Sustainability of the “Community Action for Health” Project

Abstract

This chapter aims to assess the sustainability of the “Community Action for Health” project by expanding on the continuity of project activities, maintaining benefits, and building the capacity of a recipient community (Shediac-Rizkallah & Bone, 1998). Focusing on community-based organizations, it also elaborates on their leadership, mobilization of resources (Labonte & Lervack, Capacity building in health promotion, Part 1: For whom? And for what purpose? Critical Public Health, 11(2), 111–127. https://doi.org/10.1080/09581590110039838, 2001a; Capacity building in health promotion, Part 2: Whose use? And with what measurement? Critical Public Health, 11(2), 129–138. https://doi.org/10.1080/09581590110039847, 2001b), and survival beyond the duration of the project funding. This chapter commences with a description of the project, its goals, and its relation to national health policy. Then, it zooms into the continuity of tuberculosis and HIV/AIDS-related activities by overviewing their dynamics during and beyond the project duration and what roles the socioeconomic and political factors had in this process. Furthermore, it assesses the availability of training and handouts essential to the quality of health-related information provided by community-based organizations established within the framework of the “Community Action for Health” initiative. Finally, this chapter elaborates on the capacities of these organizations, meaning their survival beyond the project duration, their mobilization of resources, leadership, mutual support, and activities, also in the face of the COVID-19 pandemic.

This chapter introduces the “Community Action for Health” project in Kyrgyzstan and discusses the sustainability of this project. It commences with an overview of the project and its objectives. The following sections focus on the analysis of project sustainability as the long-term continuity of project activities, maintenance of benefits, and community capacity-building once the project has officially ended (Shediac-Rizkallah & Bone, 1998). The chapter also examines how factors relevant to the sustainability of health care interventions, principally funding, and account for the influence of general conditions, including political, economic, sociocultural, and organizational factors, unfold in this project.

6.1 Project Description

The “Community Action for Health” lasted for almost 17 years and had an overall budget of 24,500,000 Swiss francs (around €24,736,236¹) (Gotsadze & Murzalieva, 2017, vi). The project was implemented in seven phases (ibid.). It started off with a pilot project, which covered 16 villages in the Jumgal rayon of Naryn oblast (Schueth, 2009, p. 10). After its acknowledgment by the Minister of Health, who also referred to community engagement with the health care system as the “Jumgal model” (IO Partner 11), the project was included in the national health care reform program, “Manas Taalimi” (2006–2010) (Government of KR, 2006). The project was then expanded throughout the country, which was also made possible with assistance from the United States Agency for International Development (USAID) and the Swedish International Development Cooperation Agency (Sida) (see Diagram 6.1).

Diagram 6.1

Chronology of the project (Source: Adapted from Schueth (2009, p. 11) and complemented with information from project-related documents)

The “Community Action for Health” Project (CAH) was set up to empower² Kyrgyz communities through their engagement in health care. Previously known as the Kyrgyz-Swiss Health Reform Support Project (Schüth, 2000, p. 7), and the Kyrgyz-Swiss-Swedish Health Project (Jamangulova et al., n.d.), the project commenced by renovating five hospitals in Kyrgyzstan, before beginning its work in the community (SDC, 2008, pp. 1–2). As part of its collaboration with local communities, it had two goals: to “enable rural communities to act on their own for the improvement of their health” and to support the state health care system “to work in partnership with communities for improving health” (Schüth, n.d., n.p.). First, “acting on their own” means the emancipation of communities, which, following Kessler and Renggli’s definition (2011), implies the participation of local communities in the health care system by defining the services those communities need and taking responsibility for their own health care. Second, the project was also intended to facilitate the collaboration of communities with Kyrgyz state institutions in this regard.

The emphasis of the project on communities and their engagement with health care provision echoes the ideas laid out in the Ottawa Charter for Health Promotion (1986) and the Alma-Ata Declaration (1978). The Charter stressed health as being the responsibility of individuals and communities, rather than just being the responsibility of the health sector alone (WHO/Europe, 1986). The Declaration went further by calling for the eradication of health inequalities, both between countries, and within countries, through the participation of individuals and communities in health care (WHO/Europe, n.d.-a). These international documents—the Ottawa Charter and the Alma-Ata Declaration—were referred to specifically in several of the documents setting out the CAH project (see Kickbusch, 2003; Schüth et al., 2005). Thus, in addition to increasing communities’ control over their health (WHO, 2023), “empowerment” in the project also implied overcoming health inequalities within the country, a goal which was also reflected in the project’s focus on rural areas.

The “Community Action for Health” project has been positively evaluated by academics and practitioners for its achievements in disease prevention and health promotion. According to the Swiss Tropical and Public Health Institute, preventive activities pursued by the project saved about US $3 million in patient travel and treatment costs, and around US $1.5 million in loss of income by patients who would otherwise have been unable to work (Schüth et al., 2014, p. 11). These preventive activities, together with health promotion, are believed to have contributed to improved public (Gotsadze & Murzalieva, 2017) and hypertension (WHO/Europe, n.d.-b), as well as a decrease in the incidence of brucellosis (Schüth et al., 2014) and goiter (Schueth, 2009), decreased infant and maternal mortality, and decreased mortality from cardiovascular diseases (Gotsadze & Murzalieva, 2017). The project has been positively evaluated by representatives of the Government of Kyrgyzstan, local Kyrgyz communities, and external experts (see Ibraimova et al., 2011; Kickbusch, 2003; Maier & Martin-Moreno, 2011). Moreover, the CAH is referred to as a “good example” of collaboration between rural communities and their state health care system (Kessler & Renggli, 2011, p. 24), with “good practices” and “documented knowledge” of this project being beneficial to countries willing to adopt a similar model (Gotsadze & Murzalieva, 2017, p. 5).

6.2 Continuity of Project Activities

The “Community Action for Health” targeted wider community concerns including, but not limited to, tuberculosis (TB) and human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS). However, to ensure comparability with another case selected for this book, sustainability refers to the continuity of project activities and benefits related to TB and HIV/AIDS and community capacity-building. This section discusses the continuity of project activities by elaborating on the types of activities (“what”) and the extent of their continuity (“to what extent”) (Scheirer & Dearing, 2011, p. 2062). As previously noted, the Village Health Committees (VHCs) largely provided awareness-raising and health promotion in their villages but no medical services. The discussion also incorporates the factors critical to the continuity of activities, such as the sociocultural, economic, and political context in the country.

