Keywords

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

4.1 Aid Predictability

In the context of health assistance, aid predictability refers to the duration that donor organizations can commit themselves, financially or by other means, to the assistance they offer (Chap. 2). Both SDC and the Global Fund acknowledge the significance of aid predictability and commit themselves to improving it. However, the outcomes are diverse due to the development assistance organizational structure offered by these two actors.

First, the Swiss Development Cooperation structure allows for multiyear predictability. The Swiss Parliament adopts the “Dispatch on International Co-operation” every four years (Federal Department of Foreign Affairs and State Secretariat for Economic Affairs, 2020). This document underpins the country’s view of development, such as poverty reduction and sustainable development (2021–2024), and is not limited to official development assistance (ibid.). Three organizations are responsible for implementing the Dispatch: (1) the Swiss Agency for Development and Cooperation, (2) the Human Security Division within the Federal Department of Foreign Affairs, and (3) the Economic Cooperation and Development Division of the State Secretariat for Economic Affairs within the Federal Department of Economic Affairs, Education and Research (OECD, 2019, pp. 13–14). Nevertheless, the SDC manages the most significant part of the Dispatch on International Cooperation program (68%), including technical and financial cooperation and humanitarian assistance (ibid.). The four-year budget planning of the program, combined with sound forecast information and multiyear funding agreements, provides the basis for the reliability of Swiss aid (ibid., p. 18). Moreover, Swiss aid agencies have buffer funds to rely on; this means that Swiss aid organizations can make four- to five-year commitments, and in the case of the SDC, this extends up to ten years (OECD, 2009, p. 213). Accordingly, Switzerland offers more predictable aid from a multiyear perspective.

The “Community Action for Health” Project (CAH) is a vivid example of the predictability of Swiss development assistance in Kyrgyzstan and beyond. With the average duration of Swiss projects in Kyrgyzstan being approximately ten years (see Embassy of Switzerland in KR, 2013), the CAH lasted for seventeen years (2001–2017). Several interviewees stressed that this long-term duration was essential to the project performance (IO Partner 5) because working with existing structures takes time, with the first three years spent on building networks (IO Partner 9). This multiyear predictability is a strong feature of the Swiss Development Cooperation (OECD, 2014). According to estimates of the Global Partnership for Effective Development Co-operation (n.d.), which is a multistakeholder platform aiming to promote the effectiveness of development efforts, Swiss aid demonstrates high aid predictability. In 2018, for instance, Switzerland performed better (70%) than the average bilateral member of the Organization for Economic Co-operation and Development’s Development Assistance Committee (OECD DAC) (53.2%) in terms of the medium-term predictability (two to five years) of its aid (ibid.).

In addition to funding, another significant aspect of predictability in the CAH was the long-term engagement of the project coordinator. Invited by the Swiss Red Cross (SRC) to conduct a pilot study on community involvement in health care in 2001, Dr. Tobias Schütz stayed in Kyrgyzstan for almost thirteen years. He administered most of the project process, from its early initiation to countrywide expansion and further extension of community-based organizations at the national level. According to one interviewee, the absence of short-term consultants benefited the project (IO Partner 5). Indeed, the project coordinator’s continuous engagement contributed to building partnerships and uniformity of principles and approaches throughout the CAH. Notably, the long-term presence of key staff members is one of the aspects of Swiss aid appreciated by partner countries as beneficial to collaboration (OECD, 2019). However, thirteen years is probably an exception rather than a rule to a long-term presence.

Second, the Global Fund encourages the initiative of countries, multilateral and nongovernmental organizations, and private foundations willing to unite their efforts against tuberculosis, human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS), and malaria worldwide. In this way, the initiative to establish the Global Fund came from Japan, the European Commission, United Nations agencies, participants of the African Summit on HIV/AIDS (2001), the United States, and a number of other stakeholder countries (Global Fund, n.d.-b). However, one could specifically highlight the role of the Bill and Melinda Gates Foundation, which provided the “single largest nongovernment pledge” in the amount of US $100 million in 2001 (ibid., pp. 15–24). Over eighty countries made or pledged contributions to the Global Fund, with the Organization for Economic Cooperation and Development’s Development Assistance Committee (OECD DAC) members and the European Commission representing, as of the end of 2021, the leading government donors (Global Fund, 2023a).

Similar to Swiss aid, the Global Fund (2023b) offers relatively predictable assistance by allocating funding to countries on a three-year basis. This period corresponds with the replenishment cycle, during which the governments and organizations supporting the Global Fund (2023c) pledge their financial contributions. Adopted in 2005, this approach was intended to provide “more stable and predictable” financing (ibid.). Benefiting ongoing programs, the three-year period also allowed sufficient time for countries to prepare their applications. In so doing, this approach aimed to eliminate gaps between calls and inflated costs in applications prepared on short-term notice observed during the time when the organization made announcements on an ad hoc basis in the past (Global Fund, n.d.-b). Additionally, as part of its 2012–2016 strategy, the organization introduced the New Funding Model, which, among others, stipulated early feedback on proposals, intending to decrease the waiting time and increase their chances of success (Global Fund, 2013). The Global Fund has equally aimed to increase the predictability of ongoing projects. Its Rolling Continuation Channel Initiative, for instance, stipulated up to six years of funding for “high-performing grants,” with applications reviewed quarterly instead of on an annual basis (Global Fund, n.d.-b, pp. 37–38). Furthermore, the organization aimed to further increase transparency by announcing the eligibility of countries for grants based on their disease burden in each of the three components supported by the Global Fund (i.e., tuberculosis, HIV/AIDS, and malaria) and income classification (Global Fund, n.d.-c). Overall, the Global Partnership for Effective Development Co-operation (n.d.) estimates that the Global Fund performs better (66.8% in 2016) than the average vertical program (see Chap. 1 for a definition) (42.8%) in terms of medium-term predictability of its assistance.

Kyrgyzstan has been a long-term recipient of Global Fund grants. The country has received tuberculosis (TB) and HIV/AIDS grants since 2004, with the average duration of grants being approximately 4.5 years (Global Fund, n.d.-a). It should be noted that each grant was built around the objectives and activities of the former. This approach contributed to the continuity of efforts in both areas. This continuity and uniformity laid the foundation for approaching the grants as continuous projects against tuberculosis and HIV/AIDS, respectively.

Nevertheless, the Global Fund’s financial commitment remains limited to three years, with financing beyond being dependent on the availability of funds. The Global Fund’s dependence on financiers was also visible during the accusations of fraud in the grants. Confirmed in “a very small number” of countries and activities, reports in the mass media about fraud have nevertheless contributed to the perception that the organization lost control over its grant disbursements (Brown & Griekspoor, 2013, p. 139). In response to these allegations, several countries announced the halt of their financing, resulting in a seven to eight billion dollar funding shortfall (The Lancet, 2011). Consequently, at the 25th board meeting in November 2011, the Global Fund suspended the planned call for new grants but assured financing for ongoing programs (Moszynski, 2011). It took several measures to address the problems related to fraud allegations. In addition to replacing several senior managers, it changed its operational model and emphasized “more risk-based supervision” in grant implementation (Brown & Griekspoor, 2013, pp. 139–142).

