Keywords

The Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) delegates the realization of its project in Kyrgyzstan to the relevant national actors involved in tuberculosis (TB) and human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS) programs. However, external development actors are equally relevant since the Global Fund project is implemented in parallel with other health aid provided to the country. These actors are grouped into the following three analytical categories:

  • First, the recipient state refers to the Ministry of Health, represented by the National Center of Phthisiology and the Republican AIDS Center.

  • Second, civil society organizations (CSOs) are the local nongovernmental organizations (NGOs) receiving the Global Fund grants, but not the community-based organizations, as in the case of the “Community Action for Health” project in Kyrgyzstan.

  • Third, donors denotes the Global Fund and other international organizations working on TB and HIV/AIDS, such as the United States Agency for International Development (USAID); World Health Organization (WHO); German Development Bank (die Kreditanstalt für Wiederaufbau—KfW); Joint United Nations Programme on HIV/AIDS (UNAIDS); United Nations Population Fund (UNFPA); and United Nations Educational, Scientific and Cultural Organization(UNESCO).

In addition to these three analytical categories, the grants involve the Local Fund Agent (LFA) and the United Nations Development Programme (UNDP). LFA involvement is a standard part of all Global Fund financing, being responsible for validating the information provided by grant recipients. The UNDP is not on the list of donors, but rather became the first-line recipient of the Global Fund grants after the misappropriation of funds by the official(s) of the state organization. The following subsections expand on the roles of these national and international actors throughout the project cycle (i.e., the initiation, design, implementation, and monitoring phases).

8.1 Initiation

This phase is critical to understanding who stands behind the objectives targeted by health aid. According to Andrews (2013), ideally, assistance is driven by the pressing problems of the aid recipient and not by the objectives imposed by donors from outside. This section discusses whether TB and HIV/AIDS were perceived as significant issues in Kyrgyzstan before the assistance from the Global Fund.

Indeed, the problem of HIV/AIDS and TB was recognized as pressing in Kyrgyzstan long before the country received the Global Fund grant. To address the increasing HIV incidence in the country, the government initiated the National Program on Prevention of HIV and Sexually Transmitted Infections (STIs) (1997–2000). It restated the country’s commitment to the Paris Declaration (1994) by recognizing the threat of the AIDS pandemic and the need to fight against HIV/AIDS (WHO, 1995). This program prioritized the prevention of Sexually Transmitted Infections (STIs), including HIV, through awareness-raising activities, improved blood donor screening, and distribution of condoms (Government of KR, 1997). However, it also acknowledged insufficient financing for health care and noted that even a small number of HIV cases represented a burden on the state budget (ibid.). Correspondingly, the national program highlighted the contributions of the UNDP, UNFPA, UNAIDS, UNESCO, and WHO to HIV/AIDS-related activities (ibid.). International development organizations were equally significant to the National Tuberculosis Program (1996–2000), which aimed to develop an affordable solution to the growing number of TB cases in the country. In addition to vaccinating newborns and children and identifying the sources of infection, this program intended to standardize chemotherapy treatment (Government of KR, 1995). The country adopted the WHO-recommended Directly Observed Treatment Short course (DOTS). A countrywide roll-out of the DOTS was possible due to the WHO’s technical assistance and a continuous supply of medications from the German government. Still, problems with limited financing and a disparity between the activities and the TB epidemic in the country remained (Government of KR, 1995, 2008).

As seen above, TB and HIV/AIDS-related activities were present in the country before the Global Fund. The presence of these activities, despite their insufficient funding, hints at the political commitment of the government to combat the two diseases. Furthermore, its collaboration with multiple donor organizations points to the fact that the state initiative was in place long before the arrival of the first Global Fund grants to the country in 2004.

8.2 Design

The design phase expands on stakeholders’ roles in defining the content of grant applications and their participation in the application process. This section discusses the compliance of grant applications with national programs; how recommendations and requirements of the Global Fund still shape the content of grants; and elaborates on the roles of national and international stakeholders in drafting the country’s applications to the Global Fund.

First of all, in terms of the content, the grant applications are consonant with the health care objectives of recipient countries in the areas targeted by the Global Fund. A close overview of project activities and national TB and HIV/AIDS programs of the Kyrgyz Republic demonstrates adherence of activities to national goals. My interviewees support this observation (State Partners 4 and 9) and note that compliance with national strategies is the foremost evaluation criterion for the applications (IO Partner 4). Nevertheless, this adherence focuses on diseases targeted by the Global Fund (TB, HIV/AIDS, and malaria) and not necessarily on those causing the most deaths on the local level.

To illustrate, non-communicable diseases, such as ischemic heart disease and stroke, were the leading causes of death in the Kyrgyz Republic between 2009 and 2019 (Institute for Health Metrics and Evaluation, 2023). TB, by contrast, ranked 10th in 2009 and 16th in 2019, and HIV/AIDS was not among the most common causes of death (ibid.). One state official noted that, despite the clarity of this data, cardiovascular diseases received the least funding in the national health care program (2012–2018), whereas TB and HIV/AIDS received the most (State Partner 6). In fairness, it should be noted that the ranking mentioned above may be an outcome of the Global Fund grants improving the detection and treatment of the two diseases and, in doing so, extended the lives of persons affected by TB and HIV/AIDS—the relative fall in TB as a cause of death over the period 2009–2019 being one piece of evidence for this argument. Still, the extensive funding for two diseases alludes to the role of the organizational mandate in shaping grant applications. In this regard, a state representative notes that “technical specifications are developed by the donor, and all the rest is adjusted to its tune” (State Partner 4).

The Global Fund’s requirements and recommendations also considerably shape the grant applications. Recommendations are not binding, but requirements are implicitly put forward via the explicit conditions the applicant is expected to meet to receive or continue receiving the grants.Footnote 1 Joint application and “dual-track financing” could be typical instances of recommendations, whereas the incorporation of human rights, co-financing, and the Country Coordinating Mechanism (CCM) serves as illustrative examples of the Global Fund’s requirements. However, in this regard, an interviewee notes that applicants, including Kyrgyzstan, equally follow both recommendations and requirements, though the former are not binding (IO Partner 20).

Kyrgyzstan submitted a joint application for two diseases. The Global Fund introduced the submission of joint applications as part of its New Funding Model (2012–2016) in order to facilitate dialogue and decision-making between the disease programs and ensure greater synergy and strategic use of funding (Global Fund, n.d.-c). The new scheme was designed exclusively for those countries with high TB-HIV coinfection rates, and encouraged those ineligible for further financing to submit joint applications for diseases (ibid.). Thus, in addition to applicants transitioning from the Global Fund grants (ibid.), joint proposals were relevant to many countries in Sub-Saharan Africa, where, for instance, nearly half of TB patients were HIV-positive in 2012 (Nelson, n.d., p. 4). Kyrgyzstan was neither transitioning from the grants nor did it have high TB-HIV coinfection rates. In 2012, for instance, only 2.2% of TB cases were found to be HIV-positive (Global Fund, 2014, p. 8). Still, the country submitted a joint TB/HIV application in 2015 for the first time since it received the Global Fund grants. This fact corresponds to the country’s acquiescence to recommendations, suggested by the interviewee in the previous paragraph.

