Keywords

The grants of the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) provided to the Kyrgyz Republic are still ongoing, but the country is preparing to transition from its assistance. This chapter discusses the sustainability of Global Fund grants provided to the country by expanding on the continuity of project activities, maintenance of benefits, and community capacity building within the grants. As discussed in Chap. 3, within ongoing projects, the continuity of project activities and maintenance of benefits received by the targeted population refer to the services taken over by a donor, recipient state, or civil society organization. Community capacity building, in its turn, implies the leadership of civil society organizations, their ability to continue their work and mobilize the necessary resources for it. In addition to discussing the three components of sustainability, this chapter also examines the significance of the factors relevant to these components, such as the commitment of the recipient state, quality of services, and financing. This chapter commences with a description of the grants and major activities stipulated by them.

9.1 Description of Grants

The Global Fund is among the largest financiers of activities targeting tuberculosis (TB), human immunodeficiency virus infection, and acquired immunodeficiency syndrome (HIV/AIDS) problems worldwide. In the Kyrgyz Republic, it covered the costs of antiretroviral therapy (ART), treatment of TB and HIV/AIDS coinfection, prevention of mother-to-child transmission of HIV (Ancker et al., 2013), TB medications, laboratory reagents, and more (State Partner 9). The organization also provided equipment and staff training to support health systems strengthening in the country (Murzalieva et al., 2009).

The Global Fund provided multiple grants to facilitate TB control in the country.Footnote 1 The first grant (2004–2009) aimed to prevent the disease by training medical specialists, providing treatment and detection of TB, increasing the awareness of TB in the civilian and penitentiary sectors, and other activities (Grant Performance Report External Print Version. Kyrgyzstan KGZ-202-G01-H-00, 2011). The following grant (2007–2012) provided training to health care workers, social supportFootnote 2 to TB patients, and quality control in the labs to integrate TB services into primary health care (PHC) (Grant Performance Report External Print Version. Kyrgyzstan KGZ-607-G04-T, 2012). It also offered directly observed treatment short-course (DOTS) for both drug-susceptible and drug-resistant forms of TB for the patients in prisons (ibid.). The third grant (2011–2015) intended to increase TB detection and treatment in the country by implementing drug-resistance surveillance and improving the regulatory basis for service delivery (Grant Performance. Report External Print Version. Kyrgyzstan KGZ-910-G07-T, 2016). It stipulated social support for TB patients, training of medical workers and the Village Health Committees, and other activities (ibid.). The following grant (2011–2016) intended to consolidate the DOTS framework by improving the detection and treatment of all forms of TB, providing quality control in the labs, training TB specialists, and so on (Grant Performance Report External Print Version. Kyrgyzstan KGZ-S10-G08-T, 2016). Kyrgyzstan was also among the eleven countries benefiting from the TB Regional Eastern Europe and Central Asia Project on Strengthening Health Systems for Effective TB and drug-resistant TB Control, financed by the Global Fund. This grant aimed to reduce TB-related stigma and discrimination, promote people-centered outpatient care, and facilitate the participation of persons affected by this disease in the decision-making process (Amanzholov et al., 2018). The Kyrgyz NGO “Association of AIDS Service NGOs of the Kyrgyz Republic Anti-Aids” promoted outpatient TB care among the decision-makers, the general public, and health care professionals (ibid.).

In parallel with TB grants, the Global Fund also provided grants to control HIV/AIDS in the country. The first grant (2004–2009) focused on HIV prevention among the general population and the groups most vulnerable to this disease, including commercial sex workers (CSWs), persons who inject drugs (PWID), men who have sex with men (MSM), and others (Global Fund, 2006a). The grant stipulated a wide range of activities, such as establishing needle-exchange points, providing methadone treatment and antiretroviral therapy (ART), HIV prevention and counseling, training for journalists and health care workers, and other activities (Grant Performance Report External Print Version. Kyrgyzstan KGZ-202-G01-H-00, 2011). The following grant (2011–2016) aimed to achieve universal access to prevention, diagnosis, and treatment, particularly among vulnerable groups (Grant Performance Report External Print Version. Kyrgyzstan KGZ-H-UNDP, 2016). It stipulated HIV prevention, ART, training of health care workers, and capacity building of communities affected by the disease (ibid.).Footnote 3 In 2016, the country received a joint grant for TB and HIV/AIDS (2016–2023) aimed at universal access to TB and HIV diagnostics, treatment, and care (UNDP, 2023). In addition to TB and HIV/AIDS prevention, testing, and treatment, this grant emphasized treating coinfection of these two diseases (Grant Performance Report External Print Version: Kyrgyzstan KGZ-C-UNDP, 2016) and achieving sustainability of the national programs targeting them (UNDP, 2023).

9.2 Continuity of Project Activities

This section discusses the continuity of grant activities by elaborating on the types (what) and the extent of activities related to the treatment and prevention of TB and HIV/AIDS. It also discusses the factors relevant to the continuity of activities, namely, the formal character of state support, financing, the epidemiological situation in the country, and the quality of services.

Regarding HIV/AIDS, I focus on grant activities related to prevention (testing, condom distribution, needle- and syringe-exchange program, opioid substitution therapy) and treatment services (ART and treatment of sexually transmitted infections).

First, the Global Fund grants increased the breadth of prevention activities. The grants contributed to the establishment of testing services at NGOs and state health care facilities. This included the provision of consent-based testing for pregnant women and children under five at health care facilities (Murzalieva et al., 2009) and the establishment of rapid saliva-based HIV testing at nongovernmental organizations (NGOs) for the groups unwilling to receive the services at state health care facilities. As of 2015, 20 NGOs and 63 state health care institutions provided saliva and capillary blood-based HIV testing free of charge (Mansfeld et al., 2015, pp. 9, 16). As a result, the amount of HIV testing in the country increased (European Centre for Disease Prevention and Control and WHO/Europe, 2019). The number of HIV tests in 2020 alone reached 32,299 (Global Fund, n.d.-b). There are concerns that this increase is primarily attributed to extensive testing among pregnant women, not of the groups most vulnerable to HIV (Mansfeld et al., 2015; Semerik et al., 2014). Nevertheless, in 2020, HIV tests taken among MSM, CWS, and PWIDs cumulatively represented 82% of the total number of HIV tests (Global Fund, n.d.-b). Therefore, the plausibility of concerns about insufficient testing among vulnerable groups requires further research.