Overall, both Switzerland and the Global Fund acknowledge and plan to ensure the predictability of their assistance, which is also reflected in their performance compared to an average donor. However, lasting for almost seventeen years, the CAH is a striking example of the predictability of Swiss aid, supported by the long-term presence of the project coordinator. Similarly, lasting 4.5 years on average, the Global Fund grants to Kyrgyzstan demonstrate the commitment and efforts of this organization to aid predictability. Furthermore, building around the preceding objectives, each grant contributed to the continuity of activities, laying the foundation for analytically treating them as ongoing projects against tuberculosis and HIV/AIDS. Nevertheless, the organizational dependency on the replenishment cycles limits its ability to make longer commitments, which will be discussed in the following section.

4.2 Aid Flexibility

Aid flexibility in this book denotes the stakeholders’ abilities to change the development assistance and the extent to which this change demands specific procedures that may indirectly hinder the stakeholders from initiating this process (Chap. 2). Switzerland and the Global Fund acknowledge and commit to providing flexible assistance consonant with recipients’ needs and objectives, albeit with differing success.

Flexibility is a strong feature of Swiss aid within and beyond Kyrgyzstan due to the relevant emphasis and organizational structure. Switzerland allows flexible programming and budgeting adaptable to changing circumstances at country and project levels (OECD, 2019). This emphasis is further supported by the structure of the Swiss development cooperation stipulating decentralization and allowing a certain level of autonomy for field offices. Although part of Swiss embassies, the Swiss Cooperation Offices are still “fairly autonomous” (OECD, 2005, p. 73). They report directly to headquarters in Geneva, have policy dialogs with the recipient governments and other donors, and manage local staff and local budgets (ibid., p. 74). Country directors have some flexibility in allocating funds according to the priorities annually defined in collaboration with partner countries (ibid., p. 218). This flexibility of Swiss aid is also reflected in the SDC’s operations in Kyrgyzstan. The organization is among the three organizations providing budget support to assist in the realization of the national health care program. It also provides project-related health assistance, which benefits from organizational flexibility, as the CAH shows.

The autonomy of Swiss aid agencies was conducive to the flexibility of the “Community Action for Health” and its responsiveness to local needs. Driven by specific objectives of empowering the communities to improve their health and to support the partnership between the state health care system and local communities (Schüth, n.d.), the project was nevertheless open to local initiatives. As demonstrated in Chap. 5, the CAH targeted the issues and solutions identified by local communities and those prioritized in national health care. This openness to activities suggests that although covering all significant areas, the project description and funding still provided space for introducing alterations. It also permitted rather unbureaucratic approval of budget changes, including further adjustments of costs and activities (IO Partner 11). This guaranteed the project’s responsiveness to the changing circumstances, also in terms of the needs of community-based organizations and the areas of concern highlighted by the local community.

At the same time, Swiss aid faces challenges in balancing the different levels of accountability, which may also affect its flexibility. As demonstrated above, Switzerland ensures the accountability of its aid to recipients by providing flexibility and responsiveness to local needs. Nevertheless, Swiss development organizations, as any others, are primarily accountable to citizens paying taxes for aid or, in practice, the organizations representing these citizens. Switzerland has no political ties to its aid (OECD, 2019), but there are growing voices about conforming official development assistance to national interests. One example thereof is the political pressure to target irregular migration to Switzerland by linking the assistance to migration policies of recipient countries (ibid.). If successful, these initiatives will provide political ties to Swiss aid, which will also affect its flexibility.

However, the link to national interests is not the only pressure on development assistance, as accountability to taxpayers also presumes the achievement of stated objectives and the use of funds accordingly. This may increase the control over finances and, in so doing, restrict the “spontaneity” of allocations. One interviewee noted that the control over the financing and budget specifications in the CAH increased, reducing the initial flexibility of the initiative (IO Partner 11). Although in need of further investigation, in the broader context of increasing pressure on the accountability of aid, this suggestion points to the controversial relationship between accountability and flexibility. In other words, increased control over the assistance is opposite to its flexibility.

Like Switzerland, the Global Fund commits itself to providing flexible assistance. The organization recognizes the problem with requesting project proposals instead of accepting the existing national strategies or applying project cycles instead of adjusting themselves to the cycle of the national program of an aid-recipient country (UNAIDS, 2005a, pp. 14–15). Accordingly, the Global Fund asks applicants to conform their proposals with national strategies (Chap. 8) and allows sending funding requests at any time during the initial three-year allocation period to ensure alignment with national budgeting cycles (Global Fund, 2013).

Nevertheless, as the case of the Global Fund project in Kyrgyzstan shows, the three-year period does not necessarily comply with the duration of national health care programs. According to a state representative, the Global Fund is among the few donors explicitly committing finances. For this reason, the organization is also explicitly stated as a source of financing for specific activities (Government of KR, 2017b). Other organizations may similarly support the national program, but their commitments are not stated anywhere (State Partner 2). Nevertheless, even a three-year commitment does not cover the entire duration of the national program. Another interviewee explained that with national programs (i.e., against TB and HIV/AIDS) being developed for five years, the funding for the remaining two years remains unknown (State Partner 4).

Furthermore, the allowable changes to approved grants seem insignificant. The Global Fund attempts to consider recipients’ suggestions and implement relevant changes (CSO 8) by adjusting to unexpected expenditures, savings, cancelations, and transfer of some activities (IO Partner 20). However, these changes are “typically not substantial” (Vujicic et al., 2011, p. 2) and remain within 10–15% of the grant’s total amount (IO Partner 20). More substantial changes, such as providing treatment instead of prevention, may be problematic (ibid.) and involve additional bureaucratic hurdles, as suggested by another interviewee (State Partner 4). The respondent noted that the approval might come or not, with different conditions and limitations applied and negotiations lasting months, particularly in the cases involving medications (ibid.). The interviewee emphasized that these hurdles caused issues in the grant realization process, adding that organizational responsiveness also depended on the individual(s) coordinating the relevant matter, with some being more open to interpretations than others (ibid.). Indeed, individual perspectives and behavior are significant to aid flexibility, as they are to predictability, as demonstrated in the previous section in the case of the CAH.

Nevertheless, the issues with responsiveness and bureaucratic hurdles are also related to the organizational structure of the assistance. The Global Fund aims to ensure the recipients’ ownership over grants by delegating the process of its realization to stakeholders present in the recipient country. The absence of field offices also intends to ensure organizational neutrality (IO Partner 4). Remaining in continuous communication with recipients, the Global Fund bases its judgments and decisions on the information provided by (inter)national stakeholders about the achievements and issues. Nevertheless, this concentration of decision-making in one place contrasts with decentralization and autonomy, contributing to the responsiveness of Swiss aid.

Furthermore, the flexibility of grants, similar to Swiss aid, is contingent upon external factors. Following the allegations of fraud in grants to multiple countries, the flexibility of projects decreased. The Global Fund introduced new regulations requiring all grant recipients to submit their training plans for approval, and it proved difficult to make any changes to these plans during the implementation process (Benjamin, 2011). There were also issues with adjusting activities to inflation in the country (see Ancker & Rechel, 2015a). Overall, the changes introduced after the fraud allegations intended to demonstrate the organizational ability to control finances, pointing to the organization’s accountability before its funders. Once again, the increased control over finances seems to counterpoise aid flexibility.

