The Africa Centre for Inclusive Health Management’s director, Dr Munya Saruchera, was interviewed on Smile 90.4 FM about the PEPFAR/USAID funding cutback and review. In a news interview on Thursday 30 January, he highlighted several key implications.
SMILE: Given the significant role of US foreign aid in South Africa’s health sector, particularly for programmes addressing HIV/Aids, TB and other critical health challenges, what immediate disruptions do you anticipate during this 90-day review period? How might this impact service delivery and access to essential medication for vulnerable populations?
SARUCHERA: The implications are huge for SA’s HIV/Aids counselling, testing and treatment services, given the prevalence rate of 12,7% and the (still too high) infection rate of 19%. South Africa spends R44,4 billion on HIV counselling, testing and treatment per year, and PEPFAR contributes 17% of this budget. The balance comes from domestic budget and other donors like the Global Fund to Fight Aids, TB and malaria.
Specific areas and issues that will be adversely affected include:
- the number of people that will lose access to ARV treatment – SA, Mozambique, Kenya, Tanzania, Uganda, Nigeria and Zimbabwe will be some of the most affected
- health professionals, especially the clinical workforce, with SA being one of the most affected countries in this regard, alongside Malawi, Kenya, Uganda, Tanzania, Nigeria and Mozambique
- pregnant women and babies acquiring HIV or already infected (including prevention of mother-to-child transmission) – SA alongside Zambia, Mozambique, Uganda, Tanzania are among the most affected
- orphans and vulnerable children, with the most affected countries being Nigeria, Kenya, Uganda, Tanzania and Zambia
- cervical cancer, of which the most affected countries include Zimbabwe, Zambia, Kenya, Mozambique and Tanzania
- sexual and gender-based violence – rape kits, HIV testing, post-exposure prophylaxis (PEP) and other related service, with Kenya, Uganda, Tanzania, Nigeria and Mozambique being the most dependent on PEPFAR support for this aspect
- HIV testing services, mostly affecting SA, Nigeria, Mozambique, Uganda and Tanzania. There will be delays in the communication chain from the USA to the villages and towns on the ground where the implementation happens and the work is done. This will cause immense disruptions of the treatment programme, also affecting the personnel that implement the programmes
Given the era of multilateralism, regionalism, globalisation and polycrisis, we should be cautions to balance individual and collective interests by not over-essentialising SA or any other country at the exclusion of others in as much as we have different and individual national needs, context and challenges. The big brother mentality is often a source for downfall in the times we are now experiencing and moving towards.
SMILE: Beyond the immediate 90 days, what are your concerns regarding the potential long-term effects of this funding pause and review? Could this lead to a restructuring of US health aid to South Africa, and how might that affect the sustainability and efficacy of existing programmes?
SARUCHERA: There will likely be a restructuring of health aid, trade and security, among other issues, given the USA’s geopolitical context and interests, especially under Donald Trump. SA’s Israel-related court case, support for Palestine and Russia, as well as its presence in the DRC are some of the issues in the backdrop of the new era of relations with the USA. The return of Ebrahim Rasool as SA’s ambassador to the USA could be telling.
SMILE: How can the South African government and local health organisations mitigate the potential negative impacts of this funding pause? Are there alternative funding sources or strategies that can be explored to bridge any gaps? What role can public-private partnerships play in this situation?
SARUCHERA: Implementing the NHI has never been more urgent. The funding development plus other stringent measures and forthcoming drastic changes remind us about the strategic need for facilities like the NHI. That said, a lot still needs to be done to address the implementation challenges and concerns various stakeholders have raised.
SA and other African countries (as an African Union block, because there will be individual country competition) have an opportunity to engage entities like the European Union, Canada, Australia, Japan and China to step into the breach and increase their contributions to the Global Fund, or even to directly plug holes left by PEPFAR using bilateral aid, though such funding may come too late for some people.
This year South Africa assumes the presidency of the G20, which is a pivotal moment in the country’s international diplomatic efforts. This is an opportunity for SA under President Cyril Ramaphosa to demonstrate effective leadership by meeting with leaders of wealthy countries and convincing them to increase spending to support the health systems of African and other poorer countries.
SMILE: Do you think this situation highlights the need for South Africa to strengthen its domestic health financing mechanisms and reduce its reliance on external funding? What specific steps could be taken?
SARUCHERA: Yes, definitely, while SA finances a portion of its own annual health budget (R60 billion in 2024/2025), which is much higher than most LMIC (lower and middle-income countries) and African countries, a significant amount still comes from donors such as PEPFAR and the Global Fund. The complexity of world politics is such that the president who perhaps did more than anyone else to unravel confidence in global rules and norms (by invading Iraq) also championed a programme that has saved many millions of lives.
There is a huge opportunity for African countries, many of which remain too dependent on foreign aid to run their health systems. A country like South Africa should be able to pay for every last cent of its health systems. Corruption and mismanagement have had an inordinate role in making this difficult. Countries like Malawi, Mozambique and others have a long way to go before they can pay their own way for HIV treatment. But pressure from within and outside these countries must be put on their governments to build robust economies capable of delivering tax revenue to spend more on health. In a divided world where nationalist populism is on the rise, on the backdrop of a polycrisis and where African governments remain weak and corrupt, these opportunities should be seized.