Keywords

This chapter discusses the interaction among the principal actors over the life cycle of the “Community Action for Health” (CAH) project by grouping them into the following analytical categories.

First, the recipient state refers to the Ministry of Health, represented by the Republican Centre for Health Promotion and Mass Communication under the Ministry of Health (hereinafter the Republican Center) and its subunits, and primary health care workers who participated in the project and collaborated with community-based organizations. It also encompassed local self-governments at the village, city, and district levels, which are directly accountable to the President of the Kyrgyz Republic and the Cabinet of Ministers. Community-based organizations at the district level work with authorities at this level, but for those at the village level, the local self-governance bodies at the village level are of particular importance. These are local councils (ayyl kengesh) elected by local communities, with the size of these councils being proportional to the size of the related constituency (Government of KR, 2021). A structure of an executive body (ayyl ökmötü) is defined by the Cabinet of Ministers at the national level, but the head of the executive body at the district level appoints the head of ayyl ökmötü (ibid.).

Second, civil society organizations are community-based organizations (CBOs) established within the framework of the CAH project. These include the Village Health Committees (VHCs) in a village, Rayon Health Committees in a district, and the Association of VHCs at the national level.

Third, donors denote the Swiss Agency for Development and Cooperation (SDC), which financed the CAH, and the Swiss Red Cross (SRC), which implemented it. I conceptualize each as a “donor” because the SRC was the key actor working with CBOs, and in so doing performed the role of the “donor” on the ground. However, a number of other development organizations supported CAH. The Swedish International Development Cooperation Agency (Sida) and the United States Agency for International Development (USAID) joined the project at a later stage and were essential to the expansion of the initiative throughout the country. The list of other international organizations contributing to the project includes the Liechtenstein Development Service (Schüth et al., 2014a), the German Corporation for International Cooperation (die Deutsche Gesellschaft für Internationale Zusammenarbeit—GIZ), the United Nations Children’s Fund (UNICEF), the World Bank, the Soros Foundation, the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund), the Interchurch Organization for Development Cooperation, the Asian Development Bank, and the World Health Organization (WHO), among others (www.cah.kg n.d.). Nevertheless, Sida and USAID remained the major donors (in addition to the SDC), since the contributions of other organizations were limited to specific project activities complying with the areas targeted by those organizations.

5.1 Initiation

The initiation of the “Community Action for Health” project coincided and corresponded with the country’s transition from the Soviet-style Semashko health care system. The government aimed to optimize health care spending and emphasize citizens’ responsibility for their health, as opposed to the idea of health care being a state responsibility, which was in the foreground of the previous system. First, as part of optimization reforms, the national health care reform program “Manas” (1996–2005) intended to address the majority of health care issues at the primary health care (PHC) level and decrease the number of referrals to secondary (or hospital) care (Government of KR 1995). Accordingly, the government aimed to increase public funding to PHC and cut the number of hospital beds per capita to decrease the maintenance and utility costs spent on health care facilities and secondary care. A state representative interviewed for this research estimated that in one district of the Naryn region, for instance, just two or three facilities were retained out of twenty, with the rest being demolished (State Partner 1). Second, the “Manas” program emphasized people’s responsibility for their own health (Government of KR 1995). The government propagated the idea of citizens taking preventive measures to improve their health instead of depending on the health care system (State Partner 1). In so doing, it attempted to delegate at least part of its responsibility for health to the population.

The CAH project was in line with the health care reform agenda at that time, but it is not clear who initiated the project. According to Gotsadze and Murzalieva (2017, p. vi), the Ministry of Health approached SDC in the early 2000s to design a program for health promotion in rural areas. In other words, the Ministry was the one who initiated the project. However, the CAH also may have been the outcome of a donor initiative. Indeed, the national program “Manas” highlighted the responsibilities of the population for their own health (Government of KR 1995), but it did not stipulate any means for citizens to express their wishes and concerns about the reform process. The CAH, on the contrary, stressed the role of the local population in defining the issues to be targeted by the program. This emphasis on the involvement of groups targeted by health care programs in the decision-making process (SRC n.d.) and the empowerment of communities (SDC 2003) corresponded to the objectives of the organizations financing and implementing the project.

