Learning to integrate? Multimorbidity, chronic care and health system adaptation in post-USAID Zimbabwe

Multimorbidity exposes tensions between complex health needs and health systems historically organized vertically around single diseases. While integrated chronic care has become a policy priority for many low- and middle-income countries, responses remain constrained by disease-specific configurations of knowledge, policy and practice. The USAID cuts represent a critical rupture in these arrangements, exposing dependencies while creating opportunities for integration, institutionalisation and local ownership. We examined challenges and opportunities for multimorbidity-responsive primary healthcare through a Learning Health System (LHS) lens, focusing on how information, deliberation, and action shape learning and adaptation processes in Zimbabwe during this period of transition. We conducted an ethnographic study in two urban metropolitan centers in Zimbabwe between October 2025 and February 2026, using patient journey mapping (n=23), participant observation, and in-depth interviews with healthcare workers, patients, decision-makers, health information specialists, and technical partners (n=19). We analyzed data thematically using an iterative framework informed by LHS concepts. Participants widely recognized multimorbidity as an increasingly common feature of primary care, yet care remained constrained by systems organized around individual diseases. Fragmentation was evident not only in clinical pathways but also in the information, accountability, and decision-making architectures through which health priorities were recognized and acted upon. At the same time, frontline providers routinely adapted care around patients' multiple conditions, revealing capacity for more integrated and person-centered approaches. Existing HIV platforms, including differentiated service delivery models and regional learning networks, were frequently identified as foundations for broader chronic care integration. These findings suggest that advancing multimorbidity-responsive care requires more than service integration; it requires strengthening the learning architectures through which health priorities are defined, knowledge is generated, and action is coordinated.