GOVERNMENT assurances that the scaling back of the US President’s Emergency Plan for AIDS Relief (Pepfar) programme in SA will be carefully managed to protect patients are welcome, but as the rising incidence of service delivery protests illustrates, the road to hell is paved with good intentions.

The reality is that the Department of Health is struggling to cope with severe medical staff shortages, financial resources that never seem to stretch far enough, inadequate infrastructure and maintenance programmes, and administrative bottlenecks. The problem is particularly acute in the poorer provinces, where it is not uncommon for doctors to go unpaid for months, clinics to run out of essential consumables and medicines and to literally fall apart through lack of upkeep.

In addition, preparations for the introduction of the mooted National Health Insurance scheme will demand more funding each year if the government is to stick to its rollout plan, vague as it may be. While the scaling back of Pepfar will be implemented over a five-year period and does not entail the complete loss of the almost $500m in annual funding budgeted for the most recent fiscal year, the shortfall will have to come from somewhere.

The Pepfar funding is projected to fall to about $250m a year by 2017, and much of the remaining money will be shifted from service delivery — the supply of medicines and payment to the nongovernmental organisations (NGOs) doing much of the anti-HIV/AIDS work on the ground in SA’s poorest parts — to technical support services.

It will be tragic if, just as we are starting to see light at the end of the long, dark tunnel of the HIV/AIDS epidemic in SA, the gains of the past few years were to be reversed due to the loss of critical foreign funding and the government’s lack of capacity to plug the gap. Hardly a month ago we were celebrating research results that seemed to indicate the government’s policy about-turn after getting through the denial stage was showing results. There were marked improvements in the number of mother-to-child transmissions, people on antiretrovirals, and those voluntarily being tested for HIV, using condoms and adopting other behavioural changes to protect themselves from infection.

The prognosis is mixed; most NGOs’ five-year grants come to an end when the US fiscal year closes next month, and they will have to either urgently secure funding from the applicable provincial health departments or start preparing to transfer patients to the care of government clinics. There is not much room for error, since even a short break in treatment can lead to drug resistance or allow opportunistic infections to become established.

However, many NGOs have secured funding extensions, so in most cases there should be ample time to ensure an orderly transition. Unfortunately, the state of some provincial health departments is such that an eternity would not be sufficient to ensure that no patient’s prophylactic treatment is compromised. Unless there is determined intervention by the national health department, it seems likely that some patients will be worse off as a result of the changeover.

Of course, as the name implies, Pepfar was always intended to be an emergency programme, and it was inevitable that it would be scaled back once the South African government got its act together and the HIV/AIDS explosion was under control. SA is not the only beneficiary country that is seeing its funding cut, so the decision does not seem to have anything to do with our increasingly fractious diplomatic relationship with the US.

It does seem likely, though, that the decision has been prompted in part by US domestic politics. The federal budget deficit is going to have to be tackled at some point, whoever wins the November presidential election, and foreign aid programmes are low-hanging fruit.