Tamsin tests the waters

Just eight months after the United States cut its President’s Emergency Plan for Aids Relief (Pepfar) funding to South Africa and other countries, the local health sector is facing another reduction in international aid support, this time from the Global Fund.

The Global Fund is a worldwide partnership geared towards defeating Aids, tuberculosis (TB) and malaria. However, recent turbulence in the financing landscape for international health programmes has left it with a gap between its grant commitments and available resources. In May, it announced that it would be “reprioritising and revising” its allocations to countries in its seventh grant cycle, which kicks off on 1 October for South Africa.

Read more in Daily Maverick: ‘The axe has fallen’ — Trump’s USAID issues notices to terminate funding for key health programmes across SA

What does this mean for South Africa?

In a letter dated 30 June and addressed to Minister of Health Dr Aaron Motsoaledi and chairperson of SA’s Global Fund Country Coordination Mechanism, Dr Thembisile Xulu, the Global Fund confirmed the reduction in South Africa’s allocation, calling it a “difficult and unavoidable decision”.

South Africa is facing a US$77,1-million (R1,3-billion) reduction in its Global Fund allocation for Grant Cycle 7, which covers a three-year period from 1 October 2025 to 31 March 2028. The fund had initially committed US$479,5-million to the country, but this was reduced to US$402,4-million in light of resource constraints.

“The Global Fund Board has discussed and endorsed a reprioritization [sic] approach to guide this process, with a view to ensuring that the organization is able to best support countries and communities to preserve and enable access to lifesaving interventions,” stated the letter.

The implementation of the funding is guided by South Africa’s Country Coordination Mechanism (CCM), a partnership composed of all key stakeholders in the country’s response to HIV and tuberculosis. The CCM is responsible for submitting proposals to the Global Fund based on priority needs at the national level, and nominating the entities that serve as “principal recipients” of grants.

The four principal recipients of the Global Fund allocation for Grant Cycle 7 are the National Department of Health (receiving 55%); the Networking HIV/AIDS Community of South Africa (19%); the Aurum Health Institute (13%); and the Centre for Community Impact (13%).

The principal recipients receive proposals from other HIV and TB community-based organisations as part of the selection process for sub-recipients of grant funding, a process that has been underway for the past few months.

How will this impact our embattled HIV sector?

The funding cuts triggered a “reprioritisation” process that included focusing on high-burden HIV districts and more investment in “high-impact interventions”, according to Xulu, who also serves as the CEO of the South African National Aids Council (Sanac).

“As part of efforts to maximise resources for service provision in the face of budget cuts, programme overheads have been minimised, which then meant a reduction in the number of sub-recipients,” she told Daily Maverick.

Despite the reduction in the overall Global Fund allocation, the number of areas receiving grant funding has increased. The reprioritisation process included the addition of districts that were previously supported by Pepfar.

“For the Adolescents and Youth Programme (AYP) in particular, high-burden sub-districts have increased from 14 to 19. Similarly, key populations coverage has increased by two districts instead of a reduction – the [Global Fund] has also reworked the service delivery model to utilise outreach teams to cover all districts as per the previous grant allocations,” said Xulu.

For the TB programme, the districts receiving grants have remained the same.

Key populations are groups that are particularly vulnerable to HIV and often lack adequate access to services, such as men who have sex with men, sex workers, transgender people and people who inject drugs.

Read more in Daily Maverick: Key populations in Cape Town battling to access HIV state clinics after Pepfar aid cuts – study

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“The Key Population programme has been expanded to two districts – City of Johannesburg and City of Cape Town, which were initially supported by Pepfar but discontinued due to the US Stop Order. These two districts have been added because they both fall under high-burden districts, and the Global Fund and Country Coordinating Mechanism wanted to ensure that there is continuity of services,” said Xulu.

What are the concerns from community-based organisations?

There have been some concerns from civil society organisations about the levels of community engagement in the Global Fund reprioritisation process, particularly given the tight timelines for rolling out the changes.

