Maintenance dynamics in digital health public goods: a quasi-experimental study of issue resolution during the 2025 USAID funding disruption.

Open-source digital public goods play a growing role in point-of-care health service delivery in low- and middle-income countries. Many of these systems are developed and maintained by organizations that rely heavily on donor funding, making their long-term sustainability vulnerable to funding instability. The January 2025 U.S. Agency for International Development funding freeze created a rare natural experiment to observe how different organizations maintaining these systems respond under external funding shocks. Using 7922 issues from eight repositories created between June 2023 and June 2025, a DistilBERT model was fine-tuned to classify bug severity. Organizations were categorized into three funding-based models: donor-driven (primarily grant-funded), revenue-driven (sustained through commercial or internal investment), and hybrid (combining grants and revenue). Interrupted time series and Cox proportional hazards models were then applied to evaluate changes in bug-resolution efficiency. Revenue-driven organizations did not exhibit a statistically significant immediate level change but experienced significant deterioration in the post-intervention period. Donor-driven organizations exhibited no substantial changes following the intervention, maintaining stable baseline levels. Hybrid organizations showed resilience to the immediate funding shock, with a gradual decline in bug resolution as time went on after the shock. These findings suggest that the funding shocks function as a stress test for digital public goods and highlight the resilience advantages of various governance models.