Keywords

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

12.1 Aid Relationships

This book aimed to synergize the discussion of aid relationships in the development aid literature with a discussion of power and its sources in political theory to provide a more refined analytical framework for analyzing aid relationships (Chap. 2). It differentiated between the conventional and alternative perspectives on stakeholder relationships and power and expands on the latter. More specifically, the analytical framework aimed to enable further examination of recipients’ roles, actors’ interdependence, and the changing nature of power throughout the assistance. This book pursued four steps in analyzing these aspects.

The first step commenced with a reflection on the meaning of power and the common terms associated with it, such as resources, consensus/conflict, and interests (Chap. 2). Then, to more fully grasp the inequality present in development assistance, it followed the distinction between “power over,” which is associated with a hierarchy between stakeholders, and “power to,” which corresponds to changes in this hierarchy. Whether these two types of power are separate or merely represent distinct aspects of the same power is debated among scholars. Nevertheless, the distinction between the two types of power helped differentiate the power dynamics between stakeholders, establishing the basis for identifying the sources of power.

As a second step, this book emphasized the relevance of both stakeholders and the context in which they interact. It approached stakeholders as agents who act depending on incentives provided in the relevant structures and the roles assigned to these agents (Dowding, 2017, p. 22). Both individual and collective agencies were emphasized as being equally important. An empirical analysis confirmed this assumption. Individual agency featured in multiple instances, such as in the cases of the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) grants and the “Community Action for Health” (CAH) project. However, the empirics also demonstrated the equal importance of collective agency on behalf of organizations, as well as abstract categories, such as donors, recipient states, and civil society organizations.

In addition, this book emphasized the relevance of the context in which these agents operate by defining them as structures or “recursively organized sets of rules and resources” that enable and constrain stakeholders (Dowding, 2011, p. 10). An extensive literature review highlighted the significance of aid dependency, capacity, volatility, and flexibility. The empirical analysis of each of these aspects provided the following insights:

  1. 1.

    In both the Global Fund grants and the CAH, the aid recipients (state and civil society organizations) were dependent on the donors’ financial and technical support. Following Lensink and White (Lensink & White, 1999, p. 13), this book attributed aid dependency if a country (in this framework, a recipient state or a civil society organization) could not “achieve objective X in the absence of aid for the foreseeable future.” This book demonstrated the limits of the conventional quantitative indicators, which are normally used to illustrate the share of external assistance for health care; instead, it proposed using the sector-specific definition of aid dependence. Despite the relatively low share of donor contributions compared to the total share of health financing, this research provided compelling evidence for the extensive dependence of state and civil society organizations on the financing and technical assistance offered by donors. This was found to be particularly visible in the cases of human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS)-related preventive activities, antiretroviral therapy, and treatment of multidrug and extensively drug-resistant tuberculosis (TB).

  2. 2.

    Defining capacities as individual-, organizational-, and system-level abilities to implement functions (European Centre for Development Policy Management, 2008, p. 2), this book specifically focused on the structural issue, namely, the availability of human resources. Overall, staff turnover in ministries and state agencies, which is also due to the political situation in the country and low salary rates, was found to significantly jeopardize their abilities to perform their functions (see Isabekova & Pleines, 2021). Relevant to both cases, the problem of the limited capacity of state organizations, also in terms of monitoring, was particularly evident in the Global Fund grants, which resulted in a corruption scandal. In addition, there were cases of former state officials working for international organizations and NGOs. Although the scale of this phenomenon requires further research, it resonates with the conclusions of other relevant studies (Swedlund, 2017; Toornstra & Martin, 2013). Notably, staff rotation and attribution in nongovernmental organizations (NGOs) varied, depending on organizations and specific positions. While it was found to be substantial in the case of outreach workers, it did not seem equally pressing in other positions of NGOs.

    Furthermore, in contrast to the high level of attrition in community-based organizations, which is described at length in the literature (e.g., Glenton et al., 2010; Khetan et al., 2017), the CAH was actually characterized by a low level of attrition among the Village Health Committee (VHC) members, demonstrating the persistence of the VHC members. Labor migration and conventional gender roles contributed to the “female” profile of the volunteers in the VHCs, for whom VHC membership offered the possibility of participating in social life and decision-making processes. Most of those women did not migrate to other parts of the country or abroad, which contributed to the stability of VHC membership.

