Table 1

Overview of study settings and healthcare context

Malawi, a country with a population of 17.6 million, is among the poorest countries in the world.59 It ranks 174 out of 189 countries in the human development index and had a per capita gross national income (GNI) in 2019 of $550.60 Malawi gained independence from British colonial rule in 1964, with Hastings Kamuzu Banda governing the country under autocratic rule until 1994. He used international donor money for large-scale infrastructure projects,61 often in urban centres leaving rural areas underdeveloped. Severe debt, limited public sector funds, corruption and HIV have undermined modest development gains.62–64 Today, the majority of funds for public services, including health, come from international donors.65 Chikwawa is a rural district in the country’s southern region, where subsistence farming is the predominant livelihood. Malaria is endemic and, annually, Chikwawa records one of the highest rates in Malawi.66 As is the case nationally, government health services are free, and residents are highly reliant on primary facilities.67 However, there are geographical inequities in healthcare coverage, with rural areas facing persistent staff shortages and regular medicine stockouts.62 67 Private and informal providers exist but are less prominent in Chikwawa than in cities, partially due to the lack of cash available to most residents.Zimbabwe has a population of 14.6 million, of which 1.5 million live in the capital of Harare. Zimbabwe ranks 150 of 189 countries in the human development index and in 2019 had a per capita GNI of $1200.68 Zimbabwe boasted one of Africa’s strongest postcolonial healthcare systems following independence in 1980, with robust primary healthcare infrastructure and a strong essential drugs programme.69 However, by the late 1990s, these achievements were undone by political repression, structural adjustment, hyperinflation, increasing privatisation and the HIV pandemic.70 Life expectancy was less than 50 years during the 2000s, and the neglect of water and sanitation infrastructure led to a cholera outbreak in 2008–2009 that killed over 4000 people, many in high-density suburbs of Harare.39 Since then, frequent and increasingly drug-resistant outbreaks of cholera and typhoid have occurred.40 Mbare and Budiriro, where we conducted research, are among such suburbs. Most residents live within walking distance of a public clinic, yet healthcare is not readily accessible: residents must pay a user fee and, furthermore, must often purchase prescribed medicines at a retail pharmacy.50 While Zimbabwe has historically had a strong regulatory environment, since economic collapse, informal markets have grown substantially, with Mbare’s expansive marketplace a hotspot of medicine vending.Uganda has a large population of 44.2 million and ranks 159 of 189 in the human development index, with a per capita GNI in 2019 of $780.71 Before independence in 1962, the Ugandan health system was entirely funded by the government but, following political unrest and economic decline in the 1970s and 80s, during the 1990s health sector reforms were implemented, including decentralisation, forming a multilayered public healthcare system.72 Healthcare in the public sector in Uganda is free but suffers severe resources shortages, including frequent drug stockouts and a lack of equipment and supplies.73 The country’s large private sector includes hospitals, clinics, pharmacies and drug shops, the latter of which are licensed and regulated but generally extend beyond their formal roles. This includes the unlicensed sale of antibiotics.74 Namuwongo is a large informal settlement in Kampala, where many people who work in the city centre and the surrounding affluent suburbs reside. The settlement has notoriously poor water and sanitation infrastructure.75 Nagongera is a subcounty in the rural district of Tororo, where over 70% of the population survive on subsistence farming and where most live hand to mouth, with over 50% of the population living on less than $1 per day.76