> For the complete documentation index, see [llms.txt](https://research.ambitiousimpact.com/llms.txt). Markdown versions of documentation pages are available by appending `.md` to page URLs; this page is available as [Markdown](https://research.ambitiousimpact.com/bemonc/simulation-based-training-for-emergency-obstetric-and-newborn-care/7-implementation.md).
# 7 Implementation
This section discusses implementation factors that we think are of relevance for both (1) deciding whether we should recommend the ideas, and (2) the entrepreneurs considering taking the idea to scale.
## 7.1 What does working on this idea look like?
**This is a capacity-filling intervention, reliant on the organization’s ability to create a supportive in-service structure that actively improves the quality of maternal and neonatal care around** [**birth**](#user-content-fn-1)[^1]**.** Ultimately, impact depends on actors outside of the organization’s direct control (clinicians) and is mediated by factors that the organization will not have a remit over (such as infrastructure).
**We expect actors to be willing and able to engage with the organization’s services.**
* Partnership with government early on will facilitate a longer-term end-game where in-service upskilling can be taken over reliably by government and private providers.
* We remain open to the possibility that some private healthcare networks may be interested in hiring the organization for in-service training consulting.
**Figure 7 notes how we’d characterize this proposed idea along an explore-exploit spectrum.**
* This intervention idea follows a set playbook established by the WHO and experts, and likely will rely on training regimens that have been developed and open sourced by other actors.
* While there are some “known unknowns” that seem relevant, these are largely relevant to implementation decisions, and we do not expect them to be a make or break factor for the effectiveness or cost-effectiveness of the intervention.
Figure 7: Where this charity lies on the explore–exploit continuum.
## 7.2 Key implementation factors
This section summarizes our concerns (or lack thereof) about different aspects of a new charity putting this idea into practice.
**Table 9: Implementation concerns**
| Factor | Level of concern |
| ---------------------------------------- | ---------------- |
| Talent | Low |
| Access to information | Low |
| Access to relevant stakeholders | Low |
| Feedback loops/monitoring and evaluation | Moderate |
| Execution difficulty/tractability | Moderate |
| Complexity of scaling | Moderate-high |
| Risk of harm | Unconcerning |
### Talent
The following backgrounds, skills or profiles would likely be useful—though not strictly necessary—for the co-founders or early hires in this organization:
* Experience working in or with low-resource health facilities, in particular those with birthing facilities.
* Past work designing or delivering simulation-based training, in particular of clinical nature.
* A background in medicine or a related field.
While these profiles would certainly facilitate early work, we largely expect people from a wide array of backgrounds to be able to create a successful organization in this space, and are not concerned with talent, both for co-founders and senior hires.
### Access to information and stakeholders
Previous organizations we have incubated have established successful, trusting relationships with health facilities in several countries (e.g., India, Nigeria and Ghana). We expect there to be sufficient interest and motivation for the nonprofit to gain access to facilities to deliver training and monitor progress. Early traction is likely to support further development and engagement with government, which could ultimately fund or deliver the intervention at scale.
**Support from key stakeholders will be critical to achieve high scale.**
* **Professional councils**, for instance, may need to approve courses for accreditation purposes. Our understanding from experiences in Nigeria, India and Zambia is that gaining access and building a productive relationship with these institutions is feasible. Professional councils can often be stretched beyond their capacity and therefore be slow or difficult to engage with. In some cases this may lead to de-facto permission to work on training directly, or difficulties in getting traction.
* **Facility leadership** buy-in will be critical in each case, and cannot be skipped. Here, we expect resource constraints to be a key determinant of openness. A new training program may be perceived as carrying a resource burden that is not worth pursuing unless the benefits are clear across the organization and the lift from facility staff is relatively low effort.
### Feedback loops / monitoring and evaluation
The availability of validated indicators and clinical observation templates means that monitoring and evaluation challenges are likely to be primarily operational. These may include designing sufficient incentives for staff to engage with the nonprofit, digitizing or aligning disparate reporting standards, and validating monitoring data provided by third parties. We do not expect significant methodological challenges in assessing practice against BEmONC signal functions. Effects on maternal and neonatal mortality are likely to be evaluated using observational designs based on facility mortality rates. We expect experimental designs to be less suitable here, particularly given the additional costs involved.
### Tractability
Delivering training with fidelity requires creating a supportive learning environment. In addition, the organization will rely on many factors outside its direct control to improve outcomes for beneficiaries, requiring careful alignment of incentives across stakeholders.
### Complexity of scaling
We view skill decay as a core concern. To address this, we think the nonprofit will need to revisit facilities every six months to a year to refresh skills through simulation, alongside maintaining ongoing peer networks and monitoring. Maintaining fidelity will become increasingly complex as the nonprofit expands its network of trainers.
We see two potential routes to financial sustainability at scale. One is for government to fund trainers of trainers, who continue providing training until facilities can reliably manage quality control themselves. The other is for the nonprofit to continue relying on philanthropic funding as it scales. We are uncertain whether sufficient philanthropic funding would be available, although maternal and neonatal mortality is a major focus of many aid programs. The nonprofit could also potentially subsidize its programming by charging providers that are willing and able to pay (e.g., for-profit healthcare networks), but we have not investigated this option in depth.
### Risk of harm
We see little risk of harm from this intervention.
[^1]: For a breakdown of how we characterize our ideas, please see [here](https://ambitious-impact.gitbook.io/ambitious-impact-docs/explainers-and-house-views/our-charity-taxonomy).
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