  3. 3.

    Acknowledging the uncertainty in which stakeholders operate because of aid appropriation procedures and the relatively short duration of development programs, this book focused on aid volatility as another structural factor. As demonstrated in Chap. 4, both the Global Fund and the Swiss Agency for Development and Cooperation (SDC) worked on increasing the predictability of their assistance. However, the SDC offered higher predictability than the Fund, which depended on its financiers’ replenishment of its three-year cycle. The Global Fund’s inability to provide long-term commitments was explicitly visible in the National Program for HIV/AIDS Prevention, where the financing from the Global Fund was only confirmed for the first three years, and the funding for the two remaining years was unknown. However, in contrast to the findings made by Swedlund (2017), this research did not find any evidence that the actors involved were unaware of upcoming assistance or that the volatility of the aid had any impact on the recipients’ commitment to the aid. However, despite this outcome, the long-term duration of the CAH (approximately 17 years) did contribute to the commitment of the recipient state and community members to the project.

  4. 4.

    Emphasizing the significance of aid flexibility to the relationships present among stakeholders, this book examined this phenomenon by associating it with the ability to adjust to local priorities and context (see Hirschhorn et al., 2013). An empirical analysis showed that the CAH was more flexible to the recipients’ changing needs and priorities than the Global Fund grants. The SDC, similar to other Swiss development agencies, provides a high level of decision-making autonomy to its field offices, meaning that these offices can decide on important issues without prior approval from the head office. The Global Fund, in contrast, does not have branches in the recipient countries; rather, it has a designated officer who deals with specific regions. While this officer is closely involved in all the processes relating to the implementation of the grant, the key decisions are made by the Global Fund’s head office in Geneva. Although it was open to making minor adjustments to the program, the Global Fund proved to be reluctant to consider more substantial changes. Meanwhile, the availability of senior staff from the SDC in Kyrgyzstan and the strong personality of the project manager from the Swiss Red Cross (SRC) contributed to the remarkable flexibility of the CAH toward the changing needs and priorities of the local communities. Based on these findings, this book would argue that the decentralization of donor organizations and a high level of decision-making autonomy of local field offices, along with a strong personality in the project manager, could contribute to the responsiveness of development projects to the recipients’ changing needs and priorities.

Overall, the first two steps composed the initial level of the analysis, as they laid down the conceptual basis for understanding power, stakeholders, and the context in which they interact. The following steps linked this conceptual basis to the alternative perspective of stakeholder relationships that this book aimed to expand on. More specifically, the following steps offered the analytical depth and tools necessary to grasp recipients’ roles, actors’ interdependence, and the potentially changing nature of power in development assistance.

The third step called for a project-level analysis that differentiated among initiation, design, implementation, and evaluation phases. An empirical analysis at this level offers a detailed and yet standardized (in terms of a project cycle) analysis of development projects. Thus, Chaps. 5 and 8 in this book provide an elaborative overview of stakeholders’ roles throughout the realization of the CAH and the Global Fund grants. In addition to understanding the agency (both individual and collective) of stakeholders, this depth of the analysis was critical to understanding the actors’ interdependence. It also allowed a better grasp of the recipients’ agency and a glimpse of the changes in stakeholders’ roles throughout the project cycle.

The fourth step culminated the analytical framework by linking the empirical insights from step three and the conceptual basis defining stakeholders, power, and the context in the first two steps to a theorization of power dynamics and aid relationships. This step was necessary to understand the empirical cases by placing them in a broader theoretical framework. This step combined the seven ways of creating power suggested by Haugaard (2003) with the “ideal” types of aid relationships defined by the author of this book in Chap. 2. For simplicity of comprehension, this analysis was conducted in a dyadic manner by referring to broader analytical categories: donor–recipient state, donor–donor, recipient state–civil society organizations (CSOs), and donor–CSOs. This step synergized the findings of all three other steps.

