What happens when donors leave?

'What happens when donors leave: Health financing transitions in fragile and conflict-affected settings’ is a new policy brief from members of the Thematic Working Group on Health Systems in Fragile and Conflict-Affected Settings (TWG FCAS). The brief was produced following a TWG call for contributions, at which members shared their reflections, experiences and work on the topic of aid cuts and their impacts. Read full brief here.

The impact of aid cuts

In recent years, official development assistance has experienced a marked contraction after several years of growth, reflecting declining contributions to international organizations, reductions in bilateral aid, and lower spending on donor refugee costs. Health financing is among the sectors most exposed to these shifts, with the reductions especially severe in fragile and conflict-affected states, where health systems are highly dependent on external aid.

The TWG FCAS policy brief responds to growing concern within the group about the implications of abrupt donor exit for FCAS. It synthesizes available evidence and country experience (with a particular focus on Nigeria and Cameroon) to address two questions:

1. What happens on the ground when donors leave abruptly?

2. How do countries in FCAS respond financially to donor retrenchment?

Key messages

• Abrupt donor withdrawal creates immediate financing gaps, service disruptions, and institutional stress, and can also trigger social and political consequences, with effects often disproportionately severe in FCAS.
• Harm is unevenly distributed: frontline services, subnational systems, and vulnerable populations tend to bear the greatest burden when exits are sudden, poorly planned, or simultaneous.
• Countries may respond through a combination of budgetary adjustments, stop-gap measures, and selective reforms, though these are constrained in FCAS by limited fiscal space, weak institutions, and insecurity.
• Evidence from Cameroon and Nigeria suggests that exit design, timing, and domestic absorptive capacity shape outcomes, and that transitions can also catalyze positive adaptations such as strengthened domestic financing, workforce absorption, and improved governance.

Special thanks go to the brief’s authors: Ilaria Mosca (Tagliente), Abdelrahman JK Alfar (UK-based lecturer) and Atunde Ahmed Olarewaju (Medbase Africa), and Wesam Mansour who also contributed. 

Image: Cover of the brief. Photo - a quarantined family in Sierra Leone receives an emergency interim care kit. © Paloma Clohossey / USAID / OFDA 2015 via Flickr