Implementing care for vulnerable infants
under 6 months of age and their mothers‘Learning by doing’ case study series: Pakistan

August 2024

Authors
Emergency Nutrition Network (ENN): Hedwig Deconinck, Stephanie V. Wrottesley, Marie McGrathThe Indus Hospital Health Network: Saba Shahid and Riija Zaheer

Acknowledgements
We gratefully acknowledge the support of the Department of Foreign Affairs, Ireland, and the Bill &Melinda Gates Foundation, which enabled us to undertake this case study. The ideas, opinions andcomments included here are entirely the responsibility of the document’s authors and do not necessarily
represent or reflect the policies of the donors. We thank the reviewers, Philip T. James and Nicky Dent
(ENN), for their valuable suggestions.

Recommended citation
Hedwig Deconinck, Stephanie V. Wrottesley, Saba Shahid, Riija Zaheer and Marie McGrath (2024).
Implementing care for vulnerable infants under six months and their mothers. ‘Learning by doing’ casestudy series: Pakistan. Emergency Nutrition Network (ENN). Oxford, UK.

Keywords
Infant health; mother child health; continuity of care; infants at-risk of poor growth and development;
small vulnerable infants

Further information
For more information on the case study process and findings, please contact mami@ennonline.net.
To find out more information on the Pakistan case and to discuss how this work can be taken forward,
please contact Dr Saba Shahid at saba.shahid@tih.org.pk.

Clinical health worker conducting the risk assessment.

2‘Learning by doing’ case study series: Pakistan

Abstract
Background
Many infants are born vulnerable, or become soin the first six months of life, and thus are at anincreased 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 thisat the required level of quality and at scale. This casestudy investigates the process of implementing,
adapting, normalising and embedding an integrated care pathway approach for the managementof small and nutritionally at-risk infants under six
months (u6m) and their mothers (the MAMI Care
Pathway) in the Pakistan context, to inform sustainable scalability.

MethodIn the Pakistan case the MAMI Care Pathway approach was integrated into paediatrician-led services in a private charity hospital in Karachi, Pakistan. In the case study, mixed methods were used
to provide a detailed description of the planningand 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 ‘learningby 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 notseek the perspectives of mothers, as service users
or decliners, and involved only a few clinical healthworkers. Nor did it evaluate the cost effectiveness,
acceptability or feasibility of the Care Pathway
approach or compare it to alternative approaches.

Results
In Pakistan, no national policies specifically cover
at-risk infants u6m and their mothers. The MAMI
Care Pathway approach was introduced at Indus
Hospital to address a care gap by facilitating
continuity of care for vulnerable mother–infant
pairs from birth.
As a first step, a MAMI hospital policy paper wasdeveloped that defined a budget for operations andthe re-allocation of staff to secure approval from the
medical directorate department. In consultation
with the hospital management, a maternal and childhealth (MCH)/MAMI clinic was then set up within‘Learning by doing’ case study series: Pakistan

the outpatient department (OPD) of the paediatricunit. The MCH/MAMI clinic operated three times per
week, receiving vulnerable mother–infant pairs who
were referred from paediatric and maternity services
within the hospital.
Rotation in the MCH/MAMI clinic was established
as a mandatory part of the paediatric residency
programme that was well supported by the MAMI
manager. Provision of services that addressed themother–infant pair together and that monitored
and addressed risk factors impacting growth anddevelopment over time required a new mindset andskills from the paediatric residents, such as guiding
and motivating mothers to adhere to care over timeand addressing wider issues beyond the medical
condition. Many mothers did not return for follow-up
visits due to logistical challenges and the view thatthe visits were not essential if their infants were notperceived to be sick. Also, vulnerability factors related to the socioeconomic household environment of
the vulnerable mother–infant pairs were difficult toassess and influence.
The experience of implementing the MAMI Care
Pathway approach in the tertiary hospital facilitatedimportant learning on planning, strengthening
capacities and implementing the MAMI Care
Pathway in a specialised unit. The approach provided
opportunities to reinforce maternal and childhealthcare and strengthen collaboration between
hospital services. Monitoring and evaluating theeffectiveness of the approach was a research
objective, which limited opportunities for immediate
quality improvement. Reaching colleagues andmajor health actors, including the State Ministryof Health and the World Health Organization, wasdifficult from a hospital position, but leveraging the
MAMI Global Network and academic and research
networks may facilitate this.

Conclusion
The Pakistan case study provides insights into thefeasibility of integrating the MAMI Care Pathway
approach into a tertiary hospital to fill a locallyperceived gap in care, with limited additional resources available. Addressing vulnerability factors
for mother–infant pairs with a person-centred andcontinuity of care approach required skills andleadership that were available or acquired. The academic setting had the components needed togenerate evidence. Successful implementation
was highly dependent on a catalytic individual anddecision-maker buy-in. This experience can informto similar hospital settings, while also considering
the potential for and implications for involvementof community and primary health care levels.
3

Table of contents
Abbreviations

5

1. Addressing care gaps for vulnerable at-risk infants and their mothers

6

2. Case study series

8

3. Country health context

10

4. Planning and implementation

12

4.1. Understanding the health system

12

4.2. Planning for service delivery

14

4.3. Implementing services

16

4.4. Monitoring, improving quality and collaborative learning

19

4.5. Making suggestions for improving planning and implementation

21

5. Embedding the MAMI Care Pathway in routine services

22

5.1. Exploring adoption

23

5.2. Overall appraisal of the adoption process

26

6. Considerations for scalability and sustainability

28

6.1. Exploring challenges to scale-up, spread and sustainability

28

6.2. Exploring potential scalability

32

7. Learning to inform practice and scale-up in Pakistan (summary findings)

34

7.1. Planning and implementation

34

7.2. Normalisation and adoption

35

7.3. Considerations for scalability and sustainability

35

7.4. Collective learning and suggestions to strengthen potential for scale

35

8. Conclusion

37

9. References

38

10. Annexes

40

4Annex 1. MAMI Care Pathway Package who, what, where matrix

40

Annex 2. Definitions

41

Annex 3. Methods and limitations

44

Annex 4a. Data tool: Planning and implementing the MAMI Care Pathway approach50

Annex 4b. Data tool: Adopting the MAMI Care Pathway approach

61

Annex 4c. Data tool: Scale-up, spread and sustainability of the MAMI Care Pathway approach

63

Annex 4d. Data tool: Planning for successful scale-up of the MAMI Care Pathway approach

67

Annex 5. Implementation materials

69

Annex 6. Training sessions

70

Annex 7. Appraising the adoption process

71

Annex 8. Appraising readiness for scale

75‘Learning by doing’ case study series: Pakistan

Abbreviations
ENN		

Emergency Nutrition Network

IYCF		

Infant and young child feeding

IMNCI

Integrated management of neonatal and childhood illness

LAZ		

Length-for-age z-score

LBW		

Low birthweight

MAMI

Management of small and nutritionally at-risk infants under		

six months and their mothers

MCH		

Maternal and child health

MOH

Ministry of Health

MUAC

Mid-upper arm circumference

OPD		

Outpatient department

PCM		

Protein calorie malnutrition

u6m 		

Under six months of age

UNICEF

United Nations Children’s FundWAZ 		

Weight-for-age z-score

WHO

World Health Organization5

1.

Addressing care gaps forvulnerable at-risk infants
and their mothers

Infant vulnerability
Many infants are born vulnerable, or become soin the first six months of life. These infants areat increased risk of poor growth and development, immediate and long-term ill health, andincreased mortality (1). Each year, an estimated
8.9 million infants (14.6%) are born with low birthweight (LBW) (2), carrying short- and long-term
health risks, especially for those born premature(1). In low- and middle-income countries, an estimated 9.2 million (15.5%) infants under 6 monthsof age (u6m) are wasted, 10.3 million (17.4%) are
underweight, and 11.8 million (19.9%) are stunted(3). An episode of wasting, particularly in the first
three months of life, increases the risk of subsequent and persistent wasting, and concurrent
wasting and stunting, as children age (4, 5). This
poor start to life contributes to the global burdenof 45 million children under five years of age who
are wasted and 149 million who are stunted (6),affecting health outcomes in current and future
generations and compromising individual andcommunity potential (4, 7).

Gap in evidence to practice
Vulnerable or at-risk infants u6m may be described or present to services in many ways (8).
They include newborns with LBW, especiallythose born preterm or small for gestational age;
infants identified with wasting or acute malnutrition, stunting or underweight; infants who are nutritionally at risk, or with acute or chronic illness,disability or other growth and development concerns; and infants whose mothers have nutrition,
physical or mental health or social challenges.
Many services are provided for these infants, andsometimes their mothers, across health and nutrition services, including for reproductive health(e.g., for LBW, small and sick newborns), nutrition(wasting prevention and treatment), paediatrichealth (integrated management of neonatal and6childhood illness (IMNCI) integrated community
case management) and maternal health. However, continuity of comprehensive, quality care
centred on at-risk mother–infant pairs is needed
to mitigate immediate risks and safeguard future
health (9), and this is challenging to deliver atscale (10). Care is therefore complex at both theindividual level and service delivery level.
Connecting within and across services is the ideal but is elusive in practice. One critical barrier islack of evidence on how to do this in different contexts. The 2013 World Health Organization (WHO)guideline update on wasting recommended outpatient care for stable and “uncomplicated” severely wasted infants u6m (11). However, uptake
in national policy and practice has been low andslow, with most countries still recommending
inpatient treatment. In 2023, WHO updated theguideline (12) to cover infants u6m at risk of poor
growth and development. Knowing how to deliver such care in different settings is critical fornational policy-makers and those who support
their efforts. National decision-makers need contextualised evidence on what works, where, how
and for whom in different settings, to enable informed policy and service development withincost and capacity. Without addressing the ‘how’,realising adequate care will remain elusive.

Health worker taking infant’s MUAC.
‘Learning by doing’ case study series: Pakistan

Commitment to country-led
learning on ‘how’
To help put the WHO 2013 guidelines into practice,
the Emergency Nutrition Network (ENN) coordinated the development of the Management of
Small and Nutritionally at-Risk Infants Under Six
Months and their Mothers (MAMI) Care Pathway
in 2015 through a global collaboration of experts
and practitioners. Version 3 was released in 2021.
The provisions are consistent with the 2023 WHO
guideline update’s extended scope (12). The MAMI
Care Pathway applies, and expands on, updated
health and nutrition guidance, including IMNCIand United Nations Children’s Fund (UNICEF)/
WHO breastfeeding counselling materials andframeworks, as well as integrated continuity ofcare for at-risk infants u6m and their mothers
across health and nutrition services. It has beenused in pilot studies, small-scale programmes
and, increasingly, government services to help
navigate and plan care in multiple settings.
Evidence is needed to show that an intervention is effective, but also to assess the conditions
under which it is implemented, to maximise thepotential for replicability and sustainable delivery at scale. Learning from small-scale implementation is essential before expanding, which
requires active planning from the outset. As acollective, the MAMI Global Network is an active
forum practitioners around the world use to collaborate, exchange experience and support eachother in caring for at-risk infants and mothers
through policy, research and practice. Activities
are guided by a five-year strategy (9) that aims
to achieve sustainable, scaled care by supporting
country leadership, priorities and action to help
mothers and their infants to survive and thrive.
The MAMI Global Network is committed to supporting learning to capture and appraise experiences of the MAMI Care Pathway and examine
implementation models and delivery systems in
different contexts.

‘Learning by doing’ case study series: Pakistan

Health worker taking infant’s length.

7

2.

Case study
seriesThree in-depth case studies were carried to explore different implementation modalities of the MAMI
Care Pathway approach in three different small-scale settings: in Pakistan, South Sudan and Yemen.

Objectives
The overall objective of the case studies was toexplore, capture and generate learning from theapplication of the MAMI Care Pathway approachin different contexts to inform approaches forsustainable scalability of care.
Specific objectives
1. Describe and learn about what was done, andhow and why, in each context.
2. Describe and learn about what worked (ornot), for whom and under what circumstances, to bring about routine practices.
3. Examine the spread, scale-up and sustainability of the approach within and across settings.
4. Provide suggestions on how to improve practice and ensure sustainability at scale.

•

The Pakistan case was selected as an example
of integrating the MAMI Care Pathway approach
into paediatrician-led services in a private charity
hospital in Karachi, Pakistan. The country healthcontext (section 3) described the implementation environment for our phased investigation:••

Methods
We applied a mixed-methods approach within
and across the three case study settings, including
the following elements:

•

•

•

•

•

8

Developing a Planning and Implementation Process Framework for the MAMI Care
Pathway Approach to describe in detail theplanning and implementation process ineach context.
Exploring the sequential steps of ‘normalisation’ (adoption) of care, spread, scalability
and sustainability in sequential steps by
applying the Normalisation Process Theory(NPT) (13–15); the Non-adoption, Abandonment, Scale-up, Spread and Sustainability(NASSS) Framework (16); and the Checklist
for Assessing the Potential Scalability of Pilot
Projects or Research (17, 18).
Using these methods to apply different lenses
to examine experiences in each context andto generate insights that may be transferable
to other settings (19).

Using a participatory and reflective approachof ‘learning by doing, together’, to deepen theunderstanding and build the capacity of allparticipants.

First, we described the process of planningand implementing the MAMI Care Pathway
approach to understand what was done, andhow and why (section 4).
Second, we explored factors that influenced
the process of normalisation and adoptionof the approach and explored perceptions
about what worked for whom and underwhat circumstances (section 5).
Third, we triangulated and synthesised dataon descriptions and perceptions to appraise
the potential scalability and sustainabilityof the approach (section 6).
Finally, we synthesised insights generated
through the collective learning process intosuggestions for policy, research and practice,
to strengthen the potential for future scale(section 7).

Annex 1 provides an overview of the MAMI Care
Pathway approach (who, what, where). Annex
2 lists definitions. Annex 3 details the methods
applied in the three case studies, and their limitations. Annex 4 presents a set of generic questionnaires and Annexes 5 and 6 provide more detailed
information on the materials used for implementation and training. Annexes 7 and 8 present thedetailed findings from the appraisal of the adoption process and readiness for scale.

‘Learning by doing’ case study series: Pakistan

The case study did not draw 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 only involved a few clinicalhealth workers. Nor did it evaluate the cost effectiveness, acceptability, or feasibility of the Care
Pathway approach, or compare it to alternative
approaches.

Health worker assessing the infant and mother.

‘Learning by doing’ case study series: Pakistan

93.

