Impacts of the One Big Beautiful Bill Act on African Public Health Systems.

The enactment of the One Big Beautiful Bill Act (OBBBA) in July 2025 represents a fundamental shift in United States global health financing, with significant implications for African public health systems. For more than three decades, US development assistance for health particularly through initiatives such as the President's Emergency Plan for AIDS Relief (PEPFAR), the President's Malaria Initiative, and maternal and child health programs-has been central to disease control and health system strengthening across sub-Saharan Africa. OBBBA institutionalizes reduced funding baselines under an "America First Global Health Strategy," constraining bilateral assistance and limiting flexible mechanisms that previously supported surveillance, laboratory systems, workforce development, and pandemic preparedness. This perspective examines the anticipated consequences of OBBBA for African public health through three interconnected lenses: disease-specific impacts on HIV/AIDS, tuberculosis, malaria, and maternal and child health; systemic effects on health systems, including workforce sustainability, supply chains, surveillance, and research infrastructure; and broader economic and geopolitical implications for health sovereignty and partnership dynamics. Drawing on existing empirical evidence, modeling studies, and historical analogues of funding disruptions, we argue that abrupt reductions in US global health financing risk reversing hard-won gains in disease control, exacerbating health system fragility, and increasing vulnerability to emerging infectious threats. At the same time, the policy shift may accelerate diversification of partnerships and prompt renewed debates on domestic resource mobilization and African health sovereignty. We conclude that coordinated responses by African governments, regional bodies, international institutions, and development partners are urgently required to mitigate risks, protect treatment continuity, and sustain progress toward global health security and the Sustainable Development Goals.