The first proposal ever drafted, to Delegation of the European Commission to Nepal, during my professional career; scored 82% in technical evaluation, and was rejected. It led to encouragement for number of successful proposals/concept notes.

1. 1
Ensure Quality Health Services through Health Facilities using
Client Oriented Provider’s Efficiency/Participatory
Learning Approach (COPE/PLA)
A Concept Note submitted to Delegation of the European
Commission to Nepal, Uttar Dhoka Sadak,
Lainchaur, Kathmandu,
Nepal
By
XXXXXXX NEPAL
P.O.Box: 23932
Dhobighat, Lalitpur, Nepal
Phone: 977-1-2051027, 977-1-5525486
Fax: 977-1-5525486
Email: info@samjhautanepal.org.np
Website: www.samjhautanepal.org

2. 2
Date: May 30, 2008

3. 3
Title: Ensure Quality Health Services through Health Facilities using Client Oriented Provider’s
Efficiency/ Participatory Learning Approach (COPE/PLA)
1. Relevance of the Action
 General Information/Problem Analysis
Problem and Constraints in general: Over the past two decades, there has been some progress in the
field of preventive and curative health care infrastructure but still health sector in Nepal is facing many
problems. Access to health care delivery is affected by many factors. There has been difficulty in access due
to ethnicity, language, dialects, religion and lack of sound responsive attitude of health providers to client
needs. Government has not been able to afford the supply of Essential Drugs and basic equipments to
health institutions (Three Year Interim Plan of Nepal, 2007). Some of the indicators like low bed occupancy
rates, low contraceptive prevalence rate, high fertility rates, high maternal and infant death rates and high
proportion of malnutrition indicate that there is still underutilization or mal utilization of health care services in
our country. Ample resources have been invested to develop health care infrastructure but most of such
infrastructures are either non-functional or mismanaged. Hence, people are deprived of basic level health
services, which are meant to be delivered through PHCC (Primary Health Care Centre) or S/HP (Sub/Health
Post). So, with this proposed project, Samjhauta Nepal wants to address this gap in health care delivery and
ensure Basic Quality Health Services to the people of Dhanusha district by using COPE/PLA.
COPE, which stands for "client-oriented, provider-efficient" services, is a process that helps health care
staff continuously improve the quality and efficiency of services provided at their facility and make services
more responsive to clients' needs. COPE is cost-effective and does not involve large investments of time
because some activities will be conducted while staffs carry out their routine work. It is also results-oriented.
The COPE tools include a series of self-assessment guides including a record-review checklist, Client-
interview guides, Client-flow analysis and Action plan. Staff will use 10 self-assessment guides containing
several trigger questions. The guides will be based on the clients' rights and staff's needs framework. At
larger sites, the staffs break up into teams assessing the services they provide according to one or two
guides each. Small sites (fewer than 10 people) may conduct the self-assessment over a few weeks along
with their regular work, using one or two guides at a time. The client interviews will be developed to
increase staff's understanding of the client perspective. The self-assessment guides and client interviews will
provide staff with information to identify problems related to the service-delivery process and to develop an
action plan. Staffs will identify and state the problems, their root causes, and appropriate solutions.
Finally, establishing a COPE committee will do the institutionalization of COPE. This proposed project aims
to bring the local people, Health Management Committee (HMC), representatives of VDC offices, and other
possible stakeholders in a forum to understand the needs together, plan and implement together.
 Specific Problems
Dhanusha will be the main focus of this proposed project. It has a population of 671,364 (CBS 2001) and
each VDC has a population of about 5-10 thousands. Altogether, there are 1 Hospital, 5 PHCCs (Primary
Health Care Centres), 9 HPs (Health Post) and 88 SHPs (Sub-Health Post) and these institutions have been
serving about 671,364 population. PHCC, HPs and SHPs served a total of 318,340 populations in
2003/2004 A.D. Some very common diseases like skin diseases, Acute Respiratory Infection (ARI), ear
infection, gastritis and sore eye and complaints are the major prevailing diseases in these districts (Nepal
District Profile 2006, Nepal Development Information Institute (NDII)).
The above information shows that there is still huge burden of very common diseases in Dhanusha district.
This proposed project will address the following problems:
 Strength and weakness analysis of the health facility(ies)
 Identify client’s rights and provider’s duties and responsibilities
 Identify gap between providers and clients
 Training needs identification of health care providers
 Develop action plan and implement it
 Increased awareness and demand of health care delivery
 Infrastructure development of health facilities
(These problems have been traced with reference to the table under ‘Relevance to Dhanusha
situation’) given below.
To sum up this proposed project will address mainly three major problems:
 Accessibility
 Acceptance and
 Infrastructure development and capacity building and of providers

