aimed
to reward a stakeholder for its acquiescence to the social order. Still, this
positive sanctioning operated together with gatekeeping the Global Fund
exercised to support the structural bias in favor of the roles of civil society
organizations in health aid and, more specifically, its grants.
At the same time, the grant realization process suggests that the Global
Fund has also exercised the “power over” local NGOs through social
order and discipline to ensure the predictability of grant outcomes. In the
implementation stage, the grants demonstrated limited openness to
NGO suggestions. The indicators and objectives stated in the country’s
applications constituted structural constraints that disregarded recom-
mendations made beyond the design phase. This closedness aimed to
ensure the predictability of outcomes in relation to grant objectives.
Though logical in an organizational setting, this predictability consid-
erably hinders responsiveness to the changing environment in which
health aid is implemented. The “power over” created through predict-
ability here was the outcome of a social order in which actors built struc-
tures concerning specific meanings (Haugaard, 2003, p. 107), in this case
in the form of grants targeted at fighting certain diseases. The limited
openness to NGO suggestions brought specific associations with the
division of labor corresponding to the hierarchical relations between the
“provider” and the “recipient” of aid. In these relationships, the recipient
is fully aware of and limited by what a civil society representative recalled

as functionary duties that were bestowed upon them. This hierarchy is
further strengthened by NGOs’ limited English proficiency and limited
awareness of Global Fund regulations. In these circumstances, the local
NGOs became “passive” recipients of assistance (Rasschaert et al., 2014,
p. 7) and are reduced to the status of being the “means” for implementing
it (Morgan, 2001, p. 221).
Another source of predictability was discipline in defining the roles and
responsibilities of actors in the monitoring process. Following Haugaard
(2003, p. 108), “practical consciousness knowledge” and “socialization
through discipline” can be used to ensure the reproduction of existing
power structures. As Sub-Recipients, the local NGOs do not directly par-
ticipate in the monitoring process but rather report to the primary recipi-
ent, Country Coordinating Mechanism, and Local Fund Agent (discipline).
This socialization of NGOs is based on the idea that by assigning specific
roles to actors involved in grants, the Global Fund can avoid conflicts of
interest. This idea is further supported by practical knowledge the NGOs
apply in their reports. Sub-Recipients report using grant indicators stated
in the country’s application and following administrative and financial
regulations and changes (if any) that the Global Fund representative com-
municates during her visits to the country. Though affected by the finan-
cier’s regulations, Sub-Recipients have little say in the monitoring process.
This power created through discipline reiterates hierarchical relations
between the donor and the recipient. NGOs working with multiple donors
spend extensive time reporting to each using different templates and com-
plying with at times contradictory requirements.
Overall, the relationship between the Global Fund and the Sub-
Recipient NGOs vividly demonstrates the affinity between the “power
to” and “power over.” It also shows that both conflict (limited flexibility)
and consensus (promoting civil society) were integral to this relationship.
Reiterating the hierarchy between the provider and the recipient of aid,
this relationship is still based on freedom, an essential element of power
relations (Foucault, 2002). Both providers and recipients of aid have the
freedom to choose to (dis)engage in relationships with each other.
What incentives does the Global Fund have to utilize the “utilitarian”
approach toward grant-recipient NGOs? First, civil society involvement
298 G. Isabekova
corresponds to its organizational objectives and provides access to the

groups targeted by the grants (e.g., commercial sex workers, men who
have sex with men, injecting drug users, and others). These groups are
often close to the state health care system due to stigma and discrimina-
tion in society. The expertise and context-awareness (Pape, 2014) make
local NGOs essential to the provision of health services and health pro-
motion among vulnerable groups (IO Partner 4). Furthermore, CSOs
may advocate for a broader range of issues. For instance, NGOs can raise
public awareness and demand action on issues that ministries and state
agencies would not prioritize due to budget deficits (CSO 8). Popularity
concerns and voters’ support also restrict state actions on issues, such as
the rights of sexual minorities, in conservative contexts.
Why do local NGOs engage in the “utilitarian” approach with the
Global Fund? Participation in the Global Fund grants, even in terms of
the “utilitarian” approach, offers capacity building and involvement in
decision-making. Thus, through their relationships with the Global
Fund, local NGOs have the possibility to advocate for the interests of
their organizations and the groups they claim to represent. As Sub-
Recipients, they also have access to financing. In the context of increasing
competition among NGOs due to decreasing assistance for TB and HIV/
AIDS, access to financing allows Sub-Recipient NGOs to continue their
activities and ensure their own survival. In this way, the interaction with
the Global Fund provides NGOs access to resources. Closely associated
with power (Giddens, 1984), resources are crucial to understanding it.
However, as the analysis of donor–CSO relations in the “Community
Action for Health” project shows, resources alone do not define the
power, nor does having similar access to resources mean that actors neces-
sarily exercise similar power.
10.2 Recipient State–CSOs:

“Utilitarian” Approach
The Ministry of Health, the National Center of Phthisiology, and the
Republican AIDS Center pursue a “utilitarian” approach toward their
collaboration with local NGOs, primarily driven by an interest in
securing donor funding rather than a genuine perception of NGOs as

equal partners.
Interestingly, the structural factors could have equally laid down the
basis for the state organizations’ “empowerment” approach toward local
NGOs. The CSOs are financially independent of state agencies, which
also explain their ability to raise “uncomfortable” issues, such as the rights
of commercial sex workers and men who have sex with men. Furthermore,
local NGOs seem to have greater capacity in terms of human resources
than the Ministry of Health and its agencies. Thus, though the services of
both actors are dependent on external aid, the actors themselves are inter-
related but financially independent from each other. This situation may
change as the country progresses with social contracting for NGOs,
which will make them accountable to state agencies (Chap. 9). However,
within the framework of the Global Fund grants, the structural factors
did not favor hierarchical relations between the state and nongovernmen-
tal organizations.
Similarly, stakeholder participation in grants did not favor hierarchy
among stakeholders. Both actors equally participated in the grant realiza-
tion process, and both had limited roles in the monitoring process. Still,
the project life cycle showed that NGO engagement in health aid was
imposed on state organizations by the conditions set by the Global Fund.
This involuntary engagement found its reflection in the power dynamics
between the state and civil society organizations, as discussed below.
The accountability of public services, promoted by the Government of
the Kyrgyz Republic and development partners, allowed for civil society
scrutiny over state institutions. As demonstrated in the project cycle,
local NGOs scrutinize the government in terms of use of funds. More
specifically, they can send requests to a relevant state institution to obtain
information on financing and other matters. The state organizations are
expected to respond to public requests (including NGOs) within two
weeks. In this way, the government aims to ensure the openness and
responsiveness of state institutions to public concerns.
This social order, created by the government, opens up local NGOs
access to necessary data. However, the form of reply and information is
not necessarily straightforward. One civil society interviewee noted that
her organization had to hire an external consultant to comprehend the
300 G. Isabekova
information provided by the Ministry of Finance. Nevertheless, it did

gain access to data necessary for analyzing the use of finances, with the
goal of pointing at possible areas for rearrangement to ensure additional
funding for the areas the organization advocated for. The interviewee
highlighted that, if previously the state officials could refer to the budget
deficit, now NGOs could show that the required funding was available
by referring to the data the Ministry provided as evidence for it (CSO 8).
In addition to the regulation mentioned above, this NGO scrutiny over
state agencies is now possible thanks to the Sector Wide Approach.
During the meetings with donors and civil society organizations, the
Ministry of Health reports on the achievement of indicators stated in the
national program and the use of funding. Thus, the NGOs can obtain
data at the national level and on matters of particular interest to them.
At the same time, the project life cycle showed that state agencies con-
tended with civil society participation in decision-making. Promoted by
the Global Fund, this social order aimed to empower persons affected by
diseases and local NGOs representing them to ensure their participation in
drafting and implementing grants (see the previous subsection). The Global
Fund initially rejected the country’s application as the CCM did not com-
ply with “minimum requirements.” State organizations outnumbered the
civil society representatives who had limited capacity to fully participate in
designing the grants (see Chap. 8). This situation, along with the issues
between state and civil society actors during the grant implementation pro-
cess, hints at the state organizations’ unwillingness to accept the social order
promoted by the Global Fund. This unwillingness also relates to the gov-
ernment’s perception of its role as the leading actor in health care.
In addition to opposing the social order on civil society participation,
the state partners have aimed to exercise their “power over” local NGOs
by creating a favorable system of thought. The state institutions, particu-
larly the Ministry of Health, advocate for the central role of the govern-
ment in health care. As demonstrated in the project life cycle, the former
Minister of Health has repeatedly questioned the expertise and ability of
NGOs to provide health care services. He also advocated for scrutinizing
their use of finances by highlighting the leading role of the Ministry in
the health sector. These remarks were not limited to a single politician. In
both the grant implementation and monitoring stages, state officials
viewed the NGOs as “grant eaters” (Spicer et al., 2011, p. 1750) rather
than equal implementation partners (Murzalieva et al., 2009). These sys-
temic biases about stakeholders and their roles are based on two premises.
First, health in the post-Soviet region is viewed as purely medical and not
a social phenomenon. Second, health care remained the state domain,
which is also reflected in the leading role of state institutions in the regu-
lation and provision of health care services. Both interpretations corre-
spond to the Semashko health care system present in the former Soviet
Union, in which the government was the main financier, regulator, and
service provider. Due to budget deficits, state organizations gave up on
the financial part of this obligation, but seemed to be keen on keeping
their authority in the two other areas.
Notably, the remarks about the use of funding by NGOs and the role
of the state were limited to individual figures during the data collection
process for this book in 2018. However, on June 26, 2021, these state-
ments materialized into a new law necessitating NGOs to report on the
sources of their financing and the use of these funds (Government of KR,
2021). Accordingly, the state organizations gained access to the financial
data they had longed for.
What interests did stakeholders have in the selected form of aid rela-
tionships? The interaction of the Ministry of Health and its agencies with
local NGOs is largely driven by access to donor financing. Although
openly disagreeing with the work of the CSOs, the state institutions con-
tinued to follow the Global Fund’s requirements because incompliance
would have resulted in a rejection of the country’s grant application. A
similar logic lay behind the Ministry’s collaboration with NGOs during
the negotiations with the Ministry of Finance and Parliament. NGOs’
advocacy was the key to increasing the TB and HIV/AIDS financing
necessary for the gradual transition of the country from the Global Fund’s
assistance. In both cases, the Ministry and other state agencies seem to
perceive the local NGOs as a means to an end, not as equal partners.
Furthermore, the NGOs provided access to groups, such as commercial
sex workers, men who have sex with men, and injecting drug users, that
are typically beyond the outreach of state health care organizations. In so
doing, they offer expertise and skills necessary to combatting HIV/AIDS
(Pape, 2014).
302 G. Isabekova
What are the NGOs’ interests in engaging in a “utilitarian” approach

with state organizations? NGOs interact with state institutions largely
due to their dominant role in health care. As one civil society representa-
tive noted, donors cover some activities, but the government is still
responsible for regulating health care facilities, providing social benefits,
and the rule of law—all relevant to the NGOs’ work (CSO 6). Through
collaboration with state health institutions, NGOs gain access to public
resources and infrastructure critical to achieving sustainable results (Pape,
2014). The role of the government can grow only further in the context
of decreasing donor financing for TB and HIV/AIDS and the introduc-
tion of social contracting to ensure continuous funding for NGO services
(see Chap. 9). In these conditions, collaboration with state organizations,
particularly on the terms of a “utilitarian” approach, becomes even more
sensible.
10.3 Donor–Donor: Coordination

Based on the actors’ roles throughout the project life cycle and the lack of
a hierarchy and power dynamics, the relationships between the Global
Fund and other donors can be qualified as coordination.
The project life cycle showed the continuous involvement of develop-
ment organizations working in tuberculosis and HIV/AIDS in the real-
ization of the Global Fund grants. The engagement seems to work well,
particularly in the design and implementation phases. However, the rela-
tionships among actors are somewhat limited in the monitoring process,
which causes duplication of efforts and an additional burden on national
stakeholders having to report to different aid providers.
In contrast to donor–recipient relations, there is no explicit hierarchy
in the relationship among donors. Therefore, the structural factors are
not prone to a ranking among donors. For instance, although leading in
financial terms, the Global Fund adheres to standards set by other orga-
nizations that have established themselves in particular niches (e.g., the
United Nations organizations).
In terms of power dynamics, relationships of the Global Fund with
other development actors in tuberculosis and HIV/AIDS combine the
attributes of both “power over” and “power to.” The former is related to
the preeminent position of some organizations as norm-setters in health,
whereas the latter concerns the ability of organizations to work with
each other.
First, the World Health Organization (WHO) and the Joint United
Nations Programme on HIV/AIDS (UNAIDS) exercise “power over”
other organizations working in health through their expertise. Explicitly
devoted to health, the WHO has established itself as a norm-setter in
health (Kaasch, 2015). Its recommendations are equally followed by the
state, civil society, and donor organizations. For instance, in Kyrgyzstan,
the WHO recommendations provided the basis for the clinical protocols
on methadone substitution therapy (Subata et al., 2016), HIV treatment
(Murzalieva et al., 2009), and treatment of TB/HIV coinfection
(Government of KR, 2012). In addition to the recipient state, the WHO
recommendations are equally followed by donor organizations in the
health sphere. The Global Fund, for instance, may specify the procure-
ment of medical products accredited by the WHO and compliance of
treatment activities with WHO standards, as it did in the grant to
Armenia (see Global Fund, 2009, pp. 9–12). Similarly, the Country
Coordinating Mechanism introduced through the Global Fund grants
connates with the “Three Ones” principles (one national AIDS frame-
work, one national AIDS authority, and one system for monitoring and
evaluation—all categories are listed verbatim) promoted by UNAIDS
(2005, p. 8). Though UNAIDS is less salient in comparison to its coun-
terpart, its regulations are equally followed in HIV/AIDS.
Why do other stakeholders adhere to the WHO and UNAIDS regula-
tions and suggestions? Again, following Haugaard (2003, pp. 104–105),
this compliance could be on the grounds that actors perceive a proposed
system of thought more than a “simply arbitrary convention.” The WHO
positions itself as an “evidence-based multilateral agency” (Kaasch, 2015,
p. 27) and promotes a typical “evidence-based” approach to health.
Though less assertive, a similar system of thought, based on evidence,
could be attributed to UNAIDS. This reference to the evidence suggests
that the non-arbitrariness of norms suggested by these organizations has
a scientific underpinning, which serves as a basis for reification (see
Haugaard, 2003, pp. 104–105). In other words, by following the WHO
304 G. Isabekova
and UNAIDS guidelines and recommendations, organizations, in a way,

comply with the scientific evidence.
The “power to” among donors manifests itself through their coordina-
tion with each other. This coordination follows the social order outlined
by the Paris Declaration on Aid Effectiveness (2005) and the following
Accra Agenda for Action (2008) (hereinafter “Paris Agenda”) outlined
the five principles of development assistance that became the synonym
for effectiveness and guiding norms for aid in the twenty-first century
(Brown, 2020). The five principles are ownership, alignment, harmoniza-
tion, managing for results, and mutual accountability (OECD, n.d.).
The Paris Agenda set the social order recognized and reproduced by
development actors. The analysis of the Global Fund grants to Kyrgyzstan
demonstrated that the multilateral organization closely coordinated its
activities with other donors in the design and implementation phases. At
the core of this coordination lies the principle of harmonization of donor
activities, aimed at avoiding the duplication of efforts to ensure the
greater effectiveness of aid. Similarly, donors jointly supported the
Ministry of Health, its agencies, and NGOs in designing the grant appli-
cations to the Global Fund. This support complied with the principles of
ownership. By building the capacity of national stakeholders, donors
aimed to support their ownership over development aid. The division of
labor among donors was intended to avoid duplications and ensure the
complementarity of their support (harmonization). By following these
principles, donors confirmed the meaning of aid effectiveness in the
social order promoted by the Paris Agenda. This recognition and repro-
duction of meaning are at the core of the social order (Haugaard, 2003,
pp. 90–93).
However, during the grant monitoring process, the donor coordina-
tion cracks due to each donor’s visibility concerns. The duplication prob-
lems in monitoring indicate the limits of donors’ adherence to the
harmonization principle. In reference to the social order, Haugaard
(2003, p. 96) notes that the structures accepted and taken for granted
today were fought for in the past. In this way, the limits of harmonization
in monitoring may suggest that the social order has not fully established
itself. Furthermore, donors’ accountability to their financiers additionally
hinders the realization of harmonization principles. The Global Fund is
expected to demonstrate the result of its activities by specifying the num-

ber of patients treated, health products distributed, and training sessions
organized. This health impact of the Global Fund is essential to its con-
tinued funding by donor countries (see Chap. 4). Other donor organiza-
tions have similar concerns.
Despite the consensus over the harmonization principles, there is con-
flict regarding its implementation. Both consensus and conflict are inte-
gral to the social order (Haugaard, 2003, p. 90). Notwithstanding the
issues observed during the monitoring phase, the relationships among
donors still qualifies as coordination due to the visible adherence to non-
duplication in other stages of the grant realization process.
What interests did stakeholders have in the form of aid relationships
selected? The abovementioned social order on aid effectiveness is essential
to understanding the actors’ interests in coordinating their activities with
each other. There are no explicit sanctions for noncompliance spelled out
in the Paris Agenda, but rather peer pressure standing behind this Agenda,
supported by the global call for the sustainable use of resources. The proj-
ect cycle shows that as the share of its grants to the country decreases, the
Global Fund has intensified its coordination with other donors to ensure
the sustainability of its TB and HIV/AIDS activities. Other donors have
similar concerns. Yet, power dynamics among donors have remained rela-
tively equal throughout the project life cycle.
10.4 Donor–Recipient State:

Unequal Cooperation
The relationships between the Global Fund, the Ministry of Health, the
National Center of Phthisiology, and the Republican AIDS Center quali-
fies as unequal cooperation.
The domination of the Global Fund is visible throughout the project
cycle, except for during the initiation phase. Thus, the Global Fund proj-
ect unequivocally increased the type and breadth of services offered to TB
and HIV patients affected by TB and HIV. Still, the initiative behind the
TB and HIV/AIDS services was already in place before this project. For
this reason, the grant activities and objectives corresponded to the issues
306 G. Isabekova
present and pressing to the country. However, during other phases, the
recipient state complied with the Global Fund recommendations and
regulations with few reservations.
Additionally, the structural factors remained in favor of hierarchical
relations. The Global Fund attempted to increase the predictability of its
assistance by introducing continued financing for well-performing proj-
ects and announcing the list of countries eligible for grants. However,
grant disbursements are guaranteed for only three years, due largely to
the organizational dependence on replenishments by its financiers every
three years. Although relatively independent from the Global Fund’s
technical assistance, government institutions largely rely on financing for
prevention and treatment programs. The Global Fund project also pro-
vides limited space for change during the implementation process. Time-
and effort-consuming bureaucratic processes discourage state agencies
from suggesting any revisions to the initial grant agreed to with the
Global Fund. All these factors, namely, the Global Fund’s limited flexibil-
ity, aid dependency, and capacity issues of government institutions, con-
tributed to the situation in which the aid recipient fully complied with
the terms established by the aid provider as long as the donor controlled
the finances.
The combination of stakeholders’ roles through the project life cycle
and structural factors in the grants laid down the basis for power dynam-
ics contributing to unequal cooperation. Overall, the power relations
between the Global Fund, the Ministry of Health, the National Center of
Phthisiology, and the Republican AIDS Center were probably the most
comparatively complex. Combining the “power to” and “power over,” the
Global Fund has opted for a more diverse array of sources of power,
including social order, structural bias/constraints, discipline, coercion,
and systems of thought.
The Global Fund empowered the recipient state (“power to”) through
social order. Ownership, or compliance of development aid with the
needs and structures of aid recipient countries, is one of the five norms
promoted by the Paris Agenda discussed in the previous section. The sup-
port for the existing structures is inherent to the effective development
assistance promoted by the Paris Agenda. This social order, reproduced
and confirmed by donor organizations, empowered the recipient state by
providing financial and technical assistance to the national monitoring

and evaluation systems. As discussed in the project life cycle, the Global
Fund integrated its monitoring indicators into national systems and
assigned a part of grant finances to strengthen them (Chap. 8). This assis-
tance did not solve structural issues, but still advanced parts of the health
care monitoring system relevant to grants. Through its support, the
Global Fund reproduced and confirmed the meaning of “ownership”
stated in the Paris Agenda and, in so doing, confirmed the social order on
aid effectiveness empowering the grant-recipient state.
At the same time, the Global Fund exercised the “power over” the
recipient state through structural biases/constraints, empowering NGOs
and, in so doing, challenging the dominant role of state organizations in
health care. It also turned to discipline, limiting the roles of state agencies
involved in grants in the monitoring stage. The organization also resorted
to coercion in response to grant misappropriation, combined with a jus-
tification to keep an international organization as the primary recipient
of its grants.
First, the Global Fund exercised the “power over” the recipient state
through structural biases. According to Haugaard (2003, p. 107), struc-
tural biases occur when social order produces power through structural
constraints that eventually (dis)empower others. As the project cycle
shows, the Global Fund regulations on co-financing, human rights, and
CCM considerably shaped the content of grant applications, along with
its recommendations for a joint application for two diseases. As noted
earlier, although not obligatory, the recommendations nevertheless were
followed by grant applicants, most likely in order to secure positive feed-
back from a financier (see Chap. 8). Both recommendations and regula-
tions represented structural constraints that intended to ensure the
predictability and stability of a system by enabling desired outcomes
(Haugaard, 2003, p. 94). Thus, they intended to demonstrate growing
state funding for target diseases, support for human rights, and inclusion
of civil society organizations in the decision-making process.
Not necessarily “repressive,” these structural constraints may be
enabling to some stakeholders but disabling to others (ibid.). For the
recipient state, the regulations and recommendations were rather dis-
abling as they supported the role of CSOs in health, both in
308 G. Isabekova
decision-making and service provision, which are traditional state

domains. The authorities were also compelled to increase their financial
commitments and introduce changes regarding the rights of vulnerable
groups of society. In the context of the continuous budget deficit and
rather a conservative attitude toward reproductive health and sexual
rights, these changes did not necessarily correspond to voters’ or politi-
cians’ agendas.
The second source of the Global Fund’s “power over” the recipient
state was discipline. In both the implementation and monitoring phases,
state agencies comply with indicators and activities indicated in the coun-
try’s proposal. This practical knowledge provides for the “socialization
through discipline” that secures existing power relations (Haugaard,
2003, p. 108). Furthermore, the discipline establishes a routine which
ensures the predictability of an outcome, as opposed to irregularities
unwanted by the existing social order (Haugaard, 2003, p. 106). Grant
agreements spell out the responsibilities and rights of all parties. As long
as stakeholders comply with these agreements, there is a sense of predict-
ability and foreseen achievement of stated goals.
Nonetheless, the grant implementation and monitoring phases dem-
onstrated the limits of power created by discipline. According to Haugaard
(2003, p. 107), compliance with discipline depends on the extent routine
is internalized by stakeholders. Implementation and monitoring routines
outlined in the agreement and supported by the Global Fund regulations
and recommendations intended to preempt irregularities. Yet, the misap-
propriation of grant finances by the National Center of Phthisiology is an
irregularity it did not prevent. The Global Fund audit and investigation
outcomes indicated limited internalization of the “routine” by some
stakeholders. It also pointed to the mismatch between personal and orga-
nizational interests, highlighting the relevance of individual and organi-
zational perspectives on actors.
Further non-reimbursement of missing finances demonstrated a simi-
lar limitation of discipline. As noted in the project cycle, the Global Fund
repeatedly requested state authorities to repay unaccounted-for finances.
The Ministry of Health ignored these requests on the grounds of not hav-
ing access to the finances, or (allegedly) not having received these requests
in the first place (see Chap. 8). The money that had been
misappropriated by state official(s) was deducted from the following

grant to the country, but this has probably affected TB and HIV patients
much more than the Ministry itself. The reaction from the Global Fund
was remarkable in that it did not halt the project funding. Instead, it
continued its project in the country while combining multiple means of
creating “power over” the recipient state.
The third source of power, coercion, followed the delinquency of dis-
cipline. Following the misappropriation and mismanagement of grants,
the United Nations Development Programme (UNDP) became the
Principal Recipient (PR). The organization was proposed by the Country
Coordinating Mechanism and approved by the Global Fund. One may
disagree with my attribution of coercion here due to the fact that the
Country Coordinating Mechanism is composed of national stakeholders,
and the Global Fund merely confirmed the choice made by these stake-
holders. However, in relation to the recipient state, this decision was
indeed coercion. The project cycle shows that the reassignment of the PR
functions was a remerging issue repeatedly brought up by state organiza-
tions and discussed in the Country Coordinating Mechanism already in
2014. Continuous discussions resulted in the establishment of the Project
Implementation Unit under the Ministry of Health. This continuity of
discussions and content raised by state officials interviewed for this
research points to the presence of a conflict and the fact that the decision
to keep the UNDP as the Principal Recipient of grants was made against
their will. The notion of willingness is critical to defining the activities of
aid providers as coercion.
At the same time, consonant with Arendt’s (1970) notion of power,
coercion did not represent its strongest form but was used as a measure of
last resort (Barnes, 1988, p. 15). Maybe for that reason, to create power,
coercion was not applied alone, but rather in combination with the sys-
tems of thought, discussed below.
The fourth source of power is the system of thought related to the
recipient state’s capacity. As discussed in the project cycle, both state and
non-state actors may become Primary Recipients of grants as long as they
have the necessary capacity to fulfill the related functions. The lack of this
capacity was the main justification for the donor’s decision to keep the
UNDP as the Principal Recipient. Indeed, the Project Implementation
310 G. Isabekova
Unit failed to meet the minimum criteria to demonstrate its ability to

implement the grants. This failure showed that the Ministry of Health
was “not ready” to take over the PR responsibilities (see Chap. 8).
Following this line of argumentation, compliance with specific criteria
demonstrates the “capacity” and “readiness” necessary to become the
PR. In power created by systems of thought, specific meanings are not
just “out there,” but instead are the results of knowledge based on “par-
ticular interpretative horizons” (Haugaard, 2003, pp. 107–108). Thus,
the interpretation of capacity and fulfillment of criteria as necessary pre-
conditions for resuming PR functions supports the decision of the Global
Fund by making it non-arbitrary and based on reasoning. It also creates
a relevant perception among the state, civil society, and international
actors working in the country that the lack of Ministry of Health capacity
is the reason for reassigning the UNDP as the Principal Recipient (“social
consciousness-sustaining structural practices” in Haugaard’s words)
(2003, p. 108).
Overall, the relationships between the Global Fund and state organiza-
tions combined both “power to” and “power over,” generated through the
multiple sources discussed above. This multiplicity also points to the fact
that the aid relationships did not solely rely on the premise that one actor
had resources another wanted to access, but also on how stakeholders
used these resources to create power (e.g., coercion and sanctions). The
power to and the power over also occurred in a combination of conflict
and consensus among actors, vividly demonstrated in the project cycle.
What interests did stakeholders have behind the selected form of aid
relationships? It should be noted that despite the “power over,” actors still
have freedom. For instance, structural bias (here in the form of donor
regulations and recommendations) can be changed but may require
changing the “rules of the game” (donor–recipient hierarchy), which may
be costly for some actors, and therefore they resist doing so (Haugaard,
2003, p. 95). Free to choose, the recipient state opts for compliance with
recommendations and regulations as compliance offers access to grant
finances and technical assistance the actor would forego otherwise.
The access to resources is essential to understanding the recipient states’
interests in unequal cooperation. During an interview in 2018, a state
representative noted that 95% of financing for preventive activities,
including syringes, condoms, methadone, and lab tests, came from inter-
national organizations. For this reason, “willingly or not,” the govern-
ment worked with them as “one team” (State Partner 2). Though
decreasing with time, the Global Fund remained critical to TB and HIV/
AIDS activities (Chap. 9), which explains the Ministry and its agencies’
readiness to engage in unequal cooperation with this organization.
In turn, the Global Fund was interested in working with government
institutions due to its key role in regulating and providing health care
services. Government authorities are essential to accessing the country’s
health care system and ensuring the sustainability of health care provision
beyond the duration of the grants. Moreover, cooperation with state
institutions allows donors to influence national policy (Ancker & Rechel,
2015). For the Global Fund, it meant the ability to advance its agenda on
the rights of groups vulnerable to TB and HIV/AIDS.
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right holder.
11
“Missing Link”
This book aims to make a theoretical contribution to understanding the

interaction between the relevant actors and the impact of that interaction
on the sustainability of development assistance for health care. The notion
of impact in the research question presumes a causal relationship between
interaction and sustainability. For this reason, this book refers to causal
inferences in qualitative research for guidance. This chapter expands on
the formulation of causal inferences within cases covered in this book by
referring to causal mechanisms formed in the “Community Action for
Health” and the Global Fund grants to Kyrgyzstan. This section is fol-
lowed by hypotheses that help us understand how the relationships
between stakeholders influence the sustainability of health aid. Although
developed on the basis of causal mechanisms, these inferences are more
general and applicable across cases. This chapter concludes with limita-
tions of causal inferences made in this book.
The intention of the detailed analysis of selected project phases is to
provide a basis for causal inferences within these cases. A within-case
analysis is essential for the identification of mechanisms linking the cause
(aid relationships) and the outcome (aid sustainability) and the factors
relevant to these mechanisms (Rohlfing, 2012, p. 12). The project-level
analysis offers sufficient context specificity, which is essential for

316 G. Isabekova
developing causal mechanisms. It provides the necessary environment for

the mechanisms to function (see Falleti & Lynch, 2009; Hedström &
Ylikoski, 2010), because depending on the context, the same mechanism
may produce different outcomes (Beach & Pedersen, 2019). I use the
concept of a social mechanism as “a constellation of entities or activities
that are linked to one another in such a way that they regularly bring
about a particular type of outcome” (Hedström, 2005, p. 11). This
approach to mechanisms as units composed of “entities” and “actions” is
also in accord with scholars working in this field (see Beach & Pedersen,
2019, p. 70; Hedström & Swedberg, 1998; Rohlfing, 2012, p. 35).
11.1 The “Community Action

for Health” Project
Based on the relationship between the actors throughout the project and
the power dynamics between them, I have defined the following types of
aid relationships: “empowerment” approach (donor–civil society organi-
zations [CSOs]), “utilitarian” approach (recipient state–CSOs), and
(un)equal cooperation (donor–recipient state; donor–donor).
11.1.1 Impact of an “Empowerment” Approach

on Sustainability
I argue that the “empowerment” approach by the donor influenced the

sustainability of the health care program in two ways, namely, through
the mechanisms of “ownership” and “learning.”
First, community engagement throughout the duration of the project,
following an “empowerment” approach by the donor, influenced the sus-
tainability of the project by developing a sense of ownership in the VHCs.
This contributed to community capacity building, and continuity of
project activities (Diagram 11.1):
The “empowerment” approach had a considerable impact on commu-
nity capacity building, by contributing to the continued survival of
community-based organizations beyond the end of the “Community
11 “Missing Link” 317
VHCs develop Community capacity

“Empowerment” the sense of building
approach ownership over Survival of the VHCs
their activities Leadership of the VHCs
mechanism of ownership
Diagram 11.1 The impact of the donor’s “empowerment” approach on

sustainability
Action for Health” project (CAH). It did so by contributing to their lead-

ership skills, and their ability to mobilize resources. I visited the Village
Health Committees (VHCs) almost a year after the end of the project,
and the community-based organizations were still functioning. The
VHCs continued their work and were “thinking of extending it” (CSO
5). A literature review of studies of sustainability of development pro-
grams emphasizes the involvement of volunteers as being vital to pro-
gram sustainability (Scheirer, 2005). Yet, volunteerism alone does not
guarantee sustainability (Glenton et al., 2010), as high attrition among
health volunteers is common (e.g., Khetan et al., 2017; Sivaram &
Celentano, 2003). For this reason, it was not volunteering that ensured
the organizations’ continuity beyond the end of the project, but, rather,
the sense of ownership the VHCs developed throughout the CAH.
The VHCs raised their own initiatives and worked on solving broader
social issues, which contributed to their leadership skills. This included
the construction of a bridge so that children would no longer have to go
through water on their way to school (CSO 4) or solving residents’ waste
management problems (CSO 5). The VHCs I visited showed me a notice
board of their initiatives, such as support for poor households (CSO 1),
for the elderly, for persons with disabilities (CSO 5) and others. One
interviewee showed me the photos of the sports competition the VHC
had organized to raise funds for a villager in need of surgery, and they had
collected about 27,000 KGS (about €290)1 as a result of this event (CSO
1
318 G. Isabekova
2). In this way, the VHCs not only identified problems, but also sought
solutions, which contributed to their leadership capacity.
The Swiss Red Cross (SRC) encouraged the “self-initiatives” and
included such initiative-taking in the evaluation criteria.2 The VHCs
were expected to suggest and implement activities based on their own
initiative (CSO 5). This encouraged the freedom of the community-
based organizations to initiate their own activities. According to one of
my interviewees, at some point there was “a fear” that VHCs were “leav-
ing the health care” (IO Partner 5), since the scope of their activities was
very broad. Following the SRC’s suggestion, the VHCs adopted a mis-
sion statement, which described the organizational goals and their focus
on health care.3 This mission statement was intended to emphasize the
VHCs’ activities in health care, but not limit it to this area, as the
community-based organizations still continued their work on solving
broader social problems.
The community-based organizations look for various resources with
which to conduct their self-initiatives. The VHCs also use their organiza-
tional funds to finance their self-initiatives. Thus, one of my interviewees
conducted the self-initiatives for 25,000 KGS (around €268) grant the
VHC received from the SRC during the CAH to finance various initia-
tives in the village (CSO 2). It should be noted, however, that the size of
the VHCs’ budget varies greatly between 2000 and 3000 KGS (€21–32)
in the case of the smallest budget, and 100,000 and 150,000 KGS
(€1072–1608) in the case of the largest budget (CSO 4). According to
the interviewee who was working closely with the VHCs, the size of the
budget depends largely on the VHC leaders and their ability to work
with local actors and donors to increase the size of their organizational
budget (CSO 4). The VHCs write appeals to local self-governments to
solve residents’ problems (CSO 5). Although not offering financing, the
local authorities provide in-kind support to the VHCs (State Partner 12).
The community-based organizations also write project applications to
donors, which they learned how to do in the training courses provided by
the CAH (CSO 7). However, the VHCs do not seem to simply sit back
2
These criteria are used by the VHCs and HPUs to assess the VHCs and their activities.
3
The author has the sample of the statement in Kyrgyz.
and wait for donor support (CSO 2); rather, they try to use other means
to mobilize resources instead.
The “empowerment” approach between the Swiss organizations (e.g.,
the Swiss Agency for Development and Cooperation and the Swiss Red
Cross) and the VHCs, also reflected in the encouragement of “self-
initiatives,” contributed to community capacity building by developing a
sense of “ownership” among the community-based organizations. The
VHCs did not just define the issues on their own, but also looked for the
solutions. As one development partner noted, “from a passive [role of ]
providing information,” they transformed themselves into organizations
seeking solutions to the issues pressing their communities “at this point
at the local level” (CSO 1).
Secondly, the VHCs’ sense of ownership, developed through the
“empowerment” approach, contributed to the continuity of project activ-
ities on tuberculosis (TB) and HIV/AIDS, after the project ended. The
VHCs defined the issues targeted by the CAH, either by surveying the
local population or by suggesting their own initiatives. Andrews (2013)
suggests that aid recipients tend to take ownership of development pro-
grams which are driven by local problems and solutions, rather than the
ones guided by a global agenda. At the same time, as described in Sect.
5.2, Design, reproductive tract infections were among the issues identi-
fied by the local population, while tuberculosis was not (see Schüth et al.,
2014). Nevertheless, the VHCs continued their activities around TB and
HIV/AIDS, beyond the end of the CAH. Based on this, I argue that the
community-based organizations continued their activities targeting both
diseases because of the sense of “ownership” they developed through the
“empowerment” approach. It should be noted that this sense of owner-
ship was not limited to a specific activity or area of health care, but
extended to the health of the communities as a whole:
Since we have collected all this information, well, our village needs it; the Swiss
Red Cross or Tobias [Dr. Schüth] does not need all this, [but] we need [it] our-
selves, to preserve our health, to maintain the health of our village, [these] were
the reasons for us to learn all that. (CSO 2)
320 G. Isabekova
Thus, TB and HIV/AIDS prevention continued along with the other