Country healthcontext

Pakistan is a lower middle-income country thatfaces ongoing political and socioeconomic instability, as well as regular natural disasters, suchas flooding, resulting in displacement, damaged
infrastructure, and loss of livelihoods. From 2014
to 2015, an estimated 39% of people living in Pakistan experienced multidimensional poverty(poverty in regard to education, health and living
standards).
Over the past three decades, Pakistan has documented improvements in maternal and childhealth (MCH) indicators, including a 59% reduction in maternal mortality since 1990 (20). Howev-

er, rates of neonatal and infant mortality (41 and55 deaths per 1,000 live births, respectively) remain high and have been slow to decline (Table 1).
There are also substantial disparities in health access between provinces and districts, with manyof the most vulnerable women and children lacking access to quality health services. There is currently limited understanding of the numbers ofinfants at risk of, or experiencing, poor growthand development, and of those whose mothers
need additional care and support. However, data
show that almost one-fifth of infants are bornwith LBW (19%) and fewer than half of infants(49%) are exclusively breastfed.

Table 1: Key health and nutrition indicators, Pakistan
Total population (million)

240.8 (2023) (21)Fertility (births per woman)

3.2 (2023) (22)Live birth (births per 1,000 people)

26 (2023) (22)

Neonatal mortality (neonatal deaths per 1,000
live births)

41 (2018) (23)Infant mortality (infant deaths per 1,000 live
births)55 (2023) (22)

Low birth weight

19% (2023) (24)Skilled birth attendance

74% (2019) (25)

Exclusive breastfeeding

49% (2018) (23)

Wasting (children 6–59 months)

18% (2018) (23)

Stunting (children 6–59 months)

40% (2018) (23)Severe wasting and nutritional oedema (children
6–59 months)

2% (2018) (26)10‘Learning by doing’ case study series: Pakistan

The MAMI Care Pathway approach has been introduced in Pakistan at Indus Hospital, in the cityof Karachi. Indus Hospital is a charitable, freeof-cost tertiary hospital that is funded throughdonations. The MAMI Care Pathway approach
was implemented in the outpatient department(OPD) through the MCH/MAMI clinic, which is run
three times per week by paediatricians and nurses, with support from a protein calorie malnutrition (PCM) clinic nutritionist when needed. Since
Indus Hospital is a teaching facility, paediatricresidents rotate through the MCH/MAMI clinic formonths at a time as part of their training, withvarying levels of experience depending on theirstage of residency.
Preparation for implementing the MAMI Care
Pathway approach started in June 2021, with thefirst mother–infant pairs enrolled from October
2021. There is a desire to spread the MAMI Care
Pathway approach to the hospitals’ satellite clinics in the future, which would require further
commitment and resources that are not currently in place.

Figure 1. Location of Indus Hospital in Karachi, Pakistan (see blue dot‘Learning by doing’ case study series: Pakistan

)

11

4.

Planning andimplementation

This section describes the inquiry into the planning and implementation of the MAMI Care Pathway in
the Pakistan case that included the following steps:
1.
2.
3.
4.
5.

Understanding the health system.
Planning for service delivery: who, what and how.
Implementing services: steps taken to implement the MAMI Care Pathway approach.
Monitoring, improving quality and collaborative learning.
Making suggestions for improving planning and implementation.

4.1. Understanding the health system
Key information
•

•

•
•
•

12

In Pakistan, no national policies specifically cater to at-risk infants u6m and their mothers. Carefor infants u6m is informed by a mix of relevant WHO guidelines and primarily implemented
through national guidance on IMNCI, infant and young child feeding (IYCF) counselling, andinpatient care, as part of community management of acute malnutrition services.
At Indus Hospital, the MAMI Care Pathway approach was introduced to address a care gap andto facilitate early identification of infants u6m with malnutrition, growth problems, feedingproblems and disabilities, and to facilitate continuity of care for vulnerable mother–infant
pairs from birth.
Introducing the MAMI Care Pathway approach provided opportunities to reinforce andintegrate existing services that are relevant to at-risk infants u6m and their mothers, and tostrengthen or introduce referral mechanisms between services.
Opportunities for learning and capacity building of clinical health workers, such as
strengthening IYCF counselling skills, were created.
The Chair of Paediatrics at Indus Hospital spearheaded the introduction of the MAMI Care
Pathway approach. She worked with a core group of internal multi-speciality stakeholders(the MAMI implementation group) to develop a MAMI hospital policy and adapt MAMI Care
Pathway materials to the context. She also provided training to clinical health workers andsupport staff.

‘Learning by doing’ case study series: Pakistan

Burden and perceived health priority. Malnutrition services at Indus Hospital were implemented through the PCM clinic in the OPD, targetingchildren aged six months to five years. However,it was recognised that infants u6m with malnutrition, growth problems, feeding problems anddisabilities were falling through the gaps in care.
The MAMI Care Pathway approach was introduced to identify at-risk infants at an earlier age
and to provide comprehensive care to children
from birth to six months of age, while also considering the health, nutrition and social care needsof their mothers.
Policy context. No formal policy analysis was
conducted prior to introducing the MAMI Care
Pathway approach; however, knowledge anddata from local literature were used to inform development of a MAMI hospital policy and guide
implementation. Currently, there are no specificnational policies to address at-risk infants u6m;
however, their care is informed by various relevant WHO guidelines and implemented primarily through the approaches of IMNCI, IYCF counselling, and inpatient care, as part of community
management of acute malnutrition services.
Local health system capacities. No formal capacity analysis or feasibility study was conductedprior to implementation of the MAMI Care Pathway approach as robust data on the resources,
capacities and logistics of the hospital were available and planning was further informed by the
Chair of Paediatrics’ knowledge and local networks. Since Indus Hospital is a teaching facility,
introduction of the MAMI Care Pathway approachprovided an opportunity for learning and capacity building related to infant growth and development. For example, IYCF counselling skills wereidentified as inadequate and MAMI training on
breastfeeding counselling and support has since
improved these.
While the MAMI Care Pathway approach was new
to Indus Hospital, some services relevant to atrisk infants u6m were already being provided, including breastfeeding and nutrition counselling,
inpatient management of sick infants, follow-up
care for preterm and LBW infants, and screening
for congenital metabolic disorder, hypothyroid-‘Learning by doing’ case study series: Pakistan

ism and congenital deafness. However, gaps inreferral mechanisms – for example, from neonatology to the paediatric department and for infants u6m with medical problems like cerebral
palsy, congenital heart disease, or inherited metabolic disorder – compromised continuity of care.
For mothers, there was no formal referral system to the psycho-social department for mental
health concerns or to the fertility clinic for familyplanning counselling. Introduction of the MAMI
Care Pathway approach provided an opportunity to locate existing services under one umbrella,linking psycho-social, nutrition, speech therapy,
cardiology, paediatric medicine, and hearing assessment services.
Stakeholders. The Chair of Paediatrics at Indus
Hospital championed the MAMI Care Pathway
approach, identifying and acting on the opportunities it presented to fill gaps in care for infants
u6m and their mothers. She advocated for implementation of the MAMI Care Pathway approachand has since acted as the MAMI manager, overseeing planning and implementation of the approach at the hospital. A core MAMI implementation group was formed at the hospital, which
includes stakeholders from key departments
such as neonatology, paediatrics, psycho-social,family planning and hearing screening departments. This core group was involved in adapting
MAMI Care Pathway materials (e.g., assessment
forms) according to context specifications, in developing new materials (e.g., to support breastfeeding assessments), and in training of doctors
and nurses. So far, no external stakeholders at national level have been involved in planning andimplementation; however, there is recognised
potential to engage government agencies likethe People’s Primary Healthcare Initiative, theAccelerated Action Plan Against Hunger, and the
Pakistan Paediatric Association, who are delivering nutrition services and who can build on thenumber of facilities implementing the MAMI Care
Pathway approach in future. During conceptualisation, and periodically through implementation,
the Chair of Paediatrics sought feedback andshared progress with global practitioners, facilitated by ENN through the MAMI Implementers
Working Group of the MAMI Global Network.

13

4.2. Planning for service delivery
Key information
•
•
•
•
•

Planning for implementation was done internally: a MAMI hospital policy, including budgeting for medications, was drafted, and was approved by the hospital’s medical directors.
The MAMI Care Pathway approach was integrated into hospital services and utilised existing
hospital staff and equipment. Referrals occurred within the hospital.
All MAMI Care Pathway materials were used during implementation, following context-specific adaptation by the local MAMI implementation group. Initial piloting with 20 mother–infant pairs informed further adaptations.
Forms were translated into Urdu as needed.
Clinical health workers were trained to implement the MAMI Care Pathway approach, according to their level of care. The MAMI manager provided ongoing mentorship and support
for providing quality care.

Agency’s preparedness, stakeholder engagement and approval. All planning for implementation was done internally, starting with development of a MAMI hospital policy and budgetingfor medications. Approval was received from the
medical directorate department of the hospital
after three months.

Defining the target population. Criteria for describing at-risk infants u6m during screening
and assessment were defined by the neonatologist and paediatrician within the core MAMI implementation group (Box 1). For mothers, at-risk
criteria were informed by the MAMI Care Pathway Package materials (27). A low Apgar score1
was taken as a red flag that an infant may have
cerebral palsy and to ensure active screening for
cerebral palsy at 3-4 months of age.

Health worker recording patient information on the hospitalmanagement information system.

1 The Apgar score is a quick way for health professionals to evaluate the health of all newborns at one and five minutes after birth and in responseto resuscitation. Most newborns score 7, 8 or 9 on the Apgar test, which is considered a good Apgar score. About 90% of infants have Apgar scoresof 7 to 10 (https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2015/10/the-apgar-score).

14‘Learning by doing’ case study series: Pakistan

Box 1. Criteria to identify small and nutritionally at-risk infants under
6 months of age (u6m) and their mothers during screening andassessment at Indus Hospital in Pakistan, 2021-2023
Criteria to identify at-risk infants u6m and their mothers during rapid screening in health
units of the hospital, for referral for in-depth assessment in the maternal and child health(MCH)/ MAMI clinic
Infant u6m:

Mother of infant u6m:

•
•
•
•

•
•

Preterm infant <37 weeks
Low birthweight newborn <2500 g
Small-for-gestational age
Infant receiving mixed feeding or top-up
feeding•Mother with feeding difficulties
Mother with mid-upper arm circumference (MUAC) <230 mm
Mother with mental health concerns,
according to mental health score

Criteria to identify high-risk infants u6m and their mothers during in-depth assessment
for referral to inpatient care
Infant u6m:

Mother of infant u6m:

•
•

•

•
•

MUAC <110 mm
Weight-for-age z-score (WAZ) <–3 orlength-for-age z-score (LAZ) <–3
Infant with confirmed medical condition(e.g., congenital heart disease, metabolic
disease, cerebral palsy)
Infant with weight loss at follow-up••

Mother with depression identified by apsychologist
Mother with persistent MUAC <230 mm
after management
Mother with persistent anaemia after
management

Criteria to identify moderate-risk infants u6m and their mothers during in-depth assessment for enrolment in outpatient care
Infant u6m:

Mother of infant u6m:

•
•
•
•

•
•

•
•
•

Preterm infant <37 weeks
Low birthweight newborn <2500 g
Small-for-gestational age
Infant receiving mixed feeding or top-up
feeding
Infant with feeding difficulties
MUAC ≥110 and <115 mm
WAZ ≥–3 and <–2 or LAZ ≥–3 and <–2‘Learning by doing’ case study series: Pakistan•

Mother with MUAC <230 mm
Mother with mental health concern(mental health score PHQ-9)
Mother with breastfeeding difficulty15Selecting implementation sites. The MAMI Care
Pathway approach was integrated into hospital services for inpatients and outpatients andutilised existing staff and equipment. Referrals
for specialised care occurred within the hospital, including to paediatric emergency for inpatient admission, the PCM clinic for children with
undernutrition over six months of age, the psycho-social department for maternal counselling,and speciality clinics for cerebral palsy and congenital heart disease.
Designing the implementation modus. Following development of the hospital policy, local adaptations were made to the MAMI Care Pathwaymaterials and forms. Implementation was initiallypiloted with 20 mother–infant pairs and feedback
from health workers informed further adaptations. Data collection then began, using REDCap
software. Data collected from the first 900 mother–infant pairs are currently being cleaned for further analysis and to inform future adaptations.

Adapting, aligning, simplifying, testing and using materials. All MAMI Care Pathway package
materials were applied during implementation.
Initial adaptations to the MAMI forms were madein consultation with the core MAMI implementation group at the hospital, and further amended
in response to feedback during implementation(Table Annex 5). Forms were translated into Urdu
and tested.
Training for implementation. Three MAMI training workshops were held between 2021 and 2023
for medical doctors, nurses, nutritionists and receptionists working at the hospital. The MAMI
manager, nutrition nurse and research department supervisors also participated in management and supervisory capacities. Details of the
training sessions are provided in Table Annex 6.
The MAMI manager provided ongoing mentorship and support for providing quality care during
implementation.

4.3. Implementing services
Key information:
•
•
•
•
•
•

The MAMI Care Pathway approach was introduced at Indus Hospital in June 2021, with the firstmother–infant pairs enrolled in October 2021. Research data collection stopped at enrolmentof about 900 pairs. Implementation of the approach has continued since.
All inpatient and outpatient services provided to mother–infant pairs at Indus Hospital are
free of charge. All referrals took place within the hospital, including to inpatient care, andthere were no community-based components.
The MAMI Care Pathway approach was implemented in the OPD through MCH/MAMI clinics
held three days per week. A maximum of 18 mother–infant pairs were seen at the MCH/ MAMI
clinic per day.
Not all mother–infant pairs were followed up until the infant reached six months of age.
Sufficiently recovered infants were discharged and invited to return to the clinic if an issue
was identified by the mother/caregiver.
Sufficient skilled staff were available at the hospital to implement the MAMI Care Pathway
approach. Refresher workshops were regularly conducted, and paediatric residents attended
sessions on MAMI topics every six months.
Motivating mothers to return for follow-up visits was a key challenge given practical andeconomic constraints and the cultural context, and this limited the accessibility of care. The
high numbers of absentees compromised continuity of care for mother–infant pairs.

Access: Availability, geographic accessibility,
affordability and acceptability. Indus Hospitalis in the Korangi health district in Sindh province.
As a free-of-cost hospital, all services are provided
to mother–infant pairs free of charge. All referrals
took place within the hospital, including to inpatient care and outpatient clinics.
16

Organisation of care. All activities implemented
as part of the MAMI Care Pathway approach were
provided at the hospital site in inpatient or outpatient services (no referral required outside thefacility) and there were no decentralised community-based components. Table 2 lists the activities
according to where they were provided and who‘Learning by doing’ case study series: Pakistan

provided them across the hospital. Screening
took place at the MCH/MAMI clinic in the OPD
three days per week, with referrals between services facilitated by hospital receptionists. A maximum of 18 appointments were made for mother–infant pairs at the MCH/ MAMI clinic per day.
Pairs identified as at risk were initially followed
up weekly, and then fortnightly. Those moth-er–infant pairs who were not identified as at risk
were followed up at one-, three- and six-month
periods. Not all pairs were followed up until the
infant reached six months of age; instead, if sufficiently recovered prior to six months, they endedcare and were invited to return to the clinic if an
issue was identified by the mother (or caregiver).

