By Gulnaz Isabekova
This publication is based on part of the article ‘Wer bekommt wieviel? Entwicklungshilfe im Gesundheitswesen der zentralasiatischen Staaten’, published in Zentralasien-analysen 108, 23.12.2016, pp. 02-11. To access the original article please follow http://www.laender-analysen.de/zentralasien/pdf/ZentralasienAnalysen108.pdf
Executive summary:
Central Asian countries have been target of international donors since independence in the early 1990s. Investing around 2 billion $ in the region, international donors make a substantial contribution to the Asian countries’ economic, social, humanitarian and security sectors. Yet, the distribution of aid in the region is not equal. This article reviews aid allocation across and within the Asian countries taking the example of the healthcare sector. It explain in countries variation of aid allocation by taking into consideration the democracy index, gross domestic product (GDP) per capita, and ‘openness’ and ‘closedness’ of the recipient countries to development aid. Defining major donors and their activities in healthcare, this article highlights the need for improving the scope of data for better analyzing the aid, its effectiveness and sustainability over time.
Introduction
The aid to healthcare in the Central Asian region is uneven. Kyrgyzstan receives $460 million (around $5 per capita), followed by Tajikistan $417 million ($3 per capita), Uzbekistan $697 ($1,3 per capita), Kazakhstan $239 million ($0,76 per capita) and Turkmenistan $59 million ($0,62 per capita). Why do some countries receive more, whereas others receive considerably less? There is an extensive discussion of ‘donor darlings’ and ‘donor orphans’ in the literature. General determinants of development aid allocation are donors’ strategic interests and their historical ties to the recipient country. The political system and the economic well being of the recipient country also matter, as countries with higher democracy index and lower GDP are likely to receive more assistance. However, donors also cooperate with less democratic states. Large donors in health care, namely the United States, the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund), Germany, Japan and the International Development Association of the World Bank (the World Bank) are present in all five Central Asian countries.
There is limited data on development aid, its allocation and distribution in Central Asia. However, data are essential to the coordination of development assistance and non-duplication of activities. This paper overviews aid allocation to healthcare in the region. By analyzing donors and their contributions to the sector, it defines the largest donors and areas of their activities in each country. The analysis is based on data available at the Organization for Economic Cooperation and Development Creditor Reporting System (OECD CRS) for the period of 1995-2014. This database contains information on aid officially committed by ‘traditional’ donors or members of the Development Assistance Committee. Healthcare does not constitute the largest part of aid to Central Asia, but allocations in this sector correspond to the general pattern of aid distribution (total) in the region.
| Development aid 1995-2014 (US Dollar, Millions) |
|||
| Countries | All sectors (total) | Health care | % of health care in aid total |
| Kazakhstan | 3495.1 | 239.0 | 6.8% |
| Kyrgyzstan | 6077.7 | 460.0 | 7.6% |
| Tajikistan | 5532.8 | 416.9 | 7.5% |
| Turkmenistan | 502.5 | 59.2 | 11.8% |
| Uzbekistan | 6987.9 | 696.6 | 10.0% |
| Central Asia total | 22595.9 | 1871.6 | N/A |
| *development aid in absolute values. rounded to one decimal place | |||
| Source: The OECD.Stat. Creditor Reporting System. Available at: http://stats.oecd.org/Index.aspx?datasetcode=CRS1# | |||
Country focus: the largest donors and their areas of activity
The largest recipient of development assistance in Central Asia is Kyrgyzstan. Three out of five top donors in this country, namely Germany, the World Bank and Switzerland, participate in the Sector Wide Approach (SWAp)[1] and provide direct budgetary assistance to the country. The Ministry of Health allocates this assistance to priority areas, agreed in the national strategy and reports to donors on implementation and achievements of indicators. All three donors additionally pursue parallel projects. Germany targets emergency care, mother and child health care, personnel training, infectious diseases and the rehabilitation of regional hospitals. The World Bank aims at broader health sector reforms, avian influenza control, water supply and sanitation. Switzerland, in its turn, focuses on regional community health care projects. The United States targets the primary health care and infectious diseases, whereas the Global Fund focuses on tuberculosis and HIV/AIDS.
Tajikistan, the second largest recipient of aid in the region, has a similar donor landscape. There are attempts to improve donor coordination by introducing the coordination council and joint annual reviews. The largest donors in this country are Germany, the United States, the World Bank, the Global Fund and Switzerland. German projects aim at the rehabilitation of hospitals and healthcare facilities by providing equipment, supporting emergency care and combatting infectious diseases. The United States targets primary health care, mother and child care and infectious diseases. The World Bank aims at broader health care reforms and service improvement. The Global Fund fights infectious diseases, whereas Switzerland promotes family medicine.