Second, the grants contributed to condom distribution among the groups most vulnerable to HIV, but the availability and use of condoms in the country remained limited. In 2014 alone, about 1.5 million condoms were distributed at the expense of the Global Fund grants. Yet, these condoms had a “supplemental” character, and they did not meet the needs of grant beneficiaries (UNDP, 2015d, p. 4). The availability of condoms in prison settings also remained limited (Burrows et al., 2018). Unmet needs contributed to the irregular use of condoms. For example, a survey conducted within the framework of the Global Fund grants showed that the CSWs did not use condoms with their regular sexual partners or if a client paid extra (UNDP, 2015d).

Third, the Global Fund expanded the needle and syringe exchange program (NSP) in the country, but the coverage of this program remained limited due to the criminalization of drug use. Kyrgyzstan introduced the NSP in 1999 with the support of the Soros Foundation Kyrgyzstan, the United Nations Development Programme (UNDP), and Joint United Nations Programme on HIV/AIDS (UNAIDS) (Wolfe, 2005). By the end of 2004, the program covered twelve prisons and two large cities—Bishkek and Osh (ibid.). The Global Fund grants expanded the NSP further by including all pre-trial detention centers, open prisons, and ten large and ten small cities into the program (Murzalieva et al., 2009). As of 2015, there were 31 state and 15 nongovernmental organizations and eight pharmacies offering NSP services to the population (Foundation for AIDS Research, 2015, p. 18). In 2014 alone, seven million syringes and needles were distributed at the expense of the grants (UNAIDS, 2015).

Nevertheless, the NSP services covered only 36% of PWID (Grant Performance Report External Print Version. Kyrgyzstan KGZ-202-G01-H-00, 2011, p. 24). Despite the high demand (Murzalieva et al., 2009), the actual use of services was limited due to the criminalization of PWID for possession of used syringes (Spicer et al., 2011a). There were cases in which police officers confiscated NSP supplies of outreach workers (Wolfe, 2005),Footnote 4 arrested them for carrying needles (Mansfeld et al., 2015), and asked for bribes (Spicer et al., 2011a) and/or information about the grant beneficiaries using the NSP services (Murzalieva et al., 2009). Police officers’ activities contributed to the high attrition of outreach workers (ibid.) and the distribution of new syringes without exchanging the old ones (Spicer et al., 2011a). Despite the countrywide expansion, the actual use of NSP services by persons who inject drugs remained limited.

Similarly, the use of opioid substitution therapy (OST) services remained limited due to the harassment of and discrimination against persons who inject drugs. Kyrgyzstan is among the few post-Soviet countries offering methadone maintenance treatment to opiate addicts (Wolfe, 2005). The Global Fund expanded the maintenance therapy, which was initially financed by the Soros Foundation and the UNDP (ibid.), by ensuring continuous financing and supply of methadone (Murzalieva et al., 2009). Between 2008 and 2015, the number of health care facilities providing OST in civil and penitentiary sectors more than doubled, increasing from 13 to 31 (Subata et al., 2016, pp. 1–4).

Still, methadone remains “an extremely controlled substance” (Wolfe, 2005, pp. 46–47), since possession of drugs is illegal and may result in a fine or imprisonment of up to four years (Foundation for AIDS Research, 2015). PWID willing to receive the OST are required to undergo registration at narcological centers (ibid.) and come to health care facilities on a daily basis for the therapy (Mansfeld et al., 2015). The coverage of OST services remains low (18% of all PWID) due to the negative attitude of medical staff, policy-makers, and some PWID toward these services (ibid., pp. 33–34) as well as social disapproval (Semerik et al., 2014). There are also cases of harassment (Subata et al., 2016), detention (Spicer et al., 2011a), and police officers’ use of withdrawal syndrome to torture the PWID receiving the OST services (Foundation for AIDS Research, 2015).

Overall, the Global Fund grants contributed to the expansion of HIV prevention activities, such as HIV testing, condom distribution, NSP, and OST, in the Kyrgyz Republic. But the outreach of these activities, particularly among the groups most vulnerable to HIV, seems unclear.

In addition to preventive services, the Global Fund grants contributed to the treatment of sexually transmitted infections (STIs) and the introduction of antiretroviral therapy in Kyrgyzstan, though the ART coverage and patients’ adherence to it are still low. The Global Fund also contributed to the introduction of ART in 2005, which was not previously available in the country (Murzalieva et al., 2009). The National AIDS centers offered limited immune monitoring to persons living with HIV (Wolfe, 2005). The Global Fund supported the revision of clinical protocols on HIV treatment and the provision of relevant training to medical workers (Murzalieva et al., 2009). ART is provided by all AIDS centers and 76 PHC facilities throughout the country (UNDP, 2015a, p. 29). In 2020, 4435 persons received ART (Global Fund, n.d.-b). 100% of pregnant women with HIV and 72% of children born to them receive ART (Grant Performance Report External Print Version: Kyrgyzstan KGZ-C-UNDP, 2016, p. 25), yet only half of registered HIV cases are covered by the therapy (Government of KR, 2017a). Persons living with HIV (PLHIV) often reject the treatment (UNDP, 2015a) due to its side effects, potential interruption of drug supplies, and misperception of ART as a “new drug trial” (Murzalieva et al., 2009, p. 82). In addition to limited coverage, there are issues with poor knowledge of PHC workers about the therapy (Mansfeld et al., 2015), stigma around and discrimination against PLHIV (Murzalieva et al., 2009), patients’ non-adherence to treatment (Semerik et al., 2014) and development of acquired antiretroviral drug resistance (Masikini & Mpondo, 2015). Similar to prevention, the outreach of treatment activities remains an issue, often due to factors lying beyond grant activities.

Along with targeting HIV/AIDS, the Global Fund grants contributed to TB prevention in Kyrgyzstan by improving lab services, training health care workers, and increasing the awareness of the population about this disease. The grants stipulated equipment (Grant Performance Report External Print Version. Kyrgyzstan KGZ-202-G02-T-00, 2011) and quality assurance measures in the labs, including improved lab safety, appropriate collection and analysis of specimens (Grant Performance Report External Print Version. Kyrgyzstan KGZ-607-G04-T, 2012; Grant Performance Report External Print Version. Kyrgyzstan KGZ-S10-G08-T, 2016), and training for lab technicians (Grant Performance Report External Print Version. Kyrgyzstan KGZ-202-G02-T-00, 2011). The grants aimed to improve TB detection at PHC facilities by providing the relevant training to general practitioners (Grant Performance Report External Print Version. Kyrgyzstan KGZ-607-G04-T, 2012; Grant Performance Report External Print Version. Kyrgyzstan KGZ-S10-G08-T, 2016). Similar activities were initiated in the health care facilities in prisons to improve the identification of TB patients among detainees. These activities contributed to the detection of about 1700 new smear-positive TB cases annually (Grant Performance Report External Print Version. Kyrgyzstan KGZ-202-G02-T-00, 2011; Grant Performance Report External Print Version. Kyrgyzstan KGZ-607-G04-T, 2012). The grants also covered information and educational campaigns on TB among the population through media outlets, schools, and detention centers (Grant Performance Report External Print Version. Kyrgyzstan KGZ-202-G02-T-00, 2011). It should, however, be noted that awareness-raising activities fighting against the stigmatization of and discrimination against TB patients were not explicitly stated in the grants.