Table 2: MAMI Care Pathway components unpacked for integration into health services at Indus
Hospital in Pakistan, 2021–2023
Activity

Detailed activities

What

Where

Who

Sensitisation

Sensitisation on risks

Through advocacy,counselling, charts andpublic message videos

In MCH/MAMI clinic,
inpatient department andpatient waiting areas

Doctors, nurses

Health and nutrition
promotion

Through advocacy,counselling, charts andpublic message videos

In MCH/MAMI clinic,
inpatient department andpatient waiting areas

Doctors, nurses

Screening

Screening (rapid
assessment)

Through MAMI forms

MCH/MAMI clinic

Doctors, nurses

Assessment

IMNCI assessment,
triageThrough MAMI forms

MCH/MAMI clinic

Doctors, nurses

Anthropometry
assessment

Through MAMI forms

MCH/MAMI clinic

Doctors, nurses

MAMI risk
assessment

Through MAMI forms

MCH/MAMI clinic

Doctors, nurses

Feeding assessment

Through MAMI forms

MCH/MAMI clinic

Doctors, nurses

Mental healthassessment

Through MAMI forms,
Edinburgh postnatal
depression scale

MCH/MAMI clinic andpsycho-social department

Doctors, nurses,
psychologists

Classification andreferralThrough MAMI forms

MCH/MAMI clinic

Doctors, nurses

Treatment andsupport plan

Through MAMI forms

MCH/MAMI clinic

Doctors, nurses

Enrolment

Through MAMI forms

MCH/MAMI clinic

Doctors, nurses

Treatment andsupportThrough MAMI forms

MCH/MAMI clinic

Doctors, nurses

Targeted counselling Through MAMI forms
on feeding issues

MCH/MAMI clinic

Doctors, nurses

Targeted counsellingon mental healthissuesPsycho-social department

Psychologists

Follow-up

Through counsellingsessions

Targeted counselling In paediatric OPD
other (specify)
Referral in case ofdeterioration during
enrolment

Inpatient admission

Evaluate progress

MCH/MAMI clinic

Evaluate outcome

MCH/MAMI clinic

Referral in case of
non-recovery at six
monthsTo nutrition clinic in
hospital catering tochildren aged six months
to five years‘Learning by doing’ case study series: Pakistan

Doctors

Paediatric ward/ neonatal
intensive care unit

DoctorNutrition clinic

Doctors, nurses

17Organisation of staff. Sufficient skilled staff
were available at the hospital to implement the
MAMI Care Pathway approach. In addition to initial MAMI training, refresher workshops were regularly conducted, and paediatric residents (medical doctors) attended sessions on MAMI topics
every six months. Family medicine residents who
expressed an interest were also invited to attend
these sessions to learn about the MAMI Care
Pathway approach. REDCap software was used
to monitor data flow and regular meetings were
held with receptionists to discuss patient referrals to other outpatient and inpatient services.
Participation. Caregivers were not specificallyasked about their experiences of, or satisfaction
with, care during implementation and no qualitative data were collected. For teaching purposes, residents discussed cases and gaps in care,with a focus on mother–infant pairs who failed to
improve or failed to attend their appointments.
There were high numbers of absentees, which
compromised continuity of care for infants up to
six months of age. Follow-up for missed appointments was conducted via phone calls to mobile
numbers, but many caregivers either did not
answer or did not attend the facility, even after
agreeing to do so on the phone.

Partnerships. As previously discussed, there wasminimal engagement external to the hospital on
implementing the MAMI Care Pathway approach,although the Chair of Paediatrics championed
the approach during engagement with healthactors at global and national levels when possible. For example, discussions with the Pakistan
Paediatric Association were encouraging, butfailed to result in active participation, with theirfocus currently being on developing a consensus guideline for acute care, which would include
acute emergency care for infants u6m. UNICEF
and WHO were reached out to, and visited Indus
Hospital, but were primarily interested in services
for children over six months of age. More broadly, the current remit of WHO in Pakistan tends tofocus on supporting programmes in rural areas.
While there was an intention to implement the
MAMI Care Pathway approach in the hospital’ssatellite clinics, it was agreed that further simplification and monetary support were needed forthis to be successful.

Indus Hospital, Karachi campus where MAMI
clinics are run three times a week.

18‘Learning by doing’ case study series: Pakistan

4.4. Monitoring, improving quality and collaborative
learning
Key information:
•
•
•
•

•

Data on implementing the MAMI Care Pathway approach were collected via the hospital’sroutine electronic records system and captured using REDCap software.
Data collected via REDCap were exported by Indus Hospital’s research department every two
to three months for consolidation, cleaning and analysis.
Duplication of monitoring data in hospital records and in REDCap was burdensome for healthworkers, but provided valuable information for case management and to identify mother–
infant pairs who did not return for follow-up visits.
Currently, there is no in-country sharing about the MAMI Care Pathway approach outsideof Indus Hospital. Outside of Pakistan, experiences were shared through the MAMI Global
Network’s Implementers Group, and learning is planned for dissemination through peerreviewed publications and other research channels.
Those implementing the MAMI Care Pathway approach were accountable to Indus Hospital’s
administration and quality department for providing quality services, maintaining patient
flow and ensuring continuity of care.

Monitoring and reporting. The Indus Hospitalis fully digitised, with an electronic records system. Data on implementation of the MAMI Care
Pathway approach were collected via the routine hospital system and also captured in REDCap (patient flow and monitoring data). Paper
forms were kept by the clinicians and data wereentered into REDCap using mobile phones eachweek. Data collected via REDCap were exported to Excel from the hospital’s research department for consolidation and cleaning. This wasdone every two to three months, with data thentransferred to SPSS software for analysis. Duplication of monitoring data for implementation of
the MAMI Care Pathway in hospital records andin REDCap was burdensome for the health work-‘Learning by doing’ case study series: Pakistan

ers. At the same time, the data collected through
REDCap were valuable in informing case management, allowing for identification of infantsneeding particular support and facilitating earlyreferrals. These data also flagged mother–infant
pairs who failed to return to the MCH/MAMI clinic
for follow-up visits and allowed health workers tomonitor the proportions of infants and mothers
who experienced vulnerabilities, such as infants
born preterm or identified as malnourished, andmothers experiencing depression. Table 3 summarises the data on implementation of the MAMI
Care Pathway approach (screening, assessment,
enrolment, and outcomes for at-risk pairs) overa 12-month period at Indus Hospital (December
2021–December 2022).

19

Table 3. Assessment, enrolment, and outcomes of mother–infant pairs, 12-month period(December 2021–2022), Pakistan
Key indicators:
Pairs assessed

1,238

Pairs assessed identified at moderate risk(% of pairs assessed)

807 (65.2%)

Pairs assessed identified at high risk(% of pairs assessed)

NA

Pairs assessed boy/girl ratio

1.23

Key reasons infants’ moderate risk

Mixed feeding, slow weight gain

Key reasons mothers’ moderate riskWork-related absence

Pairs enrolled in care

807

Pairs recovered at infant aged 6 months(% pairs attending care until infant aged 6 months)

MUAC: 358 (59.6%)
WAZ: 447 (74.4%)

Pairs not recovered at infant aged 6 months(% of pairs attending care until infant aged 6 months)

MUAC: 243 (40.4%)
WAZ: 154 (23.6%)

Pairs missed before or at infant aged 6 months (died,absented, did not return, lost to follow-up) (% of pairs
enrolled)

206 (25.5%)

LBW= low birth weight; MUAC= mid-upper arm circumference; WAZ= weight-for age z score.

Improving quality and disseminating informationand learning. So far, there had been no in-country
sharing of information and learning about the
MAMI Care Pathway approach outside of Indus
Hospital. While attempts were made to involve
national research institutions, there had been no
progress in fostering collaborations. Outside ofPakistan, experiences were shared through the
MAMI Global Network’s Implementers Group, andthere was a plan to disseminate learning throughpeer-reviewed publications and other researchchannels.

20

Improving, maintaining and sustaining quality
services. The MCH/MAMI clinic was accountable
to the Indus Hospital’s administration and quality department for providing quality services,maintaining patient flow and ensuring continuityof care. Paediatricians, paediatric residents andother colleagues at the hospital were continually engaged to strengthen service provision andmaintain quality care, and the approach was advocated for through informal discussions acrossthe hospital. Educational brochures on topics
related to MAMI, including breastfeeding, complementary feeding, anaemia and vitamin D deficiency, were developed for distribution in the
OPD and videos were played in patient waiting
areas to further promote and advocate for the
MAMI Care Pathway approach.

‘Learning by doing’ case study series: Pakistan

4.5. Making suggestions for improving planning andimplementation
Key information:••••

Implementers appreciated the potential of the MCH/MAMI clinic to fill a care gap for at-risk
infants u6m and their mothers.
Implementation could be improved by strengthening guidance and materials on counsellingon nutrition-specific and nutrition-sensitive topics, such as water, hygiene and sanitation, andfamily planning.
More detailed guidance on care for specific at-risk groups was identified as needed; e.g., forinfants with cerebral palsy.
Since the WHO growth charts do not distinguish between preterm and term babies’ growth,and since gestational age was available within this hospital setting, the INTERGROWTH-21
growth charts were used for preterm infant growth monitoring.

Based on their experiences of implementing the
MAMI Care Pathway approach at Indus Hospital,
the case study participants appreciated its potential to fill a care gap for at-risk infants u6mand their mothers. They also made several suggestions to further strengthen implementation.
For example, there was a perceived need to either
add – or to strengthen and contextualise – content on nutrition-sensitive and nutrition-specific counselling topics, such as on water, hygiene
and sanitation, addressing common micronutrient deficiencies (e.g., iron, vitamin D, zinc), familyplanning and complementary feeding, as part of
the MAMI Care Pathway approach. More detailed
guidance on managing specific risk groups, suchas infants with cerebral palsy, was also identified
as needed.

‘Learning by doing’ case study series: Pakistan

During implementation of the MAMI Care Pathway
approach it was recognised that the WHO growth
charts do not distinguish between preterm andterm babies’ growth. Given the high numbersof infants born preterm in this setting, and thefact that data on gestational age were available
within this hospital setting, the INTERGROWTH-21
growth charts were used for preterm infant growthmonitoring.

21

5.

Embedding the MAMI
Care Pathway in routine
services

Key information:
•

•
•
•
•
•
•

Adequate training, orientation, and adaptation to their contexts helped health workers
understand how the MAMI Care Pathway approach built upon and strengthened existing
services for at-risk mother–infant pairs, they appreciated its value and they recognised what
was required of them.
Rotation in the MCH/MAMI clinic was introduced as mandatory for all paediatric residents, andimplementing the MAMI Care Pathway approach was incorporated into their job descriptions
and training.
Training, context-adapted forms, and ongoing mentorship were critical for effective
implementation and ensuring quality of care.
Person-centred care for the mother–infant pair was a new approach that required a mind shift
and a broader skill set from clinicians, as well as connecting paediatric and maternal (adult)
health services.
Since staff were appointed to undertake specific clinical and counselling tasks, sharing oftasks across roles within the implementation team was not common and frequent rotation
disturbed routine practices.
Standardised individual medical records were used for individual case management, toidentify difficult clinical cases (red flags) and to monitor individual quality of care.
Data on individual care were collected and analysed digitally but were not available for routine
feedback on quality of care, or for encouraging learning or adaptive management.

This section describes whether and how clinicalhealth workers in the tertiary care setting of Indus
Hospital understood and adopted (normalised)
the MAMI Care Pathway approach and embedded it in routine practice using a framework approach (13, 14). (See Annex 3 for methods and theirlimitations and Annex 7 for detailed findings). We
interviewed the paediatric resident in charge ofproviding services to at-risk mother–infant pairs.
First, the inquiry explored the degree to which
the approach was adopted in routine work, thecontribution of individual and collective action toachieve this and what promoting and hinderingfactors were involved. Four components of the
adoption process were considered: coherence,cognitive participation, collective action, and reflective monitoring. Next the likelihood of the
MAMI Care Pathway becoming routine practicefrom a clinician’s perspective was appraised.
Health worker taking infant’s weight.

22‘Learning by doing’ case study series: Pakistan

5.1. Exploring adoption
The clinician participating in the inquiry was asked 16 questions to explore whether she:••••

Understood the components of the MAMI Care Pathway approach (coherence, or what it is about);
Was committed to and engaged in implementing the practice (cognitive participation, or who does it);Worked with colleagues to enable the practice (collective action, or how it gets done); andAppraised the benefits of the practice (reflective monitoring, or how it is understood).

Understanding the MAMI Care
Pathway (coherence)
The paediatric resident understood and saw thevalue of the MAMI Care Pathway approach. She
compared how services were provided before
and after implementing the MAMI Care Pathway
approach and shared how the new components
of care, such as measuring MUAC for infants u6m,
monitoring growth across follow-up visits, andassessing issues related to the mother’s health,were feasible following training and ensuringlinks were established across necessary inpa-

tient and outpatient services. From her experience of implementing the MAMI Care Pathway
approach, the paediatric resident appreciated its
importance and cited its benefits, including opportunities for early identification of at-risk mother–infant pairs, resulting in fewer cases of malnutrition among older children (six months of age
and beyond) and fewer referrals to the PCM clinic.
Since in the MCH/MAMI clinic a cap was placedon the number of mother–infant pairs seen perday (maximum 18), clinicians were able to engage
and counsel mothers on care practices, and, inturn, they became more engaged.

Coherence was influenced by the following factors:
Enablers•••

Initial and repeated training and mentoring built a good base of understanding.
The competent MAMI manager adapted and shared the new knowledge and materials relevant for their level of care and context.
The roles and responsibilities were assigned based on staff competencies.

Barriers•

The clinician was initially uncertain about how to operationalise the MAMI Care Pathway,
which included a more in-depth inquiry regarding the infant’s health and added an inquiry
regarding the mother’s health and care practices.

‘Learning by doing’ case study series: Pakistan

23

Engaging with the MAMI Care
Pathway (cognitive participation)
Commitment and engagement by practising
staff were required to implement the MAMI Care
Pathway approach in clinical practice. Because
paediatric residents were required to rotate into the
MCH/MAMI clinic as a new part of their defined roleat the hospital, they invested the time needed toprovide quality care in accordance with the MAMI
Care Pathway approach. The MCH/MAMI clinic also

had additional fixed staff (e.g., a senior “feeding
nurse”, a clinical nurse to monitor vital signs andtriage, a receptionist to manage referrals) to
support implementation. The MAMI manager wasvery involved, providing mentorship (supportive
supervision) and being available for consultation
when issues arose. There was enthusiasm andwillingness to further implement the MAMI Care
Pathway approach at the MCH/MAMI clinic, butthere was no assurance that care would continue
without the MAMI manager.

