International Journal for Quality in Health Care 2005; Volume 17, Number 5: pp. 391–399 10.

1093/intqhc/mzi057
Advance Access Publication: 10 June 2005

Improving the quality of child health

services: participatory action by providers
JANET BRADLEY1 AND SUSAN IGRAS2
1
EngenderHealth, New York, USA, and 2Consultant, EngenderHealth, New York, USA

Abstract
Objective. To test a quality improvement approach called COPE® (Client-Oriented, Provider-Efficient services), for use in

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strengthening health systems and supporting Integrated Management of Child Health (IMCI) efforts.
Design. Pre- and post-intervention observations of client/provider interactions, facility audits, staff and client surveys, and
focus groups to evaluate differences between eight COPE intervention and eight matched non-intervention facilities after a
15-month intervention in 2001.
Setting. Primary care clinics in Guinea and Kenya.
Study participants. Health care providers and child caregivers.
Interventions. Over 15 months, the intervention supported four COPE exercises at each intervention site, supported supervisor
training in quality management, and organized minimal training in topics selected by site staff as areas where training was needed.
Main outcome measures. Differences in staff’s and child caregiver’s knowledge, attitudes, and practices; differences in the
quality of services provided.
Results. On almost every quality indicator (over 65 indicators), whether reported by staff, observed by evaluators, or reported
by clients, the intervention sites performed statistically significantly better than control sites. Intervention sites were cleaner
and more pleasant, with more respect and information for clients, and more privacy. Staff had better personal communication
skills, better diagnostic skills, and prescribing practices and gave better home care instructions to carers. Clients in intervention
sites were more informed and more satisfied, and their children had better immunization coverage than those in control sites.
Conclusion. COPE is a simple process, yet our study confirms that it can have a very dramatic effect on the quality of services.
This study demonstrated how all areas of quality can be addressed by empowering health care providers to take action by using
COPE. We suggest that COPE can complement Integrated Management of Childhood Illness (IMCI) training and can help to
achieve better health for children.
Keywords: child health, health services, participation, quality improvement

In recent years, new strategies for improving the diagnosis
and holistic treatment of childhood illness, including the Inte-
grated Management of Childhood Illness (IMCI), which
focuses on the five major childhood diseases [1], have been
introduced in many developing countries. Early results of
IMCI performance show that clinicians have had consider-
able success in correctly identifying certain conditions [2–4].
However, many studies have also noted that there is insuffi-
cient emphasis on improvement of health systems or on how
quality improvement can be operationalized [5].
COPE®1, which stands for Client-Oriented, Provider-Effi-
cient services, is a participatory, problem solving approach
that invites health facility staff to identify and prioritize qual-
ity of care problem areas and encourages them to find their
own solutions and subsequent actions to improve health
services. Simple to implement and low cost, COPE was pio-
neered by EngenderHealth in the early 1990s and has been
adapted by a variety of agencies working in low-resource set-
tings at hospital and health center levels.
Because past experience had demonstrated anecdotally that
COPE could be easily adapted to address a range of reproduc-
tive health service areas, several agencies with child health
mandates (UNICEF and USAID) asked EngenderHealth to
adapt COPE for use in child health services. To determine
whether such a process could and should be scaled up, these
agencies provided primary technical inputs and/or financial
support to EngenderHealth’s Research and Evaluation Unit to
conduct this study, the first systematic research to assess the

1
COPE is a registered trademark of the U.S. Patent Office.
Address reprint requests to Janet Bradley, EngenderHealth, 440, Ninth Avenue, New York, NY 10001, USA. E-mail:
jbradley@engenderhealth.org

