Trump Funding Cuts Won't Sink HIV Program, South Africa Says
South Africa has the world's biggest HIV epidemic and about 17% of the funding for its response has come from America's President's Emergency Plan for AIDS Relief, or Pepfar. President Donald Trump suspended that program in January, leaving a hole of 7.9 billion rand.
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3 hours ago
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Inside SA's multimillion-rand plan to fill US funding void
Health Minister Aaron Motsoaledi recently announced that National Treasury had released roughly R753 million to help plug the gap left by US funding cuts to South Africa's health system. Another R268 million is also being released in the following two years for researchers that lost their US grants. But this may only constitute the first round of emergency funds from government, according to sources we spoke to. The health department is planning on submitting a bid for an additional allocation later on, which will be considered by Treasury. But this will likely only be approved if the first tranche of funding is properly used. So how is the money supposed to be used? To find out, we spoke with officials from the National Treasury, the National Department of Health and the South African Medical Research Council (SAMRC). Money for provinces is for saving jobs at government clinics The current tranche of money comes from Treasury's contingency reserve, which exists partially to deal with unforeseen funding shortfalls. It was released in terms of Section 16 of the Public Finance Management Act. Of the R753 million that's been announced for this year, Motsoaledi stated that R590 million would be going to provincial health departments via the District Health Programme Grant – a conditional grant for funding the country's public health efforts, particularly HIV, TB, and other communicable diseases. Such conditional grants typically give the health department more say over how provincial departments spend money than is the case with most other health funding in provinces. To explain how government officials arrived at this figure, it's worth recapping what services the US previously supported within provinces. Prior to Donald Trump becoming US president on 20 January, the US Agency for International Development (USAID) had financed health programmes in specific districts with high rates of HIV. These districts were scattered across all South Africa's provinces, save for the Northern Cape. The funds were typically channelled by USAID to non-governmental organisations (NGOs), which used the money to assist the districts in two ways. The first is that NGOs would hire and deploy health workers at government clinics. The second is that the NGOs would run independent mobile clinics and drop-in centres, which assisted so-called key populations, such as men who have sex with men, sex workers, transgender people, and people who inject drugs. Following the US funding cuts, thousands of NGO-funded health workers lost their jobs at government clinics, while many of the health centres catering to key populations were forced to close. In response, the health department began negotiations with Treasury to get emergency funding to restore some of these services. As part of its application, the health department submitted proposals for each province, which specified how much money was needed and how it would be used. (Though this only took place after significant delay and confusion). Since Treasury couldn't afford to plug the entire gap left by the US funding cuts, the provincial-level proposals only requested money for some of the services that had been terminated. For instance, funding was not requested for the key populations health centres. Instead, the priority was to secure the jobs that had been lost at government health facilities. As such, the total amount that was requested from Treasury for each province was largely calculated by taking the total number of health workers that NGOs had hired at clinics and working out how much it would cost to rehire them for 12 months. Rather than paying the NGOs a grant to deploy these workers as was done by USAID, the health department proposed hiring them directly. This meant that they calculated their wages according to standard government pay scales, which is less than what these workers would have earned from the NGOs. The total came to just under R1.2 billion for all the provinces combined. Treasury awarded roughly half of this on the basis that the money would be used to finance these wages for six months, rather than 12. This amounts to the R590 million for provinces that was announced by Motsoaledi. If all goes smoothly and this money is used effectively to hire these staff over the next six months, then a new tranche of Section 16 funding could be released in order to continue hiring them. Funds might also be released to fund the key populations health sites. A concern, however, is that the money may just be used by provinces to augment their ordinary budgets. If the funds aren't actually used to respond to the US cuts, then it is much less likely that more emergency funding will be released. At this stage, it is too early to tell how provinces will use the money, particularly given that it appears that at least some of them haven't received it yet. Spotlight and GroundUp sent questions to several provincial health departments. Only the Western Cape responded. The province's MEC for Health and Wellness, Mireille Wenger, said that the funds had not yet been received by her department, but that once they were, they would be directed to several key priority areas, including digitisation of health records, and the strengthening of the primary healthcare system. It's thus not clear whether the province will be using any of the funds to employ health staff axed by US-funded NGOs. In response to a question about this, Wenger stated that 'further clarity is still required from the National Department of