DISCUSSION COMMENTARY

 

Navigating public health priorities: Substance use research in a constrained funding environment

 

 

Nadine Marker^{I, II, III}; Goodman Sibeko^{I, III}

^IMental Health, Alcohol, Substance Use and Tobacco Research Unit, South African Medical Research Council, Cape Town, South Africa
^IISchool of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
^IIIDepartment of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa

Correspondence

 

 

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ABSTRACT

SIGNIFICANCE:
South Africa's substance use, which affects 13% of the population, fuels injuries, disease and mental health issues, and disproportionately impacts at-risk groups. Reduced international funding jeopardises vital research, harm reduction interventions and healthcare access. Increased domestic investment, braided funding and diverse partnerships are critical to maintain services and reduce reliance on external donors. These endeavours ensure long-term public health interventions to comprehensively combat substance use disorders.

Keywords: substance use, harm reduction, funding crises, public health, South Africa

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Substance use is a critical public health issue in South Africa, which directly fuels intentional and unintentional injuries as well as communicable and non-communicable diseases, and has a multidirectional association with mental health problems. Over the last decade and a half, US federal agencies like the Centers for Disease Control (CDC), the National Institutes of Health, and the National Institute of Mental Health have supported much of the research and implementation in this area. The current funding crisis will severely undermine South Africa's ability to gather essential epidemiological data, combat the substance use epidemic, and deliver evidence-based and harm reduction interventions.

Substance use crises, harm reduction initiatives, and impacts

South Africa faces a deepening substance use epidemic, with illicit drug consumption increasing tenfold between 2002 and 2017.¹ Approximately 13% of the population meets DSM-5 and ICD-11 criteria for substance use disorders during their lifetime, driven by alcohol, tobacco, cannabis, heroin, cocaine and methamphetamines.² Among illicit drugs, opioids are the largest contributor to the global burden of disease, accounting for almost 12 million disability adjusted life years lost.³ South Africa has seen an increase in the proportion of treatment admissions for opioid-related disorders over the last 6 years.⁴ At-risk populations, young people, and key populations are disproportionately affected, with socio-economic factors such as unemployment (38.8% nationally) and poverty amplifying vulnerability.

In response to the growing substance use crisis, South Africa has implemented various harm reduction initiatives aimed at mitigating the adverse effects of substance use. These initiatives include needle and syringe programmes, opioid substitution therapy (OST), and community-based outreach programmes. Harm reduction services are crucial in reducing the transmission of infectious diseases such as HIV, tuberculosis, and viral hepatitis B and C, because people who inject drugs (PWIDs) and those who use drugs (PWUDs) are at increased risk of contracting these infections. Despite the importance of these programmes, coverage remains low in South Africa, with less than 1% of PWIDs receiving OST (far below the World Health Organization threshold of 40% of PWIDs accessing OST). Additionally, the distribution of needles and syringes is also far below the recommended levels for effective HIV and hepatitis C prevention, at 30% of the target of 200 sterile needles and syringes per person per year.^5-7 In South Africa, the funding for these initiatives primarily comes from international sources, such as the US President's Emergency Plan for AIDS Relief (PEPFAR), with minimal domestic funding limited to isolated provincial initiatives, such as the City of Tshwane municipality.⁶ It is also worth noting that harm reduction initiatives have played a significant role in destigmatising substance use disorders, intending to increase access to care and ultimately improve control of the HIV epidemic and other infections. While significant strides have been made towards destigmatising harm reduction initiatives and improving treatment for PWIDs/PWUDs, the loss of funding threatens to reverse these important gains.

Research institutions and treatment and harm reduction service providers have received federal funding for studies ranging from identifying the tuberculosis and HIV disease burden among PWUDs - including studies testing evidence-based behavioural interventions across the continuum of care, which include polysubstance use monitoring and text-based health promotion - to decreasing polysubstance use (i.e. alcohol and tobacco/ cannabis) during pregnancy, preventing adverse clinical outcomes such as Foetal Alcohol Spectrum Disorders, as well as studies investigating drug use and sexual practices that place injection and non-injection substance users at risk. The cuts in federal funding will have a profound impact on the continuity of South Africa's current programmes aimed at addressing these adverse outcomes. For instance, CDC/PEPFAR has supported a multi-city harm reduction project in South Africa, a significant portion of which was for methadone (USD1 172 260).⁶ While it is not possible at this time to source consolidated and granular budgets, the estimated federal funding towards substance use research is estimated at USD2 181 101.