Overall, Switzerland and the Global Fund emphasize and provide flexibility in their assistance. Both highlight recipients’ ownership by adjusting the activities to changes occurring throughout the project realization process. Nevertheless, the extent of possible adjustment without bureaucratic hurdles is associated with the organizational structure of development partners. Thus, decentralization and a certain level of autonomy of field officers in Swiss aid contrast with concentrated decision-making in the Global Fund. However, both development partners struggle with balancing accountability before funders and recipients of their aid.

4.3 Capacity

Capacity in this book primarily refers to the abilities of organizations to fulfill their functions and set and achieve the stated objectives before them (Chap. 2). Accordingly, this section discusses the capacities of civil society organizations and state institutions addressed in the two case studies.

First, approaching the operationalization of civil society organizations in a broader sense, this section discusses the capacities of community-based organizations (CBOs) involved in the CAH and nongovernmental organizations (NGOs) participating in the Global Fund grants.

The CBOs established within the framework of this project include the Village Health Committees, Rayon Health Committees, and the Association of Village Health Committees.

Village Health Committees (VHCs) carry out preventive and health promotion activities among their communities in areas identified by community members as pressing and those targeted by national health care development programs (Chap. 5). These areas include hypertension, alcoholism, iodine and iron deficiency, influenza, brucellosis, and others (see Isabekova, 2021). It should, however, be noted that although they measure the blood pressure of their fellow villagers or the level of iodine in the salt sold in the local shop, VHCs do not provide medical services. Instead, the organizations serve as mediators between health care institutions and the population by noting health care issues and encouraging their villagers to refer to medical organizations and get timely treatment (AVHC, 2020).

VHCs are present in all seven regions, and most have official registration. Recent estimates suggest that there are 1606 VHCs in the country (AVHC, 2018, pp. 11–12). The organizations are composed of volunteers who come mostly from the villages in which they conduct their activities. The VHC members meet regularly, on average from 1–2 times per week to 2–3 times a month (Kickbusch, 2003, p. 18). Interviewees note that although generally proportional to the size of the relevant village, the number of volunteers fluctuated throughout the CAH from an initial 20–30 (CSO 4) down to 5–10 (CSO 7; State Partner 1). Subsequently, the total number of VHC members ranged from 10,215 in 2010 to 15,566 in 2014 and to 13,267 in 2016 (PIL Research Company, 2017, n.p.).

The Rayon Health Committees (RHCs) are composed of the leaders of the VHCs. Registered as nonprofit organizations (Schüth et al., 2014), they serve as a platform for VHCs to meet and discuss the work conducted and activities omitted and decide on the work plan for the next quarter (AVHC, 2018, pp. 5–6). This platform also serves two other purposes. First, it is used to pass on information from the association to the VHCs. Furthermore, at the end of quarterly meetings, RHCs report to the Association of VHCs by sending the following documents: a list of participants, a work plan, a meeting agenda, and a table of the VHCs’ self-initiatives (ibid.). Since the RHCs have no office space of their own, their meetings take place on the premises of Family Medicine Centers or in the offices of the local self-government at the district level, where the authorities are able or willing to offer space for VHC meetings (CSO 4).

In addition to connecting and reporting functions, RHCs aim to solve health care issues at the village and district levels and coordinate capacity-building activities for VHCs (AVHC, n.d.). They are also expected to support Family Medicine Centers in their health care activities and coordinate the annual assessment of VHCs (ibid., pp. 8–9). According to recent estimates, there are 58 organizations in total in the country (AVHC, 2020, p. 3), with the number of RHC members proportional to the size of the population in the relevant district (rayon) (CSO 4).

The Association of Village Health Committees (hereinafter AVHC or the Association of VHCs) coordinates and represents Rayon and Village Health Committees before the state and donor organizations. Established in 2010 as a voluntary association of RHCs, it aims to promote health and improve sanitation and hygiene and the living circumstances of the rural population in Kyrgyzstan (AVHC, 2020, p. 3). The executive body of the AVHC has two permanent staff members and four staff on short-term contracts, although the number of staff at any given time largely depends on the workload since the staff on short-term contracts are taken on at times of increased workload (CSO 4). In contrast to the Village and Rayon Health Committees, the staff members of the executive body of the AVHC members receive a salary. Nevertheless, the AVHC is a nongovernmental and noncommercial organization whose primary responsibility is coordinating health committees and representing them before the state and donor organizations. Actors willing to work with health committees contact the Association of VHCs first (CSO 1). Examples of AVHCs’ collaboration with other actors include disease prevention and health promotion activities conducted within the framework of programs funded by the World Bank, the German Corporation for International Cooperation (die Deutsche Gesellschaft für Internationale Zusammenarbeit—GIZ), the United States Agency for International Development (USAID), SDC, and others. With the Ministry of Health, the AVHC mainly works via the Republican Center for Health Promotion and Mass Communication under the Ministry of Health (hereinafter the Republican Center), but it also sought collaboration with the Mandatory Health Insurance Fund on the assessment of medical services (see Development Policy Institute, 2017).

Notably, the Association of VHCs has essential developmental and supervisory functions. It seeks collaboration with other actors primarily to support and strengthen the capacities of RHCs and VHCs. Therefore, in addition to organizations approaching the organization themselves, it also looks for potential donors and projects that could support the community-based organizations by financial means or by training and other forms of technical assistance (CSO 4). The AVHC also pursues supervisory activities by collecting the information provided by RHCs during their quarterly meetings to assess the VHCs’ ongoing work and initiate supportive measures.

Organizational capacity closely relates to the composition and rotation of staff members. It should be noted that most CBO members (approximately 90%) are women (Tobias Schüth, 2011a). The CAH initiated several studies on the role of gender in VHCs and their activities (Development Planning Unit, 2010; Walker, 2013), but external evaluators did not find any conclusive impact of gender on CBOs. The project has also attempted to encourage male participation in the project, particularly in the areas of brucellosis, alcoholism, and tobacco abuse (SDC, 2014). These attempts also included organizing competitions, such as “Ülgülüü Ata” (a model Dad in Kyrgyz), where men had to complete certain tasks and answer questions relating to the VHCs’ work to receive valuable prizes (PIL Research Company, 2017). The project, however, did not achieve its intended 70/30% gender representation since male participation dropped over time (Gotsadze & Murzalieva, 2017). Civil society representatives interviewed for this research similarly suggested that just two or three men participated in their activities, though these men were not members: one worked as a veterinary, one for the local authorities, and one in social services (CSOs 2 and 5). The majority of VHC members were women (ibid.).

Extensive labor migration and conventional gender roles in the Kyrgyz society contribute to the prevalence of women in community-based organizations. These roles, for instance, include the assumption that a household’s health is viewed as a woman’s “responsibility” and that women (in contrast to men) are not associated with a role of breadwinner. Men in rural areas leave for the cities, go abroad to work in construction, or go to the mountains to look after the livestock (CSO 5). As the men leave, the women stay at home to take care of the household. The VHCs’ outreach activities target the villagers who are at home, and these are mainly women (Development Planning Unit, 2010). Traditional roles in the Kyrgyz society also view men as “breadwinners” and women as “caregivers” in households. My interviewee emphasized the fact that health continues to be seen as “the responsibility of women” (CSO 1). Men declined to participate in the CAH due to the unpaid nature of the work and the inconvenience of discussing health issues, such as female reproductive health (Development Planning Unit, 2010). Overall, the prevalence of women, however, was not limited to community-based organizations but mirrored the general tendency in civil society organizations in Kyrgyzstan (see the following section).

