GPAF COMMUNITY PARTNERSHIP PROPOSAL FORM (Round 1) The proposal documentation provides detailed information about your proposed project. This information is used to assess the strengths and weaknesses of the initiative and will ultimately inform the DFID funding decisions. It is very important you read the GPAF Community Partnership Window Guidelines for Applicants and related documents before you start working on your Proposal to ensure that you understand and take into account the relevant funding criteria. Please also consider the GPAF Proposals - Key Strengths and Weaknesses document which has been adapted from the document prepared following the appraisal of full proposals submitted to GPAF Innovation windows. This document identifies the generic strengths and weaknesses of proposals submitted in relation to the key assessment criteria.

How?: You must submit a Microsoft Word version of your Proposal and associated documents by email to [email protected]. It should be written in Arial font size 12. We do not require a hard copy.

When?: All Proposal documents must be received by Triple Line on or before 23:59 GMT on Friday 5th April 2013. Proposal documents that are received after the deadline will not be considered.

What?: You must submit the following documents: 1. Narrative Proposal : Please use the form below. The form has been designed to allow you to record all the information DFID needs to assess your proposed project. Please note the following page limits: . Sections 1 – 8 : Maximum of 15 (fifteen) A4 pages . Section 9 : Maximum of 3 (three) A4 pages per partner Please do not alter the formatting of the form and guidance notes. Proposals that exceed the page limits or that have amended formatting may not be considered. 2. Logical framework: All applicants must submit a full Logical Framework/Logframe and Activities Log. Please refer to the GPAF Logframe Guidance and How-To-Note and use the Excel logframe template provided. 3. Project Budget: Applicants must submit a full project budget with the Proposal. Please refer to the GPAF Community Partnership Window Guidelines for Applicants and Financial Management Guidelines and the notes on the budget template (for Round 4). The Excel template has three worksheets/tabs: Guidance Note; Budget; and Budget Notes. Please read all guidance notes and provide full and detailed budget notes to justify the budget figures. 4. Your organisation's governance documents: e.g. Memorandum and Articles of Association, Trust Deed, Constitution. We need this to check your eligibility. If you have any doubts about your eligibility please contact Triple Line Consulting immediately. 5. Organisational Accounts: All applicants must provide a copy of their most recent (less than 12 months after end of accounting period) signed and audited (or independently examined) accounts. 6. Project organisational chart/organogram: All applicants must provide a project organisational chart or organogram demonstrating the relationships between the key project partners and other key stakeholders Please use your own format for this. 7. Project Schedule or GANTT chart: All applicants must provide a project schedule or GANTT chart to show the scheduling of project activities (please use your own format for this). 1

Before submitting your Proposal, please complete the checklist below to ensure that you have provided all of the necessary documents.

CHECKLIST OF PROPOSAL DOCUMENTATION Please check boxes for each of the documents you are submitting with this form. All documents must be submitted by e-mail to: [email protected] Check Mandatory items for all applicants Y/N Proposal form (sections 1-8) Y Proposal form (section 9 - for each partner) Y Project Logframe Y Project Budget (with detailed budget notes) N* Your most recent set of audited or approved organisational annual Y accounts Project organisational chart / organogram Y Project bar or GANTT chart to show scheduling Y Please provide comments on the documentation provided (if relevant) *Reference telephone conversation with Tony Maher on 4 April 2013. Budget to be provided on Monday 8 April 2013.

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GLOBAL POVERTY ACTION FUND (GPAF) – COMMUNITY PARTNERSHIP WINDOW PROPOSAL FORM

SECTION 1: INFORMATION ABOUT THE APPLICANT 1.1 Lead organisation name 1.2 Main contact person Name: Sheaian Lee Position: Project Officer Email: [email protected] Alternative email address: [email protected] Tel: 0207 794 4856 1.3 2nd contact person Name: Mimi St John Austen (If applicable) Position: Executive Director Email: [email protected] Alternative email address: [email protected] Tel: 0207 794 4856 1.4 Please use this space to inform The applicant named on the Concept Note, Tom Hoyle, of any changes to the applicant is no longer with our organisation. organisation details provided in Our income for year ending October 2012 was your Concept Note (including £279,590 any more up to date income figures)

SECTION 2: BASIC INFORMATION ABOUT THE PROJECT 2.1 Concept Note Reference No. INN-05-CN-1031 2.2 Project title Treating young rural Ethiopians with cleft conditions

2.3 Country(ies) where project is to be implemented 2.4 Locality(ies)/region(s) within Somali (Zonal authorities) country(ies) 2.5 Duration of project (in months) 36 months

2.6 Anticipated start date of project 1st January 2014 (not before 01 April 2013) 2.7 Total project budget? (In GBP £175,000 sterling) 2.8 Total funding requested from £175,000 DFID (in GBP sterling and as a % of total project budget) 100% 2.9 If you are not requesting the full Source: amount from DFID, please list the amounts and sources of any £ other funding (In GBP sterling and as a % of total project funds) % 3 2.10 Year 1 funding requested from To be supplied on Monday 8 April 2013 (reference DFID (In GBP sterling) telephone conversation with Tony Maher on 4 April 2013) 2.11 Please specify the % of project 100% funds to be spent in each project country 2.12 Have you approached any other NO part of DFID to fund this If Yes, please state which fund or department: project? 2.13 ACRONYMS (Please list all acronyms used in your Proposal in alphabetical order below, spelling out each one in full. You may add more rows if necessary) HEP Health Extension Programme HEWs Health Extension Workers PHE Project Ethiopia PHUK Project Harar UK SLT Speech and Language Therapy

SECTION 3: CAPACITY OF THE APPLICANT ORGANISATION 3.1 EXPERIENCE: Please outline your organisation's experience that is relevant to the proposed areas of work Project Harar has more than 10 years' experience in providing health outreach to rural communities in eastern and southern areas of the region of Ethiopia, for those specifically affected by facial disabilities, namely cleft lip and palate, , burns, tumours, accidents and animal attacks.