International Journal for Quality in Health Care vol. 17 no. 5

© The Author 2005. Published by Oxford University Press on behalf of International Society for Quality in Health Care; all rights reserved 391
J. Bradley and S. Igras

effectiveness of COPE in improving service quality. This art-
icle presents the findings of a prospective, quasi-experimental
study examining the effects of COPE® for Child Health [6] on
improving the quality of health services at the facility level.
The intervention
The COPE process is based on four simple tools and the belief
that staff from all areas of a health facility should participate in
problem identification and resolution, from administrative and
support staff to service providers from wards and clinics. The main
COPE tool is a set of self-administered guides with trigger questions orga-
interspersed with the implementation of staff action plans. In
the first month of the project, external facilitators oriented
district supervisors and intervention site managers to COPE
in a one-day workshop, their first introduction to ‘facilitative’
supervision concepts, quality improvement, and self-assessment
techniques. After the orientation, COPE was introduced in
four sites in each country. As is the usual process, district
supervisors were encouraged to attend (and mostly they did
attend), the first and subsequent COPE exercises, to help site
staff address some of the more difficult issues. The district
supervisors continued their routine supervisory visits to inter-
vention and control sites during this period.
As per the usual COPE process, external resources were used

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nized within a framework of client rights (to information; access;
informed choice; safety; privacy and confidentiality; dignity, com-
fort, and expression of opinion; and continuity of care) and health
care staff needs (for facilitative supervision and management;
information, training, and development; and supplies, equipment,
and infrastructure)—all elements defined in this study as key com-
ponents of quality of care at the facility level [6]. The questions help
facility staff to systematically and consciously look at issues related
to service quality, some of which may have never considered
before (such as waiting times or client perceptions). The client exit
interview tool encourages staff to talk with and listen to their clients
about the quality of the services offered. The client-flow analysis tool
measures how long clients wait for services and how much contact
time they have with service providers. The action planning tool helps
staff to identify root causes of their self-identified problems and to
develop a realistic, time-bound plans that assign responsibilities to
individuals. The whole exercise occurs several hours each day over
a 2- to 3-day period when the clinic is quietest and when clients are
not too inconvenienced. Action plans are reviewed at the next
COPE exercise, three to four months in the future, when the
COPE reflection–analysis–action cycle begins again. In the interim
period, staff work to implement their action plans.
The COPE study in Guinea and Kenya occurred over a
15-month period and was comprised of four COPE exercises
to conduct short, on-site training in all intervention sites on top-
ics identified as priorities by facility staff. In Kenya, training was
organized in facilitative supervision and quality management,
immunization updates, and infection prevention. In Guinea,
training was organized in facilitative supervision, infection pre-
vention, counseling and information, education, and communi-
cation. Any other staff training or updates that occurred during
the 15-month period were not considered part of COPE.
Study hypothesis
Evidence from the field of organizational development theory
and from participatory action research suggests that individual
or team identification and ownership of problems lead to more
effective actions than do reporting of issues by external asses-
sors [7–9]. Our hypothesis was that by giving the power of
change to facility staff, rather than by imposing change from
outside, by giving guidelines about how they might work together
rather than what they might work on, and by providing simple
tools that reflect quality concerns, staff would start to improve
services, and clients would find the facility more attractive and
would learn more about how to take care of their children’s
health (Figure 1). Consequently, quality improvements in service

Personal and organizational change

COPE Simple Outside
philosophy tools help

Participation, Guides to Better

ownership, problem supervision • Shared
and teamwork identification responsibility
Facilitation and ownership
Focus on Client
Minimal • Reduction of
systems interviews
equipment hierarchy and Actions
Focus on cost- Client-flow bureaucracy
Minimal, to
consciousness analysis
relevant • Raised morale improve
and efficiency
Record training and commitment quality
Focus on reviews
clients • Skills
Action plans enhancement
Engagement
of supervisors • Empowerment

Staff capacity- • Supervisor

building support

Figure 1 COPE® and the quality improvement process.