activities, due to the VHCs’ sense of ownership, and responsibility for the
health of the local population.
The VHCs use various means to continue their health-related activi-
ties. The VHC member I interviewed reported that she contacts the
feldsher-midwife [akusher] point to get up-to-date information on diseases
and their prevalence, and she disseminates this information in her village
(CSO 2). The VHC also uses the brochures available in the organization
to “refresh” the knowledge of the local population about certain diseases
from time to time (ibid.). The VHCs do not limit themselves to the train-
ing courses provided by the Health Promotion Units (HPUs), and try to
attend other events and training courses to learn more about health issues
and their prevention (ibid.), even where travel costs are not covered by
the organizers (CSO 5). All these attempts to continue health-related
activities point to the sense of ownership the VHCs have developed
toward all of their activities, which has also resulted in continuity of TB
and HIV/AIDS-related activities, more specifically (Diagram 11.2).
Furthermore, the “empowerment” approach contributed to commu-
nity capacity building through the mechanism of “learning.” According
to the VHC member, the SRC stressed learning throughout the project,
and community-based organizations were aware of its importance for the
continuation of their activities beyond the CAH (CSO 2). The SRC pro-
vided extensive training to support the VHCs’ organizational capacity
(book-keeping, budgeting, how to organize the seminars, write appeals,
etc.) and health-specific activities (essential information about the
VHCs develop
“Empowerment” the sense of Sustainability
approach ownership over Continuity of project
their activities activities
mechanism of ownership

sustainability
diseases, their prevention, and health promotion). Using this knowledge,

the VHCs overcame structural barriers, such as illiteracy, disinterest on
the part of the local authorities and local population, to pursue their
activities. Although important (Walsh et al., 2012), training alone is not
sufficient for community capacity building. The VHCs learned exten-
sively through their participation in implementing and evaluating the
project-related activities, and by exchanging their experiences with each
other. I argue that this involvement of community members through the
“empowerment” approach contributed to their learning, and resulted in
community capacity building. Through engagement during the period of
the CAH, the VHCs developed their expertise and planning skills, which
contributed to their organizations’ survival.
Firstly, as they work closely with communities, the VHCs are well
aware of community issues, which make them the first point of contact
for local authorities and donor organizations. During their initial dis-
semination campaigns, members of community-based organizations vis-
ited local households:
VHCs know more about the problems in their village … because they make the
rounds in the village [and] visit the households to disseminate their informa-
tion. (CSO 4)
Through this close contact with the villagers, the community-based

organizations became aware of the living conditions and concerns of
most of the households in their villages. It was this awareness which even-
tually contributed to the acknowledgement of the VHCs by local author-
ities and donor organizations. Being well aware of the problems of the
local population, the VHCs serve as mediators between the villagers and
the local authorities (CSO 4). The community-based organizations sup-
port the villagers in their claims to the local self-governments by helping
them write petitions for example, but also assist the authorities with out-
reach in their community by mobilizing the villagers to meet the authori-
ties. The VHCs are also the first point of contact for donors who are
willing to work with communities. The local authorities refer any devel-
opment partners looking for local initiative groups to the VHCs,
322 G. Isabekova
emphasizing the fact that there is no need to establish any new groups,
when the VHCs already exist (ibid.) (Diagram 11.3).
Secondly, by implementing and evaluating the project-related activi-
ties, the VHCs started planning their activities and their connection to
other organizations. The community-based organizations had the free-
dom to organize their activities as they saw fit. They defined the timing
and the frequency of their meetings (Schüth, 2011) and activities, with
no intervention from the SRC. This freedom contributed to improving
the VHCs’ planning skills. One community member I interviewed
explained that in order to manage their household responsibilities and
project-related activities, the VHC members started to divide their labor
and plan their activities (CSO 5). This planning also allowed them to
distribute the villages and households among each other to ensure a
broader coverage of their seminars (ibid.).
The VHCs’ self-assessment strengthened this planning further. The
community-based organizations compared their current performance to
the previous years, identified the issues and the possible ways for improve-
ment, which were then included in the organizational work plan (CSO
4). The VHCs also enlisted the key local organizations they sought to
cooperate with, including local self-governments, schools, associations,
the court of elders, and others (CSO 2). Some of these organizations
approached the VHCs themselves, proposing to develop a joint plan of
activities (ibid.).
In this way, by implementing and evaluating the project-related activi-
ties, the VHCs planned their activities and their links to other
Community capacity
“Empowerment” VHCs develop
building
approach their expertise
Survival of the VHCs
mechanism of learning

sustainability
institutions, which is essential for the survival of the community-based

organizations. The VHCs collaborate with multiple local actors, includ-
ing the family medicine centers, feldsher-midwife (akusher) points, youth
councils, local association of women, and so on (CSOs 2, 4, and 5).
Collaboration with local actors provides access to technical (in the case of
health care organizations) and administrative support (from local self-
governments, schools, etc.), which is essential for the VHCs and the con-
tinuation of their activities beyond the end of the CAH. This link to local
actors is important for the survival of community-based organizations
(see Glenton et al., 2010) (Diagram 11.4).
Thirdly, the VHCs continued to meet and share their experiences,
which also contributed to the continued survival of the organizations
beyond the end of the CAH. During the CAH, there were monthly meet-
ings at district level (Rayon Health Committees), where the VHCs shared
their experiences and learned from each other (Schüth, 2011, p. 44). The
associated costs were covered by the project (CSO 4). One interviewee,
closely working with the community-based organizations, suggests that
the exchange of experiences during these meetings stimulated competi-
tion between the VHCs and contributed to their performance (ibid.).
Since the end of the project, the frequency of the VHC meetings has
decreased to a quarterly basis (CSO 2), with travel costs being covered by
funds from the Rayon Health Committees (CSO 7) or the VHCs (CSO
4). One representative of the Rayon Health Committee reported that
where, before, the community-based organizations had waited for the
CAH to gather them together for a meeting, now they initiated the
“Empowerment” Community capacity

VHCs develop
approach building
their planning

sustainability
324 G. Isabekova
Community capacity
“Empowerment” VHCs continued
building
approach training each other

sustainability
gathering themselves, even if it was at their own expense (CSO 7).

Although the frequency of the VHC meetings has decreased, neverthe-
less, the meetings are still continuing, and therefore so, too, is this
exchange of experiences between organizations, which has contributed to
their continued survival beyond the end of the project (Diagram 11.5).
In addition to community capacity building, the mechanism of learn-
ing, developed through the “empowerment” approach, also contributed
to the maintenance of benefits. In addition to attending training courses,
the VHCs learned extensively by carrying out project-related activities,
and through the evaluation of the VHCs. This learning was essential for
the maintenance of benefits, namely, the survival and quality of the infor-
mation provided by the VHCs. In addition to evaluating their own orga-
nizations, the VHCs I have met supported others by organizing “nomadic
seminars” and training courses.
During these “nomadic seminars” the VHCs share their experiences
following the principle of “nondominance,” which encourages the organi-
zations to continue their work. During the annual self-assessment, the
VHCs take note of the organizations which are having problems with
their documentation. For instance, if there was a problem with documen-
tation in one of the VHCs, the organizations offering the “nomadic semi-
nars” organized joint visits for the heads of organizations to a VHC, which
performed well in this regard (CSO 5). The example of an organization
encouraged others to improve their documentation accordingly (ibid.).
The exchange of experience follows the principle of “nondominance,”
and instead of pointing out problems, the organizers of the seminars
appeal to the consciousness of the heads of the VHCs. Organizers of the

“nomadic seminars” use their organizational funds to cover their travel
expenses (CSO 5). My interviewee suggested a growing interest in their
initiative, which encouraged the VHCs to continue their support to
other organizations (ibid.). She stressed that the seminars encourage the
VHCs to continue their work, because the organizations that discontinue
their work miss out on opportunities to collaborate with development
projects coming to their villages (ibid.).
Furthermore, some organizations share their knowledge with other
organizations that did not have access to the same training. Since the end
of the CAH, there is no longer any donor covering all of the VHCs;
instead donor organizations provide specific training courses for
community-based organizations in certain regions, depending on the
project-specific objectives and tasks. However, community-based organi-
zations which are not covered by donor organizations are also interested
in learning (CSO 1). The VHCs have solved this inequality in access to
training by sharing their knowledge with each other. One development
partner notes that the community-based organizations covered by the
project started training the organizations in the neighboring villages and
regions (ibid.). Thus, one of my interviewees visited two other villages at
her own expense to provide training in the areas covered by the develop-
ment project she was working on (CSO 7). Related to this, the above-
mentioned development partner stressed the motivation of the VHCs to
learn and continue learning. The interviewee noted that as unpaid VHC
members, they were not interested in a mere formal existence of their
organizations; they were “interested in changing something” instead and,
in so doing, gaining “some authority” (CSO 1).
This motivation to learn contributes to further exchanges of experience
and learning; despite the inequality in their access to training, the VHCs
share their knowledge with other organizations. Similar to the “nomadic
seminars” the training courses organized by the community-based orga-
nizations for each other evolved during and beyond the CAH and con-
tributed not just to the continued survival of the VHCs, but also to their
organizational capacity and their ability to conduct their awareness-
raising activities through continued learning.
326 G. Isabekova
11.1.2 Impact of a “Utilitarian” Approach

on Sustainability
In this section, I argue that the interaction between the recipient state
and the CSOs had differing influences on sustainability. To examine the
influence of the interaction between the recipient state and the CSOs, I
differentiate between the interaction between the Ministry of Health and
the VHCs, and the interaction between local self-governments and
the VHCs.
In the case of the interaction between the Ministry of Health and the
VHCs, the Ministry’s “utilitarian” approach on its own did not influence
sustainability. Certainly, the HPUs continued to provide training for the
community-based organizations after the end of the CAH, which con-
tributed to the maintenance of benefits. However, the Ministry estab-
lished the HPUs in response to the SRC’s request to provide the health
care workers, and not in response to the VHCs. Although the interaction
between the VHCs and the Ministry of Health contributed to changing
the perspective of state officials, this was not the reason for the Ministry
to provide the HPUs. For this reason, I propose that the interaction
between the Ministry and the community-based organizations on its own
did not influence sustainability, but did so in a combination with the
relationship between the Ministry of Health and the SRC.
At the same time, the “utilitarian” approach taken by local self-
governments toward the VHCs influenced sustainability by contributing
to the continued survival of the community-based organizations beyond
the end of the CAH. The local authorities provide administrative support
to the community-based organizations by offering office space, and refer-
ring any donor organizations that approach them on to the VHCs.
Furthermore, the local authorities involve the community-based organi-
zations in decision-making, and, in doing so, recognize their activities
and their authority in the village. Collaboration with and recognition by
the local authorities is essential to the activities of community-based
organizations (Glenton et al., 2010), and for this reason I would argue
that the interaction between the local authorities and the VHCs has con-
tributed to the continued survival of community-based organizations
beyond the end of the CAH.
the local authorities Community capacity

“Utilitarian”
provide administrative building
approach
support to the VHCs Survival of the VHCs
mechanism of recognition
Diagram 11.6 The impact of the local self-governments’ “utilitarian” approach

on sustainability
Although both levels of government in the recipient state, national and

local, have pursued a “utilitarian” approach to the community-based
organizations, the interaction of the Ministry of Health with the VHCs
and the interaction of the local authorities with the VHCs have had dif-
ferent impacts on sustainability. Both have contributed to sustainability
by supporting the maintenance of benefits and the ongoing survival of
the organizations. However, the impact in the case of the Ministry was
the outcome of the interaction of the Ministry with the SRC, whereas in
the case of the local self-governments, the impact on sustainability was
the result of the direct interaction with the VHCs (Diagram 11.6).
11.1.3 Impact of (Un)equal Donor-Driven

Cooperation on Sustainability
First of all, I argue that (contingent) equal cooperation between the

Ministry of Health and the SRC contributed to the long-term sustain-
ability of the Community Action for Health project, namely, by contrib-
uting to the maintenance of benefits through the mechanism of
“institutionalization.” In the literature on development, the term “insti-
tutionalization” is frequently used interchangeably with the term “sus-
tainability” (see Chap. 3); however, in the framework of this book, by
institutionalization I refer to the Ministry of Health’s formalization of its
commitments by including them in the Sector Wide Approach, and
establishing the Health Promotion Units (Diagram 11.7).
328 G. Isabekova
the Ministry of Health

(equal) cooperation
provides the HPUs and Sustainability
between the donor
includes the CAH project Maintenance of benefits
and recipient state
in the SWAp
mechanism of institutionalization
Diagram 11.7 The impact of (contingent) equal cooperation on sustainability
By including the CAH in the Sector Wide Approach, the Ministry

authorized the extension of the project throughout the country, and
committed its resources to ensuring continuity of the VHCs beyond the
end of the CAH. By including the CAH in the SWAp in 2005, the
Ministry encouraged its nationwide rollout (IO Partner 11). This
acknowledgement and commitment from the Ministry was essential for
the extension of the CAH, and for the commitment from the United
States Agency for International Development (USAID) and the Swedish
International Development Cooperation Agency (Sida) to support the
extension process (ibid.). In addition to the rollout, inclusion in the
SWAp also provided resources for the continuity of the VHCs beyond
the CAH. More specifically, the commitment of the Ministry of Health
to commit its resources to this initiative facilitated further support from
other donors (ibid.).
In this way, the VHCs became part of the national health care pro-
gram: “Manas Taalimi” (2006–2011), “Den Sooluk” (2012–2018), and
the “Healthy Person—Prosperous Country” programs (2019–2030)
mention the VHCs (see Government of KR, 2006, 2012, 2018). The
Ministry of Health established the HPUs, and assigned salaries for them
from the state budget, as part of primary health care. Even so, as one of
my interviewees noted, because of underfinancing, the majority of the
expenses in the area of health care promotion are still covered by donors,
and not by the recipient state (IO Partner 5). Another interviewee how-
ever, emphasized the fact that the ministerial support to the VHCs will
continue, as the activities of community-based organizations in health
promotion comply with the interests of the Ministry (IO Partner 11).
HPUs remained among the key sources of training for community-based
organizations, particularly within the framework of the “Den Sooluk”

program. Similarly, the ongoing (2019–2030) program stipulates the
development of training modules for the VHCs (Chap. 6). For this rea-
son, the mechanism of institutionalization triggered by the donor-driven
cooperation was the key to continuous training of the VHCs and main-
tenance of benefits beyond the duration of the CAH.
Furthermore, the unequal cooperation between the SRC, Sida, and
USAID influenced sustainability by contributing to the survival of the
community-based organizations beyond the end of the CAH through a
process of “uniformity.” The national rollout of the CAH resulted in the
establishment of the network of VHCs throughout the country, and the
establishment of the Association of VHCs to support this network. The
financing from Sida and USAID was essential for the establishment of
the HPUs by the Ministry of Health. However, it was not just their
financing alone which contributed to the continued survival of the VHCs
beyond the project, but rather the compliance of these two donors with
the SRC’s approach to community capacity building. The presence of the
SRC as “lead” donor ensured the uniformity of the donor relationship
with the VHCs, and the process of establishing the community-based
organizations. Thus, the VHCs in Issyk-Kul region had similar structures
and received similar training to the VHCs in Batken or Talas regions.
This uniformity was essential for the interaction between the community-
based organizations during their joint meetings, and their ability to share
their experiences and issues, based on the similarity of the activities they
were all conducting. In 2010, the network of VHCs was strengthened
further with the establishment of the Association of VHCs, which pro-
vides supervision (IO Partner 5) and support to the community-based
organizations throughout the country.
Though it did contribute to the survival of the VHCs beyond the
CAH, unequal cooperation between the donors, in itself, does not neces-
sarily result in sustainability. It was the mechanism of “uniformity” which
was the key to the expansion of the “empowerment” approach the SRC
pursued with the communities. A similar expansion under a “utilitarian”
approach, however, would not necessarily have contributed to sustain-
ability to the same extent as did the “empowerment” approach’. However,
the presence of the “lead” donor would nevertheless ensure the expansion
330 G. Isabekova
USAID and Sida contributed to

