The “golden age” of donor assistance, when there was an abundance of donor aid, is over. “It’s decreasing not just for health, but for development broadly” is the stark warning issued by Professor Yogan Pillay, Director of HIV and TB research at the Bill and Melinda Gates Foundation.
“This means the only way to do it is to increase domestic financing or change the way we do business,” says Pillay, speaking at the South African AIDS conference currently underway.
“Instead of looking backwards and how to find more money, we should be looking forward and changing the way we run the programme and the entire primary healthcare system,” says Pillay.
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Prior to the US funding cuts, South Africa funded about 75% of its HIV programme. But, Dr Anna Grimsrud, a senior technical advisor at the International AIDS Society, argues that external funding still made a significant contribution, with PEPFAR providing R6.6 billion annually and the Global Fund R3.2 billion.
Eight months since funding was withdrawn, ‘South Africa must be honest about the funding gap caused by U.S foreign aid cuts’, she says.
“We must stop saying everything is fine. Admitting challenges is not conceding dependence; it’s owning the work ahead,” Grimsrud says.
The U.S President’s Emergency Plan for AIDS Relief (PEPFAR) supported 27 health districts in the country with a high HIV burden, providing services mainly to key populations at increased risk of HIV acquisition. Staff funded by PEPFAR included data capturers, nurses, lay counsellors, and pharmacist assistants. The withdrawal of funding brought all these programmes to an abrupt halt.
A long time coming
But activists say the government should have prepared for an eventual end to donor assistance.
“PEPFAR was here to support the government in some of the challenges that we had early in the days of HIV,” says Yvette Raphael, co-founder and co-director of Advocacy for Prevention of HIV and AIDS (APHA).
“However, some of our government officials and our government saw this as a way of evading their responsibility. And we are now here.”
Raphael, who has a long history of activism sparked by her own HIV diagnosis in the year 2000, argues that PEPFAR’s withdrawal from the country started years ago when the organisation stopped providing food parcels and other forms of support to people living with HIV.
“PEPFAR was never here to stay. Our government must now step up and close the gap.”
How did we get here
South African National AIDS Council (SANAC), CEO Dr Thembisile Xulu, agrees: “We all knew this day was coming.”
Xulu is the chairperson of the HIV leadership forum, which consists of the CEOs of the National AIDS Councils from over 40 countries. The collective has compiled a sustainability position paper where they reflect on how countries got so dependent on donor funding that the withdrawal jeopardises entire programmes.
“We collectively allowed donor funds to create systems outside of our own, leading to overlapping structures designed for donor requirements,” she says.
Xulu adds that, as a country, South Africa has failed to leverage private sector capacity in the form of technology, innovations, and expertise to design a sustainable HIV programme.
These factors have left countries vulnerable as PEPFAR and other programmes reduce support.
What now?
Grimsrud stresses that time is essential to minimise the impact of funding withdrawal.
“We cannot wait to make choices; waiting for stability is like waiting for a train that’s never coming.”
She says the country must identify components of HIV delivery that are essential to maintain, and figure out how to keep these services running more efficiently.
“We must build on our differentiated models of care, putting the people at the centre, supporting self-care, and using these models to drive integration and equity.”
In addition, Grimsrud argues that the country’s budget must align with its commitments.
“We know that the National Department of Health has plans to expand HIV treatment coverage to seven million people as part of the 1.1 million campaign,” she states.
“But the budget we saw only supports a growth from 6 to 6.5 million people over the next three years. That gap between ambition and resources is exactly why prioritisation is so urgent.
“We need to plan realistically, cost honestly, protect what works, and innovate where efficiencies are possible.” – Health-e News