392
 Improving the quality of child health services

delivery and client satisfaction with child health services would
be more pronounced in settings where COPE was used than in
settings where no COPE interventions had occurred.
Study methodology
The study was designed to monitor COPE exercises and
associated interventions over a period of about 15 months
and then to examine differences in facility staffs’ attitudes and
practices, the quality of services, client satisfaction, and serv-
ices’ utilization between COPE intervention and ‘control’ or
non-intervention sites. This report focuses on differences
whom had undergone IMCI training, but where the Ministry
of Health thought such training might potentially happen.
Selected facilities were rural or periurban health centers, located
many hours’ drive from better-resourced capital cities. Findings
from the baseline survey [11] confirmed that intervention and
control sites were very similar to key variables: facility size,
number of staff, number of child health consultations, range
and type of services provided, and the disease pattern of chil-
dren attending the clinics. The study baseline also confirmed
no differences between intervention and comparison sites in
service quality, e.g. on indicators such as availability of equip-
ment and supplies for child health service provision and infec-
tion prevention, lack of information and outreach to clients,

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seen between intervention and control sites at the end of the
intervention period. Results for Kenya and Guinea are com-
bined; a more complete analysis may be found elsewhere [10].
Eight interventions and eight control or non-intervention
sites were included in the study, four of each type in each
country. In consultation with Ministry of Health officials, we
selected health centers with approximately ten staff, none of
adequate infrastructure, and privacy and confidentiality.
External evaluators (one in each country) were hired to col-
lect baseline and end-of-project data and also to note other
changes or externalities that might have confounded the
study results. Several instruments were used (Table 1) to col-
lect data and allow triangulation of information for data inter-
pretation purposes.

Table 1 Instruments used in the evaluation

Site descriptions (conducted with clinic managers)1

All eight intervention and eight control sites in Kenya and Guinea
Total of 16 sites
Purpose: To have a general picture of the site who works there, what services are offered, how well is it accessed,
and what are principle child health problems in the area it serves
Facility audit (conducted with clinic managers)
All eight intervention and eight control sites in Kenya and Guinea
Total 16 sites
Purpose: To measure the availability of child health materials, equipment, and supplies
Interviews with site staff
All eight intervention and eight control sites
Total interviews: 77 in Kenya and 80 in Guinea (with 76 in intervention sites and 81 in control sites)
Purpose: To measure provider knowledge of quality of care issues, feelings about teamwork and personal involvement in
problem solving, attitudes to and relationships with clients, attitudes to work, support from management, adequacy of
training and information, adequacy of supplies and an enabling working environment, and problems solved and services
improvement
Client exit interviews with caregivers of children
All eight intervention and eight control sites
Total interviews: 160 in Kenya and 160 in Guinea (with 10 well children and 10 sick children at each facility, for 80 sick and
80 well in each country)
Purpose: To measure client satisfaction (various indicators), information retained by clients, reporting of quality, client
knowledge of medications, management of sick children, immunization timing, and side effects
Observations of caregiver/provider interactions
All eight intervention and eight control sites
Total observations: 160 in Kenya and 160 in Guinea (with 10 sick children and 10 well children at each facility)
Purpose: To measure provider competence (various indicators), information given to clients (medications, management,
immunization, and so on), respect for client, privacy, confidentiality, safety issues, and amount of contact time
Focus group discussions with site staff1
All eight intervention sites
Total of eight focus group discussions (one in each intervention site in Kenya and Guinea, with a total of 88 staff)
Purpose: To solicit staff views about the COPE process
1
All the instruments, above, were used to collect data at baseline and at the end of the evaluation period except these two instruments. The
site description was only used at baseline. The focus group discussions were only conducted at the end of the intervention period.

