Impact of drug resistant tuberculosis on livelihoods of people and their households and mitigating effects of conditional cash transfers in Zimbabwe

Tuberculosis (TB) leads to income and non-income losses among people and their households. Often times TB comes as an extra shock over and above shocks which exist within communities. In responding to TB, households, depending on resources they have, apply different coping strategies which may be reversible or non-reversible. These coping strategies in turn determine whether households become resilient or vulnerable to shocks. Current measures of socioeconomic impact of TB e.g. incidence of impoverishment and patient costs are money centric, one-dimensional and are benchmarked against income. However, income is difficult to measure especially in low and middle income countries where employment is informal and/or unstable. Estimates of current measures are dependent on how income is estimated. Consequently, they tend to overestimate the impact of TB in poor people and in people who have strong social networks. By contrast, they potentially underestimate impact of TB since they do not capture other facets of wellbeing e.g. deterioration of social relations and sale of assets. In this PhD thesis, I applied the sustainable livelihood framework to investigate socioeconomic impacts of TB on livelihoods and mitigating effects of conditional cash transfers (CCTs) in Zimbabwe. Firstly, I conducted a mixed methods study to investigate coverage and effectiveness of CCTs for people on drug resistant TB (DR-TB). Secondly, I used qualitative methods to explore how people with DR-TB cope with the disease and other stressors within their communities. Thirdly, I proposed a multidimensional measure of socioeconomic impact of TB on people and their households. Finally, I conducted a cross sectional study to compare loss of livelihood between TB-affected households and households not affected with TB during the COVID-19 pandemic. This thesis revealed that TB affected households are twice more likely to experience loss of livelihood compared to non-TB affected households within their community. Among TB affected households, there were no differences in loss of livelihood by DR-TB status. TB leads to post TB sequalae and narrows job opportunities, especially in people who work in dusty environments. While people who received CCTs were 35% more likely to attain successful TB outcomes (treatment completion and cure), CCT disbursements were inconsistent and were characterised by delays. Moreover, coverage of CCTs was suboptimal and the value of CCT (US$25 per month) was inadequate to mitigate both income loss and socioeconomic impacts of TB, especially among people who delayed starting TB treatment. Consequently, people ended up adopting harmful coping strategies e.g. selling productive assets and withdrawing children from school. The impact of TB can be reduced through complementing biomedical approaches e.g. early diagnosis of TB with multisectoral social protection targeting households affected by TB and at risk households. Delays and inconsistent disbursements remove the protective effect of social protection against harmful coping strategies. Hence, timely, consistent and shock responsive social protection is crucial to mitigate income loss, socioeconomic impacts of TB including harmful coping strategies.