An Executive Order from the United States President halting foreign aid for an initial 90-day review period, amongst others to South Africa, has had far reaching implications around the world. South Africa has in addition been more specifically targeted with a further Executive Order indicating that all financial transfers to South Africa are halted. The major health implication for this country was funding allocated via PEPFAR and USAID for a wide spectrum of health related initiatives many of which are focused on programs supporting people living with HIV and AIDS. The sudden and largely unexpected actions of the US President have caused chaos and uncertainty. While it will be argued by the new US Administration that some aid programs that have been funded through these agencies are now not a priority for America, this action has in effect reneged on signed agreements entered into in good faith. There was a measure of relief when it was announced that some PEPFAR funding would be reinstated in term of a “waiver’ allowing funding for “life saving and humanitarian aid” to continue.
The actions of the United States President described as mercurial and maddening by one political commentator have evoked angry and emotional responses. The consequences starkly illustrate the consequences of dependency on donor funding to resource programs essential to healthcare delivery in this country. The President’s Emergency Plan for AIDS Relief (PEPFAR) was introduced in 2003 with significant bipartisan support by then American President George Bush, a Republican as is President Trump, in response to the emergency of the increasing devastation caused by the rapid spread of AIDS mostly in Africa. President Bush describes in his book, Decision Points1, the impact that his visits to Africa had on him before and during his presidency where he personally experienced the impact of HIV and AIDS on the populations of the countries that he visited. This was the stimulus to start a process that lead to him signing PEPFAR into US law in 2003. In a poignant aside Bush in his book relates how on his African visit subsequent to that signing in 2003 in “South Africa, where nearly five million lived with HIV, I urged a reluctant President Thabo Mbeki to confront the disease openly and directly”. This he contrasted with his interaction with the then President Feastus Mogae of Botswana who he indicated pledged to utilise PEPFAR funds to continue the “impressive effort he had begun to fight the disease“.
South Africa has benefited to date by an estimated R140 billion and was in line to continue to receive significant continued funding through both PEPFAR and USAID funding streams. Currently an estimated 15 000 people are employed by programs in South Africa based on this funding stream. It was, however, at its inception an emergency plan and an assumption should have been that over time that the South African health budget would have been structured such that a mitigation strategy would exist to address a reduction or, as now has occurred, albeit hopefully temporarily, cessation of this funding stream.
From the American perspective, faced with trillion dollar budgetary deficits, it is understandable that resistance has grown to continue with indefinite funding of this nature. While it must be accepted that it is at the discretion of America to do so, however the manner in which it has been done is questionable. The sudden withdrawal of funding of this nature that has existed across four presidential terms without warning, other than statements made by a then Presidential candidate in his election campaign, has not allowed for even emergency contingency measures to bridge the gap created. It is a sobering lesson that dependency on donor funding, especially for key programs that should be regarded as a core government function is an unhealthy situation.
This begs the question as to why government funding for HIV/AIDS for the last 23 years was not sufficiently prioritised to ensure that in a measured and responsible manner the PEPFAR funding received initially to address a crisis situation in 2003 was not replaced by funding from a health budget derived from the South African national fiscus? Although the effective antiretroviral therapy now available, was not available when PEPFAR was instituted and effective programs to prevent mother to child transmission were in their infancy, a country such as South Africa should have long integrated the funding of these programs into the national health budget. Understandably with the largest antiretroviral treatment program in the world, this was and remains a formidable challenge, but a challenge that should have been met. South Africa should not be in a situation in 2025 where 17% of the funding for these programs relies on donor funding.
However, since the current situation has now been brought about by the actions of the US President, as inopportune and unjustified as they may seem, rather than railing against his unpredictable actions, the country should use any breathing space afforded by the apparent “waivers” granted and move as rapidly as possible to replace this situation of dependency with one of self sufficiency. It will not be easy but in my view ongoing reliance on future funding from any American based government agency would be very unwise. The temptation may be to seek alternative funding from alternative external funding agencies but given the uncertain political environment world-wide although this may offer a temporary respite the lessons now learned with American aid should not go unheeded.
There is indeed a place for donor funding but as attractive as it may seem initially, in principle donor funding should be only utilised for projects that are time bound and do not form part of the ongoing core business of government. Salaries for health staff providing basic health services in particular should not be based on donor funding other than where this can be justified as part of an operational research project which in itself should have a clear and agreed end point. If justified, a firm commitment from the recipient government department should exist that funding for the recurrent staff and operational costs will be available once the project is terminated.
Painful as it has been and may be into the immediate future, a country such as South Africa should not be dependent on donor health funding. South Africa has the natural resources, people, expertise and potential for economic growth to be able to afford the health services that the country requires without the crutch of ongoing donor funding. Others in Africa are not so fortunate. Whatever we may think of the current American administration that is a matter for the American people, let us ensure that we as a country overcome the hurdle that has been placed in front of us and progress to a stronger and more self-sufficient future!