393
J. Bradley and S. Igras

Selection of facility staff and clients to observe and/or performed. Chi-squared tests were undertaken to examine
interview was purposive. Given the limited number of clients differences between intervention and control sites.
and providers available each day for consultation, that clients
were served on a first-in/first-out basis as they arrived at the
facility, and in an effort to maintain a normal patient flow, it
was neither possible nor desirable to randomly select clients
Results
or facility staff. Instead, several provider–client consultations
Range of problems identified and successfully
of well and of sick children were observed sequentially each
solved by staff in intervention sites
day by evaluators over a period of three to four days, until the
desired number of observations were reached. Several women The COPE exercises conducted in all intervention sites
with well and with sick children were interviewed each day, yielded remarkably similar problems in each country, ranging
until the desired number of interviews were completed over a from the simplest-to-address, such as cleaning toilets, to more
three to four day period. Several staff were interviewed each challenging ones, such as reorganizing work space or improv-

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day based on availability and to ensure that different cadres of
staff were interviewed, e.g. ensuring that not only doctors and
nurses were interviewed but also facility support staff and
administrators. At the end of the study period, external evalu-
ators conducted focus group discussions with available staff
in intervention sites, ensuring that the group composition
represented the different cadres at the end-of-evaluation data
collection period. Group discussions were held on the final
day of data collection to limit potential bias that could have been
created by discussing the value of COPE earlier in the week.
External factors that might have affected the results seen
and attributed to COPE were regularly monitored over the
intervention period. These factors (such as training events,
equipment donations, and facility renovations) were minimal
or occurred equally between intervention and control sites.
All quantitative data were entered into an SPSS database,
where frequency distributions and cross tabulations were
ing immunization rates.
After 15 months, the great majority of problems listed on
facility action plans were considered ‘solved’ by staff. Table 2
summarizes an illustrative list of the wide array of problems
identified and solutions that were implemented. Solutions
were often creative. For example, in-service training in a vari-
ety of areas was identified as a major need, and local solutions
involved staff training each other and finding hitherto
untapped local resources. In Guinea, solutions to information
and service provision gaps went beyond the clinic and into
the community, with staff deciding to provide community
education on critical child health themes and to organize
more service outreach through mobile clinics. Resources to
solve infrastructure problems varied, and smaller activities
(e.g. minor construction and painting) were financed with
cost-sharing money available for use by sites, whereas larger
ticket items (e.g. constructing a maternity unit) came from

Table 2 Illustrative changes in service quality that occurred due to COPE/quality improvement-related efforts at eight
intervention sites, as described by focus group discussion participants in Guinea and Kenyan Health Centers [12]

Infrastructure and equipment issues —Maternity wards built in two centers

Human resources issues
Changes in service delivery
—Most centers improved supply of running water, electricity, or telephones
—Renovations of some rooms (e.g. waiting rooms)
—Limited improvements in availability of materials and supplies were noted; newly
available items included light microscopes, privacy screens, mattresses and linen,
gas lamps
—Improvements in staff performance improvements included timeliness (in providing
services and being on time for work), being better informed, and being better able to
perform their duties (due to formal and on-the-job training)
—Improvements in staff-to-staff relations (between all levels of staff), more open
dialogue was occurring between staff
—Improvements of staff–to–client interactions included staff treating clients with
greater respect, ensuring clients had to wait less time for services, had more privacy,
were provided more information. Community leaders were more involved in the
health centre than before
—Improved record keeping and use of information
—More systematic outreach services being provided. One example included staff
received training and licenses to ride motorcycles to do regular outreach
—Integration and expansion of the availability of Child Health services occurred—
through physical integration of outreach unit services to reorganization of the
physical structure and staff responsibilities to ensure the full complement of Child
Health services was provided (including family planning and nutrition)