In addition to prevention, the Global Fund grants contributed to the consolidation of the DOTS throughout the country. The grants stipulated the expansion of DOTS (against drug-susceptible TB) and DOTS-plus (against drug-resistant forms) in the civilian and penitentiary sectors (Grant Performance Report External Print Version. Kyrgyzstan KGZ-607-G04-T, 2012; Grant Performance Report External Print Version. Kyrgyzstan KGZ-S10-G08-T, 2016). The Global Fund guaranteed a continuous supply of TB medications, restructured storage facilities (Government of KR, 2013), and provided training to TB specialists on storage, quantification, and forecasting of drugs. It also financed the establishment and refurbishment of PHC service delivery points (Grant Performance Report External Print Version. Kyrgyzstan KGZ-607-G04-T, 2012). This integration of TB services into primary health care facilities contributed to the development and availability of outpatient care throughout the country. In addition to achieving timely detection and quality treatment (ibid.), the grants aimed to increase patients’ adherence to TB treatment through counseling and follow-up of patients by NGO volunteers and medical workers (Grant Performance Report External Print Version. Kyrgyzstan KGZ-202-G02-T-00, 2011; Grant Performance Report External Print Version. Kyrgyzstan KGZ-S10-G08-T, 2016). In 2020, 4435 individuals with TB received treatment (Global Fund, n.d.-b).

Regarding the extent of activities (“to what extent”), TB and HIV/AIDS programs vary in their readiness to transition to purely state-budget funding. The following sub-sections take a closer look at the factors affecting the government’s compliance with its commitment to continue TB and HIV/AIDS-related services beyond the duration of the grants.

HIV prevention activities largely depend on the Global Fund, but the government took multiple steps to take over the financing. The initial state contribution to HIV prevention was insignificant. It included some parts of lab services (Gulgun Murzalieva et al., 2007), operation and maintenance costs of health care facilities, and medical workers’ salaries (Maytiyeva et al., 2015). State financing did not extend to HIV prevention among vulnerable groups (International Charitable Organization “East Europe and Central Asia Union of People Living with HIV,” n.d., p. 13). Condom distribution, NSP, and OST relied entirely upon the Global Fund (see Mansfeld et al., 2015), also illustrated by the interruption of services and supplies during the delays of grant disbursements (Murzalieva et al., 2009; Semerik et al., 2014). However, following the Global Fund’s request to gradually transfer the grant activities to domestic or “alternative” sources of financing (Global Fund, n.d.-a, pp. 13–14), the government started increasing its contribution to HIV.

The government’s commitments to HIV/AIDS services are outlined in related state programs. However, as of the beginning of December 2022, the Draft Programme of the Kyrgyz Republic on Combating HIV Infection for 2022–2026 was still not available. Therefore, in addition to interviews with stakeholders conducted in 2016 and 2018 (see Chap. 1), the analysis is based on the previous national program (2017–2021) and recent sustainability assessments provided by organizations such as the Eurasian Harm Reduction Association.

It should be noted that the government took extensive responsibility to increase its contribution to HIV prevention and treatment. In terms of preventive activities, the National HIV Program for 2017–2021 stipulated increased state financing for methadone (from 50 to 100%) and distribution of condoms among the groups vulnerable to HIV to cover at least half of their needs (Government of KR, 2017b). In terms of treatment, the Kyrgyz government has committed itself to providing ART and STI treatment to groups vulnerable to HIV and ART to HIV-positive pregnant women and children born to them (ibid.). Overall, the government aimed to increase the number of individuals on ART fourfold (from 2109 to 8644) and achieve adherence to treatment for no less than 12 months for 90% of patients on ART (ibid.).

Among the sources of financing, the government defined the contributions of national and local authorities. Thus, the Mandatory Health Insurance Fund (MHIF) and the Ministry of Health were responsible for procuring methadone (Government of KR, 2017a). Similarly, the local self-governments in the Osh and Chui regions contributed to HIV prevention services in their areas by providing 20% of necessary funding (by agreement) (Government of KR, 2017b). In addition, the program stipulated an increase in financing for antiretroviral (ARV) drugs and test systems from 10% to 50% between 2018 and 2020 (Government of KR, 2017a).

However, despite multiple sources of financing, the program was accompanied by a considerable budget deficit (33%) (Eurasian Harm Reduction Association, 2021, pp. 21–22) due to a substantial decrease in Global Fund grants. Nevertheless, despite the reductions by almost half, Global Fund grants represented 48% of funding, followed by the state budget (23%), the President’s Emergency Plan for AIDS Relief (PEPFAR) (15%), and other donors (13%) (ibid.). The state acknowledged that insufficient financing due to reductions in and possible termination of Global Fund grants and other donors’ assistance might jeopardize HIV services in the country (Government of KR, 2017a).

The state fulfilled its commitments but with mixed results. Eurasian Harm Reduction Association (2021) assessment indicates considerable progress in HIV diagnosis and treatment, human rights, and related barriers. This included improvement in HIV-related incidence and morbidity, awareness of HIV status (also among vulnerable groups), and the share of PLHIV on ART who have suppressed viral loads at the end of the reporting period (Eurasian Harm Reduction Association, 2021). The assessment also demonstrated improvements in reducing the stigma and discrimination against groups vulnerable to HIV and improved coverage of HIV prevention services (ibid., pp. 33–48). However, the achievements in other areas were less impressive. For example, the awareness of HIV status among CSWs and the share of CSWs receiving ART remained low, and the use of opioid agonist therapy in vulnerable groups decreased (ibid.). In this regard, the assessment notes that despite the improvements, stigma and discrimination continue to jeopardize access to health, vividly demonstrated by low coverage of treatment and prevention services, particularly among some groups (e.g., CSWs) (ibid.).

It should be noted that the government lived up to its financial commitments. It increased the funding for TB and HIV by 169 million KGS (around €1,812,236) in 2017–2020 and committed itself to providing an additional 280 million KGS (€3,002,521) for the 2021–2023 period (Eurasian Harm Reduction Association, 2021, pp. 23–25).Footnote 5 HIV expenses represented 80 million in additional funding, which allowed for the procurement of some ARV drugs, payments to medical professionals, and social contracting (ibid.). However, despite the considerable increase, state funding is insufficient to purchase second-line ARV drugs, rapid tests, and CD4 tests used to assess viral load (ibid.). Moreover, prevention services in vulnerable groups are still largely financed by donors (Eurasian Harm Reduction Association, 2021, p. 61).

