This follow-up project aims to integrate into adaptation and resilience policy-making some of the lessons gained through the Why We Disagree About Development (WhyDAR) research project (NE/P01609X/1). WhyDAR aimed to identify different ways in which urban resilience is understood while investigating the role of science, technology, ethics and expertise in the making of resilience strategies in the Global South. It drew out key ethical questions arising from disagreement about conceptions to resilience, and asked what an equitable approach to resilience would look like in the face of this disagreement. Aiming to integrate these lessons into real-life adaptation and resilience policy, this project will work together with the climate adaptation team at the municipal level in Cape Town, South Africa (upper middle income). South Africa is likely to experience - and, in some cases, have already experienced - the negative effects of climate change, such as droughts and floodings. Unfortunately, access to resilient infrastructures, including housing, health care, and food chains, and representative institutions is highly unequal, inequitable, and inadequate within South Africa. Consequently, especially the poorest and most vulnerable community members are often left out and underrepresented within resilience and adaptation strategies, threatening their lives, health, food security, livelihoods, well-being, and access to crucial services, such as water and energy supply. This situation raises ethical issues of how adaptation and resilience planning within the most climate vulnerable LMICs can become more equal, equitable, and representative of those who are most in need of inclusion, including taking into account the fact that different stakeholders have different conceptions of and aims for resilience. Working together with the municipal climate adaptation team of Cape Town, the project will develop and implement three procedural methodologies for inserting ethical deliberations into adaptation and resilience planning and policy-making at the local and municipal level: (i) Stakeholder dialogues bring together representatives of different affected groups, including policy-makers, city council members, service providers, NGOs, businesses, and not members of the local communities. Through dialogue, deliberators will be forced to take into account the interests of other groups, explain and provide justification for their own views. (ii) Scenario building exercises will encourage deliberators to reflect on the ethical aspects of different resilience scenarios and how they may be resolved. In particular, we will try out an exercise in which the deliberators will be behind a 'veil of ignorance' when considering a scenario and will not know what identity they have within it. Only afterwards will their identities be revealed to them and they will then evaluate whether the solutions that they came up with behind the veil were really fair to all stakeholders. (iii) Problem-oriented deliberations focus on solving particular, real-life resilience challenges. At different stages during the planning process, the planners will be asked to reflect, with the help of a trained ethicist, on the ethical implications of their plan. The aims of these exercises will be to test different framework for inserting ethics into resilience planning in Cape Town; to draw lessons and best practices from that, which can be scaled up and implemented in similar LMIC contexts; to identify and co-produce knowledge about the ethical aspects of resilience planning; and to build capacity for taking into account ethics when deliberating on resilience within municipal and local institutions. The project will involve researchers at the University of Warwick and the University of Cape Town in collaboration with the City Climate Adaptation Team of Cape Town and the non-governmental organizations Practical Action and Christian Aid.

