Just days before the world pauses to celebrate health workers, life-saving medicines, and the progress made against preventable disease, a quiet but devastating crisis is unfolding across South Africa’s clinics and community health centres. The lifeblood of the nation’s HIV and tuberculosis (TB) programmes — international donor funding — is drying up. And the organisation that sounds the alarm is one that rarely speaks in headlines.
Inyathelo: The South African Institute for Advancement, a leading non-profit that supports civil society organisations, issued a stark warning on Friday: South Africa’s healthcare sector faces serious sustainability risks, with dangerous gaps already appearing in service delivery for HIV and TB programmes. The warning comes just four days before World Health Day on Tuesday, an annual event that this year carries a theme of “My health, my right.”
But for millions of South Africans living with HIV or drug-resistant TB, that right is hanging by a thread.
“The funding cliff is not coming. It is already here,” said Inyathelo executive director Nazeema Mohamed, her voice heavy with urgency during a press briefing in Cape Town. “We have spent two decades building one of the largest HIV treatment and prevention programmes in the world. Now, we are watching it crumble in slow motion because international donors are pulling out — and the government has not filled the gap.”
The Numbers Behind the Crisis
To understand the scale of the threat, one must look at the ledgers. South Africa has the largest HIV epidemic in the world, with approximately 7.8 million people living with HIV — nearly 13% of the population. The country also has one of the highest burdens of TB, including extensively drug-resistant (XDR-TB) strains.
For years, international funders — particularly PEPFAR (the US President’s Emergency Plan for AIDS Relief), the Global Fund to Fight AIDS, Tuberculosis and Malaria, and various European bilaterals — have bankrolled a significant portion of the response. At its peak, foreign donors contributed up to 70% of South Africa’s HIV/TB budget, funding everything from antiretroviral (ARV) distribution to community health worker salaries to mobile testing units in rural villages.
But those taps are turning off.
The reasons are multiple and overlapping:
- Donor fatigue in wealthy nations facing their own economic pressures.
- Shifting global priorities following the COVID-19 pandemic.
- A deliberate transition strategy by funders like PEPFAR, which has been gradually reducing its footprint in middle-income countries like South Africa, expecting national governments to take over.
- Recent aid freezes linked to political decisions in donor capitals, including the United States Congress’s repeated threats to cut global health spending.
The result is a perfect storm. According to Inyathelo’s analysis, at least 120 civil society organisations that provide frontline HIV and TB services have either closed, scaled back, or are operating on month-to-month survival since 2023. Thousands of community health workers — many of whom earn small stipends rather than salaries — have been let go.
“These are the people who walk into shacks in informal settlements,” said Mohamed. “They hold the hands of patients who are too sick to stand. They ensure that a mother in the Eastern Cape does not miss a single dose of her ARVs. And now they are being told: ‘There is no more money. Go home.'”
The Ripple Effects: What Gaps in Service Delivery Look Like
When funding disappears, it does not happen with a bang. It happens with a quiet, creeping erosion of care.
Inyathelo’s field monitors have documented the following dangerous gaps already emerging:
📉 ARV stockouts at primary healthcare clinics in three provinces, forcing patients to travel further or go without.
📉 Closure of mobile testing units in rural KwaZulu-Natal, where HIV prevalence exceeds 25% in some districts.
📉 Suspension of TB contact tracing in the Western Cape, meaning that family members of TB patients are no longer being screened.
📉 Loss of adherence clubs — support groups for stable HIV patients — which free up clinic resources for sicker patients.
📉 A halt to prevention of mother-to-child transmission (PMTCT) outreach, putting a generation of newborns at risk.
Dr. Thabo Mbeki (no relation to the former president), a senior clinical manager at a large community health centre in Khayelitsha, described the situation as “terrifying.”
“We have patients who have been virally suppressed for years,” he said. “They take their pill every day. Their viral load is undetectable. They are healthy, working, raising children. But if we lose the community health workers who remind them to collect their medication, who deliver refills when they can’t come to the clinic, those patients will fall off the treatment cascade. They will become sick again. They will develop resistance. And some of them will die. This is not alarmist. This is medicine.”