394

facility staff successfully exerting pressure on district staff to
allocate district funding.
Some issues were never solved during the intervention
period. Drug supply, despite renewed advocacy by site staff,
remained problematic. Those issues requiring more senior, or
off-site administrative approval and direction, such as how to
reduce service costs for the poor in Guinea, were not
resolved, although not without trying.
Changes in quality of services provided to
children and their caregivers
Observations of the client–provider consultation. To view the range of
child health services, we included both ‘well’ and ‘sick’ chil-
dren and their caregivers in the study. Well children were
defined as those coming to the facility with a caregiver to be
immunized. Sick children were those coming to the facility
with a caregiver for treatment of an illness.
Changes in the quality of child health services that were meas-
ured are summarized in Table 3. These indicators were selected
by using IMCI protocols outlining ideal consultative behaviors of
providers and included things like privacy and confidentiality of
the consultation, appropriate interpersonal communication,
using consultations to identify ‘missed’ opportunities to diagnose
other child health problems or provide preventive services, pre-
scribing practices, and ensuring caretakers were sufficiently
informed to adequately manage the illness episode at home.
To determine whether there was a similar illness pattern in
intervention and control sites, we assessed examined illness
symptoms of sick children. In both countries, the observed
symptoms were very similar, reassuring us that changes seen
between intervention and control sites at end line would not
be biased by a different illness pattern and subsequent treat-
ment actions. The most common complaints in children pre-
senting at intervention and control sites, respectively, were
fever (85.0 versus 86.3%), cough (56.3 versus 56.3%), diarrhea
(25.0 versus 22.5%), and vomiting (18.7 versus 15.0%).
For the well child consultations, indicators were again
selected, based broadly on IMCI protocols outlining ideal
consultative behaviors of providers, including privacy and
confidentiality of the consultation, discussing immunization
schedules with caregivers to reduce missed vaccinations, giv-
ing information on why the child is being vaccinated, and
ensuring informed and adequate home management of side
effects of vaccines like fever and discomfort.
After 15 months of the COPE intervention, on almost every
indicator of quality of the client–provider observations—whether
of well or of sick children—there was a significant difference
between intervention and control sites (Table 3). For well children
consultations, there were statistically significant differences in all
measures of quality. For sick children, most quality indicators also
differed, although on a few variables, there was no significant dif-
ference in diagnosing or treating sick children at intervention ver-
sus control sites. Oral rehydration salts (ORS) were rarely used in
either intervention or control sites (5.0 versus 5.0%), despite
almost one quarter of all sick children complaining of diarrhea.
Client perceptions of quality of services. Client perceptions of serv-
ices are important indicators of the quality of services being
Improving the quality of child health services
provided, and although one expects courtesy bias overall,
the study sought to determine any differences between cli-
ents in intervention and control sites (Table 4). Client per-
spectives on the way they were treated by staff were
solicited by reading several statements and asking clients to
say on a Likert (picture) scale, how much they agreed with
the statements. For all statements, there was a statistically
significant difference between intervention and control sites
(P < 0.01).
To measure the effect of the intervention, evaluators also
asked clients whether they had observed any changes in ser-
vice delivery over the past year. Resoundingly, 80% of clients
in intervention sites said that they were better than they had
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been the year before, compared with 26.9% of clients in con-
trol sites (P < 0.01).
The role of management, facilitative supervision,
and site staff ability to effect change
To measure changes in management and supervision and
how this might influence staff behavior, we asked interviewed
staff in all sites their opinions about the way the facility was
managed and their ability to participate in decision making
and influence decisions about service delivery. In all manage-
ment and self-efficacy areas that were covered during inter-
views (being valued as a staff person, management taking an
interest, being able to make suggestions, feeling part of a
team, feeling that management is responsive, and feeling that
colleagues have high morale), the staff in intervention sites
had significantly higher morale and were more satisfied with
their jobs than at comparison sites (Table 5).
Facilitative supervision is promoted by COPE to reinforce
site self-improvement efforts and staff self-efficacy, and off-
site/district supervisors received training in facilitative super-
vision early in the project. Staff who were interviewed were
asked their perceptions of management support, morale, and
their opinions about supervision by off-site/district supervi-
sors. Although there was no significant difference in the
number of recent supervisory visits between intervention and
control sites, the responses to statements about what supervi-
sors did during their visits (working with providers, helping
with problem solving, helping with training, and helping with
supplies) were significantly (P < 0.01) different between the
two types of sites (Table 5).
Discussion
Significant improvements seen in quality of services
On almost every quality indicator, whether reported by staff,
observed by evaluators, or reported by clients, the interven-
tion sites performed statistically significantly better than the
control sites only 15 months after these low-key interventions
began. Although there were (expected) quality improvements
in both countries related to the more direct contributions
made by the project per se, such as improvements in infection
prevention after training, there was also evidence of a whole
395
J. Bradley and S. Igras