Cognitive participation was influenced by the following factors:
Enablers•••

Involvement in implementation of the MAMI Care Pathway was mandatory because it became part of the paediatric residents’ rotation and training.
Access to a knowledgeable and supportive MAMI manager was inspiring and helped professional development.
The ability to identify and address risks that would otherwise not be known or would be ignored increased levels of professional satisfaction.

Barriers•

Despite the MCH/MAMI clinic cap of 18 mother–infant pairs seen per day (maximum), theMAMI Care Pathway approach introduced more and longer consultations, creating long working days.

Health worker taking infant’s weight.

24‘Learning by doing’ case study series: Pakistan

Organising changes andrelationships (collective action)
Operationalising the MAMI Care Pathway
approach in the tertiary care setting required
collective action from all clinical staff, the senior
management of Indus Hospital, and the hospitals research department. Training and mentorship (including supportive supervision) ensured
that health workers collaborated and were able
to complete the tasks required at their level.
However, more experienced paediatric residents
showed greater competency in the tasks. In cases

where the MCH/MAMI clinic was overburdened,
additional staff, primarily the feeding nurse, wereavailable to assist with counselling. While it was
acknowledged that the skills required to implement the MAMI Care Pathway approach were notso different to those already used in their routine
practice, training was required to ensure competency in growth monitoring and IYCF counselling,
and practical advice was given on how to respondto different scenarios. The MAMI manager, and insome cases supervisors from other units, continuously motivated the residents in training andprovided on-the-job support for implementing
the approach.

Collective action was influenced by the following factors:
Enablers•••

Comprehensive and contextually adapted implementation materials and forms (staff themselves participated in adaptation) ensured standardised and quality actions (appropriate
tools).
Competent, well-trained health workers were enabled to implement the approach with confidence; continuous on-the job mentoring expanded knowledge and improved skills.
A competent manager and competent supervisors supported the implementation.

Barriers•••

A broad set of skills was required to apply the MAMI Care Pathway approach, which combines components together as person-centred care covering many questions and dealing
with many issues, both for infants and mothers.
Staff were appointed to undertake specific clinical or counselling tasks; sharing of tasks acrossroles (e.g., when staff capacity was limited) was not common.
Frequent staff changes disturbed routine practices.

‘Learning by doing’ case study series: Pakistan25

Appraising the MAMI Care Pathway(reflective monitoring)
Implementing the MAMI Care Pathway approachrequired ongoing monitoring and reflection toensure and maintain quality of care. Indus Hospital
has a paperless data system, and a separate datacollection system (using REDCap) was establishedfor capturing research data on MAMI implementation. The MCH/MAMI clinic data were managed by
the MAMI manager for research purposes and dataon the quality of individual care were evaluated ona regular basis (weekly): for example, to review ‘red
flag’ patients who required follow-up. Data on thequality of service delivery were not readily accessible.

Reflective monitoring was influenced by the following factors:
Enablers••

The standardised individual records were a tool for ensuring and monitoring the quality of
individual care.
Discussions of difficult clinical cases (red flags) were held on a regular basis for problem solving.

Barriers•

Data were collected and analysed digitally, and thus were not available for immediate feedback or to encourage learning or adaptive management.

5.2. Overall appraisal of the adoption process
The success of implementing the MAMI Care
Pathway approach based on the interviews
appraised the four adoption components on a
five-point Likert sliding scale, with a score from 1(“not adopted at all”) to 5 (“completely adopted”):

Pathway materials, briefs and videos); learning
experiences from other settings were available(e.g., in the ENN publication Field Exchange
publication); and evidence was published in
medical journals.

Coherence, score 4.8. The confident MAMI
manager translated existing knowledge
and experiences from practice into good
guidance for clinical health workers. Several
advancements made this possible: specificrecommendations on outpatient care for thisage group were included in the 2013 WHO
guideline on the management of severe acutemalnutrition; materials for advocacy andimplementation were available (e.g., MAMI Care

Cognitive participation, score 4.3. The score
for the level of engagement with the MAMI
Care Pathway may be explained by the factthat clinical health workers’ involvement was
not a choice, because they were allocatedspecific clinical tasks and task sharing acrossroles within the team (e.g., when staff capacity
was limited) was not common. However,they received occasional support from otherclinicians and had auxiliary health workers who
assisted with defined tasks.

26‘Learning by doing’ case study series: Pakistan

Collective action, score 4.3. Changes andrelationships across implementing teams
were facilitated by positive commitment to theassigned tasks and variation in staff skills.
Reflective monitoring, score 2.5. The low score
for continuous reflection and improvement
in quality of care indicated that quality of
individual care was addressed but the quality ofthe service was not; e.g., health workers did nothave an overall understanding of the quality
and impact of the service and were not involvedin adjustments or changes in implementation
modalities and materials.

The scores for the four adoption components
were plotted on a spider chart showing thedegree of success in the adoption of the MAMI
Care Pathway (Figure 2): the larger the area of the
spider web, the better the success in adoption.

Figure 2: Interpreting the adoption of the MAMI Care Pathway approach in Indus Hospital, 2023
(Adoption was scored on a sliding scale from 1 “not adopted at all” to 5 “completely adopted”.)

We concluded that the clinical health professionals successfully adopted the MAMI Care Pathway
in the context of a conducive policy environment
with senior management buy-in (average scoreof 4.0). Even though research data collection had
ended, implementation had continued in the
MCH/MAMI clinic. Paediatric residents were required to rotate in the MCH/MAMI clinic as part of‘Learning by doing’ case study series: Pakistan

their paediatric residency programme and therefore had been adequately trained and well supported by a motivational leader who championed
the MAMI approach in the hospital. Subsequent
steps in quality improvement could consider
overcoming the barriers identified in this section
to improve implementation and thus the effectiveness of the approach.

27

6.

Considerations
for scalability andsustainability

This section examines the readiness to scale up the MAMI Care Pathway approach, applying two methods to identify challenges and generate insights to improve scalability.

6.1. Exploring challenges to scale-up, spread andsustainability
Key information:
•
•
•
•
•
•
•
•

Clinicians understood the condition of “small and nutritionally at-risk infants and theirmothers” but found some vulnerability factors difficult to understand (e.g., maternal mental
health, socioeconomic factors).
The technology (methods, tools) involved in the MAMI Care Pathway required new skills to put
the mother–infant pair at the centre of assessment and care, with sociocultural vulnerability
factors difficult to access from a hospital setting.
Both clinicians and mothers understood and appreciated the MAMI Care Pathway, which
addressed a perceived need.
Introducing the MAMI Care Pathway threatened the professional identity, values and scopeof practices of some health workers, because care aspects fell outside of their comfort zone ofexpertise.
Understanding, trust and appreciation increased for mothers, but some opportunity costs
posed challenges that hindered their returning for follow-up.
Organisation of care was driven by good leadership but was fragile due to limited resources
and competition for financial resources among the different units of the hospital.
Expanding learning was identified as important but was difficult to do in the single hospitalsetting.
The paediatric outpatient department of a tertiary hospital was a conducive setting for testing
implementation of the approach, and generated learning for integrating the MAMI Care
Pathway into routine paediatric care.

The first method identified challenges and generated insights to improve scalability to explore
facilitating or hindering factors that might predict the success of sustainable scalability of the
MAMI Care Pathway (16). (See Annex 3 for methods and their limitations and Table Annex 8a for
detailed findings.) We interviewed the Chair ofPaediatrics (MAMI manager) only, as the paediatric resident had rotated to a new duty station.

28

Reflective participatory discussions examined
the MAMI Care Pathway approach across seven domains to identify challenges related to thecondition (“small and nutritionally at-risk infants
and their mothers”), the technology, the value
proposition, who the adopters are, the health orcare organisation, the wider system, and embedding and adapting over time. Next, the case study
investigators graded the challenges as 1 (simple– straightforward, predictable, few components),‘Learning by doing’ case study series: Pakistan

2 (complicated, with multiple interacting components or issues), or 3 (complicated, dynamic,
unpredictable, not easily disaggregated into constituent components).
The condition. The condition “small and nutritionally at-risk infants and their mothers” wasconsidered by the MAMI manager to have been
well understood by the paediatric resident working at the tertiary health care level. However,some risks were not easily detectable or predictable because the resident was not experienced inthese (e.g., maternal mental health) or the speciality level did not usually consider these (e.g.,socioeconomic factors). The mother–infant pairfocus was a new way of approaching care for conditions.
We graded the vulnerable mother–infant condition as complicated (grade 2) because somefactors that contributed to vulnerability were lessclear to the clinician, and thus more difficult to
detect, which potentially affected care provision.
The technology. The methods and tools used toassess, classify and support “small and nutritionally at-risk infants and their mothers” (technology) were mostly known. Putting the mother–infant pair at the centre of the assessment and care
was new (change from a disease focus to focusing on the comprehensive wellbeing of the pair)
and including maternal health and nutrition aspart of infant care required additional skills. Detecting changes in the health and nutritional status of the infant was easy and detecting changes
in the health and nutritional status of the motherwas manageable, but changes in behaviour weredifficult to assess from the hospital position. Detailed instructions, available in the MAMI Care
Pathway package materials, were found easy to
use and adapt to the level of care but were simplified for use in the clinic.
We graded the technology involved in detecting and addressing the vulnerable mother–infant condition as complicated (grade 2) because
while this process was easy for the clinician, considering the mother–infant as a pair, and adding
maternal physical and mental health issues in theassessment and care, were unusual and required
new skills.
The value proposition (benefit, or unique selling point). The contribution of the MAMI Care
Pathway to improving the health of infants byaddressing issues early, preventing poor growth,and reducing future complications was appreciated. Rotating residents in the MCH/MAMI clinic
offered the opportunity to train new incoming
residents on the MAMI Care Pathway, who then,when moving on, would take their newly ac‘Learning by doing’ case study series: Pakistan

quired skills to their new positions.
Mothers were initially satisfied with the care
and attention, but many would not come for follow-up visits because they felt the baby was well,or for other reasons (e.g., mothers were working,could not afford the transport, or had to be accompanied).
We graded the value proposition of the vulnerable mother–infant condition as simple (grade 1)
because the perceived benefit of the Care Pathway was understood and appreciated, addressing a perceived need.
The adopters. New paediatric residents rotatedinto the MCH/MAMI clinic and some staff were reorganised and allocated to the MCH/MAMI clinic
to cover the clinic activities. At the start, the additional tasks and longer working hours created some resistance but this mostly disappeared
when the benefits of the clinic were better understood. Also, other departments were affected
as they were embraced by the MAMI Care Pathway approach (e.g., accepting referrals). Overall, it
took four months to establish all MAMI activities
and to start the clinic activities.
Mothers previously would go to the nursery toattend vaccination and then go home. With the
MCH/MAMI clinic in place, mothers and infants
at-risk received more attention and were asked
to return for regular follow-up visits. Barriers toreturning to follow-up visits included that themother had to be accompanied by a family member to go to the clinic, employment of the mother, time investment of mother and companion,
and the cost of transport. Some mothers brought
other mothers and their infants with a problem,
which showed that mothers conferred with andinfluenced each other, were able to identify risks
and share knowledge that they could act upon,and valued the service as impactful. When mothers were in the clinic, they were happy and appreciative, but on leaving the clinic, other contextual
factors came into play that were beyond the control or influence of the hospital system.
We graded adopters of the Care Pathway as complex (grade 3) because the MAMI Care Pathway
required changes to professional career paths
and scope of practices that were difficult to value. Also, while mothers who attended care experienced an increase in their understanding, trust
and appreciation, there remained challenges inthese areas for those who could not continue toattend care.
The health or care organisation. The initiativeof starting and maintaining the MAMI clinic wasdriven by the Chair of Paediatrics, who, with the29agreement of the hospital’s directors, took responsibility for making the clinic operational andchampioned the innovation to address an observed and unmet need. All organisational steps
were managed by her, with the support of andtrust from superiors and colleagues, and the financial resources from the hospital’s charity system. Staff (paediatric residents and the nutrition
nurse) were available through adapting the rotation system and were trained to take on their
specific tasks.
We graded the health or care organisation ascomplicated (grade 2) because many organisational factors and good leadership were needed
to establish the services, which were challenged
in a hospital context with limited or competing
resources.
The wider system. Interest was expressed in expanding learning to beyond the hospital premises and efforts made to this end, needed to become regularised (e.g., involving more cliniciansin training, involving nutritionists and dieticians
in managing infants u6m and not just thoseabove six months, reaching out to the Paediatric
Association of Pakistan, expanding to hospitals in
Karachi with high burden of undernutrition but
no services, reaching out to the Ministry of Health(MOH) and WHO for their involvement and learning). The MOH was committed to addressing malnutrition in children but there were disparities inservice provision across provinces for which risk
stratification would be required to ensure humanresources and funding were allocated.

Embedding and adapting over time. The current
setup showed the good potential of adopting the
MAMI clinic as a routine service in a tertiary hospital. Challenges included further simplifying theapproach, ensuring ongoing learning and implementation support, and solving financial challenges relating to staffing, training, and medicines. Also, the whole approach, carried forward
by one influential person, was not sustainable.
We graded embedding and adapting the MAMI
Care Pathway approach over time as complex(grade 3) because there were significant barriers
to the further adaptation or co-evolution of the
MAMI Care Pathway approach towards becoming a routine service in a single hospital setting,without this being mandated by a policy change.
The seven scores were plotted on a spider chart(Figure 3) indicating grade 1 challenges (simple)
are understandable or predictable, and relatively straightforward to address; grade 2 challenges(complicated) are less understandable, controllable, and straightforward to address; and grade
3 challenges (complex) are incomprehensible orunpredictable, thus requiring systems dynamics
methods to understand their changing or emergent behaviours. The scores aimed to indicate
the feasibility of managing the identified challenges. The area of the spider web in figure 3 appraises the overall feasibility or ease of managing
the challenges to implementing the MAMI Care
Pathway approach in the Pakistan case at scale:the larger the area of the spider web, the morechallenging the scalability.

We graded the wider system as complex (grade3) because many factors influenced financial andpolicy support, due to competing health priorities, and they were difficult to know or predict.

30‘Learning by doing’ case study series: Pakistan

Figure 3: Appraising challenges to the scalability of the MAMI Care Pathway implementation in the
Pakistan case, 2023
(Challenges were graded as 1 “simple”, 2 “complicated” and 3 “complex” to address.)
We conclude that while clinicians involved in implementing the MAMI Care Pathway approach in
the Pakistan case found addressing the condition“small and nutritionally at-risk infants and theirmothers” with a person-centred and continuityof care approach challenging but feasible as partof tertiary hospital care. Key for sustainable scale-up was good leadership to organise services andsecure resources, and aligning the hospital directors behind this new approach. Peer-reviewed
publications would leverage learning in-houseand beyond, secure resources and advocate for
spreading the approach for scale-up.

Waiting area of the MAMI clinic.