The synergy of the four steps unfolded as follows in the case of the CAH. The donor pursued an “empowerment” approach toward community-based organizations (CBOs). In addition to continuous participation, the CBOs maintained a decision-making role throughout the project cycle (based on the project life cycle analysis in Chap. 5). Moreover, structural factors, including aid flexibility and predictability (Chap. 4), were favorable to altering the conventional stakeholder positions by ensuring continuous project responsiveness to community needs. Volunteering or unpaid roles of community members and their leadership (individual agency) were additional assets. These findings from two chapters strongly hinted at the feasibility of an “empowerment” approach of a donor toward CBOs. However, the theorization linking these empirical findings to types of power, stakeholders’ interests (step one), and the ways of creating power (step four) was critical to the validity of my claims. The theorization showed that the donor primarily pursued the “power to” the CBOs for several reasons because of its emphasis on and belief in the decisive role of communities in aid (“system of thought” in Haugaard’s terms). A relevant practice of nondominance followed by SRC staff members further supported this belief, contributing to community members’ realization of their decisive roles (transformation of tacit knowledge into discursive, according to Haugaard). These ways of creating power vividly demonstrated that the SRC used its resources to produce “power to” CBOs rather than “power over” them. Additional reflections on donor and CBOs’ interests in following the specific forms of power, namely, bringing change to a community, self-development, organizational perspective, and individual agency, further supported an “empowerment approach” (Chap. 7).

In contrast to the CAH, donor–CSO relationships in the Global Fund grants followed a “utilitarian approach.” In addition to uneven levels of participation throughout the project life cycle (Chap. 8), the structural factors remained in favor of hierarchical relations (Chap. 4). Indeed, the Global Fund committed itself to ensuring the predictability of its assistance, which, nevertheless, in practice, remains dependent on its replenishment cycle. Furthermore, although driven by the grantee’s needs in the design phase, the provider offered the limited adaptability of grants during the implementation stage (e.g., limited flexibility). In addition, local NGOs and their activities depended considerably on donor financing, which varied across organizations but strengthened the inequality between the provider and recipient of aid. Theoretically, the relationship between the Fund and NGOs was characterized by a combination of “power over” and “power to.” Notably, the Global Fund’s emphasis on civil society participation in decision-making (a structural bias in Haugaard’s term) offered a window of opportunity for NGOs to strengthen their positions in the project life cycle. This opportunity was further reinforced by solid organizational support in the form of finances and technical assistance from the Global Fund. However, this “power to” came along with the aid provider’s “power over” the recipient. One source of this form of power was the propensity to predict grants and their outcomes (“social order”), while another source was assigning specific roles and tasks to stakeholders in the project lifecycle (discipline in Haugaard’s theory). Similar to the CAH, a “utilitarian approach” was found to have its underpinning in stakeholders’ interests, including access to resources, reaching out to vulnerable groups, and organizational perspective.

The analysis of aid relationships between other stakeholders in the CAH and the Global Fund grants followed a similar logic (for more information, see Chaps. 7 and 10).

12.2 Sustainability of the Selected Health Projects

In addition to analyzing aid relationships, this book also offered a systematic analytical framework to assess the sustainability of health care interventions, in which various approaches to the operationalization of sustainability and relevant factors were given special attention. Following the most frequently used approach in the literature, namely, the approach developed by Shediac-Rizkallah and Bone (1998), this book defined sustainability as the continuity of project activities, the maintenance of benefits (e.g., services and infrastructure), and community capacity building. This book complemented this approach with three extensions.

First, it acknowledged the relevance of the analysis of both ongoing and complemented projects. In the former, it approached state commitment in terms of necessary legislative amendments and financing as the sign for sustainability of ongoing initiatives. The analysis of the Global Fund grants vividly demonstrated both the validity of and issues with this approach (Chap. 9). In contrast, the CAH presented the case for a completed health care project in which the actual fulfillment of obligations and activities upon the end of the donor funding could be assessed. However, both ongoing and completed initiatives are subject to continuous socioeconomic, political, and epidemiological changes (e.g., the coronavirus disease 2019 [COVID-19]), representing similar uncertainty and jeopardy to the sustainability of projects. Moreover, by acknowledging that sustainability does not automatically come at the end of aid but rather is built throughout its realization process, this book highlighted the equal validity of the analysis of ongoing and completed initiatives.

