By Svetlana Ancker and Bernd Rechel
Abstract
Kyrgyzstan has adopted a number of policy initiatives to deal with an accelerating HIV/AIDS epidemic. This article explores the main actors in HIV/AIDS policy-making, their interests, support and involvement and their current ability to set the agenda and influence the policy-making process. Fifty-four semi-structured interviews were conducted in the autumn of 2011, complemented by a review of policy documents and secondary sources on HIV/AIDS in Kyrgyzstan. We found that most stakeholders were supportive of progressive HIV/AIDS policies, but that their influence levels varied considerably. Worryingly, several major state agencies exhibited some resistance or lack of initiative towards HIV/AIDS policies, often prompting international agencies and local NGOs to conceptualize and drive appropriate policies. We conclude that, without clear vision and leadership by the state, the sustainability of the national response will be in question.
KEY MESSAGES:
- This is the first comprehensive stakeholder analysis of HIV/AIDS policy-making in Kyrgyzstan, offering insights relevant for HIV/AIDS policy-making in other low- and middle-income countries that depend on external donors.
- Several influential state agencies only showed mixed support and a lack of concern with HIV/AIDS, negatively affecting policy development and implementation and creating a leadership void. It is thus essential to look beyond the official façade of governments’ political declarations.
- Some of the international agencies, even though lacking formal veto power, have exerted substantial direct and indirect influence over national HIV/AIDS policy-making.
- National NGOs have become vocal and active stakeholders; however, their donor dependence inhibits their capacity to act as independent and stable contributors to the policy-making process.
Introduction
Throughout Central Asia, the incidence of HIV/AIDS has increased notably during the 2000s and Kyrgyzstan is no exception. As of June 1, 2013, a total of 4747 HIV infections were officially registered in the country (CCC 2013b). However, as in other countries of the region, this is likely to be an underestimate. The United Nations Joint Programme on HIV/AIDS (UNAIDS) estimated that in 2011 there were around 12,000 people living with HIV/AIDS (PLWHA) in Kyrgyzstan, equivalent to an HIV prevalence rate of 0.4% among those aged 15–49 years (UNAIDS 2013). The populations most at-risk are injecting drug users, sex workers, men who have sex with men, prisoners, young people and migrants. There have also been several outbreaks of nosocomial (hospital-acquired) infections (CCC 2012).
Major efforts to deal with the HIV/AIDS epidemic started in the late 1990s, when the National AIDS Service was set up, the first Law on ‘AIDS Prevention in the Kyrgyz Republic’ was adopted, and the first state HIV/AIDS programme launched, along with joint projects between the government and international agencies (Bashmakova et al. 2003; Murzalieva et al. 2007). This period was followed by another wave of intense policy revisions and improvements in 2004–2007, with a greater focus on protecting the human rights of most at-risk populations, PLWHA and other affected populations (Bashmakova et al. 2009; Murzalieva et al. 2007).
Over the years, the legislation related to HIV/AIDS has undergone significant changes (CCC 2010). For example, in 1997–98 articles on voluntary sex work and sexual contacts between men were removed from the Criminal Code, while in 2007 the amounts of drugs and psychotropic substances that individuals could possess without facing criminal charges were increased, aiding HIV prevention efforts among injecting drug users (Aidarov et al. 2012; Bashmakova et al. 2003; Jogorku Kenesh 2012; MOH 2012; SSDC 2013). This progress is partly due to the global commitments Kyrgyzstan has entered, as it is a signatory of a number of international agreements on HIV/AIDS, including the 2001 United Nations General Assembly Special Session (UNGASS) Declaration of Commitment on HIV/AIDS and the 2004 Dublin Declaration on Partnership to fight HIV/AIDS in Europe and Central Asia (Murzalieva et al. 2007). Furthermore, the Manas Taalimi health reform programme (2006–2010) included HIV/AIDS prevention among its priority programmes and HIV/AIDS prevention was also described as a priority in the subsequent Den Sooluk health reform programme (2012–2016). As in other countries of the former Soviet Union, Kyrgyzstan has created a separate, vertical system of HIV/AIDS services, complemented by NGO activities.
Although many ministries and administrations develop and implement their own internal normative acts related to HIV/AIDS, the main programme that guides all major efforts and sets targets in the area of HIV/AIDS prevention, treatment and care is the State HIV/AIDS Programme (Aidarov et al. 2012; Murzalieva et al. 2007). The Fourth State Programme on HIV/AIDS Prevention (2012–2016) sets out five strategic directions, implemented by a variety of state agencies and local institutions, with overall coordination assigned to the Country Coordinating Committee (CCC) (CCC 2012; Government 2013; MOH 2012).
Kyrgyzstan has gained the reputation of having a higher level of political commitment to the HIV/AIDS cause than most of its neighbours (Ancker et al. 2013). It was one of the first countries in the region to set up a multi-sectoral framework for dealing with HIV/AIDS. Yet, its declared commitment has not been backed with adequate state resources. In 2011, out of $5.7 million spent on Kyrgyzstan’s HIV/AIDS response, only about $1.4 million came from state sources, whereas the rest was funded by international donors (CCC 2012), yielding them considerable political influence. Over the years, Kyrgyzstan has received funding from a variety of multilateral and bilateral agencies, including the World Bank, the World Health Organization, Soros Foundation-Kyrgyzstan and the United Nations Development Programme (UNDP). These actors not only played a crucial role in setting up and funding many HIV/AIDS projects but also helped to improve the normative and legislative basis for HIV/AIDS prevention and control efforts (CCC 2010; 2012; Bashmakova et al. 2009).
