This high-impact project is concerned with how an interdisciplinary approach to fire science and engineering can improve the resilience of informal settlements against fires. Through a combination of state-of-the-art experimental and modeling fire science coupled with unique data gathering in informal settlements and novel applications of existing satellite data, we will deliver a framework to assess fire risk in informal settlements and propose technologically appropriate, data driven risk reduction methodologies. Over one billion people across the globe live in informal shack settlements, and this number is ever increasing as urbanization increases. Many of these informal settlements are at constant risk of lethal and large scale fires, due to flammable construction materials, heating and cooking methods, proximity of the shacks, and a lack of effective fire services, amongst other factors. For occupants of these shacks, death and injury from fire constitute 'a serious public health problem'; 96% of the world's burn-related deaths (about 300,000 deaths annually) occur in lower- and middle-income countries. Africa is the fastest urbanizing continent at 7% average increase between 1990-2015 and the population in urban clusters has increased by 484 million people in 25 years. In South Africa it is estimated that up to one third of the population now live in informal settlements, and in Cape Town the number of informal dwellings grew from around 28,000 in 1993 to 104,000 in 2006. Cape Town is known as the fire capital of South Africa and between 1990 and 2004 the Mandisa GIS database tracked over 18,500 fire incidents recorded, 47% occurred in informal settlements. On an annual basis there are around 500 deaths and 15,000 fire related hospital related admissions due to fire in the city, of which a substantial proportion are people from informal settlements. The project will develop the new methods and tools required to evaluate and model the fire risks within South African informal settlements of the Western Cape so that situationally appropriate and cost-effective solutions and strategies can be suggested to improve the resilience of South African informal settlement communities against large-scale conflagrations. This will be achieved through producing new guidelines, based on unique experimental data generated in the UK and in South Africa, surveying of Western Cape informal settlements to improve stochastic data on their composition and topography, probabilistic modelling of informal settlements based on validated models using experimental data, and important engagement and consultation with the stakeholders within informal settlements (NGOs, fire services, policy makers and local residents) to ensure that any new guidelines are appropriate and effective. Additionally, a framework for risk mapping and monitoring, based on results of experiments and modelling within this project, will direct and inform where interventions using the guidelines are the most important, by highlighting the areas of highest conflagration risk. The modelling tools, frameworks, and associated data will be disseminated through free workshops and CPD events to informal settlement stakeholders, with the aim of developing capacity within South Africa to continue and improve research developments and design specifications of informal settlements with respect to fire safety engineering The proposed developments of understanding, tools, frameworks and guidelines, whilst based on South African informal settlements will be produced in a way that can be easily transferred and applied to similar settlements elsewhere in the world. The benefit to all these settlements, in the Western Cape and elsewhere globally, will be a reduction of loss of life, property, and will increase the economic prospects of those who live in the poorest areas of the world.

In every country in the world, especially poor countries, people experience ill-health because of what they eat. Not eating enough nutritious foods, and eating too many unhealthy foods means young children do not grow properly, women do not get enough vitamins and minerals, and many more people are affected by overweight and diseases like diabetes. This is often called "malnutrition" and is especially serious for young children, including babies, many of whom are not properly breastfed or receive inadequate nutrients when they are under the age of five. One country with a major malnutrition problem is South Africa. Most people in South Africa live in cities, where life is difficult for poor people. These people have long travel times to work and live in tiny houses. This makes it really difficult for them to store and prepare nutritious foods at home. As a result, they often rely on food that they can eat straight away or does not spoil, like fatty fried food and sugary snacks and drinks. Because they have so little money and time, they often feed babies watery, starchy foods without enough nutrients. Where they live and work, this food is readily available and cheap. In fact, the whole system of things that bring food into their neighbourhoods makes it easier and cheaper to create an environment around them that's full of the wrong types of food. This system is known as a "food system." This all means, too, that the many efforts the government has made in South Africa to help people eat better have not really reached their potential, efforts such as the extra money they give to poor families for their children, or programmes designed to help them feed their toddlers better. While South Africa has its own specific context, this is also the case in many other countries around the world. In our project, we want to change this. We want to see a whole system of actions that will actually work for people who live in cities. This means ensuring that existing actions to help them are better aligned with and supported by that food system, as well as designing new actions within the system that recognise the challenges in peoples' lives. We are going to provide evidence to know what this system of actions would look like. We will do this in a way that is not done very much: to actually start by listening to the people in urban settings who experience the problems we are talking about. We will talk to families who have children under the age of 5, as this is the group the evidence says needs most support, along with their mothers and other women who might have babies quite soon. We will walk with them around their neighbourhoods and find out what influences the foods they eat, and what could change that. We will talk to them about the ways the government already tries to help them and whether they know about them, or are able to respond to them. And together with them, we will design a system of actions that would actually work for them and their children. We will also talk to the government about what they can do, especially about changes further back into the entire food system, as well as in urban planning. And we will bring into a broader conversation all the people who have influenced what these people eat. Together we will work to design a system that supports children and their mothers eating foods that support their health and development. We will do this in two communities in the fourth largest province in South Africa: the Western Cape. We have chosen that place because the local government is already committed to improving food systems to address poor nutrition in their communities, and have asked us to help them identify what could effect real change. Although we will conduct this study in South Africa, it will be relevant to the region and the whole world. So we will produce reports and other materials that help other people in other cities create a more effective response to poor diets in their communities.