The third largest recipient in the region is Uzbekistan, which is also puzzling considering its political system and comparatively higher GDP. The largest donors in this country are the World Bank, South Korea, the Global Fund, the United States and Japan. Similar to previous states, the World Bank targets general service improvements. Uzbekistan has strong economic cooperation and diplomatic relations with South Korea since 1992, including the free economic zone, projects on mining, logistics, transport and IT. Economic ties contributed to financing the health care. South Korea has minor representation in other countries of the region, limited to dental training, oncology and medical equipment provision, but in Uzbekistan South Korea supports hospital management, orthopedics, health care personnel training, equipment supply, and diagnosis improvement. Other three donors, namely the Global Fund, the United States and Japan focus on infectious diseases, child health and provision of medical equipment.
The next to the last recipient of development aid to healthcare is Kazakhstan. Kazakhstan has higher a democratic index in comparison to Uzbekistan and Turkmenistan. Natural resources of Kazakhstan ensured its highest GDP per capita in the region and decreased its dependence on foreign aid. The largest top five donors in Kazakhstan are the United States, the Global Fund, Japan, the United Arab Emirates and the Islamic Development Bank. The Global Fund targets the infectious diseases. Similar to other countries in the region, Japan in Kazakhstan provides medical equipment, emergency care and hospital renovation. The Islamic Development Bank provides renovation and equipment of surgery center, whereas the United Arab Emirates finance hospital construction. The United States, as the largest donor in the country, targets primary health care, child health and infectious diseases.
The least recipient of the assistance in the region is Turkmenistan. The country has the lowest democracy index and the second highest GDP per capita in the region. However, low development assistance to the country could also be explained by the closed system of the state. The Presidential Resolution (2013) requires coordination and control of foreign technical, financial assistance, humanitarian aid and grants. The top five donors in Turkmenistan are the United States, the Islamic Development Bank, Japan and the Global Fund, and UNICEF. The United States operates in Turkmenistan since 1995 and implements projects on infectious diseases, primary health care and child health. The Islamic Development Bank finances diagnostic centers, Japan targets infectious diseases, child and maternal care and provides medical equipment. The Global Fund focuses on infectious diseases, whereas the UNICEF – implements maternal and child care projects. The amount of the development assistance in total and healthcare in particular in Turkmenistan is the lowest in the region.
Why do some countries receive more, whereas others considerably less? Political system and economic wellbeing of the recipient potentially explains aid allocation differences across the countries, particularly in relation to Kyrgyzstan and Tajikistan. However, the third largest recipient, Uzbekistan, is among the least democratic in the region. I argue that in addition to donor considerations, position of the recipient state, its ‘openness’/ ‘closedness’ to assistance matters. Thus, development aid to Uzbekistan increased President’s statement (2011) urging for finding low interest rate credits and grants to enhance healthcare reforms. Similarly, Kazakhstan and Turkmenistan, in addition to relatively high GDP are distinguished by positioning themselves as donors, rather than recipients of the assistance or as a self-sufficient country without need for assistance.
Implications for Policy Makers
There is limited data on development aid, its distribution and allocation across and within the countries in Central Asia. Awareness of ‘who does what?’ is essential to aid coordination and non-duplication of activities. Using the data on development assistance to healthcare, this article overviewed allocation patterns across the countries. It also highlighted the top five donors in healthcare and their activities in each recipient state. Further analysis of donors’ impact requires more comprehensive data that are lacking at the moment. For instance, the OECD CRS database does not cover ‘emerging’ donors, such as Russia, China and Turkey. Meanwhile, their role in Central Asian region is increasing. Theoretically, information on ongoing donor activities can be obtained from the recipient countries, but relevant agencies are unlikely to collect and retain consistent data for longer period due to limited institutional capacity. Supporting the recipient states and other donors in establishing new or expanding existing databases could be one of the first steps towards aid effectiveness and its sustainability over time.
[1] The framework for coordinating and managing development assistance
Consulted Literature
Hoeffler A. and Outram V. 2011. Need, merit, or self-interest – what determines the allocation of aid? Review of development economics 15(2), 237-250. Available at: http://onlinelibrary.wiley.com/doi/10.1111/j.1467-9361.2011.00605.x/epdf
Ulikpan A., Mirzoev T., Jimenez E., Malik A., Hill Peter S. 2014. Central Asian Post-Soviet health systems in transition: has different aid engagement produced different outcomes? Global Health Action. 1-18. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4166545/pdf/GHA-7-24978.pdf
Hoen H.W. 2010. Transition strategies in Central Asia: is there such a thing as “shock-versus-gradualism”? Economic and Environmental Studies 10(2). 229-245. Available at: http://ees.uni.opole.pl/content/02_10/ees_10_2_fulltext_04.pdf