In addition, donor funding transformed the country’s NGO sector, with about 200 NGOs working in the area of HIV/AIDS (Murzalieva et al. 2007). Most of them focus on prevention activities and the provision of services to most-at-risk populations and PLWHA (Murzalieva and Bogatikova 2010). However, in recent years, some of the larger NGOs and NGO associations have become more active on the HIV/AIDS policy arena, demanding the revision of existing or the introduction of new legislation to better meet the needs and interests of their client populations.
In view of such a multitude of stakeholders with potentially competing interests and agendas, the question arises who yields most power to shape HIV/AIDS policies in the country. This article aims to address this question, which, to our knowledge, has so far not been explored in the academic literature. It maps all stakeholders relevant for HIV/AIDS policy-making in Kyrgyzstan and analyses their position and influence. Understanding the complex relations at play in the policy process is vital not only for informing decision-makers and assisting the future design and implementation of effective and sustainable HIV/AIDS policies, but also for building consensus among national stakeholders and advocacy efforts in Kyrgyzstan. The article also carries lessons for other low- and middle-income countries, in particular those that are heavily dependent on international donors.
Methods
Our study followed the stakeholder analysis approach, which seeks to gather knowledge about policy actors and their interests, their formal and informal relationships, the distribution of power, as well as the degree of influence and available resources. All of these factors should be taken into account in the planning and implementation of policies to ensure they are realistic and sustainable (Crosby and Brinkerhoff 2002; Gil et al. 2010; Varvasovszky and Brugha 2000; World Bank 2001). The findings reported here are part of a larger study on HIV/AIDS policy-making in Kyrgyzstan in 2004–2011, which recognizes actors (stakeholders) as one of the key dimensions of policy-making (Walt and Gilson 1994). By understanding actors’ interests and motivations, it becomes possible to unravel why and how certain policies come to life.
Stakeholders are actors that have direct impact on an issue or can affect it indirectly by enhancing or weakening the authority of key decision-makers and influencing implementation processes (Crosby and Brinkerhoff 2002; Varvasovszky and Brugha 2000). Depending on the aim of the research, stakeholder analysis offers different tools that can be applied to various settings, contexts and policy levels (Varvasovszky and Brugha 2000). For the purpose of this study, the scope was intentionally kept broad and not focused on any particular policy, while the timeframe was limited to the analysis of national policy-making dynamics at the time of the field research (2011). The primary sources of data for the stakeholder analysis were 54 semi-structured in-depth interviews, complemented by a review of policy documents (including government, donor and NGO reports and programme documents) and academic literature on HIV/AIDS policy-making in Kyrgyzstan.
During two research trips to Kyrgyzstan (in June and October–November 2011), and based on a review of the literature and the interviews themselves, a list of key stakeholders in the HIV/AIDS sector was compiled and key informants identified, using the techniques of purposive sampling and snowballing. Selection criteria included informants’ professional knowledge and experience, as well as their influence and involvement in HIV/AIDS policy-making, willingness and availability to participate in the research, and ability to provide reflective answers to the posed questions. New key informants were added until no additional stakeholders were identified and saturation was reached. Respondents included heads of HIV/AIDS departments and programmes in state institutions (including various ministries, public health and law enforcement agencies), top policy-makers in the parliament and the government office, programme managers in international organizations, heads of NGOs and community organizations, and journalists covering HIV/AIDS in several leading newspapers and news agencies.
Each interviewee signed an informed consent form and steps were taken to ensure respondents’ confidentiality. Ethics approvals were given by the Research Ethics Committee of the London School of Hygiene & Tropical Medicine (application 6045, approved on October 6, 2011) and the Ethics Committee of the Ministry of Health of the Kyrgyz Republic (meeting protocol 12, approved on October 10, 2011). Interviews were semi-structured and followed a pre-tested topic guide that allowed interviewees to expand on issues they felt important. The interviews elicited information on the development of HIV/AIDS policies in Kyrgyzstan, including with regard to the respondents’ organizations and touching on such issues as agenda-setting, decision-making, power and influence, motivation and interests. The interviews also aimed to gain insights into critical moments for HIV/AIDS policy-making and the role that key actors played in those moments. Although some respondents mainly spoke in their official capacity on behalf of their current employer, others also gave their personal opinion or provided information on their experience at previous employers, switching between different accounts during the interviews. Information on these multiple allegiances allowed unique and in-depth insights into the ways that different stakeholders perceived and treated the issue of HIV/AIDS.
For the purpose of this study, all stakeholders were grouped under four broad headings: the state, NGOs, the media and international organizations; these categories were then further divided into sub-groups, according to institutional focus and mandate (Table 1). For ease of comparison, we further divided state agencies into those at the level of government/parliament and those in the area of public health or law enforcement. NGOs were sub-divided into NGO associations, individual NGOs (recognizing that some of them were members of the larger associations) and community organizations of PLWHA. International organizations included bi- and multilateral agencies, international NGOs and global health initiatives, notably the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund). Newspapers and news agencies were grouped under the ‘Media’ heading.