Our organisation acts as a bridge, collaborating with families, HEWs and Ethiopian surgeons to enable rural patients to access treatment, commonly available in the capital city . In 2012, we arranged treatment for 538 young people with serious facial disabilities, at a cost of less than £250 per person. As a result of our success and reputation we have built, PHE has recently extended their work across the Oromia region and in parts of the Afar region, with expanded coverage from 3% to 26% in two years.

An important aspect of our work is to carry out check-ups and follow-up with patients who have been treated. In 2011, we began a ground-breaking piece of research, assessing the impact of treatment for 400 previously treated cleft patients and evaluating our outreach model. This evaluation demonstrated that treatment is vitally important not only aesthetically but for education; only 44% of school-age students in this study attended school prior to surgery, after surgery 78% of these students attended school, as a direct result of greater self-confidence and a decrease in bullying.

PHE’s outreach team come from the communities in which they work and have strong local links, ensuring cultural sensitivity and practical understanding. Furthermore, PHE’s senior staff has extensive experience in diplomacy and partnership building, especially with government officials and partner organisations, which has led to significant expansion of our work over the last decade. 3.2 FUNDING HISTORY: Please describe your organisation's main sources of funding, with an indication of the amounts received and the purpose of the funding. The most recent financial statements (October 2012) show annual income of £279,590. Funding received from the following sources enables PHUK to fund year round identification of

4 young people with cleft conditions and other facial disabilities, predominantly in the Oromia region, and their transport to Addis Ababa for treatment and recovery. The funding also enables the organisation to fund an annual surgical mission, made up of a volunteer medical team from the UK and Europe, to treat patients with complex facial conditions and build the capacity of local medical teams.

Individual donations 16.9% Regular giving 3.1% Trusts and Foundations 46.1% Appeals 7.4% High net worth donations 11.9% Fundraising events 3.9% Fee for service 5.0% CAF/Other 5.7%

3.3 CHILD PROTECTION (projects working with children and youth (0-18 years) only) What is your organisation's capacity and experience in relation to child protection? How will you work with your partner(s) to ensure children are kept safe? PHUK and PHE have an overarching child protection policy which is adhered to by all staff and volunteers. The UK office intend to work closely with the local partner office (PHE) to develop a more comprehensive local policy, to comply with the International Convention on the Rights of the Child and will be overseen by specialist lawyers.

At the recruitment stage, PHE employees are carefully screened and references are sought and provided. 3.4 FRAUD: Are you aware of any fraudulent activity within your organisation within the last 5 years? How will you minimise the risk of fraudulent activity occurring in future? There has been no fraudulent activity within our organisation. We minimise the risk of fraud occurring by insisting on regular reporting on expenditure and patient treatments from our local partner office. Expenditure accounts are managed by the local partner office, and benchmarked and reconciled by both a local independent chartered examiner and a UK accountant. In addition to our own independent audit, our local partner is financially regulated by the Ethiopian Government through the ChSA (Charity and Societies Agency) and the Finance Bureau of Oromia, according to the requirements of local NGO licensing. PHE are required to submit annual financial reports to the ChSA and quarterly financial reports to the Finance Bureau of Oromia.

SECTION 4: FIT WITH GPAF COMMUNITY PARTNERSHIP WINDOW 4.1 CORE SUBJECT AREA - Please identify between one and three core project focus areas (insert '1' for primary focus area; '2' for secondary focus area and; '3' for tertiary focus area) Agriculture Health (general) 2 Appropriate Technology HIV/AIDS / Malaria / TB Child Labour Housing Climate Change Income Generation Conflict / Peace building Justice Core Labour Standards Land Disability 1 Livestock

5 Drugs Media Education & Literacy 3 Mental Health Enterprise development Reproductive Health / FGM Environment Rural Livelihoods Fisheries / Forestry Slavery / trafficking Food Security Water & sanitation Gender Violence against women/ girls/children Governance Other: (please specify) 4.2 Which of the Millennium Development Goals will your project aim to address? Please identify between one and three MDGs in order of priority (insert '1' for primary MDG focus area; '2' for secondary MDG focus area and; '3' for tertiary MDG focus area) 1. Eradicate extreme poverty and hunger 3 2. Achieve universal primary education 1 3. Promote gender equality and empower women 2 4. Reduce child mortality 5. Improve Maternal Health 6. Combat HIV/AIDS, malaria and other diseases 7. Ensure environmental sustainability 8. Develop a global partnership for development 4.3 Explain why you are focusing on these specific MDGs. Are the above MDGs “off track” in the implementing countries? If possible please identify sub- targets within not just the national context but also related to the specific geographical location for the proposed project. Please state the source of the information you are using to determine whether or not they are “off track”. Your response should also inform section 5.3. While Ethiopia has made significant progress towards several MDGs, including health service coverage (MDGs 4, 5 & 6) and school enrolment (MDG 2), there remain significant gaps in services and substantial barriers to access confronted by some social groups. This project addresses four such groups: the rural poor, women, infants, and disabled people residing in the , notably one of the poorest regions in Ethiopia.