Table 3 Provider performance observations of interactions between providers and child carers in Guinea and Kenya sites at
the end of the 15-month intervention period

Observed provider Indicator % observations % observations Significance

performance of intervention of control sites (P value)
sites
.............................................................................................................................................................................................................................
Sick children and well children (N = 320)
.............................................................................................................................................................................................................................

Privacy and confidentiality Auditory privacy 60.5 40.9 <0.001

Visual privacy 58.8 40.3 0.001
Uninterrupted sessions 81.3 57.9 <0.001
Maintenance of privacy of client records 100.0 94.3 0.002

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Interpersonal skills Offered client a seat 80.5 63.9 0.001
Greeted client well 63.8 14.4 <0.001
Explained things well 64.2 15.2 <0.001
Confirmed client understood 48.1 6.9 <0.001
Listened to client 75.0 35.6 <0.001
Was gentle mannered 70.0 23.6 <0.001
Smiled 55.6 10.0 <0.001
Maintained eye contact 61.9 20.6 <0.001
.............................................................................................................................................................................................................................
Sick children (N = 160)
.............................................................................................................................................................................................................................

History taking Asked about appetite 37.5 17.5 0.005

Asked about drinking 10.0 0 0.004
Asked about fever 42.5 25.0 0.02
Asked about convulsions 13.8 5.0 0.05
Asked about vomiting 42.5 40.0 0.74
Asked about cough 45.0 40.0 0.19
Asked about diarrhea 32.5 26.3 0.38
Asked about breathing difficulty 20.0 12.5 0.19
Physical examinations Examined neck for stiffness 45.0 18.8 <0.001
Examined abdomen 72.5 57.5 0.04
Checked hands for pallor 26.3 3.8 <0.001
Took child’s temperature 63.8 38.3 <0.001
Felt the neck 45.0 18.8 <0.001
Examined the ears 20.0 10.0 0.07
Prescribing Correct malaria prescription given 61.9 50.7 0.06
Correct antibiotic prescription given 78.8 45.9 <0.001
Information given by provider Continue to breast feed the child 25.0 7.5 0.003
Give more fluids to child 23.8 5.0 0.001
Informed at least two aspects of home care 46.3 13.8 <0.001
Bring child back if no improvement 48.8 12.5 <0.001
Bring child back if fever continues 35.0 3.8 <0.001
Bring back if loss of appetite continues 23.8 1.3 <0.001
Bring child back if vomiting continues 22.5 7.5 0.008
Bring back if difficulty in breathing 22.5 5.0 0.001
Bring child back if she/he has convulsions 26.3 5.0 <0.001
Information on any danger signs 37.5 8.8 <0.001
.............................................................................................................................................................................................................................
Well children (N = 160)
.............................................................................................................................................................................................................................

Immunization Discussed immunization schedule 87.5 72.5 0.02

Mentioned two or more side effects 63.3 25.3 <0.001
Discussed management of side effects 69.9 36.5 <0.001
Client–provider discussions Discussed family planning 21.3 2.5 <0.001
Discussed child’s growth 26.3 16.3 0.03
Discussed general health 26.3 8.8 <0.001
Discussed nutrition 42.2 19.6 <0.001

396
 Improving the quality of child health services

Table 4 Client ratings and perspectives on services in Guinea and Kenya sites at the end of the 15-month intervention period
(N = 320)

Aspect of service Indicator positive responses % clients in % clients in Significance

intervention control sites (P value)
sites (n = 160) (n = 160)
.........................................................................................................................................................................................................................