A civil society-led analysis of the process was led by an independent cohort of organisations and networks from around the world, including the Eastern Africa National Networks of AIDS and Health Service Organizations; the Community Health & HIV Advocates Navigating Global Emergencies; the Coalition to build Momentum, Power, Activism,

Strategy & Solidarity; and the Middle East Harm Reduction Association.

The study’s survey engaged respondents from across a number of Global Fund regions, including southern and eastern Africa; central Africa; the Middle East and north Africa; Latin America and the Caribbean; and eastern Europe and central Asia.

The study, published on 10 September, found that access to information around the reprioritisation process was highest among “non-community CCM members”, such as government representatives. In this group, 100% of respondents were aware of the reprioritisation process, and 87% were aware of the final cuts.

However, awareness was lower among CCM members who were

community representatives, with 6% not knowing about reprioritisation and more than one-third (37%) not knowing which activities were cut.

“Outside of the CCM, access to information was lower. Among

community members engaged in Global Fund processes, a high proportion (84%) knew about reprioritisation, but just half received information about the changes to programme budgets,” stated the study.

Will Global Fund contracts be finalised by 1 October?

Another concern raised by community-based organisations was whether the selection process for sub-recipients would be finalised by the deadline of 1 October.

Eugene van Rooyen, legal and policy advisor at the nonprofit Sex Workers Education and Advocacy Taskforce (Sweat), said that the call for sub-recipient proposals from sex worker programmes closed in the second week of September.

“We foresee challenges with that. We don't know how people are going to be up and running so fast,” he said.

Emily Craven, CEO of Sweat, said: “I think one of the problems is that civil society, who are a big part of Sanac and the CCM, are unhappy about the way the process has rolled out, and I don't blame them. There's definitely been some skipped steps in terms of consultations and such. I don't really blame the [principal recipients] either. They were presented with timeframes that were pretty crazy.

“One of the things that this massive reduction in the number of [sub-recipients] means is that a lot of small organisations located in certain districts, who were the sub-recipients, are going to be cut out, to be replaced by bigger organisations who are going to run programmes. And that's going to cause great unhappiness.”

Xulu noted that the CCM was not in control of the timeframes for the Global Fund reprioritisation process, as those were defined by the fund itself. She added that the CCM did “everything in its power” to ensure adequate consultations were done within the “extremely narrow window” for implementing the reduced allocation, including sector-based consultations.

The selection of sub-recipients was “currently underway”, with the expectation of being completed by the end of the month, continued Xulu. However, she noted that if the process was not finalised by 1 October, it would continue until all recipients were appointed, as had been the case in previous grant cycles.

“Although contracts may be finalised by 1 October, funding disbursements to [sub-recipients] take longer owing to the necessary due diligence that must ensue. Those who may not have been awarded contracts will institute catch-up plans for programme implementation and [have] their funding back-paid. This has also been a practice in previous grant cycles,” she said.

When asked what a gap in Global Fund support could mean for HIV organisations and the people relying on their services, Xulu responded that principal recipients worked closely with government facilities to ensure sustainability in the event of a discontinuation in funding.

“[People living with HIV] are being referred to government health facilities for continuum of care,” she said.

“For some key populations where the [Global Fund] provided funding for outreach services, such as harm reduction interventions for people who use drugs, such gaps will be addressed through catch-up plans (where there may be delays) as soon as the [sub-recipient] contracting processes are concluded.”

What does this mean for the future of the Global Fund?

In a press release dated 22 September, Doctors Without Borders (Medecins Sans Frontieres/MSF) noted that nearly $3-billion of the $6-billion the US had pledged to the Global Fund to fight Aids, tuberculosis and malaria for 2023 to 2025 remained unfulfilled. Key donors, including the US, had yet to announce pledges for the fund’s next three-year cycle.

MSF said it was “deeply concerned” about the impact of weakening support for the Global Fund.

“The Global Fund has long played a fundamental role in supporting fragile health systems across Africa, Asia, Latin America and beyond… Without substantial pledges in the coming weeks and months, decades-long progress in reducing illness and death could be reversed,” it said.

Daily Maverick reached out to the National Department of Health about the Global Fund reprioritisation process but had not received a response at the time of publishing. DM