Interests and involvement of key stakeholders in HIV/AIDS policies
| Organization (abbreviation) | Interests/involvement |
|---|---|
| State agencies | |
| Government/Parliament | |
| Jogorku Kenesh (Parliament) | Review and adoption of HIV/AIDS-related legislation |
| Office of the Government | Development and oversight of HIV/AIDS legislation and policies |
| Ministry of Defence | HIV prevention among military forces and youth |
| Ministry of Internal Affairs | Drug trafficking control, HIV prevention among police forces |
| Ministry of Health | Development and implementation of overall HIV/AIDS policies |
| Ministry of Education and Science | HIV education and prevention among young people in the education system |
| Ministry of Social Development | Social protection for PLWHA and other affected groups |
| Ministry of Justice | Conception and oversight of the regulatory framework for HIV/AIDS control efforts |
| Ministry of Finance | Review and approval of state budgeting for HIV/AIDS-related activities |
| Country Coordinating Committee | Multi-sectoral coordination of HIV/AIDS efforts by national and international agencies; oversight of the implementation of Global Fund grants |
| Public health | |
| National AIDS Centre | Overall HIV/AIDS surveillance, data collection and reporting, diagnostics and treatment and distribution of supplies |
| Family Group Practice Association | Training of Family Group Practice physicians in the diagnosis, prevention, treatment and care of HIV/AIDS and co-infections |
| Republican Narcology Centre | Harm reduction, distribution and oversight of opioid substitution therapy |
| Republican Centre for Infectious Disease Control | HIV prevention in medical settings; research, training, policy development and support for the control of infectious diseases |
| Kyrgyz State Medical Academy | Training of medical students in HIV/AIDS prevention, treatment and care |
| Law enforcement | |
| State Penitentiary Service | HIV prevention, harm reduction and drug use rehabilitation in the penitentiary system |
| State Agency on Drugs Control | Drug trafficking control, harm reduction among injecting drug users (IDUs) in public and prison settings |
| Academy of the Ministry of Internal Affairs | Training of future police officers in HIV prevention and protection of the rights of most-at-risk populations (MARPs)/PLWHA |
| NGOs | |
| Associations | |
| Association of Harm Reduction Programmes ‘Partnership Network’, ‘Harm Reduction Network’ and ‘Partnership Association’ |
Representing and supporting the interests of member organizations with regard to HIV/AIDS prevention, care and support, advocacy and policy input |
| Individual | |
| Central Asian Training Information Centre on Harm Reduction | Informational and training support in harm reduction in four Central Asian countries |
| NGO ‘Socium’ | HIV prevention, harm reduction and social support for IDUs |
| NGO ‘Tais Plus’ | HIV and sexually transmitted infections (STIs) prevention among sex workers |
| Public Foundation ‘Legal Clinic “Adilet”’ | Legal support and human rights protection of MARPs and PLWHA, policy support |
| Youth R.I.S.E. | HIV prevention among youth |
| PLWHA groups | |
| Association ‘Country Network of PLWHA’’ Association ‘Solidarity of PLWHA’ NGO ‘Terra Sana’ |
Representation of the interests and needs of PLWHA, and provision of care and support services, advocacy and policy input |
| Media | |
| AkiPress news agency Argumenty i Fakty newspaper Kabar news agency MSN newspaper Slovo Kyrgyzstana newspaper Vechernii Bishkek newspaper 24.kg news agency |
Reporting HIV/AIDS-related news and stories to the general public |
| International organizations | |
| Multilateral | |
| United Nations Joint Programme on HIV/AIDS (UNAIDS) | Policy setting and support, and overall coordination of UN agencies’ HIV/AIDS activities |
| United Nations Development Programme (UNDP) | Capacity building and support in HIV/AIDS response and advocacy |
| United Nations Population Fund (UNFPA) | HIV prevention in young people and women, linking with reproductive health |
| United Nations Children’s Fund (UNICEF) | Prevention of mother-to-child transmission (PMTCT), HIV/AIDS prevention and treatment among children |
| United Nations Office on Drugs and Crime (UNODC) | Harm reduction, HIV/AIDS prevention and treatment among IDUs, including prison settings |
| World Health Organization (WHO) | Policy support, in particular with regard to clinical protocols and standards in HIV/AIDS, STIs and TB prevention, treatment and care |
| World Bank (WB) | Grants support, regional HIV/AIDS policy development, and coordination |
| Bilateral | |
| United Kingdom Department for International Development (DFID) | HIV prevention and harm reduction among MARPs, policy advocacy and support |
| German Society for International Cooperation (GIZ) | Institutional capacity building for health promotion, harm reduction and health care |
| United States Agency for International Development (USAID) | Improving access to and delivery of HIV/AIDS and TB services, health systems strengthening and integration of HIV/AIDS services |
| U.S. Centers for Disease Control and Prevention/President’s Emergency Plan for AIDS Relief (CDC/PEPFAR) | Technical support in PMTCT, HIV diagnostic capability, health systems and human capacity strengthening |
| International NGOs | |
| Soros Foundation-Kyrgyzstan (Soros) | Legal support for MARPs and PLWHA, HIV prevention and harm reduction, NGO capacity building, legislation and advocacy support |
| AIDS Foundation East-West (AFEW) | HIV prevention, treatment and social support for MARPs and PLWHA, law enforcement training, harm reduction |
| Population Services International (PSI) | HIV prevention and drug reduction programmes |
| Global health initiatives | |
| Global Fund to Fight AIDS, Tuberculosis and Malaria | Grant funding and support of HIV/AIDS prevention and treatment programmes |