The CAH occurred in the second phase of the Kyrgyz–Swiss Health Reform Support Project. Following the request from the Ministry of Health, the first fifteen months of this initiative, from January 2000 to March 2001, were dedicated to the renovation of two remote hospitals in the Naryn region (Schüth 2011b). However, as the agreement between the SDC and the Ministry stipulated supporting health care reform in the Naryn region as a whole, the SRC planned to increase the scope of activities in the second phase of the project, which commenced in the summer of 2000 (ibid.). The organization invited the SRC for this purpose. This choice was not surprising since Swiss development agencies tend to provide a large part of the development assistance through Swiss nongovernmental organizations (OECD 2014). The increase in the scope of activities materialized through the involvement of communities in the planning, implementation, and evaluation phases of the project, corresponding to the principles of the SDC and SRC (Schüth 2011b). To identify the priorities of the population in health care reforms, the SRC invited a project coordinator, Dr. Tobias Schüth, to conduct a qualitative study among the communities.

The initiative on community involvement in health care reforms commenced with an appraisal of people’s views on health care services and their priorities for reforms. The appraisal was conducted in the At-Bashi and Ak-Talaa districts of the Naryn region. The study covered district centers and three villages of various distances from the center (Schüth 2000), and used the Participatory Reflection and Action approach, formerly known as Participatory Rural Appraisal (PRA). PRA encompasses approaches and methods that “enable local (rural and urban) people to express, enhance, share and analyze their knowledge of life and conditions, to plan and to act” (Chambers 1994, p. 1253). By using this approach, the SRC intended to understand communities’ perceptions through their analysis of problems and solutions. The SRC trained a study team of eight members, which also included representatives of different state departments (Schüth 2000). To cover various community groups, the organization engaged volunteers to conduct separate interviews with vulnerable groups, such as the poorest households, pregnant women, mothers with young children, and people with disabilities (ibid., pp. 16–19).

The communities were asked about the most pressing diseases, their priorities in health care, and their awareness of the “Manas” health care reform program. The most frequent diseases identified by people were brucellosis, anemia (mainly in women), high blood pressure, dental diseases, goiter, and liver disease (Schüth 2000). People’s priorities in health reforms related to access and quality of health care. This included the availability of specialized health care services and ambulances in remote areas, higher salaries for medical staff, combatting bribery at district hospitals, and so forth (ibid., p. 8). The appraisal demonstrated uneven access to health care, dependent on the social status of a household. Traditional healers were the first point of contact for the villagers, though better-off households also used health facilities at the district level (ibid., p.7). In general, the villagers spent less on health care than the residents of districts did. Overall, the respondents “had heard” about the “Manas” health care reform program and were willing to learn more about family group practices and eligibility for the health insurance scheme (ibid., pp. 8–9, 47–48). People were even ready to pay a small amount of money for the health brochures (ibid.). In general, the initial study demonstrated the interest of communities in the health care reform program and their readiness to participate in health promotion.

Notably, the recipient state participated in the initial appraisal of the population’s concerns and priorities (e.g., the PRA sessions), which was essential to state interaction with community members. The study team of eight members, trained by the SRC, included representatives of different state departments (Schüth 2000). The state actors worked with communities in defining their concerns. The participation of the recipient state in the appraisal was key to its interaction with communities. The SRC also encouraged community members to present the results of the initial study to the Ministry of Health in Bishkek, which was “well received” by the Ministry (Schüth 2011b, p. 24).

It should be noted that the Swiss actors (SDC and SRC) were the only donors involved in initiating the CAH, possibly due to the general division of labor among the donors in the country, a result of the sector-wide approach (SWAp) to health care in the country (see Chap. 1). Formalized in 2005, the SWAp has been in use in Kyrgyzstan since 1996 (see Isabekova and Pleines 2021). For this reason, the fact that the Swiss actors were the only donors working in the area of community engagement in health care reforms also may be the outcome of negotiations taking place in the SWAp.

Overall, the initiation phase suggests that the CAH may have equally been a donor initiative and an initiative of the recipient state. The initiation of this project coincided with the transition from the Semashko health care system. This transition was consistent with the interests of the recipient state, which, in the face of social and economic crises in the country, was willing to delegate part of its responsibilities to citizens. However, the project emphasized community engagement in the decision-making process, which was consonant with the principles of the SDC and SRC. Although the source of the initiative is ambiguous, the CAH nevertheless addressed pressing issues of the local population, which also was reflected in their interest and readiness to collaborate with the project.