Adolescence is a formative phase of life which shapes the health and well-being of an individual for adulthood. In South Africa, adolescents are experiencing large and growing burdens of disease with high rates of communicable diseases (like HIV and TB), pregnancy, obesity, mental illness and trauma. Government policies to support adolescent healthcare have been widely implemented, however, challenges remain in how such policies are operationalised to strengthen adolescent healthcare: primary care clinics report low attendance of adolescents and school health reviews show low service provision. The Knowledge Translation Unit in Cape Town has developed the PACK Adolescent guide and training programme to support primary care clinicians (nurses and doctors) with tools to meet the needs of adolescents. The aim of this study is to understand the status of adolescent healthcare in primary care clinics and schools in order to refine and adapt PACK Adolescent to meet the needs of adolescents and the challenges faced by clinicians in providing care to this underserved grouped. Once refined, we shall pilot and evaluate PACK Adolescent in schools and clinics to see what more we need to do to optimise PACK Adolescent and what we need to alter about the delivery of adolescent healthcare to enable its use in primary care clinics and schools in other settings. From the outset, the design of this study involved the input of adolescents themselves, primary care clinicians and policymakers in health and education sectors during a stakeholder workshop. Throughout the grant's duration, stakeholder input and co-production will characterise the study through theory of change workshops and an advisory board. The study seeks to assess adolescent primary health care in six clinics and twelve schools in the Western Cape province of South Africa through a facility questionnaire to determine various aspects of adolescent healthcare services and the clinical characteristics of adolescents using these services. We shall observe the processes that adolescents follow to receive health care, including their consultations with clinicians. Focus group discussions with school and clinic managers, clinicians, community-based organisations, policymakers and adolescents will provide a broad understanding of existing adolescent health care. We shall then refine the PACK Adolescent guide and training programme following a theory of change workshop (a workshop intended to develop a system of ideas to explain how we think change happens in the area we want to address, and how we intend to work to influence these changes) with key stakeholders. The adapted intervention will then be piloted and evaluated in the six clinics and twelve linked schools (primary and secondary). Through observations of the use of PACK Adolescent and resultant changes to the clinical pathway for adolescents as well as interviews with adolescents, clinic clinicians and school health nurses we will see how PACK Adolescent meets the needs of adolescents and clinicians along with the challenges to its use. A survey questionnaire completed by clinicians in schools and clinics along with routine health data will help us to assess its impact. The outcomes of the study will provide an understanding of adolescent primary healthcare across schools and clinics. It will allow us to identify the minimum system strengthening components needed to support adolescent healthcare in an integrated way in both health and education sectors. We shall share these outcomes with participating schools and clinics, as well as the Departments of Health and Education in the province and nationally. They will inform the design of a future study evaluating whether PACK Adolescent leads to improved outcomes for young people.

Mitigating the rapid global spread of Covid-19 requires real-time data on community infection prevalence in order to guide targeted intervention measures on regional, national and global scales. Individual diagnostic testing is of paramount importance for short- and long-term management of the pandemic, but limits on capacity (both of kits and trained workers) mean that healthcare settings are prioritised over the community. Here we propose a novel supplemental low-resource approach for broad community-wide surveillance of SARS-CoV-2 infection prevalence. We aim for a real-time Covid-19 risk prediction platform for community-wide diagnostics via wastewater-based epidemiology (Figure 1). Disease markers present in domestic wastewater can reveal the health status of contributing population, and we propose that this includes the infection prevalence by SARS-CoV-2. Real-time spatiotemporal estimation of this novel coronavirus in urban water across several sites in South Africa (Cape Town) and Nigeria (Lagos) will provide a broad picture of community infection prevalence, even for asymptomatic cases, as well as the level of acquired immunity, thus identifying hotspots for priority testing, contact-tracing and quarantine and will provide more accurate projections of the spread of the virus and the infection fatality rate. As communities contribute directly to wastewater, we will be able to estimate true infection rate at the community level, including also asymptomatic and pre-symptomatic people. The virus loading levels will be used to establish status and time trends. This would enable rapid identification of hot spots for management via targeted intervention measures and potentially support important decisions regarding entry into and exit from 'lockdown' periods as well as focussed screening of selected communities.