Health and National Treasury regarding the precise provincial allocations and conditions tied to the additional funding'. What about research? Of the R753 million that's been released for this year, R132 million has been allocated to mitigate the funding cuts for research by US federal institutions, primarily the National Institutes for Health (NIH). Unlike USAID, the NIH is not an aid body. It provides grants to researchers who are testing new treatments and medical interventions that ultimately benefit everyone. These grants can be awarded to researchers in the US or abroad as part of a highly competitive application process. Researchers in South Africa are awarded a few billion rands worth of grants from the NIH each year, largely due to their expertise in HIV and TB. But over the last few months, much of this funding has been terminated or left in limbo. (See a detailed explanation of the situation here). The R132 million issued by Treasury is supposed to assist some of these researchers. It will be followed by another R268 million over the following two years. The Gates Foundation and Wellcome Trust are chipping in an additional R100 million each – though in their case, the funds are being provided upfront. All of this money – R600 million in total – is being channelled to the SAMRC, which will release it to researchers via a competitive grant allocation system. According to SAMRC spokesperson Tendani Tsedu, they have already received the R132 million from Treasury, though they are still 'finalising the processes with the Gates Foundation and Wellcome Trust for receipt of [their donations]'. ALSO READ | SA, Gates Foundation pledge funds to sustain HIV research after US cuts The SAMRC is also in negotiation with a French research body about securing more funds, though these talks are ongoing. In the meantime, the SAMRC has sent out a request for grant applications from researchers who have lost their US money. The memo states: 'Applicants may apply for funding support for up to 12 months to continue, wind down or complete critical research activities and sustain the projects until US funding is resumed or alternative funds are sourced.' 'The plan,' Tsedu said, 'is to award these grants as soon as possible this year.' Professor Linda-Gail Bekker, CEO of the Desmond Tutu Health Foundation, told us that the hope is that the grants could fill some of the gaps. 'This is a bridge and it is certainly going to save some people's jobs, and some research,' she said, but 'it isn't going to completely fill the gap'. Indeed, the SAMRC has made clear that its grants aren't intended to replace the US funding awards entirely. This is unsurprising given that the money that's being made available is a tiny fraction of the total grant funding awarded by the NIH. It's unlikely that research projects will continue to operate as before, and will instead be pared down, said Bekker. 'It's going to be about getting the absolute minimum done so you either save the outcome, or get an outcome rather than no outcome,' she said. In other cases, the funds may simply 'allow you to more ethically close [the research project] down,' Bekker added. For some, this funding may also have come too late. Many researchers have already had to lay off staff. Additionally, patients who had been on experimental treatments may have already been transitioned back into routine care. It's unclear how such projects could be resumed months later. In response, Tsedu stated: 'For projects that have already closed as a result of the funding cuts, the principal investigator will need to motivate whether the study can be appropriately resurrected if new funds are secured.' The SAMRC has established a steering committee which will adjudicate bids. They will be considering a range of criteria, Tsedu said, including how beneficial the research might be for the South African health system, and how heavily the project was impacted by the US funding cuts. They will also consider how an SAMRC grant could 'be leveraged for future sustainability of the project, personnel or unit', added Tsedu. An endless back and forth The job of the SAMRC steering committee will likely be made a lot more complicated by the erratic policy changes within the NIH. On 25 March, the body sent a memo to staff – leaked to Nature and Bhekisisa – instructing them to hold all funding awards to researchers in South Africa. After this, numerous researchers in the country said they couldn't renew their grants. However, last month, Science reported that a new memo had been sent to NIH staff which said that while South African researchers still couldn't get new grants, active awards could be resumed. Since then, some funds appear to be trickling back into the country, but certainly not all. For instance, Spotlight and GroundUp spoke to one researcher who had two active NIH awards before the cuts. He stated that one of these was resumed last month, while the other is still paused. READ | US funding cuts imperil search for HIV vaccine Bekker also told us that she had heard of one or two research grants being resumed in the last week, though she said the bulk of active awards to South Africa are still pending. 'Where people are the prime recipients [of an NIH grant] without a sub awardee, there seems to be a queue and backlog but some [of those awards] are coming through,' she said. 'But how long this is going to take and when it might come through, we're waiting to hear.' Bekker said a strategy might be to apply for the SAMRC bridging funding and 'if by some miracle the [NIH funding is resumed]', then researchers could then presumably retract their SAMRC application. In the meantime, health researchers will have to continue spending their time working out how to respond to the abrupt and increasingly confusing changes to funding guidelines that have dogged them since Trump assumed office. 'It's such a dreadful waste of energy,' said Bekker. 'If we were just getting on with the research, it would be so much better.'