Furthermore, these global funding cuts as a consequence of changed funder priorities have resulted in significant uncertainties, given that researchers in the substance use treatment, prevention, and harm reduction fields have historically relied on international funding to conduct vital studies on substance use and its associated health risks among vulnerable and key populations. The withdrawal of funding will undoubtedly lead to the suspension or termination of several key research projects, particularly those focused on HIV, tuberculosis and viral hepatitis B and C, and studies focused on prevention and treatment more broadly. This disruption not only hampers scientific progress but also directly impacts research participants, many of whom depend on these projects for access to healthcare services. For instance, participants in HIV prevention and maternal health trials often receive regular medical check-ups, counselling, and treatment for other health conditions as part of the study. While the basic health service is well supported by the Department of Health, the termination of these projects leaves participants without essential healthcare support, exacerbating their vulnerability.

Notwithstanding the significant health impacts, the likely epidemiological outcomes of the significantly reduced access to funding are also of concern, given that the reduction in research activities hampers the ability to monitor and respond to emerging trends in substance use. This lack of data makes it challenging to develop effective public health strategies and interventions.

However, despite the negative impacts, the current funding situation can perhaps be seen as timely. It brings to the fore the importance of prioritising substance use research and evidence-based interventions in South Africa by building a more robust financial framework to address the substance use crisis comprehensively. For example, South Africa could adopt braided funding mechanisms to integrate domestic contributions with international contributions for substance use disorder research. This can be done by increasing government department allocations toward substance use programmes and research, by aligning budgets under the National Drug Master Plan, and abandoning historical, siloed approaches.⁸ The Central Drug Authority in South Africa is responsible for overseeing and monitoring the implementation of the National Drug Master Plan, which aims to combat substance abuse through prevention, treatment, and harm reduction strategies. It also facilitates coordination among government departments, provincial forums, and local drug action committees while advising the Minister of Social Development on policies and measures to address substance abuse effectively.⁹ In addition, collaborations with non-govenrnmental and community organisations can attract both domestic and international research funding, thereby both addressing research needs and ensuring essential services continue to reach those most vulnerable.⁶ Furthermore, Hatcher and colleagues¹⁰ argue for leveraging support from private foundations, wealthy individuals, and pharmaceutical companies' entities whose generational wealth and revenue streams have been shaped by advancements in HIV treatment, prevention, and care. By doing so, we can possibly reduce our reliance on external sources of funding and instead invest more of our national departmental budgets into this critical area, under the purview of the Central Drug Authority. External funding can then serve to enhance a more robust internal system instead of being the main source. This shift would not only strengthen the country's ability to address the substance use crisis comprehensively but also build a sustainable model for long-term public health interventions.

 

Conclusion

South Africa's challenge in funding the research and treatment of substance use disorders highlights the urgent need for sustainable solutions. Reduced funding for research and intervention efforts hinders the ability to respond to emerging trends; but this moment also presents an opportunity to prioritise evidence-based approaches. By adopting braided funding mechanisms, increasing government allocations under the National Drug Master Plan, and fostering partnerships with non-governmental and community organisations, essential services can continue to reach vulnerable populations while addressing research gaps. Leveraging resources from private foundations, pharmaceutical companies, and individuals connected to fighting the HIV epidemic offers a way to diversify funding streams and reduce reliance on external donors. Strengthening domestic investment and aligning efforts across sectors will enable South Africa to comprehensively tackle its substance use crisis and build a more equitable public health system.

 

Declarations

We have no competing interests to declare. The Grammarly writing assistant tool was used to improve writing by checking for grammar, spelling and punctuation errors. It also offered suggestions for enhancing writing style, tone and vocabulary. Both authors read and approved the final manuscript.

 

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Correspondence:
Nadine Harker
Email: nadine.harker@mrc.ac.za

Published: 29 May 2025