5.2 Design

The design of the project was developed in collaboration with community members. The CAH commenced in the Jumgal district of the Naryn region. Selection of this region complied with the renovation of hospitals (IO Partner 11), which took place in the same area. Another reason for the selection of this region was poverty. My interviewees note that the project commenced at a time of extreme impoverishment (CSO 7), and the Naryn region was among the poorest in the country (IO Partner 5). The CAH pursued two overarching goals, namely, supporting the communities in taking action for their health and building the partnership between the state health care system and communities (Schüth n.d.). These goals were further divided into smaller objectives and project activities, jointly identified by the SRC and communities in the PRA sessions.

The PRA sessions followed the principle of “nondominance.” In a nutshell, this principle meant respectful behavior, which aimed to provide a space for the actors to express themselves and be heard by another party. This respectful behavior intended to overcome conventionally unequal roles between the providers and recipients of aid by emphasizing the fundamental equality of all stakeholders involved in development assistance (Schüth 2011b). The sessions stressed the expertise of local people and noninterference in the discussions. The emphasis was on local people as the ones “who know” and the project team being the ones “who learn from the people” (ibid., pp. 23–24). The SRC and the primary health care staff aimed to encourage the discussions without “guiding” them. Noninterference in the discussions meant “accepting people’s views without judging them as right or wrong” (ibid.).

Dr. Tobias Schüth, a project coordinator invited by the SRC, stressed the role of nondominance in relationships among the actors throughout the project cycle. Both the SRC and state representatives engaged in the project complied with this principle. The project recruited staff members who “were good with people, behaved in a good way, and were quick to pick up things” (IO Partner 11). The SRC also trained and involved the local primary health care staff in the PRA. A former state official interviewed for this study emphasized the collaboration of the Ministry of Health and the SRC in forming health committees in the Jumgal district (State Partner 1). The involvement of state institutions was critical for the further nationwide rollout of the program because the recipient state, and not the SRC, conducted the PRA sessions beyond the pilot districts. No other donor organization participated in the initial design of the CAH, as USAID and Sida joined the project at later stages.

The PRA sessions were intended to define those diseases that were of pressing concern to communities and to the community perspective on how to stay healthy (IO Partner 11). The sessions took place in every village and involved approximately 50–80% of households (Schüth 2011a, p. 147). A PHC representative gathered approximately ten people from a neighborhood and supported them during their analysis using the PRA approach (ibid.). Since most of the PRA participants were women (as they were the ones at home), separate sessions were organized for men to consider their opinions (ibid.). The outcomes of the survey varied across the regions but generally included goiter, alcohol consumption, anemia, hypertension, brucellosis, and so forth (see Isabekova 2021). In addition to listing problems, the PRA participants also brainstormed and listed their ideas on “what do you need to stay healthy in this village?” (Schüth 2011b, p. 32). They compiled a list of determinants of health, which included broader issues, such as the lack of public baths or access to potable water. The facilitator (e.g., the SRC or primary health care staff) compared this list to the elements of primary health care outlined in the Alma-Ata Declaration (1978) (see WHO/Europe n.d.), which encouraged the participants since their list often contained most of or even went beyond the elements outlined in the declaration (Schüth 2011b).

In addition to defining the problems and potential solutions, the PRA sessions were used to mobilize community members. The participants were asked to nominate trustworthy, “active and community-minded” people from their neighborhoods (Schüth et al., 2014a, pp. 5–6) to become members of the VHCs, which intended to take action on the problems and determinants of health. My interviewee noted that the project, in a way, identified “people respected and influential in villages” (CSO 2). Nomination and election to the VHCs by village residents contributed to the recognition of candidates by the local population, which was essential to the subsequent implementation of the project. Importantly, the selection of the VHC members took place via secret voting of PRA participants to ensure the election of persons willing to work and not merely influential in their communities (Tobias Schüth 2011a, p. 151). During a public vote, people were often willing “to be seen” to vote for persons influential in their communities (ibid.).

The CAH was built around close collaboration with local communities. During the initial stages, project staff members lived in the local communities (Schüth 2011a). This has allowed continuous interaction with community volunteers. The interviewees noted that the project members incorporated the perspectives of local communities into ideas by asking for feedback from community members and adjusting these ideas accordingly (IO Partner 11). Thus, the decision could have been made in the morning and changed in the evening if the initial idea did not work out (IO Partner 5). This interaction allowed further adjustments of activities to the lives of community volunteers. As one interviewee noted, while present on site, the project workers did not limit themselves to the “usual” working hours but to the time the community members could spare between their daily responsibilities. The interviewee highlighted that this flexibility and immersion into the context discerned the differences with other projects following the “usual” working hours and visiting community members on an occasional basis (IO Partner 5).

