District manager perspectives on USAID/PEPFAR funding cuts and service delivery in the Western Cape, South Africa
1
Health Economics and Epidemiology Research Office, Faculty of Health Science, University of the Witwatersrand, Parktown, Johannesburg, South Africa
2
Department of Work and Social Psychology, Maastricht University, Maastricht, Netherlands
Popul. Med. 2026;8(Supplement Supplement 1):A1754
ABSTRACT
BACKGROUND:
USAID/PEPFAR funding has been critical to South Africa’s public-sector HIV service delivery over the past two decades. Recent funding reductions and scale-downs by non-governmental organizations (NGOs) have strained primary health care (PHC) facilities. We examined district health managers’ experiences with these funding cuts and strategies used to mitigate operational impact across three districts in Western Cape province of South Africa.
METHODS:
Between January and May 2025, we conducted in-depth interviews with purposively selected district health managers overseeing PHC facilities in rural (Cape Winelands) and urban (Garden Route and Cape Town Metro) districts. Interviews were audio-recorded, transcribed verbatim, thematically analysed using NVivo 14. Four researchers independently coded to enhance reliability, discrepancies were resolved by consensus, and findings were reported in line with the Consolidated Criteria for Reporting Qualitative Research.
RESULTS:
Eighteen participants (6 males and 12 females) were interviewed. Participants reported that funding cuts resulted in the loss of NGO-supported clinical staff and the discontinuation of some outreach services. The Cape Town Metro district was perceived as the most impacted. Staff shortages were more pronounced in HIV services, particularly in data capturing, counselling and nurse-led antiretroviral therapy management. Despite these challenges, managers reported maintaining service through task-shifting, involving redistribution of work to available staff, interns and volunteers, complemented by targeted capacity-building, training and mentorship. In Cape Winelands, cessation of some mobile outreach services was partially mitigated through partnerships with farmers, who provided spaces for service delivery to farm workers, reducing pressure at clinics. Across the districts, facility managers experienced lengthy procurement processes when implementing mitigation strategies and replacing NGO-supported staff and equipment.
CONCLUSIONS:
District health managers adapted rapidly to sustain HIV services following USAID/PEPFAR funding cuts, demonstrating system's resilience amid persistent structural constraints. Improving procurement responsiveness and planning for absorption of critical functions may improve continuity during future funding shocks.
USAID/PEPFAR funding has been critical to South Africa’s public-sector HIV service delivery over the past two decades. Recent funding reductions and scale-downs by non-governmental organizations (NGOs) have strained primary health care (PHC) facilities. We examined district health managers’ experiences with these funding cuts and strategies used to mitigate operational impact across three districts in Western Cape province of South Africa.
METHODS:
Between January and May 2025, we conducted in-depth interviews with purposively selected district health managers overseeing PHC facilities in rural (Cape Winelands) and urban (Garden Route and Cape Town Metro) districts. Interviews were audio-recorded, transcribed verbatim, thematically analysed using NVivo 14. Four researchers independently coded to enhance reliability, discrepancies were resolved by consensus, and findings were reported in line with the Consolidated Criteria for Reporting Qualitative Research.
RESULTS:
Eighteen participants (6 males and 12 females) were interviewed. Participants reported that funding cuts resulted in the loss of NGO-supported clinical staff and the discontinuation of some outreach services. The Cape Town Metro district was perceived as the most impacted. Staff shortages were more pronounced in HIV services, particularly in data capturing, counselling and nurse-led antiretroviral therapy management. Despite these challenges, managers reported maintaining service through task-shifting, involving redistribution of work to available staff, interns and volunteers, complemented by targeted capacity-building, training and mentorship. In Cape Winelands, cessation of some mobile outreach services was partially mitigated through partnerships with farmers, who provided spaces for service delivery to farm workers, reducing pressure at clinics. Across the districts, facility managers experienced lengthy procurement processes when implementing mitigation strategies and replacing NGO-supported staff and equipment.
CONCLUSIONS:
District health managers adapted rapidly to sustain HIV services following USAID/PEPFAR funding cuts, demonstrating system's resilience amid persistent structural constraints. Improving procurement responsiveness and planning for absorption of critical functions may improve continuity during future funding shocks.
| eISSN: | 2654-1459 |
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