First of all, regarding the types of activities (“what”), my fieldwork in Kyrgyzstan in 2018 substantiated the continuity of TB-related services. The interviewees reported that there had been a continuity of awareness-raising activities for TB (State Partner 12; CSO 5), including dissemination campaigns in streets or schools (CSO 7). Each VHC decided on the timing of the activities by themselves. While some of the VHCs had a specific day for their campaign (CSO 5), others defined a longer time period and suggested that campaigns to fight TB should not be limited to one day, but should rather last up to a month. Overall, the campaigns had broad involvement, including representatives of local self-government, health care workers, school pupils, local residents, and others.

TB activities pursued multiple objectives. Community-based organizations intended to raise awareness among the population about the transmission of the disease and tackle discrimination and stigmatization against people with TB. A VHC representative noted widespread discrimination against persons with TB, driven by a misconception that this disease was not treatable. The VHCs informed the population that it was an airborne disease and not transmitted through the shared use of towels and dishes, as many believed (CSO 2). The organizations also aimed to prevent TB by raising population awareness of the symptoms of the disease and the need to refer cases to a health care facility. By stressing that no one is safe from TB and that it can be treated, the VHCs also intended to overcome the discrimination TB patients have to suffer from their family members and neighbors (ibid.).

Still, the awareness of TB and its treatment, as well as discrimination against persons affected by it, continued to be relevant in 2022. The Association of VHCs (AVHC) emphasizes the importance of treatment and that the treatment is provided for free (AVHC, 2022). The VHCs continue their awareness-raising activities. For instance, in Arkalyk village of the Jalal-Abad region, a VHC member used the break cotton pickers take after harvesting to bring information related to TB, social and behavior change, and other matters out into the open (ibid.). A VHC in Suusamyr village in the Chui region conducted a campaign among pupils of grades 5–11 by providing books, notebooks, and pens as rewards for active participation (ibid.). Similarly, discrimination and stigmatization of TB patients remained relevant, also reflected by a seminar that included representatives of local self-governments and police workers of two villages in the Chatkal district of the Jalal-Abad region (ibid.). On March 24, VHCs annually celebrate the World TB Day.

Similarly, the fieldwork demonstrated continuity of activities targeting HIV/AIDS (CSO 5). The VHCs organized seminars in schools, roundtables, and community walks to raise awareness (ibid.). As with the activities targeting TB, some VHCs chose a specific day for these activities (CSO 7), while others stipulated a longer duration, with the campaigns being conducted over the period of a week or even a month (VHC activities related to HIV/AIDS in 2019. Reports from Batken, Chui, Issyk-Kul, Naryn, Osh, n.d.). Similar to TB, these activities had a broad coverage, including representatives from local self-government and from the health care facilities in the village and at district levels (CSO 5; State Partner 12), as well as the local population, school pupils, and so on.

The main goal of these activities was to increase awareness among the population about HIV prevention and discrimination against persons living with HIV (PLHIV). However, the attitude of Kyrgyz society toward sexually transmitted diseases remains conservative and moralistic. In this regard, one of the project-related documents reports a case of a man coming forward during the PRA seminar to ask for information about syphilis. However, as elderly residents of the same village approached, the man fell silent (Schüth, 2000, p. 25).

The population’s awareness of HIV transmission avenues, preventive measures, and nondiscrimination of persons living with HIV remained relevant. VHCs annually commemorate World AIDS Day (December 01). In 2019, the organizations organized a number of activities in collaboration with Rayon Health Committees, Health Promotion Units, primary health care workers, local self-governments, mass media, and other representatives. The awareness-raising activities included contests at schools, seminars by medical professionals (also for school teachers, pupils, and their parents), roundtables, processions of pupils, school performances, flashmobs, Q&A sessions, and essay-writing contests (VHC activities related to HIV/AIDS in 2019. Reports from Batken, Chui, Issyk-Kul, Naryn, Osh, n.d.). With support from other actors, the VHCs also organized walking campaigns and hung posters on HIV/AIDS in public spaces, public transportation, and bus stops (ibid.). In addition to increasing the awareness of the epidemiological situation via various media outlets, the activities touched upon themes such as “HIV is not transmitted through friendship” or “say no to drugs” (ibid., n.p.).

Similar to the smaller Village Health Committees, Rayon Health Committees have continued their awareness-raising activities in TB and HIV/AIDS. They have also continued supporting the VHCs in their organizational development and activities (AVHC, 2017b). This continuity of activities both at the district and at the village level suggests that the TB and HIV/AIDS campaigns did not cease immediately after the end of the project in 2017. Still, the simple fact of the continuity of activities does not tell us much about their extent. This topic will be discussed in the following subsection.

Furthermore, regarding the extent of their continuity (“to what extent”), the number of general activities implemented by the VHCs fluctuated throughout the project. One development partner noted that the VHCs had around sixteen different areas of activity at one particular moment in time, which caused the “burn-out” of VHC members (IO Partner 5). In this regard, the decision was taken to highlight certain key areas, leaving other areas up to the VHCs’ discretion (ibid.). This was intended to ease the workload of volunteers. The community-based organizations also used this momentum to reshuffle their objectives. One VHC member who was interviewed stated that since 2013 the organization had started to discontinue campaigns that had achieved their goals. These included activities targeting alcohol abuse, iodine deficiency, and brucellosis. As of 2018, the interviewee stressed that the organization was currently focusing on five or six activities (including TB and HIV/AIDS), but had the relevant material to revive the discontinued campaigns, if necessary (CSO 5). This availability of multiple brochures on various health care issues was also evident during my visit to the offices of other VHCs.

Still, a certain level of letup in activities seems to have accompanied the end of the project. For example, in response to my question about the changes since the end of the CAH, several interviewees pointed to a general “slowing down” in the VHC’s work. One emphasized that the workload decreased without funding, and with the decrease in the frequency of meetings, some VHC members wondered if they were “unemployed” now (CSO 4). Indeed, some volunteers seem to have perceived their work in the CAH as employment. Therefore, the end of the project brought a sense of uncertainty about the future of their activities.

One important indicator was the number of meetings between VHC members. One interviewee noted that these meetings, also taking place through tea gatherings, were crucial to bonding between members and their discussions of ongoing issues and future plans (CSO 4). It should be noted that the number of meetings among Rayon Health Committees (RHCs) also fell from 393 in 2014 to 275 in 2018 (AVHC, 2018). Devoted to a specific topic suggested by the Association of VHCs or Health Promotion Units (HPUs), these meetings are also used to discuss the outcomes, opportunities, and issues in the VHCs’ work (AVHC, 2017b). They were also used to discuss the yearly report, the work plan, and activities targeted at the VHCs’ organizational development (AVHC, 2022).