Overall, this section demonstrated a close collaboration among community representatives, the SRC, and PHC workers commissioned by the Ministry of Health to support the initiative. The following countrywide rollout of this project involved the health promotion units (HPUs) established by the Ministry of Health. The expansion also has involved the USAID representatives that funded the Jalal-Abad and Issy-Kul regions. The countrywide extension of the project is elaborated on in the following section.

5.3 Project Implementation

Multiple stakeholders participated in implementing the “Community Action for Health” in Kyrgyzstan. Nevertheless, close collaboration among the donor, state PHC, and community-based organizations was a distinctive characteristic of this project. The health-related activities in the project included three components: essential research, awareness-raising, and data collection for monitoring and further research (Schüth 2011a).

First, the essential research conducted and analyzed by the VHCs was intended to provide deeper insights into community problems and further encourage the CBO members to work with them (Schüth 2011a, p. 151). A participant interviewed for this research notes that following the PRA seminar, its participants surveyed the local population by visiting “every second house” (CSO 2). In addition, they attempted to organize general meetings by gathering people “from every street.” However, the participant admits that convincing people to attend these meetings was “difficult.” The interviewee notes that surveying the local population and disseminating the information about the CAH in a way demonstrated the abilities of those nominated to become VHC members to reach out to the local population (ibid.).

Second, the awareness-raising was conducted within the project, mainly by providing information materials, although at times individual consultations and explanations aimed at behavioral and lifestyle changes (Schüth 2011a). The VHCs targeted a broad spectrum of health care issues (see Isabekova 2021). These included decreasing alcohol consumption, controlling brucellosis, anemia, tuberculosis (TB), smoking, hypertension, sexual–reproductive health (Schueth 2009), promoting “safe nutrition” (iodized salt, fortified flour, meat consumption), and increasing awareness of childhood diseases such as diarrhea, influenza, acute respiratory infection, and others (PIL Research Company 2017). Most of these issues were identified by the village population in the surveys conducted by the VHCs during the project design. In addition to survey results, the VHCs also targeted priority areas highlighted in the national health care program.

Following the focus of this research on TB and HIV/AIDS, I will describe the VHCs’ activities in regard to these diseases. TB was not one of the priority areas defined by the population (Schüth et al., 2014a, p. 19), but it was among the issues targeted by the VHCs, also due to the problem of drug-resistant tuberculosis in the country. Kyrgyzstan, similar to other countries in the post-Soviet region, has a high prevalence of the multidrug-resistant form of tuberculosis, particularly among previously treated patients (Isabekova, 2019b). The absence of tuberculosis among the issues prioritized by the communities may relate to its prevalence in urban, rather than rural, areas (ibid.). The “Manas” (1996–2006), “Manas taalimi” (2006–2012), and “Den Sooluk” (2012–2018) health care reform programs listed TB among their priority areas (Government of KR 2006, 2012; WHO/Europe and UNDP 1997). Therefore, the inclusion of TB in the areas targeted by the VHCs made their work compliant with national health care policy. The VHCs received leaflets on the importance of treatment continuity and its completion, as well as nondiscrimination against patients with TB (Schüth et al., 2014a, p. 20). First piloted in Chui and Issyk-Kul regions, these dissemination campaigns were expanded to the country as a whole in 2013 (ibid.).

In contrast, HIV/AIDS was, in a way, among the issues prioritized by the villagers and the national health care programs. Reproductive tract infections were among the priorities listed by people in all oblasts (Schüth et al., 2014a, p. 19). HIV/AIDS also was among the priority areas listed in the national health care reform programs “Manas” (1996–2006), “Manas taalimi” (2006–2012), and “Den Sooluk” (2012–2018) (Government of KR 2006, 2012; WHO/Europe and UNDP 1997). Correspondingly, the VHCs implemented campaigns to raise awareness of sexually transmitted infections, including HIV/AIDs, in collaboration with the SRC, other donors, and local actors. Working with school parliaments (a body composed of pupils elected by pupils to represent their interests before the school administration) and teachers, the VHCs circulated an educational course called “The road to safety” for students of the 9th–11th grades. This course used DVDs on sexual and reproductive health, developed in the framework of CAH’s collaboration with GIZ (Schüth et al., 2014a, p. 19). To target the working-age population, the VHCs visited local businesses (CSO 2) and conducted seminars with potential labor migrants—the youth—due to a large amount of labor migration to Russia and Kazakhstan. For instance, in the city of Osh, in the south of the country, the VHCs informed migrant workers about TB, HIV/AIDS, and treatment possibilities as part of CAH’s collaboration with a global nongovernmental organization—the Interchurch Organization for Development Cooperation (Schüth et al., 2014a, p. 25). Thus, in contrast to the VHCs’ activities for TB, the awareness-raising campaigns for HIV/AIDS complied with the priorities of both the local population and the national health care program.