In a second step, we developed a matrix to organize and classify the information on stakeholders. One method to do so was to assess stakeholders’ levels of influence and position towards HIV/AIDS policies at the time of the fieldwork (2011), using previously developed criteria (Akinci et al. 2012; Gil et al. 2010; Knai et al. 2010; Moise et al. 2011; Varvasovszky and McKee 1998; Varvasovszky and Brugha 2000). Information on stakeholders’ interests and involvement in HIV/AIDS, including their professional affiliation, agendas and status within the HIV/AIDS community (Varvasovszky and McKee 1998), was derived from an analysis of existing literature on HIV/AIDS policy-making in Kyrgyzstan, as well as the field interviews. The influence of stakeholders on HIV/AIDS policy-making, ranging from High to Low, was assessed and determined based on the following criteria: ability to put HIV/AIDS on the policy agenda, assert their position as major decision-makers and exercise power with regard to final policy outcomes. In line with previous stakeholder analyses (Akinci et al. 2012; Gil et al. 2010; Knai et al. 2010; Moise et al. 2011; Varvasovszky and McKee 1998; Varvasovszky and Brugha 2000), the positions of stakeholders were categorized either as Support, Mixed (with varying degrees of support or opposition) or Non-support, based on how willing, open and supportive they were with regard to the development of HIV/AIDS policies. In a few instances, differences in assessments between various respondents and literature sources were noted and adjusted in line with prevailing assessments and the judgments of the researchers. Thus, the overall analysis of the role, impact, interest and involvement of each stakeholder is a synthesis of respondents’ views (taking account of respondents’ perceptions of their own role and their organizations and views of other stakeholders), secondary sources, and the authors’ interpretation and judgment. Draft versions of the overview tables were shared with three national experts on HIV/AIDS in Kyrgyzstan and their feedback was incorporated.
Representatives of some stakeholder organizations, such as UNAIDS and Population Services International, were not available for an interview due to logistical or scheduling problems. Two state agencies, the Ministry of Finance and the Ministry of Justice, were not interviewed during the field research, as they were not deemed by the authors and key informants as particularly important or active in HIV/AIDS policy-making, beyond their jurisdiction and mandate. However, they were nevertheless included in the stakeholder analysis and their assessment was based on information provided by other respondents and a review of available literature. We also recognize that, due to various reasons, not all respondents may have shared their true opinions and that views represented in this study may change over time. Other limitations include time and resource constraints.
Results
Estimated position and influence of key stakeholders with regard to the development of HIV/AIDS policies in Kyrgyzstan
Most stakeholders in Kyrgyzstan were supportive of HIV/AIDS policies, although their influence differed greatly (Table 2). In contrast, some of the major state agencies and media outlets only showed mixed support towards HIV/AIDS policies, with the state agencies possessing great influence over the policy-making process. Yet, a positive finding is that none of the stakeholders has shown a complete lack of support. Nevertheless, the question arises why some stakeholders chose to support HIV/AIDS policies, and what their interests in and influence over HIV/AIDS policy-making are.
| Influence | Position | ||||
|---|---|---|---|---|---|
| Low | Low–medium | Medium | Medium–high | High | |
| State: Family Group Practice Association, Kyrgyz State Medical Academy, Academy of the Ministry of Internal Affairs, Ministry of Defence | State: National AIDS Centre, Republican Narcology Centre | State: Country Coordinating Committee, Ministry of Social Development, Republican Centre for Infectious Disease Control, State Penitentiary Service | State: Ministry of Education and Science, State Agency on Drugs Control | State: Ministry of Health | SUPPORTIVE |
| NGOs: Youth R.I.S.E. | NGOs: Association ‘Country Network of PLWHA’, Association ‘Solidarity of PLWHA’, Public Foundation ‘Legal Clinic “Adilet” ’, Central Asian Training Information Centre on Harm Reduction, NGO ‘Socium’, NGO ‘Tais Plus’, NGO ‘Terra Sana’ | NGOs: Anti-AIDS Association, Association of Harm Reduction Programmes ‘Partnership Network’, ‘Harm Reduction Network’, and ‘Partnership Association’ | |||
| International: UNFPA | International: GIZ | International: CDC/PEPFAR, DFID, PSI, UNAIDS, UNDP, UNICEF, UNODC, USAID, WHO, WB | International: AFEW, Soros | International: Global Fund | MIXED |
| State: Ministry of Justice, Ministry of Finance | State: Ministry of Internal Affairs | State: Jogorku Kenesh, Office of the Government | |||
| Media: AkiPress, Argumenty i Fakty, Kabar, MSN, Slovo Kyrgyzstana, Vechernii Bishkek, 24.kg | |||||
Supportive stakeholders with high and medium-high influence
As illustrated in Table 2, there are only a few national and international agencies with high and medium–high influence in Kyrgyzstan, which are supportive of HIV/AIDS policy development based on international principles and best practices. Although the executive branch of government is responsible for approving state HIV/AIDS policies and overseeing their implementation, its ministries prepare and implement sector-related HIV/AIDS policies and programmes. For example, the Ministry of Health prepares and implements its own legislation, leads the development of national HIV/AIDS programmes, prepares the regulatory framework for health service provision and financing, and collaborates with other state and non-state actors in the implementation of various national and international policy agreements (Ibraimova et al. 2011). By the nature of the political mandate granted to them, these state agencies serve as the last point of authority and, without their formal approval, no activities, both by state and non-state actors, can take place. As one respondent from a UN agency described it:
“Each player has their own role in this process, but I think the state is still a principal player. It doesn’t matter what we say, how we push certain issues, the last word belongs to the state, i.e. the government and the Ministry of Health. If they see it necessary, they will work on it and implement it.”