According to www.mdgmonitor.org, the goal to achieve universal primary education (MDG 2) is on track in Ethiopia. However the achievement of this goal is contingent on the inclusion of all disabled children. Although the Ethiopian Ministry of Education and the World Bank have reported that there are no reliable statistics on the number of disabled children attending school (Lewis I, 2009) (Education for Disabled People in Ethiopia and Rwanda, World Bank), studies by PHE researchers and many others have demonstrated that for the one in 600 children born with cleft lip/palate, whether due to bullying, communications problems or another cause, a substantial majority will never attend school unless they access treatment (Fell, McGurk, Hoyle et al). PHE’s research specifically showed that among school-aged patients born with a cleft, only 44% had ever attended school prior to receiving treatment and many dropped out, with marginalisation being strongest for girls (Fell, McGurk, Hoyle et al). Following primary treatment, 78% attended school, compared with the official of 72.3% net enrolment ratio in primary education (UNSD, 2007). Treatment can therefore be seen as a strong contributing factor to universal primary education.

6 Cleft conditions create particular challenges for females; female patients are disproportionately affected by problems such as attending school, getting married and negotiating at market (Fell, McGurk, Hoyle et al), Cleft palate, in particular, is a serious impairment and affects females disproportionately. Since it involves the roof of the mouth, it is a disguised disability and easily concealed in girls, who then lead hidden lives, unable to eat and speak. Ethiopia has only offered palate treatment on a routine basis since 2010, and thus there is a substantial legacy of untreated cases, typically affected by speech and eating problems. The project therefore aims to address MDG 3, which promotes gender equality, through specifically identifying females and those with cleft palate within the target group. This project will also focus on the training and capacity building of female Health Extension Worker’s (HEWs) therefore promoting empowerment (MDG 3) in the community.

It is important to recall that, unlike high-income countries, being born with a cleft lip/palate in Ethiopia represents a life-threatening condition due to the risk of severe malnutrition (difficulties of breastfeeding) & abandonment, & the lack of safe, affordable alternative feeding (MDG 1). The safe water rate in Harari, for example, is 24% (DfID EV697, April 2009). According to the Ethiopia Atlas of Key Demographic and Health Indicators (2005), more than half of Somali residents living in rural regions are in the lowest national wealth quintile and up to 50% of children in the Somali region are stunted. Less than one in 400 families has access to a motor vehicle (OCHA) and the level of adult and female literacy is the lowest in all of Ethiopia (Ethiopia Atlas, 2005). This underlines the need for a well-trained network of HEWs to inform and link the poorest families in Somali region with quality health services. 4.4 Please list any of the DFID’s standard output and outcome indicators that this fund will contribute to? Please refer to the DFID Standard Indicators document on the GPAF website. Please note that if you are using the standard indicators, these also need to be explicit in your logframe.  Number of health professionals trained

SECTION 5: PROJECT DETAILS 5.1 PROJECT SUMMARY: maximum 5 lines - Please provide a brief and clear project summary including the overall change(s) that the initiative is intending to achieve, why it is considered to be innovative and who will benefit. (This is for dissemination about the fund and should relate to the outcome statement in the logframe. Please avoid jargon). The project will enable 600 rural young people in Somali region to be treated for cleft conditions, enabling them to eat, speak, breathe and engage with their community. It will also enhance the capacity of 50 HEWs to identify cleft conditions and make referrals for treatment. Finally, the project will facilitate the expansion of free cleft treatment to one local hospital, benefiting many more rural young people both during the project and in the future. 5.2 PROJECT DESIGN PROCESS Describe the process of preparing this project proposal. Who has been involved in the process and over what period of time? Were representatives of the target group consulted, and if so, how? If a consultant or anyone from outside the lead organisation and partners assisted in the preparation of this proposal please describe the type of assistance provided. This project proposal was designed internally by PHUK, in close consultation with our local partner office PHE. PHE has delivered health outreach services for facial disabilities in the Oromia region for the past 10 years and have been formally endorsed by the regional Oromia government for their work. The design of this project is based on the successful outreach model used in the Oromia region.

In June 2012, local government officials from Somali region approached PHE and invited them to provide assistance to those with facial disabilities in rural communities within the Somali region. Over the last 6 months our senior outreach staff have begun informal discussions with local government

7 and health officials concerning our proposed project, and have been encouraged to set up the proposed project. 5.3 PROJECT CONTEXT / PROBLEM STATEMENT Describe the context for this project. What specific aspects of poverty is the project aiming to address? Why have these particular project locations been selected and at this particular time? What gaps in service delivery have been identified that necessitate the intervention that you are proposing? It is estimated that globally, one baby in every 500-750 is born with a cleft condition (Hardin-Jones, Karnell, & Peterson-Falzone, 2001). Being born with a cleft lip/palate in a low income country represents a life-threatening condition due to the risk of severe malnutrition (difficulties of breastfeeding), abandonment and the lack of safe, affordable alternative feeding. Left untreated, a child with a cleft may not learn to speak properly and can suffer hearing problems. Apart from daily communication and physical difficulties, they confront great social stigma, and most are denied the opportunity to attend school. Cleft conditions create particular challenges for females; participants in our follow-up research study described how their disability had prevented them from marrying or negotiating in market.