Third, data collection and monitoring took place at a district level, based on the essential research conducted by the VHCs during their work with target groups or selected research (Schüth 2011a). The data compiled at the district level were further sent to the Republican Center and supporting health care projects at regional and national levels (ibid.). The information exchange also was intended to inform both state and donor organizations about the VHCs’ findings and to compare the coherence of priorities with those identified at the community level.

It should be noted that the SRC supported the VHCs in their activities by providing technical and financial assistance for dissemination campaigns, organizational capacity, and resource mobilization. The SRC offered training courses in a number of areas, but I focused only on those indicated in the project-related documents and mentioned by my interviewees.

First, the VHCs learned how to work with the population and organize seminars. During the dissemination campaigns, the VHC members gathered the villagers to inform them about preventive measures and health promotion. In this regard, the VHCs followed the principle of nondominance promoted by the SRC. A VHC representative interviewed for this research noted that training pertained to building relationships with others and identifying issues. According to her, becoming a VHC member implied “understanding the work” and finding “a common language with people.” Therefore, “giving orders to others” by pointing at the information they “should learn” about the diseases relevant to them was “not right” (CSO 5). The VHCs used the principle of nondominance during the seminars to build a dialogue between medical workers and the population groups affected by the various diseases. They also followed this principle in relation to each other, irrespective of their position in the VHC, be it a head or a member of the organization.

Through their close work with communities, the VHCs, unlike the state health care workers, were familiar with the health issues of specific households. By offering blood pressure checks, for example, the CBOs were aware of members of the community who had hypertension (CSOs 2 and 5). The VHCs prepared coffee breaks and gathered local health care workers and people affected by the different diseases (CSO 5) to increase awareness of danger signs, symptoms, and preventive measures against specific diseases, such as hypertension, anemia, diabetes, and others.

It should be noted that medical personnel were not always supportive of the VHCs’ work. There were occasions when health care workers did not perceive community-based organizations as equals or even competed with them. However, this attitude changed due to the support the VHCs provided to primary health care professionals in outreaching the local population and the joint implementation of health promotion campaigns. This change also is demonstrated by medical and community-based organizations congratulating each other on their professional days, namely, September 9 for the VHCs and July 2 for medical professionals (AVHC 2022).

Similarly, the attitude of local self-government bodies has transformed from an initial disinterest to cooperation. My interviewees recalled the initial detachment of local authorities toward the VHCs and their activities (CSO 5) and questions of why VHC members “needed this” (CSO 1). According to one, there also were remarks hinting at a superior position of authorities over community-based organizations, such as “some five women are running around, are those the VHCs?” (CSO 4). However, this attitude changed during the joint implementation of activities. The CAH forethoughtfully offered small grants to which VHCs could apply jointly with local authorities. This collaboration strengthened further within the framework of the project implemented by the Development Policy Institute, which sought to enhance the partnership between the state and VHCs through their joint realization of initiatives (AVHC 2017a). The cooperation also has continued beyond donor assistance. The VHCs I interviewed in one of the northern regions participated in the meetings and the joint committees of the local authorities on social issues, for example, working with poor households (CSO 5). According to the local authority representative in this region, this collaboration had been going on for 4–5 years, and the authority had provided a Certificate of Merit to the VHC member in appreciation of her work (State Partner 12).

In addition to the joint implementation, the attitude of local self-governments toward community-based organizations changed as the authorities realized the potential of community-based organizations (CSO 1). The VHCs work closely with the local population and are aware of their concerns and their living circumstances (CSO 4). This contributes to the expertise of community-based organizations, which is valuable to the local authorities. One VHC representative from another region I visited noted that not a single activity organized by the local authorities took place without the VHC. The interviewee noted that in recent years, authorities often asked for support in mobilizing the local population on the grounds that people’s attitude toward the VHCs was “positive,” in contrast to their attitude toward the authorities (CSO 2). Engaging with the VHCs is essential for the work of local authorities since the VHCs have not only the capacity for dissemination activities but also a certain status in their communities.