Unequal the countrywide expansion of Community capacity
cooperation the VHCs, in compliance with building
between donors the SRC’s “empowerment” Survival of the VHCs
approach
mechanism of uniformity
Diagram 11.8 The impact of the unequal cooperation between donors on

sustainability
of community-based organizations according to the approach pursued by

the lead donor, as other donors would comply with its approach
(Diagram 11.8).
To summarize, in the case of “Community Action for Health,” the
missing link unfolded in the following way:
1. The “empowerment” approach between the SRC and the VHCs influ-
enced the sustainability of the CAH in two ways, namely, through the
processes of ownership and learning. The mechanism of ownership
contributed to the continued survival of the community-based orga-
nizations beyond the end of the project, as well as to the continuity of
the VHCs’ activities, including those targeting TB and HIV/
AIDS. The mechanism of learning similarly contributed to the VHCs’
survival beyond the CAH and maintenance of benefits, or the pres-
ence and quality of information on disease prevention and health pro-
motion provided by the VHCs.
2. The (contingent) equal cooperation between the Ministry of Health
and the SRC resulted in the maintenance of benefits through the
mechanism of institutionalization. The HPUs, established, by the
Ministry, have continued to provide training in the four areas priori-
tized in the national health care program, which contributes to the
quality of the relevant information provided by the VHCs.
3. The “utilitarian” approach of the Ministry of Health and the local self-
governments toward the VHCs had different impacts on sustainabil-
ity. The interaction of the Ministry with the community-based
organizations affected the maintenance of benefits only in combina-
tion with the interaction between the Ministry and the SRC. The
“utilitarian” approach of the local self-governments, however, contrib-
uted to the continued survival of the VHCs beyond the end of the
project, due to the dependence of the local authorities on the expertise
and the authority of the VHC members in their villages.
4. The unequal cooperation between the SRC, USAID, and Sida con-
tributed to the ongoing survival of the community-based organiza-
tions through the process of uniformity. In combination with the
“empowerment” approach of the SRC toward the community mem-
bers, the mechanism of ‘uniformity’ resulted in the establishment of
the network of VHCs. This was essential for their unity and exchange
of experience. It should be noted, however, that the “empowerment”
approach of the “lead” donor (the SRC) was essential to this outcome.
11.2 The Global Fund Grant to Kyrgyzstan

Based on the relationship between the actors throughout the project and
the power dynamics between them, I have defined the following types of
aid relationships: “utilitarian” approach (donor–civil society organiza-
tions [CSOs]; recipient state-CSOs), unequal cooperation (donor–recip-
ient state), and coordination (donor–donor).
11.2.1 Impact of a “Utilitarian” Approach

on Sustainability
The “utilitarian” approach of the Global Fund toward grant-recipient

NGOs contributed to community capacity building by ensuring the
CSOs’ survival beyond the grants. The Global Fund grants to the country
increased the number of NGOs and facilitated their competition over
332 G. Isabekova
Sustainability
Local NGOs gain skills and
Donor’s “utilitarian” Community capacity
knowledge relevant to their
approach toward building
CSOs organizational capacity and
services offered by them Sub-Recipient NGOs’
survival
mechanism of “professionalization”
Diagram 11.9 The impact of the donor’s “utilitarian” approach toward CSOs on
sustainability
resources. According to the NGO representatives interviewed for this

research, civil society needs to continuously increase its capacity and exper-
tise in all areas, including treatment, medication supply, procurement, and
budgeting (CSO 8). The organizations also improved their advocacy skills
by arguing from legal and health care perspectives and not just going on
strike and demanding a revolution (CSO 6). The competition between the
NGOs contributed to their development and selection of well-performing
organizations in the Global Fund project. These organizations had to com-
ply with the Global Fund’s standards and requirements for project man-
agement, accounting, monitoring and evaluation (M&E), and reporting,
facilitating the introduction of new positions and the recruitment of addi-
tional personnel in the NGOs and subsequently contributing to their
“professionalization” (Harmer et al., 2013, p. 304). The skills obtained
during the design and implementation of the Global Fund grants contrib-
uted to the NGOs’ survival by advancing their negotiation skills essential
to fundraising (Diagram 11.9). However, similar to other sustainability
components, NGOs’ survival beyond the duration of the Global Fund
project depends on broader political and economic factors.
11.2.2 Impact of Unequal Donor-Driven Cooperation

on Sustainability
Unequal cooperation, formed between the Global Fund, the Ministry of

Health, and its agencies, contributed to sustainability through the mech-
anism of institutionalization. The Ministry and its agencies comply with
the Global Fund’s requirements throughout the project life cycle by

establishing the CCM and increasing the share of government co-
financing of the grants. Government institutions also took over first-line
TB medications and increased their financing for antiretroviral therapy
(see Chap. 9). All these commitments contributed to the continuity of
treatment activities beyond the duration of the Global Fund project
(Diagram 11.10):
In addition, “unequal” cooperation between the Global Fund, the
Ministry of Health, and its agencies contributed to community capacity
building by supporting the local NGOs’ mobilization of resources. The
Global Fund facilitated civil society involvement in the design and imple-
mentation of its grants. As an NGO representative interviewed for this
research noted, “willingly or not,” the recipient state was open to civil
society participation (CSO 8). Furthermore, following the Global Fund
conditions, social contracting featured the country’s joint application for
TB/HIV to Fund 2017–2019 (Zardiashvili & Garmaise, 2017). By
incorporating social contracting, the government committed itself to
financing NGOs. As a state official interviewed for this research noted,
the donors “come and leave,” and social contracting is the only possibility
for the continuity of NGO activities (State Partner 2). The Ministry of
Health agreed to sign a contract with two NGOs in 2018 and six NGOs
in 2020 (see Government of KR, 2017). The Ministry also committed to
developing the normative-legal basis for social contracting by 2021
(ibid.). In this way, the unequal cooperation between the Fund, the
Ministry, and its agencies ensured continuous financing of the NGOs
Following the Global Fund Sustainability

Unequal cooperation requirements, the recipient Continuity of project
between the donor and state increased its financing activities
recipient state for TB and HIV/AIDS treatment (treatment)
Diagram 11.10 Donor–recipient state: the impact of unequal cooperation on

sustainability
334 G. Isabekova
Following the Global Fund Sustainability

Unequal cooperation requirements, the recipient Community capacity
between the donor and state introduced social building
recipient state contracting for NGOs • Resource mobilization
Diagram 11.11 Donor–recipient state: the impact of unequal cooperation on

sustainability
working on TB and HIV/AIDS beyond the duration of the Global Fund

project (Diagram 11.11).
Overall, the interaction that developed between the actors involved in
the Global Fund project in Kyrgyzstan had various impacts on sustain-
ability and its components. As the interaction between the recipient state
and the local NGOs was the result of the Global Fund’s condition, I sug-
gest that it did not impact the sustainability of the Global Fund project
in Kyrgyzstan.
11.2.3 Impact of Coordination on Sustainability
The Global Fund is the largest financier of TB and HIV/AIDS programs,

and the country depends on its contributions in these areas. The financial
gap in the national HIV/AIDS program demonstrates the government’s
inability to meet the ongoing and increasing demand for antiretroviral
therapy and other services. Furthermore, Kyrgyzstan is among the coun-
tries with a large number of multidrug-resistant TB, which requires long
and expensive treatment. In this way, the government’s ability to provide
these services after the country’s transition from Global Fund grants is
questionable (see Chap. 9). However, in addition to the state budget defi-
cit, the country’s dependence on the Global Fund is also the outcome of
its coordination with other donors. Throughout the project life cycle,
except for the monitoring phase, the Global Fund demonstrated exten-
sive coordination with other donors working on TB and HIV/AIDS.
However, this coordination was not limited to the duration of the

Global Fund project in Kyrgyzstan. Before the award of the Global Fund
grants to Kyrgyzstan in 2004, the government had already collaborated
with multiple donors. These are the Soros Foundation Kyrgyzstan,
German Development Bank (die Kreditanstalt für Wiederaufbau—KfW),
World Health Organization (WHO), Joint United Nations Programme
on HIV/AIDS (UNAIDS), United Nations Development Programme
(UNDP), the United Kingdom’s Department for International
Development (DFID),4 International Committee of the Red Cross
(ICRC), Doctors Without Borders/Médecins Sans Frontières (MSF), and
the World Bank.
Upon the commencement of the grants, these donors gradually dis-
continued their TB and HIV/AIDS-related activities. Some respondents
in the study by Ancker and Rechel (2015, pp. 822–823) connected the
World Bank and DFID’s retrenchment from HIV/AIDS to nonduplica-
tion of efforts, rather than donor “fatigue.” A state representative inter-
viewed for this research similarly pointed to continuous cuts of HIV
funding in the Sector-Wide Approach due to Global Fund grants (State
Partner 9). The Global Fund is the largest international initiative against
TB, HIV/AIDS, and Malaria, financed by multiple countries, including
Germany, the United States, France, and the United Kingdom, among
others (see Global Fund, 2023). For this reason, the countries financing
the Global Fund decreased their bilateral assistance in the area of TB and
HIV/AIDS to avoid the duplication of activities with the grants. In doing
so, however, they have also contributed to the dependency of the country
on a single donor—the Global Fund.
The coordination between donors activates the mechanism of “replace-
ment,” which contributes to the continuity of TB and HIV/AIDS activi-
ties after the country’s transition from Global Fund grants. Currently, no
international organization, except for the MSF, who made an oral com-
mitment, can guarantee the stock of TB drugs in the case of interruptions
in the Global Fund grants to the country. Similarly, the continuity of
HIV/AIDS-related prevention and treatment is uncertain. However, the
lack of commitments does not necessarily hint at donors’ unwillingness
4
DFID was replaced by Foreign, Commonwealth and Development Office in 2020.
336 G. Isabekova
to support the government in its fight against the two diseases; instead, it
points to their inability to make long-term commitments. Aid predict-
ability is a general problem in development assistance, and the Global
Fund is among the few donors, along with Swiss aid agencies, offering
longer commitments (see Isabekova, 2019). According to my interview-
ees, the national and international actors in Kyrgyzstan attempt to avoid
the situation of all donors leaving the country at once (IO Partner 3). As
the Global Fund grants to the country decrease, other donors, such as
USAID and the President’s Emergency Plan for AIDS Relief (PEPFAR),
increase their contributions (State Partner 9). This tendency is not lim-
ited to Kyrgyzstan. In Sub-Saharan Africa, USAID and PEPFAR took
over most of the activities previously provided by the Fund. Coordination
among the donors triggers the mechanism of “replacement,” according to
which an area left by one donor is taken over by another actor or other
actors working in the same area. Continued provision of TB medications
in Kyrgyzstan is another example of the mechanism of “replacement” in
practice. The German government provided first-line medications against
drug-resistant TB between 2002 and 2004 based on the agreement that
the Government of Kyrgyzstan would take over financing these medica-
tions in 2005 (Government of KR, 2001). However, with the commence-
ment of Global Fund grants to Kyrgyzstan in 2004, all costs of TB
medications were transferred to these grants, not to the state budget.
Nevertheless, the mechanism of “replacement” does not necessarily
guarantee the same level of assistance, which affects the sustainability of
the Global Fund project in Kyrgyzstan. The Global Fund, unlike other
donors, was explicitly established to combat TB, HIV/AIDS, and
Malaria. Other donors approach TB and HIV/AIDS but not as the cen-
tral parts of their aid portfolio. As a result, their financial contribution to
these areas will be significantly lower than that offered by the Global
Fund. Although contributing to the continuity of some activities after
the country’s transition from the Global Fund grants, other donors are
unlikely to provide the same level of services. Despite the continuity of
preventive and treatment activities, financial incentives to patients are
likely to be discontinued (see Chap. 9). Lower donor financing also
implies less funding to the local NGOs working on TB and HIV/AIDS
that are dependent on the Global Fund grants. Since the Global Fund
Sustainability
Donors complement each
Donor-donor Continuity of project
other by filling in the gaps
coordinaton activities
related to the departure of
? Maintenance of benefits
some organizations
? Community capacity
building
mechanism of replacement
Diagram 11.12 The impact of coordination among donors on sustainability
project is still ongoing and due to the high level of uncertainty in

Kyrgyzstan’s economic and political situation, the impact of coordination
among donors on sustainability is uncertain. Though one is clear, the
donor that steps in following the Global Fund will not offer the same
level of services unless several organizations take over the TB and HIV/
AIDS programs in Kyrgyzstan (Diagram 11.12).
To summarize, in the case of the Global Fund grants to Kyrgyzstan,
the missing link unfolded in the following way:
1. The “utilitarian” approach of the Global Fund toward the local NGOs
contributed to community capacity building through the mechanism
of “professionalization.” Through participation in the grants, the
NGOs developed skills and knowledge in service provision and other
areas, which are essential to their survival of the organizations beyond
the grants.
2. The “utilitarian” approach of the Ministry of Health and its agencies
on TB and HIV/AIDS toward local NGOs did not affect the sustain-
ability of grants. Notably, the interaction between the state and civil
society was triggered by the conditions established by the Global
Fund. Although contributing to collaboration between actors, the
joint realization of grants has demonstrated continuous disagreement
and conflict between the state and non-state sectors.
3. The unequal cooperation of the Global Fund with the Ministry of
Health and its agencies contributed to the continuity of grant-related
activities and community capacity building. Following the Global
338 G. Isabekova
Fund’s requirements, the recipient state gradually took over the treat-
ment of TB and HIV/AIDS, which contributed to their continuity
beyond the grants. Furthermore, the recipient state committed to
concluding social contracting to continue the work of local NGOs
with the key groups. This work provided additional funding to the
NGOs (e.g., mobilization of funds).
4. The coordination between the Global Fund and other donors contrib-
uted to sustainability through the mechanism of replacement. The
amount of the Global Fund grants to Kyrgyzstan has decreased, but
the project is still ongoing. Due to donor organizations’ inability to
provide long-term commitments, epidemiological situations, and the
political and economic instability in the country, estimating the exact
impact of this coordination on specific components of sustainability is
not feasible.
11.3 Cross-Case Causal Inferences

At the same time, this exploratory study aims to build (but not test)
hypotheses about the potential impact of the interaction between actors
on the sustainability of development aid. Therefore, a cross-case analysis
of the findings from within-case analysis to explore the possibilities for
theorizing these mechanisms beyond the selected cases is foreseen. The
generalization of causal mechanisms to a “population of causally similar
cases” is possible (Mahoney, 2008, pp. 413–420), also via simplification
of specific boundaries of cases or “layered generalization” (Rohlfing,
2012, pp. 209–212). In other words, the less specific the case, the more
generalizable the causal mechanism, which, however, also means that the
claims are less specific as well. Following this logic of the “layered gener-
alization,” I conduct a cross-case analysis, which offers the possibility of
examining and theorizing causal effects, or what Rohlfing calls “theoreti-
cally intelligible and systematic” relationships (Rohlfing, 2012, p. 12).
These effects provide the foundation for the formulation of hypotheses
about the causal impact of interaction on sustainability.
By relying on cross-case analysis of how the actors’ relationships in the
selected countries might have causally shaped the sustainability of the
relevant health care programs, it is possible to formulate the following

findings:
First, an “empowerment” approach of a donor toward CSOs contrib-
utes to community capacity building by improving and streamlining the
leadership of the CSOs, and their capacity to mobilize resources, as well
as by facilitating their survival beyond the duration of development assis-
tance projects. As demonstrated in the case of the CAH project, an
“empowerment” approach may also develop in the environment of
unequal power dynamics between a provider and a recipient of develop-
ment aid. Illiteracy (Jana et al., 2004), gender-related biases (WHO,
2008), the political situation in the country, and poverty (Fawcett et al.,
1995) may prevent the CSOs from initiating a development project
without external assistance. For this reason, the Swiss Agency for
Development and Cooperation (SDC) and the SRC were essential to the
initiation of the CAH. However, the design, implementation, and evalu-
ation phases of the project largely depended on community members’
leadership and their consent to engage in voluntary work. The Village
Health Committees’ extensive role throughout the project, along with
the SRC and SDC’s emphasis on community empowerment, flexibility,
and predictability of development assistance, was critical to altering the
initially unequal power dynamics between the actors. This changing
nature of power identified in the CAH corresponds to the findings in the
literature on aid relationships (e.g., Andrews, 2013; Swedlund, 2017). In
addition, it points to the possibility of changing the power dynamics
despite the aid recipient’s capacity issues and dependence on develop-
ment assistance. Furthermore, the CAH project demonstrated a causal
link between the donor’s “empowerment” approach and community
capacity building. The impact of this approach was clearly seen in the
continued survival of the majority of the Village Health Committees
beyond the end of the CAH and their mobilization of resources through
fund-raising, member contributions, and donor support.
Second, a “utilitarian” approach of a donor toward the CSOs contrib-
utes to their survival beyond the duration of development assistance pro-
grams, but it does not affect the quality of the leadership of these CSOs.
A “utilitarian” approach may also facilitate resource mobilization for
CSOs, but only in a situation in which the relevant donors cooperate on
340 G. Isabekova
an unequal basis with the authorities in the recipient country. The cases
of the Global Fund grants vividly illustrate a “utilitarian” approach of a
donor toward the CSOs engaged in the design and implementation of
grants, though on the terms defined by the donor, and not by the CSOs
themselves. The unequal power dynamics established between the Global
Fund and grant-recipient NGOs, due to the latter’s aid-dependence and
capacity issues, intensified in the course of the grant realization process.
The Global Fund used disbursements as leverage to ensure the grant
recipients’ performance and their compliance with its regulations. The
limited flexibility of the assistance precluded responsiveness to changing
needs and approaches of NGOs that followed the activities and indica-
tors stated in the projects instead. This compliance contributed to NGOs’
awareness of the Global Fund’s procedures and other technical skills, but
not their leadership, which was not stimulated through their implemen-
tation of grants. At the same time, the Global Fund’s “utilitarian”
approach toward the NGOs contributed to their existence beyond the
projects by providing access to resources (i.e., social contracting) through
authorities of grant-recipient countries, which cooperated with the
Global Fund on an unequal basis.
Third, unequal cooperation between a donor and the relevant authori-
ties of aid-recipient countries does in fact contribute to the continuity of
project activities. However, the extent of the services that might continue
beyond the period of the development assistance is highly dependent
upon decision-makers’ priorities, the presence of stigma and discrimina-
tion against groups targeted by assistance, as well as the epidemiological,
political, and economic situation in the aid-recipient countries. The case
of the Global Fund grants illustrated unequal cooperation between the
donor and the recipient state. Government authorities’ participation in
the design and implementation of grants did not change the unequal
power dynamics. Limited flexibility of the Global Fund in regard to the
grant activities and indicators, along with the state authorities’ aid-
dependence and capacity issues, strengthened the unequal power dynam-
ics. The inequality between the actors intensified further as the Global
Fund used the grant disbursements to impose its conditions and
regulations on the recipient governments. To access the financing, the

