The COVID-19 pandemic and its aftereffects have undoubtedly increased the amount of development assistance for health provided to low- and middle-income countries. However, the issues associated with the sustainability of health projects, including those implemented before the pandemic, remain.
Where and Why Health Aid Matters
Development assistance for health (DAH), also known as international health aid, is intended to support and improve health in low- and middle-income countries. Its share of the country’s total health budget depends on the recipient country’s income level and the issues targeted by the assistance. Health aid represents a substantial contribution to low-income countries, making up on average 28.5% of their respective health budgets, and a complementary contribution for lower-middle-income countries that may rely more heavily on individual out-of-pocket payments for healthcare services - making up, on average, 47.3% of health spending in those countries. However, even in lower-middle-income countries, health aid may be used to procure expensive medications, including those used to treat tuberculosis and HIV/AIDS. Deploying health aid in these kinds of cases helps reduce the catastrophic health expenditures that would otherwise be forced upon affected households.
The COVID-19 pandemic evidenced the role and significance of health aid: between 2019 and 2020, DAH grew by an unprecedented 43.9%, compared to 11% annual growth between 2011 and 2019. But this increase was not felt throughout the sector: the share of DAH spending provided for reproductive, maternal, newborn, and child health, as well as for malaria and tuberculosis treatment actually decreased compared to the period before 2019. The sharp increase was mainly due to COVID-19 spending; in fact, assistance committed to other areas was in some cases redirected for this purpose. Still, the disease-specific focus of COVID-19 aid was not unique, with similar global efforts targeting smallpox and malaria, among other diseases.
Such a focus on specific diseases is known as the ‘vertical’ approach to health aid, as opposed to the ‘horizontal’ approach focusing on healthcare systems as a whole. Both approaches have their benefits and shortcomings. The concentrated and quick response of the vertical approach allows for rapid and substantial progress in specific areas. The Global Fund to Fight AIDS, Tuberculosis and Malaria, established in 2002 to fight these three diseases, is estimated to have saved 59 million lives since its creation. In 2022 alone, it contributed to the treatment of 6.7 million people with tuberculosis, providing lifesaving antiretroviral therapy to 24.4 million people living with HIV and distributing 220 million nets to stop malaria (ibid.). In turn, the results of horizontal assistance targeting health systems strengthening, be it health policymaking, service delivery, or financing, are slower to appear – and perhaps less sensational – than those of the vertical approach. Yet this approach is believed to be beneficial to advancing health systems as a whole and avoiding situations in which selected areas targeted by health aid are disproportionately advanced compared to other healthcare services.
Discontinuity of health aid or any other kind of development assistance may result in the reemergence of diseases and issues previously targeted by this assistance. In multiple countries, HIV-related service disruptions and an increasing number of cases were observed after the discontinuity of Global Fund grants to several countries. The sustainability of health aid remains a pressing issue, particularly in the context of increasing emphasis on health and global preparedness and response to ongoing and future challenges. ‘Sustainability’ is understood differently across disciplines and by diverse stakeholders. Within the field of health aid, sustainability is defined by three key components: the continuity of activities, community capacity-building, and maintenance of provided benefits.
The Sector-Wide Approach in the Kyrgyz Republic
My book Stakeholder Relationships and Sustainability: The Case of Health Aid to the Kyrgyz Republic builds on the abovementioned concerns with the objective of understanding the factors contributing to the sustainability of health aid. Based on an extensive analysis of the academic literature, international agreements and declarations, and 52 semi-structured interviews conducted with the government, civil society and development partners involved in health aid to the Kyrgyz Republic, this book focuses on the relationships between recipients and providers of health aid to understand under what conditions that aid becomes sustainable.
In addition to the three components of sustainability indicated above, the research highlights the role of broader and project-specific factors such as financing, the political and economic situation in the country, national priorities, availability of healthcare workers, and project duration, among others. All these factors can ‘make or break’ the sustainability of health aid. Similarly, one must account for power dynamics, dependency on health aid, the predictability and flexibility of that aid, and capacity of stakeholders involved to understanding the relationships between these stakeholders.