Secondly, during the first two or three years after their formation, the community-based organizations received training on bookkeeping and budgeting, and were given office equipment, which intended to improve their organizational capacity (Schueth 2009). The CBOs learned essential budgeting skills to calculate the current financial balance of their organization, and plan their activities accordingly. The SRC also explained how to write appeals to local self-government and enclose the relevant attachments (CSO 5). The VHCs obtained their office spaces from local authorities or medical organizations (CSOs 2 and 5); however, maintenance of these offices and the relevant equipment were provided by the SRC. During my fieldwork, the VHCs presented me their books, receipts for activity-related expenses, as well as the equipment and furniture provided by the SRC, including table, chairs, PCs, printers, and so on (CSO 5).

Thirdly, the CBOs received training on how to write grant applications, and financing to mobilize their resources. My interviewee stressed that the SRC provided not only guidance on how to write proposals, but also the opportunity to work on relevant issues. Another community member interviewed for this research noted that members were unaware of how to write project applications, but trainers elaborated on the writing process. She added: “they explained to us [the application process]… taught us like children. Other projects do not do that” (CSO 7).

In addition, the SRC offered small grants and materials for the VHCs to top up their organizational budget. The VHCs applied for these grants to address the problems highlighted by communities in the initial survey. These grants were used to build public baths, feldsher-midwife (akusher) points (primary health care facility in rural areas), repair water pipes (Health Worker 3; State Partner 1), and support vulnerable households. Poor families received chickens, roosters, chicken feed (CSO 7), and chicken coops built by the VHCs (Schüth et al., 2014a, p. 25). The VHCs used their small grants to build public baths and establish social enterprises, such as sewing workshops and hairdressers, which contributed to the organizational funds of these community-based organizations.Footnote 1 Overall, mobilization of resources was emphasized throughout the CAH. The SRC provided project-related materials, such as gloves to prevent brucellosis, quality seeds to plant beetroot, carrots, tomatoes, and so forth to combat anemia, that were sold by the VHCs to the local population (CSO 4). At the end of the CAH, the SRC announced another round of small grants, namely 25,000 Kyrgyzstani som (KGS) (around €268)Footnote 2 to be provided to the VHCs based on their project applications (CSO 2). These grants were intended to ensure an additional financial basis for the VHCs to continue their activities beyond the end of the project (CSO 4). In general, the SRC’s technical and financial support was essential for the VHCs’ organizational capacity. Yet this assistance complemented, rather than dominated, the project implementation, because it targeted the issues identified by communities themselves.

It should be noted that the donor did not conduct the training activities alone. The Ministry of Health supported the VHCs after it became acquainted with the VHC members and their work. During the pilot phase of the CAH in fifteen villages in the Jumgal district of the Naryn region, the VHCs organized a campaign against goiter, where they promoted the usage of iodized salt, and checked iodine in the salt sold by local retailers (see Isabekova 2021). This campaign caught the Ministry’s attention and contributed to its acknowledgment of the initiative (Schüth 2011b). The VHC member I interviewed notes that the Ministry’s support was dependent on the “success” of the project. If the initiative “worked out,” the Ministry wanted to retain the VHCs to disseminate the information among the population; if it didn’t, the community-based organizations (CBOs) would be discontinued (CSO 2). According to project-related documents, this acquaintance was decisive, since “no amount of explanation can be as convincing as an hour spent with a VHC” (Schueth 2009, p. 47; Schüth 2011b, p. 49). Equally significant was the support of individual persons, including the Minister of Health at that time, Tilek Meimanaliev, who supported community engagement, despite the relatively modest attention to this matter in the national health care program (Schüth 2011a).

The recipient state actively participated in training activities, particularly after the countrywide expansion of the CAH. The Ministry of Health included the CAH in the national health care program and requested its countrywide extension. The SRC, in turn, asked the Ministry to provide health care staff for this purpose and offered calculations on the number of staff needed. The Ministry agreed and promised to establish HPUs in regions in which donors funded the expansion of the “Jumgal model” (IO Partner 11). Notably, the HPUs are part of the health care system and are accountable to the Republic Center for Health Promotion under the Ministry of Health. The HPUs received extensive training on how to work with communities from the SRC before taking over the training of PHC workers on the PRA approach. They equally took over training the VHCs on how to work as an independent civil society organization and conduct health-related activities (Schüth 2011a).