4. 4
 Target District: Dhanusha
 Target Group and final beneficiaries
(Total No. of participants per orientation/training =80 participants)
 All staffs of selected Primary Health Care Center (PHCC), Health Posts (HP) and Sub-Health Posts
(SHPs) and 153 Female Community Health Volunteers (FCHV) (i.e. 9 FCHVs from each health
facilities)
 170-340 people from religious minorities (i.e. 10-20 people from religious minorities per health
facility)
 85-170 indigenous people (i.e. 5-10 indigenous people per health facility)
 170-340 poor and disabled people (i.e.10-20 poor and disabled people per health facility)
 85-170 socially disadvantaged people (i.e. 5-10 socially disadvantaged people per health facility)
 85-170 women representatives (i.e. 5-10 women representatives)
 85 VDC (Village Development Committee)/Municipality representatives (i.e. 5 representatives from
each VDC/Municipality office)
 85 representatives of local CBOs (Community Based Organizations)(i.e. 5 representatives from 5
different CBOs where health facility lies)
Estimated beneficiaries and budget: Altogether 7,500 (approx. population of village)*17= 127,500
population will be benefited by the project. Total Estimated Budget is 210,000€.
So, the average cost per head for 3 years comes to be 210,000€/127,500= 1.647€
The average cost per head per day comes to be 0.0015€ (NRs 0.1609) (1€ = NRs.107)
Average cost per village per year: 210,000€/17/3= 4117.647€
Average cost per person per day: 0.0015€ (NRs 0.1609) (1€ = NRs.107)
Average cost per health facility per month: 343.137€ (1€ = NRs.107)
Contribution from Samjhauta Nepal: 21,000 € (10% of total estimated cost)
Contribution from European Commission: 189,000 € (90% of the total estimated cost)
 Relevance of the proposal to the needs and constraints
Relevance to national situation: Government of Nepal has conducted several trainings and also signed
protocols to ensure quality basic health services to her people. To make health service accessible to the
poor, marginalized, indigenous, socially disabled and disadvantaged population, the basic health services
was declared free of cost by the government. The accessibility can be increased substantially but only with
some sorts of intervention like COPE at the basic levels.
COPE was originally developed in Kenya and Nigeria in 1988 and since then has been introduced in 50
countries around the world, with proven success. Over the years, the COPE tools have been adapted for a
wide range of health services. Ministry of Health and Population (MoHP), Nepal is using COPE/PLA to
develop the action plan in many districts and they are in the process of nationalizing this tool for its use
nationwide. The objective is to shift the ownership from the very beginning of the planning to the local
people. Similarly, UNFPA has used this tool in Dadeldhura, Dang, Kapilbastu, Rautahat, Mahottari and
Saptari; and there are still so many districts where this tool needs to be put into practice.
Relevance to Dhanusha situation: This tool (COPE/PLA) is new to Dhanusha district with regard to its
implementation. However, Samjhauta Nepal has tested this tool in Mugu, Siraha and Rupandehi districts.
This tool has executed some good results in shifting ownership to the local community. The socio-cultural
setting of Dhanusha is similar to the successful terai district Siraha. So, we have tempted to use it.
Indicators Dhanusha National
Incidence of ARI among Under 5 children per 1,000 population 684 360
Incidence of diarrhea among Under 5 children per 1,000 population 255 219
Incidence of malnourished Under 3 children (Wt/Age) 17.0 10.5
Case Finding rate of Tuberculosis (%) 56* 70
Kala-azar incidence per 100,000 population at risk 29.7 26.4
*Target defined by WHO is to diagnose 70 percent of the estimated cases.
Source: DoHS (Department of Health Service ) report 2004/2005
The above data show that there is mismatch between health care provision and utilization at Dhanusha
district. The indicators are far poorer than overall national indicators. Hence, it shows the urgency of
implementation of some effective measures to upgrade the health status of the district. COPE/PLA can be
one of the effective tools in this mission.

