The Root Of The Science Podcast
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The Root Of The Science Podcast
EP 163: How Aid Cuts Affect Patients, Research and Jobs in Africa
What happens when life-saving funding disappears? How do healthcare systems adapt? Can domestic resources fill the gap?
The sudden freeze of US aid disbursements in January sent shockwaves through healthcare systems across Africa. Six months later, what was once a policy announcement has turned into a devastating reality for millions who depend on life-saving HIV and TB services.
Stepping into the aftermath of these cuts, we explore the human cost behind the headlines, through conversations with those on the frontlines.
Today we hear from Dr. Limpho Ramangoaela, who witnesses patients presenting later with preventable complications. George Mbombi, a technical advisor who lost his job in the cuts, describes how youth support programs have collapsed. Tabita Ntuli from UNAIDS shares how people living with HIV have been affected.
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People living with HIV have said they refuse to die. The Roots of the Science Podcast with your girl, anne Woveney. The Roots of the Science podcast with your girl, anne Wethene. Now is the time to renew faith in global solidarity, with accountability and with ambition. We need the global community, especially the donor community, to drive this agenda, especially because people living with HIV have said they refuse to die.
Speaker 2:Hello everyone and welcome to the Roots of Science podcast. You're listening to Roots of Health. This is a podcast series in collaboration with the Global health strategies. Today we'll be speaking about the recent aid cuts that have happened. In January this year, the global health world was stunned by the news the US government announced a near total freeze of US aid disbursements. Almost overnight, billions in critical support were pulled from life-saving health services, including the PEPFAR program, which has been central to the HIV and TB responses across Africa. This marked a major turning point, which has become a sharp decline in international development funding, especially official development assistance, otherwise known as oda. According to a recent report by the organization for economic cooperation and development, oda for health is projected to fall between 14 to 29 this year alone, to 29% this year alone. This takes us back to funding levels last seen in the mid-2000s. Fast forward six months later. These effects are no longer just projections. They are real. In South Africa alone, over 8,000 healthcare workers have lost their jobs. More than 39 TB and HIV research and treatment sites are now at risk of closure. Clinics are overwhelmed, critical services are stalling and health workers, researchers and communities are facing impossible choices as resources are drying up In this episode the, the ripple effects, how aid cuts affects patients, research and jobs in africa.
Speaker 2:We want to understand what actually happened. What does it look like when global funding disappears? What happens to the people at the front lines the nurses, the researchers, the medical doctors, as well as the communities? And, more importantly, where do we go to from here? To help us answer these questions, I'm joined by three incredible voices. Firstly, we're joined by Tabitha Ntuli, an advocate and a UNAIDS equality and rights advisor. We are joined by George Mbombi. He is a technical advisor and a trained nurse. Lastly, we're joined by Dr Lempo Ramohele, a medical doctor with first-hand experience in the front lines. Let's get into it. Hello everyone, and welcome to the show.
Speaker 1:Hello, good afternoon.
Speaker 2:Hello Hi, good afternoon. Hello hi, em. It's so lovely to have you all on the show with us this afternoon to talk about this very important issue that we faced. So when we speak about funding and when we speak about funding cuts, I want us to really understand what the international funding efforts used to look like in practice when they were working. What did they make possible?
Speaker 3:When you worked both as a nurse and a technical advisor when aid was working. What kind of scale and impact did these resources allow in the health system? Okay, yes, that's ANOVA. In Limpopo, we had a major expansion in terms of supporting the public sector. In terms of clinical mentoring, we implemented differential care of models and also supporting vulnerable and key populations, such as men who had sex with men. In my program, I was supporting UOPs, adolescents and VTP, which is vertical transmission and prevention, so we were supporting the facility in terms of human resource. Part of our role was to do clinical mentoring.
Speaker 2:Fantastic, fantastic. So now, to speak on this part, I would like to bring in Tabitha Tabitha rather to this conversation. In your work, in your advocacy work, how did these funds make a difference, particularly for women, for children and these key populations?