Still, the community-based organizations continued their activities. As of 2021–2022, the VHCs were implementing campaigns on multiple issues, including noncommunicable diseases, healthy nutrition, nonsmoking, physical activity, clean water, handwashing, and awareness of breast cancer symptoms (AVHC, 2022). Similarly, despite the decrease in the number of meetings, the RHCs increased the share of meetings funded entirely on their own (without third-party funding). Thus, if in 2014, 74 out of 393 meetings were self-funded, in 2018, 209 out of 275 meetings were financed entirely by the RHCs (AVHC, 2018). As one interviewee acknowledged, the range of activities may not have been as extensive as before, and there was an overall “slowing down,” but the community-based organizations continued their work (CSO 7).

The collaboration with donor organizations supported the continuity of some, but not all areas. The CAH coordinated its campaigns with other donor organizations throughout the entire duration of the project. Some examples thereof are awareness-raising activities conducted in collaboration with the German Corporation for International Cooperation (die Deutsche Gesellschaft für Internationale Zusammenarbeit—GIZ) and the Interchurch Organisation for Development Cooperation or complementarity ensured through the USAID funding the RHC meetings (Gotsadze & Murzalieva, 2017). After 2017, the Association of VHCs continued working with the World Bank, USAID, GIZ, SDC, and the United Nations (UN) agencies. Though beneficial to the capacities of the Village and Rayon Health Committees, the projects implemented by these organizations did not necessarily target infectious diseases. For example, the GIZ project pursued the incorporation of community priorities in its socioeconomic development plans (Development Policy Institute, 2016). The World Bank initiative aimed to strengthen the capacities of Village Health Committees to collaborate with local self-governments (Independent Auditor’s Report, 2018). The joint project of four UN agencies (the UN Women, the Food and Agricultural Organization, the World Food Programme, and the International Fund for Agricultural Development) focused on providing economic opportunities for women in rural areas (AVHC, 2022). The SDC initiative, in its turn, focused on the management and prevention of noncommunicable diseases (SDC, the Federal Department of Foreign Affairs, n.d.-a).

In the Kyrgyz Republic, USAID is among the few organizations, except for the Global Fund to Fight AIDS, Tuberculosis and Malaria (discussed in this book), focusing on TB and HIV/AIDS. The AVHC has collaborated with several of its initiatives, including “Defeat Tuberculosis” (2014–2019) and “Cure Tuberculosis” (2019–2024). The former involved RHCs and VHCs in selected regions, with main activities targeted at raising the population’s awareness of ambulatory treatment, nondiscrimination, and protecting the interests of TB patients (AVHC, 2018). The latter closely involves the AVHC and the Rayon and Village Health Committees in five regions, and the Kara-Suu district of the Osh region. Activities range from raising the population’s awareness of TB treatment opportunities and the nondiscrimination of persons affected by this disease (AVHC, 2022), to fundraising and advocacy, to financially assisting TB patients from vulnerable groups (JSI Research & Training Institute, 2020).

Yet the activities also continued beyond the donor-funded areas. These include, for instance, the VHCs’ annual countrywide awareness-raising campaigns dedicated to International TB Day (March 24) (AVHC, 2022). The scale of activities varies. Yet, delineating the campaigns supported by a development partner or conducted at the expense of the VHC is tricky, especially since the “Cure TB” project expanded its campaigns throughout the country in 2021. The activities are inextricably related, complementing each other. There are, for instance, cases in which the development partner provided the leaflets, but the VHCs organized and conducted the walking campaigns or seminars at their own expense. Notably, the VHCs conduct TB activities also at their own organizational expense (AVHC, 2017b) but mostly in collaboration with other actors, such as representatives of local self-governments, HPUs, RHCs, medical workers, school administrations, and others.

In contrast to TB, USAID’s involvement in HIV/AIDS activities is somewhat limited. The organization instead collaborates with local NGOs having access to and working with targeted groups, such as PLHIV and intravenous drug users (see USAID, 2019). Due to stigma, discrimination, and anonymity concerns, these groups are closed to the state health care system and presumably to community-based organizations working on broader issues. This may explain the financier’s inclination toward NGOs specializing in and closely working with persons affected by HIV/AIDS. In this way, the community-based organizations continued the awareness-raising activities mainly at their own expense. The lack of donor support is also reflected in the limited availability of information materials in different languages during the awareness-raising campaigns in 2019 (VHC activities related to HIV/AIDS in 2019. Reports from Batken, Chui, Issyk-Kul, Naryn, Osh, n.d.).

In these circumstances, state support proved critical to the continuity of HIV/AIDS-related activities. Decrees of the Ministry of Health and local state administrations on HIV/AIDS prevention were the basis for medical professionals and representatives of local self-governments to organize and support the campaigns (VHC activities related to HIV/AIDS in 2019. Reports from Batken, Chui, Issyk-Kul, Naryn, Osh, n.d.). As of 2019, the scale of activities varied across the country, ranging from small seminars to large-scale campaigns involving up to 900 participants (ibid.). The extensive involvement of actors allowed a broad range of activities, including printing articles in local newspapers and broadcasting videos (ibid.). Thus, similar to TB, VHCs organized HIV/AIDS-related activities in collaboration with a wide range of actors, including Rayon Health Committees, the Republic Center, HPUs, regional AIDS centers, mass media representatives, medical professionals, pupils, religious leaders, and others (ibid.).

Overall, the community-based organizations continued their activities despite the end of the project. The presence of a donor organization in a relevant field, such as USAID in TB, did surely strengthen the campaigns by providing additional resources. However, the awareness-raising in the areas not covered by donors, such as HIV/AIDS, has continued mainly at the expense of community-based organizations. Notably, state support proved to be critical to these campaigns. However, state support is also changeable, which impacts the maintenance of benefits (discussed in the following subsection).

6.3 Maintaining Benefits

The VHCs’ activities in relation to TB and HIV/AIDS largely relate to dissemination campaigns. Therefore, the benefits maintained refer to the information received by the communities in regard to these two diseases. This assumes, however, not just the existence of the information activities but also the quality of the information.

One of the ways to look at the quality of the information provided by the VHCs is to look at the external evaluation of project activities both during the project and at the end of it.