As in the case of HIV/AIDS, the government committed itself to taking over TB activities. It should be noted that the government lived up to its financial commitments. It increased the funding for TB and HIV by 169 million KGS (€1,812,235) in 2017–2020 and committed itself to providing an additional 280 million KGS (€3,002,521) for the 2021–2023 period (Eurasian Harm Reduction Association, 2021, pp. 23–25). HIV expenses represented 80 million in additional funding, which allowed for the procurement of some ARV drugs, payments to medical professionals, and social contracting (ibid.). However, despite the considerable increase, state funding is insufficient to purchase second-line ARV drugs, rapid tests, and CD4 tests used to assess viral load (ibid.). Moreover, prevention services in vulnerable groups are still largely financed by donors (Eurasian Harm Reduction Association, 2021, p. 61).

As in the case of HIV/AIDS, the government committed itself to taking over TB activities. In its strategy for Eastern Europe and Central Asia, the Global Fund explicitly asked countries to take over the provision of first-line medications for drug-susceptible TB by 2017 and develop a plan for a similar transition of second-line drugs for MDR-TB (WHO/Europe, 2014). Since 2015, the government of Kyrgyzstan has fully financed first-line medications (State Partner 9), and it plans to increase its contribution to second-line drugs to 20% in 2023 (Global Fund Office of the Inspector General, 2022, p. 4).

In addition to medications, the Global Fund (n.d.-a, p. 10) also expects grant-recipient countries to transfer the costs of laboratory reagents and consumables, maintenance of equipment, and services to domestic or “alternative” sources of funding. As of 2015, TB diagnostics were “almost exclusively” financed by the Global Fund (Mansfeld et al., 2015, p. 9), which also covered laboratory supplies, equipment (van den Boom et al., 2015), co-payments to specialists working with hazardous materials and other costs (State Partner 9). The government intends to increase its contribution to these areas as well, but fulfilling these commitments in the context of a budget deficit is challenging. Thus, the financial gap in the national health care reform program (2019–2030) is approximately 45% or approximately 2.3 billion KGS (approximately € 24,663,564), with the optimization and redirection of resources ensuring 57 million KGS (about €611,227); the rest is foreseen from other sources (Government of KR, 2018).

The country initiated optimization reforms to ensure additional financing. The TB Roadmap for 2016–2025 aims to decrease unnecessary hospitalizations by 5–8% annually, reduce bed capacities by 60% compared to 2015, and increase coverage with full ambulatory treatment by 60% by 2025 (Ministry of Health of KR, n.d.). These reforms mainly target problems related to excessive hospitalization (also among patients whose TB diagnosis is not confirmed) to reduce the length of hospital stay, which could last up to two to three months (ibid.). A savings of 137.7 million KGS (approximately €1,476,597) resulting from these reforms are to be spent on PHC strengthening, procurement of medications, laboratory supplies, and reagents, and improving the conditions of buildings (ibid.). Nevertheless, the Government of Kyrgyzstan (2017a) acknowledged that these savings were insufficient to meet the country’s TB needs. Thus, procurement of second-line medications, laboratory maintenance, and supplies remain dependent on external support.

Despite explicit commitments and reforms initiated by the government, there is skepticism regarding the actual fulfillment of its obligations. My interviewees noted that the country was “unique” in the sense that there were many “good” laws and decrees that nevertheless fizzled out with time (CSO 3). They questioned the actual implementation of the “written promises” (State Partner 4) and suggested that many documents were not further realized (State Partner 6). Studies by Ancker and Rechel (2015a, 2015b) similarly suggest a “declaratory manner” of state policies, targeting donors rather than actually guaranteeing the continued implementation of the programs.

I suggest that the actual implementation of commitments depends on two factors, namely, national priorities and the choices of decision-makers. TB and HIV were explicitly prioritized and delineated in previous national health care reform programs (2005–2018), but the new program, “Healthy People, Prosperous Country” (2019–2030), incorporates these two into broader priority areas, such as public health and primary health care. Indeed, improvements in other areas highlighted in the program, including laboratory services, access to medications, human resources, information systems, eHealth, and an increase in state financing, equally benefit TB and HIV (Government of KR, 2018). The program pursues an interdisciplinary approach to health and intends to take this perspective to a new level by harmonizing legislation, engaging a broad spectrum of stakeholders, and emphasizing their responsibilities in health (ibid.). The program still targets TB and HIV but in an integrated manner.

This comprehensive and non-disease-specific focus nevertheless has implications for prioritization. For instance, the new program defines the following TB- and HIV-related indicators: the percentage of patients successfully completing TB treatment at the PHC level and the number of HIV notifications and TB prevalence per 100,000 people (Government of KR, 2018). “Den Sooluk” delineated TB and HIV and defined six indicators (three for each) (Government of KR, 2012). Indeed, this program aimed to strengthen the health care system by targeting key barriers, including public health, financing, and stewardship, but it still delineated cardiovascular disease, mother and child health, TB, and HIV as “core services” (ibid.). Surely, indicators in the new program hint at the prioritization of these diseases but in the context of broader health care reforms. This difference in the approaches of the two programs also relates to broader changes beyond the country (Chap. 12).

In addition to national priorities, the continuity of the project activities, among others, depends on the decision-makers’ personal interests and beliefs. Increased state financing of health care programs requires an “active position” of the Ministry of Health and the relevant state agencies (IO Partner 3). However, the leaders, often political appointees, may not necessarily be committed to TB and HIV/AIDS or other services (IO Partner 4). On the contrary, some members of the parliament and government seem to have “a detrimental or disruptive effect” on the HIV/AIDS policies due to their “moral” beliefs and conventional positions toward CSWs, MSM, and PWID (Ancker & Rechel, 2015b, pp. 8–16).

Although legal commitments hint at the government’s intention to continue HIV/AIDS and TB services, the extent and depth of these services depend on other factors. Among others, there are procurement costs and opportunities, the epidemiological situation, the political environment in the country, the availability of trained personnel, and other factors (e.g., the COVID-19 pandemic).