World Health Day: A Bitter Irony
World Health Day, observed annually on April 7, was established by the World Health Organization (WHO) in 1948 to mark the founding of the WHO itself. It is meant to be a day of celebration and commitment. This year’s theme, “My health, my right,” was chosen to champion the idea that access to quality healthcare is a fundamental human right, not a privilege.
Inyathelo is using the irony deliberately.
“What does ‘my health, my right’ mean to a woman in Soweto who cannot get her ARVs because the clinic has run out?” asked Mohamed. “What does it mean to a man with a persistent cough in a Limpopo mining town who cannot get a TB test because the mobile unit has been sold? The government cannot declare a right and then refuse to fund it.”
The non-profit is calling on the National Treasury and the Department of Health to urgently release a health sustainability fund — a dedicated budget line that would gradually absorb the programmes previously funded by international donors. They are also demanding a transparent transition plan with clear timelines, so that civil society organisations can plan beyond month-to-month survival.
Government’s Response (Or Lack Thereof)
When asked for comment, the National Department of Health acknowledged the funding pressures but insisted that “no patient will be left without treatment.” A spokesperson pointed to the government’s own HIV and TB investment case, which estimates that South Africa needs an additional R10 billion annually to fully fund the response domestically.
But the National Treasury has not allocated that money. In the most recent budget, health received a real-terms cut, with increases failing to keep pace with inflation and population growth.
The Democratic Alliance’s shadow health minister, Dr. Michéle Clarke, accused the ANC government of “sleepwalking into a public health catastrophe.”
“We have known for years that PEPFAR would eventually phase out,” Clarke said. “Instead of planning for that day, the government pretended it would never come. Now it has come. And the people who will pay the price are the poorest and most vulnerable South Africans.”
The Human Face of the Crisis
Behind the policy briefs and the budget spreadsheets are real names. Inyathelo shared the story of “Thandi” (not her real name), a 34-year-old mother of two in a township outside Port Elizabeth. Thandi has been on ARVs for eight years. Her viral load has been undetectable for six. She works as a domestic worker. Her clinic’s adherence club was shut down last month due to lack of funding.
“The nurse told me I have to come every month now instead of every three months,” Thandi said in a recorded statement. “But I cannot take that much time off work. My employer will fire me. So I have missed two months of medication already. I am scared. I feel tired again. I think the virus is coming back.”
Thandi’s story is repeating itself across the country. And unless something changes, World Health Day 2026 will be remembered not as a celebration of rights, but as the beginning of a preventable tragedy.
What Inyathelo Is Demanding
In a formal memorandum delivered to the Department of Health and National Treasury on Friday, Inyathelo outlined three urgent demands:
- Immediate emergency funding of R2 billion to prevent further clinic closures and health worker layoffs for the remainder of the 2026 financial year.
- A published transition roadmap by June 1, detailing how international programmes will be phased into the national budget over the next 24 months.
- The reinstatement of tax incentives for corporate donors to civil society health organisations, which were removed in 2023.
“We are not asking for charity,” said Mohamed. “We are asking for accountability. The South African government has a constitutional obligation under Section 27 to provide access to healthcare. That includes HIV and TB treatment. They cannot outsource that responsibility to international donors and then look away when the donors leave.”
The Clock Is Ticking
As World Health Day approaches, Inyathelo will join forces with the Treatment Action Campaign (TAC), SECTION27, and other advocacy groups for a series of nationwide actions. On Tuesday morning, activists will gather outside the Department of Health in Pretoria, holding placards that read: “My health, my right. Fund it.”
For now, the clinics remain open. The community health workers who still have jobs show up. The ARVs are dispensed — for today.
But everyone in the sector knows the truth: the foundation is cracking. And if the government does not act soon, the entire edifice of South Africa’s celebrated HIV and TB response could come crashing down.
“In 20 years, we went from a country that denied AIDS existed to a country that built the world’s largest treatment programme,” said Mohamed. “That was our greatest victory. But victories are not permanent. They have to be defended. And right now, we are losing the defence.”
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