Some respondents believed that, unlike donors and NGOs, state agencies such as the Ministry of Health are taking a reactive approach to HIV/AIDS, characteristic for many bureaucracies that get bogged down in day-to-day operations and processes. For example, following the first nosocomial outbreaks in 2004, the Ministry of Health and other state agencies reacted by revising appropriate policy and programmatic documents, addressing issues such as the safety of medical procedures, legal and criminal responsibility in case of nosocomial transmission and securing the rights and entitlements of patients infected in medical settings. However, this did not entirely prevent future nosocomial outbreaks (see below).
Other respondents felt more sympathetic towards state agencies, realizing that they are overwhelmed with a number of health and social issues they need to prioritize and resolve with limited funding and overworked staff. A representative of an international agency pointed out that state agencies take on leadership roles when invited to do so:
“State agencies, they are a bit passive, yet they don’t refuse the opportunity to lead these processes. Their very active participation in CCC is encouraging. And when they are nominated to leading positions, they don’t turn [the nomination] down, but agree to participate.”
Opinions were also divided over the role and influence of HIV/AIDS NGOs, which are often set up by representatives of most-at-risk populations and people living with HIV/AIDS. NGO representatives were proud of their achievements and described themselves as active and motivated leaders and equal players on the HIV/AIDS policy arena. They were also seen by others as proactive and vocal, energetic and quick to mobilize, and have been described by some as ‘engines’ or ‘leaders’ of change due to their advocacy efforts. Together with international agencies, NGOs have contributed to the development and implementation of some key policies on harm reduction, based on a human rights approach. One representative of a donor agency said:
“We have a very strong NGO sector that works in the area of HIV/AIDS. By and large, today they are the drivers of change.”
One example of NGOs using a ‘window of opportunity’ was a major outbreak of nosocomial infections in 2007. The PLWHA community, together with the mothers of infected children, drew renewed attention to the problem of HIV/AIDS and the need for social benefits for PLWHA and their families. However, other stakeholders spoke negatively about NGOs, describing them as rivals and challengers of state power. Furthermore, NGOs were often seen as donor-dependent, spoiled and opportunistic. Their total financial dependency on external sources of funding was seen as undermining their agency to make independent decisions, whereas power struggles and competition over resources within the NGO sector made their policy actions less coordinated and coherent.
Among the donors, the AIDS Foundation East–West, the Soros Foundation-Kyrgyzstan and the Global Fund have assumed particular importance. Although the AIDS Foundation East–West has recently become a sub-recipient of the Global Fund grant, the Soros Foundation-Kyrgyzstan has been working to establish political commitment among policy-makers, as well as building and sustaining leadership and advocacy capacity among marginalized populations, such as drug users and sex workers. It has been particularly credited for its advocacy work in the area of harm reduction and for supporting activities geared towards revision of national HIV/AIDS legislation to make it more humane and in line with international norms.
The Global Fund is one of the biggest global health initiatives and the largest funder of HIV/AIDS programmes in Kyrgyzstan, clearly out-weighing all other international contributions. Local stakeholders have identified the arrival of Global Fund funding in Kyrgyzstan as one of the most critical moments for HIV/AIDS policy-making. By funding all major activities in the areas of prevention, treatment and care, the Global Fund, including both its Geneva headquarters and the Programme Implementation Unit (PIU) in Kyrgyzstan, in some ways took over the decision-making and funding responsibilities of the Ministry of Health, becoming the major driver of the HIV/AIDS agenda in the country, according to local stakeholders. Our analysis of field interviews and Global Fund framework documents and country grant applications revealed a certain degree of tension over national decision-making power. On the one hand, the Global Fund aims to strengthen national participation, ownership and accountability by supporting country-led formulation and implementation of programmes that are aligned with national health planning and priorities (Global Fund 2001; 2010). On the other hand, as part of the eligibility criteria, it places stringent requirements on its applicants, such as the use of best international practices and approaches, high-level political commitment and participation, involvement of vulnerable populations, alignment with the international legal framework and multi-sectoral coordination through a robust and well-functioning Country Coordinating Mechanism (Global Fund 2010, 2001). These requirements then often become a blueprint for national policies and programmes. For instance, informants in Kyrgyzstan mentioned that the 2012–2016 State HIV/AIDS Programme is based exclusively on the aims and activities funded by the Global Fund.