‘Learning by doing’ case study series: Pakistan

31

6.2. Exploring potential scalability

Key information:••

Actions the Pakistan case took that facilitated future sustainable scale-up of the MAMI Care
Pathway approach included the following:
Addressing a persistent health condition, or service.
Assessing and documenting health outcomes and the process of implementation.
Designing mechanisms to review progress and promote learning.
Sharing understanding on the importance of evidence on feasibility and outcomes priorto scale-up.
Actions the case missed that might facilitate future sustainable scale-up included thefollowing:
Engaging key stakeholders in a participatory process.
Considering expectations for scale-up in the design.
Considering constraining or supporting socio-cultural and gender factors.
Planning to advocate for changes in policies and regulations.
Testing the intervention under existing human and financial resources constraints.
Engaging with donors and technical partners to support early and continuous scale-up.
Keeping the intervention simple, without jeopardising outcomes.
Testing the intervention in a variety of sociocultural and geographic settings.
Planning advocacy for changes in policies and regulations.

The second method explored potential scalability to assess readiness for scale-up by considering critical steps in the design to enhance potential large-scale impact (18). (See Annex 3 formethods and their limitations and Table Annex
8b for detailed findings.) The case study team32

triangulated the case study information to populate the table in Annex 8b. They explored 12 key
actions in the design of the approach to provide
useful insights for scale-up decision-making. Table 4 shows whether these actions were taken or
missed.

‘Learning by doing’ case study series: Pakistan

Table 4: Appraising potential scalability of the MAMI Care Pathway implementation at Indus Hospitalin Pakistan, 2023
Appraisal of actions for sustainable scale-up
1. Involved future stakeholders

No

2. Addressed a persistent health condition or service

Yes

3. Considered expectations about scale-up in the design

No

4. Considered constraining or supporting socio-cultural and gender factors

No

5. Kept package of interventions simple, without jeopardising outcomesNo

6. Tested in a variety of socio-cultural and geographic settings

No

7. Required no extra human and financial resources for implementation

No

8. Assessed and documented health outcomes and process of implementation

Yes

9. Engaged with donors and technical partners to support scale-up early and continuouslyNo

10. Planned to advocate for changes in policies and regulations

No

11. Designed mechanisms to review progress and incorporate new learning

Yes

12. Shared understanding on the importance of adequate evidence on feasibility
and outcomes prior to scale-up

Yes

The findings suggest that the implementation
modus of the MAMI Care Pathway at Indus Hospital in Pakistan was not designed with scale-up
in mind. Instead, it was intended to make services routinely and sustainably available in their
setting. Therefore, several of the recommended
steps for scale-up were either not applicable orwere not undertaken. However, discussions withthe team indicated that thinking was evolving on
this subject, and some initial steps had been tak-‘Learning by doing’ case study series: Pakistan

en, and some steps had been mulled over but not
yet implemented.
There was certainly a desire and willingness toshare learning, and help scale-up and expansion, as well as to involve paediatric associations.
Peer-reviewed publications that are planned
would support this endeavour and better attract
the attention of paediatric colleagues.

33

7.

Learning to inform practiceand scale-up in Pakistan(summary findings)

The process of accessing learning from implementing the MAMI Care Pathway approach in thetertiary charity hospital in Pakistan involved anempirical investigation in a real-life context. Interviewing members of the implementation team tocollect their perspectives, using several sources ofevidence, and discussing emerging findings revealed implicit knowledge and expanded learning. Using different lenses to explore what wasdone, where, by whom, and how uncovered andhelped further generate a range of rich learning
about implementing the Care Pathway approachin the given context.

7.1. Planning andimplementation
As a first step, a MAMI hospital policy paper outlining operations and re-allocating staff, including a budget, was approved by the medical directorate department. In consultation with thehospital management, the MCH/MAMI clinic
was established as a new unit in the paediatric
OPD where the necessary resources and support
were made available. It took four months to gain
approval and to set up the clinic. Three times aweek, the MCH/MAMI clinic received a maximum34

of 18 vulnerable mother–infant pairs per day as
outpatients who were referred from paediatricand maternity services within the hospital.
The organisation of clinical consultations by the
MAMI Care Pathway approach was familiar toclinicians, but the implementation modality demanded a shift in mindset and good leadership.
First, offering services that addressed both the infant and the mother in a paediatric unit required
new knowledge and skills, as well as strengthened links with other specialised services in thehospital. Thanks to the MAMI manager’s coordination, early hurdles were overcome. Second,taking a longer time to carry out in-depth assessment of, and to provide care to, infants, andincluding mothers and requiring them to returnfor follow-up visits until the infants reached six
months of age, were new ways of working for a
hospital unit.
On the other hand, it was difficult to assess andinfluence vulnerability factors related to the socioeconomic household environment of the vulnerable mother–infant pairs. Also, returning forfollow-up visits was challenging for mothers who
were working or lived far away, and was not seen
as essential if their infants were not perceived tobe sick. Mothers always needed to be accompanied by a family member.

‘Learning by doing’ case study series: Pakistan

7.2. Normalisation andadoption
Appraisal of the adoption of the MAMI Care Pathway approach generated detailed information on
facilitators and barriers that will be useful to improve health workers’ behaviours to ensure moresustainable health outcomes.
Because rotation in the MCH/MAMI clinic wasmade mandatory as part of the residency programme, the resident paediatricians received
good support from their supervisor, the MAMI
manager, to carry out their tasks and, in turn,were eager to perform their work properly. Monitoring and addressing risk factors that impact
growth and development over time required a
new skill set from the clinician, to guide and motivate mothers to comply with care.

7.3. Considerations
for scalability andsustainability
Two methods applying different lenses examined
the readiness to scale up the MAMI Care Pathway approach, not to determine whether the approach was scalable, but to provide insights onchallenges that need to be addressed when preparing for scale-up. Challenges were characterised as easy (simple), difficult but possible (complicated) or challenging (complex) to overcome
to consider in the future.
Challenges identified included the need to develop new skills to put the mother–infant pair at thecentre of assessment and care, which fell outsideof the comfort zone of available expertise, generate learning that is accessible to monitor qualityof care, and establish links to primary care facilities that have health activities that reach communities.

7.4. Collective learning andsuggestions to strengthen
potential for scale
The experience of implementing the approach in
the tertiary hospital facilitated important learningon planning, building capacities and implementing the MAMI Care Pathway in a specialised unit,
which can be transferred to other similar sites. It
was also assumed that the resident paediatricians
would take their new knowledge and skills when
they rotate to new sites and adopt elements of theapproach in their future practice. A strengthened
monitoring, evaluation, accountability and learning system, and peer-reviewed publications, wereplanned to support the learning process. Attempts
were made to share experience and advocate forpolicy changes. Reaching colleagues and major
health actors, including the State MOH and WHO,was difficult from a hospital position, but leveraging involvement in the MAMI Global Network andacademic and research networks may facilitate this.
The findings of the detailed learning are intended
to improve service delivery, encourage research anddrive mindful, sustainable approaches for scale-up.
Regarding mothers’ perceptions, as understood byhealth workers, we learned the following:
•
•
•
•

•

Vulnerable mothers considered the integrated
Care Pathway beneficial and were grateful forthe care and support received.
Adherence of mothers to care improved when
there was clear communication and support.
In cases where barriers in their home environments affected mothers’ compliance with care,they could not be corrected.
Because risk factors for the vulnerable mother–
infant pair were mostly invisible, and because
there was no perceived tangible benefit fromdoing so, interest in returning for follow-up orcomplying with care was easily lost.
The ability to travel to the hospital with an attendant and the cost of doing so were perceived as
major barriers to attending follow-up visits.

The challenges to implementing the MAMI Care
Pathway in a tertiary hospital system remains
limited in scope in the absence of a community-based support system for the vulnerable
mother–infant pairs closer to their homes.

‘Learning by doing’ case study series: Pakistan

35

From service implementation, we learned the following:•

Quality MAMI care was provided by a team ofmultiple experts, filling a gap in care for vulnerable infants and their mothers that was previously not addressed.
MAMI medical records need to be simplified
and adapted to the healthcare level (e.g., condensed on breastfeeding support, and expanded on medical conditions and developmental
disabilities).
The shift from a disease focus to a person-centred and continuity of care focus was new for
the paediatrician and required adapting hospital procedures. Linking with specialised services and referring cases in-house were well coordinated by a dedicated person.
Because the organisation of the MCH/MAMI
clinic was well managed, care provision wassmooth, and the quality of individual case management was monitored closely.

•

•

•

From the health system, we learned the following:
•

•
•

•

The MAMI manager was influential in setting
up the MCH/MAMI clinic and getting agreement from the hospital direction for allocating
staff and residents and using technical and financial resources.
Adapting and simplifying the approach to thehospital context was necessary and was carriedout as a continuous process.
Monitoring and evaluating the effectiveness of
the approach was a research objective and results were not (yet) made available for quality
improvement, which limited opportunities.
Learning in house and beyond was limited andremained largely in the hands of the MAMI
manager, but sharing learning was considered
and is planned.

Health worker taking infant’s MUAC.

36‘Learning by doing’ case study series: Pakistan

8. Conclusion
In the Pakistan case, the MAMI Care Pathway was introduced in an urban tertiary hospital in response
to a locally identified gap in care need, and with limited resources could easily establish quality care to
at-risk infants and their mothers. Addressing vulnerability factors for the condition “small and nutritionally at-risk infants and their mothers” with a person-centred and continuity of care approach required
skills that were available. The academic setting had the components required to generate evidence.
Successful implementation was highly dependent on a catalytic individual and decision-maker buy-in.
This experience can inform applying the approach in similar hospital settings, while also considering
involving primary healthcare levels and the community.

‘Learning by doing’ case study series: Pakistan

37

References

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Lawn, J.E., Ohuma, E.O., Bradley, E., Idueta, L.S., Hazel, E., Okwaraji, Y.B., et al. (2023) Small babies,
big risks: global estimates of prevalence and mortality for vulnerable newborns to acceleratechange and improve counting. Lancet, 401(10389), 1707-19.

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Blencowe, H., Krasevec, J., de Onis, M., Black, R.E., An, X., Stevens, G.A., et al. (2019) National,
regional, and worldwide estimates of low birthweight in 2015, with trends from 2000: a systematic
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Kerac et al. (2024) Prevalence and assessment of malnutrition in infants aged <6 months in lowand middle-income countries: secondary data analysis. Under review.

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Mertens, A., Benjamin-Chung, J., Colford, J.M., Coyle, J., van der Laan, M.J., Hubbard, A.E. et al.
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Mertens, A., Benjamin-Chung, J., Colford, J.M., Hubbard, A.E., van der Laan, M.J., Coyle, J. et al.
(2020) Child wasting and concurrent stunting in low- and middle-income countries. medRxiv,
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McGrath, M., Wrottesley, S.V., Brennan, E., Samnani, A., Deconinck, H. (2024) Invisible pursuit:global policy guidance on care of vulnerable infants under 6 months and their mothers, ascoping review.

9.

ENN (2021) MAMI Global Network Strategy 2021–2025.

10. Muriuki, A., Yahner, M., Kiragu, M., de Graft-Johnson, J., Izulla, P. (2022) On the road to universal
coverage of postnatal care: considerations for a targeted postnatal care approach for at-risk
mother–baby dyads in low-income and middle-income countries informed by a consultation with
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WHO (2013) Guideline: Updates on the management of severe acute malnutrition in infants andchildren.

12. WHO (2023) WHO guideline on the prevention and management of wasting and nutritional
oedema (acute malnutrition) in infants and children under 5 years.
13. May, C.R., Finch, T., Ballini, L., MacFarlane, A., Mair, F., Murray, E., et al. (2011) Evaluating complex
interventions and health technologies using normalization process theory: development of asimplified approach and web-enabled toolkit. BMC Health Services Research, 11(1), 245.
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BMC Medicine, 8(1), 63.

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15. May, C., Rapley, T., Mair, F.S., Treweek, S., Murray, E., Ballini, L. et al. (2015) Normalization Process
Theory on-line users’ manual, toolkit and NoMAD instrument.
16. Greenhalgh, T., Wherton, J., Papoutsi, C., Lynch, J., Hughes, G., A’Court, C. et al. (2017) Beyond
adoption: A new framework for theorizing and evaluating nonadoption, abandonment, andchallenges to the scale-Up, spread, and sustainability of health and care technologies. J MedInternet Res., 19(11), e367.
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WHO (2010) ExpandNet. Nine steps for developing a scaling-up strategy.

18. WHO (2011) ExpandNet. Beginning with the end in mind: planning pilot projects and otherprogrammatic research for successful scaling up.
19. Gilson, L. (2012) Health policy and systems research: a methodology reader. Report No.:
9789241503846 (CD ROM) 9789241503136.
20. UNICEF (2018). Policy brief - Improving quality of care around the time of birth in Pakistan.
21. World Population Review (2023). Total population by country 2023: Pakistan. https://worldpopulationreview.com/countries.
22. Macrotrends (2023) Macrotrends: Health https://www.macrotrends.net.
23. National Institute of Population Studies (Pakistan), ICF (2019) Pakistan Demographic and Health
Survey 2017-18
24. Ngo, N., Bhowmik, J., Biswas, R.K. (2022) Factors associated with low birthweight in low-andmiddle income countries in South Asia. Int J Environ Res Public Health, 19(21).
25. National Institute of Population Studies (Pakistan), ICF (2020) Pakistan Maternal Mortality Survey
2019.
26. Action Against Hunger (2023) State of Acute Malnutrition: Global and country data. https://
acutemalnutrition.org/en
27. MAMI Global Network, ENN, London School of Hygiene & Tropical Medicine (2021) MAMI Care
Pathway Package, Version 3.

‘Learning by doing’ case study series: Pakistan

39Annexes

Annex 1. MAMI Care Pathway package
who, what, where matrix

Source: MAMI Global Network, ENN, London School of Hygiene & Tropical Medicine (2021) MAMI Care
Pathway Package, Version 3.