The country has also incorporated “dual-track financing” in the grant implementation process (see the section on “Implementation”). According to this approach, the Global Fund streams financing via “two tracks”—state and non-state actors—to strengthen the role of civil society and the private sector in grants (Global Fund, 2015, p. 3).Footnote 2 It encourages the CCM to use this approach to financing each disease and asks for an explanation if the CCM do not apply this approach (ibid.). Yet, unlike the CCM, dual-track financing is not a requirement, although my interviewees’ perceptions of it varied: some saw it as a recommendation based on international practice (CSO 8), and others approached it as a condition for financing (State Partner 2).

Despite the country’s compliance with both recommendations, this book differentiates between recommendations and requirements to distinguish their (non-)binding nature. Though possibly increasing the chances for funding, the recommendations are not preconditions for financing, unlike the Global Fund requirements discussed below.

First, the applicants are expected to incorporate human rights into their grant applications. The Global Fund denies supporting programs violating human rights (“Local Fund Agent manual. Section G—Global Fund essentials,” 2014, p. 18). It asks applicants to target human rights and gender constraints on health care services (Global Fund, 2016a) and stipulates additional financing, also known as “catalytic investments,” for this purpose. In the case of Kyrgyzstan, the catalytic investments in the amount of US $1 million focused on eliminating human rights constraints on HIV-related health care services (Global Fund, 2023b). The country took several steps to address human rights issues among groups vulnerable to HIV, including men who have sex with men (MSM), commercial sex workers (CSWs), persons who inject drugs (PWIDs), and others. The Government of the Kyrgyz Republic decriminalized sex between men and voluntary adult sex work and introduced changes to the law on possession and use of drugs (Ancker et al., 2017). Although these changes cannot be attributed to the Global Fund alone, they nevertheless constitute changes corresponding to the human rights perspective in the country’s applications to the Global Fund. Thus, the country’s joint HIV/TB proposal for 2017–2019 aimed to eliminate the “legal barriers to human rights-oriented services” (Zardiashvili & Garmaise, 2017, n.p.). Similarly, the country’s previous applications stipulated training of law enforcement officers on stigma, discrimination, and HIV/AIDS prevention (see UNDP, 2015b).

Another example of Global Fund regulations followed by the applicants is co-financing or a domestic contribution by the grant recipient country in the form of government revenues, loans, health insurance, and others to the areas supported by the Global Fund (2016a, p. 12). The goal of this scheme is to demonstrate that the Global Fund grants are complementary to (Brown & Griekspoor, 2013) but do not replace state funding to relevant areas (Vujicic et al., 2011). Applicants are allowed to waive this requirement upon the provision of a detailed plan on how they intend to catch up with co-financing in the future (Global Fund, 2016a).

The Global Fund negotiates the share of cofinancing with each applicant individually, but sets general thresholds depending on income groups. Lower low-middle-income countries such as Kyrgyzstan are expected to cover at least 50% of financing for disease programs and progressively absorb the key program costs (Global Fund, 2016a, pp. 5, 16). Notably, 15% of grant disbursements are conditional on the fulfillment of this requirement (ibid.). In compliance with co-financing (State Partners 2 and 9), the country planned to increase the share of state funding for TB and HIV. More specifically, national stakeholders developed detailed plans, also known as roadmaps, to gradually transfer donor-funded services in these two areas to the state budget. My interviewees note that the cofinancing increased the state funding for TB and HIV/AIDS (CSO 3; IO Partner 3) and that without this condition, the government “would not even move a centimeter to look [for money] in its budget” (CSO 8). In this way, the country followed this explicit regulation from the Global Fund, similar to the accounting for human rights in grant applications.

Third, the most salient yet implicit requirement grant applicants, including Kyrgyzstan, comply with is the CCM. Applicants are expected to have a unit to supervise the planning, implementation, and use of grant resources (Global Fund, 2008, p. 9). Although not explicitly asking for the establishment of the CCM, the Global Fund accepts applications without CCM only in “exceptional circumstances,” that is, from countries in conflict or without a legitimate government and those facing natural disasters and other emergencies (Global Fund, 2018, p. 21). Established during the country’s first application to the Global Fund, the CCM in Kyrgyzstan has 23 members (nine CSOs, nine state, and five donor representatives) (Committee on TB and HIV under the Government of KR, 2023) and 23 alternates (State Partner 10 and Academic Partner 2). Alternates are primarily recipients of Global Fund grants. In contrast to members, they have observer status, which precludes them from voting or participating in grant monitoring due to conflicts of interest. CCM meetings are case-dependent, but their frequency increases during the development of grant applications (IO Partner 3).

The CCM in Kyrgyzstan underwent multiple changes because of a narrow focus on three diseases and duplication of existing institutions. The CCM added to at least three coordinating platforms the country had before the application to the Global Fund (see Table 8.1). In 2005, these platforms merged into the Country Multisectoral Coordinating Committee to fight HIV/AIDS, Tuberculosis, and Malaria (Murzalieva et al., 2007, p. 22). It engaged representatives of state agencies and ministries, international organizations, CSOs, and persons living with HIV (Government of KR, 2006) and dealt with the Global Fund grants exclusively (State Partner 2).

Table 8.1 Evolution of the Country Coordinating Mechanism in Kyrgyzstan
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However, in 2007, the responsibilities of the Committee expanded to over 40 infectious human and animal diseases (Ancker et al., 2013, pp. 75–76). Though aimed at enlarging the Committee’s competence beyond malaria, TB, and HIV/AIDS, this change jeopardized its ability to supervise the grants (Manukyan & Burrows, 2010) and resulted in the delegation of responsibility over three diseases to the Country Coordination Committee under the Ministry of Health. Yet, the Committee had limited impact beyond the supervision of grants. It did not participate in developing and evaluating national policies relevant to the three diseases (Ancker & Rechel, 2015b). Furthermore, grant-related issues required broader engagement of stakeholders. For instance, irrespective of the decision taken at the level of the Ministry of Health, discrimination against sex workers and prosecution of drug users by police forces continued due to their accountability to the Ministry of Internal Affairs and not the Ministry of Health (State Partner 4). The following reform aimed to address these issues.

Integration into the Country Coordination Council for Public Health under the Government of the Kyrgyz Republic elevated the authority of the Committee and partially addressed the issues with duplication of existing institutions. This integration guaranteed a high level of authority for the Committee’s decisions (CSO 8) and compliance of stakeholders beyond the Ministry of Health (State Partner 4). The Council involves all relevant ministries and stakeholders, including the Parliament, under the chairmanship of the vice prime minister responsible for social affairs (WHO/Europe, 2019). This merger also aimed to reduce the duplication of organizational mandates (Government of KR, 2017a).

Similar to the Committee, the Council sought to coordinate the actors, though not only in the areas of three diseases but rather for Kyrgyz public health in general. Its functions include developing and implementing public health policy, monitoring and evaluating public health programs, and coordinating actors working in this area (Government of KR, 2014). It aimed to address the shortcomings of state stewardship in health care observed in the Sector-Wide Approach (SWAp) to health care implemented in Kyrgyzstan. Covering health care systems as a whole, the SWAp still faces multiple issues, including the limited capacity of the Ministry of Health and oversight of development organizations to provide the relevant support (see Isabekova & Pleines, 2021). Before incorporating the Committee into the Council, the Government of the Kyrgyz Republic, with financial assistance from the Global Fund and SDC (Health Focus, 2020), initiated a study that ascertained the feasibility of integrating the Committee into the SWAp (Global Fund Office of the Inspector General, 2016). However, the decision was taken in favor of the Council due to, among other reasons, the limited representation (IO Partner 4) and participation of civil society organizations in SWAp (see Isabekova & Pleines, 2021).