At the same time, not all women join community-based organizations. Depending on their age, women enjoy different statuses in society and in their families. Young women are expected to look after their children and in-laws and are under the strict supervision of their husbands and in-laws. Older women, however, have a higher status in society and in their families, fewer household responsibilities, and, therefore more time and freedom. My interviewee stressed the inability of younger women to participate in the VHCs despite their willingness due to resistance from their husbands and in-laws (CSO 7). For this reason, the VHC members are mainly women aged 40–50, who are unwilling to leave their positions in community-based organizations (ibid.). The majority of these women are housewives (CSO 5) and have just secondary school-level education (CSO 2). For this reason, training courses for the VHCs, for instance, were adjusted accordingly and used simplified terminology (CSO 1). Previous research on the VHCs was ambiguous about the social status and profession of VHC candidates (e.g., Kickbusch, 2003). Although this research cannot generalize the findings gained from a limited number of interviews, it nevertheless provides an important insight into the profile of the VHCs.

Remarkably, there was no issue with high staff turnover in the community-based organizations. On the contrary, my interviewees pointed to the opposite problem, the difficulty of cadre renewal. There are regulations in the statute of the VHCs or the statute of RHCs regarding the length of service of committee members (CSO 4), but some members are unwilling to step down or to delegate their authorities to younger counterparts (CSO 4; IO Partner 5). This concern was also expressed in external evaluations of the project, which stated that the majority of the VHC members who were interviewed had worked there for 10–13 years (T. Gotsadze & Murzalieva, 2017, p. 18). In other words, they were not newcomers to the committee. However, in addition to their unwillingness to leave, local culture was also a contributing factor in the age profile of the VHC leaders. The VHCs I interviewed stated that they were trying to attract younger volunteers, but young women cannot participate if their husbands or in-laws are against it (CSOs 5 and 7). These findings confirm the problem of recruitment of new volunteers but contradict the issue of high staff turnover pointed to in the literature on community-based organizations (e.g., Ajayi et al., 2012; Sebotsa et al., 2007; Walsh et al., 2012).

Consequently, VHCs as organizations depend on single leaders. Earle et al. (2004, pp. 31–32) point out that community-based organizations in Central Asia are built around a “charismatic, strong leader,” and with fifteen members registered, only one can actually be active. Similarly, my interviewees, closely working with the VHCs, noted that the organizations largely depend on the leader (CSO 4). If a leader left without an “equally strong” successor, the VHC started “losing its positions” since the work and initiatives depended on one or two people, with others “passively” following them (CSO 1). In the long-term perspective, this dependence on one single leader jeopardizes the capacity of the community-based organizations.

Overall, community-based organizations demonstrate exceptional capacities due to their members’ motivation to bring positive changes to their communities. Interestingly, the social and economic factors in the country, along with the conventional gender roles, contributed to the prevalence of women among community-based organizations. Nevertheless, this section emphasizes the necessity for differentiating the statuses of women in society (e.g., age), which finds its reflection in the CBOs’ composition. Interestingly, in contrast to the literature on community volunteers in health, findings from Kyrgyzstan suggest that organizations struggle more with recruiting new members than with attrition. However, difficulties with recruitment further aggravate organizational dependence on single leaders and increase the vulnerability of organizational survival from a long-term perspective.

In contrast to the CAH, the Global Fund grants involve NGOs working on TB and HIV/AIDS. Overall, the political course Kyrgyzstan took during the initial years after gaining its independence provided a favorable environment for civil society development. The global agenda toward civil society engagement, in combination with the inflow of donor funding, nourished this situation further, encouraging the establishment and development of nongovernmental organizations. Once called the “land of NGOs” (see a quote by Edil Baisalov in Pétric, 2015, p. 49), the country had, in 2007 alone, more than 14,000 officially registered NGOs (Ancker et al., 2013). This increase also owes to the Global Fund grants to the country. Several respondents interviewed for this research noted that some NGOs were deliberately established to “siphon off” Global Fund grant money (IO Partner 21), implement the grants, and close right after the grant completion (IO Partner 3). However, the number of these “pocket” NGOs seems to have decreased with time under the pressure of other civil society organizations (ibid.) and their “collective action” (Spicer et al., 2011b, p. 1752).

Local NGOs in Kyrgyzstan have relatively good capacity. Organizations are known to have a “strong workforce” compared to their counterparts in state institutions or even civil society organizations in Central Asia (G. Murzalieva et al., 2009, pp. 64–69). Like community-based organizations, the NGO sector is dominated by female members (Development Planning Unit, 2010). Despite some attrition, particularly at the level of outreach workers (Harmer et al., 2013), core staff members remain in their positions, contributing to the advantage of NGOs also vis-à-vis state organizations discussed in the following subsection. However, problems with organizational skills were reported in areas such as legal protection for the participants of harm reduction programs (Wolfe, 2005), data collection, and some staff members’ limited understanding of the end goals of their activities (Murzalieva et al., 2009). Reported among the social and outreach workers, the last problem could also be the outcome of frequent staff rotation at this level.

The Global Fund contributed to the NGO’s capacity. The grants advanced the managerial and administrative capacities and “professionalization” of the NGOs (Harmer et al., 2013, pp. 302–304) by organizing multiple training activities for the organizations implementing the grants (see UNDP, 2014). The grants also facilitated the recruitment of additional staff members (Spicer et al., 2011a) and the introduction of new positions, such as “social workers” and “outreach workers” (G. Murzalieva et al., 2009, p. 58). In addition, the limits on personnel costs in the grants resulted in low salary levels and significant staff rotation (ibid.). The NGOs solved these issues by decreasing the number of outreach workers and increasing the workload of the existing staff members (ibid.).

Capacities vary across NGOs depending on the area in which they are working. Smaller organizations have limited resources, fewer skills, and less knowledge than larger NGOs (Spicer et al., 2011b). Moreover, the organizations established earlier and those working with multiple partners have gathered sufficient experience and networks to rely on. These NGOs, as a rule, are less dependent on single funding sources than those working with few partners (Chap. 9). In addition to size, organizational abilities seem to vary across areas. Several interviewees noted the higher capacities of organizations working in HIV/AIDS (State Partner 4) than those in TB (CSO 6). This difference results from varying opportunities and emphasis in the two areas.

Tuberculosis was seen as a state realm, with detection and treatment provided mainly by state medical institutions. HIV, in contrast, involved NGOs in detecting persons affected by this infection and persuading them to commence and continue their treatment. This difference in attitudes precipitated the incentives and opportunities for civil society organizations. Underdeveloped in tuberculosis, NGOs flourished in the area of HIV. In 2007, for instance, 200 organizations focused on this area (Ancker & Rechel, 2015b). Although insignificant in relation to the total number of registered NGOs, this number is still impressive in the context of population size and the burden of disease. NGOs working in HIV also have a network of organizations with considerable advocacy and community-mobilization skills, which contributes to their participation in HIV policy and decision-making processes (Foundation for AIDS Research, 2015). One interviewee emphasized that there were continuous training, roundtable, and meeting opportunities in HIV, with analogous activities for the organizations working in tuberculosis having commenced rather recently (CSO 6). Following the growing emphasis on TB and the decreasing share of external aid for HIV, civil society organizations seem to have reshaped their profiles and worked accordingly (CSO 8).

