Keywords

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 followed 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 limitations 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 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 organizations [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 sustainability 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):

Diagram 11.1
An illustration of the donor's empowerment approach on sustainability has 2 elements. 1. Mechanism of Ownership. V H Cs develop the sense of ownership over their activities. 2. Community capacity building through the survival and leadership of the V H Cs.

The impact of the donor’s “empowerment” approach on sustainability

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The “empowerment” approach had a considerable impact on community capacity building, by contributing to the continued survival of community-based organizations beyond the end of the “Community Action for Health” project (CAH). It did so by contributing to their leadership 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 programs emphasizes the involvement of volunteers as being vital to program 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)Footnote 1 as a result of this event (CSO 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.Footnote 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 “leaving the health care” (IO Partner 5), since the scope of their activities was very broad. Following the SRC’s suggestion, the VHCs adopted a mission statement, which described the organizational goals and their focus on health care.Footnote 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 organizational 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 initiatives 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 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 activities 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 programs 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 identified 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 ownership 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] ourselves, to preserve our health, to maintain the health of our village, [these] were the reasons for us to learn all that. (CSO 2)

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 activities. 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 training 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).

Diagram 11.2
An illustration of the donor's empowerment approach on sustainability has 2 elements. 1. Mechanism of Ownership. V H Cs develop the sense of ownership over their activities. 2. Sustainability through the continuity of project activities.

The impact of the donor’s “empowerment” approach on sustainability

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Furthermore, the “empowerment” approach contributed to community 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 provided 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 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 extensively 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 dissemination campaigns, members of community-based organizations visited 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 information. (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 eventually contributed to the acknowledgement of the VHCs by local authorities 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 support the villagers in their claims to the local self-governments by helping them write petitions for example, but also assist the authorities with outreach in their community by mobilizing the villagers to meet the authorities. The VHCs are also the first point of contact for donors who are willing to work with communities. The local authorities refer any development partners looking for local initiative groups to the VHCs, emphasizing the fact that there is no need to establish any new groups, when the VHCs already exist (ibid.) (Diagram 11.3).

Diagram 11.3
An illustration of the donor's empowerment approach on sustainability has 2 elements. 1. Mechanism of learning. V H Cs develop their expertise. 2. Community capacity building through the survival of V H Cs.

The impact of the donor’s “empowerment” approach on sustainability

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Secondly, by implementing and evaluating the project-related activities, the VHCs started planning their activities and their connection to other organizations. The community-based organizations had the freedom 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 improvement, 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 activities, the VHCs planned their activities and their links to other institutions, which is essential for the survival of the community-based organizations. The VHCs collaborate with multiple local actors, including 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 continuation 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).

Diagram 11.4
An illustration of the donor's empowerment approach on sustainability has 2 elements. 1. Mechanism of learning. V H Cs develop their planning. 2. Community capacity building through the survival of the V H Cs.

The impact of the donor’s “empowerment” approach on sustainability

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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 meetings 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 competition 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 gathering themselves, even if it was at their own expense (CSO 7). Although the frequency of the VHC meetings has decreased, nevertheless, 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).

Diagram 11.5
An illustration of the donor's empowerment approach on sustainability has 2 elements. 1. Mechanism of learning. V H Cs continued training each other. 2. Community capacity building through the survival of the V H Cs.

The impact of the donor’s “empowerment” approach on sustainability

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In addition to community capacity building, the mechanism of learning, 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 information provided by the VHCs. In addition to evaluating their own organizations, 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 organizations 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 documentation in one of the VHCs, the organizations offering the “nomadic seminars” 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 organizations 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 development project she was working on (CSO 7). Related to this, the abovementioned 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 organizations for each other evolved during and beyond the CAH and contributed 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.

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 contributed to the maintenance of benefits. However, the Ministry established 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 referring any donor organizations that approach them on to the VHCs. Furthermore, the local authorities involve the community-based organizations 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 contributed to the continued survival of community-based organizations beyond the end of the CAH.

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 different 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).

Diagram 11.6
An illustration of the local self-governments' utilitarian approach has 2 elements. 1. Mechanism of recognition. The local authorities provide administrative support to the V H Cs. 2. Community capacity building through the survival of the V H Cs.

The impact of the local self-governments’ “utilitarian” approach on sustainability

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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 sustainability of the Community Action for Health project, namely, by contributing to the maintenance of benefits through the mechanism of “institutionalization.” In the literature on development, the term “institutionalization” is frequently used interchangeably with the term “sustainability” (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).

Diagram 11.7
A diagram of the impact of equal cooperation on sustainability. The cooperation between donor and recipient state leads to mechanism of institutionalization, the Ministry of Health provides the H P Us and includes the C A H project in the SWAp, which leads to sustainability via maintenance of benefits.

The impact of (contingent) equal cooperation on sustainability

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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 program: “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 however, 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 reason, the mechanism of institutionalization triggered by the donor-driven cooperation was the key to continuous training of the VHCs and maintenance 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 provides 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 necessarily 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 sustainability to the same extent as did the “empowerment” approach’. However, the presence of the “lead” donor would nevertheless ensure the expansion of community-based organizations according to the approach pursued by the lead donor, as other donors would comply with its approach (Diagram 11.8).