During the process of applications, the CCM is intended to serve as an inclusive platform for stakeholders working in TB and HIV/AIDS.Footnote 3 It aims to facilitate the collaboration between stakeholders (Spicer et al., 2011a) and provide a broader representation of all relevant actors, including people affected by the diseases and representatives of the private sector, academia (IO Partner 20), international development organizations, state institutions, and civil society (State Partner 9). Civil society representation is one of the critical aspects of the CCM: grant applicants are expected to provide evidence for CCM membership of persons affected by diseases or their representation by NGOs and individuals advocating for their interests (Global Fund, 2018). Notably, delegate representation may be waived by the Global Fund’s Secretariat to protect key populations (Global Fund, n.d.-c, p. 7), for instance, if direct participation of persons affected by diseases, and subsequent disclosure of their status or sexual orientation, may subject them to discrimination and criminalization. In any case, national civil society should compose at least 40% of the CCM, and CCM leadership (e.g., chair and vice-chairs) should be elected from state and non-state actors on a rotational basis (Global Fund, n.d.-c, p. 9).

However, the design of grant proposals in Kyrgyzstan shows that the ideal scenario does not always play out. One state representative notes that, in comparison to neighboring countries where CSOs have “no voice,” the Kyrgyz state institutions take their opinions into account (State Partner 2). However, the literature on civil society organizations and development programs in Kyrgyzstan still points to the “tokenistic” participation of NGOs (Spicer et al., 2011b, p. 1752) and persons living with HIV (Ancker et al., 2013). Outnumbered by state representatives (Harmer et al., 2013), civil society members have limited resources of their own to take part in meetings, and there are, in fact, no “effective mechanisms” in the CCM to support their participation (Spicer et al., 2011a, p. 10; Spicer et al., 2011b, p. 1752). This unequal distribution of powers between the state and civil society organizations urged CCM reforms in Kyrgyzstan (Manukyan & Burrows, 2010), particularly after the Global Fund’s rejection of the country’s application.

CCM reforms addressed insufficient civil society representation and participation in designing the grant applications. By 2014, the CCM included two persons living with HIV, one affected by TB, one by coinfection of TB and HIV, two persons who inject drugs, one commercial sex worker, and one MSM (UNAIDS, 2015a, p. 20). Despite this increase in numbers, civil society participation in the decision-making process remained limited. For instance, most civil society organization representatives had difficulties understanding the proposals written in English. Due to the lack of documents in Russian and Kyrgyz, CSOs had a limited understanding of the country’s application to the Global Fund (Global Fund, 2016b). Following the Global Fund’s rejection of the HIV proposal due to its noncompliance with the CCM eligibility criteria in 2014, the CCM members applied for the Community, Rights, and Gender Special Initiative of the Global Fund (ibid). This initiative covered extensive consultations with and capacity-building activities for CSOs, based on findings from situation analysis and review of the country’s HIV proposal (ibid, pp. 12–15). Interviews with multiple stakeholders, including the state, NGOs, and international organizations, identified issues that were targeted during the capacity-building activities (ibid.), contributing to the improved participation of civil society in the following grant applications as well (Zardiashvili & Garmaise, 2017).

In addition to the Global Fund, multiple donor organizations support national stakeholders in designing the applications. The organizations providing technical assistance are the Stop TB Partnership, USAID, UNAIDS, WHO, BACKUP Health,Footnote 4 and others (Global Fund, 2023b). A few individual examples of this assistance include the UNAIDS, USAID, and the United Kingdom’s Department for International Development (DFID)Footnote 5 support to the state agencies and NGOs in preparing the country’s HIV proposal and making the relevant budget calculations (Manukyan & Burrows, 2010). The WHO, in its turn, provided an evaluation of the HIV situation in the country to support the government in defining the priority areas for the HIV proposal (Mansfeld et al., 2015, p. 8).

Similar assistance was provided in the areas of TB. The German Corporation for International Cooperation (die Deutsche Gesellschaft für Internationale Zusammenarbeit—GIZ), for instance, offered training to national stakeholders on the development of a joint TB/HIV proposal (2018–2020) to the Global Fund (AFEW Kyrgyzstan, n.d.). In addition to technical assistance, donors support national actors in coordinating each other’s activities. They use the CCM to inform about their plans, available budget (IO Partner 3), “preferences,” and prospective projects (State Partner 10 and Academic Partner 2). This coordination’s purpose is twofold. To avoid duplication of activities, the country’s proposals to the Global Fund focus on the areas which are not covered by donors and are consistent with the mandate of the Global Fund. Donor organizations and the national government aim to cover the remaining areas (i.e., those excluded from the country’s applications), though within the limits of the financial possibilities and interests of each donor (State Partners 4 and 9). These depend on organizational structure, earmarking, and geopolitical interests that vary across donors and considerably limit the flexibility of their assistance.

Overall, designing Kyrgyzstan’s applications to the Global Fund project involves a large number of national and international actors working on TB and HIV/AIDS in Kyrgyzstan. Donor organizations participate in the country’s proposal to the Global Fund by providing their technical assistance and taking over those areas not included in the proposal or state budget. Overall, the country’s applications to the Global Fund comply with national health care programs.

The grant applications are intended to cover the needs of all stakeholders in targeted areas. By providing a platform for civil society organizations and the persons affected by the relevant diseases, the Global Fund supports the representation of groups often excluded from decision-making. This support is demonstrated by the Global Fund’s requirement to establish the relevant platform, rejection of proposals not complying with the civil society representation requirement, and provision of additional financing to strengthen the capacity of local CSOs. All these possibilities elevated the participation of often underrepresented and vulnerable stakeholders in Kyrgyzstan. Their engagement in drafting the grant applications in Kyrgyzstan was also intended to ensure that the applications were consonant with the needs and interests of target groups and not only with the aims of the recipient government and donor organizations.

However, the design phase also shows that civil society representation and its actual participation are still in their infancy. Hence, limited capacity and awareness of grant regulations hinder CSOs from fully participating and discussing the country’s proposals. The Global Fund’s assistance provided considerable support in this regard, but this was nevertheless limited to a one-time event, and does not represent the regular activity available to CSOs. The mature engagement of civil society is further hindered by state organizations that reckon with this requirement, mainly pro forma, to receive donor financing.

Along with promoting civil society representation and participation in designing country proposals, the CCM, along with other recommendations and requirements, demonstrated the pertinence of the Global Fund and its mandate in defining the content of the applications. The evolution of the CCM vividly showed that the country complied with requirements and recommendations, even if it meant duplicating existing institutions. Multiple changes in the CCM structure allude to the dilemma between ensuring the supervision of grants and integrating the platform into the broader context of infectious diseases and health care in general. Evidence suggests that Kyrgyzstan is not alone in these struggles: an audit of 50 sample CCMs in recipient countries showed that they all “partially or entirely” duplicated existing structures (Global Fund Office of the Inspector General, 2016, p. 13). This supports the assumption about the significance of the Global Fund recommendations and regulations to grant applicants.

