The process and effects of funding withdrawal in fragile systems: a case of three International Non-governmental organisations’ exits from Tsholotsho District Hospital, Zimbabwe.

Fragile and conflict-affected settings (FCAS) are under-resourced and depend heavily on public–private engagements (PPEs) with international non-governmental organisations (INGOs) for health service delivery and financing. Yet, when donor funding ends, withdrawal processes are poorly documented, and their effects on local health systems remain under-examined. Understanding how facilities manage such exits can inform more sustainable partnership models in FCAS. A descriptive multiple‑case study examined the withdrawal of three INGOs from Tsholotsho District Hospital (TDH), rural Zimbabwe, through a two‑phase design conducted between 2018 and 2021. Phase 1, a desk review (January 2018–July 2019), informed case selection for Phase 2 (August 2019 – December 2021), which focused on PPEs ending between 2010 and 2020. Data sources included 65 organisational and government reports, 40 peer‑reviewed and grey publications, and 11 expert interviews with local stakeholders. A time‑series reconstruction mapped withdrawal events, while thematic cross‑case analysis compared processes, contextual factors, and effects. All three partnerships ended with cessation of funding, and the magnitude of disruption was shaped by the exit strategy, program integration, and the scope of support. Phased withdrawal by Médecins Sans Frontières still produced service shocks due to deep system embedding, while abrupt exits by Plan Zimbabwe and Ark Zimbabwe led to immediate losses of staff, commodities, and technical support. Across cases, outcomes were exacerbated by contextual fragility, dependency, rigid planning, and weak accountability mechanisms, including vague or inaccessible memoranda of agreement Donor transitions in fragile systems are not mere events or funding terminations, but complex processes that often trigger systemic shocks, exposing deep dependencies, weak accountability, and limited adaptive and transformative capacities. All stakeholders must therefore treat withdrawal as a co‑produced, negotiated transition embedded within complex systems, ensuring that responsibilities, resources, learning, and accountability are shared. Otherwise, what is intended as supportive can become an additional stressor on already fragile systems.