The external assessment of the VHC activities on TB is inconclusive. Becoming a “tradition” among the VHCs (PIL Research Company, 2017), the information activities for TB improved the population’s awareness of the disease. Randomized cluster surveys show greater awareness of TB indicators in the areas with VHCs than in the areas without (Schüth et al., 2014), which has also been confirmed by the external evaluation of the project (Gotsadze & Murzalieva, 2017). At the same time, another assessment found that increased awareness of the disease and its symptoms did not necessarily influence people’s knowledge of TB treatment, and discriminatory attitudes toward people with TB remained (PIL Research Company, 2017). Though contributing to improved population awareness about the disease, the activities seem to have had limited effect in regard to treatment of the disease and discrimination against patients with TB.

The VHCs’ activities also contributed to public awareness of HIV/AIDS. The VHCs surveyed school pupils from the 9th grade from the districts of Naryn, Talas, Chui, Batken, and Osh regions (five schools per district were covered), before and after the training course on HIV/AIDS. The surveys demonstrated increased awareness of HIV prevention among the pupils as a result of the training course conducted by the VHCs (Schüth et al., 2014, p. 19). Similarly, the external evaluations of the project pointed to increased population awareness of HIV transmission, preventive measures (Gotsadze & Murzalieva, 2017), and increased awareness of sexually transmitted diseases (PIL Research Company, 2017). However, the impact of activities on stigma and discrimination against PLHIV is unclear.

Overall, the evaluations conducted both within the project and by external actors point to the contribution of the VHCs’ information activities to increasing population awareness of the two diseases. Yet these assessments alone are not sufficient to evaluate the quality of information. I propose looking at the training received by the VHCs as another way to estimate the maintenance of benefits. VHC members are volunteers, and the majority of them have no medical education. For this reason, the quality of information they provide closely relates to their training.

The primary source of training for the VHCs was the Swiss Red Cross (SRC), which gradually transferred this function to the Health Promotion Units (HPUs). This transfer took place during the rollout of the program from the initial pilot districts to the country as a whole. The HPUs are essential to the VHCs’ training. A development partner closely working with the community-based organizations supported this assumption, suggesting that the quality of, or problems with, HPUs inevitably reflected upon VHCs (IO Partner 11). Indeed, the HPUs continuously train the VHCs by visiting them in the villages. Therefore, they have firsthand knowledge of the issues faced by community-based organizations, as well as the opportunities to address them.

However, the frequency of HPU visits and the scope of training areas have decreased over time. During the period of operation of the CAH, the SRC covered the relevant travel costs for HPU staff to travel to the villages. After the project ended, the Ministry of Health took over the financing but decreased the frequency of visits. Previously monthly visits changed to quarterly (CSO 4). The Ministry of Health also limited the scope of training to four areas prioritized by the national health care program “Den Sooluk” (2012–2018), namely hypertension, HIV/AIDS, tuberculosis, and mother and child care (IO Partner 5). Explicit prioritization of TB and HIV/AIDS was beneficial to the continuity of training by state-funded HPUs. Albeit with decreased frequency, these activities nevertheless contributed to the uniformity of the information received and provided by the VHCs, and their compliance with the state health care program.

Still, the quality of training largely depends on staff availability and motivation. One interviewee noted that the organizational decline of VHCs was, to a certain extent, expected without the CAH but also dependent on HPUs and broader issues, such as the availability of qualified medical professionals in the country (IO Partner 11). By the end of the CAH, some trainers continued their work with community-based organizations in HPU roles. However, as elsewhere, low salaries and limited motivation contribute to the high rotation of medical professionals and inequity between urban and rural areas.

Furthermore, with the adoption of the “Healthy Person—Prosperous Country” program (2019–2030), Kyrgyzstan’s priorities changed toward a systemic and away from its previous area-specific approach to health care. In contrast to “Den Sooluk” (2012–2018), which, along with other activities, targeted the four areas mentioned above, this program pursues a systemic approach to the health care system and reforms instead. Priority directions of the new program are public health, further strengthening primary health care, improving and rationalizing the hospital sector, developing emergency medical care and lab services, and improving the regulations of and access to medicines and medical devices (Government of KR, 2018a). It also intends to ensure strategic management of the health care system, target the problems with human resources in this sector, develop E-Health and health financing, and ensure the successful realization of stated objectives (ibid.). In contrast to “Den Sooluk,” it does not explicitly prioritize TB or HIV/AIDS, but rather integrates them into the public health and primary health care areas of the program (ibid.).

Despite the aforementioned changes, community-based organizations are still central to the Kyrgyz health care system. The systemic approach of the “Healthy Person—Prosperous Country” (2019–2030) program envisions a broad engagement of stakeholders and community-based organizations. In addition to emphasizing citizens’ responsibilities for their own health, the new program also intends to increase awareness of the right to quality health care and modernize the planning and organization of health care according to the population’s needs (Government of KR, 2018a). VHCs are indispensable to achieving these objectives. Not explicitly prioritizing TB and HIV/AIDS, the program still offers distance learning modules on organizational development and public health and training activities on population needs assessment for health care (ibid.). However, the actual implementation of training activities largely depends on the availability of funding.

Furthermore, along with state institutions, donor organizations provide training to VHCs within the scope of their activities. For example, the World Bank-funded project (2014–2017) implemented by the Development Policy Institute aimed to build the capacities of VHCs and AVHC in identifying social determinants of health and working with local authorities to solve them (Development Policy Institute, 2014). It also allowed VHCs to expand their activities in unexplored areas, such as participating in the formation of local budgets at a village level. The emphasis on the role of the PRA in defining social determinants of health has also allowed the VHCs and the AVHC to then use this approach later to assess health care quality (see Development Policy Institute, 2017). Despite the wide range of benefits offered by this initiative, its coverage was limited to 30 pilot villages (Development Policy Institute, 2014). In addition to geographic coverage, the scope of activities may also be related to specific areas. The SDC-funded project on the “Effective Management and Prevention of Non-communicable Diseases” targeted Chui, Naryn, Issyk-Kul, and Talas regions in the first phase (2017–2022), and Batken, Osh, and Jalalabad regions and two cities, Bishkek and Osh, in the second phase (2022–2026) (SDC, the Federal Department of Foreign Affairs, n.d.-a, n.d.-b).