Supportive stakeholders with medium influence
Supportive stakeholders with medium influence on HIV/AIDS policy-making include the CCC, the Ministry of Social Development, several state agencies in the areas of health and law enforcement, and the majority of NGOs and international organizations. The CCC, under the auspices of the government but dependent on international sources of financial support, serves as the main coordinating body and platform for HIV/AIDS policy dialogue and collective decision-making, as part of the Global Fund grant eligibility requirements. Yet, according to the CCC’s new mandate, its rights and responsibilities are limited to the development and implementation of proposals for the Global Fund. Its functions no longer include the development and review of national strategies and policies, such as the State HIV/AIDS Programme. With the Principal Recipient role in the hands of UNDP (at the time of the interviews) and the strong position of the Global Fund Programme Implementation Unit, many local stakeholders felt that the CCC, as a collective representative of the country, had been deprived of its ownership and national decision-maker status. As a local staff member in an international project explained:
“Kyrgyzstan has won these funds, wrote the application, invested its own resources, knowledge and so on. We won and we were supposed to distribute them, but some other ‘mister’ is doing it for us and doesn’t give us any space for manoeuvring.”
Specialized state agencies concerned with social services, health or law enforcement, such as the Ministry of Social Development, the State Penitentiary Service, the Republican Centre for Infectious Disease Control and the State Agency on Drugs Control, not only provide vital expert information, but also participate in and drive some of the policy changes. For instance, the Ministry of Social Development has actively participated in the revision of policies on social entitlements to children infected with HIV in medical settings. The State Penitentiary Service and the State Agency on Drugs Control played an important role in setting up policies and programmes on harm reduction and HIV prevention among injecting drug users, which are considered some of the most progressive in the region.
Last but not least, their ideational (persuasion) and material (financial) power (Beland and Orenstein 2010) gives international agencies in Kyrgyzstan weight and authority to suggest certain policy actions that the state may be inclined to adopt. International agencies often serve as technical advisors when it comes to introducing new or revising existing HIV/AIDS-related policies, making use of their expertise and access to best international practices. The UN Thematic Group for HIV/AIDS, led by UNAIDS, for example, consulted local experts during the development of the ‘HIV Prevention’ Law to bring it closer to international standards (Bashmakova et al. 2003). International agencies were described as proactive, highly organized, mobile and strategic—working at a higher, political, level. As a representative of a state agency noted:
“Probably, international organizations […] if they have such a direction as part of their work, they form political support of the leadership of the country, of the leadership of individual ministries, departments, and, of course, the political will, it comes from the top.”
Closely working with government structures, international agencies (such as UNDP and its project ‘Support to the Government to Respond to HIV/AIDS’) were able to cultivate a high degree of understanding and political commitment towards the issue of HIV/AIDS among top national policy-makers. They also worked with state agencies on joining key international agreements and conventions on HIV/AIDS (such as the Millennium Development Goals), and assisted individual ministries in developing appropriate local HIV/AIDS policy documents and guidelines and designing appropriate programmes. Yet, respondents believed that sometimes there is strong pressure to adopt certain guidelines over others, essentially stripping local stakeholders and policy-makers of their authority and decision-making ability. For example, when a State Programme for HIV Prevention was developed, as one of the respondents described, there was pressure from the WHO office to use their format and recommendations.
Supportive stakeholders with low and low-medium influence
Supportive organizations, which agree that Kyrgyzstan should have appropriate HIV/AIDS policies in place but possess less influence on HIV/AIDS policy-making, include health and non-health state institutions outside of the HIV/AIDS sector, a youth-oriented NGO and several international agencies. Ministries that focus on other issues than health, such as the Ministry of Defence, participate in the multi-sectoral mechanism; however, their involvement and influence on overall national HIV/AIDS policy development has been described as low.
Although some public health institutions, such as the Republican Narcology Centre or the Kyrgyz Medical Academy, are mostly involved in service provision or medical education and have a low impact on policy decisions, the responsibilities of others, such as the National AIDS Centre and the Republican Centre for Infectious Disease Control, include some participation in the development and support of policies, such as the State HIV/AIDS Programme. These specialized agencies see themselves and are seen by others as keepers of the official epidemiological data and expert knowledge, which is used in priority-setting and decision-making. Health sector representatives and some other stakeholders believed that they should be the leaders in HIV/AIDS policy initiation, formulation and implementation. Yet, serious question marks over grant oversight and management on the part of the previous Principal Recipient of the Global Fund grants, the National AIDS Centre, have severely undermined its reputation and authority, creating a sense of disillusion with the state health sector among many stakeholders. As a representative of a donor agency shared:
“… you know, there has been a lot of corruption in Global Fund money and you know, it’s just, it’s not the optimistic time any more than it was in 2005 … ”
Although some other international organizations, such as the United Nations Population Fund and the German Society for International Cooperation, have been involved in several HIV/AIDS-related projects, their contribution to and impact on overall HIV/AIDS policy-making has been limited or non-existent.
