The US President's Emergency Plan for AIDS Relief (PEPFAR) has invested approximately USD 6.5 billion in South Africa's HIV/AIDS response since 2004, currently providing around USD 650 million annually (roughly R12 billion) to support antiretroviral treatment for 5.5 million people, community health worker programmes, laboratory networks, and civil society organisations. The Trump administration's 2025 executive order initiating a review of all PEPFAR programming created an acute fiscal risk for South Africa's health system: approximately 2 million patients on PEPFAR-supported ART programmes, 15,000 community health workers employed through PEPFAR-funded NGOs, and 47 PEPFAR-supported laboratory facilities face potential disruption. The DOH's PEPFAR Transition Plan (2024–2027) proposes phased domestic absorption of the HIV programme into the NHI conditional grant framework, using HIV/AIDS conditional grant increase of R8 billion over three years to absorb the highest-priority programmes. International Development Finance from GFATM (Global Fund) and EU development partners provides potential bridge financing. This reform intersects directly with CHW formalisation (id=108) and NHI implementation (id=104).
National Treasury's PPP Unit administers South Africa's public-private partnership framework under Treasury Regulation 16, which requires extensive feasibility studies, value-for-money assessments, and multi-stage National Treasury approval. While this oversight protects public finances, the process has been criticised as too slow and costly — particularly for smaller social infrastructure PPPs covering schools, health centres, and correctional facilities — with fewer than 40 PPP agreements reaching financial close since 2000. DPWI and National Treasury are reviewing streamlined approval pathways for social infrastructure PPPs below a defined threshold, an off-balance-sheet framework for municipal-level PPPs, and better alignment with the Infrastructure Fund's blended finance model established in 2020.
The Property Management Trading Entity (PMTE) within DPWI manages approximately 83,000 immovable state assets valued at over R100 billion, including offices, warehouses, police stations, courts, and vacant land, yet operates at a chronic deficit because large portions of the portfolio are underutilised, poorly maintained, or yield below-market rentals from user departments. National Treasury spending reviews have identified the PMTE portfolio as a significant unrealised fiscal asset. Key reforms under review include disposing of non-strategic assets, commercialising well-located land parcels for affordable housing, enforcing accurate user department lease payments, and implementing a government-wide facilities management system. The AGSA has persistently flagged irregular expenditure, incomplete asset registers, and audit backlogs in the PMTE as governance concerns.
South Africa's e-toll system on Gauteng freeways was officially discontinued on 12 April 2024, after more than a decade of near-total public non-compliance. Gantries were physically disconnected; the Gauteng Freeway Improvement Project (GFIP) debt of approximately R20 billion is being settled 70% by National Treasury and 30% by the Gauteng Provincial Government. SANRAL's traditional toll plazas continue to operate nationwide, with tariffs increased by 4.84% effective 1 March 2025. The e-toll episode exposed the fundamental challenge of road funding in South Africa: the fuel levy, historically the primary source of road maintenance revenue, is declining in real terms as vehicles become more fuel-efficient, and faces accelerating long-term erosion as EVs (which pay no fuel levy) gain market share. The Department of Transport is developing a Road Funding Policy that must address: the fiscal gap left by the fuel levy decline, the replacement revenue model for EVs and electric trucks, the equitable contribution of heavy freight vehicles that cause disproportionate road damage, and the feasibility of distance-based charging (a modern tolling concept) without repeating the political failure of e-tolls. The R1 trillion infrastructure programme requires SANRAL to maintain and expand the national road network, but its revenue base is structurally challenged.
The Road Accident Fund (RAF), a statutory insurer that compensates victims of road accidents regardless of fault, carries an actuarial liability of R600 billion (2024)—equivalent to 10% of GDP—making it the largest contingent liability on South Africa's books after Eskom. The RAF is structurally insolvent: fuel levy revenue of R45 billion annually (2025/26) covers only current claims, while the unfunded liability grows by R50–80 billion per year as courts award increasingly large general damages. The RAF Amendment Act and the Road Accident Benefit Scheme (RABS) Bill, proposed since 2014, would replace the tort-based system with a no-fault social insurance model (fixed benefit schedules, income replacement for injured workers, functional rehabilitation rather than lump-sum damages). The reform eliminates the R20 billion in legal fees and disbursements that currently absorb 40% of the RAF's total payments, redirecting them to claimant benefits. The PC on Transport BRRRs 2021–2024 have unanimously recommended RAF structural reform for a decade, noting that the legal profession's opposition (protecting a R20 billion annual fee income) is the primary political obstacle. National Treasury's fiscal risk register classifies RAF as the highest-risk contingent liability.