Attachments
Authors:
Hedwig Deconinck, Stephanie V. Wrottesley, Ahmed Aljabi, Million Markos Mena, Gamal Saleh Ali Mohammed, Aina Ahmed Kareef Mahmood, Emily Hirata, and Marie McGrath
‘Learning by doing’ case study series
Many infants are born vulnerable or become so in the first six months of life and are at greater risk of poor growth and development, ill health and mortality. The MAMI Care Pathway is an approach to guide risk-differentiated personalised care for at-risk mother-infant pairs integrated within systems of health and nutrition. We have undertaken three ‘learning by doing’ case studies to investigate the process of implementing, adapting, normalising and embedding the approach in Pakistan, South Sudan and Yemen to inform feasible sustainable care.
Background
Many infants are born vulnerable, or become so in the first six months of life, and thus are at an increased risk of poor growth and development, ill health, and mortality. To mitigate risks and safeguard future health, comprehensive continuity of person-centred care for at-risk mother–infant pairs is needed, but it remains challenging to deliver this at the required level of quality and at scale. This case study investigates the process of implementing, adapting, normalising and embedding an integrated care pathway approach for the management of small and nutritionally at-risk infants under six months (u6m) and their mothers (the MAMI Care Pathway) in the Yemeni context to inform sustainable scalability.
Method
In the Yemen case the MAMI Care Pathway approach was applied as an implementation pilot integrated within a health and nutrition emergency programme operated by the Adventist Development and Relief Agency (ADRA) in Yemen. In the case study, mixed methods were used to provide a detailed description of the planning and implementation processes, to explore influences on the adoption of the approach, and to appraise the potential scalability and sustainability of care. Different lenses examined health workers’ experiences of implementing the MAMI Care Pathway, which enhanced their capacities through ‘learning by doing’. Reflective discussions generated transferable insights into implementation.
The case study did not paint an exhaustive or exclusive picture of the implementation of the MAMI Care Pathway approach. For example, it did not seek the perspectives of mothers, as service users or decliners, and involved only a few clinical health workers. Nor did it evaluate the cost effectiveness, acceptability or feasibility of the Care Pathway approach or compare it to alternative approaches.
Results
In Yemen, policies and guidance on providing comprehensive continuity of care for vulnerable infants u6m outside of hospital settings are limited. ADRA’s health and nutrition emergency programme provided an opportunity to introduce the MAMI Care Pathway approach to fill gaps in providing continuity of care for vulnerable mother–infant pairs, because of its favourable organisational environment and established relationships.
The MAMI Care Pathway approach was implemented in nine Ministry of Public Health and Population- (MOPHP-) run health centres supported by ADRA in four districts across three governorates in Yemen. Following consultation with MOPHP, start-up was quick and required minimal financial and technical support. The brief infusion of external expertise was sufficient for ADRA staff and MOHPH health workers to acquire the knowledge and skills needed for implementation.
ADRA’s support to health and nutrition services on behalf of MOPHP included making the necessary adaptations in generic materials; training and mentoring health workers; providing supportive supervision; and collaborating within and across health services. The support included a small remuneration to motivate MOPHP health workers to take on the additional workload.
Comprehensively addressing vulnerability factors for “small and nutritionally at-risk infants and their mothers” with a person-centred and continuity of care approach required good skills and continuous mentoring. The intentional shift from disease-focused care to comprehensive person-centred care of the infant and the mother was appreciated by the health workers but its implementation was not fully realised, nor were tasks shared or alignment between services encouraged to streamline care and reduce workload.
Since ADRA focused on implementing and expanding the MAMI Care Pathway approach within the emergency portfolio to reach a wider population, no major attempts were made to advocate for health policy changes or to seek development funding to support further expansion. However, changes in policies and practice and wider local stakeholder engagement were envisaged to mainstream the approach in routine services at scale, including a feasible monitoring, learning and evaluation system.
Conclusion
The Yemen case study provides insights into the feasibility of implementing the MAMI Care Pathway approach in an existing emergency health and nutrition intervention by building on ongoing support for maternal and child health and nutrition services. Showing by example, the success of ADRA’s work has sparked the interest of other health and nutrition actors, who have begun making plans to implement and expand the MAMI Care Pathway in Yemen.