40‘Learning by doing’ case study series: Pakistan

Annex 2. Definitions
Adoption. Implementing new ways of thinking, acting and organising in healthcare, and integrating
new systems of practice into existing organisational and professional settings. (1)Continuity of care. The provision of services that are coordinated across levels of care – primary careand referral facilities – and across settings and providers; the provision of care throughout the life cycle;
care that continues uninterrupted until an episode of disease or risk is resolved; the degree to whichpeople experience a series of discrete health care events as coherent and interconnected over time andconsistent with their health needs and preferences. (2)Embedding. Routinely incorporating a practice or practices as an integral part of the everyday work ofindividuals and groups. (1) (3)Family-centred care. An approach to care delivery that can be practised in health facilities at all levels
and that promotes a mutually beneficial partnership among parents, families and health care providers to support health care planning, delivery and evaluation. The principles of family-centred careinclude dignity and respect, information sharing, participation and collaboration. (4)Implementation. The social organisation of bringing a practice or practices into action. (1)Innovation. A health intervention or practice that is new in the local setting and tested in a pilot projector research. (5)Integrated care pathways. Structured multidisciplinary care plans that detail essential steps in thecare of patients with a specific clinical problem and that describe the expected progress of the patient(6). See clinical pathway.
Integrated services. The management and delivery of health care services so that people receive acontinuum of health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation and palliative care through different levels and sites of care in the health system, according totheir needs throughout the life course. (7)Integration. Reproducing and sustaining a practice or practices among the social matrices of an organisation or institution. (1)Normalisation. The successful implementation and integration of interventions into routine work. (1)People-centred care. Care that is focused on and organised around the health needs and expectationsof people and communities, rather than diseases, encompassing clinical encounters as well as attention to the health of people in their communities and their crucial role in shaping health policy andhealth services. (8)Person-centred health care. The conscious adoption of the perspectives of individuals, families andcommunities as participants in and beneficiaries of trusted health systems; respecting patients’ values,
preferences and expressed needs in coordinating and integrating care, information, communicationand education, physical comfort, emotional support, alleviation of fear and anxiety, involvement of family and friends, transition and continuity. (9)Quality of care. Health services for individuals and populations that increase the likelihood of desired
health outcomes and that are consistent with current professional knowledge, (10) characterised byeffectiveness, efficiency, accessibility, patient-/people-centred care, equity and safety (11). The quality of patient care focuses mostly on technical quality, appropriate referral, continuity of care and patient-centredness. (12)Scale-up. The deliberate attempt to increase the impact of a health service innovation (successfully
tested in a pilot or experimental project) to benefit more people and foster lasting policy and programme development. (13)‘Learning by doing’ case study series: Pakistan

41

Spread. The geographic expansion of a health service, making the service available. (3)Sustainability. The potential to sustain beneficial outcomes for an agreed period at an acceptable levelof resource commitment within acceptable organisational and community contingencies. (2, 14)
Sustainability of health services. The capacity to provide ongoing prevention and treatment for ahealth problem after termination of major financial, managerial and technical assistance from an external donor. (15)
Sustainable. Able to be maintained, to be upheld or to persist over the long term. (3)System. A set of things working together as parts of a mechanism or an interconnecting network; acomplex whole. (16)Tacit knowledge. Knowledge-in-practice developed from direct experience and action; highly pragmatic and situation-specific knowledge that is subconsciously understood and applied, difficult to articulate, and usually shared through interactive conversation and shared experience. (17)Theoretical framework. A conceptual tool that is useful in making sense of a complex social reality
and that helps design a research question, guide the selection of relevant data, interpret the data andpropose explanations of causes or influences. (18)Theoretical generalisability. A process of reflective learning and reflective practice (what, how, why).
(19)
Theory. A set of analytical principles or statements designed to structure observation, understanding
and explanation of the world; an explanation of how and why specific relationships lead to specific
events. (20)42

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May, C.R., Mair, F., Finch, T., MacFarlane, A., Dowrick, C., Treweek, S. et al. (2009) Development of atheory of implementation and integration: Normalization Process Theory. Implementation Science,
4(1), 29.

2.

WHO (2011) Health systems strengthening glossary.

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Greenhalgh, T., Wherton, J., Papoutsi, C., Lynch, J., Hughes, G., A’Court, C. et al. (2017) Beyond adoption:
A new framework for theorizing and evaluating nonadoption, abandonment, and challenges tothe scale-Up, spread, and sustainability of health and care technologies. J Med Internet Res, 19(11),
e367.

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WHO (2019) Survive and thrive: transforming care for every small and sick newborn.

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WHO, ExpandNet (2011) Beginning with the end in mind: planning pilot projects and otherprogrammatic research for successful scaling up.

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Campbell, H., Hotchkiss, R., Bradshaw, N., Porteous M. (1998) Integrated care pathways. BMJ,
316(7125), 133–7.

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WHO (2008) Integrated health service. What and why? Technical brief 1.

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WHO (2010) People centred care in low- and middle-income countries. Meeting report.

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Social Care Institute for Excellence (2023). Person-centred care. https://www.scie.org.uk/prevention/
choice/person-centred-care.

10. Lohr, K.N. (Ed.) (1990) Medicare: A strategy for quality assurance, volume I. Institute of Medicine, theNational Academies Press.
11.

WHO (2023) Quality of care https://www.who.int/health-topics/quality-of-care#tab=tab_1.

12. Kruk, M.E., Freedman, L.P. (2008) Assessing health system performance in developing countries: areview of the literature, Health Policy, 85(3), 263–76.
13. WHO (2007) Practical guidance for scaling up health service innovations.
14. Swerissen, H. (2007) Understanding the sustainability of health programs and organisationalchange.
15. Health Systems 20/20 (2008) Brief: Health Systems Assessment Approach: A how-to manual.
16. Oxford University Press (2023) Oxford Advanced
oxfordlearnersdictionaries.com/definition/english/system.
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https://www.

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9789241503846 (CD ROM)9789241503136. Alliance for Health Policy and Systems Research, WHO,
Geneva, Switzerland
20. Nilsen, P. (2015) Making sense of implementation theories, models and frameworks. Implement Sci,
10, 53.

‘Learning by doing’ case study series: Pakistan

43Annex 3. Methods and limitations
These case studies used a mixed-methods design in which different theories applied different lenses
to examine the introduction, implementation and adoption of the MAMI Care Pathway in each casecontext and to generate learning and ideas on improving implementation and scalability.

Inquiry tools
First, a Planning and Implementation Process Framework for the MAMI Care Pathway Approach wasdeveloped, inspired by the 2010 WHO ExpandNet “Nine steps for developing a scaling-up strategy”, the2011 WHO ExpandNet “Beginning with the end in mind” (1) and tacit knowledge of co-researchers (BoxA3.1). This was used to generate a detailed description of the planning and implementation process
within the defined context of each country case.

Box A3.1: Planning and Implementation Process Framework
Context
Country context
Organisational context
Situation analysis prior to starting
Burden and perceived health priority
Policy context
Local health system capacities
Stakeholders
Planning for implementation
Initiating discussions – agency’s preparedness
Engaging key stakeholders
Defining the target population
Selecting sites for implementation
Designing the implementation modus – tailoring the innovation to the local context and capacities
Using, adapting, aligning, simplifying, testing materials
Training for implementation
Service delivery – implementation
Access: availability, geographic accessibility/delivery points, affordability, acceptability
Organisation of care in the community, in the health facility
Organisation of staff
Participation
Partnerships
Monitoring, improving and collaborative learning
Monitoring and reporting
Improving quality
Disseminating information and learning
Maintaining and sustaining quality services
Ensuring accountability to users, managers and funders of the services
Advocating for implementation and scale-up
Suggestions for improving implementation

44‘Learning by doing’ case study series: Pakistan

Second, the Normalisation Process Theory provided a conceptual framework that helped to understand and evaluate the processes by which the MAMI Care Pathway approach was routinely operationalised in everyday work (2-4). The theory used a participatory method to explore the four componentsof the adoption process to uncover what individuals and groups either do or do not do to enable normalisation of the intervention:
1.
2.

Coherence – meaning and sense-making – defines and organises the components of a practice;
Cognitive participation – commitment and engagement – defines and organises the people implicated in a complex intervention;
3. Collective action – work done to enable the intervention to happen – defines and organises the enacting of a practice; and4. Reflective monitoring – reflecting on or appraising the benefits – defines and organises the assessment of the outcome of a practice.
The success of implementing the MAMI Care Pathway approach by health workers adopting the practice was scored by the case study team on a five-point Likert sliding scale from “not at all” (grade 1) to“completely” (grade 5).
Third, the Non-adoption, Abandonment, Scale-up, Spread and Sustainability (NASSS) Framework wasadapted and used in a participatory process to synthesise insights on evaluating adoption challenges
that impact on scaling up and sustainability (5) (Figure A3.1). It was used as a reflexive guide to generate
ideas on challenges related to the following: (1) the condition, (2) the technology, (3) the value proposition, (4) the adopters, (5) organisation, (6) the wider system, and (7) embedding and adapting over time.
A grading system was used to express whether the challenges identified were simple, complicated, orcomplex: (1) simple – meaning understandable or predictable, relatively straightforward to address; (2)complicated – meaning less understandable, controllable, thus less straightforward to address; and (3)complex – meaning not understandable or predictable, a dynamic or emergent behaviour.

Figure A3.1. The NASSS Framework for considering influences on the adoption, non-adoption, abandonment, spread, scale-up, and sustainability of a health intervention.

‘Learning by doing’ case study series: Pakistan

45

Fourth, the Checklist for Assessing the Potential Scalability of pilot projects or research (1, 6) was used
to explore how easy or difficult it would be to scale up each case and to provide insights into what steps
to take to facilitate sustainable scale-up. The checklist provides recommendations in 12 steps on how todesign pilot projects considering scale-up that lead to lasting and larger-scale impact (Box A3.2).

Box A3.2: Twelve recommendations on how to design pilot projects
with scaling up in mind
Step 1 		Engage in a participatory process involving key stakeholders

Step 2 		

Ensure the relevance of the proposed innovation

Step 3 		

Reach consensus regarding expectations for scale-up

Step 4

Tailor the innovation to the socio-cultural and institutional settings

Step 5 		

Keep the innovation as simple as possible

Step 6 		

Test the innovation in the variety of socio-cultural and institutional settings where		

it will be scaled up

Step 7 		

Test the innovation under the routine operating conditions and existing resource		constraints of the health system

Step 9 		

Advocate with donors and other sources of funding for financial support beyond		the pilot stage

Step 8Develop plans to assess and document the process of implementation

Step 10Prepare to advocate for necessary changes in policies, regulations and other health		systems components
Step 11Develop plans for how to promote learning and disseminate information

Step 12

Plan on being cautious about initiating scale-up before the required evidence is		available

Case study selection
Case selection sought a variety of implementation modalities or characteristics, such as the following:
•
•
•
•
•
•
•
•

Implementing a care pathway addressing at-risk infants and their mothers, as a pilot, research or
programme;
Differences in terms of context, implementers, geography;
Either government-led or partner-led;
In a development, emergency or fragile setting;
In a low- or middle-income country setting, either urban, rural or mixed;
With the availability of data on processes and outcomes;
With expressed interest and availability to participate in the case study;
Either in an English- or French-speaking environment.

A primary selection criterion was that participating in this process would add value and contribute to
local learning and progress on implementing the MAMI Care Pathway approach.
The country cases selected encompassed a variety of settings where the MAMI Care Pathway approach
was applied:
•
•
•

46

Pakistan: Paediatrician-led services in a private charity hospital in Karachi.
South Sudan: An implementation study where the MAMI Care Pathway approach was integrated
into maternal and child health services in urban and rural sites by MIHR project.
Yemen: Pilot implementation integrated into a health and nutrition emergency programme by
ADRA.
‘Learning by doing’ case study series: Pakistan

Data collection
An iterative and participatory process of reflective learning took place across four phases that built oneach other. Data tools consisted of generic questionnaires that served as interview guides specificallydeveloped for the MAMI Care Pathway approach and adapted to each country case (Box A3.3) (see Annex 3).
The first phase of investigation was largely descriptive, involving written feedback and clarification.
Next, the shared information was built upon, through interviews, to further explore ‘how’ things happened or not, paying particular attention to social dimensions.
The second phase consisted of participatory discussions with clinical service providers which explored
adoption of the MAMI Care Pathway approach as part of their routine work.
The third phase brought together senior managers and clinical health workers to discuss challenges in
adopting the MAMI Care Pathway approach.
The fourth phase synthesised the discussion in the third phase across the country cases, allowing forreflection on potential scalability based on triangulating information collected across the three cases.

Box A3.3: Data tools
Phase 1 (Annex 4a): Questionnaire (written and oral investigation) using the Planning and Implementation Process Framework; respondents were (sub-)national health, nutrition, and MAMI
managers or advisors.
Phase 2 (Annex 4b): Interview guide applying Normalisation Process Theory; respondents wereclinical healthcare workers implementing the Care Pathway approach.
Phase 3 and Phase 4a (Annex 4c): Checklist for participatory group discussions using the NASSS
Framework; respondents were the participating national and (sub-)national health, nutrition,
MAMI managers or advisors who discussed their country context in phase 3, and then came together to discuss across countries in phase 4a.
Phase 4b (Annex 4d): Checklist for Assessing the Potential Scalability using the information
generated across phases.

Respondents were asked to provide their informed consent prior to their participation and withdrawal
from the inquiry was possible at any time.
Data were collected through written feedback and during interviews, which were digitally recorded
following receipt of consent from all interviewees. Respondents could skip questions for any reason.
Where possible, the reason for not answering was recorded but this was not mandatory. Audio recordings were transcribed verbatim within 48 hours of collection using Otter.ai software. All digital data
were stored in a password-protected digital space accessible only to investigators. All country-specificdata were shared with the country teams.
During data collection and analysis, notes on possible biases, interferences or limitations were recorded
and reported on.

‘Learning by doing’ case study series: Pakistan

47

Analysis
The stepwise and iterative inquiry appraised the case experiences by applying different lenses to generalise learning through repeated cycles of testing and building ideas (theories) about why things haveworked or not, and how (mechanisms of action). This ‘theory-driven’ iterative analysis involved the following steps:
Descriptive data analysis: Data on introducing and implementing MAMI were summarised by topic
to understand processes of planning, introducing, adapting, implementing, monitoring and improving the MAMI Care Pathway approach, to uncover what was done, and how, to appraise readiness for scale-up.
Explorative data analysis: Data on the perceptions of clinical healthcare workers on implementing
and adopting the MAMI Care Pathway approach were analysed for emerging themes to explore
perceptions on what worked, for whom, and under what circumstances, and to appraise adoption.
Explanatory data analysis: Data on descriptions and perceptions were triangulated and synthesised
to inform updates to and evolution of our theories/ideas on the MAMI Care Pathway approach andto identify practical, pragmatic ways to help progress towards scalable, sustainable care.
Data were analysed both deductively (testing our ideas/theories) and inductively (finding new ideas/
theories), involving the respondents and requesting their opinion, as well as confirming the generated
ideas/theories. Data were synthesised in each step by intuitive-reflective appraisal – which involved perceptions about what immediately felt right or made sense, and then questioning these by consideringother possibilities.
Participatory and adaptive, reflexive learning: Interviewers and interviewees were involved in reflective
learning building upon each step, thereby ‘learning together by doing.’ This collaborative ‘learning together’ deepened the understanding of embedding and adapting the MAMI Care Pathway approachin diverse local systems of health. Besides the strengthening of own capacities and understanding of
respondents by tapping into implicit and often invisible and under-appreciated tacit knowledge, thisapproach was useful for contributing to overall collective learning on the ‘how’ of the MAMI Care Pathway approach.