In the Somali region of Ethiopia, 91% of the population live in rural communities on subsistence incomes and more than half of residents of very rural regions are in the lowest national wealth quintile (Ethiopia atlas of Key Demographic and Health indicators, 2005). With only one doctor for every 70,000 people in these areas and around 50 dentists in the whole country, the vast majority of farming families are excluded from professional healthcare. Although treatment for facial disabilities and injuries is now available in the capital, Addis Ababa, the communities we work with cannot access it. Fewer than one in 400 families in Somali region have access to a motor vehicle (OCHA) and the cost of a parent and child travelling for treatment in the capital is equivalent to a coffee farmer’s entire annual household income. Free cleft treatment is currently not available in local hospitals outside of Addis Ababa.

The Ethiopian Health Extension Programme, launched in 2003, is an ambitious government-led community health service delivery programme designed to improve access to and utilization of preventive, wellness and basic curative services (Chuhan-Pole and Angwafo, 2011). At the heart of this program is the production and deployment of more than 30,000 predominantly female, front-line community health workers (HEWs). However, according to the WHO, the curriculum and modules for HEWs training have omitted some interventions. This has been evident during the expansion of our outreach services to other districts of the Oromia region, where it is evident that HEWs have little knowledge of cleft conditions and the treatments available.

Furthermore, cleft conditions are poorly understood in the Somali region, where the level of adult and female literacy is the lowest in all of Ethiopia (Ethiopia Atlas, 2005). Our research shows that 95% of patients interviewed considered the cause of their cleft to be ‘God’s will’, but that they felt unequal and unhappy before surgery; almost half of our research participants reported verbal insults and quarrelling.

This project will directly address three aspects of poverty; malnutrition, primary education and female empowerment by helping 600 young patients access quality treatment for cleft conditions, providing training and capacity building for 50 female HEWs and facilitating the expansion of the availability of free treatment in a local hospital.

The Somali region has been selected because it is considered one of the poorest and most rural, isolated regions in Ethiopia. Access by communities to free cleft treatment is hampered by distance and expense and lack of knowledge. Furthermore, Project Harar has been invited to extend its outreach coverage to this region by local government and health officials, demonstrating local demand

8 and need for the proposed project.

Gaps in service delivery which this project intends to address is the lack of knowledge by HEWs of cleft conditions and the free treatments available, as well as their ability to make secondary and tertiary referrals. In addition, there is a lack of free hospital transport to Addis Ababa and free treatment available more locally. 5.4 ANTICIPATED IMPACT ON POVERTY (within the lifetime of the project) Please describe the anticipated real and practical impact of the project in terms of poverty reduction. What changes are anticipated for the main target groups identified in 5.5 within the lifetime of the project? The project will directly improve the life chances and social inclusion of 600 young rural people with untreated cleft conditions, especially women and infants. This is a serious facial disability which can be substantially addressed by a safe, quick primary treatment (one hour surgery, two-day recovery).

Specifically cleft treatment will boost infant nutrition and survival; increase speaking and communication functions; promote educational participation among this group of disabled children; improve the standing of women and acknowledge their right to healthcare; enhance the self-esteem and participation of all people with a treated cleft among family and community; contribute to increased social standing and economic opportunities. Ultimately this will lead to an enhanced quality of life.

Within the lifetime of the project, 50 trained HEWs will be empowered to reach, inform and support more untreated patients, especially women and infants; and support linkages between primary, secondary and tertiary healthcare services. The availability of free treatment in at least one local hospital will ensure that even more young people can access the services they require. 5.5 TARGET GROUP (DIRECT AND INDIRECT BENEFICIARIES) Who will be the direct beneficiaries of your project and how many will be expected to benefit directly from the anticipated poverty-reducing changes within the lifetime of the project? Please describe the direct beneficiary group(s) under a) below, differentiate where possible and provide numbers for each sub-category and then provide a total number in b). DIRECT: a) Description 600 young cleft patients from rural, impoverished areas of the Somali region (45% female).

50 Health Extension Workers (HEWs), who work in rural areas advising communities on medical treatments and making referrals to clinics and hospitals (100% female)?

b) Number 650 Who will be the indirect (wider) beneficiaries of your project and how many will benefit within the lifetime of the project? Please describe the indirect beneficiary group(s) and numbers on each category under a) and then provide a total number in b). INDIRECT: a) Description Relatives of cleft patients – 4,080 people (average 6.8 persons per household, CSA census 2007) Target communities - 121,850 people (based on a ratio of HEWs to people 1:2,437, WHO) Surgeons & health care practitioners – 25 (number of trained plastic surgeons providing free surgery in Addis Ababa, known to PHE & their surgical support team) b) Number 125,955

9 5.6 PROJECT APPROACH / METHODOLOGY Please provide details on the project approach (or methodology) proposed to address the problem(s) you have defined in section 5.3. Please justify the timeframe and scope of your project and ensure that the narrative relates to the logframe and budget. If this project is based on similar project experience, please describe the outcomes achieved and the specific lessons learned that have informed this proposal. Methodology The project has been designed as an extension of an existing successful health outreach programme in the Oromia district, and has been modified using specific regional knowledge and cultural understanding. The project will address the lack of access to treatment by facilitating the extension of free treatment to a local hospital as well as providing transport and support for 600 young patients for treatment in Addis Ababa. Furthermore, this project will address the lack of knowledge and understanding of cleft conditions by training 50 HEWs in the identification and referral of cleft conditions.