Speaker 1:Thank you again, anne, for having us here. You know UNAIDS' greatest resource to the world globally is its human capital, so we are able to have presence globally and support governments in their AIDS response. So the impact first has been on the human capital within UNAIDS herself in that, just like other organizations that have been impacted by the funding cuts, we also have had to scale down a whole lot drastically strategic presence of UNAIDS in countries globally, a footprint that is much more intentional not that we hadn't been, it's always been intentional but really, really strategically focusing as best we could in terms of how we support governments in the AIDS response work. And I think, if you mention the populations you've mentioned, that are women, children and key populations of people living with HIV, this work has had a very devastating impact on people living with HIV, our constituency, the people we exist to serve as an organization, as a joint program on HIV and AIDS in the UN. So we really have had to take time to listen in from communities and governments and find best ways on how we navigate this.
Speaker 1:We come from a place where, as my executive director was alluding to the statistics, at the Global AIDS Response launch now in July, on the 10th of July, which was done in South Africa. We went back to statistics and I just want to quote that statistics globally, where we have come from. As a whole AIDS response globe, the decline of deaths related to AIDS was 56%. The number of people living with, I mean 73% of people living with, I mean 73% of people living with HIV on treatment, and we've seen a decline by 62% of what we used to call PMTCT, which is vertical transmission of mother to child transmission of HIV. As you would know and I wouldn't be on this podcast and not speak to data so that's where we've come from and I think initially I gave you a bit of where we are now, but the statistics has also alluded to where we've come from and that's not old history, it's our recent history.
Speaker 2:Thank you. Thank you so much, Tabitha, for pointing that out and it's quite amazing that, with the stats, like you bring it in, it shows facts and figures of why, when everything was working, the type of impact that it had I'd like to bring in Dr Limpo here as a medical doctor. You are on the ground right. So when the funding was working, when this external funding was made possible, what did it make possible in terms of care and services on the ground?
Speaker 4:Thank you for that question. On the ground, it really made significant change. It's significant impact in the sense that I am from a TB background I've been working with drug resistant TB mostly and on the ground you would find that there was significant impact in terms of the screening that was capacitated or that was enabled, that we're able to screen more patients than we've ever screened and up until 2023, 2024, we had screened over 2 million people for TB, and this also includes people living with HIV. So this was quite a significant impact. And this was enabled by having a rollout program that was implemented by the National Department of Health, supported by the partners, to actually roll out the GeneXpert testing machines. This was supported through foreign funding and it enabled to reach more people than we could, and also through research. This also capacitated more people who did not even show symptoms. So, with funding availability, this enabled us to reach even more people than we could, other than those people who actually presented to facilities with symptoms. So research also enabled this. Over and above that, we're able to, you know, reach and test people for TB and initiate them on TB treatment. More so, those that are also living with HIV, who are, you know, co-infected, those that are also living with HIV who are, you know, co-infected. We had reached over 57% of people, over 60% of people living with HIV who in turn, also had TB. These people were able to be put on treatment and this was enabled by funding that was made available for support for these you know, these TB HIV programs.
Speaker 4:We're able to also reduce death rates because we're able to put people on treatment early. We're able to retain people on treatment and more people were actually getting preferential outcomes where they were really cured from TB. Death rates reduced from, you know, significantly by 50% in the latter years, as opposed to where we had significant death rates of 60, 70% in the near past. So this was quite a significant reduction in terms of death rates. We're able and this was an up-and-coming process that we had already started of putting people on preventative therapy for TB, especially patients who were HIV positive. Tb preventative therapy was the key program to actually reduce even the incidence, transmissivity and also, you know, complications that come as a result of TB. So, significantly, we were able to have good gains.
Speaker 4:We had a setback when COVID hit, where we had reduction of up to 29, 30% of, you know, testing and screening of patients and, as well, we had, you know, reductions from the gains that were already made on death rates that you know amounted to about 14% or so of people who were unable to be saved as a result. Now we were on the recovery plan at this point from COVID, where we were trying to make gains to try and meet all the challenges that we faced through COVID so that we can recover all that efforts that were already being gained. We're already on an upward trajectory to reaching the TB and goal strategies. But now, with the funding availability, we were actually excelling. Programs that were implemented by the Department of Health, through partners as well, included medicines availability, where we had repurposed medicines that were made available, and these were made available because of funding. We also had quite a number of activities that were happening on the ground through research world-class research entities that were funded to actually, you know, bring forth significant data that influenced guideline change.