8.3 Implementation

The Global Fund delegates implementation of its projects to the Principal Recipients (PRs) and Sub-Recipients (SRs) of its grants. Both are nominated by the CCM and approved by the Global Fund. Grant recipients could equally be state or nongovernmental organizations, as long as they have programmatic, financial, and management capacities (see Global Fund, 2015). Great emphasis is placed on PRs, responsible for assessing SRs, concluding contracts with them, and achieving the indicators stated in the grant agreement with the Global Fund. The PR also provides a procurement plan, reports on prices and quality of health products, coordinates with partners, and fulfills other functions (see Grant Performance Report External Print Version. Kyrgyzstan KGZ-202-G01-H-00, 2011; Grant Performance Report External Print Version. Kyrgyzstan KGZ-H-UNDP, 2016).

Not all actors are capable of accomplishing these responsibilities in a timely manner. Nine to sixteen months may pass from the commencement of a project until the arrival of the procured products (Global Fund n.d.-c, p. 31). Delays in tasks may cause disruptions in treatment or other services stipulated by grants. Ideally, the grant recipients are local public, private sector, or civil society organizations, although in “exceptional circumstances” (e.g., conflict, currency risks), the Global Fund may temporarily approve the nomination of a multilateral organization or an international NGO (Global Fund n.d.-c, p. 2). These organizations are then required to provide a capacity-building plan and a timeline for transferring their PR functions to national actors (ibid.).

In Kyrgyzstan, the Principal Recipients of the grants changed from government institutions to international nongovernmental and multilateral organizations in 2011 (Table 8.2). The following subsections discuss the reasons behind this transfer of PR functions that are also relevant to understanding the relations between the Global Fund, the state institutions, and the NGOs involved in the grant implementation process.

Table 8.2 Principal Recipients of the Global Fund grants to Kyrgyzstan
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Initially, the Principal Recipients of the first Global Fund grants to Kyrgyzstan were the National Center of Phthisiology (for TB) and the Republican AIDS Center (for HIV grants). Implementation of both grants was initially rated “strong” (Global Fund 2006a, p. 2, 2006b, p. 2). My interviewees note that both agencies procured health products according to the World Bank procedures (IO Partner 21), but the loopholes in the National Procurement Law still provided room for corruption schemes (State Partner 7). During the TB grant period (2007–2012), the Global Fund hinted at management issues and agreed to continue its funding primarily due to the engagement of the UNDP in building the capacity of the two state agencies (Grant Performance Report External Print Version. Kyrgyzstan KGZ-607-G04-T, 2012). Yet an anonymous call to Global Fund headquarters about the financial violations taking place in the country (IO Partners 11 and 21) resulted in a visit of its Audit Unit, which took place between November and December 2009 (Global Fund Office of the Inspector General, 2012). It found “significant financial irregularities” in the implementation process and urged an investigation into this matter (Global Fund Office of the Inspector General, 2013, p. 3).

This investigation, conducted by the Global Fund between February 2010 and August 2012, found multiple violations in the grant implementation process. There were violations in medical supply procurement (IO Partner 21), unauthorized cash advances, and transfers to unauthorized entities (Global Fund Office of the Inspector General, 2013). Preposterous justifications for the misuse of funds included the construction of a fish pond fencing to serve fish to TB patients (IO Partner 21). The head of the National Center of Phthisiology also used grant finances to buy a vehicle for his wife (Global Fund Office of the Inspector General, 2013, p. 3), with “maintenance costs” exceeding the value of the vehicle itself (IO Partner 21). Three out of four Sub-Recipient NGOs had family ties to the head of the National Center of Phthisiology, and one of these NGOs was used to misuse finances (Global Fund Office of the Inspector General, 2013, p. 3). Similar issues were found in the grant implemented by the Republican AIDS Center. My interviewees suggest that the initial amount of misused finances identified during the audit reached several million USD, but the state agencies provided supportive documentation in their own defense (State Partner 4; IO Partner 21). However, US $120,974 remained accounted for (Friends of the Global Fight Against AIDS, Tuberculosis and Malaria, 2018). Despite the National Center of Phthisiology’s disagreement with the investigation results (Global Fund Office of the Inspector General, 2013, p. 68), the General Prosecutor’s Office of the Kyrgyz Republic opened a criminal case on suspected misuse of position (Office of the Attorney General of KR, 2012). The head of the National Center of Phthisiology passed away before the investigations were concluded.

The Global Fund repeatedly asked the Ministry of Health to return finances that were unaccounted for. The Minister of Health neither replied to the Global Fund requests (Kasmalieva, 2015) nor returned the finances, referring to the budget deficit (Bengard, 2017). Notably, Kyrgyzstan was not the only case of grant mismanagement. “Misuse” of the grants was identified in Cameroon, Djibouti, Haiti, Mali, Mauritania, and Zambia (Benjamin, 2011, p. 3). In response, the High-Level Independent Review Panel on Fiduciary Controls and Oversight Mechanisms of the Global Fund to Fight AIDS, Tuberculosis and Malaria developed a report. Its recommendations included strengthening the capacity of the CSOs to ensure their supervisory roles as well as a closer evaluation of training activities in the grants. In Kyrgyzstan, the Global Fund neither discontinued the grants nor contacted the supranational authorities, as it usually does in corruption cases (see Global Fund, 2018). Instead, it took a disciplinary measure by deducting US $241,948 or “two dollars for every dollar that the Global Fund sought to recover” from the following grant to the country in 2017 (Friends of the Global Fight Against AIDS, Tuberculosis and Malaria, 2018).

After the mismanagement of finances by the state agency, the UNDP became the main recipient of Global Fund grants in Kyrgyzstan. It contracted with 33 local NGOs to work with persons living HIV, persons who inject drugs, commercial sex workers, men who have sex, and others (see UNDP, 2015a, pp. 34–47; 60–61). The organization also cooperates with state institutions, such as the National Center of Phthisiology, the Republican AIDS Center, the State Service for the Execution of Punishment, the Republican Center for Narcology, the Republican Center for Dermatovenereology, and others (UNDP, 2014). Notably, before assuming this new role, the UNDP implemented TB and HIV grants along with these state agencies and Project HOPE. The Global Fund rated the performance of these two organizations as “excellent,” “exceeding expectations,” “meeting expectations,” and “adequate” (Grant Performance. Report External Print Version. Kyrgyzstan KGZ-910-G07-T, 2016, pp. 19–28; Grant Performance Report External Print Version. Kyrgyzstan KGZ-H-UNDP, 2016, p. 36). Yet, the nomination of UNDP by the CCM and its approval by the Global Fund was not random. Globally, the UNDPs are Primary Recipients of 31 Global Fund grants in 18 countries (UNDP, 2018). In Kyrgyzstan, the organization has worked on HIV issues since 1997 (Manukyan & Burrows, 2010). In other words, the UNDP received Primary Recipient status due to demonstrated country-based expertise and extensive experience with grants.

Still, both state and non-state actors were concerned with the transfer of PR functions to the UNDP. In 2015, the local NGOs appealed to the President, and the Parliament of the country, threatening to discontinue their activities if the national actors did not reconsider this transfer, which purportedly was not agreed with the CSOs (Ismanov, 2015). Similarly, the state actors criticized the transfer of PR functions to the UNDP, referring to the high administrative costs and loss of the country’s ownership over the grants. According to state officials, about 20% of the grant funds were spent on administrative management due to the high salaries of foreign managers and project coordinators (State Partner 9), although state institutions could complete the same work (even with “good salaries“) for one-ninth the cost, or about 2% of the grant valueFootnote 6 (State Partner 2). Validating these estimates was not feasible within the framework of this research: administrative expenditures are not visible in the Global Fund reports (e.g., Grant Performance Report External Print Version. Kyrgyzstan KGZ-H-UNDP, 2016), and the UNDP representatives in Kyrgyzstan (PR) did not answer research requests on multiple occasions. According to a news agency report, the total administrative costs were about US $3 million (Èrkebaeva, 2017).

