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Our project will be conducted in South Africa, an upper-middle income ODA country and will primarily address the development challenges of sustainable health and wellbeing. Our work will contribute towards ensuring good health and wellbeing (Sustainable Development Goal (SDG) 3), with particular emphasis on goal 3.4 - reducing premature mortality from non-communicable diseases. We will achieve this by generating knowledge that will inform the design of innovative interventions that will optimise the benefits of self-management of chronic health conditions and tackle the growing problem of multimorbidity affecting people in rural marginalised settings in South Africa. This will improve health, wellbeing and economic productivity of individuals, households and communities and facilitate economic development. In this way, our work will address an explicit development challenge and directly inform the wider development agenda for South Africa, as recognised by the South African National Development Plan which aims to eliminate poverty and reduce inequality by 2030. This also aligns with the UK Aid Objective 4 (tackling poverty and helping the world's most vulnerable). The project investigators have different strengths and expertise which will be shared across the team. Therefore, the project will strengthen mutual collaboration between the investigators and improve their capacity and skills in multimorbidity research methods, data collection, processing, analysis and interpretation. As part of the proposed research we will train local fieldworkers in Agincourt in quantitative and qualitative data collection methods. This will help build research capacity and enhance the skill set of those involved. This is likely to increase their professional standing within their peer group. The project will also contribute to the career development of early career researchers that will be mentored by the project team's senior investigators. Further, our research will contribute to training of masters and doctoral candidates at Wits and UCL by providing data for their research projects. In addition, our research will provide a valuable data resource for advancing research capacity of other researchers beyond the named project investigators following the public release of the data. The research work in this project will lead to an increase in knowledge regarding multimorbidity and self-management that is likely to have applicability beyond the study setting and may impact on people living in other areas in South Africa and beyond. The proposed study will form the basis for future projects on implementation and evaluation of innovative self-monitoring and self-management strategies to tackle the rising burden of multimorbidity in rural South Africa. The leading role of the Agincourt HDSS in the South African Population Research Network- a South African Government Department of Science and Innovation funded network of HDSS sites, founded on the existing rural HDSS sites in South Africa (Agincourt in Mpumalanga Province, Africa Health Research Institute in KwaZulu Natal Province and DIMAMO in Limpopo Province) and extending to one more rural site in Eastern Cape Province and three urban sites in (Gauteng, KwaZulu-Natal and Western Cape Provinces) will make it possible to expand future work to other areas in South Africa. The potential to inform future research work on self-monitoring and self-management among individuals living with multiple chronic conditions in sub-Saharan Africa is also enormous through the involvement of Agincourt HDSS in the International Network for the Demographic Evaluation of Populations and Their Health and the leading role played within the network by the MRC/Wits-Agincourt Unit researchers.

Because it increases the morbidity and mortality of bacterial infection, as well as the duration and cost of antibacterial treatment, antibiotic resistance constitutes a significant threat to global public health. The problem is even more critical in low- and middle-income countries which have higher infectious disease burdens, often higher rates of antibiotic resistance, less access to diagnostic tools, and fewer financial resources to purchase newer more effective antibiotics. In South Africa, antibiotic resistance is particularly high, despite an effective drug regulatory system and various initiatives to tackle the problem. Antibiotic resistance is accelerated by the overuse and over-prescription of antibiotics, which is the product of complex interactions between providers' decisions and knowledge, and patients' expectations. Yet research on the determinants of prescribing behaviours from LMICs in general, and South Africa in particular, is limited, and has been criticised for being too descriptive and superficial, with limited insight into the relative importance of different behavioural determinants to be able to prioritise interventions. In South Africa, most research efforts have focused on hospitals rather than primary care, despite the fact the majority of antibiotics are prescribed in primary care, mostly for respiratory infections. This study aims to explore how the interactions between providers and patients influence inappropriate antibiotic prescribing for URTIs in public and private primary care in South Africa. The study will include three components. First, drawing on medical anthropology, we will explore qualitatively providers' and patients' perceptions an experiences of antibiotic prescribing. This will be done through observations of consultations, interviews with providers and focus group discussions with patients. Second, building on the first part and drawing on methods from marketing research, we will design a survey consisting of a series of hypothetical clinical cases where clinical and patient characteristics will be systematically varied; for each case, the providers taking part will be asked indicate what drugs they would prescribe in a list of proposed drugs. The results will allow us to quantify the relative importance of the factors influencing antibiotic prescribing, with a view to inform policy-makers design future interventions. Finally, drawing on recent economics and medical education research, we will move beyond observational research and design a small randomised field study to test the impact of patients' knowledge and financial incentives on the prescribing practices of public and private primary care providers. This will be achieved with the use of standardised patients, who are healthy subjects trained to portray specific symptoms and disclose a rehearsed medical history. These patients will be sent to visit providers who agreed to take part in the research, at a time and under an identity unknown to them. The standardised patients will only differ in their expectations of antibiotics and the insurance status they will disclose. This will allow us to test the impact of these different characteristics on the likelihood of antibiotic prescription. We anticipate that the results will provide invaluable insights into our understanding of prescribing decisions in the public and private sector in South Africa, thereby informing the stewardship programmes for antimicrobial resistance in this country. Beyond this setting, these findings will be useful to other middle-income countries with a similar mix of public and private providers. More generally, we aim to produce high-quality research and develop innovative methods that could be replicated in other low-income settings to study antibiotic prescribing.