Overall, local NGOs, similar to community-based organizations, have relatively high capacities. Organizations are dominated by female members and face a certain level of attrition, although not necessarily among the core staff members. The Global Fund has contributed to the increase in the number of NGO staff and the growth of this sector in the country in general. Indeed, the organizations also developed in response to the emphasis and consequent funding and opportunities, which found its reflection in differences among the organizations working in TB and HIV/AIDS. As the emphasis is changing, the organizations seem to reshape their focus accordingly, which may also change the capacities and number of organizations working in tuberculosis.

Furthermore, similar to other developing countries, Kyrgyzstan faces the problem of human resources in state organizations, which affects their abilities to perform their functions. There is a general problem with high staff turnover (Majtieva et al., 2015), political instability (Ancker et al., 2013), and the low human resources capacity in government organizations (Spicer et al., 2011b).

The Ministry of Health is a natural choice for a state partner for health care projects, but this book focuses on the organizations subordinate to the Ministry and directly involved in the selected health care projects. The Ministry of Health is the major state actor in health, which is responsible for defining and implementing the national policy in this area, ensuring access to and the quality of health care, and coordinating all actors in this area (see Government of KR, 2009). Although critical to health care programs and policies at the national level, the Ministry rarely participates in health care programs directly, instead via agencies representing it. For this reason, this section focuses on the capacities of relevant agencies and not the Ministry itself.Footnote 1

The CAH closely collaborated with the Republican Center for Health Promotion and Mass Communication under the Ministry of Health (hereinafter the Republican Center) and its subunits at district and regional levels, also known as Health Promotion Units. The Republican Center (2022) is responsible for health promotion and disease prevention. Although recently renamed, it was established as early as 2001 to separate health promotion and protection services traditionally provided by the Department of State Sanitary-Epidemiological Surveillance under the Ministry of Health and its branches (Meimanaliev et al., 2005). The Republican Center has branches in Bishkek and Osh, as well as at regional and district levels. The Health Promotion Units (HPUs) at district levels were piloted and supported within the framework of the CAH (ibid.). HPUs are part of primary health care (Family Medicine Centers) but report directly to the Republican Center (Tobias Schüth, 2011a). There is approximately one HPU per 10 villages or 20,000 people (ibid.). HPUs support the organizational development of the Village Health Committees by providing training and monitoring their health care activities (Schüth, 2011b). As of 2017, there were approximately 130 HPUs in the country (Gotsadze & Murzalieva, 2017).

HPUs are critical to the activities and development of community-based organizations, but low salaries and extensive workloads jeopardize HPUs’ ability to perform their functions. HPUs have firsthand experience working with Village Health Committees by supporting organizations in their awareness-raising activities and conducting training areas targeted in national health care programs. HPUs also collaborate with Rayon Health Committees by jointly conducting awareness-raising activities and evaluating VHCs’ capacities. At the end of the CAH, many trainers who had previously worked with the SRC moved to jobs in the HPUs, which contributed to the continuity of knowledge and experience of the project (Gotsadze & Murzalieva, 2017). However, one interviewee emphasized that some positions were unfilled since trainers were unwilling to work for a monthly salary of 6000 KGS (about €64).Footnote 2 In these cases, the responsibilities were reassigned to existing medical personnel already tasked with receiving patients and home visits and would therefore have little time to engage with community-based organizations (State Partner 4). Combining the functions of the HPU with another job certainly affects the HPU’s abilities to work with the VHCs.

Accordingly, the actual work of HPUs with community-based organizations is contingent upon the motivation and willingness of individual HPU members. It also depends on Family Medicine Centers (FMC) employing the HPUs. The interviewee noted that the HPUs collaborated closely with the VHCs in cases in which the heads of the FMCs were committed to working with community-based organizations (State Partner 4). Indeed, support from FMCs is also critical to the evaluation of VHCs because medical organizations provide transportation and per diem costs for HPUs to conduct evaluation activities.

Furthermore, local self-government bodies are pivotal to community-based organizations and their activities. Regulated at the national level by the Cabinet of Ministers, these are elected (representative) and appointed (executive) at the local level but are accountable to the President and the Cabinet of Ministers (Government of KR, 2021).Footnote 3 The sizes of local self-governance bodies differ. The executive bodies are set by the Cabinet of Ministers, whereas the representative bodies are proportional to the sizes of related constituencies (ibid.). The local self-governance bodies have critical responsibilities in their domain. The organizations are responsible for drafting, approving, and implementing the local budgets and for social and economic development of their constituencies, including issues with access to potable water, sanitation, waste disposal, and other matters (ibid.). Major sources of funding for these purposes come from public finances received from higher levels and finances obtained from local taxes (Tobias Schüth, 2011a).

Nevertheless, the financial and administrative capacities of local self-government bodies are case dependent. One interviewee reported that the financial capacity of the local self-governments varies throughout the country, and yet, most are subsidized by the national government (State Partner 9). In addition to the budget deficit, administrative capacities are further hindered by the unstable political situation in the country, causing rapid turnover among local authority officials. In this regard, several interviewees aptly noticed that representatives of local self-governments change as if “one is changing dresses” (CSO 2). As soon as the village health committee starts collaborating with a state official, (s)he is replaced by a new one (CSO 7). This high turnover of state officials has a negative impact on collaboration with community-based organizations (ibid.). Indeed, the financial and administrative capacities are case-dependent, and a more general overview of this matter requires a comprehensive analysis of rotations in local self-government bodies throughout the country. However, frequent changes of state officials at the national level support the assumptions made by the interviewees.

CAH also involved representatives of family group practices and feldsher-midwife (akusher) points, which are the first points of contact with the health care system in rural areas (Meimanaliev et al., 2005). These organizations supported the VHCs during the initial stages of the project, also in terms of the analysis of population health (Tobias Schüth, 2011a). This collaboration has also continued beyond the project duration, vividly demonstrated by joint activities on infectious and noncommunicable diseases (AVHC, 2022). Their capacities are reviewed in the following subsection, as the role of medical professionals is equally significant to the Global Fund grants.

In contrast to CAH, the Global Fund grants essentially collaborate with the agencies responsible for tuberculosis and HIV/AIDS services. These are the National Center of Phthisiology (NCPh) and the Republican AIDS Center. Both organizations represent a broader network of vertical services focusing on and responsible for preventing and treating related diseases.

Tuberculosis services in the country include NCPh at the national and tertiary levels, regional and city tuberculosis clinics and centers at secondary levels, and tuberculosis cabinets in family medicine centers at primary care levels (Ministry of Health of KR, 2013). NCPh is responsible for the diagnosis, treatment, research, and coordination related to tuberculosis services throughout the country (Government of KR, 2014). The organization dates back to the Kyrgyz Scientific Institute for Tuberculosis Research, established in 1957 (NCPh, 2022).