In addition to increasing management expenses, the transfer of the PR functions to the UNDP allegedly jeopardized the country’s ownership of the grants. Several interviewees emphasized the ownership of state institutions over the finances provided to the country (CSO 3; State Partner 9). Others noted that even though frequently argued by the Ministry of Health (State Partner 14), this notion of ownership does not prioritize the interests of the population affected by the diseases (IO Partner 4). This discussion raised the pertinent question of whether the recipient state’s ownership over the grants represented the “country” and the interests of the population affected by the diseases.

In response to the allegations mentioned above, the UNDP pointed to grant savings and the small number of NGOs that signed the petition against it. The organization reported US $1.7 million in savings achieved through changing the suppliers and contractors previously involved through the state agencies (Eurasianet, 2012). Although more expensive, the UNDP represented a “safe” option for the Global Fund (IO Partner 20), notably due to the reliability of its procurement procedures. According to an anonymous “UN source” interviewed by an independent news organization, the costs of 13 essential items in the grants were 300% higher during the period of grant implementation by the state organizations (Eurasianet, 2012). Thus, despite the seemingly higher administrative costs, the UNDP assured the effective use of finances. In response to the CSO petition, the UNDP emphasized the small number of NGOs that signed the appeal, which merely attempted to “discredit” the organization’s work (Ismanov, 2015). Yet, the small number of signatures could also relate to CSOs’ aid dependency. Spicer et al. (2011b, p. 1752) note that the NGOs in Kyrgyzstan refrained from criticizing the PR (a state agency) due to the fear of not receiving further financing. This observation could, however, be equally relevant to the NGOs’ relationship with PRs in general and not limited to the state PR.

Following the grant agreement, the UNDP committed itself to building the capacity of national actors. The replacement of NGOs previously involved in the grants implemented by the state agencies caused “serious protests,” and in response, the new PR offered capacity-building activities to the excluded organizations to support their potential future return to grant activities (Grant Performance Report External Print Version. Kyrgyzstan KGZ-H-UNDP, 2016, p. 6). Twenty-one CSOs received training on quality of services, HIV prevention, adherence to treatment, and other areas (Grant Performance Report External Print Version. Kyrgyzstan KGZ-H-UNDP, 2016, p. 32). The UNDP has equally committed itself to building the capacity of state agencies and gradually transferring its PR functions to them (IO Partner 3).

Nevertheless, the Global Fund grants remained with a multilateral organization. Government organizations repeatedly emphasized their willingness to resume their roles as PRs (CSO 9; IO Partner 4), and in 2014, the CCM voted in favor of this resumption. To enable this, the Ministry of Health had to fulfill several conditions, namely, to develop the necessary mechanisms for contracting the local NGOs and to register the medications currently procured by the UNDP as humanitarian assistance (Minus Virus, 2017). The Ministry was also expected to provide timely reporting and financial management within the grants. The Global Fund and USAID provided US $600,000 to establish the Project Implementation Group under the Ministry of Health to support it in these tasks. However, there were multiple inefficiencies in its work. For instance, a supervisor of this group, appointed by the Minister of Health, ended up sending personal acquaintances for training abroad (ibid.). The Ministry also once delayed its report to the UNDP for two months, subsequently delaying for six months the payout of financial incentives for adherence to treatment for persons living with HIV for six months (ibid.). One and a half years after its establishment, the Project Implementation Group did not achieve all of the agreed goals, fulfilling eight of eleven indicators (Bengard, 2017). The Global Fund evaluated the Ministry as not yet ready to take over the PR functions (State Partners 4 and 9). The Ministry of Health continued negotiating the transfer of PR functions and reductions in the UNDP’s administrative costs (Èrkebaeva, 2017).

There are in theory no restrictions on the types of organizations receiving the grants, but the Global Fund’s requirements for grant implementation in practice result in the selection of organizations with specific qualifications. Following the Global Fund requirements, the UNDP has also developed a transition plan to transfer PR responsibilities to the national stakeholders. However, a state official noted that the donor procedures do not specify the period within which the organization is expected to transfer PR functions to national actors (State Partner 4). During both field trips to Kyrgyzstan in 2016 and 2018, multiple interviewees expected the near-term transfer of PR functions to state organizations. Yet, to this day, the UNDP remains the PR of grants.

It should be noted that regardless of other actors taking over the PR functions, local NGOs remained Sub-Recipients of the Global Fund grants. NGOs’ interaction with the donor is limited to meetings with the portfolio manager of the Global Fund. There are no statistics about the frequency of these meetings, but in 2014 alone, the portfolio manager visited Kyrgyzstan at least three times (UNDP, 2015b, 2015c). Encompassing multiple actors, including the Primary and Sub-Recipients of grants, members of the Parliament, and others, these meetings are used to discuss the issues and achievements in the grant implementation process, the administrative, financial, and management systems of the Global Fund, and other matters (ibid.). The portfolio manager also answers questions and explains the changes (if any) in the Global Fund policies and regulations (ibid.). Still, the interaction between the local NGOs and the financiers beyond these meetings remains limited. In contrast, the financier seems to have continuous communication with the PR of the grants (IO Partner 4), which is the main point of contact for the local NGOs.

Still, the Global Fund and PR have hierarchical relations with local NGOs. According to one NGO representative interviewed for this research, donors greatly vary in their approach toward NGOs. She pointed to hierarchical relations in the Global Fund grants and stated that during the interaction with donors and project managers, the SR was frequently reminded of grant objectives and indicators that prevailed over the changes and suggestions made by the NGO (CSO 6). The interviewee noted that as “implementers,” they were well aware of their “functions” and target groups, and their inability to go beyond these (ibid.). The interviewee contrasted this experience with her work on another health project. There, project managers “listened to” and considered the NGO’s suggestions because, working on the ground, they had first-hand knowledge on how to improve the situation (ibid.). The interviewee was “astonished” by the appreciation and respect she experienced in this project, which aimed to introduce, not reject, the NGO’s suggested changes (ibid.). This interviewee’s perspective is not generalizable, but it does echo certain issues raised in the literature on health aid to Kyrgyzstan.

Multiple studies point to the limited flexibility of donor organizations. According to Benjamin (2011), the Global Fund assessment criteria focus on input and output indicators but leave little space for qualitative information. Yet this openness to suggestions is essential to the responsiveness of health assistance to local needs. For instance, multiple studies note increased emphasis on prevention (Murzalieva et al., 2009) but not advocacy in health care programs (Harmer et al., 2013; Spicer et al., 2011b). However, this may not reflect the priorities of target groups, such as commercial sex workers, who consider police harassment as their most significant problem (Ancker & Rechel, 2015a). Some interviewees in the study by Burrows et al. (2018) go even further by partially relating the increased violence and hostility toward the groups vulnerable to HIV to the reductions in donor funding and its growing emphasis on testing and treatment instead of advocacy for human rights. Designed by local stakeholders, the Global Fund grants ideally target issues identified by them. Yet, further openness to suggestions by local implementers would ensure the responsiveness of the assistance to the changing realities on the ground.