As noted above, USAID’s “Cure TB” program is among the few projects with countrywide coverage and a focus on TB. In collaboration with the AVHC and the Republican Health Promotion Center, this project offered a series of trainings for HPUs, which, in turn, conducted seminars for VHCs to increase awareness of TB, reduce stigma and discrimination, and support adherence to treatment (JSI Research & Training Institute, 2021). Initially, the project covered only Talas, Naryn Chui, and Jalal-Abad, but in 2021 it expanded to the Batken region and the Kara-Suu district of the Osh region (ibid.). To date, USAID’s “Cure TB” program seems to be the main source of training for HPUs and VHCs in the area of TB.

Despite the fluctuations in development assistance, the AVHC serves as a stabilizing factor by coordinating training activities. Through its coordinating role and direct engagement in initiatives, the Association of VHCs keeps an overview of development assistance provided to VHCs, including a record of organizations covered and excluded from aid. This perspective is essential to quality assurance and equity among community-based organizations, as the AVHC uses health projects to support and expand the training offered to VHCs. For instance, during the Development Policy Institute, the VHCs outside the piloted areas also expressed their interest in learning more about collaboration with local self-government bodies (AVHC, 2017b). In response, the Association developed a strategy for sharing experiences within the network. The Rayon and Village Health Committees discussed this strategy further, along with funding options and mechanisms for methodological support, during the RHC meetings (ibid.). Based on these discussions, the AVHC stipulated funding for experience-sharing within the network depending on the willingness of RHCs and VHCs and their financial capacities (ibid.). As a result, the coverage of training activities expanded beyond those piloted in the project. The VHCs from piloted areas conducted 1–2 seminars in areas not covered by aid, the organizers taking over small tea and coffee breaks, and the visiting CBOs covering commuting costs (ibid.).

Overall, both state and donor support are critical to maintaining benefits. However, the Association of VHCs and its network organizations and members demonstrated a remarkable initiative in extending training programs beyond their initial scope. In so doing, they contributed to the equality of awareness-raising activities in regions not covered by aid. Certainly, the shift in government priorities toward a systemic approach affects TB and HIV/AIDS, which had been explicitly prioritized in the previous health care program. Still, the maintenance of benefits also depends on the availability of training material, as discussed below.

In addition to training, dissemination campaigns presume the availability of relevant leaflets and other supporting material, which had previously been ensured by the CAH. VHCs interviewed for this research used the leaflets they accumulated during their work with the SRC and other international organizations (CSO 2). However, replenishment of these stocks is uneven.

Indeed, training material and handouts provided within the framework of the “Cure TB” project ensure access to updated information on TB, also in the context of the COVID-19 pandemic (see JSI Research & Training Institute, 2021). The project supported the preparation of information in Kyrgyz and Russian, online and in the form of postcards and videos (AVHC, 2020). There has been an increased use of social networks, such as Facebook, Odnoklassniki, and Instagram, among the AVHC and the VHC members that, for instance, follow the relevant pages of the Association (JSI Research & Training Institute, 2020). The project also supported the development of methodological handouts for conducting seminars (on- and offline formats) and booklets for volunteers providing extensive and brief information on TB and its prevention (AVHC, 2020). This support ensures access to updated information across the VHCs, which contributes to the uniformity of the information provided.

The situation with HIV/AIDS is different. Due to the lack of an ongoing project with countrywide coverage, the information provided by community-based organizations is limited to content from previous projects. The AVHC aims to increase public awareness of HIV via its social media posts. Yet, a more systematic approach to and the broader availability of information on treatment options, preventive measures, and risks of HIV in the context of the global pandemic would be desirable, certainly benefiting the efforts of community-based organizations.

Overall, a closer look at training provided within the areas of TB and HIV/AIDS vividly demonstrates the changing agenda and differing stakeholder involvement, which also contributes to inequity in terms of access to training and supporting materials.

6.4 Community Capacity-Building

Survival of civil society organizations (CSOs) beyond the end of a donor-financed project is a key indicator of community capacity-building. Therefore, in this section, I examine the extent to which community-based organizations set up under the CAH continue to exist beyond the end of the project, and I look at their leadership and mobilization of resources (see Labonte & Laverack, 2001a, 2001b).

In 2018, the Association of VHCs conducted a “mapping” of the VHCs and RHCs to identify the number of VHCs still operating and those who discontinued their work or needed additional support. In so doing, the Association intended to support “quality” over “quantity” of community-based organizations (CSO 4). The mapping showed some attrition, but most of the VHCs, and all of the RHCs continued their work. As of 2020, the AVHC (2020, p. 3) reported that there were 58 RHCs and over 1500 VHCs in the country. Following these results, the AVHC organized a general meeting of its members to discuss the VHCs’ self-evaluation outcomes and strengthen the VHCs in need of assistance (ibid.). Participants divided themselves into groups and worked on own initiatives, support to the poor, reanimation of organizations, and VHCs’ connections to other actors as part of the VHCs’ and RHCs’ work plans (ibid.). The processes and issues encountered during this activity would require research on their own.

As noted above, there has been some attrition of members and organizations. However, most VHCs have continued to exist after the end of the project. In response to my question about organizational performance, my interviewee, closely working with the VHCs, noted that the majority of “weak” organizations were in close proximity to the capital. The interviewee stressed that in contrast to their rural counterparts, members of these organizations had little time and did not have such close communication with local residents (CSO 4). This corresponds to the findings in the literature about the strength of social bonding (e.g., Agnitsch et al., 2006) and the persistence of community-based organizations in rural areas in contrast to urban settings (Gryboski et al., 2006).

Indeed, the survival of community-based organizations depends on several factors, including the leadership of its members (see Labonte & Laverack, 2001a, 2001b). My interviewees similarly stressed the importance of leadership of VHCs (IO Partner 5) and the ability of its members to express and formulate their concerns (IO Partner 11). In this section, I elaborate on the issues the VHCs faced in their work, the solutions they developed, and the strategies they used to overcome the structural inequalities.

During their work, the VHCs came across a number of issues, including mistrust from the local population and the local authorities. There were cases of people throwing away the health information brochures provided by the VHCs (CSO 2) and actually chasing the VHC members out of the seminars (CSO 5). There were also negative remarks toward the members, most of whom were women. There were claims that these women had “nothing else to do” but were “just fishwives running around the streets”³ (CSO 2). A similar misunderstanding was common among representatives of local authorities. My interviewees recalled disinterest on the part of local authority officials (CSOs 4 and 5). At times, the remarks were also related to gender, with individual government representatives pointing to the VHC members to “go and look after husband and children” and not to “interfere” in matters that did not concern them (CSO 1).

