Trump's aid cuts signal urgent need for sustainable healthcare solutions in South Africa

11 Feb 2025

By facilitating knowledge-sharing between organisations that have successfully reduced external funding dependence and those seeking to do the same, we can build on proven approaches to sustainable healthcare delivery.

A challenge in global health funding has exposed a fundamental vulnerability in our healthcare systems. While recent debates have centred on US President Donald Trump’s executive order regarding foreign aid to South Africa, the temporary exemption of Pepfar (President’s Emergency Plan for Aids Relief) programmes until April 2025 through a 90-day waiver merely masks a deeper systemic problem.

The waiver preserves critical services — from HIV testing and treatment to prevention of mother-to-child transmission and essential administrative operations — but its temporary nature reveals a troubling reality about global health security.

Pepfar, launched by President George W Bush in 2003, has made significant contributions to HIV prevention and treatment. The programme has transformed healthcare approaches, providing critical support to communities struggling with the HIV epidemic.

However, Pepfar’s success reveals an important challenge: millions of lives are substantially influenced by funding from donor nations. While the current waiver maintains lifesaving services like TB treatment, laboratory services, and the procurement of essential medicines, its limited time frame creates uncertainty for healthcare providers and patients alike.

The fact that such important health services can be subject to political decisions made in distant capitals highlights not just the complex dynamics of international health support, but also the precarious nature of relying on externally funded healthcare systems.

Implications

The implications of this situation extend beyond healthcare delivery — it strikes at the heart of our constitutional democracy. Former Constitutional Court Justice Edwin Cameron, a prominent HIV/Aids activist and himself openly living with HIV, has articulated that access to healthcare is fundamentally intertwined with the right to dignity and equality under our Constitution.

Through his jurisprudence and advocacy, he has emphasised that any regression in HIV/Aids treatment access represents not only a public health concern but a constitutional matter that affects the basic human rights of our most vulnerable citizens.

The current funding uncertainty disproportionately affects vulnerable populations, putting pressure on decades of legal precedent establishing that healthcare access must be equitable and non-discriminatory.

This principle was highlighted in landmark cases like Minister of Health v Treatment Action Campaign (2002), in which the Constitutional Court affirmed the government’s obligation to ensure accessible HIV treatment.

The present situation warrants careful attention as it could potentially challenge these hard-won constitutional protections, requiring vigilance to maintain the progress South Africa has made in healthcare rights.

Building a sustainable future

At Khulisa Social Solutions, despite not receiving direct Pepfar funding for more than 15 years, we acknowledge that this crisis necessitates systemic change in line with our constitutional obligations. The current situation mirrors past struggles where political decisions threatened essential healthcare services.

Drawing on South Africa’s network of healthcare organisations, we propose strengthening the informal collaboration among existing civil society organisations, healthcare providers, and community initiatives that are already doing vital work across the country.

By facilitating knowledge-sharing between organisations that have successfully reduced external funding dependence and those seeking to do the same, we can build on proven approaches to sustainable healthcare delivery.

This collaborative network would focus on sharing resources, expertise, and successful funding strategies — from community health funds to social impact bonds — while maintaining the independence and unique strengths of each participating organisation.

Rather than creating new structures, this approach leverages and connects our existing healthcare ecosystem’s capabilities, helping organisations support each other in developing sustainable, locally driven solutions that fulfil our constitutional healthcare obligations.

The current Pepfar funding situation presents an opportunity to address longstanding vulnerabilities in our health system. This moment isn’t just about maintaining current services — it’s about building a healthcare system that truly serves our people, protected by strong legal frameworks and sustained by local resources.

After two decades of Pepfar support, South Africa must break free from the cycle of international funding dependency while strengthening our commitment to constitutional healthcare rights.

Human rights principles

Future decisions about our healthcare system must be grounded in human rights principles and shielded from political instability. Only then can we ensure that decades of progress in combating HIV/Aids will endure, independent of external political influences.

At Khulisa, we are looking forward and proposing a solution that reduces reliance on international funding. By leveraging South Africa’s network of healthcare organisations, we aim to strengthen informal collaborations among civil society organisations, healthcare providers, and community initiatives.

This approach focuses on sharing resources, expertise and successful funding strategies, ensuring that our healthcare system remains resilient and sustainable.

By building on local strengths and fostering independence, we can protect our progress in healthcare rights from the whims of international political decisions. DM

Dr Lesley Ann van Selm is the founder and managing director of Khulisa Social Solutions, a non-profit organisation dedicated to addressing social challenges through innovative community-based interventions. Deepna Desai is an attorney and volunteer at Khulisa Social Solutions.

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Maverick Citizen

Implications

Building a sustainable future

Human rights principles