We are pleased to present an interview with Dr. Gulnaz Isabekova-Landau, a research fellow and a long-time friend of Crossroads Central Asia. Gulnaz is currently a postdoctoral research fellow at the Collaborative Research Center 1342 “Global Dynamics” and the Research Center for East European Studies at the University of Bremen. Her research focuses on healthcare systems, access to healthcare, social policy, and labor migration. Gulnaz’s recent book, Stakeholder Relationships and Sustainability: The Case of Health Aid to the Kyrgyz Republic, is one of the few works that applies key questions from the development industry to a specific policy area in Kyrgyzstan. The book can be accessed at Springer (link)
Shairbek Dzhuraev, President of Crossroads Central Asia, spoke with Gulnaz about the book’s insights and the broader implications for health aid sustainability in Kyrgyzstan.
Crossroads Central Asia: Congratulations on your new book, an excellent contribution to the literature on development assistance in healthcare. Before diving deeper into the findings, can you share what you consider the core thesis of your research? Additionally, why did you choose Kyrgyzstan as your primary case study for this work?
Dr. Gulnaz Isabekova-Landau: Thank you very much for having me here and for your interest in this book. I feared my audience would be much smaller due to its sectoral specificity, but it is good to see that it is not the case!
One summer evening, after long hours of work at a non-governmental organization in Bishkek, I stayed longer at the office to look up similar projects on the Internet to potentially expand on ongoing partnerships, and to see what the completed projects did and with whom they worked. I was new to the area and curious to learn more. Clicking multiple links made me realize that information on many completed initiatives was unavailable, their websites showing error messages. I wondered: what remains after the closure of initiatives after they are heatedly implemented during their all-too-short funding periods?
This was the beginning of my quest to understand the sustainability of development assistance. In the following years, it developed into a study abroad experience resulting in an encounter with academic discussions on approaches to development and stakeholders’ roles in defining and providing development. My work at the Collaborative Research Center 1342, “Global Dynamics of Social Policy” (funded by the German Research Foundation) and at the Research Center for East European Studies at the University of Bremen allowed the publication of a book on stakeholder relationships and the sustainability of health aid in 2024 based on the years-long research done before that.
sustainability isn’t a categorical yes or no question
The book shows that sustainability isn’t a categorical yes or no question. It’s more about the degree to which a project is sustainable and which parts of sustainability are actually in place. It demonstrates that specific aspects of aid relationships may affect certain components of sustainability, be it community capacity building, continuity of project activities, or maintenance of benefits.
The main idea when it comes to aid relationships is that the inequalities inherent between those giving and receiving aid can become less important if there’s flexibility and a willingness to empower the recipients. However, the unequal power dynamics may grow in cases of conditionality and the threat of funding withdrawal.
unequal power dynamics may grow in cases of conditionality and the threat of funding withdrawal
These findings emphasize the significance of contextual, structural, and individual factors, and they refine the suggestions in the literature that show donors tend to have more power at the start, while recipients gain more influence toward the end of the aid process.
The Kyrgyz Republic was known as a forerunner in healthcare reforms and as one of the few countries to have fully implemented the sector-wide approach, which intended to put aid recipients in the “driver’s seat.” This choice is also related to my background of growing up in the Kyrgyz Republic, using healthcare services there, and being exposed to the continuous discussion of external assistance and the role of stakeholders in implementing and monitoring it.
Crossroads Central Asia: Speaking of stakeholders: one of the themes you discuss in your book is the power dynamics among stakeholders in health aid. Could you elaborate on the most common power imbalances you observed and their impact on project outcomes?
Dr. Gulnaz Isabekova-Landau: Good question! The health projects studied in this book followed the “bottom-up” approach, meaning that the aid recipients – not the providers – defined project objectives and activities, precisely to overcome historical provider-recipient hierarchies and contribute to the sustainability of results. Still, power imbalances frequently occur due to the differences in actors’ financial leverage and technical knowledge. However, financing is, though essential, not the only source of power – technical skills/knowledge are equally important. The World Health Organization (WHO) and UNAIDS vividly demonstrate this through their science, community, and evidence-based norm-setting authorities in their areas of work. Grants financed by organizations as large as the Global Fund to Fight AIDS, Tuberculosis and Malaria aim to procure WHO-accredited medical products and ensure their treatment activities comply with WHO standards – precisely due to the evidence-based expertise of these organizations.
Crossroads Central Asia: Your research also reveals a causal link between stakeholder relationships and sustainability. Did you encounter any unexpected finding while investigating these dynamics?
Dr. Gulnaz Isabekova-Landau: Examining a possible causal link between stakeholder relationships and the sustainability of assistance was one of the key objectives of this book. In so doing, it aimed to conduct a detailed case-study analysis and offer insights generalizable to a similar population of cases. I will not bore you with all the details of the analytical framework, structural factors, temporal aspects, and methodology to consider, as these are explained in the book at length.