state authorities designed the grant applications and established the insti-
tutions (i.e., Country Coordinating Mechanism) according to the focus
and procedures of the Global Fund. Moreover, a prolongation of a stan-
dard three-year-long project cycle also depended on grant recipients’
compliance with the Global Fund’s regulations and achievement of the
objectives stated in the grant agreements. As part of the Global Fund’s
conditionalities, the recipient governments also increased their contribu-
tion to the treatment of TB and HIV/AIDS, which contributed to the
continuity of these activities beyond the duration of the projects. At the
same time, the long-term commitment of the government remains
unclear.
Fourth, coordination between donors decreases aid fragmentation and
contributes to the sustainability of benefits and activities resulting from
sponsored health care programs, as long as these activities and benefits
comply with the donors’ objectives and priorities in the aid-recipient
countries. The analysis of the Global Fund grants unveiled a curious fea-
ture of the national actors’ dependence on the Global Fund by linking it
to the donors’ coordination with each other. The arrival of the Global
Fund grants to a certain degree resulted in the retrenchment of other
donors from TB and HIV/AIDS. In addition to reinforcing the financial
dependence of state authorities and CSOs on the Global Fund, this
retrenchment evidently pointed at coordination among the donors,
which was also visible throughout the realization (i.e., design, implemen-
tation, and evaluation) of grants. The Global Fund took over the activi-
ties previously provided by other donors, such as the Soros Foundation,
ICRC, and others. This book suggests that the transition of Kyrgyzstan
from the Global Fund grants does not necessarily presume discontinuity
of the project activities currently financed by the Fund; it rather suggests
the transfer of these activities to the account of other donors, who will
replace the Global Fund. Clearly, this replacement strongly depends on
the presence of a donor whose objectives and priorities include TB and
HIV/AIDS. The range of benefits and activities may also change depend-
ing on the priorities and financial means of this donor.
342 G. Isabekova
11.4 Methodological Limitations

I acknowledge the limits of causal effects and causal mechanisms defined
through exploratory research. The mechanisms identified in this book
may be only a part of many alternatives leading to the same outcome (for
the problem of indeterminacy, see Rohlfing, 2012, p. 7). While empha-
sizing the significance of the necessary and sufficient conditions behind
the causal effects, this book nevertheless acknowledges the uncertainty
regarding the inclusion of all possible relevant conditions. Moreover,
multiple conditions or their combinations may lead to the same outcome
(the problem of equifinality, see King et al., 1994; Mahoney, 2008), and
some conditions may produce the outcome “only if they are simultane-
ously present” (conjunctural causation) (Rohlfing, 2012, p. 56).
Furthermore, in defining the causal mechanisms and causal effects behind
interactions and sustainability in development assistance, this book may
have unwittingly overlooked other conditions of equal relevance to the
outcome and included only those known to the literature (Gerring, 2010,
pp. 1508–1512).
Other than acknowledging the exploratory limits of this study and
incorporating the causes relevant to interaction and sustainability into the
“scope conditions,” there are no known solutions to the problems of equi-
finality and conjunctural causation. The “scope conditions” are the
“boundary conditions, delineating the domain within which a specific
causal relationship is expected to exist” (Rohlfing, 2012, p. 9). An increase
in the number of boundary conditions contributes to the validity of iden-
tified mechanisms by specifying the population of cases and decreasing the
number of nonexamined cases (Rohlfing, 2012, p. 8). However, increased
case specification also decreases the generalizability of the identified mech-
anisms (Rohlfing, 2012, pp. 147–148). The specificity of boundary con-
ditions relates back to the “layered generalization” indicated above.
I do not pretend to solve the issues associated with causal effects and
causal mechanisms, most of which go beyond the scope and interest of
this book. However, acknowledging the limits of the selected methodol-
ogy, it nevertheless aims to make a meaningful contribution to under-
standing the link between the interaction among stakeholders and the
sustainability of health aid.
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346 G. Isabekova

right holder.
12
Conclusion and General Implications
of This Study
Uncovering the “missing link” between aid relationships and sustainabil-

ity was one of the major reasons for conducting this research. During the
extensive analysis of the literature on aid and public health programs, I
came across the association of project sustainability with stakeholder rela-
tionships. This relationship seemed intuitive, particularly given the Paris
Agenda and its emphasis on ownership and harmonization. Nevertheless,
in light of the lack of a systematic analysis of the two phenomena and the
link between them, I aimed to develop an analytical framework by syner-
gizing the findings of other researchers. This academic curiosity and
endeavor found further support in practice during the first fieldwork
conducted in 2016, during which multiple actors expressed their con-
cerns over the sustainability of initiatives beyond donor funding.
Similarly, inequality among stakeholders and broader structural issues
were repeatedly recalled by stakeholders, along with collaboration. These
considerations reiterated broader concerns in the literature. The sections
below outline the major findings concerning aid relationships, the sus-
tainability of selected initiatives, and the possible link between these two
phenomena. This chapter also outlines the academic and practical bene-
fits of this research, along with limits and directions for further studies.

348 G. Isabekova
12.1 Aid Relationships

This book aimed to synergize the discussion of aid relationships in the
development aid literature with a discussion of power and its sources in
political theory to provide a more refined analytical framework for ana-
lyzing aid relationships (Chap. 2). It differentiated between the conven-
tional and alternative perspectives on stakeholder relationships and power
and expands on the latter. More specifically, the analytical framework
aimed to enable further examination of recipients’ roles, actors’ interde-
pendence, and the changing nature of power throughout the assistance.
This book pursued four steps in analyzing these aspects.
The first step commenced with a reflection on the meaning of power
and the common terms associated with it, such as resources, consensus/
conflict, and interests (Chap. 2). Then, to more fully grasp the inequality
present in development assistance, it followed the distinction between
“power over,” which is associated with a hierarchy between stakeholders,
and “power to,” which corresponds to changes in this hierarchy. Whether
these two types of power are separate or merely represent distinct aspects
of the same power is debated among scholars. Nevertheless, the distinc-
tion between the two types of power helped differentiate the power
dynamics between stakeholders, establishing the basis for identifying the
sources of power.
As a second step, this book emphasized the relevance of both stake-
holders and the context in which they interact. It approached stakehold-
ers as agents who act depending on incentives provided in the relevant
structures and the roles assigned to these agents (Dowding, 2017, p. 22).
Both individual and collective agencies were emphasized as being equally
important. An empirical analysis confirmed this assumption. Individual
agency featured in multiple instances, such as in the cases of the Global
Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) grants
and the “Community Action for Health” (CAH) project. However, the
empirics also demonstrated the equal importance of collective agency on
behalf of organizations, as well as abstract categories, such as donors,
recipient states, and civil society organizations.
12 Conclusion and General Implications of This Study 349
In addition, this book emphasized the relevance of the context in

which these agents operate by defining them as structures or “recursively
organized sets of rules and resources” that enable and constrain stake-
holders (Dowding, 2011, p. 10). An extensive literature review high-
lighted the significance of aid dependency, capacity, volatility, and
flexibility. The empirical analysis of each of these aspects provided the
following insights:
1. In both the Global Fund grants and the CAH, the aid recipients (state
and civil society organizations) were dependent on the donors’ finan-
cial and technical support. Following Lensink and White (Lensink &
White, 1999, p. 13), this book attributed aid dependency if a country
(in this framework, a recipient state or a civil society organization)
could not “achieve objective X in the absence of aid for the foreseeable
future.” This book demonstrated the limits of the conventional quan-
titative indicators, which are normally used to illustrate the share of
external assistance for health care; instead, it proposed using the
sector-specific definition of aid dependence. Despite the relatively low
share of donor contributions compared to the total share of health
financing, this research provided compelling evidence for the exten-
sive dependence of state and civil society organizations on the financ-
ing and technical assistance offered by donors. This was found to be
particularly visible in the cases of human immunodeficiency virus
infection and acquired immune deficiency syndrome (HIV/AIDS)-
related preventive activities, antiretroviral therapy, and treatment of
multidrug and extensively drug-resistant tuberculosis (TB).
2. Defining capacities as individual-, organizational-, and system-level
abilities to implement functions (European Centre for Development
Policy Management, 2008, p. 2), this book specifically focused on the
structural issue, namely, the availability of human resources. Overall,
staff turnover in ministries and state agencies, which is also due to the
political situation in the country and low salary rates, was found to
significantly jeopardize their abilities to perform their functions (see
Isabekova & Pleines, 2021). Relevant to both cases, the problem of
the limited capacity of state organizations, also in terms of monitor-
ing, was particularly evident in the Global Fund grants, which resulted
350 G. Isabekova
in a corruption scandal. In addition, there were cases of former state

officials working for international organizations and NGOs. Although
the scale of this phenomenon requires further research, it resonates
with the conclusions of other relevant studies (Swedlund, 2017;
Toornstra & Martin, 2013). Notably, staff rotation and attribution in
nongovernmental organizations (NGOs) varied, depending on orga-
nizations and specific positions. While it was found to be substantial
in the case of outreach workers, it did not seem equally pressing in
other positions of NGOs.
Furthermore, in contrast to the high level of attrition in community-
based organizations, which is described at length in the literature (e.g.,
Glenton et al., 2010; Khetan et al., 2017), the CAH was actually char-
acterized by a low level of attrition among the Village Health
Committee (VHC) members, demonstrating the persistence of the
VHC members. Labor migration and conventional gender roles con-
tributed to the “female” profile of the volunteers in the VHCs, for
whom VHC membership offered the possibility of participating in
social life and decision-making processes. Most of those women did
not migrate to other parts of the country or abroad, which contrib-
uted to the stability of VHC membership.
3. Acknowledging the uncertainty in which stakeholders operate because
of aid appropriation procedures and the relatively short duration of
development programs, this book focused on aid volatility as another
structural factor. As demonstrated in Chap. 4, both the Global Fund
and the Swiss Agency for Development and Cooperation (SDC)
worked on increasing the predictability of their assistance. However,
the SDC offered higher predictability than the Fund, which depended
on its financiers’ replenishment of its three-year cycle. The Global
Fund’s inability to provide long-term commitments was explicitly vis-
ible in the National Program for HIV/AIDS Prevention, where the
financing from the Global Fund was only confirmed for the first three
years, and the funding for the two remaining years was unknown.
However, in contrast to the findings made by Swedlund (2017), this
research did not find any evidence that the actors involved were
unaware of upcoming assistance or that the volatility of the aid had
any impact on the recipients’ commitment to the aid. However,
despite this outcome, the long-term duration of the CAH (approxi-

mately 17 years) did contribute to the commitment of the recipient
state and community members to the project.
4. Emphasizing the significance of aid flexibility to the relationships
present among stakeholders, this book examined this phenomenon by
associating it with the ability to adjust to local priorities and context
(see Hirschhorn et al., 2013). An empirical analysis showed that the
CAH was more flexible to the recipients’ changing needs and priori-
ties than the Global Fund grants. The SDC, similar to other Swiss
development agencies, provides a high level of decision-making
autonomy to its field offices, meaning that these offices can decide on
important issues without prior approval from the head office. The
Global Fund, in contrast, does not have branches in the recipient
countries; rather, it has a designated officer who deals with specific
regions. While this officer is closely involved in all the processes relat-
ing to the implementation of the grant, the key decisions are made by
the Global Fund’s head office in Geneva. Although it was open to
making minor adjustments to the program, the Global Fund proved
to be reluctant to consider more substantial changes. Meanwhile, the
availability of senior staff from the SDC in Kyrgyzstan and the strong
personality of the project manager from the Swiss Red Cross (SRC)
contributed to the remarkable flexibility of the CAH toward the
changing needs and priorities of the local communities. Based on
these findings, this book would argue that the decentralization of
donor organizations and a high level of decision-making autonomy of
local field offices, along with a strong personality in the project man-
ager, could contribute to the responsiveness of development projects
to the recipients’ changing needs and priorities.
Overall, the first two steps composed the initial level of the analysis, as
they laid down the conceptual basis for understanding power, stakehold-
ers, and the context in which they interact. The following steps linked
this conceptual basis to the alternative perspective of stakeholder rela-
tionships that this book aimed to expand on. More specifically, the fol-
lowing steps offered the analytical depth and tools necessary to grasp
352 G. Isabekova
recipients’ roles, actors’ interdependence, and the potentially changing

nature of power in development assistance.
The third step called for a project-level analysis that differentiated
among initiation, design, implementation, and evaluation phases. An
empirical analysis at this level offers a detailed and yet standardized (in
terms of a project cycle) analysis of development projects. Thus, Chaps. 5
and 8 in this book provide an elaborative overview of stakeholders’ roles
throughout the realization of the CAH and the Global Fund grants. In
addition to understanding the agency (both individual and collective) of
stakeholders, this depth of the analysis was critical to understanding the
actors’ interdependence. It also allowed a better grasp of the recipients’
agency and a glimpse of the changes in stakeholders’ roles throughout the
project cycle.
The fourth step culminated the analytical framework by linking the
empirical insights from step three and the conceptual basis defining
stakeholders, power, and the context in the first two steps to a theoriza-
tion of power dynamics and aid relationships. This step was necessary to
understand the empirical cases by placing them in a broader theoretical
framework. This step combined the seven ways of creating power sug-
gested by Haugaard (2003) with the “ideal” types of aid relationships
defined by the author of this book in Chap. 2. For simplicity of compre-
hension, this analysis was conducted in a dyadic manner by referring to
broader analytical categories: donor–recipient state, donor–donor, recipi-
ent state–civil society organizations (CSOs), and donor–CSOs. This step
synergized the findings of all three other steps.
The synergy of the four steps unfolded as follows in the case of the
CAH. The donor pursued an “empowerment” approach toward
community-based organizations (CBOs). In addition to continuous par-
ticipation, the CBOs maintained a decision-making role throughout the
project cycle (based on the project life cycle analysis in Chap. 5). Moreover,
structural factors, including aid flexibility and predictability (Chap. 4),
were favorable to altering the conventional stakeholder positions by
ensuring continuous project responsiveness to community needs.
Volunteering or unpaid roles of community members and their leader-
ship (individual agency) were additional assets. These findings from two
chapters strongly hinted at the feasibility of an “empowerment” approach
of a donor toward CBOs. However, the theorization linking these empir-

ical findings to types of power, stakeholders’ interests (step one), and the
ways of creating power (step four) was critical to the validity of my claims.
The theorization showed that the donor primarily pursued the “power to”
the CBOs for several reasons because of its emphasis on and belief in the
decisive role of communities in aid (“system of thought” in Haugaard’s
terms). A relevant practice of nondominance followed by SRC staff mem-
bers further supported this belief, contributing to community members’
realization of their decisive roles (transformation of tacit knowledge into
discursive, according to Haugaard). These ways of creating power vividly
demonstrated that the SRC used its resources to produce “power to”
CBOs rather than “power over” them. Additional reflections on donor
and CBOs’ interests in following the specific forms of power, namely,
bringing change to a community, self-development, organizational per-
spective, and individual agency, further supported an “empowerment
approach” (Chap. 7).
In contrast to the CAH, donor–CSO relationships in the Global Fund
grants followed a “utilitarian approach.” In addition to uneven levels of
participation throughout the project life cycle (Chap. 8), the structural
factors remained in favor of hierarchical relations (Chap. 4). Indeed, the
Global Fund committed itself to ensuring the predictability of its assis-
tance, which, nevertheless, in practice, remains dependent on its replen-
ishment cycle. Furthermore, although driven by the grantee’s needs in the
design phase, the provider offered the limited adaptability of grants dur-
ing the implementation stage (e.g., limited flexibility). In addition, local
NGOs and their activities depended considerably on donor financing,
which varied across organizations but strengthened the inequality
between the provider and recipient of aid. Theoretically, the relationship
between the Fund and NGOs was characterized by a combination of
“power over” and “power to.” Notably, the Global Fund’s emphasis on
civil society participation in decision-making (a structural bias in
Haugaard’s term) offered a window of opportunity for NGOs to
strengthen their positions in the project life cycle. This opportunity was
further reinforced by solid organizational support in the form of finances
and technical assistance from the Global Fund. However, this “power to”
came along with the aid provider’s “power over” the recipient. One source
354 G. Isabekova
of this form of power was the propensity to predict grants and their out-
comes (“social order”), while another source was assigning specific roles
and tasks to stakeholders in the project lifecycle (discipline in Haugaard’s
theory). Similar to the CAH, a “utilitarian approach” was found to have
its underpinning in stakeholders’ interests, including access to resources,
reaching out to vulnerable groups, and organizational perspective.
The analysis of aid relationships between other stakeholders in the
CAH and the Global Fund grants followed a similar logic (for more
information, see Chaps. 7 and 10).
12.2 Sustainability of the Selected