Limitations
Each country case covered the introduction and implementation of the MAMI Care Pathway approachon a small scale in a specific context, which limited the generalisability of learnings across broader
systems and services within and across countries. Each case study also engaged a limited numberof respondents (between two and four, depending on the case), which restricted the breadth of perceptions. However, the different lenses applied through the case study phases generated an in-depth
understanding for each case context, while identifying common theories/ideas which influence implementation, adoption, scale-up and sustainability, even across the diverse case contexts, thereby contributing to collective learning.
The qualitative approach involved online interviews, which lack the human presence needed to build
trust and to convey the subtleties of eye contact or body language which contribute to multidimensional and nuanced understanding of the ideas/perspectives shared (7).
Specifically, during Phase 2 (interviews guided by the Normalisation Process Theory), only one or two
clinical health workers responsible for implementing the MAMI Care Pathway approach (assessment,
support and progress monitoring of the mother–infant pair) were interviewed. The low numbers ofpeople involved likely limited the extent of perceptions on the normalisation process. The clinical healthworker responding was also either an existing, or a newly recruited, staff member accompanied bya trained supervisor or assistant, which may have influenced their answers. Responses often fell into
discussions on ‘perceived benefits’ of the MAMI Care Pathway approach, rather than building on perceptions of the adoption process. Finally, discussions went in various directions, and sometimes thesame elements were repeated, or questions were not answered well, or the answer fitted a questionthat would come later. This resulted in some reorganisation of responses to fit the flow of the interview
guide after the discussion.
48‘Learning by doing’ case study series: PakistanReferences
1.

WHO, ExpandNet (2011) Beginning with the end in mind: planning pilot projects and otherprogrammatic research for successful scaling up.

2.

May, C.R., Finch, T., Ballini, L., MacFarlane, A., Mair, F., Murray, E. et al. (2011) Evaluating complex
interventions and health technologies using normalization process theory: development of asimplified approach and web-enabled toolkit. BMC Health Services Research, 11(1), 245.

3.

Murray, E., Treweek, S., Pope, C., MacFarlane, A., Ballini, L., Dowrick, C. et al. (2010) Normalisation
process theory: a framework for developing, evaluating and implementing complex interventions,
BMC Medicine, 8(1), 63.

4.

May, C., Rapley, T., Mair, F.S., Treweek, S., Murray, E., Ballini, L. et al. (2015) Normalization Process
Theory on-line users’ manual, toolkit and NoMAD instrument.

5.

Greenhalgh, T., Wherton, J., Papoutsi, C., Lynch, J., Hughes, G., A’Court, C. et al. (2017) Beyond adoption:
A new framework for theorizing and evaluating nonadoption, abandonment, and challenges tothe scale-Up, spread, and sustainability of health and care technologies. J Med Internet Res, 19(11),
e367.

6.

WHO, ExpandNet (2010) Nine steps for developing a scaling-up strategy.

7.

You, S. (2021) Feminist Perspectives [Internet]. King’s College London. https://www.kcl.ac.uk/
challenges-and-gains-in-conducting-online-interviews-during-the-pandemic.

‘Learning by doing’ case study series: Pakistan49Annex 4a. Data tool: Planning andimplementing the MAMI Care Pathway
approach[Note that the questions in blue colour are discussed orally, all others are dealt with in writing.]
Responder(s) (name and function): ________________
Date of response: _________________
Agency: __________________

1. Context
1.1 Country context relevant to MAMI
1.

Describe the demographic and socio-economic context of your country, or the area where you areactive.
(E.g., development or emergency context, stable or fragile/fast changing/chronic, demographic pressure,climate change, political instability or insecurity, rural versus urban population, poverty, migration trends)

2.

Describe key determinants that define vulnerability in infants under six months of age (u6m) andyoung children (data from the most recent survey/surveillance).

(E.g., exclusive breastfeeding rate, inappropriate/harmful feeding and care practices, adolescent mothers, lowbirth weight)

1.2 Organisational context for starting MAMI
3.

Give name of agency or programme, and a brief description.
(E.g., expertise/mandate, aim, activities, period of interventions, impact area, future plans, donor)

4.

Give the justification for starting MAMI.
(E.g., expected change, added value, opportunity, contribution, the MAMI Care Pathway could
bring)

5.

Explain who or what was the tipping point for deciding to start MAMI.
(E.g., what or who was driving, motivating, enabling the decision; who or what enabled it just thenand not earlier)

6.

Give the aim or objective of the MAMI project that was defined at the start (and expected result if
stated).

2. Situation analysis prior to starting MAMI
2.1 Burden and perceived health priority
7.

50

Give national key health and nutrition indicators (and trend) (with source and year, most recent
survey, surveillance). Use the example table to answer.

‘Learning by doing’ case study series: Pakistan

Example table: Health and demographic information

Information (Year, Source)

Data

Population (YYYY, Ref)
Population at the MAMI sites YYYY, Ref)
Fertility rate (YYYY, Ref)
Live birth rate YYYY, Ref)
Neonatal mortality YYYY, Ref)
Infant mortality (YYYY, Ref)
Low birth weight (YYYY, Ref)
Assisted deliveries (YYYY, Ref)
Exclusive breastfeeding YYYY, Ref)
Global acute malnutrition 6-59m YYYY, Ref)
Trend information (YYYY, Ref):
8.

Prior to introducing MAMI, was the “vulnerability in infants u6m” recognised as a health or nutrition priority? Specify why or why not, by whom (in your opinion).

(E.g., for the Ministry of Health (MOH) not a priority presuming that the needs are covered by the various policies and services; for [Agency] a priority because of deteriorating indicators in their impact area)

2.2 Policy context
9.

Did you do a policy analysis prior to starting MAMI?

10. If yes, describe what you did, scope, which tool you used. Use the example table to answer.

(E.g., national integrated management of acute malnutrition (IMAM) guideline covers inpatient treatment of
wasting based on weight-for-height z-score (WHZ) <-3 z-score and presence of nutritional oedema in infants
u6m; community infant and young child nutrition (IYCN) strategy advises to assess breastfeeding problems
and counsel or refer during community growth monitoring sessions; guidelines on mental health coverpost-partum depression; guidelines on small and sick newborns include targeted counselling)
Example table: Health and nutrition policy covering infants u6m and their mothers
Policy, guideline (title, year)

Defined vulnerability in infants
u6m and their mothers

Proposed interventions

xx

xx

xx

If no, why not?
2.3 Local health system capacity
11. Did you do a capacity analysis/implementation readiness of the local health system or a feasibility
study prior to starting MAMI (or any quick appraisal of readiness of the health facilities that involvein MAMI)?
o

If yes, describe what you did, which tool you used, when you did it in regard to starting MAMI,
what are the headlines on what you found.

o

If no, why not?

12. List which MAMI activities were already covered at the community, primary care and tertiary carelevels in the planned MAMI sites that were identified prior to starting MAMI?

(E.g., counselling on breastfeeding difficulties is done by nutrition assistants in the health centre and by community health workers and volunteers in the community as part of the national IYCN strategy)

13. List gaps in services, care, referral for infants u6m and their mothers that were identified prior tostarting MAMI?

‘Learning by doing’ case study series: Pakistan

51

2.4 Stakeholders
14. Did you do a stakeholder analysis prior to starting MAMI (quick appraisal of who is a MAMI stakeholder, and how to solicit their interest for involving early for what)?
o

If yes, describe what you did, which tool you used, when you did it in regard to starting MAMI,
what are headlines on what you found. Please share any report on findings.

o

If no, why not?

15. Could you identify who is a relevant current or future stakeholder to involve in the design, planning, implementation; list who and specify why?
16. Did (could) you identify potential MAMI champions able to generate political will? If yes, who arethey?

(Note: a champion is an influential person who promotes ‘a topic’ and inspires others to take a more activerole in that topic.)

17. List key stakeholders you contacted and had preliminary discussions with on, e.g., introducing
MAMI, sharing plans, probing their interest to be involved. Use the example table to answer.
(E.g., MOH Community Health Department – ways of strengthening active case finding of vulnerable infant-mother pairs, as part of existing community services)
Example table: Level of interest of key stakeholders to involve in MAMI
Agency, department

Discussion topics on MAMI and level ofinterest

Name and email contact if appropriate

xx

xx

xx

3. Planning for MAMI implementation
18. Give an indicative time line (# months) for inception discussions, designing and planning.
3.1 Initiating discussions - Agency’s preparedness
19. Describe key elements of the initial discussions and steps your agency undertook internally, prior
to deciding and planning for MAMI implementation.
(E.g., internal discussion and decision, securing funds for which time span from which source–part of ongoing project, cost extension, additional budget–, hiring staff, securing equipment, planning)

20. Describe key elements of the initial discussions and steps your agency undertook externally, prior
to deciding and planning for MAMI implementation.

(E.g., contacted MOH to discuss the relevance or perceived need, explore their interest in the innovation, feasibility, alignment or integration into the country’s health system, roles and responsibilities, departments andtechnical partners to involve)

21. From whom did you seek approval for introducing MAMI, and how was this approval granted orformalised?
22. Was there a request for a formal description of the project prior to starting? If yes, describe theprocess, involvement of stakeholders and timeline.

(E.g., a project outline was shared and reviewed and approved by the MOH, taking two weeks; a study protocol was developed in participation with the MOH and approved (no IRB) taking two months)

23. Did you consult professional expertise within your agency; did you seek support externally? If yes,
give profile of expertise and timeline.
-

Did your agency conduct formative research prior to starting MAMI, or did you use in-house formative research? If yes, what? Share any reports.

(Note: formative research typically is done before starting a programme to understand practices and behaviours, needs for an intervention, e.g., a knowledge, attitudes, practices (KAP) survey for a reproductive
health project)

52‘Learning by doing’ case study series: Pakistan

3.2 Engaging key stakeholders in the planning process
24. Did you engage with the national and/or local MOH for planning the integration/implementation?
Explain how and on what.
25. Who else you engaged with? Explain how and on what.

(E.g., UNICEF in face-to-face meeting and orientation workshop, for planning and review of materials, offering
support for training as resources persons, offering scales and MUAC tapes)

26. In case you organised a meeting or workshop, describe who (and number) participated, howmany days, what was the objective and outcome, what topics were covered, what documentation
was shared.
27. Did key health and nutrition actors perceive MAMI a relevant innovation? Explain why or why not.
28. Are there lessons you want to share about the process?
3.3 Defining the target population
29. What criteria have been used to define vulnerability in infants u6m, and their mothers?
30. How were key health and nutrition actors involved in defining the target population for MAMI?
31. Are there lessons you want to share about the process?
3.4 Selecting sites for implementation
32. How did you define a MAMI implementation site in your project?

(E.g., specify the type of health facilities selected for implementing the outpatient Care Pathway, whether
referral sites for inpatient care are involved, whether communities in the health catchment area covered,
whether links between different sectors at different levels are established)

33. What criteria were used to select the sites?

(E.g., agency-supported health facilities; referral hospital with inpatient care for severe acute malnutrition)

34. Did key health and nutrition actors involve in selecting the sites? Explain.
35. Are there lessons you want to share about the process?
3.5 Designing the implementation modus
36. Did you tailor the implementation design for MAMI to the local context and capacities? If yes, explain how you did this, with whom and with what tools (if any)?

(E.g., participatory discussions with key stakeholders in a meeting using the ‘who what where map’; informal
discussion amongst agency staff)

37. Did you foresee ways of testing and/or adapting the implementation modus based on learningand feedback?
38. How did you appraise the capacity for absorbing MAMI by the local health system, at the selected
health facility sites prior to implementing? What tools did you use, what difficulties did you anticipate, how did you plan to fill the gaps?
(E.g., consider gaps in knowledge, skilled health workers, equipment, space, referral services)

39. Are there lessons you want to share about the process?
3.6 Using, adapting, aligning, simplifying, testing materials
40. Did you use and/or adapt the MAMI Care Pathway v3 materials? If yes, list which of the v3 materials were adapted and how this was done. Use the example table to answer.
Example table: Adaptation of MAMI Care Pathway v3 materials
MAMI Care Pathway v3 material adapted

Description of adaptation(s)(what)

Method (how)

X

xx

xx

X

xx

xx

‘Learning by doing’ case study series: Pakistan

5341. Did you use existing materials for use in the MAMI Care Pathway? Use the example table to answer.
Example table: Existing materials used and/or adapted in MAMI
Other materials used (adapted)

Description (what)

Method (how)

X

xx

xx

X

xx

xx

42. Did you develop additional materials? Use the example table to answer.
Example table: Materials developed for use in MAMI
Materials developed for use

Description (what)

Method (how)

X

xx

xx

X

xx

xx

43. Who was involved in deciding the final version of materials to use?
44. Did you test the adapted materials prior to using them for implementation? If yes, describe how
this was done.
45. Which (if any) materials were translated in a local language?
46. Describe how you overcame the local language barrier.

(E.g., developed a local language vocabulary as a cheat sheet and field tested it).

47. What were key challenges in the adaptation process?
48. Are there lessons you want to share about the process?
3.7 Training for implementation
49. Did you train health workers ahead of implementing MAMI? If yes, explain who was trained (participants), on what (topics), by whom (trainers), how (method), with what materials, for how long(number of days), aiming to achieve what (learning objectives). Use the example table to answer.
Example table: Training for MAMI prior to starting
Training(type and dates)

Participants targeted(profile and #)xx

xx

Topics covered

xx

Materials usedxx

Learning objectivesxx

50. Were the national and/or local MOH involved in training? If yes, explain.
51. Were supervisors and managers involved in training? If yes, explain.
52. Were existing national or global training materials used? If yes, explain.
(E.g., on breastfeeding, IMNCI, counselling)

53. Did the training develop specific skills? If yes, explain.

(E.g., on using the IMNCI approach, measuring anthropometry, assessing breastfeeding, assessing mental
health, targeted counselling)?

54. What skills were considered pre-requisite (skills training not covered)?
55. If you used the MAMI Care Pathway v3 materials, describe how you used these for training.
56. Are there lessons you want to share about the process?

