Calls for self-reliance must not deter SA’s efforts to fight US funding freeze

There is a risk the narrative of ‘going it alone’ will be misused to promote an unworkable NHI model or distance SA from strategic global partnerships.

The US foreign aid funding freeze is not just about dollars and “handouts” — it is about lives, human rights and SA’s enduring role in shaping a more just and effective health system.

While some see this as an opportunity for “self-reliance,” rising anti-American sentiment risks diluting focus on the immediate crisis. Oversimplifying this emergency into binaries of local self-reliance versus global support, HIV-specific care versus broader public health, and US President Donald Trump’s realpolitik versus humanitarian imperatives, also diverts attention from the reality that interdependence, not isolation, is crucial for sustaining life-saving health responses.

US funding supported specialised programmes for key populations in SA, providing safe spaces, social support and human rights advocacy for vulnerable groups. This includes sex workers, migrants, people who use drugs and LGBTQ+ individuals. Due to widespread stigma, legal barriers and other social factors, these groups face a significantly higher risk of HIV and of being denied affordable, respectful and non-stigmatising healthcare within the public system.

Research has extensively documented how some experience unfriendly facility staff, confidentiality violations and denial of services and medication in the public health system. As a result, they often depend on carefully tailored programmes to address their specific needs and the barriers they encounter.

The abrupt termination of funding has severely disrupted and in some cases halted these programmes, creating uncertainty about which services can continue. Lack of communication from a now-decimated USAID department has further eroded trust and sparked fear among both service providers and those who usually rely on these critical services.

It now seems that all money flowing from USAID will cease, and that SA will lose R3.7bn for the period until September 2025. Without adequate support for key populations the global goal of “ending Aids” by 2030, set under the UN Sustainable Development Goals, is increasingly unattainable. Weakening these specialised services jeopardises individual lives and undermines public and global health efforts. In other words, this impact extends beyond direct beneficiaries — over time, the collective health and wellbeing of all in SA will suffer.

Over the past month human rights activists, healthcare workers and lawyers in SA, the US and beyond have fought to keep critical HIV services running, which has included demonstrations, urgent appeals to US officials for clarity on confusing executive orders and waivers, and calls to safeguard programmes that provide HIV treatment and care to over 20-million people worldwide through the US President's Emergency Plan for Aids Relief (Pepfar). Legal action has also been brought. However, the information gaps and confusion on the ground suggest that little has changed.

Against this background, some commentators and aid recipients have claimed that the termination of funding poses an opportunity “to work towards self-reliance” and a push for local organisations to “step up.” These calls overlook the enduring role of SA’s leadership in the global fight against HIV and TB and the vital role international funding has played in strengthening a struggling public health system.

This is an SA story based on much pioneering research and invested time, energy and the commitment of SA healthcare workers, public health experts, activists, civil-society organisations, government and nongovernmental initiatives — made possible, in part, through US and international funding. This is a story where funds have supported those in need of care while helping SA build a broad and resilient health safety net, particularly for marginalised populations often excluded from mainstream healthcare.

Public health in SA is not a complete or perfect story. It has been marred by mistakes, deception, denialism and corruption — from the dark days of former president Thabo Mbeki’s HIV/Aids denialism to the grip of state capture and ongoing corruption. At the same time, US funding has often come with ideological strings attached, such as the Global Gag Rule’s restrictions on abortion and the Pepfar Anti-Prostitution Pledge, which has constrained support for sex workers.

Yet at its core this is a story far greater than the assumption that SA has merely relied on handouts or followed the US in setting its priorities. Where the US has attempted to impose political and moral control over the bodies of women and other marginalised populations, SA expertise, commitment and innovation have navigated these barriers. However, the increasing polarisation belies the role of this vital collaborative work carried out over decades by researchers, public servants, activists and healthcare workers in SA and the US.

None of this negates the urgent need to reimagine and restructure global health funding and power dynamics. The US and Global North hold disproportionate influence over global health decision-making — a reality that must change. At the same time, the SA government has a constitutional obligation to ensure sustainable, corruption-free healthcare that is efficient and well-managed and based on the principles of universal health coverage.

Yet these necessary structural shifts cannot come at the cost of millions of lives currently reliant on HIV, TB and other critical services supported by US foreign aid. Nor should these shifts be politicised to justify government’s push for the current version of National Health Insurance (NHI) or having key population services channelled into primary healthcare.

There is a real risk that narratives around “stepping up” or “going it alone” will be misused to promote an unworkable NHI model or distance SA from strategic international partnerships. The current NHI framework is deeply flawed for the general population and could prove disastrous for key populations, who require specialised health services to address HIV and TB.

Global health requires strong, equitable partnerships that transcend political cycles and presidential terms. Calls for self-reliance should not distract from efforts to loudly challenge the Trump administration’s abrupt funding cuts and the dismantling of diversity, equity and inclusion programmes (DEI) programmes.

Civil society, researchers and activists must resist these decisions, support legal challenges and mobilise philanthropy to bridge the funding gap. Simultaneously, the SA government must urgently implement a plan to sustain life-saving programmes and develop long-term strategies and budgets for specialised healthcare access. Prioritising rhetoric over action will have dire consequences for SA and all who live in it.