Health Projects
In addition to analyzing aid relationships, this book also offered a system-
atic analytical framework to assess the sustainability of health care inter-
ventions, in which various approaches to the operationalization of
sustainability and relevant factors were given special attention. Following
the most frequently used approach in the literature, namely, the approach
developed by Shediac-Rizkallah and Bone (1998), this book defined sus-
tainability as the continuity of project activities, the maintenance of ben-
efits (e.g., services and infrastructure), and community capacity building.
This book complemented this approach with three extensions.
First, it acknowledged the relevance of the analysis of both ongoing
and complemented projects. In the former, it approached state commit-
ment in terms of necessary legislative amendments and financing as the
sign for sustainability of ongoing initiatives. The analysis of the Global
Fund grants vividly demonstrated both the validity of and issues with this
approach (Chap. 9). In contrast, the CAH presented the case for a com-
pleted health care project in which the actual fulfillment of obligations
and activities upon the end of the donor funding could be assessed.
However, both ongoing and completed initiatives are subject to continu-
ous socioeconomic, political, and epidemiological changes (e.g., the
coronavirus disease 2019 [COVID-19]), representing similar uncertainty
and jeopardy to the sustainability of projects. Moreover, by acknowledg-
ing that sustainability does not automatically come at the end of aid but
rather is built throughout its realization process, this book highlighted

the equal validity of the analysis of ongoing and completed initiatives.
Second, this book complemented the operationalization of commu-
nity capacity building with an adaptation of Laverack’s framework by
focusing on participation, leadership, and mobilization of resources (see
Labonte & Laverack, 2001a, 2001b).1 Furthermore, in contrast to the
original framework by Shediac-Rizkallah and Bone (1998) and the oper-
ationalization of community capacity building suggested by Laverack
(see Labonte & Laverack, 2001a, 2001b), the current research introduced
a new category for assessment that is commonly highlighted by the inter-
viewees but absent in the two older frameworks, namely, the survival of
CSOs beyond the period of development assistance provision. This aspect
is important, as, for instance, unlike the NGOs involved in and highly
dependent on the Global Fund grants, the CBOs in the SDC’s CAH
demonstrated remarkable continuity beyond the development assistance.
In this way, although financing was important for the functioning of the
CSOs, it did not seem to be a necessary factor.
Third, the initial framework was complemented with a list of factors
relevant to the sustainability of health care interventions developed by
the author of this book through an extensive review of related literature.
These factors included financing; accounting for the influence of general
economic, social, and political situations in the aid-recipient country;
integrating within context; and disentangling organizational factors into
further categories (see Table 3.3 in Chap. 3).
Overall, the analytical framework and its three extensions found their
reflection in the analysis of the selected health care programs.
The CAH demonstrated the continuity of tuberculosis and HIV/
AIDS-related services previously pursued by the project beyond the dura-
tion of donor funding. Unpaid, the CBOs continued their awareness-
raising activities in these areas (among others) by informing the local
population, organizing community events and walking campaigns, and
so on. Indeed, the means available to CBOs varied depending on their
coverage with analogous donor programs, particularly given that the
1
The original source is an unpublished Ph.D. thesis by Laverack (1999), which was expanded fur-
ther by Labonte and Laverack (2001a, 2001b).
356 G. Isabekova
government training activities became uneven. Among others, the main

issues thereof were found to be related to reimbursing the travel expenses
of state trainers, which were also due to the ongoing optimization reforms
and change in the national health care toward a systemic (and not disease-
specific) target-setting. Similarly, the survival of CBOs beyond the CAH
was uneven, but the majority continued due to members’ leadership and
organizational support from the Association of Village Health
Committees. Indeed, resource mobilization remained a challenging task
due to not only the socioeconomic situation in the country but also the
lack of extensive training on this matter. However, CBOs continued and
even expanded their work by overcoming challenges, such as COVID-19
implications, and exploring opportunities for their organizational growth.
In the case of the Global Fund grants, the government demonstrated
an unprecedented commitment to continuing TB and HIV/AIDS-
related activities, although with mixed success. In addition to legislative
changes aimed at eliminating the discrimination of groups affected by
TB/HIV, it also adopted a roadmap to optimize state health care services
and facilities to provide additional financing for the areas funded by
donors. The mobilization of resources at both the national and local lev-
els was found to be challenging due to the socioeconomic situation in the
country defining its gross domestic product (GDP). However, even with
savings, state funding was found to be insufficient to cover medications
for antiretroviral therapy, the treatment of drug-resistant forms of TB,
and other areas. There was skepticism that state-level commitments
highly depended on decision-makers’ choices. However, other factors
equally mattered to the fulfillment of these commitments, such as pro-
curement costs and opportunities, the availability of medical profession-
als, the epidemiological situation in the country, and the COVID-19
implications on the already strained health care system. The maintenance
of benefits received by patients with TB/HIV similarly demonstrated the
commitment of the government, as reflected in the social support offered
by the state that was found to be nevertheless insignificant. The survival
of NGOs beyond the duration of the grants provided ambiguous answers
depending on the capacities of the organization in question. Indeed,
NGOs explored possible alternatives that were nevertheless scarce due to
a decrease in external funding. The state’s reform toward social contract-
ing, following the Global Fund grant conditions, was a reasonable
alternative, although with further implications with regard to account-

ability and the dependence of CSOs on the government.
Overall, both the theoretical and empirical discussions vividly showed
that the sustainability of health care initiatives is a complex question
requiring nuanced answers. Thus, a project may hypothetically perform
well in terms of continuity of activities or the maintenance of benefits but
not in terms of community capacity-building (or a specific aspect of it).
Are such projects still sustainable, then? As noted in Chap. 3, I refrain
from suggesting degrees of sustainability; however, I also argue that this
is not a yes/no question. Furthermore, the analysis only reflects the state
of affairs at a certain period of time. Consequently, sustainability, similar
to power and aid relationships, evolves.
12.3 The “Missing Link” between Aid

Relationships and Sustainability
The link between aid relationships and sustainability was explored at the
project level and beyond. At the project level, this link embodied mecha-
nisms or processes connecting the two phenomena (see Chap. 11 for
more details). However, these mechanisms have limited implications for
our understanding of the link beyond the selected cases. For this reason,
I used broader causal links due to the level of abstraction in both wording
and approach.
First, after providing a comprehensive picture of aid relationships and
sustainability, this book assessed the impact of the different types of rela-
tionships formed between the actors over each component of sustainabil-
ity (e.g., continuity of activities, maintenance of benefits, and community
capacity building). Based on Rohlfing’s (2012) integrative framework for
case studies and causal inference, this research identified the following
positive links between interaction practices among involved actors and
the sustainability of the selected health care programs: ownership,
358 G. Isabekova
learning, institutionalization, recognition, uniformity, replacement, and

“professionalization”2:
• The mechanism of ownership—aid-recipient community-based orga-

nizations develop a sense of ownership and responsibility for their
communities’ health. Triggered by the donor’s “empowerment”
approach toward the CSOs, this mechanism affects the CSOs’ survival
and continuity of health activities beyond the duration of health aid.
• The mechanism of learning—through their extensive participation in
the realization of development assistance, aid-recipient community-
based organizations increase their awareness of local issues and links to
local organizations. In doing so, the CSOs become the first point of
contact for local authorities and donors, which ensures their survival
beyond the development assistance. This mechanism is similarly gen-
erated by the donor’s “empowerment” approach toward the CSOs.
• The mechanism of professionalization—“professionalization” of
NGOs in specific areas takes place through their training, fulfillment
of donor requirements, and implementation of project activities. This
contributes to their survival beyond the duration of health aid. This
mechanism evolves through the “utilitarian” approach of a donor
toward the CSOs.
• The mechanism of institutionalization is characterized by a recipient
state’s formalization of its commitments, leading to the continuity of
project activities and CSOs’ survival beyond the duration of donor
assistance. This mechanism develops through unequal cooperation
between the donor and aid-recipient authorities.
• The mechanism of recognition occurs when state authorities approach
community-based organizations in order to achieve their own objec-
tives. This cooperation provides the CSOs with additional means for
their survival beyond the donor funding. This mechanism evolves
through the aid-recipient government’s “utilitarian” approach
toward the CSOs.
2
The author of this book identified and names these mechanisms according to the process they
trigger.
• The mechanism of uniformity, under certain conditions, contributes

to the expansion of development assistance and continuity of its activi-
ties. This mechanism develops through unequal cooperation
among donors.
• The mechanism of replacement—donors take over each other’s activi-
ties to ensure their continuity. This mechanism is triggered by the
coordination among donors.
In addition to identifying these mechanisms, this book also outlines

the conditions under which these mechanisms may take place beyond the
context of the selected health care programs and country. These include
aid dependency and limited capacity of government authorities and
CSOs, precarious economic and political situation in the aid-recipient
country, and the structure of development assistance, defining its flexibil-
ity and predictability. Furthermore, labor migration, conventional gen-
der roles, stigma, discrimination against sexual minorities (i.e., lesbian,
gay, bisexual, trans, intersex, and queer [LGBTQ]), and the personalities
of decision-makers and project implementers are essential to the realiza-
tion of these mechanisms in the case of health projects.
Furthermore, theory-centered, the aim of this book was to make a
general theoretical contribution toward evaluating the impact of relation-
ships between relevant actors on the sustainability of development assis-
tance for health care. For this reason, in addition to the causal mechanisms
mentioned above, identified through the intensive analysis of the selected
TB and HIV/AIDS programs, the other aim of this research was to for-
mulate tentative results in the form of causal links between the cause (aid
relationships) and the outcome (sustainability). These causal links require
a definition of causal effects or “theoretically intelligible and systematic”
relationships (Rohlfing, 2012, p. 12) defined through cross-case analysis
of the selected health care programs. Though context-specific, these
effects provide the theoretically grounded claims about the link between
the cause and the outcome:
1. An “empowerment” approach of a donor toward CSOs contributes to

community capacity building by improving and streamlining the
leadership of the CSOs, and their capacity to mobilize resources, as
360 G. Isabekova
well as by facilitating their survival beyond the duration of develop-

ment assistance projects.
2. A “utilitarian” approach of a donor toward the CSOs contributes to
their survival beyond the duration of development assistance pro-
grams, but it does not affect the quality of the leadership of these CSOs.
3. Unequal cooperation between a donor and the relevant authorities of
aid-recipient countries does, in fact, contribute to the continuity of
project activities. However, the extent of the services that might con-
tinue beyond the period of the development assistance is highly
dependent upon decision-makers’ priorities, the presence of stigma
and discrimination against groups targeted by assistance, as well as the
epidemiological, political, and economic situation in the aid-recipient
countries.
4. Coordination between donors decreases aid fragmentation and con-
tributes to the sustainability of benefits and activities resulting from
sponsored health care programs, as long as these activities and benefits
comply with the donors’ objectives and priorities in the aid-recipient
countries.
As it has provided herein comprehensive analytical frameworks

together with detailed case studies, this book is of interest to academics
and practitioners working in areas related to development and public
health, as well as area studies and regional specialists. Despite its very
specific focus on the health care programs financed by the Global Fund
and SDC in Kyrgyzstan, the intention of this book was to provide a
general perspective on types of aid relationships, components of sustain-
ability, and the link between these two phenomena. Certainly, the
abovementioned causal mechanisms and effects have been identified in
the specific context of Kyrgyzstan.
However, by easing region-specific characteristics, it is possible to gen-
eralize the causal links between aid relationships and sustainability stated
above beyond the selected health care programs. There are different “lay-
ers of generalization” (Rohlfing, 2012) for the causal mechanisms and
causal effects identified in this research. The country (Kyrgyzstan), policy
areas (TB and HIV/AIDS), and donors (the Global Fund and SDC)
represent three major “scope conditions” defining the context for specific
causal relationships (ibid., p. 9).
Kyrgyzstan offers interesting observations of a lower-middle-income

country that inherited a state-dominated health care system from the
Soviet Union. Indeed, the country’s epidemiological, cultural, historical,
and other aspects are country-specific, which may require some caution
in interpreting the results provided in this book. Nevertheless, some
issues, including the discrimination of groups affected by TB/HIV, aid
dependency, conventional gender roles in society, and other aspects, are
not unique and are equally present in other settings.
Furthermore, TB and HIV/AIDS are specific policy areas requiring
continuous access to quality medications and health care personnel to
ensure timely detection and uninterrupted treatment of persons affected
by the diseases. As shown in the analysis, health care programs’ sustain-
ability depends on political engagement, financing, training, and aware-
ness not restricted to specific country borders (e.g., the rise of HIV
infection among labor migrants). Furthermore, unlike TB, for instance,
HIV requires lifelong treatment, and in contrast to other health care areas
(mother and child health, cardiovascular diseases, etc.), HIV is burdened
with a high level of stigma and discrimination, not just on the grounds of
the disease itself, but also the “moral issue” attached to it (see Chap. 3).
Therefore, the causal links and results identified using the examples of TB
and HIV/AIDS may vary in the case of other diseases.
Moreover, this book focused on “bottom-up” health projects designed
by aid-recipients using the examples of the programs financed by the
Global Fund and SDC. Equally stressing the recipient’s ownership over
development aid and civil society involvement in it, these donors varied
in terms of their structures and approaches (Chaps. 1 and 4). While the
Global Fund grants may have comparable outcomes in other countries
with similar epidemiological profiles, the SDC’s CAH represents a
country-specific project, which can nevertheless be applicable to other
settings willing to apply a similar approach.
Causal mechanisms and effects presented in this chapter are specific to
the cases examined in this book. However, by easing the “scope condi-
tions” stated above, it is possible to generalize these causal links, connect-
ing different types of relationships relevant to the sustainability of health
care assistance into more general conclusions about the way in which key
actors and the relationships between them might affect the sustainability
of development assistance.
362 G. Isabekova
12.4 Further Findings and Limitations

of This Research
In line with the existing literature, this book finds unequal donor-driven
cooperation as the most common form of interaction between the donor
and aid-recipient government due to the limited capacity and aid depen-
dency of state authorities. The analysis of the Global Fund project in
Kyrgyzstan also shows that donor conditionalities did not end with the
World Bank and International Monetary Fund’s Structural Adjustment
Loans in the 1980s–1990s3 and continued up until nowadays.
Nevertheless, multiple findings of this book (in addition to those men-
tioned in the previous subsections) are new to our understanding of the
relationship between the interaction among stakeholders and the sustain-
ability of health projects.
First, initially unequal power dynamics between providers and recipi-
ents of aid may change during the development assistance. The analysis
of the two projects in Kyrgyzstan shows that aid flexibility and donor’s
inclination to aid recipient’s empowerment contribute to changing. In
contrast, the financial requirements and the threat of withdrawal of funds
strengthen the unequal power dynamics. These findings refine the sug-
gestions in the existing literature, which suggests increased power of
donors at the beginning and recipients—at the end of the assistance (e.g.,
Andrews, 2013; Swedlund, 2017).
Second, this book offers a new perspective on aid dependency. It argues
for a sector-specific definition beyond the quantitative indicators. In
2018, the share of external health expenditure (% of current health
expenditure) in Kyrgyzstan was about 5% (World Bank Group, 2023).
However, the analysis shows that 60–90% of tuberculosis and HIV/
AIDS prevention and treatment services depend on the Global Fund.
The country also relies on the technical assistance offered by the World
Health Organization, the German Corporation for International
Cooperation, SDC, and others. Furthermore, the empirical analysis
3
For more information on adjustment policies and outcomes, see Cornia et al. (1987, 1988).
shows that aid dependency may be an outcome of donor coordination.