The private sector provides a large proportion of health services in many low- and middle-income countries (LMICs), particularly for primary health care (PHC), even for poor patients. But the role of the private sector in expanding universal health coverage (UHC) in LMICs remains contentious. Proponents argue that the private sector could increase patient choice and PHC access, and that competition incentivises private providers to be more responsive and provide better quality care than public providers. However, evidence suggests that these advantages may not materialise. Arguments supporting the role of the private sector rely on the assumption that private providers compete for patients. Yet many factors influence market performance and health markets are often not competitive. Effective competition also requires that patients respond to changes in price or quality. Although these dynamics are critical in determining the health system impacts of private PHC provision in LMICs, they have received little attention in the literature. Understanding the role and impact of private sector provision is especially important in South Africa as policy proposals for achieving UHC promote the contracting of private providers to expand access to quality PHC for uninsured patients. There are concerns about the current performance of private PHC providers, and the functioning of the PHC market, with little empirical evidence to inform current debates. Expanding the role of the private sector as part of efforts to achieve UHC requires a more thorough understanding of the potential risks and benefits, and the likely responses of both the supply and demand sides of the market. The aim of this study is to undertake a detailed empirical investigation of the market for public and private primary care services. It will focus on the determinants of provider performance on the one hand, and demand for private services from uninsured cash-paying patients on the other. The study will be conducted in Soweto, Johannesburg, and it will include five components. Firstly, we will undertake a detailed description of the local PHC market through a census, mapping and interviews of all providers, an analysis of market concentration, and investigation of the strategies which private providers use to compete for patients. Secondly, using 'fake' standardised patients (SPs), we will compare the performance of private and public providers in terms of accessibility to services, technical quality of care and cost of treatment recommended. Thirdly, we will establish the relationship between competition and performance outcomes, testing if greater competition leads to better outcomes. Fourthly, using linked data on provider performance and cost, we will investigate if accessibility, quality and cost are important determinants of the demand for services by uninsured patients. Finally, in a small randomised pilot, we will test study how populations would react to the introduction of subsidised access to private services, and explore if information about quality influences demand. The study will provide important information on whether the private PHC market can contribute to better health system access, quality and efficiency. The results are relevant to many LMICs trying to expand UHC within mixed health care systems.

Throughout the world the numbers of people with non-communicable (NCDs) diseases, like type 2 diabetes and high blood pressure, are increasing. The risk of developing diabetes is associated with being poorly nourished as a child and then becoming obese later in life, being inactive, having a poor quality diet, as well as with genetic inheritance and poor growth in the womb. Low- and middle-income countries, like South Africa, have particularly fast-growing numbers of people with NCDs and have health systems already struggling to manage the burden of infectious diseases. We have shown that in rural South Africa a third of girls have growth faltering at one year of age, and a third of adolescents and young women are overweight or obese by 20 years of age. Five percent of 7 to 15 year olds already show early warning signs for the development of diabetes. To combat the problem of an increasing prevalence of NCDs, it has been suggested that improving adolescent nutritional status may be a successful strategy, and that developing and evaluating pre-pregnancy interventions that promote healthy behaviours in poor communities where childbearing tends to start at a younger age, may be part of the solution. Sub-Saharan Africa is the only region worldwide where the number of adolescents is predicted to grow, but it also has the worst adolescent health profile. To date, we are still unclear about how best to intervene to improve nutritional status in adolescents in low- or middle-income countries. Our extensive research over the last five years, has informed the development of an intervention targeting adolescent girls and boys. It will employ trained adolescent-focused community health workers (AHWs) to work with adolescents to address both underweight and obesity by: (i) promoting healthy behaviours and increasing their use of adolescent health services; (ii) encouraging better caregiver and friend support and increasing opportunities in the community to become more healthy; and (iii) supporting adolescent girls who become pregnant to use antenatal health services earlier in their pregnancies and more frequently. This intervention aims to identify and reduce NCD risk in adolescents, and increase their use of health services through supporting behaviour change. AHWs will be trained in 'Healthy Conversation Skills', a set of skills to support behaviour change specifically developed and tested for use with socioeconomically disadvantaged women to improve their confidence that they can achieve their health goals. AHWs will use these skills as the basis for their work in rural SA villages over two years, building relationships with adolescents and their families to encourage social support for healthier adolescent lifestyles. The intervention is flexible in its approach and will focus on the most relevant area of difficulty for each participant. AHWs will also involve their adolescent peer group in the village to promote health literacy. Health literacy will both increase adolescent access to health information and develop their ability to use this information effectively. AHWs will mobilise village community leaders to create greater opportunities to promote and support healthier lifestyles. Adolescents who become pregnant will be further supported by AHWs to access and regularly attend antenatal services, facilitate caregiver involvement, and reinforce optimal individual health (including weight gain) during pregnancy. Through these interventions we aim to reduce the incidence of low of high birthweight in the infants, as these have been associated with diabetes risk in later life. The proposed development grant will enable us to complete a feasibility and pilot study in two villages to provide critical data to inform both the design and implementation of the trial.