Keeping in mind the differences between the vertical and horizontal approaches, this research focuses on health assistance provided to the Kyrgyz Republic by the Global Fund and the Swiss Agency for Development and Cooperation (SDC), each of them reflecting one of those two approaches, respectively. In particular, analyzing selected healthcare projects in the Kyrgyz Republic, which has implemented the Sector Wide Approach (SWAp). This approach emphasizes the aid recipient’s role in allocating and monitoring health aid. In so doing, the SWAp, in a way, offers benefits for the sustainability of health aid to the country.
However, even in this context auspicious for sustainability, health projects faced issues related to the healthcare system’s dependence on financial and technical assistance, political and economic uncertainty, inflation, and intensive labor migration abroad, with migrant remittances representing about a third of the national gross domestic product. In this context, I find that though the SWAp is beneficial to project sustainability, it was the relationships established between stakeholders that contributed to the sustainability of selected initiatives beyond the duration of project funding.
A vivid example thereof is the SDC-funded “Community Action for Health” (2001–2017) project, which demonstrated the extraordinary sustainability of community-based organizations and their resilience to shocks. Despite the attrition of some members upon the project’s completion, around 1500 of the 1800 Village Health Committees (VHCs) established over the course of this project continued their work. All VHC members are volunteers from their respective communities. In addition to health promotion and disease prevention, VHCs initiated and implemented local initiatives on waste removal, maintaining bridges in emergency conditions, renovating and equipping kindergartens and local medical centers, assisting vulnerable households, and fund-raising activities for villagers in need of expensive medical interventions. These activities materialized due to VHC members’ close collaboration with the local authorities and development partners that assisted their initiatives. During the COVID-19 pandemic, VHCs also worked on increasing population awareness of vaccines and combat disinformation about the disease by providing reliable information on prevention.
Multiple factors contributed to the sustainability of VHCs and their activities beyond the project funding, with the relationships established between the VHCs and development partners being the most important among them. The “empowerment approach" utilized by SDC-funded project staff in their treatment of and communication with local community members has resulted in several social mechanisms contributing to the long-term sustainability of this project. It contributed, for example, to the sense of ownership of VHC members over the activities they initially conducted within the project.
The empowerment approach was transversal to all aspects of development partner–local community relationships and was reflected in, for instance, local communities identifying significant local issues through community surveys that were later targeted by this project. Providing training and financial assistance, the project staff avoided “dominating” local volunteers and advocated for a similar attitude among community-based organizations. The emphasis on learning from each other, self-realization, and reflection discouraged VHC members from imposing their personal views in their communities and encouraged practicing the health-related behaviors they wanted to see from others. One concrete example: to avoid embarrassment and overcome potential hierarchies due to different education levels, the VHC members were also advised not to correct each others’ spelling mistakes, instead letting the person correct such mistakes on her/his own after seeing others’ work.
The consistency in adopting an empowerment approach in project-related activities has nourished the VHCs’ leadership and survival beyond the period of project funding. Several VHC members mentioned continuing their work because it was necessary for their communities – not for the project staff, development partners, or any other external stakeholders, but for the communities in which they lived.
Outlook
There is no one-size-fits-all formula for health aid projects, and sustainability by itself is not a yes or no question. Each intervention may perform well in one or more areas but less so in others. Focusing on selected healthcare projects in the Kyrgyz Republic has allowed me to advance a comprehensive analytical framework and theoretically grounded claims useful for analyzing the sustainability of health aid in the context of other developing countries.
The crux of understanding the sustainability of health aid lies in the dynamics of aid relationships. These relationships are instrumental in fostering the longevity of health aid. For example, the sustainability of health aid is influenced by how civil society organizations are empowered or how aid providers coordinate their efforts. Furthermore, the type of relationship can have a significant impact on certain aspects of health aid, enhancing its benefits. Future research must highlight which aspects of health aid sustainability benefit from what forms of relationship between donors and aid recipients.
This contribution is a product of the research conducted in the
Collaborative Research Center 1342 “Global Dynamics of Social Policy” at the University of Bremen.
The Center is funded by the Deutsche Forschungsgemeinschaft, Project nr. 374666841—SFB 1342.
Header photo by Irene Strong - Unsplash
