Nearly half of hundreds of public health facilities surveyed by the community-led monitoring group Ritshidze have been operating at a reduced capacity since the Pepfar cuts earlier this year, with increased waiting times, staff shortages and failing filing systems, reports Daily Maverick.
The Ritshidze team has sounded the alarm after finding that among 326 of the facilities, 48% showed a “system-wide slide”.
Ritshidze, which falls under the Treatment Action Campaign (TAC), has been monitoring the state of primary healthcare since 2018 through surveys and interviews with patients and providers, and its latest report, based on data collected between April and June 2025, said there was also a prevalence of shorter antiretroviral (ARV) refills.
“The pattern is consistent across provinces and coincides with the withdrawal of partner support (through Pepfar),” said Anele Yawa, general secretary of the TAC.
Data were collected across 326 facilities in 16 districts in the Eastern Cape, Free State, Gauteng, KwaZulu-Natal, Limpopo and Mpumalanga, with 85% of the managers reporting not having enough staff to meet patients’ needs of patients, with 21% blaming these gaps on Pepfar partners no longer working or working at reduced capacity at facilities.
‘Not enough staff’
The report found that 62% of public healthcare users surveyed reported too few staff at facilities, with 19% of people saying these shortages had become worse since the Pepfar disruptions.
Waiting times had worsened, with delays attributed to reduced staff at facilities (68%) and problems with lost files or longer times for finding files (54%).
Among the healthcare users surveyed, 22% said waiting times were longer than usual after the Pepfar cuts.
Yawa said patient filing systems had “collapsed” in places like the King Cetshwayo district in KwaZulu-Natal and the Buffalo City district in the Eastern Cape.
Ritshidze reported that in some districts, 80% or more of sites had filing systems in disarray.
“For years, Pepfar implementing partners have worked directly on clinic filing systems, knowing how much disorganised filing contributes to delays and poor data quality. They also funded large numbers of data capturers who kept records up to date and files in order,” Yawa said.
“Now, with those posts gone, data capture is falling to whoever is available – including nurses who are being taken away from clinical duties – or simply not happening at all. Files pile up, waiting to be captured or refiled, and there are too few hands to keep up. It’s no surprise that filing has deteriorated sharply in districts where partners withdrew.”
The longer waiting times are particularly worrying when it comes to HIV services, noted Yawa, since they can act as a barrier to care. He said HIV patients, like many in South Africa, are under immense pressure just to survive, hustling to earn money, care for children and keep households running.
“Losing half a day at a clinic means losing income and having to neglect other responsibilities on which families depend. Long waits drive people out of the system. Every extra hour in a line is another reason to miss a treatment collection, to skip a visit or to stop coming back,” he said.
HIV care
Regarding HIV care and ARV delivery, Ritshidze said that progress had plateaued in some districts and reversed in many others.
Surveys found that 9% fewer HIV+ people reported getting a three-month supply of ARVs compared with January 2025, with decreases across all provinces except the Eastern Cape. Additionally, 8% more people reported getting only a one-month supply, with “worrying” increases in the Free State and KwaZulu-Natal, according to the report.
Other key trends noted since the Pepfar cuts were that:
• 35% of people with HIV reported that it took longer to collect their ARVs;
• The use of external pick-up points for ARVs had dropped by 8%;
• Only 47% of people not on ART said they were offered an HIV test while at the clinic, dropping below 30% in some districts;
• 12% of facilities reported fewer or no staff to perform HIV viral load testing; and
• 13% of sites reported fewer or no staff to provide pre-exposure prophylaxis (PreP) services.
Yawa said that despite a circular from the director-general of the National Department of Health, Dr Sandile Buthelezi, green-lighting six-month ART dispensation for eligible patients in February 2025, no facilities were officially implementing this strategy during Ritshidze’s reporting period.
“A small number said they had received a six-month supply, but this may reflect either individual clinician discretion or confusion between a six-month prescription and a true six-month supply of medication. In reality, refill lengths became shorter – with more people getting one-month supplies and fewer receiving three-month ones,” he said.
“This must change urgently. Six-month dispensing has only begun at a handful of health facilities since August 2025, far behind national commitments and long overdue for full roll-out.”
Report recommendations
Among the recommendations made by Ritshidze were giving out longer medicine supplies and increasing access to external pick-up points for ARVs, to reduce congestion and delays.
Ritshidze noted that many community-based organisations (CBOs) were ready to run pick-up points in their communities, but were limited by the current funding model designed for large private pharmacy networks serving thousands, rather than small CBOs supporting 50 to 100 people.
It encouraged the Department of Health and Treasury to create a “dedicated CBO-friendly model” that made it easier to register, contract and fund community-led pick-up points.
Earlier this year, Treasury allocated R753.5m to address the impacts of international funding cuts for health, including R590m for provincial Health Departments and R32m for the national department.
“Evidence on human resources shortages must be used to inform plans for use of the additional funds provided by Treasury. Counsellors are critical and must be prioritised. In addition, Centres of Excellence for members of key populations need additional staffing so they can function effectively and to support and instil culture change within the facility,” said Ritshidze.
Yawa said that there had been limited government acknowledgement of the “true scale” of the funding gaps left by international aid cuts, with the additional funds allocated by Treasury representing “a fraction of the nearly R3.3bn reductions in Pepfar and Global Fund HIV funding previously contributed”.
“Critical areas Pepfar supported – like counselling, data capture, key population services and community-led monitoring – remain largely unfunded. These are not add-ons but essential components of how the HIV response stayed accountable and people stayed in care,” Yawa said.
“Until government and donors accept and address the breadth of what was lost… the response will remain weakened, and communities will keep paying the price.”
Ritshidze itself was affected by the Pepfar cuts, which reduced its reach from 26 to 16 high-priority HIV districts. Yawa said that it pushed ahead on a “shoestring” budget, with only a quarter of the community monitors previously tasked with conducting outreach.
“We hope all this effort to understand the impact at facility level will be taken seriously by district, provincial and national departments – and that concrete action will follow. TAC and Ritshidze have had to sacrifice a great deal to prioritise getting this data collection done,” Yawa added.
Lynne Wilkinson, a public health specialist in the HIV/Aids sector, said the Ritshidze report showed the vital role of community-led monitoring in South Africa’s HIV response.
“It complements Health Department data by providing real-time warning signals that must be acted on. With nearly 2m people needing to start or restart ART, we can’t afford longer queues, fewer HIV tests, shorter refills or fewer collection options,” she said, urging sustained funding to maintain Ritshidze’s ability to give critical insights and ensure greater access to public sector HIV data.
Looking to the government
Daily Maverick asked the Department of Health about the outcomes of the Ritshidze report but had not received a response by the time of publishing.
Minister in the Presidency Khumbudzo Ntshavheni announced at a post-Cabinet media briefing on 16 October that the US Government had approved a “Pepfar Bridge Plan” (PBP) of $115m for South Africa between 1 October 2025 and 31 March 2026.
“The PBP is meant to ensure uninterrupted HIV service delivery … by supporting HIV/Aids service continuity and prioritising country-specific needs and life-saving impact… Cabinet expressed its appreciation to the government of the United States of America on its commitment to supporting and sustaining progress in the fight against HIV/Aids,” Ntshavheni said.
See more from MedicalBrief archives:
Treasury bails out HIV/Aids projects blindsided by Pepfar cuts
No time to lose to address Pepfar crisis
HIV+ groups battle to access state services, study finds
Time for SA to stand on its own, Aids experts agree