HIV services in Kyrgyzstan include the Republican AIDS Center (2021a), its regional units, and the center in the capital Bishkek. HIV testing is provided by 34 labs, including 7 in the regional AIDS centers, 24 in district and city hospitals, and 3 in the medical organizations at the republic level (ibid.). Treatment is available in AIDS centers and family medicine centers in all seven regions of the country (ibid.). The AIDS centers were established in 1989 following the first cases of HIV in the country (Republican AIDS Center, 2021b). The Republican AIDS Center is responsible for coordinating HIV-related services, including detection and treatment, as well as monitoring the HIV situation in the country (ibid.).

Despite the broader outreach, multiple factors, including political instability, staff rotation, and excessive workload, limit the state institutions’ capacity. Frequent changes in decision-makers (Majtieva et al., 2015) and staff rotation have paralyzed state agencies and ministries, affecting their ability to carry out their functions (Spicer et al., 2011b). Furthermore, the Global Fund grants increased the number of staff members of Sub-Recipient NGOs, but the number of employees in state agencies involved in the grants remained the same (Center for Health System Development et al., n.d., p. 19). In this way, the tasks related to the grants were distributed among the existing staff members of the Republican AIDS Center and the National Center of Phthisiology. However, the limited capacities of NCPh and the Republican AIDS Center also prevented them from remaining Primary Recipients of the Global Fund grants. Misappropriation and mismanagement of grants lead to the transfer of the Primary Recipient functions to the United Nations Development Programme (UNDP) (see Chap. 8).

Limited evaluation of training efforts and the broader structural issues in the country jeopardize the outcome of capacity-building activities. Donor organizations are criticized for neglecting the capacity problem in state institutions (UNAIDS, 2005b). However, multiple organizations, including the Soros Foundation Kyrgyzstan, the United Kingdom’s Department for International Development (DFID),Footnote 4 U.S. Agency for International Development (USAID), the World Health Organization (WHO) (Manukyan & Burrows, 2010), and the Global Fund (UNDP, 2015a), provided training to state officials.

Yet, the coverage and intensity of training remain unclear, as there is no system tracking the number of seminars and their attendees (Murzalieva et al., 2009). The capacity-building activities are also jeopardized by staff rotation at the ministries and agencies. As a respondent interviewed for this book noted, capacity-building presupposed having people in relevant positions. However, this was difficult because of high staff turnover, the brain drain from state agencies to donor organizations, and the appointment of relatives and friends instead of candidates with the necessary qualifications (IO Partner 4). This way, capacity-building activities seem to be trapped in a vicious cycle that can be broken only after solving broader issues related to political instability, staff appointment procedures, and low salaries.

In addition to the managerial level, the capacity of state organizations closely relates to the availability of health workers. Primary health care (PHC) workers are critical to health promotion and disease prevention activities. The reforms in the health care system since the early independence toward strengthening PHC and reducing the capacities of secondary and tertiary care levels also reemphasized its broader significance. Commencing in tuberculosis earlier, the tendency toward moving away from the vertical service provision toward its integration into PHC is also growing in HIV.

Nevertheless, the capacities of both PHC workers and those working in specialized services are uneven due to staff attrition and geographic inequity in distribution. There are a sufficient number of medical graduates in the country, but most prefer specialization over general practice. There are 700 family medicine centers in the country employing approximately 2000 family doctors, although at least 3000 are needed for the growing size of the population (Bengard, 2021). Most PHC workers are of retirement age, and there are problems attracting new cadres (ibid.). Low salary levels and limited incentives at the PHC level are among the few reasons. Furthermore, the distribution of PHC workers in urban and rural areas remains unequal. These issues affect TB and HIV, particularly given the risks of nosocomial infections associated with these services. The availability of medical professionals is also affected by larger issues in the country and beyond, including extensive internal and external migration and limited incentives for attracting new and retaining existing health care workers.

Despite government efforts, the salaries of medical workers remain low. According to the Republican AIDS Center, the salaries of a nurse and a doctor were 4000 and 7500 KGS monthly (approximately €43 and €80), respectively (Government of KR, 2017a). The situation was similar in tuberculosis. According to an interviewee, the base rate salaries were approximately 2500 for nurses and 6000 KGS for doctors (approximately €27 and €64 Euro) (Health Worker 1). The final salaries in tuberculosis also depended on the number of successfully treated patients who added to additional payments for nurses and doctors. However, an interviewee noted that with all bonuses, salaries amounted to 10,000 KGS (€107) (ibid.). In this way, the suggested salaries of medical workers in tuberculosis and HIV were lower than the average salary at the country level for 2017 and 2018 (National Statistical Committee of KR, 2023). The government initiated a number of reforms to offer additional incentives in PHC and the health care sector in general. In 2018, it introduced a payment system stipulating additional payments to doctors’ and nurses’ base rate salaries depending on their work experience and work performance (Kudrâvceva, 2018). In 2022, the government initiated an increase in the base salary levels, as a result of which monthly salaries of medical personnel increased to 9000–15,000 KGS (€97–161) (Today.kg, 2022). Despite these increases, the monthly salaries of medical workers remain below the national average (see National Statistical Committee of KR, 2023).

Overall, the capacities of state organizations involved in the “Community Action for Health” and the Global Fund grants are significantly affected by the general economic and political situation in the country. In contrast to civil society organizations, state institutions are particularly disadvantaged by frequent rotation and unequal distribution of staff members. Development organizations have attempted to support capacities by organizing training activities. However, their outcomes remain unclear. Similarly, salary rates remain below the national level despite government efforts. All these factors result in capacity issues that continue to prevent state organizations from exercising their functions to the full extent.

4.4 Aid Dependency

Aid dependency in this book refers to the abilities of organizations to perform their functions and achieve their objectives in the absence of external aid (Chap. 2). This book focuses on the provision of services, be it health promotion, disease prevention, or treatment, by examining dependency in relation to technical (e.g., expertise) and financial assistance.

First, in terms of state organizations, aid dependency varied across the two cases studied in this book. The objectives and activities of the CAH echoed the ideas enunciated in the national programs. Community involvement and strengthening PHC were in the foreground of both “Manas” (1996–2000) and “Manas Taalimi” (2006–2010) (Government of KR, 2006; WHO/Europe and UNDP, 1997). Although commencing as a pilot project in selected districts, the CAH demonstrated the ability of the rural population to take responsibility for its own health, which was essential to the abovementioned reform programs.

The governmental commitment to learning was also evident in the division of health promotion from public health. The Ministry transferred the relevant responsibilities to the newly established Republic Center for Health Promotion and, in so doing, moved away from the system inherited from the Soviet Union, in which the Sanitary Epidemiological Service was responsible for both (Schüth, 2011a). The Semashko health care system generally emphasized treatment over prevention, with limited efforts targeted at health promotion. The newly established institution had no prior experience working with communities. Therefore, the Republican Center for Health promotion closely collaborated with the CAH, supporting its capacity for health promotion and working with communities. Notably, HPUs had limited prior experience in these areas. Specifically established by the Ministry of Health for the expansion of the CAH initiative, they were intended to strengthen the abilities of PHC workers to cooperate with communities (ibid.). HPUs received extensive training within the framework of the CAH (ibid.).

Equivalently, primary health care workers had neither prior knowledge nor experience in engaging with community-based organizations. The paternalistic health care system inherited from the Soviet Union precluded citizen participation (Ferge, 1998) and treated patients as passive service recipients (Field, 1988). Working with community organizations was never a part of the PHC activities before the CAH (Schüth, 2011a). Preventive activities were conventionally limited to individual consultations with patients during their visits or home visits of medical workers to specific groups of the population, such as pregnant women, those with newborns, and those with chronic diseases (ibid.). Therefore, the PHC workers equally received extensive training in the project.