However, not all VHCs continued their work under these circumstances. One interviewee noted that only people capable of saying, “no, you sit and listen to what I say,” remained in the VHCs (CSO 1). The interviewee noted that those remaining had to be (using a Kyrgyz saying to describe it) “barking dogs”⁴ in order to be resilient to the “attitude” of others (ibid.). It should be noted that the VHCs interviewed for this research were those who continued their work despite resistance from the local population and local authorities. These women continued to advocate for their ideas and developed their own strategies to overcome the structural barriers.

First, the VHCs used “existing resources” for their dissemination campaigns. They targeted public gathering places and asked people for “five minutes” to share their information with them (CSO 2). In addition to visiting schools and local organizations, the VHC members also attended celebrations and visited communal grazing areas.⁵ The VHC members used all available means to conduct their awareness-raising activities. One interviewee, for instance, told me that she could not find a place for the seminar after the representatives of the local self-governments ignored her request. However, on the way back, the VHC member saw a young woman hanging her laundry outside and paid attention to her yard as she approached and noticed that it was “large and clean.” The interviewee asked for permission to host her event in the woman’s yard, and was granted a permit to conduct a seminar for the local community on sanitary-hygiene issues there. The VHC member recalled that this seminar turned out to be even larger than expected as neighbors and other people from the street came in response to her and the woman’s invitations to attend it (CSO 5).

Second, VHC members tried to “popularize” health care practices by following these practices themselves. Their adherence raised the interest of other people in the village. One VHC noted that as members started practicing what they called for, neighbors began to wonder why the person was “so obsessed” with a specific practice, for instance, cleaning the yard (CSO 5). This curiosity developed into interest, which was the exact objective of VHCs. But beyond this interest, the VHC practices also brought tangible results. The same interviewee emphasized that the CBOs contributed to halting the problem of alcohol abuse, which was a pressing problem in the 1990s. The VHC members persuaded people not to bring alcohol to funerals. They followed this practice and pointed out that alcohol consumption at funerals was inappropriate, also during their conversations with community members at tea gatherings after burials (ibid.). In this way, adherence to certain practices went hand in hand with information dissemination.

Third, the VHCs sought solutions for socially significant issues. Sometimes, these issues included those not initially anticipated in the work plan. For example, another VHC member interviewed for this research recalled a problem the members encountered during their dissemination campaign. One community they visited shared its concern with the dump on their street. The volunteers supported the local population in writing the relevant petition to the local self-government, which the local population had not considered before. As a result, the landfill was closed, and another one was opened elsewhere. The interviewee brightly concluded that though headed to a neighboring community for one reason, the VHCs were able to support it in solving a separate issue that was pressing to them (CSO 5).

Fourth, the VHCs pursued own initiatives on matters relevant to local communities. In contrast to socially significant issues, these initiatives were not limited to problems raised by local communities, but included support to its members and opportunities for community development. As part of the support to community members, the VHCs continued to assist vulnerable groups, including the poor and those facing catastrophic health expenditures (see Isabekova, 2021). The organizations also regularly commemorate Victory Day (May 9) and International Children’s Day (June 1) by arranging presents and organizing events for war veterans and children, particularly those from vulnerable households (AVHC, 2022). In addition, the organizations sought further development of their villages in collaboration with other stakeholders. With small grants provided during the CAH, the VHCs cooperated with local self-government institutions and local sponsors to realize the projects. These included constructing a mini-football field with changing room and shower facilities, building a bus stop, maintaining bridges in emergency conditions, renovating and equipping a kindergarten, and renovating a local medical center (AVHC, 2017a).

By the end of the CAH, the AVHC intended to support the own initiatives that varied across organizations. In the case of VHCs, the number of initiatives fluctuated over the course of the project. Though growing between 2014 and 2016, the number fell by half in 2018 to 1254 (AVHC, 2018, p. 19). In contrast, own initiatives organized by Rayon Health Committees increased over time. Thus, if in 2017, only five organizations implemented over four initiatives, by 2018, twenty-seven organizations did (AVHC, 2018, p. 16). The number of organizations that did not implement own initiatives decreased from 14 to 1 over the same period (ibid.). It should, however, be noted that in the case of VHCs the low number was related to not only the actual work but also logistical issues. The organizations not participating in regional meetings failed to pass on the information at the RHC level, which in turn delayed reporting to the AVHC (2018, p. 19). As a result, some organizations were not included in the statistics of the Association of VHCs. As a corrective measure, the Association of VHCs asked the Rayon Health Committees to fill out tables on VHCs’ activities and send this data to the AVHC immediately after the meeting via Google Forms or WhatsApp (ibid.).

The abovementioned are only a few examples of the strategies used by the VHCs to overcome structural barriers and gender-biased attitudes in their society. They used existing resources for their dissemination campaigns, popularized practices by following these themselves, sought solutions to local issues, and raised initiatives in regard to the matters relevant to the development of their communities.

It should be noted that the misunderstanding from the local population and disinterest on the part of the local authorities gradually changed into appreciation and the inclusion of the VHCs into decision-making processes (CSOs 2 and 5; State Partner 12). This appreciation is also reflected in the cases of individual VHC members receiving a medal for distinguished labor (“emgek kaarmandygy”) from local organizations, or the broader fact that September 9 is now celebrated as the “Day of Village Health Committees,” with organizations receiving congratulations from local authorities and medical institutions (AVHC, 2022). I do not make countrywide generalizations about the strategies the VHCs used to overcome the social barriers, as, in fact, not everyone did overcome them. However, the VHCs I interviewed in the north of the country demonstrated their leadership through their ability to define problems, suggest solutions, and develop various strategies to overcome gender-biased attitudes in their local society.

Finally, mobilization of resources via donor or state financing and fundraising is an essential component of sustainability, as it relates closely to the continuity of civil society organizations and their activities beyond the end of the donor-funded project. In this section, I examine resource mobilization through donors, fundraising, and income-generation activities conducted by community-based organizations and state support.