First, the continuity of services is conducive to procurement costs and opportunities. Accordingly, the low costs of methadone (approximately US $0.10 per day (Subata et al., 2016)) and condoms (approximately US $0.18 per unit (Stover et al., 2011)) may be advantageous to their continuity beyond the duration of the Global Fund grants. However, the limited state contribution to HIV prevention for vulnerable groups hints at the relevance of other factors, such as prioritization or stigma and discrimination against these groups (Chap. 3). Nevertheless, costs matter, particularly in the context of limited financial capacity, and vivid examples thereof are ARV and TB medications. ART is a lifelong therapy, and the annual cost of ARV drugs per patient ranges between US $490 for first- and US $1520 for second-line medications (Stover et al., 2011, p. 3). According to state partners interviewed for this research, the estimated costs of a single course of TB treatment in Kyrgyzstan vary from US $50–107 for drug-susceptible (State Partner 9) and US $4–15,000 for multi- and extensively drug-resistant TB per patient (State Partner 6). In this way, although taking over first-line treatment, the government may find it challenging to finance second-line medications against drug-resistant strains of TB/HIV.

Surely, treatment costs are changing following scientific progress. A state interviewee hoped that the emergence of generic drugs and license expiration of some items might contribute to the affordability of medications (State Partner 2). As of 2019, ARVs are included in the list of essential medicines intended to ensure their accessibility (UNAIDS, 2020) due to the state control of the prices of items on this list. Moreover, prices for ARVs are gradually falling, and there are several alternatives to ART, including preexposure prophylaxis products offered by pharmaceutical companies and charities, as well as the potential use of mRNA vaccines against HIV (Economist, 2022b). Following the COVID-19 pandemic, there are also plans to commence trials of TB mRNA vaccines (Economist, 2022a). Trail results may provide alternatives to existing treatment regimens for TB and HIV.

Procurement opportunities are inherent to medication costs and treatment outcomes by ensuring the continuous supply of medications necessary for quality treatment. Kyrgyzstan procures TB and HIV/AIDS-related products via the voluntary pooled procurement mechanisms of the Global Fund and the Global Drug Facility (GDF), which allow aggregation of orders and negotiation of better prices and delivery conditions (Gotsadze et al., 2019). Upon its transition from the Global Fund grants, the country is expected to procure health products on its own. However, individual country procurement will result in an increase in prices (ibid.). It may also result in situations in which manufacturers are not interested in supplying health care products to the country due to the small size of the order. One of my interviewees recalled the “bitter experience” of Kazakhstan, which encountered a drastic increase in prices after the country’s transition from the Global Fund grants (State Partner 2). To avoid this situation and allow the continued procurement via international organizations, the government actors initiated relevant amendments to the national legislation (ibid.).

In addition to access to international procurement mechanisms, procurement of health products beyond the duration of Global Fund grants requires their registration in the country. Most of the grant-recipient countries (including Kyrgyzstan) used one-time waivers for the drugs procured via the Global Fund (Gotsadze et al., 2019) by qualifying them as “humanitarian assistance.” By contrast, the medications purchased at the expense of the state budget must be registered in the country. As of 2018, most of the medications used for ART and treatment of multidrug-resistant (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB) were not registered in the country (Mandel, 2018). In other words, their procurement by the government was not possible. Accelerated registration of medications has improved since then (see Eurasian Harm Reduction Association, 2021). One interviewee, however, expressed concerns that the country may switch to drugs with treatment outcomes different from those provided in the grants (IO Partner 4). As the situation evolves, procurement requires closer consideration and research on its own.

Second, in addition to the use of certified medications, the quality of TB and HIV/AIDS services depends on the availability of qualified medical workers. To improve the quality of services, the Global Fund financed multiple training seminars on infection control, quality of lab services, management of medical waste (UNDP, 2015e), and HIV prevention. The seminars also targeted health workforce management by providing training on electronic spreadsheets, management of payments to medical workers, and other areas (UNDP, 2015c). Yet, the long-term impact of these training activities is jeopardized by high staff rotation. A health care professional interviewed for this research suggests that training of one lab specialist takes around six months and costs KGS 36,000 (about €386 Euro). However, after a year, this specialist leaves the state hospital to work in a private lab due to the better salary rates offered there (Health worker 1). Therefore, the long-term impact of training activities on the qualifications/competencies of health care personnel involved in the TB and HIV/AIDS programs remains unclear due to the structural problems in the health care system (Chap. 4).

Third, the continuity of services also relates to the epidemiological situation in the country. Despite coverage issues, there is a growing demand for HIV and TB treatment. After a nosocomial outbreak of HIV in the south of the country, the procurement of antiretroviral medications in Global Fund grants changed from an annual to biannual basis (Murzalieva et al., 2009). Correspondingly, the number of people on ART has doubled annually since 2011 (Mansfeld et al., 2015). Similarly, there is a growing demand for TB treatment, particularly in the context of the drug-resistant forms of this disease (Chap. 1). There is a considerable financial gap in the treatment of drug-resistant TB (WHO/Europe, 2011), and even donor financing cannot meet the increasing demand for treatment. The Global Fund grants and Doctors Without Borders/Médecins Sans Frontières (MSF) covered 609 out of 1136 cases of multidrug and 36 out of 60 cases of extensively drug-resistant TB (van den Boom et al., 2015, p. 88). All savings in the grants have been used to provide treatment, but the Global Fund could still not cover the existing needs of the National TB Control Program, much less meet the growing demand for treatment of drug-resistant forms of tuberculosis (see UNDP, 2013). Predicting changes in the epidemiological situation in the country goes beyond the scope of this research. However, financial struggles in meeting the growing demand for treatment suggest grim perspectives for the continuity of services.

Fourth, the epidemiological situation is closely related to other factors. For instance, the COVID-19 pandemic was an unexpected challenge that strained the health care system and led to a diversion of resources (e.g., facilities, health personnel, and finances) from other diseases (Davis et al., 2021). Health care providers and civil society volunteers demonstrated unprecedented solidarity, dedication, and commitment in tackling the pandemic. The Global Fund, along with the World Bank, the German Federal Ministry for Economic Cooperation and Development (das Bundesministerium für wirtschaftliche Zusammenarbeit und Entwicklung—BMZ), and others, supported the country in its immediate response to COVID-19.

Global Fund grants adapted to the unexpected situation by providing a range of services to mitigate the impact of the pandemic. These included mobile brigades, online services, video supervision, and opening centers and shelters for individuals to continue their TB and HIV-related treatments (see UNDP, 2020a). The grants also supported medical workers who were at the forefront of the epidemic and worked for long hours and often without access to protective equipment.

