Martin Luther King, Jr. once said, “Of all the forms of inequality, injustice in health is the most shocking and inhumane.” Health should unite all human beings, as the Global Health Council emphasizes: “When it comes to global health, there is no ‘them’… only ‘us.’”
The world has become a global village, with human movement occurring at an unprecedented rate. As a result, the spread of diseases and their transmission make all people vulnerable. Indeed, when it comes to health, there is no longer an “us” or “them.” The Global North, particularly the United States, is attempting to place health at the centre of geopolitics. However, this approach will have disastrous consequences for people in the Global South and for humanity. It must be stated unequivocally that the U.S. is advancing inequality and injustice — “the most shocking and inhumane”— by using health as a tool of political leverage. This is akin to detonating an atomic bomb, one that will first explode in the Global South before its impact spreads further.
As recent U.S. decisions have shown, South Africa is not spared. The South African government must critically examine the extent and nature of U.S. health funding in the country. If left unaddressed, this issue could snowball into a full-blown catastrophe. Our sovereignty as a nation is paramount. Relying on the benevolence of other nations limits our freedom. As Henri-Frédéric Amiel wisely stated, “In health, there is freedom. Health is the first of all liberties.” The South African government cannot evade its constitutional responsibility to provide healthcare for its people. As an Arabian proverb reminds us: “He who has health has hope, and he who has hope has everything.”
The South African government must uphold its duty to ensure health for all so that we may have hope for the future. When discussing South Africa’s healthcare expenditure, the focus is often on government spending in the public healthcare system and private sector expenditure funded through medical scheme memberships and out-of-pocket payments by both scheme and non-scheme members. The total expenditure across both sectors is estimated at around R500 billion per annum, split roughly equally between the two, despite the private sector serving only about 16% of the population. In 2024/2025, the total government spending was R272 billion. Now, with the sudden loss of foreign funding from USAID and U.S. PEPFAR, it is crucial to assess the gaps this has created and determine what is needed to bridge them.
The Overlooked Contribution of NGOs to Healthcare Funding argue that healthcare in South Africa receives a significant additional budget injection from a sector often excluded from budget analyses—the NGO sector. This includes organizations involved in health service delivery support and health research, particularly those supporting HIV and TB programs.
These funds flow directly from foreign funders into NGOs, either for independently identified projects or through collaborations with the Department of Health. These initiatives expand the scope of healthcare services available in the country, often with substantial impact. PEPFAR funding alone reportedly contributed around half a billion US dollars to South Africa in 2021, which, at current exchange rates, amounts to approximately R9 billion. This funding supports efforts to reduce HIV and TB transmission, identify new cases, initiate treatment, and sustain long-term program support to keep patients on treatment.
As stated by the U.S. Embassy: “U.S. PEPFAR supports more than 100 South African organizations working in more than 1,500 facilities to reach our shared goals of expanding lifesaving treatment and preventing new infections.”
According to UNAIDS: “Due to the U.S. Government’s freeze on foreign assistance,15,374 PEPFAR-funded HIV response staff across national and 27 priority districts have been affected, with an estimated HR cost of ZAR 4.6 billion (~USD 250 million). Approximately 222,000 people living with HIV, including 7,445 children under the age of 15, now face disruptions in their daily antiretroviral therapy supplies.” These are critical support services, particularly in a country like South Africa, which bears one of the highest HIV and TB burdens in the world. The sudden loss of this support would have devastating consequences for patients and could severely impact the control of the HIV and TB epidemic both locally and globally.
It is commendable that the Minister of Health has launched a campaign to initiate treatment for another 1.1 million people living with HIV (PLHIV) this year, aiming to bring South Africa closer to controlling the epidemic by 2030. However, we cannot ignore the reality that both the HIV and TB programmes are like leaking vessels—constantly receiving newly infected patients while simultaneously losing enrolled patients from care due to a variety of well-documented factors. A Call for Sustained and Strategic Support
For these programs to succeed, they require continuous and aggressive support through education and treatment campaigns, including:
• The distribution of condoms
• The initiation of at-risk individuals on pre-exposure prophylaxis (PrEP)
• Encouraging widespread HIV and TB testing
• Prompt initiation of treatment for all who test positive
• Ensuring patient adherence to treatment until they achieve viral suppression and stay virally suppressed, preventing further transmission
If we drop the ball now, we risk losing the progress we have already made. The true scale of this crisis cannot be underestimated, nor can the level of effort required to minimize the shock to our healthcare system. This is not just about funding; it is about the institutional memory that NGOs have built over decades - knowledge of what works and how to scale it up. It is also about protecting the rights of patients
who face stigma and discrimination within healthcare facilities and their communities. Furthermore, it is about the trained healthcare workers who now sit at home unemployed while patients desperately need their services.
What Needs to Happen?
We urgently need to establish a Healthcare System Impact Task Team to assess and address the current and potential future impact.
This task team should include:
• The Office of the Premier (Lead)
• The Department of Health, led by the HoD, including:
• District Health Services and District Management Teams
• Strategic Health Programs / HAST Unit
• Heads of all NGO support partners in the province
• Pharmaceutical Services and other relevant stakeholders
• National Treasury
• The Department of Social Development (DSD)
• The Department of Education (DOE)
• Higher Health Key Actions to be Executed
1. Map all support previously provided by PEPFAR-funded NGOs.
2. Identify services for immediate takeover by Department of Health (DoH)
3. Determine critical services that remain uncovered.
4. Explore and engage other potential partners to mobilize interim support.
5. Develop a transition plan to integrate these services into DoH facilities and staffing structures fully.
6. Explore innovative strategies to maximize limited resources, such as:
• Expediting the six-month medication dispensing model (CCMDD) to free up healthcare workers for other tasks.
• Partnering with community-based organizations to sustain outreach services.
• Assessing the potential involvement of private sector stakeholders, such as local GPs, private hospitals, and clinics.
7. Formulate a response strategy with SMART (Specific, Measurable, Achievable, Relevant, and Time-bound) objectives.
8. Develop a Theory of Change framework and a robust Monitoring; Evaluation framework.
9. Plan a joint session with broader community stakeholders to implement a coordinated, “divide-and-conquer” approach to address critical gaps.
10. Operationalise the strategy down to facility level, ensuring alignment with local war rooms and the established M&E framework.
This is a defining moment for South Africa’s healthcare system, particularly for KwaZulu-Natal and our HIV & TB response. We must act swiftly, strategically, and collaboratively to protect the gains we have made in combating HIV and TB. Failure to do so will set us back significantly, with dire consequences for public health. The time for action is now.
Author:Dr Velile Ngidi, Public Health Medicine Specialist.