First of all, in terms of donor financing, donor organizations cover specific geographic locations or issues relevant to project objectives. For instance, the World Bank-financed “Sustainable Rural Water Supply and Sanitation Development Project” (2016–2025) operates in Osh, Chui, and Issyk-Kul oblasts and provides training of trainers to the VHCs on water quality, handwashing and hygiene, improvement of sanitation facilities, and food hygiene (World Bank, 2016). As part of the USAID-funded “SPRING Project” (2014–2016), the VHCs disseminated information on nutrition and hygiene among pregnant and lactating women and parents of children under two years of age in Jalalabad and Naryn regions (USAID, 2021). There are indeed countrywide initiatives, such as the USAID-funded “Cure TB” or the SDC-financed “Effective Management and Prevention of non-communicable Diseases” projects. The former expanded countrywide in 2021 (SDC, the Federal Department of Foreign Affairs, n.d.-a), while the latter focused on a select number of regions in each phase of the project to ensure countrywide coverage (SDC, the Federal Department of Foreign Affairs, n.d.-b, p. 2). Despite their countrywide coverage, both focused on areas relevant to project objectives (i.e., infectious or noncommunicable diseases). One interviewee similarly referred to the uneven coverage of donor assistance, with some providing training but not financing (CSO 4). None covered the broad spectrum of activities, including those identified by VHCs and not necessarily prioritized by the project, as the CAH had done.

What happens to activities or VHCs not covered by donors? They remain the sole responsibility of the community-based organizations. In 2018, I interviewed one VHC representative who stated that they had no collaboration with any donor organization at the time of our conversation (CSO 2). Yet the VHC continued its activities, and the interviewee stressed that other VHCs did the same and did not necessarily wait for development projects (ibid.). Although non-generalizable, this finding suggests some continuity of community-based organizations without donor support. One could specifically emphasize the role of the Association of VHCs, which serves as a stabilizing factor, also in coordinating the project implemented by donors and experience-sharing activities to VHCs not covered by donor activities. As seen from the mapping exercise, the AVHC has also been critical in identifying and organizing support for VHCs in need of assistance.

Second, fundraising is another option for the VHCs’ resource mobilization. One of the VHC members showed me photos of the fundraising campaign the organization organized for a villager in need of surgery, namely a sports competition which raised around 27,000 Kyrgyzstani som (KGS, national currency of Kyrgyzstan), which is around €290 (CSO 2). The organizations also use other methods in addition to community fundraising for a specific purpose. Some organizations introduce membership fees to replenish their budget. The fees vary, but are relatively small, about 5–20 KGS (approximately 5–21 Euro cents) (CSO 4). However, poverty and unemployment in rural areas hinder the VHCs’ fundraising possibilities. For this reason, during the CAH, the VHCs received small grants in the amount of 25,000 KGS (around €268) based on their project applications (CSO 2). A VHC noted that in 2017, a commission was formed among the representatives of the rayon administration (ibid.). Its aim was to evaluate the VHCs and redistribute the financing previously received from the SRC. The commission visited each village, checked the documentation, VHCs’ activities, fundraising, and links to local institutions, and so on. As a result of this assessment, eleven organizations received small grants for two years, and the VHCs nominated for the first four places received additional rewards (ibid.).

Third, community-based organizations mobilize resources through social entrepreneurship and by using their organizational funds for income generation, though not all initiatives were “successful.” During the CAH, the VHCs used the small grants provided by the SRC to solve community problems and establish small social enterprises. Public baths (banya) were built to address sanitation problems. VHCs provided free entrance to vulnerable groups in the population, including the elderly and people with disabilities. In addition to covering the maintenance costs, the entrance fees to the public baths supplemented the VHC’s budget/fund (CSO 5). Community-based organizations also established sewing workshops and hairdressers. In addition to providing employment for the local population, these enterprises brought in 150 KGS (around €1.6) to the VHC’s budget on a quarterly basis (ibid.). However, not all of these initiatives were successful. The majority of public baths in the district I visited were in need of an overhaul, and the VHCs I interviewed were negotiating their transfer to the ownership of the local self-government, as the entrance fees for the public baths did not cover the amount needed for the overhaul (ibid.). In addition to social entrepreneurship, the VHCs also used their organizational funds to generate additional income. Some increased their funding by lending funds to VHC members at low interest rates (CSO 2). Others invested in cattle breeding, which was unsuccessful (CSO 7).

VHCs were not alone in their struggles. Rayon Health Committees similarly received stimulus grants within the framework of the CAH to generate additional income for organizational support. However, not all organizations benefited from this income, the amount of which also turned out to be less than expected. For instance, in 2014, fourteen RHCs received these grants, and nine of them managed to receive additional income in 2015; among twenty-nine organizations receiving grants in 2015, only six received extra income in 2016 (AVHC, 2017a, pp. 18–19). As a result, the total amount of revenue obtained through grants was considerably lower than expected due to internal as well as external factors. Internal factors were related to the organizations’ abilities to maintain income-generating activities, decision-making in crises, and their skills in financial management, further investment, accountability, and taxation (ibid.). External factors included the low level of income, lack of marketing, and falling cattle prices, among others (ibid.).

As noted above, further capacity-building may be desirable for both VHCs and RHCs in the areas of social entrepreneurship and income generation. My interviewees noted that “good” leadership was critical to the size of the organizational budget (CSO 4), and yet the community-based organizations were “not ready for business,” and despite their willingness to invest, they were unsure how to (CSO 7). Similarly, external evaluations of the CAH suggest that although the VHCs gained fundraising and strategic planning skills during the CAH, these may not be enough for them to work independently (PIL Research Company, 2017) beyond the end of the project. At this point, the Association of VHCs continues exploring investment opportunities at the national level to support community-based organizations at both village and district levels. However, further training in social entrepreneurship and income generation would undoubtedly benefit the organizations by allowing effective use of existing resources and more effective sourcing of further resources.

The fourth source of resource mobilization is state support. National authorities, including the Ministry of Health, the Republican Center for Health Promotion, and regional and district administrations, largely support the continuity of activities in the areas prioritized in the national health care program. Examples include HIV/AIDS and tuberculosis activities which benefited from the Ministry of Health and state administrations’ decrees, in turn stipulating the organization of relevant activities by medical professionals and by extension supporting the community-based organizations. In addition, the Ministry and the Republican Center for Health Promotion were also critical to the continuous training of community-based organizations provided by Health Promotion Units, thus contributing to the maintenance of benefits (i.e., quality and uniformity of health promotion information provided by VHCs). The acknowledgment and support at the national level are also critical to the capacity of community-based organizations. Thus, inclusion in the national health care program allows the CBOs to develop additional skills. For instance, the ongoing “Healthy Person—Prosperous Country” (2019–2030) program stipulates the development and implementation of remote training modules for VHCs also in areas of organizational development (Government of KR, 2018b).