Second, this book complemented the operationalization of community capacity building with an adaptation of Laverack’s framework by focusing on participation, leadership, and mobilization of resources (see Labonte & Laverack, 2001a, 2001b).Footnote 1 Furthermore, in contrast to the original framework by Shediac-Rizkallah and Bone (1998) and the operationalization of community capacity building suggested by Laverack (see Labonte & Laverack, 2001a, 2001b), the current research introduced a new category for assessment that is commonly highlighted by the interviewees but absent in the two older frameworks, namely, the survival of CSOs beyond the period of development assistance provision. This aspect is important, as, for instance, unlike the NGOs involved in and highly dependent on the Global Fund grants, the CBOs in the SDC’s CAH demonstrated remarkable continuity beyond the development assistance. In this way, although financing was important for the functioning of the CSOs, it did not seem to be a necessary factor.

Third, the initial framework was complemented with a list of factors relevant to the sustainability of health care interventions developed by the author of this book through an extensive review of related literature. These factors included financing; accounting for the influence of general economic, social, and political situations in the aid-recipient country; integrating within context; and disentangling organizational factors into further categories (see Table 3.3 in Chap. 3).

Overall, the analytical framework and its three extensions found their reflection in the analysis of the selected health care programs.

The CAH demonstrated the continuity of tuberculosis and HIV/AIDS-related services previously pursued by the project beyond the duration of donor funding. Unpaid, the CBOs continued their awareness-raising activities in these areas (among others) by informing the local population, organizing community events and walking campaigns, and so on. Indeed, the means available to CBOs varied depending on their coverage with analogous donor programs, particularly given that the government training activities became uneven. Among others, the main issues thereof were found to be related to reimbursing the travel expenses of state trainers, which were also due to the ongoing optimization reforms and change in the national health care toward a systemic (and not disease-specific) target-setting. Similarly, the survival of CBOs beyond the CAH was uneven, but the majority continued due to members’ leadership and organizational support from the Association of Village Health Committees. Indeed, resource mobilization remained a challenging task due to not only the socioeconomic situation in the country but also the lack of extensive training on this matter. However, CBOs continued and even expanded their work by overcoming challenges, such as COVID-19 implications, and exploring opportunities for their organizational growth.

In the case of the Global Fund grants, the government demonstrated an unprecedented commitment to continuing TB and HIV/AIDS-related activities, although with mixed success. In addition to legislative changes aimed at eliminating the discrimination of groups affected by TB/HIV, it also adopted a roadmap to optimize state health care services and facilities to provide additional financing for the areas funded by donors. The mobilization of resources at both the national and local levels was found to be challenging due to the socioeconomic situation in the country defining its gross domestic product (GDP). However, even with savings, state funding was found to be insufficient to cover medications for antiretroviral therapy, the treatment of drug-resistant forms of TB, and other areas. There was skepticism that state-level commitments highly depended on decision-makers’ choices. However, other factors equally mattered to the fulfillment of these commitments, such as procurement costs and opportunities, the availability of medical professionals, the epidemiological situation in the country, and the COVID-19 implications on the already strained health care system. The maintenance of benefits received by patients with TB/HIV similarly demonstrated the commitment of the government, as reflected in the social support offered by the state that was found to be nevertheless insignificant. The survival of NGOs beyond the duration of the grants provided ambiguous answers depending on the capacities of the organization in question. Indeed, NGOs explored possible alternatives that were nevertheless scarce due to a decrease in external funding. The state’s reform toward social contracting, following the Global Fund grant conditions, was a reasonable alternative, although with further implications with regard to accountability and the dependence of CSOs on the government.

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

12.3 The “Missing Link” between Aid Relationships and Sustainability

The link between aid relationships and sustainability was explored at the project level and beyond. At the project level, this link embodied mechanisms or processes connecting the two phenomena (see Chap. 11 for more details). However, these mechanisms have limited implications for our understanding of the link beyond the selected cases. For this reason, I used broader causal links due to the level of abstraction in both wording and approach.