Education Ever heard a health talk at the site 48.8 14.4 <0.001
Clients know at least 2 aspects of home 39.2 26.6 0.09
care
Clients knows at least 2 ways to know 62.0 34.2 <0.001
child is deteriorating and to bring the
child back

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Clients know at least 2 immunization 61.9 44.4 0.02
side effects
Agreement with statements about Provider was very knowledgeable 85.0 60.6 <0.001
staff that day (clients agree strongly) Provider gave enough time for 78.1 34.4 <0.001
consultation
Provider gave privacy 66.9 24.4 <0.001
Provider gave information about 35.0 8.8 <0.001
other services
Provider explained when to return 64.4 40.6 <0.001
Provider explained home care 60.0 36.3 <0.001
Provider generally explained well 81.9 40.0 <0.001
Provider was respectful 85.0 62.5 <0.001
Provider listened well 79.4 53.1 <0.001
Provider was friendly 86.9 56.3 <0.001
Overall very satisfied with visit 69.8 48.4 0.001
Agreement with statements about Very good services overall 70.0 39.5 <0.001
services and facility in general (clients Good links with other services 61.9 31.4 <0.001
agree strongly) Generally respectful 65.0 24.4 <0.001
Good confidentiality and privacy 83.0 53.1 <0.001
Services are safe 73.4 32.5 0.001
Waiting times are acceptable 32.5 11.9 <0.001
Services are at convenient times 32.5 15.0 <0.001
Services have improved in last year 80.0 26.9 <0.001

range of other improvements that resulted from staff actions
themselves. In the intervention sites, we observed greater avail-
ability of services being provided in cleaner, more pleasant,
more private settings. We also observed (confirmed by clients)
more respect and information for clients, more privacy, with
improved provider interpersonal communication skills, use of
improved diagnostic skills, improved home care instructions,
some improvement in prescribing practices, and improved
immunization practices. We also found more informed and
more satisfied clients, and their acknowledgment that changes
in services had occurred over the past year.
Why did COPE trigger staff actions to improve
quality?
The COPE exercises only suggest what standards of care
might be; there are no specific interventions. Limited short
training requested by staff in information, education, and
communication approaches, infection prevention, and facili-
tative supervision was conducted, but the changes seen in
this study are much broader in scope and begin to address
the underpinnings of quality services. Nobody told staff that
they needed to treat clients better, give out more informa-
tion, ensure uninterrupted consultations, and take better his-
tories. Working through the COPE exercises enabled those
individuals willing to look critically at themselves to plan and
make changes to self-identified problems. Working through
the exercises as a group of staff helped foster a critical mass of
enabled workers.
With an open-ended intervention like COPE, what led
staff to take specific and sometimes bold actions to improve
quality of services? Staff generally know what needs to be
done to provide quality services. But they sometimes forget;
or they are unable to do a good job because they lack the tools

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J. Bradley and S. Igras

Table 5 Provider perspectives on management and supervision in Guinea and Kenya sites at the end of the 15-month inter-
vention period (N = 157)

Perspectives Indicator positive responses % staff in intervention % staff in control Significance

sites (n = 76) sites (n = 81) (P value)
.........................................................................................................................................................................................................................

