The effects of funding withdrawals in fragile systems: a case study in Tsholotsho District Hospital in Zimbabwe
Authors: Hamisi Rashid , Olivier Jill 
Published: May 2023

Abstract
Background Fragile, Conflict-Affected and Vulnerable Settings (FCV) are under-resourced and rely on public-private engagement (PPE) initiatives for the provision of basic social services, including health, to the general population. Despite the need in FCV, termination of PPE initiatives is inevitable, but often reported to be fraught in effect on the recipient. Understanding this withdrawal process better and learning how public health facilities cope with the withdrawal of partner support, provides lessons on how to sustain gains from PPE initiatives, especially in FCVs. Zimbabwe has been in a protracted state of fragility for the past three decades, and provides a suitable context for this exploration.
Methods: A multiple case study focusing on the withdrawal process of international non-governmental organisations (INGOs) from Tsholotsho District Hospital (TDH), a rural hospital in Zimbabwe, was conducted in three sequential phases, between 2018-2021. Initially, stakeholder consultations with key health system actors were conducted, together with a scoping review to identify evidence gaps. Three cases of PPE initiatives terminated between 2009 and 2019 were purposively selected. A desk-based approach was supplemented with an additional primary research component (including expert interviews with key local stakeholders n=11), which proved to be an important checking and verification process. We describe the withdrawal processes and TDH’s coping strategies following the exit of Médecins Sans Frontières, Ark Zimbabwe and Plan International.
Results: All three PPE initiatives ended because of withdrawal of funding. Plan and Ark Zimbabwe ‘abruptly’ withdrew support while Médecins Sans Frontières gradually exited over two years. Loss of resources and services provided by INGOs was an acute shock to the district health system. Termination of support by Médecins Sans Frontières had the greatest magnitude of shock as its program had the greatest investment of resources and was deeply embedded into the system. Withdrawal of partner support from Tsholotsho District Hospital was an intricate process occurring within a changing complex health system. Challenges and unintended consequences included delayed planning; limited depth of involvement of Tsholotsho District Hospital program staff; and scaling down or stopping of program activities. The fragile context; systemic challenges; program design and implementation characteristics; and dynamics within the PPE configuration created challenges and/or amplified the shock of losing partner support. Irrespective of how abrupt or gradual the withdrawal of health system support was implemented, the outcome of the process largely depended on the interaction of the withdrawal process with the health system and contextual factors.
Conclusion: The evolving global development environment combined with the underlying drivers of fragility in FCV undermines the sustainability of PPE initiatives. The success of development initiatives in FCV should be centred on the effective implementation and termination of PPE initiatives while allowing FCV to take ownership of health service delivery. Otherwise, what is intended to be supportive can become an additional stressor on less resilient systems