Phases include: organisational development, stakeholder relationship development, training of HEWs, cleft treatment, facilitating the extension of free hospital treatment and monitoring and evaluation.

Timeframe and scope The proposed project will establish relationships with Somali regional government and health officials in the first 3 months of commencement. Within 6 months, relevant HEWs will be identified and trained allowing 30 months for trained HEWs to disseminate information and identify and refer cleft patients. A new Outreach Officer will be appointed by end of month 1 and trained by the end of month 3.This project aims to treat 150 patients in year 1, and 175 patients in years 2 and 3. In the first 4 months, PHE will hold formal discussions with local hospitals and partner organisations and these will continue at regular 6 month intervals for the duration of the project. A pilot project to assess the feasibility of surgeons conducting cleft surgery at a local hospital will be implemented in month 14 with evaluation after 2 rounds of talks with hospitals and partners and review meetings will occur every 6 months until the end of the pilot. A final evaluation will take place at the end of the project.

Previous outcomes achieved In 2012, PHE were invited to extend the health outreach service into Bale, a large mountainous zone in the Oromia region. Within one year of engaging local government officials, PHE provided training to over 100 HEWs and was able to provide treatment for 206 cleft patients. Due to the isolation and difficult terrain in this region, PHE negotiated with partner organisation Smile Train (who provide free cleft treatment in Addis Ababa based hospitals) to increase their reimbursement to PHE for outreach costs from 20% per patient to 32%. This experience led to a closer relationship with Smile Train and the recognition that they are committed to providing free cleft treatment in Ethiopia. It also encouraged PHE to replicate its successful outreach model into new areas, but to look at extending the free treatment service to hospital locations closer to communities, instead of having to transport patients to Addis Ababa. 5.7 SUSTAINABILITY OF BENEFITS How will you ensure that the poverty reduction benefits for the beneficiary population will be sustained? By providing training, capacity building and support for HEWs, they will continue to raise awareness of cleft conditions and their treatment within their rural communities long beyond the lifespan of this project. Target communities and individuals will also have a better understanding of cleft conditions. In addition, the main aspect of sustainability that this project addresses is the access to free cleft treatment for the first time in a new region and the building of the surgical capacity of a local hospital to treat many more identified patients.

10 5.8 SCALING-UP AND REPLICABILITY What is the potential for future continuation, replication or larger-scale implementation of the proposed intervention? Please provide details of any ways in which you see this initiative leading to accessing other funding or being scaled up by others in the future. Describe how and when this may occur and the factors that would make this more or less likely.

The potential for replication is very high, since this project in part is already an extension and replication of a current established health outreach programme in the Oromia region which has grown significantly in the past 10 years. If the extension of free treatment to a local hospital can be achieved by this project, then there is a significant possibility of replication in other local hospitals nationwide.

Working in partnership with Smile Train and other organisations, this project could leverage funding from global institutions and corporates working in Ethiopia. Within two years of this project’s inception, PHE plans to expand operations into northern regions (similar distances from current treatment provision), and would use the success of extending free cleft treatment to local hospitals as a future model for sustainability. 5.9 CAPACITY BUILDING, EMPOWERMENT & ADVOCACY If your project includes capacity building, empowerment and/or advocacy components, please explain how these elements will contribute to the achievement of the project’s outcome and outputs? Please also refer to the Additional guidance for GPAF Initiatives focused on Empowerment & Accountability This project aims to build the capacity of HEWs to identify cleft condition and make referrals for relative treatment. This will enable 600 young patients to be identified during the life of the project and will raise awareness of cleft conditions in the rural communities in which the HEWs work. Young patients will be empowered as, for the first time, they will be able to show their faces with greater confidence and engage in activities that they may not have been able to in the past. 5.10 GENDER AND SOCIAL INCLUSION How was the specific target group selected and how are you defining social differentiation and addressing any barriers to inclusion which exist in the location(s) where you are working? Please be specific in relation to gender, age, disability, HIV/AIDs and other relevant categories depending on the context (e.g. caste, ethnicity etc.). How does the project take these factors into account? The overall target group – individuals born with cleft lip/palate – was based on its high incidence (1:500-750 births), the severity of the physical and social impairment, and the reliability of the remedy (cleft repair). While all rural, low-income and distance patients face barriers to secondary and tertiary healthcare, it was deemed that two groups were particularly marginalised: women and infants. This is supported by PHE’s own research and by other literature.

The physical and social harm caused by a cleft can be prevented, as in high income countries, by early intervention. This project is therefore targeting infants (defined as children aged 0-4 years), and will do so by relying on the proven success of HEWs ability to reach new and expectant mothers (UNICEF, 2010).