Although it reduced deaths, the lockdown imposed by the Kyrgyz government from March 24 to May 10, 2020, caused a decrease in testing and prevention and limited access to care for both TB and HIV services (Alliance for Public Health et al., 2021). The medication supply was uninterrupted, and the share of outpatient services increased, but mobility restrictions affected health care-seeking habits for both diseases (ibid.). The medium- and long-term consequences of disruptions caused by the pandemic remain to be seen. The country has no catch-up plan against the impact of the pandemic on health (Global Fund Office of the Inspector General, 2022). However, at the global level, COVID-19 set back the global achievements made in TB and HIV/AIDS in recent decades (Economist, 2022a, 2022b). Reductions in global TB and AIDS-related funding combined with the ongoing pandemic clearly jeopardize the continuity of TB and HIV/AIDS services. How much the Global Fund manages to raise in its seventh round and how it distributes these finances remain to be seen.

To summarize, this section analyzed the continuity of the Global Fund project activities after the country’s transition by elaborating on the types (what) and the extent of the services currently provided within the grants. As demonstrated above, the Global Fund increased the geographic coverage and the type of HIV/AIDS services in Kyrgyzstan by contributing to HIV testing, distribution of condoms, opioid substitution therapy, needle and syringe exchange program, and antiretroviral therapy. The Global Fund has similarly contributed to the prevention and treatment of tuberculosis by ensuring the countrywide availability of MDR-TB treatment. Nevertheless, reaching out to the groups affected by TB and HIV/AIDS and patient adherence to treatment remained problematic.

The government, in turn, demonstrated its commitment to continuing TB and HIV services by increasing its financial contribution and indicating its responsibilities in relevant legislation. Following skepticism that some interviewees and related studies expressed, this section listed factors critical to fulfilling commitments. These included changes in national health care priorities, the choices of decision-makers, medication prices and procurement, health personnel availability, the country’s epidemiological situation, and the COVID-19 pandemic. The continuity of services in the long-term also depends on how these factors evolve.

9.3 Maintaining Benefits

In addition to diagnosis and treatment, Global Fund grants provided incentives to patients and health care workers to increase patient adherence to treatment. This section discusses the types of incentives and the maintenance of patient and health care workers’ benefits beyond the duration of the Global Fund grants to Kyrgyzstan.

First, the benefits for patients with TB included reimbursement of travel expenses (UNDP, 2014) and provision of hygiene and food parcels (Government of KR, 2013). Because of stigma and discrimination related to TB and confidentiality concerns, patients often prefer to receive their treatment in health care facilities outside their area of residence. The Global Fund reimburses all travel expenses a patient incurs on the way to examination and treatment (UNDP, 2014). Furthermore, patients received food and hygiene parcels to incentivize treatment adherence. For those in inpatient care, these parcels included butter, condensed milk, black tea, sugar, biscuits, laundry and toilet soaps, shampoo, toothpaste, and toilet paper (UNDP, 2013). The patients in outpatient care received vegetable oil, rice, pasta, grain sugar, black tea, washing powder, toilet, and laundry soaps (ibid.). These parcels could be received by TB patients themselves or their family members. A CSO representative, who distributed these parcels, noted that there were only seven rejections during the five years. Generally, people accepted these parcels as a contribution to the family budget since TB patients could not work for the duration of their treatment. An interviewee notes that the low number of rejections vividly demonstrates the economic hardships encountered by TB patients and the population in general (CSO 3).

Later, the hygiene and food parcels were replaced with vouchers and money transfers. The national actors implementing the Global Fund grants concluded an agreement with supermarkets and provided training to their staff members on how to work with the vouchers issued within the framework of the grants. The vouchers intended to provide a more “client-oriented approach,” which allowed the patients to choose the necessary food and hygiene items. The patients received the change if the amount of purchase was less than or paid extra if it exceeded the value of the voucher (CSO 9). The vouchers were later replaced with money transfers, which patients received for their adherence to treatment after being confirmed by a health care worker providing the DOTS (CSOs 3 and 9). Monthly money transfers ranged from 1300 KGS (about €14) for patients with drug-susceptible to 1800 KGS (€19) for patients with drug-resistant TB (Health Worker 1). The decrease in the amount of the Global Fund grants to Kyrgyzstan also affected the patient benefits. Since 2018, only patients with drug-resistant TB receive money transfers (ibid.), though reimbursement of travel expenses has remained available to all TB patients.

Second, patients with HIV/AIDS were entitled to reimbursement of their travel expenses related to treatment and examination. They also received psychological and peer-to-peer support from the NGOs implementing HIV-prevention activities. These NGOs supported persons living with HIV in administrative and legal issues related to obtaining identity documentation, applying for social benefits, and others (CSO 6). Adults are entitled to disability pensions, depending on their clinical stage, although the amounts remain low (not just for HIV) and insufficient to cover actual needs (ibid.). Children with HIV are entitled to monthly motivational payments of 1000 KGS (approximately €11) (see UNDP, 2021a). In 2019, for instance, 80% of registered HIV-positive children received monthly support (UNAIDS, 2020). However, there is still a problem with the coverage of support activities due to rejections from PLHIV. The main reason is the fear of their status becoming known during the preparation and request of documents necessary for receiving these benefits (ibid.). A few activists, such as Baktygul Shukurova, disclose their HIV status to draw attention to this problem (Akipress.org, 2017).

Third, in addition to patient benefits, the Global Fund grants stipulated additional incentives for health care workers working in TB and HIV/AIDS. In TB, medical workers receive bonuses for the achievement of the “favorable treatment outcome,” sputum conversion at the six-month point after the initiation of treatment (UNDP, 2015b). According to a health care worker interviewed for this research, 12,000 KGS (about €129) is awarded for the successful treatment of a patient with drug-susceptible and 24,000 KGS (around €257) for a patient with drug-resistant TB (Health Worker 1). The interviewee noted that the bonuses were divided between the health care workers participating in the treatment. Seventy-five percent is provided to a nurse supervising the patient, 15% to a head doctor, and the rest is awarded to the director and deputy director of the family group practice, the coordinating TB specialist, and others (ibid.). Similar co-payments are stipulated for health care workers in HIV/AIDS. For instance, a narcologist, nurse, and social worker are entitled to base salary and additional payments for every patient enrolled in methadone substitution therapy. A narcologist/nurse receives US $50 base monthly salary and an additional US $3 for each patient, while a social worker receives US $80 monthly and an additional US $2 per patient, respectively (UNDP, 2015d).

It should be noted that support for key groups was further reemphasized during the COVID-19 pandemic. For instance, 480 children with HIV received tablets to continue their school education during the pandemic (UNDP, 2021b). A total of 2577 individuals from vulnerable groups, including PLHIV, patients with TB, and those in precarious life situations, received food parcels (ibid.). In addition, the grants continued providing shelter opportunities, stipulating the provision of meals for vulnerable groups (ibid.). Training activities intended to inform the LGBTQ community and NGOs about COVID-19 and their rights, including access to health care and other issues, were conducted (UNDP, 2020b).

