
Last Word
The major impact of the second term of President Donald Trump on Zimbabwe is the uncertainty over United States foreign aid, which in the case of Zimbabwe is concentrated on health services, particularly the highly successful but expensive programme that is overcoming HIV and Aids, and other emergency support in food aid and the like.
The tariff and other trade measures of the new US administration will have little effect on Zimbabwe, considering the small amount of US-Zimbabwe trade.
Fairly obviously the US is highly unlikely to be contributing to the global pot for climate change funding, and it is very dubious if there will be any bilateral aid to go green or cut carbon emissions, since already such US Government programmes on its own territory have been ended. But this was future aid, not present aid. However, it does make the greening of the planet harder for developing countries.
On existing foreign aid, the initial order by President Trump to freeze foreign aid for 90 days, while assessments were made on the efficiency of the programmes and how far they served American foreign policy as set by the President, has been modified by waivers by Secretary of State Mario Rubio. These exclude for the 90 days life-saving medicine, medical services, food, shelter and subsistence assistance.
It is unclear just which medical programmes will continue during the freeze in Zimbabwe, but it is likely that continued support for the supply of anti-retroviral drugs taken by those who are HIV positive will continue, along with associated treatment programmes for tuberculosis and cervical cancer, all coming under the Presidential Emergency Plan for Aids Relief, Pepfar.
While no US health aid programmes in Zimbabwe have any of the content where Mr Rubio maintains the freeze, such as abortions and transgender surgery, there must still be doubt during the freeze over some of the Pepfar support for testing, prevention and health staffing support, unless the whole Pepfar programme is contained in the definition of life-saving medicine and medical services.
Besides Pepfar, the US has also been a supporter of the anti-malarial campaign.
The US has also pulled out of the World Health Organisation, which will have an impact on what it can do. WHO has modest membership dues and relies heavily on extra donations. The US was the largest funder, providing about 15 percent of the budget, with US$958 million. Second, and now the largest funder, is the Bill and Melinda Gates Foundation with US$689 million. The foundation concentrates on vaccines, as does the next largest donor, GAVi-the Vaccine Alliance with US$500 million.
The cut off of US funding will not cripple WHO, but will certainly force a cut back in its operations unless other funders come through with more.
The Pepfar Zimbabwe programme has in recent years been funding a fairly flat US$203,8 million a year, with small jumps for certain survey support as was seen in 2023. The support is flexible, with priorities changing over time and new circumstances. Support for programmes targeting women and children has been rising, as these were found to contain most of the gaps in Zimbabwean coverage, for example.
Pepfar Zimbabwe appears to have inched down a tiny bit from a peak of perhaps US$240 million as more is done with local resources and efficiencies rise in the programmes, but it is still the major funder of the whole Zimbabwean response to HIV and Aids. So the end of the programme, or cut backs in its coverage, will be critical and will need to be replaced by a lot more local funding.
The largest block of Pepfar funding in Zimbabwe, just over US$81,4 million, goes on clinical and treatment, which is where the antiretroviral treatment (ART) support comes in, with prevention services coming in next at US$45,3 million, which includes the US$3,8 million for condoms but that dwarfed by pre-infection and post-infection prophylactic services for vulnerable groups. Then programme management at US$34,3 million. Testing is a little under US$8 million.
Even with the waivers, or partial waivers, for Pepfar, there is still that final assessment at the end of the 90 days. The efficiency test for Pepfar across its main range, Southern and East Africa, part of West Africa and parts of southern and south-east Asia, is likely to be passed with flying colours. Administration has been tight and allocations informed by detailed data collection. Its efficacy as a programme has been excellent, with most countries including Zimbabwe now at or surpassing the 95-95-95 barrier. It has been one of the most efficient and effective US aid programmes ever.
South Africa is the largest Pepfar recipient, with a budget of about US$448 million.
So the main question will be how far Pepfar supports US foreign policy. That will be an opinion in the end. Pepfar has had extensive bi-partisan backing in the US Congress since it was introduced by President George W. Bush in 2003 with funding for the initial 15 countries from 2004. But there is a growing group of Republican legislators, plus strong voices in the Administration, who believe that the US should drastically reduce foreign aid as it serves little national purpose, and President Trump has made reducing the US budget drastically a major policy.
So what should Zimbabwe and its neighbours do. The waivers on the freeze give a small breathing space, but even if the programme is continued there can now be no guarantee it will continue for as long as had been hoped.
Zimbabwe is well on the way to eradicating new HIV infection by 2030. The 95-95-95 target has been reached: that is 95 percent of estimated infected people know their status, in fact a little over 95 percent; plus more than 95 percent of the infected are on ART, the latest figures giving a little over 98 percent; plus 95 percent of those on ART have achieved viral suppression and are no longer infectious, this figure being bound to rise as the latest of those on ART achieve suppression.
The remaining 5 percent untested are concentrated among young people, people under 18, and to a degree among women, although there are others who simply do not want to know, While HIV testing is totally confidential and without anyone being blamed, and is free for those who cannot pay, there is still the problem of gaining access by under-age children and some women, a problem now being addressed.
Zimbabwe makes a significant double contribution to its own HIV and Aids programmes through the Aids Levy, that 3 percent levied on individual and company income tax, and through the general health budget including its network of clinics and hospitals and general medical staff. But any cut back in Pepfar, or elimination of Pepfar, will require a lot more money from the budget.
There is the continuing, but gradually declining, need to bring in the remaining estimated 5 percent who are not tested, and this would include making sure that we have found everyone since the total infected population is only an estimate. Preventative programmes have to be maintained, again for a time, until all infected people are on ART with viral suppression when we should reach the point of zero new infections. So budgets for these programme have to be maintained.
The more permanent programme is supply and distribution of antiretroviral drugs. Even without new infection, HIV will remain a chronic illness needing lifelong treatment, just like hypertension and diabetes and other chronic illnesses, and that means that even as the HIV positive population declines through old age there will still be Zimbabweans on ART in 2100.
We can make shifts in how we use the Aids levy which goes to the National Aids Council. At present 50 percent is spent on ART, 10 percent on education and an eye-watering 28 percent on logistics. It would seem sensible to move more budget to ART, and logistical support coming through the standard Ministry of Health and Child Welfare supply network from NatPharm to the clinics and group providers. The education budget seems cuttable since every Zimbabwean under 50 learned about HIV in high school. We can also have fewer and cheaper conferences and workshops.
The Covid-19 pandemic and the major food relief programmes caused by last year’s severe drought show that the Government can manoeuvre within the budget for emergency funding and still maintain fiscal discipline. Hopefully the present campaign to get the informal sector to contribute to the tax pool will create some new revenue some of which can be used to push up the health budget significantly. And that is another excellent reason to really go after the tuckshops to make them pay their share. There can be savings by bringing in more of the Aids and HIV programme within the ambit of the ordinary health care system.
We also, nationally and in collaboration with our neighbours, need to build up our pharmaceutical industry. Medications for chronic illnesses seem a good base, as the demand is known in advance and is constant for decades. Someone in their 40s on hypertension tablets, diabetes medication or ART, or even all three. will still be a consumer in 40 years time. So there is minimal risk in such investment.
Vaccine manufacture for the main infectious diseases is another bankable low risk investment. Considering that the Department of Veterinary Services is now manufacturing vaccines for animal diseases, the higher standards for human vaccines seem attainable.