Cleft conditions generally affect males more than females although cleft conditions create particular challenges for females; previous female patients were disproportionately affected by problems such as attending school, getting married and negotiating at market. Cleft palate is a serious impairment and since it involves the roof of the mouth, it is a disguised disability and easily concealed in girls leading ‘hidden lives’. Ethiopia has only offered palate treatment on a routine basis since 2010, thus we anticipate a substantial legacy of untreated females, typically affected by speech and eating problems. PHE aims to specifically identify females and those with cleft palate within the target group,

11 through awareness raising among HEWs and target communities.

This project therefore has a considerable gender component, encompassing women as patients, women as mothers, and women as the majority of health extension workers. 5.11 VALUE FOR MONEY (VFM) Please explain why you believe that the proposed project would offer optimum value for money. How have you determined that the proposed approach is the most cost efficient way of addressing the identified problem? Please ensure that your completed proposal and logframe demonstrate the link between activities, outputs and outcome, and that the budget notes provide clear justifications for the inputs and budget estimates. By providing training for HEWs and access to treatment for cleft patients this project will reach around 126,000 people at a cost of less than £1.50 per person.

The benefits of directly treating 600 young patients are life-long to each patient and his/her family. Treatment ensures an infant can breastfeed, reducing the instance of malnutrition and mother/baby distress. Furthermore, treatment promotes school attendance. Education is a developmental priority in Ethiopia and offers an effective route into better paid forms of employment. Without improvement to physical functions (eating, speaking, oral continence) and the confidence to attend school with the acceptance of the community, children with a cleft condition rarely complete school. Cleft care also makes a beneficial contribution to community participation and family coherence.

Furthermore, cleft treatment is a low-risk intervention – some 99% of cleft surgeries in the partner hospitals are safe and fully successful.

By building the capacity of the existing and growing health network infrastructure (Health Extension Programme), we are working efficiently and cost-effectively. Training and deploying a new network of health workers would be disproportionately expensive and unnecessary. As a result of the success of similar projects in other regions, it has proven more cost effective to treat 600 patients than create and distribute informational material, since there are low levels of literacy in rural regions and trust is difficult to overcome. 5.12 COUNTRY STRATEGY(IES) AND POLICIES How does this project support the achievement of DFID’s country or regional strategy objectives? How would this project support national government policies and plans related to poverty reduction or other key sectoral areas? This proposal has been devised in support of the Ethiopian Government’s development objectives and DFID’s commitment to primary education and access to health services in remote rural areas through the Protection of Basic Services initiative.

In line with DFID’s country strategy and vision to put ‘girls and women at the front and centre of all we do’ (DFID, 2012) this project will empower HEWs (all of whom are female) and aims to specifically identify females for treatment.

In addition, this project’s target area, Somali region, is one of the poorest and most rural and security fragile regions in Ethiopia, therefore supporting DFID’s country strategy to ‘address geographical inequality that is cause and consequence of fragility and conflict’.

This project also directly complements the Ethiopian Government’s 2003 strategy for the ‘Accelerated Expansion of Primary Health Care Coverage’ which gives special attention to mothers and children, and emphasises the need for a responsive health system for those in rural areas. The project also addresses the Government’s policy to develop a referral system and build capacity in local hospitals. 5.13 ENVIRONMENT

12 Please specify what overall impact (positive, neutral or negative) the fund is likely to have on the environment. What steps have you taken to assess any potential environmental impact? Please note the severity of the impacts and how the project will mitigate any potentially negative effects. This project is likely to have a small negative impact on the environment due to the impact of driving motorised vehicles in order for HEWs to reach rural communities and help patients reach treatment. Where possible we will encourage our staff and HEWs to use low-impact economical vehicles. The benefits of this project on the proposed beneficiaries will far outweigh the environmental impact of vehicle use.

SECTION 6: PROJECT MANAGEMENT AND IMPLEMENTATION 6.1 IMPLEMENTING PARTNERS Please provide a list of all organisations to be involved in project implementation including overseas offices of the applicant and any partners starting with the main partner organisation(s). Please only include those partners that will be funded from the project budget. Please provide full details for each of the partners in section 9. Project Harar Ethiopia 6.2 PROJECT MANAGEMENT Please outline the project implementation and management arrangements for this project. This should include:  A clear description of the roles and responsibilities of the applicant organisation and each of the partners. You must also provide an organogram (in a separate document) of the project staffing and partner management relationships.  A clear description of the added value of each organisation (including the applicant).  An explanation of the human resources required (number of full-time equivalents, type, skills, background, and gender). Project Harar UK (PHUK) The applicant organisation is responsible for monitoring the project and ensuring the partner organisation is implementing the project in line with project objectives. Project Harar UK will compile weekly updates and quarterly reports into coherent annual reports and carry out internal evaluations. PHUK will also manage the financial aspect of the grant, ensuring the project delivery is in line with the budget and mitigating any risk. Duties to include: Financial grant management, coordination of partner discussions, annual report writing, internal project monitoring. HR required: 0.2 – Project Officer – female (experienced in overseas project management, monitoring and report writing) 0.1 – Executive Director – female (experienced in organisational and financial management)