Speaker 2:Thank you so much for that. You've really given us a rich picture of what was actually happening when it was, when everything was working. It's clear and evident that when the funding was working, a lot of things were working, and I like the fact that you brought on that it was research as well that was also well supported, and these are the types of things that help us to solve some of the challenges that we have on hand. So now it's been six months since the announcement was made and I wanted to start questioning. Dr Limpo spoke on gains that were made. Even Tabitha also spoke on gains that were made from the time that funding was implemented. So, george, are we able to see some of the effects of the cuts already? If so, on the ground as well? What exactly are some of these things that are being seen, even with some of the programs, as you mentioned earlier, that were being supported?
Speaker 3:Yes, we are seeing a force in terms of scale back In Limbopo. We recently started implementing your PrEP, which is a preventive therapy. It was announced and allowed to be implemented late last year, so we are seeing a scale back in terms of implementation of PrEP in Limpopo. We are also observing less mentoring. As clinical team in ANOVA, we're supporting all the facilities in terms of mentoring our nurses in HIV, tb and STI management. There are now fewer outreach activities in terms of outreach in terms of HIV testing and your PrEP implementation in the community.
Speaker 3:Dr Limpo spoke about the issue around quality of data. We had an MNE team that was supporting the department in terms of MNE. So because of the scale break, obviously the MNE team was also affected. But, speaking on my program that I was supporting, we had a lot of activities as we're doing things like for the adolescent. We have a youth care club where we will group all our youth to make sure that they understand the fact that they are taking treatment. We facilitate issues around disclosure and also not forgetting the fact that we want them to be suppressed With no support from the partners.
Speaker 3:Obviously, those clubs are unable to facilitate and able to sustain them because of issues around human resource. I'm also seeing issues around same day initiation as a challenge, because also supporting the facilities in terms of making sure that everyone is diagnosed with HIV are put on treatment same day. So as much as our 95-95 are doing well most people are the first 95, the second and the third we are not doing well. That's another thing that we are seeing. I think that's it from my side.
Speaker 2:Thank you so much, tabitha. I'd like to bring you in here on your end as well. You touched on it in the beginning, but let's speak on some of these communities, some of these populations, who are the ones who are most affected by this rollback or the interruptions in funding.
Speaker 1:You know what I will tell you, anne, as my chapeauing to an attempted response to you, which is not a difficult response to give, is that we serve a community of people living with HIV, so this has had an impact across board. I am not able to single out a particular community within the community of people living with HIV our constituency so it is people living with HIV that have been mostly affected by this. However, with that said, we must also really appreciate the resilience of our people, without taking the need for life to continue in ways that are fully supported, of course. When we had the launch of the report that I alluded to earlier on, we had a very powerful statement from a member of people living with, from a member or a community member a leader, for that matter from people living with HIV, and he said civil society is resolute, this work will continue as it should. People living with HIV are refusing to die. Those are marching orders for all of us seated here. Taking from that to say, if people living with HIV, a person that is living with HIV and is on ARVs and has other chronic ailments, stands as a leader and says to the global world, to the global community, that this work will continue. Come rain, come sunshine, people living with HIV are refusing to die. It speaks of them, it speaks of the caliber, it speaks of the lived experiences of people living with HIV in this country.
Speaker 1:You must remember we have been at it since 1999. Yes, south Africa 1998, actually, and people like myself or young professionals in the AIDS response of this country as far back as 2004,. And we never left. So when you have leaders within the PLHIV sector that stand up and speak like that, that's not foreign. We have walked this journey. We know what that means. The work will continue. South Africans and Africans and people of the global village have what we call hope, and hope fuels everything. We do everything. We do so with. That said, whether we jump in with the resources sooner or later, and this work will continue and people will living with hiv themselves have said they are not, they are refusing to die. Them refusing to die, then, is marching orders for all of us affected by HIV to say let us then bring in means to ensure that this refusal becomes evident, and we have data to prove that we indeed refused for people living with HIV to die, based on the current circumstances.