However, as part of resource mobilization, I focus on local self-government institutions that are somewhat unexplored and yet vital to the Village and Rayon Health Committees. The local self-government institutions provide administrative support to community-based organizations. My interviewees referred to meeting rooms the local authorities provided for the VHCs to gather and conduct their seminars and other awareness-raising activities (CSOs 4 and 5; State Partner 12). There are also cases of VHCs receiving office spaces from local authorities for their exceptional work and contribution to local development (e.g., AVHC, 2022). The VHCs often conduct maintenance work at the expense of their organizations. However, the availability of a fixed location for their activities and organizations indeed contributes to their capacity.

Community-based organizations may also receive financial assistance from local authorities, though the amounts in question are rather small due to budget deficits within state organizations. One interviewee estimated that the financial support to VHCs might range between 2000 and 5000 KGS (around €21–54) in the case of “poorer” and up to 10,000 KGS (about €107) in the case of “well-off” local authorities (CSO 2). A more accurate assessment of financial assistance would undoubtedly require access to local budgets and their countrywide comparison. However, another community-based organization representative similarly corroborated the small share of financial support. The interviewee emphasized that the eagerness of VHCs to work with donors also relates to the “little money” local self-governments had, which was not sufficient to meet the population’s needs (CSO 7). In this way, although offering administrative support, the local authorities can provide only limited financing to the VHCs and their activities.

It should, however, be noted that the state support both at national and local levels is also contingent on the support of individual officials to community-based organizations and their work. The significance of state support and understanding was emphasized already during the CAH. The project-related documents reported changing attitudes of officials, also at the level of the Ministry of Health, after their acquaintance with the VHCs and their work (Schüth, 2011). Yet, awareness does not always equal support for the VHCs, as there were cases of individual candidates for political positions attempting to involve the VHCs in their election campaigns. Driven by their own agenda, they do not necessarily consider the interests or organizational development of CBOs. One of my interviewees noted that the presence of (former) VHC members among local authorities contributes to those authorities’ understanding of and support for the VHCs’ work (CSO 5).

Notably, the Association of VHCs endorses the political aspirations of its members. In 2016, for instance, it prepared guidelines for trainers and brochures to support the VHC members running for election to local councils (jergiliktüü kengeshter) (AVHC, 2017a, pp. 15–16). The AVHC conducted 12 seminars at the regional level throughout the country for candidates to enhance their capacity and ability to participate in political processes and advance their leadership skills (ibid.). Out of 325 VHC members trained, 45 obtained seats in local councils, with two-thirds of them being women (ibid.). It should be noted that in addition to strengthening the skills of the individual CBO members, these training activities were beneficial to the local self-governance institutions’ understanding of health issues and their affinity toward the VHCs’ work.

Still, the unstable economic and political situation in the country contributes to the frequent rotation of state officials. In these circumstances, relying on state officials or, in fact, also relying on the changing agenda of donor organizations does not seem sensible.

In addition to country-specific problems, the global COVID-19 pandemic constituted an unanticipated challenge, which, however, ended up demonstrating the relevance of community-based organizations in Kyrgyzstan. The volunteers had to halt their activities during the state of emergency declared in the country. Similarly, the HPUs had to cancel the training activities planned for the Village and Rayon Health Committees (AVHC, 2020). The pandemic has profoundly impacted community-based organizations and their work. Indeed, the seminars were renewed by online means in the second quarter of 2020, and the HPUs actively used social media (e.g., WhatsApp) to communicate with volunteers and share information (ibid., pp. 13–15). However, a better understanding of capacity-building, continuity of activities, and maintenance of benefits during (and, at some point, after) the pandemic require further research. Though challenging, the pandemic has also demonstrated the relevance of community-based organizations. In collaboration with local medical workers, Village and Rayon Health Committees organized awareness-raising activities on protective measures and campaigns calling for people to vaccinate against COVID-19 (AVHC, 2022). Similarly, the Association of VHCs continued sharing information on vaccination and the virus, also in relation to TB, on its social media pages (ibid.).

6.5 Summary

This chapter evaluated the sustainability of the “Community Action for Health” project by focusing on the continuity of activities after the end of the project, maintenance of benefits received by the targeted population, and community capacity-building.

First, it demonstrated that community-based organizations continued their activities, also in TB and HIV/AIDS, after the end of the project. However, there has been a general “slow-down,” further amplified by the lack of donor assistance covering all aspects of VHCs’ work throughout the country.

Second, in terms of maintenance of benefits, since the external assessment of the VHCs’ activities and their impact on TB and HIV/AIDS was inconclusive, I used training as the assurance for the quality of the information disseminated by the VHCs. Most assistance focused and provided training on either specific issues or geographic areas and thus was incomparable to the CAH, which encompassed all initiatives and activities of health committees throughout the country. The community-based organizations continued receiving TB and HIV/AIDS-related training from the Health Promotion Units. However, the change in the national health care strategy from a disease-specific toward a systemic approach also affected the training offered to RHCs and VHCs. Still, the organizations continued their activities and demonstrated exceptional learning and training skills by sharing their experience and skills within the network. The coordinative and developmental roles of the Association of VHCs were crucial to this effort, though the leaflets and other materials used for the dissemination campaigns still primarily come from donors.

Third, as part of community capacity-building, despite some attrition, most of the organizations continued their survival beyond the end of the CAH. The organizations mobilize resources via donor funding, fundraising, social entrepreneurship, and state support, all of which are challenging in an environment of poverty, unemployment, and limited skills/training in the relevant area. Overall, the VHCs demonstrated leadership and continued their activities beyond the end of the development project. At the same time, there are a number of internal factors (mentioned here in the chapter) and external factors (the political, economic, and sociocultural situation in the country, the global pandemic) which challenge the sustainability of the community-based organizations, VHCs, and their activities in the area of TB, HIV/AIDS, and beyond.

Overall, the detailed analysis provided in this chapter demonstrated both issues and opportunities associated with the sustainability of health aid. Indeed, the CAH is a “success story,” demonstrating the long-term sustainability of the activities and organizations initially supported by the project beyond the duration of donor funding. The resilience of community-based organizations and activities to (un)anticipated challenges, including the global COVID-19 pandemic, is extraordinary. This resilience also suggests that members of community-based organizations not only overcome obstacles, but also seek opportunities for their activities and places for their organizations in these very challenges. Still, this chapter also enlisted multiple issues in this regard, including the contingency of the long-term sustainability of health projects on the broader political, economic, and social situation in the country. In so doing, it showed that the sustainability of health aid is not a categorical “yes/no” matter, but a complex phenomenon requiring a fine-grained analysis of each of its three dimensions and related factors.