Project Harar Ethiopia (PHE)– The partner organisation will be responsible for implementation of project activities, including recruitment of staff and coordination of training workshops. PHE will carry out on-the-ground project monitoring and complete financial expenditure and progress reports. HR required: 0.2 – Senior outreach officer – male – (training, mediation, diplomacy, general coordination, driving, reporting) 1 – Outreach officer – male – (training, mediation, coordination of HEWs, reporting) 0.2 – Administrator – Female – (reporting, training materials) 6.3 OTHER ACTORS Include details of any other key stakeholders or collaborative partners who will have a role in the project (but will not be funded from the project budget). How does this intervention link to or integrate with other programmes especially those of other government agencies? Smile Train Operation Smile Somali Government Officials

13 Somali region HEWs / hospital local hospitals

This project directly links with the Ethiopian Government’s Health Sector Development Program (HSDP) and its implementation of the Health Extension Program (HEP), through the training and capacity building of the HEP’s frontline worker’s – HEWs. 6.4 NEW SYSTEMS, STRUCTURES AND/OR STAFFING Please outline any new systems, structures and/or staffing that would be required to implement this project. Note that these also need to be considered when discussing sustainability and project timeframes. 1 new outreach officer

SECTION 7: MONITORING, EVALUATION, LESSON LEARNING This section should clearly relate to the project logframe and the relevant sections of the budget. Please note that you will be required to undertake a project evaluation towards the end of the funding period to assess the impact of the fund. Please allow sufficient budget for monitoring and evaluation (M&E) and note the requirements for external and independent evaluation. 7.1 How will the performance of the project be monitored? Who will be involved? What tools and approaches are you intending to use? How will your logframe be used in M&E? What training is required for M&E? How will you involve beneficiaries and other stakeholders? The performance of the project will be monitored will be monitored with the following activities:  Weekly conference calls between PHE and outreach officer  Monthly written reports on progress against activities, milestones and logframe from PHE to PHUK  Monthly expenditure reports with receipts from PHE to PHUK  Workshop reports from PHE to PHUK  Annual monitoring visit by PHUK  Full annual report by PHUK  PHUK to cross reference hospital records with patient photos and records

The tools and approaches we intend to use are:  Consistent telecommunication and email communications between PHE and PHUK  Photographs & videos of workshops and meetings  Workshop feedback forms  Participatory evaluations from target beneficiaries and communities (video)  Photographs of patients treated  Monthly and annual reporting formats

The logframe will be used as a consistent benchmark for weekly, monthly and annual planning, and as tool for evaluation when composing monthly and annual reports by PHE and PHUK.

Two days of training is required for all staff involved in the project, to standardise methods and approaches and further training will be instigated if needed. The outreach officer will receive close support from the Senior Outreach officer for the duration of the project.

This project intends to involve HEWs, previously receiving training from PHE, in the design of the training workshops, training materials and workshop feedback forms. Input shall also be taken from local Somali officials to ensure cultural accuracy and sensitivity. Interviews with beneficiaries and their communities will feed into annual (and where possible monthly) evaluations and learning.

14 7.2 Please use this section explain the budget allocated to M&E, and to demonstrate that there is adequate budget provision to support the M&E processes described in 7.1. The budget must include provision for an independent external evaluation. To be supplied on Monday 8 April 2013 (reference telephone discussion with Tony Maher on 4 April 2013)

7.3 How will lessons from your project be identified and learned, and disseminated to a wider audience? - Please explain how the learning from this project will be used within your organisation and disseminated to others. Lessons from the initial HEWs training workshops will be identified and learned through specifically designed feedback forms. Video interviews with patients and their communities will directly serve to evaluate the project’s outcomes, and inform further replication of the project. In addition, problems can be identified quickly and rectified through consistent communications and reporting structures.

Learning from this project will inform PHE and PHUK’s annual planning meetings and business plan. Learning will also be disseminated throughout PHE’s network of partner organisations and government officials through a comprehensive end of project report. Furthermore, reporting of this project and its successes will be included in regular marketing materials and annual reports to over 1,000 individual supporters. Video interviews and photographs will be disseminated to other rural communities nationwide to raise awareness and encourage cleft treatment.

SECTION 8: PROJECT RISKS AND MITIGATION 8.1 Please outline the main risks to the success of the project indicating if the potential impact and probability of the risks are high, medium or low. How will these risks be monitored and mitigated? If the risks are outside your direct control, is there anything you can do to manage their potential effects? If relevant, this may include an assessment of the risk of engagement to local partners. The risk assessment for your programme needs to clearly differentiate the internal risks and those that are part of the external environment and over which you will have less (or little) control. (You may add extra rows if necessary.)

Potential Probability Explanation of Risk impact High/Medium/ Mitigation measures High/Medium Low /Low External Risks

high Low Experienced management staff to Lack of local government engage officials at early stage, engagement encourage dialogue between Oromia officials for reassurance Lack of HEWs engagement high Low Show interviews with previously trained HEWs, encourage dialogue where possible between HEWs in other regions HEWs lack of participation high Low Encourage participation with per diems and incentives from officials. Offer training certificates. Lack of engagement with target high Low Encourage HEWs to engage with beneficiaries community and use awareness materials appropriately. Encourage dialogue between 15 treated patients.

