One year after USAID and PEPFAR funding cuts, South Africa is rebuilding its healthcare system from within

The theme of this year's World Health Day is "Together for health. Stand with science." It’s a call from the World Health Organisation to protect lives, rebuild trust, and secure a healthier future.

Just over a year ago, massive funding cuts put this future at risk – on 26 February 2025, 90% of global projects administered by the United States Agency for International Development (USAID) under the US President’s Emergency Plan for AIDS Relief (PEPFAR) were terminated. World Health Day on 7 April offered a moment to reflect on this decision and how shifts in development finance are reshaping global healthcare.

Government, civil society and social investors are working together to fill in the gaps. As we do, we’re also grappling with what it means to create a resilient healthcare system from within.

The Impact of PEPFAR Funding Cuts

PEPFAR has been a critical part in South Africa’s HIV response for over 20 years. These programmes provided resources to fight the spread of HIV when it was one of the leading causes of death in Southern Africa and contributed to bringing the number of new HIV infections down by 67% over the last two decades.

In February 2025, PEPFAR funding accounted for R7.9 billion (17%) of South Africa’s R46.8 billion HIV/Aids response. The abrupt withdrawal of much of this support put thousands at risk. PEPFAR and USAID funding to 70% of healthcare facilities stopped. Clinics closed, and key services were scaled back.

All gender-based violence and critical HIV prevention programmes linked to this funding were terminated. Essential research and clinical trials stalled and over 8 000 people lost their jobs. This shift threatened to undo decades of progress in our battle against HIV, but the public and private sector response showed our resilience.

A Coordinated Response Emerges

Minister of Health, Aaron Motsoaledi, reassured South Africans that around 74% of South Africa’s HIV response was already supported by domestic resources and 90% of antiretroviral treatment (ART) was financed by national government.

The Department of Health received an additional R753 million from the National Treasury for a treatment awareness campaign. Funders and civil society stepped up too.

The Bill and Melinda Gates Foundation and the Wellcome Trust each pledged R100 million in funding towards research on condition that each R100 million be matched by R200 million from the Treasury. UNAIDS issued urgent calls for a coordinated donor response, and supported advocacy and technical efforts, while Elma Foundation provided emergency bridging grants to NGOs.

Doctors Without Borders (MSF) provided independent resources to keep some HIV and TB clinics operational.

Strengthening Systems Through Collaboration

Taking lessons from the COVID-19 crisis, UNAIDS and SANAC called for the creation of a “South African Solidarity Fund Against HIV” modelled after the COVID-19 Solidarity Fund.

Global Fund has maintained its 7% HIV contribution and opened discussions on reallocating funds or releasing emergency reserves. The Fund also recently supported the delivery of the first 37 920 doses of Lenacapavir to South Africa, an innovative preventative treatment that represents a broader shift towards more accessible, diverse and person-centred strategies.

Despite this, consequences are still being felt across an already strained healthcare system, from large-scale initiatives to rural clinics. Staffing shortages persist, and healthcare workers and NPO staff are facing unprecedented levels of burnout.

Key populations, like LGBTQIA+ people and sex workers, have, in many cases, lost access to specialised care and treatment without stigma. We’ve shown what we’re capable of and solutions require continued collaboration.

The Critical Role of Social Investment

As we navigate this landscape, we're reminded that building a resilient South African healthcare system means reducing dependence on foreign aid and turning our efforts inward.

We are shifting from a “charity-based” paradigm to one of self-sufficiency and internal collaboration. We are seeing this play out across numerous sectors, including healthcare where social investors are uniquely positioned to accelerate collaboration and close the remaining gaps in the country's HIV response.

We also need to find ways to build a healthcare sector that is resilient enough to prevent these gaps in the first place. We need strategic social investment in systems-level change.

Increase Corporate Investment in Healthcare

South Africa’s long history of corporate social investment has created robust systems for mobilising resources independently of international aid. The solutions are there, but the private sector is falling short.

According to UNAIDS, in 2025 2% of South Africa’s HIV response was private sector-funded. The percentage of companies investing in health increased from 36% to 46% in the same year but private sector investment remains limited.

Declining funding risks a substantial increase in new infections and mortality. Increased private sector investment would let healthcare organisations continue operations regardless of fluctuations in global funding. We cannot afford cracks in our national HIV response and corporates are crucial to preventing them.

Strengthen Local Organisations and Systems

Community-based organisations (CBOs) drive change on the ground. Funding community initiatives means creating robust systems at the local level. It recognises the agency of communities and builds on their existing assets to maximise impact.

The Discovery Fund's Community Health Programme is an example of this in action. Through our work with the Discovery Fund, we’ve seen how organisations like the HIV and Aids educational and treatment programme Hlokomela have expanded and developed funding models that supplement donor funding.

The localisation of interventions supports continuity and sustainability. It also recognises that those who are part of these communities know the best way to help them thrive.

Cross-Sector Collaboration

The withdrawal of USAID and PEPFAR funding reflects a broader era of fragmentation. Now, more than ever, collaboration is essential.

Intentional public-private partnerships are needed to improve HIV prevention and treatment in communities that already have limited or over-burdened health facilities. Partnerships prevent duplication of efforts and optimise the use of available resources for more scalable and meaningful outcomes.

Effective partnerships require joint strategies around ecosystems, co-funding, and structured models of collaboration. Collaboration ensures that finite resources are used to meet immediate needs. It’s the best way to more effective social investment and impact that lasts.

Building a Resilient Healthcare Future

Just over a year ago, we were confronted with the fragility of a healthcare system reliant on foreign aid. The coordinated response from the public and private sectors and civil society showed the potential for self-sufficiency.

We’re still working towards a stronger domestic health financing model as we bridge the gaps. The only way we’re going to get there and create lasting change is through strategic investment, localisation of interventions, and cross-sector collaboration.