My interviewees emphasize that the discontinuity of some benefits was clear from the beginning, but the grants continued providing them to facilitate the fight against the two diseases (IO Partner 20). Nevertheless, some activities, such as the outpatient treatment of drug-resistant TB, may evolve into a “time-bomb” if the state or another donor will not take over the patient benefits to ensure their adherence to treatment (State Partner 10 and Academic Partner 2).

The Global Fund (n.d.-a) stipulates a gradual transition of expenses for human resources and social support from grants to the state budget. Some interviewees were skeptical in this regard. One noted that the discontinuity of some benefits was clear from the beginning, but the grants continued providing them to facilitate the fight against the two diseases (IO Partner 20). Another warned that some activities, such as outpatient treatment of drug-resistant TB, might evolve into a “time bomb” if the state or another donor would not take over patient benefits to ensure their adherence to treatment (State Partner 10 and Academic Partner 2).

Overall, the state committed itself to continuing the reimbursement of travel expenses, provision of social support to children with HIV, and financial incentives for health care workers. However, budget deficits, stigma, and discrimination against individuals affected by TB and HIV jeopardize the actual implementation of these commitments. Thus, local self-governments are expected to cover the travel costs of TB and HIV patients residing in their area (State Partner 6). However, as the majority of regions are subsidized by the national government (State Partner 9), local self-governments’ ability to fulfill this function is unclear. In addition to travel expenses, the national government committed itself to providing social support to 90% of children with HIV (Government of KR, 2017b). Since 2020, the government has stipulated a lump-sum cash compensation in cases of nosocomial HIV infection. Individuals who are 18 or parents of children under this age are entitled to compensation in an amount not less than 1000 calculation indices (Government of KR, 2005). Yet, stigmatization and discrimination of persons living with HIV, bureaucracy, and unawareness about the entitlements hinder access to these benefits (Murzalieva et al., 2009). The national government has also stipulated co-payments to primary health care workers, particularly nurses providing DOTS, to ensure the patients’ adherence to TB treatment (Health Worker 1). Currently, the nurses’ monthly salary of 12,000 KGS (around €129) is below the average national wage rate of 16,427 KGS (about €176), and nurses have no incentives to follow-up on patients defaulting from treatment (IO Partner 17).

Overall, the Global Fund provided multiple benefits to patients and health care workers to facilitate the prevention and treatment of TB and HIV/AIDS. These benefits included the reimbursement of travel expenses, provision of hygiene and food parcels, vouchers and money transfers, and co-payments to medical workers involved in TB and HIV/AIDS services. However, the majority of these benefits are unlikely to be maintained beyond the duration of the grants. The government has committed itself to reimbursing the travel expenses incurred by patients on their way to TB and HIV/AIDS-related services. It has also promised to provide social support to 90% of children with HIV and pensions to adults with HIV (as discussed above). Nevertheless, the budget deficit jeopardizes the actual implementation of these commitments. In addition, due to stigma and discrimination, individuals with TB and HIV reject state support due to the fear of exposure.

9.3.1 Community Capacity Building

This section examines the survival of the NGOs involved in the Global Fund grants, their leadership, and resource mobilization beyond the duration of the grants.

First of all, in terms of survival, a decrease in the Global Fund grants affects the NGOs working in TB and HIV/AIDS, although to different extents. NGOs compete for the “scarce resources” (Spicer et al., 2011b, p. 1753) and some organizations currently working in the Global Fund grants will have problems with finding alternative sources of funding (Zardiashvili & Garmaise, 2017). Yet, the decrease in donor financing will have a differentiated impact on NGOs.

The organizations (including those involved in the Global Fund grants) vary greatly in their human resources and work experience. For instance, “AIDS Foundation East-West in the Kyrgyz Republic” (“AFEW-Kyrgyzstan”) (n.d.) registered itself as a local Kyrgyz NGO in 2015, but it commenced its work in the country already in 2004 as part of the projects financed by AFEW-International. The organization inherited the standard operating procedures of the international organization, which ensured its strong capacity in comparison to other local NGOs (CSO 3). Another organization, “Socium,” commenced its activities in 1996 as a public association working on social development and adaptation of individuals with drug and alcohol addiction (CSO 8). Similar to “AFEW-Kyrgyzstan” (2023), “Socium” collaborated with multiple donors, such as the Soros Foundation Kyrgyzstan, the Global Fund, USAID, UNAIDS, and others. This cooperation and long-term experience ensured the relative independence of these NGOs from the Global Fund grants.

However, smaller grant recipients largely depend on the Global Fund (Nasakt, 2015). These organizations concentrate on specific groups particularly vulnerable to HIV/AIDS, such as MSM, CSWs, and PWID. This specialization contributed to the selection of NGOs receiving Global Fund grant funding, as the financier typically differentiates between the vulnerable groups and assigns organizations to work with each of them. However, in the long-term perspective, this narrow specialization negatively affects the organizations’ abilities to adjust to the changing environment of development assistance. For this reason, larger NGOs with multiple sources of financing are likely to survive, in contrast to smaller organizations working with specific groups and dependent on a single donor (IO Partner 4).

Furthermore, the leadership of the NGOs working in the Global Fund grants remains unclear due to their dependence on donor financing and the limited training provided within the grants. Leadership can be defined as the organizations’ ability to define the problems, suggest solutions, and critically reflect on the general issues relevant to their work. In the NGOs’ case, it closely relates to their ability to advocate for the issues pressing to them and the groups of the population they aim to represent. The studies on NGOs working in TB and HIV/AIDS in Kyrgyzstan note that the organizations generally refrain from criticizing the donors (Murzalieva et al., 2009) and acting independently from them (Ancker & Rechel, 2015b) due to fear of losing financing (Spicer et al., 2011b). Smaller NGOs solely dependent on the Global Fund seem to be particularly vulnerable in this regard (Harmer et al., 2013) and less likely to criticize the donor.

It should also be noted that the Global Fund stipulates limited support of the NGOs’ advocacy work. Relevant in the early 2000s, the advocacy for treatment and human rights does not seem to be relevant to the donor anymore (IO Partner 20). An NGO representative also notes that most of the training activities targeted service provision (CSO 8). Mainly focusing on prevention (Murzalieva et al., 2009) and treatment, the Global Fund grants devote limited attention (Harmer et al., 2013) and resources to advocacy for the rights of the persons affected by the diseases (Spicer et al., 2011b). Burrows et al. (2018) go further by linking the increase in violence and hostility toward vulnerable groups to the reductions in external funding for advocacy. The general dependence of the organizations on donor financing and the limited support for advocacy within the Global Fund grants do not stimulate leadership among the NGOs involved in the grants. However, a more specific estimation requires a closer look at individual NGOs, since the quality of their leadership greatly varies depending on the size and experience of organizations and their access (or lack thereof) to multiple sources of financing.