Speaker 2:That is so powerful and, again, like you said, it really shows the type of resilience that the communities are having. So, dr Nimpu, I'd like to bring in here you have patients I know we're speaking on HIV here, but I think similarly in your space as TB who are not giving up despite what's happening. So how do you, as doctors and practitioners, continue to support these communities despite these interruptions and the cutbacks? What does that look like?
Speaker 4:Thank you for that question. You know it's a little bit of a challenge when you feel, as a clinician, some of your hands have been cut off because of the support that we enjoyed. We had made a lot of gains when it came to patients' loss, to follow-up numbers, when it came to patients' death rates and these are patients who are co-infected, both TB, hiv. So, significantly supporting these patients, continuing these programs that were laid out by the Department of Health and, you know, through implementation by the partners, we are really feeling that pinch as clinicians because we are having, you know, shortcomings when it comes to tracking and tracing our patients in the communities, because a lot of these people who would do this function are people who are supported through, you know, the funding.
Speaker 4:Now, with the cuts, we are no longer able, evidently, to reach wider, you know, these patients in the communities. As a result, we are going to start again to see patients coming late or presenting late to facilities, presenting with complications you know, unnecessary complications and also being identified late or being tested late, being put late on treatment, of which we had made serious gains on this whereby, you know, on average, we are expected to at least have a patient on treatment within, you know, a turnaround time of five days. We were so close to actually ensuring that most of the patients that are diagnosed are started on treatment on a turnaround of, you know, five days, because there were people who would actually go and find these patients in the community to bring them to facilities in order for them to start their treatment. Whether we are, you know, seeing patients within the HIV realm or whether we are seeing patients within the TB realm, either way, we had a gateway to reach patients and starting them on treatment sooner, because there were people who would actually do the tracing in the community.
Speaker 4:Now supporting this strategy is going to be a bit of a challenge because as a department of health, we have seen that there has been a challenge.
Speaker 4:I've worked for both entities, through government and through NGO work, through Oram Institute NGO perspective. We also know that big programs were being supported that are now, you know, critically facing challenges. If I can make an example, with programs like your EDR web system, which was largely funded, it's an electronic record system for drug resistant TB and we know that getting correct, accurate data reported requires a number of skilled personnel, requires a number of activities behind the scenes to actually get an accurate report sent that will then be able to influence policy and guideline, as it has been. And having a significant cutback on this not only influences policy change or guideline change, but it influences a whole lot on the clinical care of the patients that we are seeing, because looking at the data, analyzing the data, we would actually be able to significantly pinpoint or map out where our patients are and be able to send people to actually go and fetch these patients in order to bring them back to care.
Speaker 2:I want to touch on that because we've spoken a lot on the patients and the communities, but I think it's also very important to speak on the issue of staffing, to speak on the people who were the foot soldiers, who are in the NGOs, who are the doctors. So you've already alluded to that, dr Limpo, that people were already strained when funding was working, but many people have lost their jobs. So for the people on the ground, george, maybe even in your space, what is the morale like? So many people lost their livelihood, what is it like for the people on the ground? Because, of course, they want to work and to help communities. But now, when your livelihood is affected, how are people navigating that space as well? In terms of the actual, the warm bodies, as we are calling them so far?
Speaker 3:Yeah, you know it's really sad. It will basically start with me from Limpopo, but now I'm finding myself now in Tata. I'm in town for the first time. It wasn't easy for me to be here. I also lost my job and I had to job hunt. Hence I'm finding myself in Tata.
Speaker 3:So, you know, with the youth program, because I was leading the DREAMS program, obviously I was dealing with youth, but it's unfortunate, my home bodies, most of them, were sort of child headed family, the majority of them were orphans. So I'm not looking at my home bodies, but also the family, the entire family. I'm still communicating with them. We have our groups. I'm trying by all means to make sure that I post whatever job I get, but I'm seeing a trend of stress from them and you know, psychologically they are not fine and we're trying our level best to refer them. But you know the number is quite high. As much as some are getting their internships and whatever, high as much as some are getting their internships and whatever.