Lack of engagement with local high Medium Encourage respected health hospital officials and surgeons to attend dialogue Poor surgical facilities in local hospital high Medium Full needs assessment in first year, engaging partner organisations and health bureau to provide equipment. Violent uprisings high low Consistent communications with outreach staff and monitoring of political situation by project management staff Threat of terrorism for expat staff Medium Medium No annual monitoring visit to visits project locations if threat is high – monitoring visit limited to PHE HQ Bad weather/food insecurity reduces High Medium Schedule patient travel activities number of participating patients away from the rainy season (March-April) ; intensify patient work at other times of year Patients content in life/appearance Medium Medium Train staff on patient sovereignty pushed towards surgery against their and the consent form, insist on its will by NGO/official usage and monitor. Analyse patient interviews. Internal Risks

Failed recruitment of local outreach high low Use established local worker connections. Provide evidence of good employment reputation. Staff illness / leave High low Ensure all employees have up to date vaccinations and medical provision is provided, prepare staff for business continuity, continuous on-job training, standby for recruitment Poor patient data recording impedes High Medium Improve IT equipment; train and evaluation advise outreach workers on good practise and back-up Approach used in Oromia unsuitable High Low Ensure dialogue between PHE for Somali and the zonal authorities to agree goals and method; recruit staff with sound local knowledge Partner medical providers stop High Low Continue dialogue with partners offering treatment at no or low cost on their plans, offer material to help their marketing/fundraising aims Breakdown in relationship with High Low Continue annual meetings and partners continuous dialogue. Share progress reports, and marketing materials.

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SECTION 9: CAPACITY OF ALL PARTNER ORGANISATIONS (Max 3 pages each) Please copy and fill in this section for each partner organisation identified in section 6.1 9.1 Name of Organisation Project Harar Ethiopia 9.2 Address Office 4, Hiwot Fana/Jijiga Roads, Hospital District, Harar 9.3 Web Site www.projectharar.org 9.4 Registration or charity number 2873 (ChSA) (if applicable) 9.5 Annual Income (from latest set Project Harar Ethiopia is funded by Project Harar UK. In of approved accounts) the most recent financial year (12 months to 31 October 2013) funds paid directly to PHE by PHUK totalled £122,384.

Income (original currency): N/A Income (£ equivalent): £122,384 Exchange rate: N/A

Start/end date of latest set of approved accounts (dd/mm/yyyy)

From: 1/11/2011 To: 31/10/2012 9.6 Number of existing staff 6 9.7 Proposed project staffing staff Existing staff Senior Outreach Officer - 0.2 to be employed under this Administrator – 0.2 project (specify the total full- time equivalents - FTE) New staff Outreach officer - 1

9.8 Partner organisation category (Select a maximum of two categories) Non-Government Org. (NGO) X Local Government Trade Union National Government Faith-based Organisation (FBO) Ethnic Minority Group or Organisation Disabled Peoples’ Organisation (DPO) Diaspora Group or Organisation Orgs. Working with Disabled People X Academic Institution Other... (please specify) 9.9 A) SUMMARY OF EXPECTED ROLES AND RESPONSIBILITIES AND B) FUNDING AMOUNT RESPONSIBLE FOR A):  Implementation of project activities  Recruitment  Expenditure reporting  Project monitoring  Workshop coordination and facilitation 0.2 – Senior outreach officer – male – (training, mediation, diplomacy, general coordination, driving,

17 reporting) 1 – Outreach officer – male – (training, mediation, coordination of HEW, reporting) 0.2 – Administrator – Female – (reporting, training materials)

B): 95%

9.10 EXPERIENCE: Please outline the experience of your partner in relation to their role and responsibility in this fund (including technical issues and relevant geographical coverage) PHE has more than ten years’ experience in providing health outreach services for rural impoverished communities in Oromia, for a variety of facial disabilities including those caused by cleft conditions, noma, burns, animal attacks, accidents and tumours. More than 2,500 patients have been treated in this time. PHE has successfully extended their services from their origins in Harar city to now cover most districts in Oromia and therefore have experience working in new areas. PHE’s senior manager has direct personal connections to the Somali region and speaks many local dialects, ensuring cultural sensitivity, practical understanding and diplomacy.

PHE’s administrators are trained in financial reporting and have experience in developing materials for training and awareness.

PHE’s outreach staff have significant experience in liaising with government, with hospitals and with communities.

9.11 FUNDING HISTORY Please provide a brief summary of your partner(s) funding history. PHE is funded by the Project Harar UK office since 2002. In the last financial year (31 October 2012) GBP 279,590 was raised, of which GBP 178,886 was assigned to programs in Ethiopia. (£122,384 paid directly to PHE. 9.12 CHILD PROTECTION (funds working with children and youth (0-18 years) only) What is this partner's capacity and experience in relation to child protection? How will you work with your partner(s) to ensure children are kept safe? PHE has a commitment to child protection. All staff must sign and adhere to PHE’s child protection policy, which is based on the UN Convention on the rights of the child and recommended practices. The high degree of collaboration between PHE staff, local health & social workers and hospital staff (who have their own child protection policies and professional standards frameworks) means there is a high degree of supervision, but vigilance is always required.

9.13 FRAUD: Has there been any incidence of any fraudulent activity in your partner organisation within the last 5 years? How will you minimise the risk of fraudulent activity occurring? No fraud has been found.

We minimise the risk of fraud occurring by insisting on regular reporting on expenditure and patient treatments. Expenditure accounts are managed by the local office, and benchmarked and reconciled by both an independent chartered examiner in Addis Ababa and by the UK staff and accountant.

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