First, after providing a comprehensive picture of aid relationships and sustainability, this book assessed the impact of the different types of relationships formed between the actors over each component of sustainability (e.g., continuity of activities, maintenance of benefits, and community capacity building). Based on Rohlfing’s (2012) integrative framework for case studies and causal inference, this research identified the following positive links between interaction practices among involved actors and the sustainability of the selected health care programs: ownership, learning, institutionalization, recognition, uniformity, replacement, and “professionalization”Footnote 2:

  • The mechanism of ownership—aid-recipient community-based organizations develop a sense of ownership and responsibility for their communities’ health. Triggered by the donor’s “empowerment” approach toward the CSOs, this mechanism affects the CSOs’ survival and continuity of health activities beyond the duration of health aid.

  • The mechanism of learning—through their extensive participation in the realization of development assistance, aid-recipient community-based organizations increase their awareness of local issues and links to local organizations. In doing so, the CSOs become the first point of contact for local authorities and donors, which ensures their survival beyond the development assistance. This mechanism is similarly generated by the donor’s “empowerment” approach toward the CSOs.

  • The mechanism of professionalization—“professionalization” of NGOs in specific areas takes place through their training, fulfillment of donor requirements, and implementation of project activities. This contributes to their survival beyond the duration of health aid. This mechanism evolves through the “utilitarian” approach of a donor toward the CSOs.

  • The mechanism of institutionalization is characterized by a recipient state’s formalization of its commitments, leading to the continuity of project activities and CSOs’ survival beyond the duration of donor assistance. This mechanism develops through unequal cooperation between the donor and aid-recipient authorities.

  • The mechanism of recognition occurs when state authorities approach community-based organizations in order to achieve their own objectives. This cooperation provides the CSOs with additional means for their survival beyond the donor funding. This mechanism evolves through the aid-recipient government’s “utilitarian” approach toward the CSOs.

  • The mechanism of uniformity, under certain conditions, contributes to the expansion of development assistance and continuity of its activities. This mechanism develops through unequal cooperation among donors.

  • The mechanism of replacement—donors take over each other’s activities to ensure their continuity. This mechanism is triggered by the coordination among donors.

In addition to identifying these mechanisms, this book also outlines the conditions under which these mechanisms may take place beyond the context of the selected health care programs and country. These include aid dependency and limited capacity of government authorities and CSOs, precarious economic and political situation in the aid-recipient country, and the structure of development assistance, defining its flexibility and predictability. Furthermore, labor migration, conventional gender roles, stigma, discrimination against sexual minorities (i.e., lesbian, gay, bisexual, trans, intersex, and queer [LGBTQ]), and the personalities of decision-makers and project implementers are essential to the realization of these mechanisms in the case of health projects.

Furthermore, theory-centered, the aim of this book was to make a general theoretical contribution toward evaluating the impact of relationships between relevant actors on the sustainability of development assistance for health care. For this reason, in addition to the causal mechanisms mentioned above, identified through the intensive analysis of the selected TB and HIV/AIDS programs, the other aim of this research was to formulate tentative results in the form of causal links between the cause (aid relationships) and the outcome (sustainability). These causal links require a definition of causal effects or “theoretically intelligible and systematic” relationships (Rohlfing, 2012, p. 12) defined through cross-case analysis of the selected health care programs. Though context-specific, these effects provide the theoretically grounded claims about the link between the cause and the outcome:

  1. 1.

    An “empowerment” approach of a donor toward CSOs contributes to community capacity building by improving and streamlining the leadership of the CSOs, and their capacity to mobilize resources, as well as by facilitating their survival beyond the duration of development assistance projects.

  2. 2.

    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.

  3. 3.

    Unequal cooperation between a donor and the relevant authorities of aid-recipient countries does, in fact, contribute to the continuity of project activities. However, the extent of the services that might 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.

  4. 4.

    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.

