People with type 2 diabetes are known to be at increased risk of complications and death from COVID-19, and yet their healthcare has been disrupted by the pandemic. This could lead to more indirect COVID-19 related deaths. Tanzania and Kenya are experiencing increases in the numbers of people with type 2 diabetes, and their ability to manage their condition during COVID-19 may be hampered through lack of access to support, economic hardship and health system challenges. In addition, increased vulnerability may prevent patients seeking treatment, and experiences for people living in urban and rural areas and in the two countries may differ. There is therefore an urgent need to understand how COVID-19 has affected the healthcare and socio-economic welfare of people with type 2 diabetes in Tanzania and Kenya to inform policy recommendations and health education messages to improve health and welfare for this vulnerable population during the pandemic. This project will provide this evidence by administering questionnaires and interviews to people with type 2 diabetes and through interviews to healthcare providers in urban and rural settings in each country. It will also identify the cost of type 2 diabetes to each country during COVID-19 and gaps in national policy and emergency planning responses. The findings will be shared with relevant stakeholders to allow them to input into the development of context-specific policy recommendations and health messages for each country.

Many health systems in low and middle income countries (LMICs) have are financing through multiple sources (taxes, insurance, donor support) and providers are paid through multiple methods (e.g. capitation, fee-for-service, salary). So, health providers are faced with multiple flow of funds, and each source has a different payment modality. Since providers can respond differently depending on which payment method are facing, it is important to implement a payment method that will stimulate providers' productivity to increase and minimise unintended responses. Tanzania, like other developing countries, is currently planning to harmonise the health financing sources (by introducing a single national health insurance) and use a harmonised/ unified provider payment mechanism. The harmonisation of funding sources and unified provider payment mechanisms are key steps towards universal health coverage. In this study, therefore, I propose to better understand providers experience, responses, and preferences for provider payment mechanisms, and also identify the effect of each payment method on service quality, coverage and equity. To know how they perceive available payment methods, how they respond differently, and which attributes they prefer most. Also, to know the varied provider responses to service quality, coverage and equity. This study will also generate policy-relevant recommendation to inform the ongoing planning of designing optimal and feasible provider payment mechanisms in Tanzania. The findings might still be relevant to other settings planning to reform their provider payment mechanisms. Understanding what provider prefer most in terms of payment method attributes, will help design a payment method that can easily be acceptable among providers and response positively to improve service delivery. The research questions will be tackled through multiple sources of data using both qualitative and quantitative data. Data will capture the perspectives and information from health providers, patients, health purchasers, and policy makers. Quantitative data will come from 120 patients exiting care from 2 districts and 240 health workers from 6 districts eliciting the preferences. An 'action-based' dissemination workshop will be conducted to provide key stakeholders with an opportunity to reflect on the key findings, develop priorities, and plans to optimally design practice, feasible and efficient provider payment methods in Tanzania.

To understand and mitigate economic inequalities, both locally and globally, we need to acknowledge inequalities within households. Yet, in most empirical studies, such intra-household inequalities are disregarded mainly because we lack appropriate measurement tools and data. Not only is this problematic for inequality measurement, this lack of understanding hampers the design of cost-effective poverty reduction and child development policies. This project has five general objectives. First, I will update the facts about inequalities through direct measurement of intra-household consumption allocations, and relate these to spousal income contributions. Second, I will develop and validate novel measures of parental resource-allocation preferences and use these to study whether children are likely to benefit more if mothers, rather than fathers, receive cash transfers. Third, I will develop and validate novel measures of household decision-making and use these to investigate how targeted transfers shape women’s empowerment. Fourth, I will study whether cash transfers or an educational parenting program is most cost-efficient for child development. Fifth, I will use an integrated framework and the new tools and data, to refine our understanding of the mechanisms behind inequalities among adults and child development. Concretely, the project will contribute to our knowledge in the following specific ways. I will carry out an extensive data collection on intra-household allocations, parental-allocation preferences and women’s empowerment, in ten very diverse countries, one from each decile of the world income distribution. I will engage in a local RCT in Tanzania on cash transfers and parenting, which also involves extensive data collection on household consumption, time use, preferences and decision-making. Finally, I will conduct lab experiments in Chile, India and Tanzania so as to validate the parental-allocation preference and decision- making measures.

HYDROMAL: Hydro-dynamic drivers of human malaria transmission hazard in Africa. Thomas, Macklin, Smith and Gamarra Summary Malaria is a vector borne disease - we become infected by the bite of an infected mosquito. There is currently great concern that climate change may improve conditions for many disease vectors, such as mosquitoes, and that diseases like malaria will increase. The main burden of this disease falls in Africa, where changes in rainfall and temperature are projected to occur over the next century. While we have a reasonably good understanding, from laboratory studies, of how changed temperature may effect mosquito populations, we have very little on the effect of changed rainfall, which controls the availability of mosquito breeding sites. The distribution of these breeding sites in relation to human hosts is the main driver of local epidemiology, and in many locations across Africa it is likely that changes in precipitation, not temperature, will drive changes in transmission. This is the critical gap our project aims to fill, not by developing new science, but by adding value to existing knowledge by coupling different disciplines. Modern challenges require interdisciplinary thinking, and our project is an example of this. We aim to link well-established tools from geophyscial hydrology with mathematical models of malaria transmission, models that have been around for over 50 years. To quantify this relationship we will spend a year in the field in Tanzania, with a parallel program of hydrology and entomology, working in a large valley with the highest levels of malaria transmission in the world. We will then spend a further year analyzing the data and linking the mathematics. Our idea is that if we can predict where the breeding sites for vector mosquitoes will be at any given time, based on rainfall and terrain, we can estimate the malaria transmission. If we can prove this simple idea works, it will pave the way for future studies linking climate change projections to impact on this disease in Africa. It may also prove useful for health planners: it may prove more effective to target resources in key locations, and it may be that different interventions are more effective in different landscapes.