There are important gaps in the primary care delivery of child health in low and middle income countries: there is little user-friendly guidance for health workers seeing children over the age of 5 or those with increasingly common long term conditions like asthma, and preventive care (like vaccinations and growth checks) is not smoothly integrated with sick-child services, making for disjointed care for children, their caregivers and health workers. The Knowledge Translation Unit in Cape Town has developed a health systems intervention for adult primary care (Practical Approach to Care Kit - PACK) that has become entrenched in health services throughout South Africa and is being piloted elsewhere in Africa and in South America. PACK comprises a clinical guide, a training package and work at policy and management level to prepare the system and the health worker for its implementation. The unit has conducted rigorous implementation science studies showing that PACK improves care and patient outcomes. The reasons for PACK's success are that it takes a comprehensive, simple approach to clinical care while tackling the systems issues that make improving primary care difficult. A partnership with the British Medical Journal is helping take PACK to a global audience (www.pack.bmj.com). In response to the gaps described above and to requests from those using PACK Adult, the KTU has now developed the first version of the PACK Child clinical guide in collaboration with local government in the Western Cape province of South Africa, and plans to implement it alongside PACK Adult in several countries. Before rollout, however, we need to work out two things: One, how best to implement the PACK Child programme in a system that has multiple other programmes and priorities - and limited capacity - and two, how best to evaluate whether PACK Child does indeed improve the care and health of children. This Foundation Grant will support the KTU to: - Develop and pilot the PACK Child health systems intervention package. - Design the research protocol to evaluate the PACK Child health systems intervention. - Establish a PACK Child Advisory Board. Each of these activities will draw on stakeholders from policy makers to nurses and doctors to children themselves to ensure that the PACK Child health systems intervention and its evaluation speaks to the needs of those who will use and benefit from it.

The problem: Building climate change resilience necessarily means building urban resilience. Africa's future is dominated by a rapidly increasing urban population with complicated demographic, economic, political, spatial and infrastructural transitions. This creates complex climate vulnerabilities of critical consequence in the co-dependent city-regions. Climate change substantially complicates the trajectories of African development, exacerbated by climate information that is poorly attuned to the needs of African decision makers. Critical gaps are how climate processes interact at the temporal and spatial scales that matter for decision making, limited institutional capacity to develop and then act on climate information, and inadequate means, methods, and structures to bridge the divides. Current modalities in climate services are largely supply driven and rarely begin with the multiplicity of climate sensitive development challenges. There is a dominant need to address this disconnect at the urban scale, yet climate research in Africa is poorly configured to respond, and the spatial scale and thematic foci are not well attuned to urban problems. Most climate-related policies and development strategies focus at the national scale and are sectorally based, resulting in a poor fit to the vital urban environments with their tightly interlocking place-based systems. Response: FRACTAL's aim is to advance scientific knowledge about regional climate responses to anthropogenic forcings, enhance the integration of this knowledge into decision making at the co-dependent city-region scale, and thus enable responsible development pathways. We focus on city-region scales of climate information and decision making. Informed by the literature, guided by co-exploration with decision makers, we concentrate on two key cross-cutting issues: Water and Energy, and secondarily their influence on food security. We work within and across disciplinary boundaries (transdisciplinarity) and develop all aspects of the research process in collaboration with user groups (co-exploration).The project functions through three interconnected work packages focused on three Tier 1 cities (Windhoek, Maputo and Lusaka), a secondary focus on three Tier 2 cities (Blantyre, Gaborone and Harare), and two self-funded partner cities (Cape Town and eThekwini). Work Package 1 (WP1) is an ongoing and sustained activity operating as a learning laboratory for pilot studies to link research from WP2 and 3 to a real world iterative dialogue and decision process. WP1 frames, informs, and steers the research questions of WP2 and 3, and so centres all research on needs for responsible development pathways of city-region systems. WP2 addresses the decision making space in cities; the political, economic, technical and social determinants of decision making, and seeks to understand the opportunities for better incorporation of climate information into local decision making contexts. WP3, the majority effort, focuses on advancing understanding of the physical climate processes that govern the regional system, both as observed and simulated. This knowledge grounds the development of robust and scale relevant climate information, and the related analysis and communication. This is steered explicitly by WP1's perspective of urban climate change risk, resilience, impacts, and decisions for adaptation and development. The project will frame a new paradigm for user-informed, knowledge-based decisions to develop pathways to resilience for the majority population. It will provide a step change in understanding the cross-scale climate processes that drive change and so enable enhanced uptake of climate information in near to medium-term decision making. The project legacy will include improved scientific capacity and collaboration, provide transferable knowledge to enhance decision making on the African continent, and in this make significant contribution to academic disciplines.