As it has provided herein comprehensive analytical frameworks together with detailed case studies, this book is of interest to academics and practitioners working in areas related to development and public health, as well as area studies and regional specialists. Despite its very specific focus on the health care programs financed by the Global Fund and SDC in Kyrgyzstan, the intention of this book was to provide a general perspective on types of aid relationships, components of sustainability, and the link between these two phenomena. Certainly, the abovementioned causal mechanisms and effects have been identified in the specific context of Kyrgyzstan.

However, by easing region-specific characteristics, it is possible to generalize the causal links between aid relationships and sustainability stated above beyond the selected health care programs. There are different “layers of generalization” (Rohlfing, 2012) for the causal mechanisms and causal effects identified in this research. The country (Kyrgyzstan), policy areas (TB and HIV/AIDS), and donors (the Global Fund and SDC) represent three major “scope conditions” defining the context for specific causal relationships (ibid., p. 9).

Kyrgyzstan offers interesting observations of a lower-middle-income country that inherited a state-dominated health care system from the Soviet Union. Indeed, the country’s epidemiological, cultural, historical, and other aspects are country-specific, which may require some caution in interpreting the results provided in this book. Nevertheless, some issues, including the discrimination of groups affected by TB/HIV, aid dependency, conventional gender roles in society, and other aspects, are not unique and are equally present in other settings.

Furthermore, TB and HIV/AIDS are specific policy areas requiring continuous access to quality medications and health care personnel to ensure timely detection and uninterrupted treatment of persons affected by the diseases. As shown in the analysis, health care programs’ sustainability depends on political engagement, financing, training, and awareness not restricted to specific country borders (e.g., the rise of HIV infection among labor migrants). Furthermore, unlike TB, for instance, HIV requires lifelong treatment, and in contrast to other health care areas (mother and child health, cardiovascular diseases, etc.), HIV is burdened with a high level of stigma and discrimination, not just on the grounds of the disease itself, but also the “moral issue” attached to it (see Chap. 3). Therefore, the causal links and results identified using the examples of TB and HIV/AIDS may vary in the case of other diseases.

Moreover, this book focused on “bottom-up” health projects designed by aid-recipients using the examples of the programs financed by the Global Fund and SDC. Equally stressing the recipient’s ownership over development aid and civil society involvement in it, these donors varied in terms of their structures and approaches (Chaps. 1 and 4). While the Global Fund grants may have comparable outcomes in other countries with similar epidemiological profiles, the SDC’s CAH represents a country-specific project, which can nevertheless be applicable to other settings willing to apply a similar approach.

Causal mechanisms and effects presented in this chapter are specific to the cases examined in this book. However, by easing the “scope conditions” stated above, it is possible to generalize these causal links, connecting different types of relationships relevant to the sustainability of health care assistance into more general conclusions about the way in which key actors and the relationships between them might affect the sustainability of development assistance.

12.4 Further Findings and Limitations of This Research

In line with the existing literature, this book finds unequal donor-driven cooperation as the most common form of interaction between the donor and aid-recipient government due to the limited capacity and aid dependency of state authorities. The analysis of the Global Fund project in Kyrgyzstan also shows that donor conditionalities did not end with the World Bank and International Monetary Fund’s Structural Adjustment Loans in the 1980s–1990sFootnote 3 and continued up until nowadays.

Nevertheless, multiple findings of this book (in addition to those mentioned in the previous subsections) are new to our understanding of the relationship between the interaction among stakeholders and the sustainability of health projects.

First, initially unequal power dynamics between providers and recipients of aid may change during the development assistance. The analysis of the two projects in Kyrgyzstan shows that aid flexibility and donor’s inclination to aid recipient’s empowerment contribute to changing. In contrast, the financial requirements and the threat of withdrawal of funds strengthen the unequal power dynamics. These findings refine the suggestions in the existing literature, which suggests increased power of donors at the beginning and recipients—at the end of the assistance (e.g., Andrews, 2013; Swedlund, 2017).

