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

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.