FROM THE EDITOR

Trump's trumpet: The challenges of being over-reliant on foreign funding

Late in January this year, we learnt that the United States (US) Agency for International Development (USAID), one of the largest development agencies in the world, was to be shut down for 90 days by the US President Donald Trump's administration, and that all USAID direct hire personnel were being placed on administrative leave globally. A review was to be done in that time to determine whether the programmes run by USAID and other federally funded initiatives aligned with Trump's foreign policy agenda. Trump did not wait for the 90-day review period, and the US President's Emergency Plan for AIDS Relief (PEPFAR)-funded HIV organisations in the country woke up on 27 February to communication that had been sent overnight informing them their grants had been permanently terminated because they were not aligned with USAID priorities, and their programmes were not in the US national interest. They were told to immediately cease all activities and terminate all subawards and contracts.^[2] Around USD40 billion are allocated annually from the US federal budget for humanitarian and development aid. Millions of people have beneffited from these USAID programmes, which range from supporting peace agreements in Colombia to fighting the spread of HIV in Africa.^[1]

The history of how international development took off is worth noting. In the wake of the Second World War, global powers competed to establish a new world order, and international development started to be built up. International agreements and multilateral institutions were created. Major industrialised nations emerged as the primary donors of foreign aid. The development has been guided by international initiatives such as the Millenium Development Goals and the 2030 Agenda for Sustainable Development. However, it is important to recognise that the governments of main donor countries have their own interests in mind when providing aid, and these can be influenced by ideological, geopolitical, economic and social agendas,^[1] as has been seen by the latest Trump directive on USAID. Funding from foreign donors is not without conditions and strings attached.

Among the most worrying aspects for the African region is the slashing of HIV and tuberculosis treatment programmes. What does this mean for South Africa (SA), which is one of the biggest recipients of PEPFAR aid, receiving USD332.6 million in 2024?^[3] The PEPFAR qualification allowed for a limited waiver only for approved activities. This limited waiver was to expire toward the end of April this year. When Trump signed the executive order to freeze all foreign aid, many clinics that were run by health workers had to shut down because there were no funds to pay salaries. Limited waivers were subsequently proclaimed for the delivery of life-saving medicines only. However, the waivers id not contain the list of qualifying drugs, hence confusion followed on which projects meet the requirements for waivers. Even where projects qualified for waivers, they were to be reassessed to ascertain whether they aligned with the Trump administration's ideologies.^[4]

On 11 February, a circular was issued by the Director General of Health outlining the health department's contingency plan to respond to the temporary suspension of support by PEPFAR and its implementing partners. The measures include redeployment of trained Department of Health staff to fill gaps left by PEPFAR-funded personnel. With the massive staff shortages in healthcare throughout most of the country, it becomes evident once again that the department remains far removed from the realities on the ground. Some other measures are that there should be facility-level task shifting and prioritising enrolment in repeat prescription collection strategies (RPCs), 3-month antiretrovial therapy (ART) and PrEP dispensing and HIV testing. In addition, to reduce clinic visits and ease the burden on health facilities, 6-month ART refills are to be provided to the patients on ART returning for prescriptions who have two consecutive suppressed viral loads <50 copies/mL and meet criteria for RPCs, including clinician-confirmed stability and voluntary patient opt-in.^[5]

Of concern is that the circular responds to the temporary suspension, as though the state was expecting Trump's administration to rescind its executive order. A robust, long-term plan that is sustainable and makes provision for SA to invest in its own healthcare and disentangle itself from its dependency on the USA and other foreign donors, especially in the context of US superiority and self-interest, is required. There is no guarantee that other donors will not follow suit. The lives and livelihoods of vulnerable South Africans should not lie in the hands of foreign funders. The state's lack of urgency in yet another crisis is appallingly woeful.

While much of the focus in the country has been on the PEPFAR programme, health research has been negatively impacted as well. Many research efforts globally have been adversely affected by Trump's actions. The South African Medical Research Council (SAMRC) receives about one-third of its funding from US federal sources, mostly for HIV and tuberculosis research, but also for other areas, including maternal and infant mortality and antimicrobial resistance.^[6] SA has ~8 million people living with HIV, i.e. the largest population with the virus globally. It is therefore not surprising that the country is a hub for research on the virus. While most of the landmark and groundbreaking studies have been conducted in SA, the benefits of the research have been reaped globally. The African-led BRILLIANT study, aiming to develop capacity to produce vaccines on the continent, is funded entirely by a USD45-million grant from USAID. The CEO of the SAMRC is pessimistic that funding for the study will resume. Hence the vaccines that are ready for clinical trials will probably remain in storage.^[6]- Besides HIV and tuberculosis, studies on other infectious diseases, gender-based violence, health systems strengthening and disease-burden monitoring are also affected by the funding cuts, which have major repercussions on staffing as well.^['7]- Universities are also affected, with Trump's halting order being felt across a range of research and academic sites. Furthermore, research participants could be put at risk of harm. Studies with research participants already enrolled and on interventions cannot be halted abruptly, or prematurely terminated. Sponsors have ethical obligations to monitor these participants for adverse events and manage them accordingly.

These immediate challenges created by the Trump administration have far-reaching ramifications. While prioritising how to address the current issues, it is also necessary that we embark on the journey to self-sufficiency, and reflect on the dependency created by our over-reliance on foreign funding. In addition, we need to see our government stepping in and showing leadership in addressing this calamity.

Ames Dhai

Acting Editor

Ames.Dhai@wits.ac.za

References

1. Duenas N. Trump's push to shut down USAID shows how international development is also about strategic interests. The Conversation, 6 February 2025. https://theconversation.com/trumps-push-to-shut-down-usaid-shows-how-international-development-is-also-about-strategic-interests-249118 (accessed 24 February 2025).

2. Malan M. BREAKING: Trump orders USAID-funded HIV organisations in SA to shut down. https://bhekisisa.org/health-news-south-africa/2025-02-27-breaking-trump-orders-usaid-funded-hiv-organisations-in-sa-to-shut-down/ (accessed 27 February 2025).

3. Ntusi N. US aid cuts are an opportunity to reimagine global health. The global south should become self-reliant by investing in health. Nature, 10 February 2025. https://www.nature.com/articles/d41591-025-00009-9 (accessed 24 February 2025).

4. Malan M, Booysen D, Mdzeke Y. Weaponising aid: The cruel ways of #Trump2025. Bhekisisa, 30 January 2025. https://bhekisisa.org/multimedia/podcasts/2025-01-30-listen-weaponising-aid-the-cruel-ways-of-trump2025/ (accessed 24 February 2025).

5. Director General, National Department of Health. Provision of uninterrupted HIV services across all health facilities. Bhekisisa, 2025. https://bhekisisa.org/wp-content/uploads/2025/02/Circular-on-the-provision-of-uniterrupted-HIV-and-AIDS-Services-1.pdf (accessed 24 February 2025).

6. Reuters. Trump's aid cuts stop South African HIV vaccine trials in their tracks. Polity, 18 February 2025. https://www.polity.org.za/article/trumps-aid-cuts-stop-south-african-hiv-vaccine-trials-in-their-tracks-2025-02-18 (accessed 24 February 2025).

7. JUTA Medical Brief. Trump's aid cuts halt crucial SA-led HIV vaccine trials. Medical Brief, 19 February 2025. https://www.medicalbrief.co.za/trumps-aid-cuts-halt-crucial-sa-led-hiv-vaccine-trials/ (accessed 24 February 2025).