Facility management Management more responsive lately 69.7 23.5 <0.001

Management encourages training 67.1 27.2 <0.001
Management discuss service statistics 42.1 27.5 0.19
Management likes to solve problems 64.5 25.9 <0.001
Management takes an interest in my job 80.3 56.8 0.007
Staff morale is high 82.9 36.3 <0.001
I feel part of a team 72.4 45.0 0.005

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My opinion is valued by management 65.8 24.7 <0.001
Outside supervisors Supervisors include us in their discussions 63.2 32.1 <0.001
Supervisors help us solve problems 61.8 21.0 <0.001
Supervisors help us with training 65.8 22.2 <0.001
Supervisors help us with supplies 65.8 18.5 <0.001
We truly benefit from supervision 60.5 22.5 <0.001

or the technical expertise, or they lack feedback on their per-
formance; or they are so demoralized that they have given up
trying to understand and interact personally with their clients.
We had hypothesized that the COPE intervention would lead
to personal and organizational change that providers would
feel empowered, more confident and free to act, assume own-
ership of the problems (and the solutions), have raised morale
and commitment, be more reflective, and feel better sup-
ported. Findings from end-of-evaluation staff focus group
discussions, reported elsewhere [12], confirmed that staff did
indeed feel that they had begun to break down some of the
communication barriers and inertia running through their
health services and that COPE had helped to provide the fer-
tile ground upon which organizational change could occur,
changes that led to improved quality of service and enhanced
client satisfaction. Staff told us that the fact of outsiders not
identifying the problems, not suggesting the answers, and not
providing the solutions, but instead creating an enabling
environment for staff to do those things themselves, is what
stimulated action and created change. This very ownership of
problems and their solutions, although daunting at first,
seems to have had a strong impact on staff attitudes toward
their work environment and in changing their own behav-
iors/interpersonal interactions with other site staff as well as
with clients. This was reinforced by feelings that manage-
ment, supervisors, and clients appreciated them and were
relying on them to make good decisions.
What types of issues were not affected by COPE?
Although COPE could effect changes on service quality in
many areas, there were a few indicators where there was little
or no observable difference between intervention and control
sites. For example, there were generally poor prescribing
practices in both intervention and control sites in both coun-
tries. Although COPE can raise issues such as these, some
problem areas still will require specific technical skills and
knowledge to address them.
There are other areas where staff are constrained in their
ability to take action. The data showed that there were little
observable or sustainable differences between the interven-
tion and control sites in availability of drugs and equipment,
even though many intervention sites had taken steps to work
with the local health committees to make funds available
from the community coffers for such purchases. The import-
ant role of external support from district management com-
mittees, supervisors, and community health councils is crucial
to solve such problems and to keep facility staff engaged in
their own problem resolution efforts.
Conclusion
The IMCI approach to child health has been shown to be useful
in helping health care providers recognize the need for holistic
curative and preventative care for children and in training pro-
viders to better manage childhood illness. Efforts, though, are
constantly thwarted by unmotivated and unsupportive col-
leagues, inadequate facility infrastructure, generally poor quality
of care by other staff (poor information, counseling, and atten-
tion to privacy), non-facilitative supervision, failing health ser-
vice support systems (supplies, record keeping, and effective
infection prevention), and poor community linkages.
COPE is a very low-tech, easy to do quality improvement
process, and our study confirms that it can have a very dra-
matic effect on the way people work and the services they
provide. Providers feel better about their work, and the cli-
ents feel better about the services. This project achieved signi-
ficant results after one person visited each site four times over
a 15-month period, encouraged supervisors to participate,
and provided a very small amount of money for (mostly on-
site) training in site-determined subjects.

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This study demonstrated that the COPE quality improve-
ment initiative can in fact bring facility staff, managers, and
supervisors together to support each other, can raise staff
morale, can effect changes to the facility infrastructure and
functioning, can improve provider attention to the care of
sick children and immunizations, and can help providers
share information between themselves.
Given political commitment, scaling up this quality
improvement process in any country would not be a costly or
difficult exercise. In addition, we suggest that COPE proc-
esses could be implemented in a way to complement other
training and quality improvement efforts, as its self-assessment
philosophy and tools create a more enabling environment for
change, and hence, could make other quality improvement
efforts more effective. To this end, more research could be
done to evaluate how COPE might be undertaken in con-
junction with IMCI training, for example, to accomplish
improvements in services that can help lead to better health
for children.
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Accepted for publication 4 May 2005
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