Introduction

Abstract

This chapter briefly introduces the evolution of health aid, its forms, and its objectives. In consonance with the prevailing emphasis on combatting diseases in health aid, also known as the “vertical” approach, it focuses on assistance targeting tuberculosis and HIV/AIDS. The chapter problematizes the achievement of the global objectives for these diseases and the sustainability of both ongoing and completed disease control activities. It argues that, though vivid in geographic areas affected by health aid reductions, these problems are not limited to these areas only due to aid fragmentation and the issues associated with the roles of aid providers and recipients in the decision-making process. Building on the long-standing academic discussion, this chapter introduces the objective of this book: to explore the link between the sustainability of aid and relationships among stakeholders involved. It further expands on case selection by introducing the selected health care projects and providing contextual information on the Kyrgyz Republic, the country in which these projects have been implemented. The chapter concludes with brief information on the data collection process and the structure of this book.

Health aid, as it is known today, is a relatively new phenomenon. Before the twentieth century, health assistance was limited mainly to missionaries, who targeted specific geographic areas (Fleßa, 2014). Official development 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 purposes 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 providers (Knox, 2020, p. 11), each having a specific structure and regulations 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 practitioners in the late 1960s, this multidimensional approach to development stressed the various aspects of human welfare, including health, 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 combatting 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 services (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 development 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 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 necessarily 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 implications 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 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 similar 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 transitioning 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 external assistance (ibid.).

In addition to reductions in health aid, the sustainability of the outcomes 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 repercussions, such as an increased burden on aid recipients and the duplication 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 threefold vaccination by three different organizations (Carbajosa, 2005).

The involvement of aid recipients is equally important to the sustainability of disease control efforts. In the measles case described above, 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 relationships between actors and sustainability in the context of health development 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 initiatives 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 process 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 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 stakeholders’ commitment to these reforms (ibid.). Following this logic, aid providers 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, compatibility, 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 relationships (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 theoretical underpinnings (Proctor et al., 2015). This situation contributes 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 literature 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 analyzing 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 provide an exhaustive basis for this examination. (1) The discussion of power and its associated terms (resources, consensus/conflict, and interests) provides 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 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 theorization 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 framework 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 reason, 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) definition 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 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 organizational 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 sustainability. 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 literature 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 stakeholders matters to the sustainability of aid. In doing so, it seeks to theorize 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 relevant factors. This mid-range approach extends beyond the alleged universal 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.

1.3 Case Selection

Empirically, this book focuses on projects pursuing the bottom-up approach in the developing country context as most favorable for changing 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 environment 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 applicable 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, budget management, and other areas, which provides them with the flexibility 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 importance 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 comply 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 regulations 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 without donor conditionalities. This difference offers another layer of complexity 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 recipients of health aid form throughout the project life cycle (i.e., its initiation, 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 comparability of projects, this book focuses on the TB and HIV/AIDS 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 combatting 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 domestic 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 population 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 of democracy” because of its initial democratic aspirations (Anderson, 1999). During the three revolutions in 2005, 2010, and 2020, the political system underwent multiple changes, from presidential to parliamentary 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 elsewhere in the former Soviet Union) and concerns with the growing censorship 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 inherited 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 services (see Isabekova, 2019a). The country has also retained vertical provision 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), impoverishing 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 dissolution 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 number of persons who injected drugs (PWID) increased by 25% annually 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 magnitude of the problem (International Charitable Organization “East Europe and Central Asia Union of People Living with HIV,” n.d.). Due to limited 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 resistance 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 transmission 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 (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 concentrated 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 problem (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 estimated that the sexual partners of eight out of twelve HIV-positive pregnant 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 collaborated with a research assistant to contact and follow up with the interviewees. A large proportion of the interview transcription was outsourced 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 categorization 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, analysis 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 problems of coverage and bias (see Rohlfing, 2012). The use of interviews as primary sources presents a limited picture of sustainability and interactions that is based on interviewees’ experiences and perspectives. The secondary 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 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 information they provided. All interviewees included in this study expressed their consent to participate in the research by signing the “Interview consent 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 sustainability advanced in this book. Chapter 4 demonstrates the application 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 further discuss the aid relationships formed in these projects by linking the empirical findings to the theoretical underpinnings. Chapter 11 discusses the “missing link” or how stakeholder relationships affect the sustainability of health aid. Finally, the conclusion summarizes the major findings by discussing their implications for the broader academic literature and health projects.