Speaker 3:But the morale is not good and you'll see it when you post things that are related to NGO, to HIV space, you can see they are no longer interested and again, remember, as peer educators they were close to their patients. Their patients are busy calling them, they were cancelling them telephonically and all that. So they are really affected. But to add on that, our department is in a good position to maintain this. All they need to do is just to reinvest and co-fund the project that we've been doing. To me, I don't see any. They didn't have any sustainability plan ahead in terms of maintaining the work we were doing on the ground and again, as a technical advisor, I was just disappointed After the cut. I think the department took time to respond in terms of management of the crisis. To me, this was a disaster which needed immediate intervention from the department.
Speaker 2:Wow, I can understand and it really also breaks my heart when you've heard these types of stories of how so many people's lives were severely impacted. And, tabitha, maybe this is where you can come in, um, from, let's say, the UN perspective now with everything that sort of happened, how you mentioned earlier about more intentional and strategic ways in terms of how you support NGOs and stuff is that is now. Is that the way the thinking that's going in in future? Um, given the ripple effects that we've seen, not only by the patients but also by the staff who were rolling out these types of programs?
Speaker 1:Yeah, you know, listening to George made my heart sink, I think, much as we've been hearing, we've been listening, and it's the kind of news one never gets used to. It just hits you each time differently and I and I empathize with us. I'm not in an exempted space myself, and both as a professional and as a contributing member of society I am, I feel it, because this touches all of us directly in ways that we are yet to retrospect in history and look back and recover from right, because this is our current reality and, as you and I, our core mandate remains. Nothing changes as far as our core mandate is concerned. Nothing changes as far as our core mandate is concerned. Whether we have reduced in number and footprint, our core mandate remains. That cannot change, because we again, as I repeatedly mentioned that we exist because of people living with HIV and therefore our hours is to stand up with our communities for human rights, with people living with HIV, and to accelerate the HIV prevention agenda. That is very, very important and we're looking to really support governments towards sustainable, inclusive, multisectoral and and agile national aid responses, because, if we are able, if there is a lesson learned or a reminder of what we already all know is that the response can only be impactful in ways that benefit communities when it is well-coordinated and that coordination includes all hands on deck, and that coordination includes all hands on deck. This is why multi-sectorality becomes very, very, very important, and we've seen also how much domestic commitment makes a difference, whether big or small.
Speaker 1:We cannot not speak about domestic commitments. We have seen, for an example, south Africa, nigeria, kenya, ghana and even Ukraine in the middle of a war. They have a domestic commitment to the AIDS response of their country, even in the heat of war. South Africa we know this I mean I'm speaking to South Africans on this call and these other countries, of course.
Speaker 1:It would be great if that could increase to cater to all of the concerns that Limpo has just alluded to in terms of how this work impacts her as a clinician, literally, practically. So if we are to increase our domestic pairs to cater to the concerns that she has already raised as they speak to how we do this work at a community level for the benefit of the patient, that would make a lot of difference, because then we would we would still be worried about one or two other things, but if we had a very, a much more richer domestic commitment. Probably our conversation would have would have had a slightly different tone, but then again, we won't take away from the countries that I've mentioned who are already putting in something towards the AIDS response in their countries by means of domestic support, resourcing of the AIDS response, and that is what UNAIDS is actually really through our executive director, is doing right now. As far as the conversations with governments are concerned, to really speak to the heads of states and governments in large to say, can you put in more?
Speaker 1:Yeah, a sustained response, because things like this happen, life like we are finding ourselves in happens. We are here, we are experiencing it. So let us increase our resource, the resourcing of the AIDS response domestically, because, whether this changes for good and maybe life changes in the coming week just citing a wild example, that then suddenly money becomes available or resourcing becomes available we cannot move on without lessons learned, just like lessons learned during COVID. We cannot live life as if we are not a generation that survived COVID. So we will never, ever, in the AIDS response, live a life that will not speak of this current chapter as part of our history and it will matter how we come out of this as a people. So domestic resourcing very, very important, and also coordination and multi-sectorality as we do this work is very, very important and sustainable efforts towards these responses is quite critical, quite critical.