The HPUs were selected and worked in compliance with the principle of nondominance. People with a “bossy attitude” were “avoided” during the selection process (Schüth 2011b, p. 48). The SRC trained the HPUs on the PRA tools (Schueth 2009, p. 22) and in the principle of nondominance. The HPU representative interviewed for this research emphasized that medical professionals should not “give orders to common people,” and instead of acting as “teachers,” they should be “equal” to people referring to them (CSO 5). The interviewee noted that the HPUs had already learned about the nondominance principle at the beginning of the project (ibid.). This timely training contributed to the HPUs’ roles as “facilitators” of the PRA sessions and training activities that support but do not overlook the community initiative.

Following the endorsement by the Minister for Health, USAID and Sida joined the project implementation to support its national rollout. The Ministry of Health’s inclusion of the “Jumgal model” in the national health care program (Schüth 2011b, p. 26) and a promise to provide the HPUs for the countrywide extension of the program encouraged other donors to support the initiative (IO Partner 11). Two organizations were critical to this expansion. First, the USAID covered Jalal-Abad and Issyk-Kul regions as part of its ongoing “Zdravplus” (2000–2005) and “ZdravPlus II” (2005–2009) projects (Dominis et al. 2018), which aimed to improve the quality of health care services in Kyrgyzstan, Kazakhstan, Uzbekistan, Tajikistan, and Turkmenistan (Abt Associates 2023). Health promotion by community members corresponded to community and population health—one of the four major components of these projects (Cleland et al. 2008). Second, Sida financed the SRC to include the Batken, Osh, and Chui regions (Schüth 2011b). Between 2006 and 2011, Sida was among the core financiers of the Sector-Wide Approach to health care (Sida 2008). Because of the joint financing from Sida and the SDC, the project changed its name in 2006 from the Kyrgyz Swiss Health Project to the Kyrgyz, Swiss, Swedish Health Project (Development Planning Unit 2010). With the Swiss organizations (i.e., SRC and SDC) taking over the expansion in the Naryn and Talas regions (IO Partner 11), the organizations ensured the countrywide extension of the program.

Despite the differences in engagement, both USAID and Sida followed the leadership of the SRC. USAID implemented the extension itself as part of its ongoing project, while Sida cofinanced the SRC. However, compliance with the Swiss model (IO Partner 5), or the SRC approach in the Jumgal district, was “part of the deal” (IO Partner 11). This was ensured throughout the extension process. The SRC trainers accompanied USAID and trained its staff on project implementation and monitoring (ibid.). In the case of Sida, no issues arose in terms of the differences in approaches, since it simply transferred finances without any direct involvement in the project implementation. As my interviewee noted, one “did not even notice that there was different money” (ibid.). The SRC reported on how the funds were used, and Sida visited the project sites. However, although it was cofinancing, Sida basically accepted the Swiss actors’ approach to project implementation and monitoring (ibid.). In this way, despite their differences in engagement in the CAH, both donors, USAID and Sida, followed the Swiss actors’ approach to project implementation.

Overall, the project implementation phase shows that participation and support of the Ministry of Health intensified further as the project recommended itself as the “Jumgal model.” It also allowed the countrywide expansion of the project, encouraging other donors to commit themselves. Notably, both Sida and USAID followed the SRC’s approach in the CAH.

5.4 Project Evaluation

The CAH, similar to other development projects, went through a number of evaluations by external parties (e.g., Gotsadze and Murzalieva 2017; Kickbusch 2003). Both USAID and Sida also conducted an external evaluation of their contribution to the expansion of the Jumgal model (e.g., by hiring consultants). USAID conducted an external evaluation of its activities within the framework of the “ZdravPlus” program. Similarly, Sida assessed the use of financing by the SRC.

However, in addition to external assessments, the project developed annual evaluations of its activities by the project participants themselves. For this purpose, the project coordinator adapted Labonte and Laverack’s (2001a, 2001b) framework for community capacity-building. This framework stresses participation, leadership, organizational structure, problem assessment, resource mobilization, “asking why,” links with others, the role of outside agents, and program management (all categories listed verbatim) (Labonte and Laverack 2001a, p. 117). The original framework was adapted into 25 indicators (IO Partner 11) and further elaborated into clarifying questions, including those related to organizational abilities and essential accounting, conflict resolution, and sources of regular income (Schüth 2011a, p. 163). These indicators and questions aimed to ensure the evaluation of the CBO activities by the CBOs themselves and the organizations working with them.