Local NGOs implemented the grants in collaboration with state agencies—former PRs of the Global Fund grants. Joint project implementation by state organizations and NGOs was possible due to the “dual-track financing” of the Global Fund, which contributed to collaboration between these actors. According to Harmer et al. (2013), this cooperation laid down the basis for overcoming the stereotypes actors had of each other. Yet, the sections below show multiple issues encountered during the joint implementation, which may not have overcome these stereotypes but did become the basis for collaboration beyond the grants.

State and civil society organizations found common ground for collaboration. The actors jointly develop the clinical protocols, organize round tables (State Partner 4), and implement harm reduction programs (Murzalieva et al., 2009) and awareness-raising activities throughout the country (CSO 3). State organizations largely provide the treatment of TB and HIV/AIDS, and NGOs complement these activities by reaching out to groups vulnerable to HIV out of reach to the state health care system (e.g., PWIDs, CSWs, MSM, and others). NGOs primarily work on disease prevention, the distribution of information materials, outreach, and care for the abovementioned population groups (Ancker et al., 2013). The state officials interviewed for this research claimed a “quite good” relationship and close collaboration with NGOs (State Partners 2 and 4). A civil society representative emphasized the significance of working with state officials, but stressed the importance of “speaking the language of state officials” by highlighting the general benefits of the services to the city and population instead of talking about the patients’ needs (CSO 6). This framing seems to have contributed to the changing attitudes of state officials toward groups vulnerable to HIV and to their readiness to make the relevant changes (ibid.).

Still, tensions, particularly regarding the role of NGOs and their expertise in health, remained. Spicer et al. (2011b, pp. 1751–1752) note that state officials merely tolerate the CSOs’ advocacy work and essentially perceive them as “helpers” rather than (equal) partners. The authors conclude that state institutions are not ready to consider NGOs’ opinions and are cautious of their growing influence on social policy (ibid., p. 1754). Indeed, often overloaded with a large number of patients, health care workers have limited capacity to work with groups vulnerable to TB and HIV that tend to avoid state health care systems due to the fear of stigma, discrimination, and anonymity concerns. NGO social workers commonly come from the groups they are working with, which contributes to the trust between the social workers and these groups (CSO 6). By filling in the gaps in the state health care system (Semerik et al., 2014), NGOs, in a way, take over some state responsibilities (Ancker & Rechel, 2015a). However, their expertise in working with vulnerable groups is not necessarily acknowledged by state officials. One interviewee pointed to the discussions in the Ministry of Health regarding the abilities and qualifications of NGO employees to deal with health care issues without having relevant medical education (State Partner 4). This finding corresponds to the statements of the former Minister of Health (2014–2018), who portrayed the Ministry of Health as the primary actor in health care and advocated for ministerial control over NGO financing and activities in this field (Majdan.kg, 2018).

Nevertheless, the collaboration between the NGO and state organizations continued, particularly in preparing for the country’s transition from Global Fund grants. The government adopted a “roadmap,” in which it committed to increasing its share of HIV-related financing to 80% during the 2017 to 2021 period (State Partner 2). The Ministry of Health “worked closely” with the NGOs on the development of a roadmap, demonstrating the gradual transition of the activities currently financed by donors to the state budget (ibid.). My interviewees emphasized civil society organizations’ role, including active lobbying efforts, in increasing state financing for HIV (State Partner 4). In addition to justifying the relevance of the roadmap before the Ministry of Finance (State Partner 2), CSOs advocated for increased funding and their role in monitoring the use of HIV-related resources. These activities found their reflection in the national program (see Government of KR, 2017a, 2017b), hinting at future collaboration between state and civil society actors.

Similar to the relationship between the recipient state and CSOs, limited financing seems to have intensified the coordination among donors. The Global Fund pays particular attention to coordination with American institutions, such as USAID, the Centers for Disease Control and Prevention (CDC), and the President’s Emergency Plan for AIDS Relief (PEPFAR) (IO Partner 20). Still, interviewees noted that coordination among donors intensified mainly due to decreased financing (IO Partner 3; State Partner 2). According to state officials, previously, a project beneficiary may have received the same service from three organizations (State Partner 2), but de-duplication was finally achieved in the recent National HIV Program (2017–2021) (State Partner 4). Yet a civil society representative notes that donor coordination intensified only due to a “catastrophic shortage of finances”:

The money was so little that if you take it here, [a gap] opens there, [if] you take it there [a gap] opens here. For this reason, they are now endlessly meeting to review [the spending] and to try to cover these holes. (CSO 8)

In addition to complementarity concerns, donor coordination during implementation is driven by attempts to de-duplicate efforts. Though expected to prevent the duplication of donor activities (IO Partner 20), the CCM may always not be able to coordinate the donors or have a complete picture of the programs implemented in the country (IO Partner 4). A single health care worker may simultaneously have contractual agreements with multiple donor organizations (Semerik et al., 2014). Data gathering in these circumstances is exceptionally challenging (see the following section on monitoring). Therefore, the Global Fund additionally meets with the relevant donor organizations, also during the visits of the portfolio manager to a grant-recipient country (see UNDP, 2015b). Through coordination with major partners, the Global Fund avoids the duplication of efforts and substantial gaps in aid-recipient countries (IO Partner 20) to ensure the continuity of services.

Overall, the roles of actors and their relations to each other during implementation demonstrated multiple differences to those of the design stage, except for the relations between the Global Fund and other donors remaining equal and driven by coordination of efforts to avoid duplication and gaps in services. However, there were considerable changes in state/civil society organization, donor/CSO, and donor/recipient state relations.

First, the relationship between the CSOs and state agencies implementing the Global Fund grants remained strained but equal. The vision of individual ministers on the mandate of the Ministry of Health and its prerogative to supervise and control all organizations working in health care complemented the general discourse about the inefficient use of finances by NGOs. The purely medical perception of health care by individual state authorities has led to additional questioning of the expertise of NGOs and their ability to work with target groups. Common to the post-Soviet region, this perspective is not unique to Kyrgyzstan. Despite these concerns, actors still continued jointly implementing the grants and lobbying for future financing. In contrast to the design phase, the local NGOs were not outnumbered by state organizations and seemed contested but equal partners here.

Second, relations of the Global Fund with the local NGOs were hierarchical. Despite its contribution to civil society participation in the implementation of grants, the financier seems to provide little space for SRs’ suggestions. With their roles defined and little space for change, local NGOs are seen merely as implementers of grant activities. This approach is different from the promotion of active participation of NGOs in drafting the country’s applications we observed in the design phase.

Third, though complying with the Global Fund’s decisions, state organizations demonstrated some resistance during the implementation phase, in contrast to the acceptance without reservations we observed during the design stage. State organizations complied with the Global Fund’s decision to keep the UNDP as the PR, as the Ministry of Health could not demonstrate its ability to do so. Still, organizations repeatedly requested the transfer of functions to state institutions and discussed the potential cost-saving in administration by returning the administration of grants to state organizations. Moreover, in response to the Global Fund’s repeated request to return the unaccounted-for finances, the Ministry of Health neither acknowledged the inquiries nor returned the missing finances. Unable to obtain finances from the recipient state, the donor cut this amount from its follow-up grant. Though the theoretical assumption about changing power assumes high provider leverage at the beginning of the grant process, this particular finding suggests an increased role of the recipient state in the project implementation phase, as well.