Speaker 2:It's very critical and I absolutely agree. We've definitely seen it and I like what you said, that we are a generation that has seen COVID, and this will also be another point in history where we look on and we reflect how we've come back from this. We've had such a rich conversation and I, just as we are closing up, I want to ask you all of you rather, we are here now, it has happened, we are living, we are dealing with it so what gives each of you hope for the future when we look back on this, like how we reflect on COVID a couple of years from now, what gives you, each of you, hope? So I'd just like to ask you briefly I'll start with you, dr Limpo what gives you hope in what will come from this moment that we are living through right now?
Speaker 4:I think what gives me hope is knowing that we have quite committed um stuff that really, through tremendous challenges, they still go up above and beyond um to, you know, to try and meet um what the patient's needs are. The patient's needs are. What gives me hope is the fact that, as much as we were, I think, taken aback when you know the funding cuts happened, we were not prepared at this juncture that the funding cuts, you know would happen. So, like a guillotine, you know cut. However, like a guillotine, you know cut. However, it gave us a platform as a nation, as a country, as you know, clinicians, to gather our thoughts and dig deep in terms of finding sustainable entities that can help us, you know, keep going even without the proposed funding. For instance, we knew that funding is not a guarantee. We always know that. You know one NGO comes and the next, you know it will exit at some point. There's always an expiry date. However, it was never an expiry date without the possibility of a replacement or a new entity in its place. However, this scenario that happened has really given us a muscle to say to ourselves that we can do this. We know that we cannot depend on aid, so we have to find strategies that work within us, that will help us to retain programs that have seen, you know, significant growth, significant outcomes for our patients.
Speaker 4:So the delay with the response from government, civil society and everyone, all the stakeholders involved, I would say it is a delay, but it's not by any means a nil response.
Speaker 4:I am confident that when we put our heads together as stakeholders clinical, political, scientific structures, public sector, private sector we can public sector, private sector, we can find ways and means to get through this.
Speaker 4:It will come slowly but, yes, we will make some gains, just like how we responded to COVID. I think if there's a big lesson learned from COVID, response was that everybody was united in the call to respond and it is in that same spirit that I know that we need to do this. We just need to, you know, dig deeper in all those lessons back from COVID to say what can we take from that and implement it. In this current stature, the only challenge here is that we need, as Tabitha said, that we need domestic resourcing, which at this point is the biggest challenge. I'm not saying that there is no response at all and there is no resources. There are resources. We need to pull together all those resources and try and unify the response to this, but what we are simply hoping for is that a joint effort will go a long way in getting us through.
Speaker 2:Thank you for that, george. What gives you hope? You know you shared your story with us. Similar to Dr Limpo, with the current situation.
Speaker 3:I think Dr Limpo read it well. The only thing that gives me hope is the patients that we have that are very resilient, and the team that we have within the department and those who are still functioning, those who are still within the NGOs. That's the only thing that gives me hope, more especially, the resilience that we're getting from the patients.
Speaker 2:Tabitha, to wrap it up for us, what gives you hope?
Speaker 1:It is in my full faith in the donor community that now is not the time they have already realized this that now is not the time to retreat. Now is the time to renew faith in global solidarity with accountability and with ambition. We need the global community, especially the donor community, to drive this agenda, especially because people living with HIV have said they refuse to die. So we have now been given matching orders that are crystal clear to ensure, together in our multisectorality, with our donor community of course at the center of this, ensuring that indeed people living with HIV do not die. That has become our core responsibility, and I think we are able to listen and articulate. Listen with our heads, our minds, our ears and, especially, with our hearts. So I am very hopeful, because we've been here for decades. I am very hopeful that things will get better, it will change together for our good eventually, and we will be here and write that history book together.
Speaker 2:Thank you, what a powerful way to close off this conversation. Thank you everyone for coming onto the show and sharing your perspective. We are hopeful that we as a community as a global community rather will come out of this and so many lessons have been learned. But at the same time, we're also very empathetic with the patients as well as the employees who were severely affected by this funding cuts that happened. Thank you once again for joining me and, to everybody else who's tuned in, thank you for listening to another episode of the Rural Science the podcast. Until next time, goodbye.