Equally, mobilization of resources via donor and state financing or fundraising is an essential component of sustainability, as it closely relates to the continuity of civil society organizations and their activities beyond the individual donor-funded projects. As mentioned above, the NGOs involved in the Global Fund grants greatly vary in terms of their access to alternative sources of financing. Therefore, instead of discussing the mobilization of resources by individual NGOs, this subsection focuses on social contracting, a source of financing for all NGOs developed as a result of the Global Fund grants to the country.

The Global Fund (n.d.-a) asks grant-recipient countries to develop social contracting to secure financing for NGOs and their activities in TB and HIV/AIDS after the end of the grant period. Social contracting presumes NGO contracting by government agencies. The Government of the Kyrgyz Republic (2017b) committed itself to developing the normative legal basis necessary for social contracting by the end of 2021. Seminars for representatives of state and nongovernmental organizations offered within the grants intended to support these aspirations (see UNDP, 2021c). Overall, by integrating social contracting into its legislation, the government aimed to continue the work of the NGOs with vulnerable groups through its integration with primary health care (Government of KR, 2017a). UNAIDS (2020, p. 6) notes that three million KGS (€32,170) were used to pilot social contracting projects on support and care to PLHIV. However, the issues and achievements in this process require further research, particularly in the face of challenges presented by COVID-19.

It is important to note that the introduction of social contracting will have further implications for the services provided by NGO social workers and the accountability of NGOs. First, as one interviewee noted, unlike the psychological and peer-to-peer support in the Global Fund grants, which targeted individuals affected by TB and HIV, an NGO social worker contracted by the government is expected to cover all patients with “socially significant diseases,” including but not limited to TB and HIV/AIDS (State Partner 2). This will affect the quality and quantity of consultations provided to each patient. Furthermore, according to the same interviewee, the breadth of services offered by a social worker (e.g., peer-to-peer support, follow-up, and outreach to target groups) will also decrease, as the government cannot maintain the breadth of services offered through Global Fund grants (ibid.). In addition, an interviewee added that social contracting would result in NGOs’ accountability to the government for the services financed by it (ibid.). This may have further implications for NGOs’ ability to criticize the government, as in the case of NGOs and donor organizations.

At the same time, the feasibility of social contracting in practice remains to be seen. Indeed, social contracting may be the only opportunity (other than donor financing) to continue the services provided by NGOs (State Partner 2). “Unavoidable” and “possibly good,” social contracting is probably something that the civil society organizations strived for (CSO 6). For the government, social contracting offers the possibility to involve knowledgeable and experienced social workers, and for NGOs, it promises some security in the context of decreasing donor funding (ibid.). Nevertheless, not all NGO employees may be willing to participate in social contracting due to salary differences. A state representative interviewed for this research suggests that project coordinators in NGOs may earn around US $500–600 per month, while a family doctor might earn about US $150 (State Partner 6). This difference in salary, along with accountability to the government, may affect the NGO employees’ willingness to conclude social contracting with state institutions.

Overall, the Global Fund has contributed to community capacity building in multiple ways. It increased the number of NGOs and facilitated the development of social contracting to guarantee the NGOs’ access to state financing after the country’s transition from the Global Fund grants. These benefits notwithstanding, the increased number of NGOs and the scarcity of resources resulted in competition among the organizations and their dependence on donor financing. The NGOs working with the Global Fund grants seem to restrain themselves from criticizing the donor or the primary recipients of the grants due to the fear of losing access to financing. This dependency, along with the limited focus of the Global Fund on advocacy work, discouraged the leadership of civil society organizations from working with the grants.

9.4 Summary

The COVID-19 pandemic demonstrated an unprecedented challenge to the sustainability of grant activities. With its medium- and long-term implications still to be seen, the impact of the pandemic on each dimension of sustainability requires further research. Although it reflected on some initial implications, this chapter was nevertheless bound to provide a more general analysis over a longer time period. This chapter reviewed the sustainability of the Global Fund project in Kyrgyzstan by focusing on the continuity of activities, maintenance of benefits, and community capacity building beyond the duration of the project.

First, the Global Fund increased the type and geographic coverage of preventive and treatment services related to TB and HIV/AIDS. More specifically, it consolidated HIV testing and TB detection, and expanded access to opioid substitution therapy and needle-exchange programs. The Global Fund introduced antiretroviral therapy, previously inaccessible to persons living with HIV. It has also contributed to the provision and expansion of treatment of multi- and extensive drug-resistant forms of tuberculosis in Kyrgyzstan. Despite these improvements, the Global Fund grants neither reached out to all persons most vulnerable to HIV nor provided treatment to all MDR-TB patients. The author reckons with these issues as not to give a false impression about the extent of project activities financed by the Fund. Since the grants are still ongoing, the continuity of the Global Fund project remains an open question, which is also vividly demonstrated by the lack of consensus on this subject among the stakeholders involved in TB and HIV/AIDS. The government committed itself to continuing most of the project activities. However, the actual fulfillment of these commitments largely depends on policy-makers’ interests and beliefs, further availability of state financing, the epidemiological situation in the country, access to certified medications, and trained health care personnel.

Second, the Global Fund provided extensive social support to patients and health care workers to increase patient adherence to treatment. The benefits included reimbursement of travel expenses, provision of hygiene and food parcels, vouchers, monetary incentives, and co-payments. Although unequally distributed among the TB and HIV patients, these benefits supported preventive and treatment activities covered by the grants. The government has committed itself to taking over the reimbursement of travel expenses, co-payments to health care workers, and social support for children with HIV. However, the actual use of these benefits is unclear due to lack of awareness of the population about these entitlements, state bureaucracy, stigma and discrimination, and budget deficits at the level of local self-governments. The maintenance of benefits not taken over by the government seems implausible without donor assistance.

Third, the Global Fund contributed to community capacity building by ensuring the NGOs’ access to state financing, as well as increasing the number of NGOs and number of NGO staff. Yet, the limited focus of the Global Fund on NGO advocacy, along with the civil society organizations’ dependence on the grants, emasculated the leadership of the NGOs working with the grants. Notably, the transition of the country from the Global Fund grants will have a differentiated impact on the survival of civil society organizations, depending on their size, experience, and collaboration with other actors.