When Resilience Fails
: The Political Economy of Treatment Seeking Behaviour and Impact of Direct Cost/OPPs on Households of People Living with HIV in Harare Metropolitan Province, Zimbabwe

  • Phillip Nyahoda

Student thesis: Doctoral ThesisDoctor of Health (DHealth)


Background: The availability and coverage of Anti-retroviral therapy (ART) has increased and led to reduced morbidity and mortality in Zimbabwe and Southern Africa in general. However, direct costs and socio-cultural factors that influence treatment seeking behaviour (TSB) continue to impede progress towards universal coverage by leaving behind people in need of treatment. The failure of the current health system due to the crisis of accumulation predicated by the lack of savings and investment has resulted in direct costs/out of pocket payments (OPPs). The direct costs/ OPPs are an obstacle towards equitable access to ART. Socio-cultural factors influence the utilization of services due to stigma and religious beliefs, as they have a bearing on treatment seeking behaviour patterns. Although coping strategies such as the borrowing and selling of assets may have been used to smooth consumption, but they have not been adequate enough to mitigate the direct costs of treatment resulting in resilience mechanisms to fail. Methodology: A sequential mixed method approach was used to collect data on treatment seeking behaviour patterns, the direct cost of treatments and the effects this had on the average household. At the quantitative level, self-administered questionnaires were distributed to 383 people living with HIV (PLWH) in Harare metropolitan province with a view to find out the treatment seeking patterns, the direct costs/OPPs by service providers, quantify the cost burden of OPPs and the number of PLWH who resorted to coping strategies. At the qualitative level, 16 key informant interviews from this sample were conducted. The aim was to get an understanding and explanation on the consequences of treatment seeking behaviour and how the direct costs/OPPs affected households of PLWH. Results: The major findings of this sequential mixed method study are at two levels; qualitatively and quantitatively, based on a total of 383 people living with HIV in Harare metropolitan province who completed the questionnaires. The findings based on the 383 people living with HIV who completed the questionnaires reveal that, ninety six percent (95.8%) of them paid to have a Cluster Differentiation 4 (CD4) count test, eighty one percent (81.4%) of them paid for treatment, and sixty three percent (62.9%) of them paid towards transport to access treatment or diagnostic services as respondents reported. Fourteen percent (14.1%) of the 383 people living with HIV in Harare metropolitan province who completed the questionnaires paid for antibiotics mainly obtained from pharmacies without a prescription. Eighteen and a half percent (18.5%) of them reported having paid for other diagnostic tests besides CD4 count. The quantitative results further show that, to mitigate against these direct costs the majority of the respondents used ‘hardship financing’ through borrowing (92.2%) and selling of assets (74.2%). The qualitative results explain and highlight the impact of direct costs on the physiological needs and on the household budgets of PLWH in Harare metropolitan province. Consequentially, most households of PLWH are forced into impoverishment and food insecure situations. The situations contribute towards the propensity to seek services of traditional healers by PLWH and they periodically default on treatment, endure multiple untreated infections, engage in transactional sex, self treatment, and work for treatment by young people. Social networks such as family and friends influenced treatment seeking behaviour and they were found to be sources from which PLWH could borrow and or receive money for treatment seeking behaviour.Conclusion and implications for practice: The political economy prevailing in the country is characterised by a crisis of accumulation. This crisis of accumulation is directly responsible for the development of a large informal sector, a fragile and weak health system due to reduced savings and investment, in addition to the mismanagement of other resources. This has resulted in health shocks that consequently, have brought about borrowing and depletion of assets as a way of households financing their health diagnostics and treatment. This has exacerbated poverty and conditions of ill-health. To reduce the impact of health shocks created by the current crisis of accumulation, there is need to adopt broad policies that are embedded in extensive social protection and accountability. There is need to invest in social and health insurance, rethink the way HIV education is taught, integrate services and broaden the scope of results based financing in the provision of health care for PLWH. This would go a long way in achieving meaningful universal treatment targets of not leaving anyone behind, in particular the realisation of the 90-90-90 transformative agenda.  
Date of Award27 Jun 2017
Original languageEnglish
Awarding Institution
  • University of Bath
SupervisorAlan Buckingham (Supervisor), David Wainwright (Supervisor) & Clifford Stevens (Supervisor)


  • Political Economy
  • Resilience
  • Poverty
  • Treatment Seeking Behaviour
  • Out of Pocket Payments
  • Crisis of Accumulation
  • Zimbabwe
  • Southern Africa
  • Africa
  • Health economics
  • Under development

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