8.4 Monitoring

The Global Fund outsources project monitoring to the Local Fund Agent, the Principal Recipient, and the Country Coordinating MechanismFootnote 7:

The Country Coordinating Mechanism is expected to have “strategic oversight” over the grants (IO Partner 4), but this ability depends on the CCM’s capacity to do so. The Oversight Committee of the CCM conducts field trips to observe the implementation of the Global Fund project (UNAIDS, 2015b) and discusses the Primary Recipients’ progress with programmatic, procurement, and financial indicators (UNDP, 2015a). For this, CCM members are expected to be aware of Global Fund policies and procedures, as well as the financial, procurement, and implementation details of the grant operation process (Sands, 2019). Yet, a study of 50 CCMs (including the one in Kyrgyzstan) found their oversight function “weak,” with a need for further improvements (Global Fund Office of the Inspector General, 2016, p. 11). The Kyrgyz CCM received technical and financial assistance from multiple donors, including the European Union, DFID, PEPFAR, USAID, and others (Manukyan & Burrows, 2010). Nevertheless, the CCM’s ability to monitor the grants remained relatively weak. Studies on health care aid to Kyrgyzstan point to lack of work plans, problems with analytical work (ibid. p. 14), and CCM members’ unawareness of their functions (Spicer et al., 2010, pp. 11–12). These issues culminated in the CCM’s inability to oversee the Global Fund grants, resulting in the mismanagement of finances discussed in the “Implementation” section.

The Local Fund Agent (LFA) monitors the grant implementation process by the PR and SRs and reports directly to the Global Fund.Footnote 8 Known as the “eyes and ears” of the Global Fund (IO Partner 21), the LFA participates in the CCM meetings, but its interaction with grant implementers remains somewhat limited to ensure the neutrality of its assessment reports. More specifically, the LFA verifies the prices, quantities, and salaries indicated in the programmatic and financial reports of the Primary Recipient (IO Partners 4, 20 and 21). In addition to desk research, it also conducts field trips to evaluate the service coverage and the end receipt of procured goods by grant beneficiaries. In Kyrgyzstan, for instance, there were instances in which commercial sex workers had to pay for the condoms they were entitled to receive for free, and cases where condoms procured within the grants and marked “the Global Fund, not for sale” were sold in local kiosks (IO Partner 21). Based on these accounts, the LFA reports to the Global Fund with suggestions for further grant-related disbursements (Global Fund, 2007). The LFA monitoring results are critical to the continuity of the grants.

In contrast to the LFA, the Principal Recipient participates in designing and implementing the grants, but also monitors the achievement of indicators and takes corrective actions to address the relevant issues. The PR visits the Sub-Recipients of grants to meet grant beneficiaries and identify and solve issues, including those related to the quality of reported data, patient adherence to treatment, and other aspects relevant to the grant indicators (e.g., UNDP, 2015b, 2015d, 2015e). During these meetings, the PR also validates the programmatic and financial data reported by the SRs. There are concerns that the local NGOs misrepresent and manipulate data in their reports (Ancker & Rechel, 2015a). There are no statistics about the frequency of PR visits to Sub-Recipient NGOs, but in 2014 alone, the UNDP conducted 63 field trips to the SRs (UNDP, 2014, p. 21). Based on the monitoring and SRs’ reports, the PR submits programmatic and financial reports to the Global Fund, the LFA, and the CCM (Global Fund, 2003) on a quarterly to biannual basis (Grant Performance. Report External Print Version. Kyrgyzstan KGZ-910-G07-T, 2016; Grant Performance Report External Print Version. Kyrgyzstan KGZ-H-UNDP, 2016). These reports aim to demonstrate the progress against the indicators stated in the grant agreement, which is essential to continuous financing from the Global Fund.

Overall, the Sub-Recipients, including state and civil society organizations, provide data for monitoring activities but do not participate otherwise to avoid conflicts of interest. Still, state and civil society organizations monitor each other’s activities.Footnote 9

State and civil society organizations share information about each other’s activities, except for data on NGO financing. CSOs participate in SWAp meetings in which the Ministry of Health reports about achievements and issues in the national health care program (see Isabekova & Pleines, 2021). A state official interviewed for this research emphasized NGOs’ reciprocal responsiveness, openness, and readiness to provide the requested material (State Partner 2). However, actors’ access to financial information on each other varied. If necessary, the CSOs could request the information, also in terms of public financing, from the relevant ministries (CSO 8). In contrast, government organizations had no right to scrutinize NGO funding until 2021. The former Minister of Health (2014–2018) accused NGOs of receiving almost half of the Global Fund grants but not reporting on their use of funding (Malyševa, 2018). The state official interviewed for this research similarly resented having no right to access the funding information, noting that NGOs are “only accountable to those who finance them” (State Partner 2). Similar concerns were raised in the literature on health aid to Kyrgyzstan, suggesting that local NGOs are accountable to donor organizations that finance and monitor their activities (Spicer et al., 2010) but not project beneficiaries or the government (Ancker et al., 2013; Ancker & Rechel, 2015a).

State organizations are mistrustful of the use of finances by local NGOs. Government organizations perceive CSOs as “foreign agents” and “grant eaters” (CSO 8) rather than equal partners (Murzalieva et al., 2009, p. 55). Exacerbated by the limited access to the data on NGO financing, these accusations are based on two main reasons:

First, there is alleged disproportionality of payments for services provided by NGOs. Several interviewees noted that the salary rates of government officials were not consistent with their workload (State Partner 10 and Academic Partner 2), and that NGO staff received higher salaries compared to health care workers (State Partner 2). To be fair, in addition to their routine workload, state officials may indeed have additional tasks related to health aid provided by donor organizations. The intensive workload, in combination with low salaries, contributes to understaffing and high staff turnover rates, also in the Ministry of Health (see Isabekova & Pleines, 2021). Health care workers in public facilities face similar issues (see the subsection below).

NGOs justified the proportionality of payment to services by referring to the “difficult cases” they take over from the state health care system and the irregular working hours these require. In contrast to general practitioners providing health care services to the general population, NGOs have a small number of patients. Yet these are the “most difficult” cases, including patients with addiction problems (drugs or alcohol) (CSO 8), as well as the homeless (State Partner 4). As a rule, these patients avoid state health care facilities and require more time for care. Therefore, the costs of finding, persuading, and supporting these patients are not comparable to the costs of patients willingly coming to health care facilities (ibid.). The latter will, as a rule, adhere to treatment, but the former require the continuous engagement of health care professionals to do so. A civil society representative in this regard notes that, in contrast to state employees, NGO staff have irregular working hours depending on the project needs and the groups they are targeting (CSO 8).

Second, the mistrust toward NGOs is also driven by the perception that the state institutions “should control” health aid. One former Minister of Health repeatedly restated the role of the state in all matters of citizens’ health (Malyševa, 2018) and emphasized that the Ministry of Health had the authority to “control any organization working in health care independently of its form of ownership” (Majdan.kg, 2018). Another state official noted that the Minister’s concern over NGO accountability mainly refers to finances because all NGO activities and indicators fully comply with the national health care program (State Partner 4). In any case, the discourse about governmental control over health assistance contributed to continuous discussions about the role of the government in scrutinizing NGOs, resulting in the amendments to the Law of the Kyrgyz Republic “On non-profit organizations.” Since June 26, 2021, NGOs are required to report on sources of their financing and the use of these funds (Government of KR, 2021).

Regarding content, the Global Fund aims to coordinate its monitoring activities and indicators with the grant-recipient government and other donor organizations.