Several donors, including the World Bank and German Development
Bank, discontinued their tuberculosis and HIV/AIDS programs shortly
after the commencement of the Global Fund projects in Kyrgyzstan,
which resulted in the country’s dependence on a single donor.
Third, in addition to the inclusion of all relevant stakeholders, this
book emphasizes further differentiation of actors within the categories of
“donors,” “recipient state,” and CSOs to understand their interaction
with each other better. The empirical analysis vividly demonstrates the
contrast between a Global Health Initiative pursuing a “standardized”
approach across the aid-recipient countries irrespectively of the SWAp
and a traditional bilateral donor providing country-specific allocations
driven by geopolitical interests. National and local state authorities also
differ in their interests and capacities, similar to community-based orga-
nizations, local and international NGOs. Differentiation of actors
grouped into one category allows for a better understanding of power
dynamics, interaction, and its implications for the sustainability of aid.
Fourth, in contrast to the existing literature on development aid,
including health aid, this book does not find high staff attrition in the
case of CSOs, though high staff rotation in government organizations
complies with the findings in development aid literature. The analysis of
community-based organizations in Kyrgyzstan shows that conventional
gender roles in the family and society ensured male migration and reten-
tion of women in households. As a result, there was no high staff attrition
among the local female volunteers working in health organizations. It
should be noted that health is primarily viewed as a “female”
responsibility.
Fifth, this book also makes some empirical findings new to the litera-
ture on development aid and its sustainability, along with the abovemen-
tioned theoretical contributions. It contains unique primary material and
thus offers new knowledge of complex processes inherent to development
assistance implemented in the region, mostly neglected in development
studies. Shortly after the collapse of the Soviet Union in 1991, newly
independent countries received significant financial and technical assis-
tance from international organizations. However, except for the number
364 G. Isabekova
of articles discussing the conditionality (e.g., Pleines, 2021; Stubbs et al.,

2020), assumptions (Wilkinson, 2014), and implications of international
support (Kim et al., 2018), the post-Soviet region is overlooked in the
literature on development aid (Leitch, 2016), which largely focuses on
Sub-Saharan Africa, Latin America, and Southeast Asia.
In addition to multiple academic and empirical contributions men-
tioned above, this book has far-reaching policy implications. The Global
Fund project is still ongoing, although the share of donor funding has
considerably decreased during the last ten years. Furthermore, the
national health care system of Kyrgyzstan, as elsewhere in the world, is
burdened by the COVID-19 pandemic. In these conditions, the sustain-
ability of the Global Fund project is essential to ending the epidemics of
AIDS and tuberculosis in the country. Similarly, the sustainability of the
SDC’s completed primary health care project is critical to achieving uni-
versal health coverage in rural regions of the country. Although context-
specific, the analysis of two projects in Kyrgyzstan nevertheless
demonstrates the issues common to other developing countries, distressed
by the shortage of finances and human resources. Therefore, the issues
and opportunities for the sustainability of health aid presented in this
book will benefit decision-makers working in the relevant areas in
Kyrgyzstan and beyond.
At the same time, this research has several limitations. Firstly, this book
focused primarily on the organizational level, and did not elaborate on
the interconnection between individual and organizational levels and on
how this could be relevant to understanding the actors that were involved
in the development assistance. Furthermore, in discussing only dyadic
relationships (meaning between two actors at a time), it did not focus on
the interdependence of actors’ choices, for instance. Thirdly, this research
defined the causal mechanisms and causal effects linking the different
types of relationships in the development assistance programs under
study, with the sustainability of those programs. As an exploratory study,
it did not further test the causal inferences and the tentative results in the
form of causal links between aid relationships and sustainability identi-
fied in this research. For this reason, this book did not elaborate on suf-
ficiency, necessity, equifinality, conjunctural causation, and other issues
pertinent to further understanding the relationship between the cause
and the outcome. Moreover, because of the fragmentation of the relevant

literature, this study acknowledges the limits of the theoretical basis of
the book, and uncertainty about the inclusion of all relevant conditions
into the analysis. These and other areas could be possible directions for
future research on this topic.
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right holder.
Appendix
The Global Fund Grants to Kyrgyzstan (2004–Present)1

# Period Grant Area PR Disbursed
1. 2004–2009 Development of preventive TB National Center US $2,771,070
programs against TB, HIV, of Phthisiology
and malaria
(KGZ-202-G02-T-00)
2. 2004–2009 Development of preventive HIV National AIDS US $17,073,306
programs against TB, HIV, Center
and malaria
(KGZ-202-G01-H-00)
3. 2007–2012 Enhancing DOTS TB National Center US $6,212,840
implementation by of Phthisiology
strengthening strategic
planning and management
of the National TB
Program (NTP) under the
Manas Taalimi National
Health Care Reform
Program and by its further
integration into health
care services, scaling-up
DOTS-plus implementation
beyond the pilot phase,
and reducing the burden
of TB, TB/HIV, and MDR-TB
in the penitentiary system
(KGZ-607-G04-T)
(continued)

Policy, https://doi.org/10.1007/978-3-031-31990-7
370 Appendix
(continued)
4. 2009–2011 Increasing universal access to HIV National AIDS US $11,020,755

prevention, detection, Center
treatment, care, and
support for key population
groups in the Kyrgyz
Republic (KGZ-708-G05-H)
5. 2011–2015 Consolidation and expansion TB Project HOPE US $5,849,523
of the “Directly Observed
Treatment, Short Term”
(DOTS) program in
Kyrgyzstan by providing
access to diagnostics and
treatment of drug-
resistant tuberculosis
(KGZ-910-G07-T)
6. 2011–2016 Promoting accessibility and HIV UNDP Kyrgyzstan US $31,893,603
quality of prevention,
treatment, detection, and
care services for HIV
among the most
vulnerable populations in
the Kyrgyz Republic
(KGZ-H-UNDP)
7. 2011–2016 Consolidation and expansion TB UNDP Kyrgyzstan US $23,349,032
of the “Directly Observed
Treatment, Short Term”
(DOTS) program in
Kyrgyzstan by providing
access to diagnostics and
treatment of drug-
resistant tuberculosis
(KGZ-S10-G08-T)
8. 2016–2023 Effective HIV and TB control TB, UNDP Kyrgyzstan US $67,184,606
project in the Kyrgyz HIV
Republic (KGZ-C-UNDP)2
1
Titles of the grants are listed verbatim according to the relevant Grant
Agreements. Disbursements, areas, and organizations are listed according to
the information provided at https://data.theglobalfund.org/location/KGZ/
grants/list.
2
This grant has been excluded from the analysis, as there are no documents
available on this grant; see https://data.theglobalfund.org/grant/KGZ-C-UNDP/3/
overview.
All other grants were analyzed by accessing the documentation available on the
Global Fund website before it moved to a new data explorer platform. Titles of
the grants are listed verbatim according to the relevant Grant Agreements.
Index1
A Aid dependency, 8, 17, 38, 39, 47,

Actors/stakeholders, 1, 5–9, 13, 50, 108–116, 187, 190, 196,
16–18, 29–53, 61, 66, 67, 71, 228, 306, 349, 359, 361–363
74, 75, 86, 87, 90, 93, 96, Aid flexibility, 8, 41, 48, 90–93, 351,
102, 112, 115–117, 129, 130, 352, 362
133–135, 137, 138, 145, 148, Aid fragmentation, 4, 5, 47,
158, 161, 162, 164, 165, 168, 341, 360
169, 172, 187–194, 196–199, Aid provider/donor, 3–6, 10, 29, 30,
201, 203, 205–207, 211–213, 194, 293, 302, 306, 309, 353
215, 217, 219–224, 227, Aid recipient, 3–6, 9–11, 29, 43, 47,
229–234, 235n7, 238, 240, 52, 63, 68, 69, 75, 91, 194,
242, 243, 263, 267, 269, 273, 212, 234, 243, 306, 319,
281, 282, 293–310, 315, 316, 339–341, 349, 355, 358–363
318, 323, 331, 334, 336–342, Aid reductions, 3, 4
347–354, 357, 359, 361–364 Aid relationships, 3–8, 17, 29–53,
Advocacy, 101, 161, 231, 232, 278, 187–207, 293–311, 315, 316,
280, 282, 301, 332 331, 339, 347–354,
Agent-structure approach, 7, 32 357–361, 364
1
Note: Page numbers followed by ‘n’ refer to notes.

Policy, https://doi.org/10.1007/978-3-031-31990-7
372 Index
Aid volatility, 8, 17, 32, 38, 40, 47, Causal inferences, 9, 315, 338–341,
48, 349, 350 357, 364
Alma-Ata Declaration, 136, 155, Central Asia, 52, 64, 69, 98, 99, 110
192, 202, 204 Changing nature of power, 7, 30, 31,
Alternative perspective of power, 339, 348, 352
7, 30, 348 Civil society organizations (CSOs),
Antiretroviral therapy (ART), 4, 7, 8, 13, 15, 31, 32, 34,
256–258, 260, 261, 263, 264, 38–40, 47, 48, 50–52, 94,
268–272, 281, 333, 334, 97–99, 101, 108, 112, 114,
349, 356 115, 117, 130, 140, 141,
Association of Village Health 144, 169, 170, 173, 177,
Committees (AVHC), 94–96, 188–200, 211, 217, 218,
104, 140, 141, 147, 148, 157, 220, 221, 223, 224,
159–161, 166–169, 172, 173, 226–229, 232–234, 237,
175–179, 356 238, 241, 243, 255, 274,
Autonomy, 10, 90, 93, 116, 351 279, 280, 282, 293–302,
307, 316, 323, 326, 331,
332, 339–341, 348, 349,
B 352, 355, 357–360, 363
Bilateral donor, 10, 363 Coercion, 46, 306, 307, 309, 310
Bottom-up approach, 5, 6, 10, 11 Co-financing, 215–217, 307, 333
Building the capacity of a recipient Commercial sex workers (CSWs),
community, 62, 76 14n8, 15, 72, 73, 111, 114,
216, 221, 231, 232, 236, 241,
257, 259, 264, 265, 268, 278,
C 298, 299, 301
Capacity, 8, 17, 32, 36, 38, 40, Community Acton for Health
47–52, 62, 64n1, 71, 74–76, (CAH), 85–87, 89–92, 94,
85, 94–109, 111, 112, 116, 96, 97, 99, 102–104,
117, 139, 141, 143, 148, 160, 108–110, 112–114, 117,
161, 166, 167, 177, 178, 187, 129–131, 133–137, 139,
190, 196, 198–200, 202, 203, 142, 143, 145, 147, 148,
206, 219, 223–226, 229, 232, 154–156, 159, 160, 164,
236, 243, 255, 257, 266, 268, 165, 168, 169, 172,
277, 280–282, 293, 295, 296, 174–176, 178, 180,
298–300, 304, 306, 309, 310, 187–189, 191, 192,
316, 318–321, 324, 325, 329, 194–198, 200–207,
331–333, 337, 339, 340, 349, 317–321, 323, 325, 326,
354–357, 359, 362, 363 328–330, 339, 349–356, 361
Index 373
Community-based organizations Country Coordination Council for

(CBOs), 40, 52, 64, 87, 91, Public Health, 219
94, 96–104, 109, 112, 113, COVID-19, 3, 62, 168, 179, 181,
115, 117, 129, 130, 137, 268, 269, 271, 272, 275, 279,
140–143, 146, 148, 157, 281, 354, 356, 364
159, 160, 162–165, Cross-case analysis, 338, 359
167–171, 174–181,
188–199, 202, 203n1, 205,
206, 211, 257n3, 316–323, D
325–331, 350, 352, 353, Den Sooluk national healthcare
355, 356, 358, 363 reform program, 138, 164,
Comprehensive analytical 165, 196, 328, 329
framework, 5, 8, 360 Diagnosis, 14, 105, 257, 264,
Conditionality, 11, 50, 51, 341, 266, 273
362, 364 Directly Observed Treatment,
Consensus/conflict, 7, 32, 35, 43, Short-course (DOTS), 213,
44, 46, 146, 217, 218, 224, 256, 262, 274, 276
237, 242, 281, 297, 305, 309, Discipline, 45, 295–297,
310, 337, 348 306–309, 354
Continuity of project activities, 8, Discrimination, 72–74, 157, 158,
63, 66, 76, 153, 156–163, 162–164, 166, 216, 219, 220,
255, 258–272, 316, 319, 340, 232, 257, 260–262, 264, 265,
354, 358, 360 268, 273, 276, 277, 282, 298,
Conventional perspective on 340, 356, 359–361
power, 29 Discursive knowledge, 44, 45,
Cooperation, 6, 47–52, 73, 86, 90, 192, 197
109, 116, 140, 141, 197–207, Disease burden, 88
231, 277, 305–311, 316, Disease control, 2–4
327–334, 337, 340, Dissemination campaigns, 138, 139,
358–360, 362 156, 163, 168, 171–173,
Coordination, 5, 6, 47–50, 105, 180, 321
110, 207, 222, 233, 234, 241, Donor financing, 62, 70, 174, 223,
242, 302–305, 334–338, 341, 271, 277, 278, 280, 301, 302,
359, 360, 363 336, 353
Country Coordinating Drug-resistant tuberculosis
Mechanism (CCM), (MDR-TB, XDR-TB), 138,
215–218, 220–224, 227, 270, 349
229, 234, 235n7, 236, Dual-track financing, 214–216,
237, 295, 300, 307, 333 231, 295
374 Index
E German Development
Eastern Europe and Central Asia Bank/Kreditanstalt für
(EECA), 3, 4, 9, 14, 265 Wiederaufbau (KfW), 110,
Economic situation, 9, 66, 117, 111, 207, 211, 335, 363
340, 360 Global Fund/the Global Fund to
Empowerment approach, 47, 52, Fight AIDS, Tuberculosis and
188–195, 197–199, 299, Malaria, 2–4, 10–12, 12n4,
316–325, 329–331, 339, 352, 14, 16, 73, 75, 85–94,
353, 358, 359 99–101, 104–106, 108–112,
Engagement/participation, 5, 6, 8, 114–117, 130, 161, 207,
17, 42, 47, 50, 65–67, 87, 96, 211–243, 255–282, 293–311,
97, 99, 101, 109, 110, 112, 315, 331–338, 340, 341,
133, 134, 143, 145–147, 154, 349–356, 360–364
155, 157, 165, 167, 188–191, Grant(s), 1, 4, 10–12, 16, 52, 85,
193–198, 200–202, 204, 205, 88, 89, 92–94, 99, 100,
207, 213, 219–221, 223, 225, 104–106, 108, 110–112, 114,
235, 239, 257, 294–296, 117, 140, 142, 172, 175, 176,
298–300, 302, 316, 321, 333, 207, 211–243, 255–282,
337, 340, 352, 353, 355, 293–311, 315, 318, 331–338,
358, 361 340, 341, 349, 351–356, 361
Equal cooperation, 51, 52, 203–207
External factors, 66, 67, 70, 74, 93,
176, 180 H
Harmonization, 51, 201, 304,
305, 347
F Health aid, 1–5, 8–11, 14, 18, 33,
Financial assistance, 108, 112, 139, 61, 68, 111, 180, 181, 211,
178, 207, 220, 236 212, 231, 238, 239, 293, 295,
(Formal) commitment, 327, 358 296, 299, 315, 342, 358,
Fundraising, 65, 66, 69, 70, 115, 363, 364
147, 161, 173–176, 180, Health Promotion Units (HPU),
279, 332 102, 103, 109, 137, 143, 144,
146–148, 158, 160, 162,
164–167, 177, 179, 180, 189,
G 195–201, 203, 205–207,
Gavi – the Vaccine Alliance, 2, 109 318n2, 320, 326–330
Gender, 44, 73, 96, 97, 99, 117, Healthy Person–Prosperous Country
170, 190, 216, 350, 359, national healthcare program
361, 363 (2019-2030), 165, 177, 328
Index 375
Hierarchy, 6, 31, 32, 34, 47, 64, 73, Interests, 7, 10, 16, 32, 35–38, 46,
74, 190, 193, 200, 297, 299, 49, 61, 66, 74, 91, 133, 134,
302, 310, 348 139, 161, 167, 171, 176, 178,
HIV/AIDS, 2, 4, 11–16, 12n4, 14n6, 189, 199, 200, 203, 206, 207,
14n8, 70, 72–74, 85, 87–89, 218, 220, 222, 223, 228, 237,
92, 99–101, 104–107, 110–112, 243, 268, 281, 297, 298,
110n5, 114, 115, 117, 138, 139, 300–302, 305, 308, 310, 325,
156–159, 161–168, 177, 180, 328, 342, 348, 353, 354,
198, 211–222, 215n2, 225, 360, 363
227, 229, 231–233, 235n7, Internal factors, 67, 74, 176, 180
241–243, 256–261, 257n3, Internalization, 197–199, 308
259n4, 263–265, 267–272,
274–279, 281, 282, 296, 298,
301–303, 305, 309, 311, 319, J
320, 330, 334–338, 341, 349, Joint application, 214, 215, 307, 333
350, 355, 356, 359–363 Joint United Nations Programme on
Horizontal approach, 2 HIV/AIDS (UNAIDS), 68,
Human rights, 215–217, 231, 264, 74, 91, 106, 111, 112, 212,
278, 295, 307 213, 221, 222, 236, 259, 269,
Hygiene and food parcels, 273, 274, 277, 279, 303, 304, 335
276, 281 Jumgal model, 143–145, 154, 201,
202, 205, 207
I
Ideal types of aid K
relationships, 8, 352 Kyrgyzstan/Kyrgyz Republic, 10,
Incentives, 30, 35, 37, 40, 48, 51, 12–16, 39, 62, 66, 71, 85–88,
101, 107, 113, 114, 116, 190, 90, 92, 95, 97, 99, 101,
199, 200, 229, 273, 274, 276, 102n1, 103n3, 105, 106,
281, 297, 336, 348 110–112, 114, 129, 133, 137,
Inequality, 8, 29–32, 38, 46–48, 52, 138, 144, 153, 155, 156, 161,
65, 155, 170, 201, 204, 325, 165, 171n5, 175, 179, 187,
340, 347, 348, 353 207, 211–228, 214n1, 215n2,
Infectious diseases, 2, 4, 160, 223 220n3, 230, 231, 234, 235n7,
Institutionalization, 60, 116, 327, 236, 238–243, 255–257,
329, 330, 332, 358 259–261, 263, 266, 268, 269,
Integration into local context, 76 272–274, 277, 278, 281, 293,
Interdependence, 7, 30, 31, 46, 348, 299, 303, 304, 315, 331–338,
352, 364 341, 351, 360–364
376 Index
L Mechanism of institutionalization,
Layers of generalization, 360 329, 330, 332, 358
Leadership, 5, 8, 38, 65, 66, 75, 145, Mechanism of learning, 324,
146, 169, 170, 173, 178, 180, 330, 358
196, 220, 255, 277–280, 282, Mechanism of ownership, 330, 358
317, 318, 339, 340, 352, 355, Mechanism of
356, 359, 360 professionalization, 358
Local authorities, 97, 104, 112, Mechanism of recognition, 358
140, 141, 147, 166, 170, Mechanism of replacement, 338, 359
173, 177, 178, 190, 197, Mechanism of uniformity, 359
199, 200, 264, 318, 321, Men who have sex with men
326, 327, 331, 358 (MSM), 14n8, 15, 64,
(Local) context, 6, 9, 71–73, 75, 76 72–74, 111, 216, 221,
Local councils, 129, 178, 179, 194 232, 257, 258, 268, 278,
(Local) expertise, 192 298, 299, 301
Local Fund Agent (LFA), 212, 216, Mid-range approach, 9
235–237, 235n7, 236n8, 239, Migration, 15, 91, 97, 107, 117,
240, 242, 297 139, 350, 359, 363
Local self-government (LSG), 95, Ministry of Health (MoH), 96, 102,
103, 104, 112, 140, 141, 157, 102n1, 105, 109, 110, 112,
158, 162, 167, 171, 172, 129, 131, 133, 135, 137,
176–178, 195, 197, 199, 200, 143–145, 162, 164, 177, 178,
203n1, 276, 282, 318, 321, 195, 198–203, 206, 207, 211,
322, 326, 327, 331 219, 226, 228, 229, 232–235,
237–240, 264, 266, 268,
298–301, 304–306, 308–310,
M 326–333, 337
Maintenance of benefits, 8, 63, Missing link, 18, 315–342,
66, 153, 163, 164, 167, 347, 357–361
177, 179, 180, 255, 281, Misuse/mismanagement of funds,
282, 324, 326, 327, 225, 226
329–331, 354, 356, 357 Mobilization of resources, 65, 66,
Manas national healthcare reform 142, 169, 173, 279, 333, 339,
program, 108, 131–133, 138 355, 356
Manas taalimi national healthcare Monitoring and evaluation (M&E),
reform, 108, 138, 154, 328 214n1, 239, 240, 243, 303,
Mandatory Health Insurance Fund 307, 332
(MHIF), 96, 264 Multilateral donor, 11, 41
Index 377
N Ownership, 5, 5n3, 11, 43, 50, 93,