Second, this book offers a new perspective on aid dependency. It argues for a sector-specific definition beyond the quantitative indicators. In 2018, the share of external health expenditure (% of current health expenditure) in Kyrgyzstan was about 5% (World Bank Group, 2023). However, the analysis shows that 60–90% of tuberculosis and HIV/AIDS prevention and treatment services depend on the Global Fund. The country also relies on the technical assistance offered by the World Health Organization, the German Corporation for International Cooperation, SDC, and others. Furthermore, the empirical analysis shows that aid dependency may be an outcome of donor coordination. Several donors, including the World Bank and German Development Bank, discontinued their tuberculosis and HIV/AIDS programs shortly after the commencement of the Global Fund projects in Kyrgyzstan, which resulted in the country’s dependence on a single donor.

Third, in addition to the inclusion of all relevant stakeholders, this book emphasizes further differentiation of actors within the categories of “donors,” “recipient state,” and CSOs to understand their interaction with each other better. The empirical analysis vividly demonstrates the contrast between a Global Health Initiative pursuing a “standardized” approach across the aid-recipient countries irrespectively of the SWAp and a traditional bilateral donor providing country-specific allocations driven by geopolitical interests. National and local state authorities also differ in their interests and capacities, similar to community-based organizations, local and international NGOs. Differentiation of actors grouped into one category allows for a better understanding of power dynamics, interaction, and its implications for the sustainability of aid.

Fourth, in contrast to the existing literature on development aid, including health aid, this book does not find high staff attrition in the case of CSOs, though high staff rotation in government organizations complies with the findings in development aid literature. The analysis of community-based organizations in Kyrgyzstan shows that conventional gender roles in the family and society ensured male migration and retention of women in households. As a result, there was no high staff attrition among the local female volunteers working in health organizations. It should be noted that health is primarily viewed as a “female” responsibility.

Fifth, this book also makes some empirical findings new to the literature on development aid and its sustainability, along with the abovementioned theoretical contributions. It contains unique primary material and thus offers new knowledge of complex processes inherent to development assistance implemented in the region, mostly neglected in development studies. Shortly after the collapse of the Soviet Union in 1991, newly independent countries received significant financial and technical assistance from international organizations. However, except for the number of articles discussing the conditionality (e.g., Pleines, 2021; Stubbs et al., 2020), assumptions (Wilkinson, 2014), and implications of international support (Kim et al., 2018), the post-Soviet region is overlooked in the literature on development aid (Leitch, 2016), which largely focuses on Sub-Saharan Africa, Latin America, and Southeast Asia.

In addition to multiple academic and empirical contributions mentioned above, this book has far-reaching policy implications. The Global Fund project is still ongoing, although the share of donor funding has considerably decreased during the last ten years. Furthermore, the national health care system of Kyrgyzstan, as elsewhere in the world, is burdened by the COVID-19 pandemic. In these conditions, the sustainability of the Global Fund project is essential to ending the epidemics of AIDS and tuberculosis in the country. Similarly, the sustainability of the SDC’s completed primary health care project is critical to achieving universal health coverage in rural regions of the country. Although context-specific, the analysis of two projects in Kyrgyzstan nevertheless demonstrates the issues common to other developing countries, distressed by the shortage of finances and human resources. Therefore, the issues and opportunities for the sustainability of health aid presented in this book will benefit decision-makers working in the relevant areas in Kyrgyzstan and beyond.

At the same time, this research has several limitations. Firstly, this book focused primarily on the organizational level, and did not elaborate on the interconnection between individual and organizational levels and on how this could be relevant to understanding the actors that were involved in the development assistance. Furthermore, in discussing only dyadic relationships (meaning between two actors at a time), it did not focus on the interdependence of actors’ choices, for instance. Thirdly, this research defined the causal mechanisms and causal effects linking the different types of relationships in the development assistance programs under study, with the sustainability of those programs. As an exploratory study, it did not further test the causal inferences and the tentative results in the form of causal links between aid relationships and sustainability identified in this research. For this reason, this book did not elaborate on sufficiency, necessity, equifinality, conjunctural causation, and other issues pertinent to further understanding the relationship between the cause and the outcome. Moreover, because of the fragmentation of the relevant literature, this study acknowledges the limits of the theoretical basis of the book, and uncertainty about the inclusion of all relevant conditions into the analysis. These and other areas could be possible directions for future research on this topic.