Diagram 11.8
An illustration of the impact of unequal cooperation between donors on sustainability has 2 elements. 1. Mechanism of uniformity. US AID and Sida contributed to the countryside expansion of the V H Cs. 2. Community capacity building via the survival of the V H Cs.

The impact of the unequal cooperation between donors on sustainability

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To summarize, in the case of “Community Action for Health,” the missing link unfolded in the following way:

  1. 1.

    The “empowerment” approach between the SRC and the VHCs influenced 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 organizations 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 presence and quality of information on disease prevention and health promotion provided by the VHCs.

  2. 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 prioritized in the national health care program, which contributes to the quality of the relevant information provided by the VHCs.

  3. 3.

    The “utilitarian” approach of the Ministry of Health and the local self-governments toward the VHCs had different impacts on sustainability. The interaction of the Ministry with the community-based organizations affected the maintenance of benefits only in combination with the interaction between the Ministry and the SRC. The “utilitarian” approach of the local self-governments, however, contributed 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. 4.

    The unequal cooperation between the SRC, USAID, and Sida contributed to the ongoing survival of the community-based organizations through the process of uniformity. In combination with the “empowerment” approach of the SRC toward the community members, 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 organizations [CSOs]; recipient state-CSOs), unequal cooperation (donor–recipient 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 resources. According to the NGO representatives interviewed for this research, civil society needs to continuously increase its capacity and expertise 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 comply with the Global Fund’s standards and requirements for project management, accounting, monitoring and evaluation (M&E), and reporting, facilitating the introduction of new positions and the recruitment of additional 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 contributed 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.

Diagram 11.9
An illustration has 2 elements. 1. Mechanism of professionalization. Local N G Os gain skills and knowledge relevant to their organizational capacity and offered services. 2, Sustainability via community capacity building and sub-recipient N G Os' survival.

The impact of the donor’s “utilitarian” approach toward CSOs on sustainability

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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 mechanism 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):

Diagram 11.10
An illustration of the impact of unequal cooperation on sustainability has 2 elements. 1. Mechanism of institutionalization. Increased financing for T B and H I V slash AIDS treatment by the recipient state. 2. Sustainability through the continuity of treatment.

Donor–recipient state: the impact of unequal cooperation on sustainability

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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 implementation 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 working on TB and HIV/AIDS beyond the duration of the Global Fund project (Diagram 11.11).

Diagram 11.11
An illustration of the impact of unequal cooperation on sustainability has 2 elements. 1. Mechanism of institutionalization. Recipient state introduced social contracting for N G Os. 2. Sustainability through community capacity building and resource mobilization.

Donor–recipient state: the impact of unequal cooperation on sustainability

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Overall, the interaction that developed between the actors involved in the Global Fund project in Kyrgyzstan had various impacts on sustainability and its components. As the interaction between the recipient state and the local NGOs was the result of the Global Fund’s condition, I suggest 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 countries 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 deficit, 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 extensive 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),Footnote 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 discontinued 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 nonduplication of efforts, rather than donor “fatigue.” A state representative interviewed 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 “replacement,” which contributes to the continuity of TB and HIV/AIDS activities after the country’s transition from Global Fund grants. Currently, no international organization, except for the MSF, who made an oral commitment, 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 to support the government in its fight against the two diseases; instead, it points to their inability to make long-term commitments. Aid predictability 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 interviewees, 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 limited 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 medications in 2005 (Government of KR, 2001). However, with the commencement 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 central 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 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).

Diagram 11.12
An illustration of the impact of coordination among donors on sustainability has 2 elements. 1. Mechanism of replacement. Donors complement each other by filling in the gaps. 2. Sustainability via continuity of project activities, benefits maintenance, and community capacity building.

The impact of coordination among donors on sustainability

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To summarize, in the case of the Global Fund grants to Kyrgyzstan, the missing link unfolded in the following way:

  1. 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. 2.

    The “utilitarian” approach of the Ministry of Health and its agencies on TB and HIV/AIDS toward local NGOs did not affect the sustainability 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. 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 Fund’s requirements, the recipient state gradually took over the treatment 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. 4.

    The coordination between the Global Fund and other donors contributed 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 generalization,” I conduct a cross-case analysis, which offers the possibility of examining and theorizing causal effects, or what Rohlfing calls “theoretically 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 contributes 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 assistance 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 development 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 evaluation 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 development 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 contributes to their survival beyond the duration of development assistance programs, 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 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 indicators 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 implementation 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 authorities 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 discrimination 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 dynamics. 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 institutions (i.e., Country Coordinating Mechanism) according to the focus and procedures of the Global Fund. Moreover, a prolongation of a standard 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 contribution 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 feature 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, implementation, and evaluation) of grants. The Global Fund took over the activities 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 depending on the priorities and financial means of this donor.

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 emphasizing 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 simultaneously 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 equifinality 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 identified 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 mechanisms (Rohlfing, 2012, pp. 147–148). The specificity of boundary conditions 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 methodology, it nevertheless aims to make a meaningful contribution to understanding the link between the interaction among stakeholders and the sustainability of health aid.