President Donald Trump’s executive order, signed on 20 January and published on 26 January, halting US foreign aid funding flows for 90 days, has sent shockwaves across the South African healthcare system.
The order, which includes a freeze on funding from the US President’s Emergency Plan for Aids Relief (Pepfar), has left numerous clinics and Non-Governmental Organisations (NGOs) scrambling to find alternative sources of funding for vital HIV/AIDS medication and support services.
This abrupt halt affects a significant portion of South Africa's HIV/AIDS programmes, jeopardizing the health and well-being of millions. The US is the largest single aid donor globally, and this decision, part of a broader "America First" policy, has immediate and potentially devastating consequences.
The impact is immediate and widespread. Gauteng-based health worker Mary, whose name has been changed to protect her identity, described waking up on Monday to a “stop work order” from her HIV/AIDS organisation. She was forbidden from performing her duties, even providing telephonic support. “I’ve never been told not to go to work before,” she said.
“As a health worker who firmly believes in advocating for patients, I couldn’t sleep last night because I was trying to think of a workaround to enable me to go to work without compromising my colleagues’ future employment. It’s unbelievable. I’m breaching my Hippocratic oath to do no harm and to do good. I’m not there, which is harming people … and I take that oath very seriously.”
This situation is mirrored across the country and globally. Brian Aliganyira, who runs a health clinic for the LGBT+ community in Kampala, Uganda, reported a complete standstill in supplies. His clinic, Ark Wellness Hub, relies on Pepfar for testing kits, medication, and operational costs. “Today is crazy,” he said on Monday.
“We are worried. As I’m chatting with you now, I’m amid lots of emails and trying to find who can stock up our supplies and drugs. Supply chains [are] all affected.” This sentiment is echoed by Asia Russell, executive director of Health Gap, an advocacy group for HIV patients, who stated that clinics worldwide face similar crises. She described the situation as a deliberate act to “sow chaos and confusion, no matter the human cost.”
She warned that a prolonged shutdown would lead to “halting service delivery, firing staff, shutting down clinics, rolling back outreach”. “You don’t recover from that kind of whiplash overnight,” she added.
The scale of the problem is immense. South Africa received approximately US$440 million from Pepfar in the 2024 financial year, representing the largest Pepfar portfolio globally. This funding supported 13,815 direct clinical providers, including doctors, nurses, midwives, and pharmacists. The abrupt cessation of this funding has left many patients at risk of being cut off from life-saving care.
Several health programmes have already announced service suspensions due to stop-work orders, including the Wits Reproductive, Health and HIV Institute’s (RHI) Key Populations Programme, and Engage Men’s Health in Johannesburg. The Wits RHI Key Populations Programme stated in a notice: “our donor, USAID, has served the Wits RHI Key Populations Programme a notice to pause programme implementation. As of close of business tomorrow … we are unable to provide services until further notice. We sincerely apologise for the inconvenience this may cause and remain committed to your health and wellbeing.”
The South African National Department of Health, while yet to receive formal communication from the US government, acknowledges the potential severity of the situation. Foster Mohale, spokesperson for the department, stated that the department is “yet to assess the impact of this, [or] communicate implications and contingency plans.”
Sasha Stevenson, executive director of SECTION27, a public interest law organisation, highlighted the potential for “massively damaging” consequences for South Africa and other African countries. While South Africa's HIV programme is relatively sustainable due to decades of investment from various sources, including Pepfar, USAID, and the Global Fund, Stevenson stressed that this funding is crucial for maintaining progress and preventing setbacks. She noted that the system hasn't faced a funding loss of this scale before, making it challenging to predict the full impact.
The consequences extend beyond direct clinical care. Lynne Wilkinson, a Gauteng-based public health specialist in the HIV/AIDS sector, pointed out that administrative staff in health facilities are also affected by the stop-work orders. The cumulative effect of their absence will be significant, leading to increased patient backlogs and heavier workloads for remaining staff.
Wilkinson explained, “[A patient] might just spend the whole day at the clinic and not be seen today, and then have to come back tomorrow. What happens with these unplanned reductions in people able to do the work is that it just starts piling up. At some point that’ll become crippling, because tomorrow you’ve got twice as many patients, and then the next day you’ve got about three times as many patients. Then half of those patients just decide not to come back because they can’t spend another day in the clinic, and then we’ve lost them off treatment. That means we’ve got five times as much work to try and track them, trace them, encourage them back.”
The broader implications are alarming. Abby Maxman, president of Oxfam America, painted a grim picture for US foreign assistance and those who rely on it. She warned of “life or death consequences for millions around the globe, as programmes that depend on this funding grind to a halt without any plan or safety net.”
She highlighted the critical need for funding for clean water, sanitation, and healthcare, beyond emergency food assistance, which has been exempted from the freeze. The One campaign estimated that nearly 3 million children could be at higher risk of malaria if the president’s malaria initiative is paused for 90 days.
Thomas Byrnes, a consultant specializing in the humanitarian sector, emphasized the far-reaching impact due to the global system's reliance on US funding, which comprises 42.3% of global aid funding according to the UN, and as much as 54% of the World Food Programme’s funding. He described the sudden stop-work orders as “forcing organisations to halt programmes abruptly, leading to job losses and reduction in essential services to vulnerable populations.” The abrupt nature of the freeze, with no grace period, adds to the severity of the situation.
Professor Shabir Madhi, dean of the Faculty of Health Sciences at Wits University, confirmed a "stop order communication" regarding USAID-funded programmes run by the Wits Health Consortium, primarily the Wits Reproductive Health and HIV Institute (RHI). This underscores the widespread impact across various institutions and programmes.
A statement from US State Department spokesperson Tammy Bruce on 26 January indicated that Secretary of State Marco Rubio was initiating a review of all foreign assistance programmes to ensure alignment with US foreign policy under the "America First" agenda. This review, however, offers little comfort to those currently facing immediate service disruptions and potential loss of life. Reports suggest that some Republican senators have long opposed Pepfar's reauthorisation, citing concerns about the programme's alleged promotion of abortions.
The situation in South Africa mirrors a global crisis. Clinics and NGOs worldwide are facing similar challenges, with reports of halted supplies and disrupted services. The 90-day review period offers little solace, as the immediate impact is already devastating.
The potential for a resurgence of HIV and other preventable diseases is a significant concern. The long-term consequences of this abrupt funding freeze remain uncertain, but the immediate effects are undeniably severe, leaving countless individuals vulnerable and at risk. The lack of a clear plan or safety net exacerbates the crisis, leaving healthcare workers and patients in a state of uncertainty and fear.