Stakeholders with mixed support and high/medium-high influence
Actors providing mixed support (i.e. support or opposition, depending on the situation and issue), but having high and medium–high levels of influence, include two top executive offices (the parliament and the Office of the Government) and the Ministry of Internal Affairs. Although the government has declared high levels of political support and commitment, many respondents admitted that the leadership of government agencies has often been tokenistic. Decisions of some non-supportive (i.e. resistant or reluctant) decision-makers in the government and parliament, such as individual Vice Prime Ministers and members of parliament (MPs), had a detrimental or disruptive effect on HIV/AIDS policies in Kyrgyzstan.
One of the most vivid examples quoted by the informants has been the impact of a Vice Prime Minister, whose decisions on the restructuring of the CCC led to its weakening and poor functioning in the late 2000s until 2011. A local manager of an international agency explained:
“But it was difficult, these were the times of Bakiev and the Vice Prime Minister, who was the head of CCC, the infamous woman Kalimbetova … She didn’t have any views, she simply didn’t want to look into the [HIV/AIDS] issue. And it was very hard then. In general, it was mostly the NGO sector and development partners, working and trying. The government sector, of course, looking at the boss, felt more trapped.”
Interviews with harm reduction experts and NGO representatives revealed that there is also strong opposition in parliament towards the draft harm reduction law, which would legally secure and protect harm reduction activities, including opioid substitution therapy. Despite great advocacy efforts of NGOs, international agencies and a few MPs, the draft law has not passed for several years. According to interviewees and the academic literature (Spicer et al. 2011), there are a number of reasons behind MPs’ resistance, ranging from personal moral beliefs and misunderstandings of opioid substitution therapy to alleged financial interests in sustaining punitive drug laws and drug trafficking.
Some stakeholders in the law enforcement sector, such as the Ministry of Internal Affairs, have, due to their traditionally punitive approach to drug use, sex work and sex between men, been resistant to the implementation of HIV prevention programmes, such as opioid substitution therapy and other harm reduction activities, while harassment and violations of the rights of at-risk populations continue. Both interviews and secondary data indicate that many representatives of the law enforcement sector resist moving away from a disciplinary approach to providing social and public health assistance to at-risk populations and the friction between the law enforcement approach, favouring policing and persecution, and a public health approach, promoting harm reduction and human rights, still exists (Beletsky et al. 2012; Latypov 2009; Mounier et al. 2007; Rechel 2010; Wolfe et al. 2009).
Stakeholders with mixed support and low/low-medium influence
As mentioned earlier, the role of ministries that focus on issues other than health, such as the Ministry of Finance and the Ministry of Justice, is limited in HIV/AIDS policy-making to their respective jurisdiction, such as ensuring compliance of policy documents with financial and legislative requirements. Thus, while their influence and involvement have been assessed as low or low–medium, their support levels have been mixed: although they support HIV/AIDS policies in general, their bureaucratic tendencies and the occasional questioning of certain approaches often leads to the delayed adoption of some key HIV/AIDS-related policies.
With regard to the influence of the media, although some media representatives believed that, thanks to their coverage and reporting, the overall awareness about HIV/AIDS among the general population has improved in recent years, the majority of stakeholders believed that its role was limited to informing the general public about HIV/AIDS. Therefore, it was not seen as an active policy player. A government representative stated:
“The media sector works on a demand basis – when we ask for something, they join us. But for now, we don’t treat them as active players in this field.”
Others saw media representatives as being out of touch and lacking understanding of HIV/AIDS policies. Admitting that their role in the policy-making process has been mainly indirect and invisible, the interviewed media representatives reported mixed support towards HIV/AIDS policies. While most journalists were supportive of progressive HIV/AIDS policies and were open to collaboration with HIV/AIDS partners, a few media informants spoke negatively about the HIV/AIDS sector, used moralistic language when describing the disease and even mentioned the need for tougher laws on drug use and sex work.
Discussion
Our analysis provides new insights into HIV/AIDS policy-making and the power dynamics between the different stakeholders in Kyrgyzstan. First, thanks to the country’s multi-sectoral approach, the majority of stakeholders have been well-aware of HIV/AIDS policy developments, demonstrating support for progressive HIV/AIDS policies and approaches, and openness to participation and input. However, despite the country’s declared political will and commitment towards HIV/AIDS, which have been mentioned time and again in various official documents, as well as in our interviews, in reality key state agencies only showed mixed levels of support, with some degree of resistance or inaction. This confirms findings of previous studies, in which the government and its ministries were described to be at times inert and apathetic, fearing any major undertakings that may challenge their status quo and require additional work for state employees without increasing their fixed modest salaries (Spicer et al. 2011).
The experience in many other countries, including Brazil, Thailand and Uganda, has shown that strong national leadership is an essential ingredient of successful responses to the HIV/AIDS epidemic (Singhal and Rogers 2003). Our stakeholder analysis has shown for the case of Kyrgyzstan that, while the majority of state agencies support HIV/AIDS policies and to some degree participate in their development and implementation, there have been instances of important policies being stalled due to opposition from key decision-makers. In other cases, state institutions, such as the Ministry of Health, may not be motivated to exercise their legal power and actively participate in HIV/AIDS policy-making, due to competing priorities and a general lack of financial and technical resources. This finding points to the need to look behind the official façade of political declarations and to investigate underlying power relations, as well as contextual issues, when assessing a country’s willingness to address health challenges.