5. 5
Relevance to the target groups and final beneficiaries: The proposed project aims to resolve the three
major problems mentioned in ‘specific problems’ earlier. The focus is on poor, disadvantaged,
marginalized, indigenous, disabled, women, health care providers and the local stakeholders like CBOs and
local authorities. So, it is likely that the problems of the target groups be addressed to execute the expected
results timely and with utmost efficiency.
Relevance of the proposal to the priorities and requirements presented in the guidelines: COPE/PLA
model falls under HEALTH CARE, one of the two priority sectors identified by the European Union proposal
guidelines. Though COPE/PLA focuses its activities mainly on ‘Basic and Quality Health Services’ its
activities will cover some other activities included in the application form. They are: capacity building of the
promotional, preventive and curative health facilities at local level, Increasing the delivery of effective and
reasonable health services and promoting community awareness actions related to health and its utilization.
2. Description of the action and its effectiveness
 Goal: The overall objective is to contribute for improved access to Basic and Quality Health Services
through COPE/PLA model to improve health delivery in remote areas of Dhanusha district by 2011.
 The specific objectives are
 Increase awareness among the general public regarding the client’s rights and responsibilities
 Increase awareness among health care providers about their duties and needs.
 Coordinate and Co-operate with District (Public) Health Office regarding supply of essential
equipments and furniture
 Increase access of ethnic minorities, indigenous and disabled population to basic health services
 Aware women about basic health services with regard to health including women’s health
 Increase health care utilization by the general public.
 Activities planning
Year 1
 Orientation of COPE/PLA and Action Plan Development in 5 PHCCs
 Implementation of Action Plan in all 5 PHCCs.
 Delivery of essential equipments, medicines, bed, furniture and other necessary items as per the
‘Action Plan’ to 5 PHCCs.
 Quarterly Review of COPE/PLA in all the implemented PHCCs.
 Quarterly monitoring
Year 2
 Develop exit plan for PHCC monitoring
 Orientation of COPE/PLA and Action Plan Development in 5 HPs
 Implementation of Action Plan in all 5 HPs
 Delivery of essential equipments and furniture to 5 HPs.
 Quarterly Review of COPE/PLA in all the implemented HPs and 5 PHCCs
 Quarterly monitoring
 Mid-term evaluation (2HP and 2PHCCs) by June 1-30, 2010 and report submission to European
Commission by August 1, 2010
Year 3
 Develop exit plan for HP monitoring
 Orientation of COPE/PLA and Action Plan Development in 7 SHPs
 Implementation of Action Plan in all 7 SHPs
 Delivery of essential equipments and furniture to 7 SHPs.
 Quarterly Review of COPE/PLA in all the implemented SHPs, 5HPs and 5PHCCs
 Quarterly monitoring
 Sharing meeting by representatives of PHCCs, HPs and SHPs
 Final evaluation by October 1-30, 2011 and report submission to European Commission by
December 10, 2011 and the lessons learned will be used in other future operations of activities by
Samjhauta Nepal
 Outputs and expected results
 HMC of the health facilities, health care providers, social leaders and the general public come
together to understand the strength and weakness of the health facility and develop a durable action
plan together to ensure quality services.
 Community people and the health care providers understand their needs, duties and responsibilities
 Skills enhancement through orientation/training which brings about Consumers’ Empowerment
 Gap reduction between providers and clients
 Increased demand of health care delivery

6. 6
 Infrastructure development of health facilities
 Effectiveness of proposed activities
 COPE/PLA will ensure the implementation of effective bottom-up planning process at the health
facility level.
 Proper implementation of this tool strengthens the government’s decentralization program.
 It assures increased access of basic health services to the marginalized population
 Increased client’s satisfaction, once the quality service is delivered from the health facility
 Community ownership will bring in the resources from the community for the development of health
facility
 Involvement of implementing partners: No partners will be involved. Samjhauta Nepal will be the sole
implementing body. However,District Public Health Office(Dhanusha), and health institutions working
under it (5 PHCCs, 5 HPs and 7 SHPs will be working as ‘Associate’ under this project. They will be
involved from inception to the end of project and will also continue this process beyond the project
duration.
 Other possible stakeholders: Health Management Committees, FCHVs, Mother Groups, Social
leaders, VDC/Municipalitiy representatives and local CBOs (Community Based Organizations) will be
our other possible stakeholders
3. Sustainability of the action
 Risk analysis /mitigation measures
Environmental risk: Increased demands for the health care services will increase health care waste
production. Health care waste management is very poor at rural areas and its hazards are substantial. So,
the local HMC will be made aware on the management of waste through training.
Political risk: The project might be facing political pressure during the selection of health facility/ies.
However, as a non-political, non-profit making organization, Samjhauta Nepal will implement its programs in
need based approach.
Economic risk: Corruption is the major possible threat that can occur in the project. To fight against, our
organization will make some strict norms for expenditures. Specific monitoring tools will also be put into
practice to mitigate economic risks.
Social risk: As the service quality improves, the demand from the clients will put more pressure for the
health institutions management committee to increase its infrastructures, equipment and other inputs.
However, this will prove as a milestone to urge and brainstorm the management committee to look for
alternatives to improve its services. The COPE committee will work for lobbying with health departments and
ministry at the policy level and also help the local HMC to explore local resources for upgrading the health
services.
Eventual contingency plans
A district level COPE committee will be formed which forms a network with the existing coordination
committees at Dhanusha district. Such a network will pull local resources to combat contingencies. It will
also build relationship with the stakeholders within the network of existing coordinating committees for other
technical and financial resources at the time of economic and technical crisis.
Main Preconditions and Assumptions
Nepal has recently conducted Constituent Assembly Poll and has indicated some clear directions towards
political change and peace-building. Our organization assumes that this political change in Nepal will create
some sound environment for program implementation. Our organization has been working in social projects
since 2001 and is economically sound enough to carry out this proposed EU project.
Sustainability after completion of the action
This proposed project aims at gap reduction between the health care providers and clients for the efficient
health delivery even after the completion of the project. By executing COPE/PLA, the training needs of the
staffs and existing hindrances to Basic and Quality Health Services will be explored. COPE/PLA can be
conducted by local HMCs even after the completion of this project and the knowledge and skills can pass to
new generations. This leads to the capacity building of the staffs and enhance their skills by which they will
serve the people throughout their working period. The project will bring awareness among the general public
with regard to health services utilization which increases the demand of quality service from the clients side.
The political instability has settled down and the project has experience of working in the remote terai even
during the Maoist insurgency period. Finally, this project leads to better health in the communities that will
have a long lasting effect.