ESTHER Switzerland Partnership Grant Fund
Application Form
A. PROPOSAL
1. AT A GLANCE
Topic
Country
Country of the partner institution
Goal
max 3 lines
Swiss institution
Name
Address
Name, position, and contact details (e-mail, phone) of the contact person
Name
Address
Name, position and contact details (e-mail, phone) of the contact person
Partner institutions
Requested grant (CHF)
Timeframe
N.B.: Please attach short resume of applicant’s professional experience (relevant to the application)
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2. CONTEXT
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Key information on the health status of the population in the country and the zone of intervention (main burden of diseases)
Key information on the health system in which the partner hospital is embedded (e.g., reference to the six WHO building blocks)
Key information on the current policy situation in relation to the scope of the intended project
If applicable, how is the project linked to other ESTHER/SDC funded projects?
(max. 400 words)
3. PARTNERSHIP
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Short description of both hospitals (partner institutions)
Short description of the partnership between the Swiss and the partner institution (rationale for origin of contact, past/current/planned
collaboration including areas of collaboration)
Is the partner institution involved in collaborations with other ESTHER or non-ESTHER partners? If so, with who and on what type of
project?
(max. 400 words)
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4. GOALS and OBJECTIVES
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Goal(s) of the intervention (where start-up fund is needed) and tentative objectives of the planned project; state the goal(s) and
typically 3 to 4 supporting/underlying objectives of your project. The overall goal should be realistic and the stated objectives should
feed into the goal.
Relevance (explanation why the intervention in this area makes sense; what is the comparative advantage of both institutions to
implement a project in the planned area?)
Explain the coherence of the planned intervention with the overall ESTHER goals and principles framework (ESTHER Switzerland,
EEA Charter etc., EEA Strategic Framework 2015-2020; with country strategies)
(max. 400 words)
In formulating your objectives, please use the SMART criteria: https://en.wikipedia.org/wiki/SMART_criteria
5. LEAD QUESTIONS
 What main questions are you looking to address?
 (max. 200 words)
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6. ACTIVITIES
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Describe the main activities planned, how each activity contributes to reaching the objectives, when they
will take place, and who is responsible
Timeframe
Activity / Milestones
Responsible person
Add rows, if needed.
7. Project Management
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Explain how the project management will be organized, both at a programmatic and at a financial level
(max. 200 words)
8. Target Group(s)
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What are the main groups/populations that should benefit from the project activities?
(max. 200 words)
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9. Intended Project Results
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Describe the expected outcomes and overall numbers that will be reached during the project. The numbers should be measurable
and achievable and clearly linked to the project objectives and activities.
(max. 200 words)
10.
Impact
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Describe the relevance of the project, the potential for change, the transfer potential, criteria to measure the impact.
What is the intended change at the level of the institution (e.g. hospital in which the partnership takes place)?
What is the intended change at the level of policies? Describe the strategy that you intend to adopt in order to influence
changes at the policy level.
(max. 200 words)
11.
Monitoring and Supervision of Activities
 Describe the planned monitoring and supervision of activities including frequency, by whom and how
(max. 200 words)
 Include broad project cycle management information (including operational and financial management)
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12.
Sustainability
 Describe how continuation of project activities is ensured upon project completion.
(max. 200 words)
13.
Any other relevant information
 Any additional information that could be of relevance
(max. 200 words)
14.
RISKS AND MITIGATION
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List main potential risks that are involved (risk externally to the start-up period and particularly risks related to the start-up proposal,
activities, etc.), assess the likelihood of the risk occurring, the severity the risks, and mitigation measures to avoid or reduce the risk.
(max. 400 words)
Risk
Probability, that risk
occurs
Impact, if risk occurs
Mitigation measures
(low / medium / high)
(low / medium / high)
Add rows, if needed.
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15.
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BUDGET
Indicate the total cost per category (please provide a detailed budget as Annex)
Hotel and food, according to SDC guidelines on “Lump-sum food reimbursements and standard hotel allowances”
Split costs by time periods whenever applicable
Costs in Switzerland
(by category)
Costs in partner’s
country (by category)
Travel expenses
Other (specify):
TOTAL requested
(CHF)
Partner contributions
Financial or in kind
contributions from the
partner institutions:
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Describe contributions
…
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In case of other funding sources, please describe
…
Other funding sources
Financial or in kind
contributions from
other institutions:
16.
AGREEMENT AND SIGNATURE
A formal agreement between the partner hospitals that covers the period of the exploration phase
will be signed ☐ or already exists ☐ .
………………………………………………………….
Name of signatory:
institution:
Date:
………………………………………………………….
Name of signatory:
institution:
Date:
Completed and signed proposal form should be submitted by e-mail and normal mail to the ESTHER
Switzerland Secretariat:
Luciano Ruggia
Secretariat ESTHER Switzerland
Institute for Social and Preventive Medicine
University of Bern
Tel. +41 31 631 34 29
E-mail: [email protected]
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