The second major finding of our analysis concerns the role of international organizations and donors. Despite the efforts of donor agencies to remain impartial, their lack of formal veto power, and their proclaimed ‘observer’ status, we found their impact on policy-making to be substantial. Whenever donors offered the country funding for HIV/AIDS efforts, there was strong pressure to adopt certain international guidelines and fulfil programmatic, procedural and funding requirements and conditions, often at the expense of the authority of local stakeholders and policy-makers. In the current context of declining donor contributions through the Global Fund and other agencies, these pressures can be expected to increase further. Many respondents in Kyrgyzstan felt that the country’s poverty and high donor dependence left it little choice but to give in to funders’ conditions and priorities, even if they are far removed from local needs. As observed in neighbouring Tajikistan (Rechel and Khodjamurodov 2010), this can undermine national health governance.
Our third major finding relates to NGOs. In the last few years, the role of NGOs in Kyrgyzstan has increased significantly. Given their aims and objectives, it is not surprising that all NGOs are supportive of HIV/AIDS policies. Yet, HIV/AIDS-related NGOs are becoming more strategic, employing a range of tools to further their agenda, and their knowledge about HIV/AIDS and policy processes allows them to pose critical questions, defend their position and manipulate the political situation to their advantage. As its members are most affected by the disease, the community of PLWHA is now also an active part of the decision-making process at the CCC and other coordinating committees and working groups (MOH 2012), trying to position themselves as ‘part of the solution rather than the problem’. In our interviews, as well as in previous research (Spicer et al. 2011), HIV/AIDS NGOs asserted their legitimacy in the policy arena through claiming their first-hand experience of identifying and meeting needs of at-risk populations, representing their interests and protecting their rights.
However, our study suggests that the input of NGOs has not been fully utilized. According to some NGO representatives, their inclusion during the preparation of policy documents has been somewhat inconsistent. Even when their feedback on such documents as the State HIV/AIDS Programme was requested, it was not, or only marginally, included in the final versions. It is also worth noting that some of the most-at-risk populations (e.g. men who have sex with men and sex workers) are still under-represented in the policy-making process, due to high levels of stigma and the absence of strong NGOs that would advocate for their needs and rights. Furthermore, many NGOs, especially smaller ones, still lack adequate infrastructure, skills and resources, limiting their capacity for advocacy and political participation, as noted by various informants during our field interviews, mirroring what has been reported in the literature (CCC 2013a; Harmer et al. 2013; Spicer et al. 2011).
HIV/AIDS policy-making in Kyrgyzstan is a highly competitive and muddled process and involves a variety of actors with different interests and agendas within and outside of government structures. Our study found an agenda-setting vacuum and weak leadership capacity of state agencies, which is often filled and challenged by other national and international actors, such as donor organizations and civil society. Not only the lack of domestic funding and capacity but also the absence of a clear state strategy and sense of direction in HIV/AIDS, makes state agencies, such as the Ministry of Health, more susceptible to the influence of donors. The latter, faced with an underfunded government and a weak health system, have become influential players, setting and driving the HIV/AIDS policy agenda. However, there is a danger that they promote pre-conceived agendas that may not always meet the needs of local populations.
Conclusion
For a truly effective, comprehensive and nationally owned response to the HIV/AIDS epidemic, the government and its ministries and agencies need to play a leading role in shaping and driving HIV/AIDS policies and programmes, making use of their legal authority and infrastructure for implementing them. Sustainability cannot be achieved until donors embrace long-term strategic planning, and state health agencies direct financial and programmatic support where it is most needed. Unlike donors and NGOs that might come and go, state agencies are the only stakeholders in the HIV/AIDS sector that are permanent and relatively secure. By integrating HIV/AIDS services into the health system, there would be less danger that efforts seize once donor funding ends. Furthermore, the appropriate legal basis to back up and institutionalize certain efforts, such as harm reduction, is needed.
Although our observations are limited to HIV/AIDS policy-making in Kyrgyzstan, there is reason to believe that the situation is similar in many other low- and middle-income countries. An in-depth understanding of the roles, interests, capacity and influence of different policy actors is crucial for policy planning and analysis. Recognizing the transient nature of policy-making, a detailed stakeholder analysis not only allows a deeper understanding of policy-making processes, but also helps to track shifting interests, so that policy strategies can be modified to achieve more sustainable policy changes.
Funding
This work was supported by a PhD studentship at the London School of Hygiene & Tropical Medicine to the lead author.
Conflict of interest
None declared.
Acknowledgements
The authors thank all interviewees for their collaboration and willingness to share their opinions. Special thanks go to the national experts in Kyrgyzstan, L. Bashmakova, A. Isakova and B. Ishemkulov, for their input into the stakeholder assessments.
Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine © The Author 2013; all rights reserved. Previous Section
Source: heapol.oxfordjournals.org