It should be noted that the compelling expertise in community capacity-building the CAH offered was further strengthened with the project collaboration with primary health care and public health initiatives. The Vaccine Alliance (Gavi), United Nations Children’s Fund (UNICEF), USAID, Global Fund, World Bank, and Aga Khan Foundation are among the organizations with which the SRC collaborated within the framework of the CAH. Among others, cooperation with Gavi supported the immunization program in the country (Akkazieva et al., 2009), and work with UNICEF (2016) and other partners launched the Gulazyk program for the distribution of micronutrient sprinkles. USAID was critical to the CAH in multiple aspects (also countrywide expansion) within the framework of its programs implemented between 1994 and 2009 on reforming and strengthening primary health care in Central Asia (see Abt Associates Inc., 2015). The Global Fund supported disease prevention, and the World Bank (n.d.), in turn, provided access to potable water and sanitation systems in rural areas. However, the closest in design was the community-based health care initiative in fifty villages by the Aga Khan Foundation, which adjusted its activities to match the CAH (Schüth, 2011b, p. 31). This coordination benefited community capacity-building efforts in health by reducing project activity duplications and contradictions. Integration with other projects has also strengthened the position of the CAH.

Overall, limited prior experience and knowledge in health promotion and community engagement left the Ministry of Health and its institutions dependent on the knowledge and skills the project offered. The CAH demonstrated the very outcomes of communities taking responsibility for their own health, which the state organizations were interested in. Thus, although not necessarily dependent on financial terms, the recipient state depended on the donor’s technical expertise.

In contrast to CAH, the aid dependency in the Global Fund grants is related mainly to financing. Donor organizations finance a large share of tuberculosis and HIV/AIDS programs in Kyrgyzstan. At its peak, in 2007, donors provided 94% (297.8 million KGS or €3,193,395) and the state approximately 6% (20.3 million KGS or €217,683) of total expenditures on HIV/AIDS services (G. Murzalieva et al., 2009, p. 18). The share of donor contributions decreased with time, but it still represents more than half of HIV-related funding.Footnote 5 Multiple donor organizations participate in TB and HIV/AIDS programs in Kyrgyzstan. The German Development Bank (die Kreditanstalt für Wiederaufbau—KfW) finances laboratory construction, and GIZ provides technical assistance in the area of reproductive health. The International Committee of the Red Cross and Doctors Without Borders cover TB services in prison. The President’s Emergency Plan for AIDS Relief (PEPFAR) and USAID finance TB and HIV programs in the civilian sector, along with an HIV grant from the Russian Federation.

Despite the multiplicity of donors, the Global Fund remained the leading financier of TB and HIV/AIDS programs in the country. In 2004–2006, it covered 69% of all HIV/AIDS-related services, with other donors and the government providing the remainder of the financing (Gulgun Murzalieva et al., 2007, p. 31). Representing over half of the external assistance, the Global Fund finances HIV treatment and nearly all HIV prevention programs among the key groups (e.g., men who have sex with men, commercial sex workers, persons who inject drugs, and others) (Majtieva et al., 2015). Similarly, in the area of TB, the Global Fund covered medications against drug-resistant forms of TB, laboratory supplies, co-payments to health care workers, and other expenses (State Partner 9). In this way, the Global Fund remained the principal financier of TB and HIV services in the country.

In contrast, multiple organizations provide technical assistance in TB and HIV/AIDS. The interviewees specifically emphasized the Joint United Nations Programme on HIV/AIDS (UNAIDS), World Health Organization (WHO), KfW, World Bank, and USAID’s contributions to the development of regulatory documents, management of health care, and building the capacity of state organizations (State Partner 10 and Academic Partner 2; IO Partner 3). Similarly, Global Fund grants stipulate training and capacity-building activities for medical personnel involved in TB and HIV/AIDS services. Therefore, the state officials interviewed for this research suggested that technical assistance was among the “most significant” benefits development organizations offered (State Partner 3) and that without it, the country would end up establishing ineffective and cumbersome systems (State Partner 6). Studies on health aid to Kyrgyzstan similarly highlight donors’ contributions to strengthening laboratory services, establishing sentinel surveillance systems (Wolfe et al., 2008), and revising HIV/AIDS-related legislation (Ancker & Rechel, 2015b).

Despite the significance of all development partners, one could specifically highlight the role of the two United Nations agencies, namely, the WHO and UNAIDS, as primus inter pares in health. Their recommendations are equally followed by the state, civil society, and donor organizations. The Global Fund itself complies with the WHO standards (e.g., Global Fund, 2009) and the UNAIDS (2005a) suggestions. In this regard, Kaasch (2015) notes that although insignificant in terms of financing, the WHO has established itself as a standard setter and a leading actor in the area of health. Similar conclusions could also be made regarding UNAIDS, which specifically maintained its expertise in the area of HIV.

Overall, the Ministry of Health and state agencies on TB and HIV/AIDS collaborate with multiple donors, but they still heavily rely on the financing provided by the Global Fund. However, in technical assistance, the Global Fund, like other donors, conforms to the standards and regulations of other partners that established themselves as standard and norm setters for TB and HIV/AIDS.

As noted in the previous section on capacity, civil society organizations refer to CBOs in CAH and NGOs in the Global Fund grants. The CAH initiated community engagement in health care and facilitated the mobilization of community members to join the VHCs. However, newly established, these organizations had neither the experience nor the resources to pursue their objectives. The literature on grassroots organizations suggests that illiteracy (Jana et al., 2004), gender-related biases (WHO, 2008), political situation, and poverty (Morgan, 2001) all make communities dependent on external aid. According to UNESCO (2023) estimates, over 99% of the population in Kyrgyzstan is literate.Footnote 6 Moreover, members of the Village and Rayon Health Committees faced and overcame multiple issues, including gender-biased treatment from their communities and local authorities, frequent rotation of local self-governments, and resource mobilization hardships (Chaps. 5 and 6).

Nevertheless, similar to the recipient state, communities did not have prior knowledge or skills to participate in the health care system. Through technical and financial assistance, the project intended to build the capacities of community-based organizations throughout the project, but this extensive support has unintentionally contributed to the dependence of community-based organizations on the donor. The CAH was the only project providing comprehensive coverage of the Village and Rayon Health Committees throughout the country. Other donors just engaged with VHCs from specific regions and in certain areas that were compliant with their project objectives. Although continued donor assistance was not the only factor relevant to community capacity-building, the end of the CAH in 2017 exposed community-based organizations to a certain level of uncertainty about their future (Chap. 6).

At the same time, although providing significant technical and financial support at an organizational level, the CAH offered only minor financial incentives to the community volunteers. The project may have covered travel and per diem costs related to health promotion activities. However, the members of community-based organizations did not receive salaries from the SRC. One interviewee pointed out that the CAH would have been able to pay salaries, and initially, volunteers did request payment for their work (CSO 4). However, no salaries were paid to support the continuity of organizations and activities beyond the project, which was also explained to community members and accepted by them (ibid.).