Twenty years after the ending of apartheid the time is ripe to evaluate South African experience of health system transformation. Much was promised and many changes have been introduced - but how much has been achieved, especially for the most vulnerable and previously disadvantaged groups? What factors have enabled or constrained change across the public health system, nationally recognised as the leading edge of efforts to improve the health and well-being of vulnerable groups? What lessons does past experience hold for continuing efforts to improve health care and health? What issues need to be tracked over time to generate the evidence needed to support future policy and managerial decision-making? This proposed grant intends to address these questions. It is jointly submitted by a team of public health system policy-makers/managers and researchers based in the Western Cape (WC) province. As South Africa is a quasi-federal state, the WC provincial government has the constitutional responsibility for ensuring an effective health system for its population. It also has a reputation for having been relatively effective in sustaining implementation of such change over the last 20 years. Examining the particular experience of one province, in comparison with wider national experience, will allow in-depth investigation of South African health system transformation. The project will consider not only what changes have been implemented, with what achievements and challenges, but also what set of political, leadership, organisational and other factors have supported or limited the implementation of change. From this analysis it will seek to identify the pathways to change underpinning health system development in the province. The project team's combination of experience and expertise will support this in-depth investigation. Better understanding of what the province has achieved and how, set against the national context, will offer insights of relevance across the country, as well as internationally. It will also, more specifically, contribute to generating the evidence base needed to support future policy and management decision-making, by supporting provincial health system monitoring and evaluation activities and identifying related, larger scale research needs.

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.

Citizens in LMICs experience a range of problems with public and private health services: from poor quality of services to rights violations. In spite of numerous calls and interventions for increased community participation in health, service users and citizens often do not have adequate opportunities to engage with the system about their problems and induce appropriate responses and remedies. Responsiveness to citizens' rights and needs is an essential quality of health systems, and is necessary in order to provide inclusive and accountable services, ensure the social rights of citizens and improve the quality of services. Mechanisms for feedback and response are varied and result in dispersed and sometimes conflicting feedback. These range from conventional facility-based complaints boxes and exit surveys to strategies such as community report cards, social audits, and hotlines. Citizen feedback at community-level has also been sought by implementing health facility committees, intersectoral forums, and community monitoring systems. Growing access to information technology in LMICs has often empowered citizens to raise their concerns through social media, the mainstream press, and even through social protest. Health system responsiveness is gaining global currency as an intrinsic goal of health systems alongside service delivery outcomes, financial fairness and equity. However our current understanding of health system responsiveness is extremely limited, and there is a significant evidence gap about the structure, implementation and effectiveness of citizen feedback and the related response mechanisms about health services currently in place in LMICs. In this study, we aim to address these knowledge gaps by asking: What policies and mechanisms (formal and informal) work for receiving and responding to citizen feedback on health systems in South Africa and Kenya? How can health systems responsiveness be strengthened towards the development of learning, equitable health systems? The proposed study is an interdisciplinary mixed methods study, running from 2018 to 2020. The study will be conducted in three phases, and we will apply several, primarily qualitative methods and tools. The first phase will consist of 'mapping' of policies, feedback mechanisms and pathways for system responsiveness in the study provinces (as well as theoretical and methodological framing relating to responsiveness). Many governments in LMICs are recognising the pressing need to improve health system responsiveness, and both countries in this study have recently implemented significant policy reforms aimed at improving responsiveness to citizen feedback on health services. We will capitalise on this window of opportunity, with the second in-depth phase consisting of case studies in each country, tracking the implementation experience of a particular innovation in this area. The third phase will focus on knowledge translation and cross-country comparison. This project will contribute to a deeper and more systematic understanding of health system responsiveness in South Africa and Kenya, with relevance for other comparable LMICs. By applying an embedded approach to HPSR, it is intended that the research will also have a health system strengthening effect: creating space for reflective practice, strengthening feedback and response within the system, and improving decision-making opportunities for HS leaders. Therefore, this study on responsiveness to citizen feedback should also improve the responsiveness of the health systems in which it is implemented. In each country, we have partnered with policy decision-makers engaged in implementing reforms for greater health system responsiveness, and this study will directly help bring about improvements in these policies. We will also engage with other health system and civil society leaders to identify strategies to strengthen health system responsiveness.