The impacts of United States foreign development assistance reductions on health system building blocks at healthcare facilities in Zambia: a mixed-methods study

Abstract The rapid reduction in foreign development assistance from the United States and other countries has led to disruptions in essential global health programming. Countries that previously received development assistance, such as Zambia, may experience weakening of health system capacity due to program cancellations. This study aimed to describe the impacts of USAID program defunding on healthcare delivery in Zambia. We conducted a cross-sectional survey at 34 healthcare facilities in three districts of Zambia in April and May 2025. Through facility-level assessments and individual surveys with 330 healthcare workers, we identified changes in health system building blocks that may have arisen from program defunding. The facility-level assessment found that 71% of healthcare facilities (n=24) experienced changes related to funding cuts within the previous three to four months. In open-ended surveys, healthcare workers reported impacts on the health system, including stock-outs of essential medicines, diagnostic tests, and infection control supplies; layoffs of US-supported healthcare workers; and reduced ability to work with electronic medical records. Workers described how these changes impacted workplace morale, patient satisfaction, and their ability to deliver essential services. This study reveals the immediate consequences of defunding foreign assistance, which, if left unaddressed, may weaken health systems and worsen health outcomes. To mitigate these impacts, country governments and partner organizations should prioritize interventions and investments that strengthen health systems, such as expanding healthcare revenue streams and building workforce capacity. In the wake of funding cuts, health system strengthening can reduce countries’ reliance on foreign assistance and improve population health. Competing Interest Statement The authors have declared no competing interest. Funding Statement This research was funded by World Vision through the Water Institute at UNC, and by the UNC Gillings School of Public Health's Joseph "Chip" Hughes Worker Education and Training Research Fund, the Daniel A. Okun Water, Sanitation, and Hygiene Student Travel Award, and SPH Student Expendable Travel Award. LKT is supported by an NSF Graduate Research Fellowship (DGE-2040435). RC and DMA were supported in part by the Wallace Genetic Foundation. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The IRB of the University of North Carolina-Chapel Hill reviewed this work and determined it to be exempt from further review (reference no. 24-0733). The Humanities and Social Sciences Research Ethics Committee (HSSREC) of University of Zambia gave ethical approval for this work (reference no. 00006464). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data Availability All data produced in the present study are available online in the Carolina Digital Repository.