Keywords

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 organizations” (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 abovementioned 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).

Table 10.1 Relationships between stakeholders involved in the Global Fund grants to the Kyrgyz Republic
Full size table

10.1 Donor–CSOs: “Utilitarian” Approach

I define the relationships between the Global Fund and NGOs as evincing 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 empowerment are at the cornerstone of the Global Fund’s mission, and this emphasis also found its reflection in the grant design and implementation 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 relations 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 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’ priorities, among other things by ensuring the broader engagement of stakeholders 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 provided 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 demonstrates 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 organizational 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 participation (social order) provided a window of opportunity (empowerment) 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 implementation process through its “dual-track” financing or channeling of funds via 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 proposal due to the noncompliance of the Country Coordinating Mechanism Country with the “minimum requirements” of civil society representation. 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 represented 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 recommendations 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 considerably hinders responsiveness to the changing environment in which health aid is implemented. The “power over” created through predictability here was the outcome of a social order in which actors built structures 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 participate in the monitoring process but rather report to the primary recipient, 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 communicates during her visits to the country. Though affected by the financier’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 complying 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 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 discrimination in society. The expertise and context-awareness (Pape, 2014) make local NGOs essential to the provision of health services and health promotion 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 necessarily 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 interrelated 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 nongovernmental organizations.

Similarly, stakeholder participation in grants did not favor hierarchy among stakeholders. Both actors equally participated in the grant realization 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 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 contended 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 comply 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 process, hints at the state organizations’ unwillingness to accept the social order promoted by the Global Fund. This unwillingness also relates to the government’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, particularly the Ministry of Health, advocate for the central role of the government 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 systemic 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 regulation and provision of health care services. Both interpretations correspond 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 statements 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 relationships? 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 continued 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).

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 representative 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 introduction 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 development organizations working in tuberculosis and HIV/AIDS in the realization of the Global Fund grants. The engagement seems to work well, particularly in the design and implementation phases. However, the relationships 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 organizations 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 procurement 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 framework, 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 counterpart, its regulations are equally followed in HIV/AIDS.

Why do other stakeholders adhere to the WHO and UNAIDS regulations 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 and UNAIDS guidelines and recommendations, organizations, in a way, comply with the scientific evidence.

The “power to” among donors manifests itself through their coordination 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, harmonization, 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 applications 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 reproduction of meaning are at the core of the social order (Haugaard, 2003, pp. 90–93).

However, during the grant monitoring process, the donor coordination cracks due to each donor’s visibility concerns. The duplication problems 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 number of patients treated, health products distributed, and training sessions organized. This health impact of the Global Fund is essential to its continued funding by donor countries (see Chap. 4). Other donor organizations have similar concerns.

Despite the consensus over the harmonization principles, there is conflict regarding its implementation. Both consensus and conflict are integral 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 project 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 relatively 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 qualifies 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 project 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 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 projects 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 provides 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 flexibility, aid dependency, and capacity issues of government institutions, contributed 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 dynamics 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 support 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 assistance 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 justification 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), structural 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 feedback from a financier (see Chap. 8). Both recommendations and regulations 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 disabling as they supported the role of CSOs in health, both in 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 politicians’ 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 country’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 predictability and foreseen achievement of stated goals.

Nonetheless, the grant implementation and monitoring phases demonstrated 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 misappropriation 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 organizational interests, highlighting the relevance of individual and organizational perspectives on actors.

Further non-reimbursement of missing finances demonstrated a similar 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 having 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 discipline. 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 stakeholders. 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 organizations 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 systems 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 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 “particular interpretative horizons” (Haugaard, 2003, pp. 107–108). Thus, the interpretation of capacity and fulfillment of criteria as necessary preconditions 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 organizations 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 international organizations. For this reason, “willingly or not,” the government 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.