One of the surprises was that if we were to scale different types of aid relationships to see their impact on sustainability, we would find the asymmetrical causal relationship between these two phenomena. In other words, more of one does not necessarily mean a similar increase in another. Instead, it is about specific types of aid relationships affecting certain components of sustainability. Thus, unequal cooperation between a provider and a recipient of aid may, in fact, contribute to the continuity of specific project activities, for instance, treatment of diseases.
But so can equal cooperation, though the focus here would be on maintaining the benefits the population receives instead of continuing specific project activities. Saying this, I by no means advocate for inequality in aid relationships. In fact, equal cooperation – especially when it empowers civil society organizations – can really help build up communities by strengthening the leadership of these organizations and boosting their ability to mobilize resources, which helps them survive beyond the duration of development assistance.
Crossroads Central Asia: As you touched on empowering civil society organizations, can tell us about the role of CSOs in Kyrgyzstan in the health aid landscape?
Dr. Gulnaz Isabekova-Landau: The Kyrgyz Republic has seen an increase in health aid from its independence in 1991 to the mid-2010s, culminating in the assistance received for the country’s fight against the COVID-19 pandemic. But this is changing as the focus shifts from fighting diseases towards general system strengthening. Its strong civil society has been a unique feature of the Kyrgyz Republic, also vividly demonstrated by the remarkable contribution of community volunteers during the peak of the pandemic, which you compellingly discuss in your report on the “Kyrgyzstan’s Fight Against COVID-19.”
Since independence, the country’s population and civil society organizations have actively participated in shaping its development and society, and CSOs count among the close partners of government bodies and international organizations. The cooperation of local self-governments with Village Health Committees and development agencies in solving social and infrastructural issues at a local level is particularly encouraging.
Crossroads Central Asia: In your research, did you come across any innovative practices or models from Kyrgyzstan’s health aid projects that stand out to you as potentially scalable in other contexts?
Dr. Gulnaz Isabekova-Landau: The above-mentioned sector-wide approach could be considered an innovative practice for its time, along with the Country Coordinating Mechanism within the context of the Global Fund grants established for broader stakeholder participation in decision-making and monitoring processes. Both structures are also used in other countries.
Within health aid projects, it was probably the “non-dominance” principle, advocated by the project coordinator in the Swiss Agency for Development and Cooperation–funded “Community Action for Health” project, that was the most striking
Within health aid projects, it was probably the “non-dominance” principle, advocated by the project coordinator in the Swiss Agency for Development and Cooperation–funded “Community Action for Health” project, that was the most striking. Not necessarily innovative by itself, this principle nevertheless laid down the basis for genuinely equal relationships of development partners with community-based organizations and equal relationships between members of these organizations. Seemingly simple, this principle nevertheless requires thorough implementation, radical rethinking, and re-assessment of stakeholders’ roles throughout the development assistance process (i.e., initiation, design, implementation, and evaluation phases). I discuss this process in detail over the course of several chapters, which can indeed benefit stakeholders working in development and health assistance by demonstrating the different facets of this principle in practice.
Crossroads Central Asia: As we look ahead, what are the key challenges and opportunities you foresee for health aid in Kyrgyzstan? How can stakeholders best prepare to address these issues?
Dr. Gulnaz Isabekova-Landau: Aid dependence remains one of the most pressing challenges for the health sector, particularly in light of the current decreases in external assistance and phasing out of some key actors. Indeed, the majority of healthcare financing in the Kyrgyz Republic is provided by private and public expenditures, in 2020 respectively comprising 46% and 45% of total spending, followed by 9% external health expenditures. Still, at the subsectoral level, health aid remains the largest source of funding, for instance at its peak in 2007 reaching 94% of total HIV/AIDS-related expenditure.
The situation has changed since then, with the government taking over some activities, but health assistance remains critical to, among other efforts, vaccination and the introduction of the latest medical technologies/approaches, but also in disease prevention, treatment, and systems strengthening. Phasing out of key actors and decreases in health aid are inevitable and natural processes. However, continuous access to healthcare services and benefits covered by health aid requires taking sustainability seriously from the beginning of the assistance as well as thorough incorporation of the necessary steps and negotiations throughout the aid period. This practice is common, but it entails further tradeoffs in terms of time, financial pressures, and the broader economic and political changes in both aid-providing and aid-receiving countries.
These factors and their impact on sustainability are discussed at length in the book. Even though foreseeing them is not feasible at all times, as COVID-19 showed, stakeholders could prepare for the steps following the end of external funding by, among other things, being aware of how the relationships they build in health aid affect specific components of its sustainability.