First, the Global Fund integrates the monitoring of its grants into national systems by aligning its monitoring requirements with the monitoring and evaluation (M&E) system of a grant-recipient country. The organization asks project implementers to provide national rather than grant-specific M&E to demonstrate the project impact, coverage, and outcome indicators (“Local Fund Agent manual. Section G—Global Fund essentials,” 2014). In doing so, it encourages the use of data already gathered by government institutions. State agencies and ministries routinely collect and report the information related to the realization of national health care programs to the Ministry of Health (see Majtieva et al., 2015). The PR is free to use this data as long as it clearly demonstrates the indicators and objectives stated in the project. Further exceptions to the use of the national M&E are the cases with no national system or in which the system is not relevant to the Global Fund grants (“Local Fund Agent manual. Section G—Global Fund essentials,” 2014).

The use of national indicators is also intended to strengthen the national M&E systems, though this support is in practice limited to the areas relevant to the grants. The applicants are also encouraged to include support for the national M&E systems in project proposals. The Global Fund may provide assistance in the amount of 5–10% of the total grant financing for data systems, registration, analytical skill development, and other purposes (“Local Fund Agent manual. Section G—Global Fund essentials,” 2014, p. 8). In the context of low- and middle-income countries, this assistance may be pivotal to strengthening the national systems. In Kyrgyzstan, for instance, this support resulted in a unified database with common indicators, data collection, and analytical mechanisms (Ancker & Rechel, 2015a). The Government planned to further increase the funding for the national M&E and provide continuous training to specialists. However, in the face of budget deficits, the national system remained “weak” and largely dependent on donor funding (see Government of KR, 2017b, n.p. Majtieva et al., 2015, p. 29).

Second, the Global Fund aims to coordinate its monitoring requirements and activities with other donor organizations to avoid duplications. Still, its emphasis on the visibility of its contribution jeopardizes these attempts. To decrease the burden on grant recipients having to report to multiple donors using different indicators, the organization negotiates the list of common indicators with the WHO, USAID, PEPFAR, and other actors (“Local Fund Agent manual. Section G—Global Fund essentials,” 2014). Furthermore, suppose the Global Fund contributes to the national program by pooling its finances together with other donors: in that case, the Primary Recipient of grants may provide a single audit report with all other donors, as long as this audit explicitly indicates the Global Fund’s contribution (Global Fund, 2019, p. 12). However, as a rule, the organization does not merge its finances with other donors due to the difficulties with tracking and validating the use of its resources (IO Partner 20). This notion of transparency hinders the Global Fund’s attempts to coordinate its monitoring activities with other donors.

Donor visibility and tracking requirements contribute to counting irregularities in the NGO sector. In Kyrgyzstan, there have been cases of double-counting of the target groups due to the multiplicity of donor approaches to the registration of project beneficiaries (Murzalieva et al., 2009). These irregularities in counting may artificially inflate the number of people covered by the services and contribute to inaccurate estimation of the size of the groups targeted by projects (e.g., commercial sex workers, persons living with HIV, and others). Local NGOs register their clients (e.g., project beneficiaries) by using a universal identification code, but the organizations do not share these data with each other and mainly concentrate on collecting the data requested by donors (ibid.). In other words, a person may have received analogous services from multiple NGOs that registered him/her in parallel to each other. As neither NGOs nor donor organizations comprehensively share the reporting data with each other, this double-counting may remain hidden in reports submitted to, and later by, development organizations.

Limited coordination among donors in terms of their monitoring requirements overwhelms civil society organizations, having to deal with various, at times contradictory criteria. After the misappropriation of grant disbursements in multiple countries, including Kyrgyzstan, the Global Fund introduced several changes in its financial reporting requirements. The increased control over finances resulted in the grant recipients spending extensive time and effort on reporting, which affected their grant implementation functions (Benjamin, 2011). Ancker and Rechel (2015a) went even further, suggesting that the NGOs spent more time reporting on projects than actually implementing them. This was true particularly for those that received financing from multiple organizations, and therefore had to comply with various project cycles, reporting forms, indicators, and other requirements of each donor (ibid.). The authors noted that the NGOs felt “torn” between the multiplicity of donor requirements that at times contradicted each other. For instance, the Global Fund stipulated 100% coverage of the groups vulnerable to HIV, while the United Nations General Assembly Special Session on HIV/AIDS defined a 60% target (ibid.). Still, the organizations were expected to fulfill the indicators to continue receiving finances.

In the government sector, donor visibility and tracking requirements caused problems with quantifying and forecasting demand for medications. The vivid examples hereof were documented in relation to TB medications. There were problems with forecasting and quantifying the drugs in Kyrgyzstan (Manukyan & Burrows, 2010) because the medications are stored, recorded, and reported in separate registers according to their sources of supply (van den Boom et al., 2015). The WHO study suggests the presence of nine registers in one health facility, which made the accurate review of the total quantity of the relevant medications impossible, and due to the lack of a unified electronic database, the personnel in this health institution recorded and reported the quantities by hand (ibid.). Unfortunately, this example is not limited to a single facility. According to a development partner interviewed for this research project, it took almost a year to monitor the overall stock of medications in the country due to the “parallel reporting systems” used by health facilities (IO Partner 4). Overall, donor visibility and tracking requirements increase the burden on health care workers already overwhelmed with routine tasks and responsibilities. It also complicates the quantification and forecasting of medications, in doing so jeopardizing the continuity of treatment.

Overall, donor coordination of monitoring activities remains limited. One state representative notes that organizations do not duplicate each other in terms of their objectives and geographic coverage, but their monitoring visits often repeat each other’s efforts. The interviewee reported receiving multiple invitations from various donors to joint monitoring visits to the same area. The state representative agreed to participate in some cases but not in others (State Partner 3).

Similar to implementation, the Global Fund delegates monitoring of its project to local stakeholders in Kyrgyzstan. The Country Coordinating Mechanism, Local Fund Agent, and Primary Recipient complement each other and provide comprehensive coverage of stakeholders (see Diagram 8.1). As Sub-Recipients of grants, the state agencies and local NGOs do not directly participate in the monitoring process to avoid conflicts of interest. Instead, they end up monitoring each other. As in the implementation phase, NGOs’ use of financing remains an issue between the state and civil society organizations.

Diagram 8.1
A 3-ring onion diagram. 1. Principal recipient monitors the sub-recipients of grants. 2. Local fund agent monitors primary and sub-recipients of grants. 3. Country coordinating mechanism oversees its implementation. They appear from the inner to the outer ring, in order.

The realm of actors monitoring the Global Fund grants

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The Global Fund attempts to coordinate its monitoring with the national M&E system and evaluation activities of other donors. It aligns its monitoring plans with the national programs on TB and HIV/AIDS and contributes to the development of the national M&E system. Though considerable in some areas, this support obviously failed to solve Kyrgyzstan’s systemic issues related to staff capacity and budget deficit. Moreover, this support also seems to primarily facilitate the alignment of national systems with grant indicators.

The Global Fund attempts to coordinate its monitoring activities with other donors, but its requirement for the visibility of its contribution hinders these efforts. Other donors have similar issues, demonstrated by the presence of nine registers in one health facility. The actors vest different interests and standards in their M&E, but until donor commitments to harmonize this area materialize, aid recipients continue bearing most of the related costs (Holzscheiter et al., 2012). In Kyrgyzstan, the multiplicity of donor requirements not only increased the burden on the state and civil society organizations, but also affected their abilities to forecast need for medications and record the project beneficiaries.