Not everyone stayed, but those who remained were not driven by financial gains but by the willingness to bring positive changes to their communities. Several interviewees noted that those who joined community-based organizations for financial reasons soon resigned (CSO 5). As a result, very few VHC members sought financial gains or declined to conduct certain activities because they were volunteers (CSO 1). Instead, as unpaid volunteers, the community volunteers implemented the project-related activities because of their willingness to bring changes to their communities. Seeing the outcomes of activities generated enthusiasm among the volunteers and a belief that they could “bring something good” to their villages through their work (CSO 5). In this way, the incentives offered by the SRC supported but did not define the VHCs’ willingness to carry out their activities.

As unpaid volunteers, the VHC members could discontinue their activities without any financial consequences to themselves. This financial independence at an individual level evened out the organizations’ dependence on the project because the SRC also depended on the VHC members’ willingness to work. As volunteers, the community members were able to decide whether to continue their work or not. As one of the interviewees noted, no one could point to them, saying, “you should work,” and only those with “initiatives in their hearts” continued (CSO 4). In this way, the SRC (implementing) and the SDC (financing the CAH) depended on the community members’ willingness to work. The lack of financial incentives limited the leverage of development partners over community volunteers.

Civil society organizations’ aid-dependency dynamics differed in the Global Fund grants. NGOs working in TB and HIV/AIDS areas depend on external aid. This dependency is evident in the interruption of services during disruptions in external funding. The delays in Global Fund financing affected NGOs’ service delivery (Harmer et al., 2013). To address the short-term breaks, the organizations involved volunteers; however, the long-term interruptions in 2007–2008 caused the termination of activities and staff turnover due to the disruption of salary payments (Spicer et al., 2011a). Some activities, such as diagnostic and treatment services to commercial sex workers, resumed only after the Global Fund restarted its financing (Murzalieva et al., 2009). Several donor organizations committed their resources to cover the financial gap and address the issue of NGOs’ service interruptions. The Soros Foundation Kyrgyzstan and the UNDP provided “emergency coverage” during funding disruptions in 2004 (Wolfe, 2005, pp. 23–24). The UNDP has also used its own resources for staff recruitment, procurement of condoms, methadone, and the “emergency stock” of antiretroviral medications during the delays in the HIV grant of the Global Fund (2011–2016) (Grant Performance. Report External Print Version. Kyrgyzstan KGZ-910-G07-T, 2016, p. 31). In doing so, the UNDP ensured a continuous supply of medications (ibid.) and provision of other services stipulated in the grants. However, in contrast to the UNDP, local NGOs do not have sufficient financing to cover these costs, even temporarily, during financial interruptions.

However, financial dependency varies across organizations. Those with multiple sources of financing were less affected by the delays (Murzalieva et al., 2009) compared with those solely dependent on Global Fund grants. Accordingly, the perspective of the NGOs interviewed for this research on the continuity of their activities beyond the Global Fund grants varied. While some were optimistic about their continuance (CSO 6), others acknowledged the inability to implement the initiatives on their own (CSO 8) and that the breadth of their activities depended on donors (CSO 9).

In terms of technical assistance, NGOs received multiple but inconsistent training opportunities from donors. The Soros Foundation, UN agencies (Godinho et al., 2005), USAID, Global Fund, and other actors offered technical assistance to NGOs. The Global Fund financed the seminars on social support, strategic planning and fundraising, accounting and document management (see UNDP, 2015b, 2015c), and other areas. However, assessing dependency in terms of technical assistance is challenging, as neither donors, recipient states, nor civil society organizations have a broad understanding of all training activities conducted in the areas of TB and HIV/AIDS. Accordingly, the impact, selection criteria, and compliance of training with the needs of targeted groups are unclear (G. Murzalieva et al., 2009). An NGO representative interviewed for this research suggests that the selection criteria for participants are guided by their rotation and not the NGOs’ specialization. However, the rotation does not contribute to the institutional memory of organizations, which would be enhanced by the more consistent and continuous support of fewer organizations for a longer period (CSO 8).

Overall, both community-based organizations and NGOs depend on external assistance. However, in the case of the former, this dependency was evened out because the community volunteers were unpaid by the project and could halt the activities at any time without any financial losses. In this situation, the donor depended on the willingness of community members to continue their activities. In the case of the latter, the dependency remained. On its own, financial benefits are natural to economic interaction. However, in the context of development assistance, they may unintentionally strengthen the conventional “gift-giving” and “gift-receiving” dynamics between stakeholders (see Hinton & Groves, 2004).

4.5 Summary

This chapter explored the structural factors relevant to both interactions between stakeholders and the sustainability of health projects. Focusing on the actors relevant to the selected cases, it examined the predictability and flexibility of aid on the sides of donors, as well as capacities and aid dependencies on the sides of recipients.

  1. 1.

    The chapter has vividly demonstrated that despite the acknowledgments of and commitments to ensuring predictable aid, Switzerland and the Global Fund varied considerably in their achievements. Although performing better than the average bilateral partner or a vertical health care program, the two actors nevertheless provided varying predictability due to their development cooperation structure. Indeed, Switzerland has performed better by offering a longer duration of assistance than does the Global Fund.

  2. 2.

    The comparative overview of the two actors has equally demonstrated their commitment to providing flexibility. Both put a great emphasis on the recipient’s ownership. Accordingly, the Global Fund finances the proposals developed by applicants and is in accordance with their national strategies. Switzerland, in turn, places great value in defining the objectives in collaboration with partner countries. Correspondingly, the decentralization and autonomy of field offices provide the space for adjusting the activities to local needs and priorities. Driven by similar objectives, the Global Fund focused on concentrated decision-making with the rest of the activities performed in recipient countries. However, this concentration hinders the flexibility of assistance by affecting the responsiveness to changes occurring in the applicant countries. Another hindering factor is accountability before financiers, which equally affected the Global Fund and Swiss aid, having to balance accountability toward the funders and recipients of aid.

  3. 3.

    The capacities of state organizations involved in both health initiatives are extensively constrained by the political and economic instability in the country, causing frequent staff rotation, limited institutionalization, and a limited range of incentives available to state employees. Notably, these factors seem to have an equally annihilatory impact at both the decision-making and service-provision levels. Interestingly, their effect on civil society organizations was less and uneven. The economic situation in the country facilitated migration, which, combined with conventional gender roles in households and society, contributed to the recruitment and retention of women in community-based organizations. Nevertheless, not all women join organizations that seem to depend on single leaders. Similarly, dominated by women, the NGO sector has also demonstrated a relatively strong capacity, particularly in comparison to state institutions. However, the capacities greatly vary across the organizations and sectors, with the organizations in HIV performing better than those in TB.

  4. 4.

    The broader political and economic instability in the country has contributed equally to the dependency of national actors on external aid. At the same time, the dependency on technical assistance observed in the CAH contrasts with the dependency on financial support offered in the Global Fund grants. Certainly, the organization provides substantial technical support to all stakeholders involved in its grants. However, the significance of this support in relation to financing seems smaller, particularly in the context of other technical partners. Having limited funding to offer, these have established themselves as arbiters of standards and norms equally followed by other development partners and state and civil society organizations. In the case of civil society, nonpayment of community volunteers evened out the dependencies of CBOs on donors, which did not occur in NGOs, whose activities remain financially dependent on donors.