The project evaluation emphasizes the roles of the state and community representatives in the assessment. The annual evaluation commences with the VHC members’ reflection on the abovementioned indicators. The CBO members additionally fill out their “happiness” and “workload” indices. Following this “internal” self-assessment, the HPUs and Rayon Health Committees conduct the “external” evaluation of CBOs (IO Partner 11). Both assessments matter to the validity of evaluation outcomes. The “internal” evaluation demonstrates the VHC members’ perception of and satisfaction with their work. The “external” assessment, in turn, shows the perspectives of organizations having firsthand experience with the VHCs. HPUs provide the training necessary for organizational development and connect CBOs to the national health care system. They are the ones having continuous contact with the CBOs and are aware of their organizational issues. Additional involvement of the Rayon Health Committees, composed of the VHC leaders, contributes to the validity of the CBO assessment by both state and civil society representatives. As one interviewee noted, one could claim many achievements on paper. However, during the actual visits to organizations, the VHC leaders witness the outcomes of the organizational work (CSO 2).

Both “internal” and “external” assessments are based on the same set of indicators. These include organizational membership, VHCs’ abilities for collective decision-making and conducting activities, documentation quality, and attracting new members (AVHC 2018). The indicators also stipulate conducting formal events and essential accounting according to the VHCs’ regulations (adopted by the Association of VHCs), engagement, and connections to authorities and other associations and organizations at a local level (ibid.). Another indicator signified and regularly monitored by the Association of VHCs is self-initiatives that, in addition to VHC funds, also can be conducted at the expense of local authorities and third-party funding sources (AVHC 2017a). Self-initiatives may include fundraising for health funds, support to the poor, community care, improving the environment in villages, organizational development, activities related to health, and participating in improving the village infrastructure (AVHC 2018). Overall, this similarity of assessment criteria ensures the consistency of internal and external evaluations (IO Partner 11).

One should specifically emphasize the roles of the Association of VHCs and Rayon Health Committees (RHCs) in the evaluation process, particularly after the end of the CAH. The evaluation of RHCs closely relates to their support for Village Health Committees. The organizations are expected to conduct at least four regional meetings funded by the organizations themselves, four self-initiatives on improving health determinants at a district level, monitoring health funds, and monitoring activities targeted at VHC development (AVHC 2018). The RHCs also are integral to the supervisory functions of the Association of VHCs. By the end of the quarterly meetings at a regional level, RHCs report to the AVHC a list of participants, meeting protocol, working plan, and a complete table with self-initiatives (ibid., pp. 15–16). This reporting is critical for the AVHCs’ overview of the organizations and their activities. Delayed reporting because of nonparticipation of VHCs at regional meetings or the inability of RHCs to report the activities on time distorted the assessment of the actual situation (AVHC 2018). Therefore, as a corrective measure, the Association of VHCs asked the Rayon Health Committees to fill the tables on VHCs’ activities right after the meeting and send the data to the AVHC immediately after the meeting via email or WhatsApp (ibid.).

Indeed, there have been multiple issues with evaluation, particularly since the end of the CAH. There were cases of HPUs not conducting the evaluation due to a lack of funding for transportation and per diem costs, although at large, the Family Medicine Centers provided the necessary funding (AVHC 2017b). The Association of VHCs discusses these issues directly with the Republican Center (ibid.), and it also intends to improve the mechanisms for collecting and streamlining HPU reports (AVHC 2017a). The attrition of medical professionals additionally challenges the evaluation process. However, foresightedly, the Association, in collaboration with donors, developed a training film for RHCs and HPUs on the assessment of VHCs (ibid.). This was intended to ensure the awareness of evaluation criteria and approaches irrespective of rotation in personnel. However, in the long run, the evaluation criteria are likely to evolve further. There also was a discussion on changing the self-assessment indicators as the organizations and their activities evolved further (AVHC 2018). These are only a few of the issues the Association of VHCs and organizations and members in the network face.

Nevertheless, the “Community Action for Health” project was remarkable in the sense that, in addition to the evaluation of project activities by external parties, it stipulated an opportunity for both state and community representatives to participate in the evaluation process. Although the SRC adapted the assessment criteria based on the academic analytical framework, these were the very HPUs, VHCs, and Rayon Health Committees that assessed the work and organizational capacity of the community-based organizations. This has changed the roles of the VHCs and HPUs from mere “subjects” of evaluation to actors assessing their own performance. It also laid down the basis for the Association of VHCs and its network members to continue evaluating their activities beyond the duration of the CAH.