In November 2025 (5 months’ ago) my co-founder, Melissa, and I came out the other side of the Charity Entrepreneurship program with an idea and some funding. The idea was a community-based solution to reduce maternal and neonatal mortality called “Participatory Learning and Action” (PLA). PLA is a problem solving approach for maternal and newborn health, which has been around since the 90s and is well-evidenced. The method brings communities together to discuss barriers to timely healthcare, identify solutions, and then take action using locally available resources. 

While this approach has decades of evidence behind its effectiveness, the implementation reality is complex. As we move toward our imminent launch, we’ve grappled with a tension that is likely familiar to EA-aligned organisations active on this forum: how to maintain the rigorous cost-effectiveness and fidelity to EA principles when our primary delivery vehicle is a government partnership. For reasons explored below, we have opted to prioritise long-term institutionalisation over the silo of direct delivery. We are curious to hear from the community: To what extent are EA funders prepared to trade off 'clean' impact attribution for the potential scale of state-integrated models?"

Despite a robust evidence base of over 8 RCTs conducted across 15 countries, including several from Africa, PLA has failed to scale in any country on the continent. To date, implementation has been confined to time-bound, research-focused programs. While these have been effectively managed in-house by nonprofits, and have demonstrated strong evidence of impact, they have lacked a pathway to sustainability.

We think that the failure to scale happens in the handover of nonprofit-owned PLA programs to the government. This is a common challenge for many types of health interventions, and especially for community-based programs because they depend on quality training and boots on the ground - a large, motivated and well-managed workforce of PLA group facilitators. Maintaining that workforce cost-effectively is a challenge at scale.

So, we’ve adopted a different strategy: integrating PLA into existing government community health structures from the outset, starting in a district in Uganda. We’re investing in the systems-level analysis and co-design process required for seamless integration and delivery that can be sustained within a government budget. Our progress so far is compelling. We’ve established partnerships at both the central level – aligning our work with the Ministry of Health’s five-year strategy – and at the local level, through an MoU with a District government. We’re currently working to secure the buy-in of existing community health workers, who will ultimately deliver the program with our oversight, and ownership among the district health team. 

We face plenty of challenges. The budget for community health workers is inadequate, health worker capability is variable, and health reporting systems are inconsistent. Some of these issues would be easier to mitigate had we opted to run the program independently, in parallel to the government. This has traditionally been the norm for NGOs: maintaining internal control through direct delivery by hiring project staff, operating in-house fleets, and maintaining proprietary data systems. Many EA organisations do this exceptionally well – creating pockets of high quality execution with great metrics. The cost-effectiveness math for these models is also comparatively simple as it's easier to track dependencies and allocate causality compared to partnership models.

The end-game for a direct delivery community health-focused model is less clear. Who, particularly given the reduction of available foreign aid, would be a payer at scale capable of supporting the systems that generate high quality delivery? Our inability to answer this question for PLA has led us to build a model adapted to government systems, motivations and capabilities with the guardrails in place to secure cost-effective delivery with increasing government ownership. We see our role as an NGO as twofold: to act as an R&D unit with the goal of discovering the most well-adapted version of the model for government, while providing the technical assistance for PLA to integrate and scale.

We’ve proven demand exists, and we’re committed for the long haul. We are currently growing our donor network and would love to hear from anyone interested in supporting us. We’d also be interested in hearing from anyone who has tried to do something similar. If that’s you, you can contact us at info@opalhealthafrica.org.