National Center for Phthisiology 116, 176, 201, 202, 207, 227,
(NCPh), 105 228, 239, 304, 306, 307, 316,
National government, 5, 16, 104, 317, 319, 320, 330, 347, 357,
222, 276 358, 361
Needle and syringe exchange Own initiatives, 169, 172,
program (NSP), 258–260, 173, 317–319
259n4, 263, 272
Noncoordination, 47, 48
Nondomination, 193 P
(Non-)duplication, 305, 335 Paris Agenda, 50, 304–307, 347
Non-governmental organizations Partnerships, 2, 6, 41, 47, 51, 52,
(NGOs), 40, 52, 64, 75, 87, 87, 90, 134, 141, 155, 204
94, 99–101, 105, 112, 114, Participation, 5, 6, 8, 17, 42, 50,
115, 117, 132, 139, 162, 211, 65–67, 96, 97, 101, 109,
215n2, 220–222, 224, 133, 145, 146, 155, 157,
226–235, 237–239, 241–243, 188–191, 193–197, 200,
257–259, 259n4, 262, 274, 202, 204, 205, 213, 220,
275, 277–280, 282, 293–302, 221, 223, 235, 257,
304, 307, 331–334, 336–338, 294–296, 298–300, 321,
340, 350, 353, 355, 356, 333, 337, 340, 352, 353,
358, 363 355, 358
Norm-setter, 112, 303 Participatory Reflection and Action
(PRA), 132–137, 144, 158,
166, 188, 189, 192
O Peer pressure, 305
Oblast/region, 12, 138, 154, 174 Persons who inject drugs (PWID),
Official development assistance 14, 14n8, 15, 72, 73, 111,
(ODA), 1–3, 2n1, 14, 86, 91 215n2, 216, 221, 232,
Opioid substitution therapy (OST), 257–260, 268, 278
258, 260, 263, 272, 281 Persons who live with HIV
Optimization reforms, 130–131, (PLHIV), 158, 162, 164, 261,
204, 266, 356 264, 274, 275, 279
Organizational factors, 9, 153, 355 Political situation, 51, 67, 70, 104,
Organizational structure, 41, 86, 90, 108, 112, 179, 189, 337, 339,
93, 146, 222, 295 349, 355, 359
Ottawa Charter for Health Post-Soviet, 10, 17, 71, 138, 234,
Promotion, 155, 204 260, 301, 364
378 Index
Power, 6–8, 10, 11, 29–53, 61, 64, Procurement, 69, 114, 214n1, 224,
73, 187–207, 221, 235, 225, 228, 236, 265, 266,
293–311, 316, 331, 339, 340, 268–270, 272, 303, 332, 356
348, 351–354, 357, 362, 363 Project, 6, 8–12, 12n4, 15–18,
Power over, 33, 42, 46, 47, 193, 194, 16n10, 31, 32, 41, 42, 45, 47,
196–199, 201–203, 205, 206, 50, 52, 62, 63, 65–72, 74–76,
295–297, 300, 303, 306–310, 85–94, 96, 98, 102–104,
348, 353 108–110, 112, 113, 115, 116,
Power to, 33, 42, 46, 47, 191, 193, 129–132, 134–137, 139,
194, 196, 197, 199, 201–203, 141–146, 148, 153–181,
205, 206, 295, 297, 303, 304, 187–207, 211–213, 222, 224,
306, 310, 348, 353 227, 230, 231, 233, 236,
Power with, 34 238–243, 255, 257n3,
Predictability, 41–45, 47, 50, 51, 258–272, 277, 279–281, 294,
85–89, 92, 116, 187, 190, 298, 299, 305–310, 315–341,
196, 203, 206, 293, 295–297, 347, 351, 352, 354–364
306–308, 336, 339, 350, 352, design, 138, 189
353, 359 evaluation, 145–148
President’s Emergency Plan for AIDS implementation, 63, 70, 71,
Relief (PEPFAR), 110, 233, 137–145, 193, 205, 229, 231,
264, 336 235, 295
Prevention, 2, 3, 14, 70, 71, 73, 92, initiation, 189
96, 102, 106, 108–111, 155, monitoring, 235
158, 161–163, 168, 196, phases, 42, 47, 315
199, 200, 204, 212, 215n2, Project life cycle, 8, 11, 42, 47,
216, 229, 231, 232, 129–148, 190, 201, 203,
256–258, 260–265, 268, 211–243, 299, 300, 302,
270, 272, 274, 276, 278, 305–307, 333, 334, 352, 353
306, 320, 321, 330, 335, Public health, 70, 74, 108, 109, 165,
350, 362 166, 204, 219, 267, 347, 360
Primary health care (PHC), 71, 102,
106–110, 129, 131, 135–137,
140, 142, 144, 158, 165, 194, R
198, 199, 203, 204, 206, 256, Rationality, 36, 37
261, 262, 266, 267, 276, 279, Rayon Health Committees (RHCs),
328, 364 12, 94–96, 98, 103, 112, 130,
Principal Recipient (PR), 224, 225, 146–148, 154, 158, 160–162,
227–231, 235–237, 235n7, 167, 169, 172, 173, 175–177,
240, 309, 310 179, 180, 323
Index 379
Recipient state, 7–8, 32, 34, 38, 39, S

48, 50–52, 75, 110, 112, 115, Sanctions, 29, 35, 296, 305, 310
129, 133–135, 143, 195–207, Scope conditions, 342, 360, 361
211, 228, 233–235, 255, 293, Sector-specific approach to aid
298–303, 305–311, 316, dependency, 349
326–328, 333, 334, 338, 340, Sector-Wide Approach (SWAp), 5,
348, 349, 351, 352, 358, 363 10, 110n5, 133, 144, 203,
Recommendation, 35, 61, 111, 197, 207, 219, 220, 237, 300, 327,
206, 213–216, 223, 224, 226, 328, 335, 363
296, 303, 304, 306–308, 310 Self-reflection, 193
Regulation, 1, 11, 35, 41, 49, 93, Semashko healthcare system, 13, 71,
98, 112, 147, 165, 206, 216, 109, 130, 134, 189, 199, 301
217, 223, 224, 230, 297, 300, Seven ways of creating power, 8, 32,
301, 303, 306–308, 310, 42, 46, 352
340, 341 Social consciousness, 44, 191, 196
Reification, 45, 201–203, 205, 303 Social contracting, 65, 265, 279,
Reimbursement of travel expenses, 280, 299, 302, 333, 338,
273, 274, 276, 281, 282 340, 356
Reporting, 95, 147, 173, 198, 229, Social entrepreneurship,
238, 241, 242, 264, 297, 332 175–177, 180
Republican AIDS Center, 105, 107, Social mechanism, 9, 316
211, 225–227, 298, 305, 306 Social order, 42, 43, 45, 201–205,
Republican Center for Health 207, 295, 296, 299, 300,
Promotion and Mass 304–308, 354
Communication, 96, 102, Source of power, 29, 45, 46, 309
109, 177 State support, 162, 163, 174, 177,
Resource mobilization, 8, 65, 66, 178, 180, 196, 258, 277
112, 139, 146, 174, 175, 177, Stigma, 72–74, 162, 164, 166, 216,
277, 339, 356 232, 257, 261, 264, 265, 268,
Resources, 4, 7, 30–32, 35, 38–40, 273, 276, 277, 282, 298,
46, 48, 52, 64–66, 64n1, 69, 340, 359–361
70, 75, 100, 101, 112, 114, Structural bias, 43, 295, 296, 306,
142, 162, 165, 169, 171, 173, 307, 310, 353
175, 177, 180, 193, 207, 217, Structure, 1, 7, 8, 16–18, 29–53, 71,
221, 233, 241, 255, 266, 267, 75, 86, 90, 93, 116, 129, 146,
271, 275, 277–280, 298, 299, 192, 222, 223, 295–297, 304,
302, 305, 310, 317–319, 328, 306, 329, 348, 349, 359, 361
332, 333, 339, 340, 348, 349, Sub-Recipient (SRs), 105, 224, 226,
353–356, 359, 364 230, 235–237, 242, 297, 298
380 Index
Survival of civil society organizations 109, 111, 115, 139,

(CSOs), 169, 282 141–144, 146, 163–168,
Sustainability of aid, 9, 363 174, 177, 179, 180, 190,
Swedish International Development 193, 194, 196–198, 200,
Cooperation Agency (Sida), 206, 216, 222, 226, 229,
130, 135, 144, 145, 154, 240, 256, 257, 261, 262,
200–203, 328, 329, 331 270, 273, 275, 278, 305,
Swiss Agency for Development and 318, 320, 321, 324–326,
Cooperation (SDC), 10, 85, 328–330, 356, 358, 361
86, 130–134, 144, 155, 160, Transition, 3n2, 69, 130, 134, 205,
161, 166, 174, 195, 203n1, 206, 230, 233, 255, 263, 266,
207, 220, 319, 339, 350, 351, 269, 272, 275, 280, 282, 301,
355, 360–362, 364 334–336, 341
Swiss Red Cross (SRC), 87, 103, Treatment, 2, 3, 13, 14, 39, 68, 69,
109, 113, 114, 130–136, 71, 74, 92, 94, 100, 101,
138, 139, 141–145, 148, 105, 108, 109, 111, 112,
164, 168, 175, 188, 189, 114, 138, 139, 155, 157,
191–198, 200–203, 203n1, 161, 163, 166, 168, 196,
205–207, 318–320, 322, 204, 213, 214, 215n2, 224,
326, 327, 329–331, 339, 229, 231, 232, 237, 239,
351, 353 242, 256–258, 260–276,
278, 281, 282, 303, 306,
332–336, 338, 341, 349,
T 356, 361, 362
Tacit/practical knowledge, 44, 45, Tuberculosis (TB), 2, 4, 11–16,
191–194, 196–199, 205, 206, 12n4, 68, 69, 73, 85, 87–89,
297, 308, 353 92, 99–101, 104–107,
Technical assistance, 10, 39, 96, 110–112, 114, 115, 117,
110–112, 115, 117, 213, 221, 137–139, 156–159, 161–168,
222, 306, 307, 310, 349, 353, 177, 179, 180, 198, 211–222,
362, 363 225–227, 232, 235n7, 242,
Testing, 13, 14, 105, 215n2, 231, 243, 255–258, 257n3,
257, 258, 259n4, 260, 271, 261–263, 265–279, 281, 282,
272, 281 293, 296, 298, 301–303, 305,
Top-down approach, 5 309, 311, 319, 320, 330,
Training, 40, 45, 64, 66, 70, 93, 333–338, 341, 349, 355,
96, 98, 100–103, 106, 108, 356, 359–364
Index 381
U V
Unequal cooperation, 47, 49, 50, 52, Vertical approach, 2
200–203, 305–311, 316, 327, Village Health Committees
329–334, 337, 340, 358–360 (VHCs), 94–98, 102–104,
United Nations Children’s Fund 112, 113, 130, 136–144,
(UNICEF), 109, 130 146–148, 156–180,
United Nations Development 188–191, 193–200, 202,
Programme (UNDP), 13, 100, 204, 205, 256, 316–331,
106, 108, 110n5, 114, 115, 318n2, 339, 350
138, 204, 212, 213, 215n2, Visibility, 35, 70, 240–243, 304
216, 225, 227–230, 234–237, Vulnerable groups, 132, 161, 172,
257–261, 270, 271, 273–275, 175, 232, 257, 258, 263–265,
279, 309, 310, 335 268, 275, 278, 279, 298,
United Nations Millennium 308, 354
Development Goals
(MDGs), 2
United Nations Sustainable W
Development Goals (SDGs), Willingness, 49, 97, 103, 113–115,
2, 3, 59 167, 176, 190, 192, 194, 229,
United States Agency for 280, 309
International Development Within-case analysis, 315, 338
(USAID), 96, 106, 109–111, World Bank, 15, 96, 109–111, 130,
115, 130, 135, 137, 144, 145, 160, 161, 166, 174, 207, 225,
154, 160–162, 166, 167, 174, 271, 335, 362, 363
200–203, 211, 221, 222, 229, World Health Organization (WHO),
233, 236, 240, 277, 328, 329, 2, 3, 13, 14, 16, 51, 66, 106,
331, 336 108, 111, 112, 130, 136, 138,
Utilitarian approach, 47, 50, 154n2, 155, 189, 204,
195–200, 294–302, 316, 211–213, 219, 221, 222, 240,
326–327, 329, 331–332, 337, 242, 258, 266, 271, 303, 335,
339, 340, 353, 354, 358, 360 339, 362

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GLOBAL DYNAMICS OF SOCIAL POLICY

Delia González de Reufels

Marianne Sandvad Ulriksen

ISSN 2661-8672 ISSN 2661-8680 (electronic)

Paper in this product is recyclable.

This book came into being as an outcome of my multisectoral work expe-

Bremen, Germany Gulnaz Isabekova

This book is a product of the research conducted in the Collaborative

the perspectives understudied in the academic literature to this point. I

Last but not least, I want to express my gratitude to my fiancé, Dario

“Through extensive and careful empirical research Gulnaz Isabekova is able to

3.3 Factors Influencing the Sustainability of Health Care

7.4 Donor–Recipient State: (Contingent) Equal

11 “ Missing Link”315

AFEW Kyrgyzstan Public Foundation “AIDS

FMC Family Medicine Center

OST Opioid Substitution Therapy

Diagram 6.1 Chronology of the project (Source: Adapted from

Diagram 11.10 Donor–recipient state: the impact of unequal

Table 2.1 Structures and their relevance to agents 38

Health aid, as it is known today, is a relatively new phenomenon. Before

© The Author(s) 2024 1

education, and political freedoms (Schafer et al., 2012). Following this

Office and Dag Hammarskjöld Foundation, n.d.). Over the decades,

1.1 Sustainability and Relationships in Aid:

with reemerging infectious diseases. A 2017 Open Society Foundation

coordination among the humanitarian organizations themselves was

defining the objectives and means of development assistance (Kaiser,

theoretical underpinnings (Proctor et al., 2015). This situation contrib-

1.2 Research Aims of This Book

development assistance provision. (3) Based on a comprehensive review

1.3 Case Selection

1.4 Contextual Information on Kyrgyzstan

of democracy” because of its initial democratic aspirations (Anderson,

number of persons who injected drugs (PWID) increased by 25% annu-

(Maytiyeva et al., 2015). Fifty-one percent of HIV incidence in Kyrgyzstan

1.5 Data Collection

collaborated with a research assistant to contact and follow up with the

provided the researcher’s contact details to ask further questions or to

1.6 Book Structure

the “missing link” or how stakeholder relationships affect the sustainabil-

Government of KR. (2017). Programma Pravitel′stva Kyrgyzskoj Respubliki po

Lamothe, H. D. (2010). Re-conceptualizing the international aid structure:

OECD. (2012). The Busan partnership for effective development cooperation.

Usenov, A. (2022). Religious politics in Kyrgyzstan: Analysis of achievements and

The analysis of relationships between providers and recipients of aid

© The Author(s) 2024 29

Furthermore, aid relationships between donors and recipients are char-

1. Inspired by scholars in political theory, the first step commences with

2.1 Conceptualization of Power

altering these relations. This difference was introduced by Pitkin (1972)

In addition to this conceptualization of power, the analytical approach

Third, closely associated with power, interests are also essential to

In addition to rationality, interests relate to actors’ perceptions of what

2.2 Conceptualizing Agents and Structures

concerns, namely, “collective” agency is “easier to comprehend” than that

Table 2.1 Structures and their relevance to agents

First, aid dependency is critical to understanding the actors receiving

that a more specific sector or subsectoral focus provides a better under-

general acknowledgment of the need for increased aid predictability (e.g.,

Bremen, Germany Gulnaz Isabekova

3.3 Factors Influencing the Sustainability of Health Care

7.4 Donor–Recipient State: (Contingent) Equal

11 “ Missing Link”315

Diagram 6.1 Chronology of the project (Source: Adapted from

Diagram 11.10 Donor–recipient state: the impact of unequal

Table 2.1 Structures and their relevance to agents 38

1.1 Sustainability and Relationships in Aid:

1.2 Research Aims of This Book

1.3 Case Selection

1.4 Contextual Information on Kyrgyzstan

1.5 Data Collection

1.6 Book Structure

2.1 Conceptualization of Power

2.2 Conceptualizing Agents and Structures

2.3 Project Life Cycle

2.4 Uniting Theory and Empirical Findings

3.1 Operationalizing Sustainability

3.2 Conceptual Definition

3.3 Factors Influencing the Sustainability

4.1 Aid Predictability

4.2 Aid Flexibility

4.4 Aid Dependency