4. Service delivery – implementation[Notes:Health services delivery is about how services are organised and managed to ensure access, quality, safety,
and continuity of care across health conditions across different locations and over time. Its core principles
are:

54

‘Learning by doing’ case study series: Pakistan

Comprehensive, equitable, sustainable, coordinated, continuous, holistic, preventive, empowering,
goal oriented, respectful, collaborative, co-produced, endowed with rights and responsibilities, sharedaccountability, evidence-informed, led by whole-systems thinking, ethical.
People-centred care is an approach to care that consciously adopts the perspectives of individuals, carers,
families and communities as participants in, and beneficiaries of, trusted health systems that respond totheir needs and preferences in humane and holistic ways. People-centred care also requires that people
have the education and support they need to make decisions and participate in their own care.
https://apps.who.int/iris/bitstream/handle/10665/155002/WHO_HIS_SDS_2015.6_eng.pdf?sequence=1&isAllowed=y]57. Give an indicative time line for starting implementation support (enrolling first pair).
58. Give an indicative time line (# months) for ending implementation support (exiting of last pair, if
relevant).
4.1 Access: availability, geographic accessibility/delivery points, affordability, acceptability
59. Specify the geographical area and sites where MAMI is implemented. Use the example table toanswer. (E.g., region, districts, health facilities, start/end date)
Example table: MAMI sites
RegionHealth district

Primary care healthcentreReferral hospital

Total

60. Did implementation start at all sites at the same time? If not, why not, how then?
61. Are services free of cost for small vulnerable infants and their mothers? Explain
62. If referral is needed, who organises, who pays for transport? Explain.
63. If referral for inpatient care is needed, who pays the admission fee, who pays for food for the caregiver? Explain.
64. Has your agency plans to expand or scale up MAMI in-country? In other countries? Specify what
actions would facilitate this move?
4.2 Organisation of care in the community (evidence-based, continuity (referral), coordinated,
integrated, comprehensive, people-centred, equipped, equity)
65. What activities are provided at the community, how, where by whom? Use the example table toanswer.
Example table: Who delivers where what services in the community
Activities

How

Where

By whom

Sensitization
Health and nutrition promotion
Screening
ReferralFollow-up in the home during
enrolment

66. Which MAMI activities were already in place? Did they have to be strengthened or re-organised?
67. Which MAMI activities had to be newly added?
68. Is active screening working well in the community? What screening criteria do you use?

‘Learning by doing’ case study series: Pakistan

55

69. How are community health workers/volunteers linking to the health facility? Explain.
70. How did community health workers perceive the extra tasks they were asked to do? Did they express concerns, and if so, what were they?
4.3 Organisation of care in the health facility (evidence-based, continuity (referral), coordinated,
integrated, comprehensive, people-centred, equipped, equity)
71. What activities are provided at the health facility, how, where by whom? Use the example table toanswer.
Example table: Who delivers where what services in the primary healthcare centre
Activities

How

Where

By whom

Sensitization on risks
Health and nutrition promotion
Screening (rapid assessment)
IMNCI assessment, triage
Anthropometry assessment
MAMI risk assessment
Feeding assessment
Mental health assessment
Classification and referral
Treatment and support plan
Enrolment
Treatment and support
Targeted counselling on feeding issues
Targeted counselling on mental healthissuesTargeted counselling other (specify)
Frequency of attendance decision forfollow-up
Referral in case of deterioration during
enrolment
Evaluate progress
Evaluate outcome
Referral in case of non-recovery at 6m
Follow-up after exit

72. Which MAMI activities were already in place? Did they have to be strengthened or re-organised?
73. Which MAMI activities had to be newly added?
74. Is routine screening done in all health services and units frequented by infant-mother pairs? What
screening criteria are used?
75. Was referral for maternal mental health possible?
76. How is referral to inpatient care organised for pairs whose status deteriorates, does it work well, ornot?
77. How is counter-referral to outpatient care organised for pairs discharged from hospital, does it
work well, or not?
78. What further support was most needed at 6 months?

56‘Learning by doing’ case study series: Pakistan

79. Is there a follow up period after pairs exit at infant age 6m? If yes, for how long? and how is it organised?
80. Describe how are pairs are followed across services and in time (continuity of care).
4.4 Organisation of staff: numbers, skill sets, sharing of tasks, supportive supervision, mentoring,job aids
81. Were sufficient number of skilled workers available to absorb MAMI? Explain.
82. What guidance or job aids did you use or develop? Explain.
83. Did you use v3 materials (if any) for organising and supporting health facility y implementation(job aids), and how?
84. How are clinical health workers linking, collaborating, sharing tasks, communicating on MAMI careat the health facility? Explain.
85. How are clinical health workers linking, communicating on MAMI care to other health facilities?
Explain.
86. How organised and ready for quality implementation were you at the start (your opinion)? Whatwent well, what went less well? Were roles and responsibilities clear for all implementers prior tostarting? Explain.
87. Is supportive supervision and mentoring being provided? If yes, how is it organised, which tools
are used?
88. How did health workers perceive to adopt the innovation/increase consistency/merge with what
they were already doing? Specify for the different activities at the different levels.
89. How did clinical health workers perceive the extra tasks they were asked to do? Did they express
concerns, and if so, what were they?
4.5 Participation
90. Do you involve caregivers (community members) in care? Explain.
91. Prior to assessing risks and enrolling, did you ask the caregiver’s perceived need and interest inreceiving this service?
92. Were caregivers well informed and had a choice, were encouraged to take active part in care,how?
93. How did caregivers perceive the effort to return for follow-on visits? How do you motivate them?
94. Prior to assessing MAMI risks and enrolling pairs, did you ask the caregiver’s perceived need andinterest in receiving this service?
95. Did you assess the caregiver’s satisfaction during and when exiting the MAMI Care Pathway?
4.6 Partnerships
96. What is the role of the local health management system; how are MOH focal points involved inplanning, supervising and improving quality, mentoring, evaluating?
97. Are there other technical partners providing support at the MAMI Sites? Who are they, what dothey cover, how you collaborate?
98. Are there other technical partners providing support at the MAMI Sites? Who are they, what dothey cover, how you collaborate?
99. Is there a communication or coordination system linking the various partners?

5. Monitoring and collaborative learning
5.1 Monitoring and reporting
100.Have you a monitoring system in place? If yes, to what degree you use existing data and systems?

‘Learning by doing’ case study series: Pakistan

57

101.List the indicators you report on monthly and give results for the period of reporting. Use the example table to answer.
Example table: Key indicators (country or site, period of reporting)
Total
Sensitization
MAMI sensitization in the community (# of people reached)
MAMI sensitization in the health facility (# of people reached)
Screening (rapid assessment)
Total pairs screened in the community
Pairs screened at risk, referred for in-depth assessment
Total pairs screened in the primary care facility
Pairs screened at risk, referred for in-depth assessment
In-depth assessment
Total pairs assessed
a. Pairs assessed - male infant
b. Pairs assessed - female infant
Pairs assessed classified at moderate risk (yellow)
Pairs assessed classified at high risk (red) and referred
Enrolment in outpatient care
Total pairs newly enrolled
a. Pairs newly enrolled - male infant
b. Pairs newly enrolled - female infant
Referral during outpatient care
Total pairs referred to hospitala. Pairs referred to hospital - infant high riskb. Pairs referred to hospital - mother high risk
Outcome of outpatient care
Total pairs exited from the outpatient Care Pathway
Total pairs exited at infant age 6m
Pairs not recovered at infant age 6m and referred to continue carea. Pairs not recovered at infant age 6m - infant special careb. Pairs not recovered at infant age 6m - mother special care
Pairs recovered at infant age 6m
Total pairs exited before infant age 6m
Pairs died before the age of 6m
Pairs lost to follow up (defaulted) before the age of 6m

58‘Learning by doing’ case study series: Pakistan

Example table: MAMI enrolment by age group (country or site, period of reporting)Total
Age of infants at enrolment in
outpatient care
<1 month
1–<2 months
2–<3 months
3–<4 months
4–<5 months
5–<6 months

102.Do you consolidate monthly monitoring data on service performance? Do you use digitized tools?
Explain.
103.Do you consolidate individual data on assessment and enrolment? Do you use digitized tools?
Explain.
104.Describe if and what qualitative data you collect, for what purpose, how you collect it, with whattools, and how you consolidate and report on them?
105.Do you capture lessons? Explain.
106.What key lessons have you learned that you think would be helpful for managing small and nutritionally at-risk infants u6m and their mothers?
107.What key successes you want to share?
108.What key challenges did you face? Which actions you have undertaken to overcome these, anddid you succeed to overcome these, or not?
5.2 Improving quality
109.Are monitoring results (data tables and figures and lessons) used for quality improvement (QI) to
identify weaknesses in data collection and quality of care that needs improvement (e.g., in monthly meetings)? Explain.
110.Do you use adaptive management for quality improvement and learning (e.g., using the plan-doverify-adapt cycle)? Explain.
111.What has MAMI added to your work and experience?
5.3 Disseminating information and learning
112.How is in-country sharing of information on MAMI organized? Explain the different pathways.
113.How is wider sharing of information on MAMI organized, outside of the country? Explain the different pathways.
114.What learning methods or communication platforms are being used by your managers, by the
implementers, and how did they come about? Explain.
115.Have you established a national learning and information sharing entity (e.g., community of practice, Country Chapter)? Explain.
116.Have you involved national research institutions in MAMI? Explain.
117.How did you explore their potential involvement in documenting lessons, evaluating evi-

dence gaps and proposing research studies (including donors).

118.Is any evaluation in progress or planned? Explain.
119.Have you identified any research gaps? If so, what are they?

‘Learning by doing’ case study series: Pakistan

595.4 Maintaining and sustaining quality services
120.Are the MAMI activities that you implement sustainable? Explain.
121.How can the specific MAMI activities be made more sustainable? what are barriers and facilitators? Explain.
122.Are they resilient to shocks? Explain.
123.Can the specific MAMI activities be made more resilient? what are barriers and facilitators? Explain.
5.5 Ensuring accountability to…
124.Who are you accountable to, how and for what?
5.6 Advocating for … strengthening services and adapting policies
125.Are you engaging decision-makers, champions, gate-keepers in MAMI?
126.What advocating tools you use or have you developed to highlight the burden, the importance ofaddressing MAMI, the effectiveness of MAMI?
127.Are you involved/do you plan to engage in national policies, guidelines, strategies, processes forcontributing to evidence and learning? If yes, in what way?
128.Is the accountability of MAMI in your implementation design sufficient, or what is missing, whatshould be strengthened and how?

6. Recommendations
129.List or describe changes you suggest for simplifying or improving the v3 materials.
130.List or describe additional resources you wish to have to improve planning, organizing, implementing, monitoring, learning, or expanding the evidence base.
131.What do you identify as most important gap / need that should be addressed, by whom and at
what level?
132.Share any other general or specific recommendations you have?

60‘Learning by doing’ case study series: Pakistan

Annex 4b. Data tool: Adopting the MAMI
Care Pathway approach
Name of the responder and position: _________________
Date of response: _________________
Agency: __________________QUESTIONS Clinical healthcare worker – key informant interview
PRE-QUESTIONS
1.

Please confirm, your name is […], your current position is […]2.

Where are you working, in which establishment, health facility?

3.

Since how long have you worked there? Give start date.

4.

When was the MAMI Care Pathway introduced at your health facility? Give start date.

5.

What is your function in relation to the MAMI Care Pathway?

6.

(If started working after MAMI was introduced) Were you exposed to MAMI before joining thehealth facility? Where? In what function?

7.

(If started working after MAMI was introduced) Did you have specific MAMI knowledge and skills
prior to joining the current position?

QUESTIONS
Questions seek the opinion of the clinical health worker about implementing the MAMI Care
Pathway in his/her setting versus what they did before for small vulnerable infants and theirmothers. Ask the respondent to explain their answer (if yes, explain how, if no, explain why not) andgive a grade on a Likert scale from 0 (not at all) to 5 (completely):
Coherence – meaning and sense-making
1.

Is the MAMI Care Pathway easy to describe? Can you appreciate how it differs from current
ways of working, from what you did before to support small vulnerable infants and their mothers?
Participants distinguish the intervention from current ways of working: not at all tocompletely

2.

Do you and your colleagues have a common understanding of the aims, objectives and expected outcomes of the MAMI Care Pathway?
Participants collectively agree about the purpose of the intervention: not at all tocompletely

3.

Do you understand what implementing the MAMI Care Pathway requires from you (specifictasks and responsibilities)?
Participants individually understand what the intervention requires of them: not at all tocompletely

4. Can you easily grasp the potential value, benefits and importance of the MAMI Care Pathway?
Participants construct the potential value of the intervention for their work: not at all tocompletely‘Learning by doing’ case study series: Pakistan

61

Cognitive participation – commitment and engagement
5.

Are you (or other key individual) able and willing to get others involved in the MAMI Care Pathway? Are you actively engaged in making the MAMI Care Pathway work in your setting?
Key individuals drive the intervention forward: not at all to completely

6. Do you believe and agree that being involved is right, and that by accepting the MAMI Care
Pathway as part of your work you contribute to its implementation?
Participants agree that the intervention should be part of their work: not at all tocompletely
7.

Do you have the capacity and are you willing to organise you and your colleagues and collectively contribute to the work involved for implementing the MAMI Care Pathway?
Participants buy in to the intervention: not at all to completely

8. Do you have the capacity and are you willing to collectively define the actions and procedures
needed to keep the practice going (invest your time, energy to keep it going)?
Participants continue to support the intervention: not at all to completely
Collective action – work done to enable the intervention to happen
9. Are you and your colleagues able to undertake the tasks required to implement the MAMI
Care Pathway (to operationalise its components in practice)?
Participants perform the tasks required by the intervention: not at all to completely
10. Do you maintain trust in the intervention and in each other’s work and expertise in implementing the MAMI Care Pathway?
Participants maintain their trust in the intervention and in each other: not at all tocompletely
11. Is the work required for implementing the MAMI Care Pathway distributed to participants withthe right mix of skills and training? Did it impact on the division of labour, resources, power,
responsibilities between colleagues (tasks and skill sharing)? Was extensive training needed
before implementing the MAMI Care Pathway? (originally Q13)
The work of the intervention is appropriately allocated to participants: not at all tocompletely
12. Is the implementation of the MAMI Care Pathway adequately supported by the advisor/manager?
The intervention is adequately supported by its host organisation: not at all to completely
Reflective monitoring – reflect on or appraise the benefits
13. Do you have access to information on the quality of care and outcome of the MAMI Care Pathway (monitoring and evaluation information)?
Participants access information about the effects of the intervention: not at all to 			completely
14. Do you collectively agree on the quality of care and the effects of the MAMI Care Pathway because of formal monitoring?
Participants collectively assess the intervention as worthwhile: not at all to completely
15. Do you individually think the MAMI Care Pathway is worthwhile?
Participants individually assess the intervention as worthwhile: not at all to completely
16. Can you make changes to the intervention as an individual or group in response to the appraisal?
Participants modify their work in response to their appraisal of the intervention: not at all
to completely

62‘Learning by doing’ case study series: Pakistan

Annex 4c. Data tool: Scale-up, spread andsustainability of the MAMI Care Pathway
approach
Applying the (non-)adoption, abandonment, scale-up, spread, and sustainability (NASSS)
framework in real time (Greenhalgh et al., 2017).
Respondents
Date of interview
Context (where, for how long, whom, purpose/design)
ORIGINAL NASSSQUESTIONSADAPTED NASSSQUESTIONSGRADING CONSIDERATIONS

1= understandable or predictable aspects are
relatively straightforward to address (simple).
2= less understandable or predictable aspects or
many factors are involved (complicated).
3= inherently not understandable or predictable,
but dynamic or emergent aspects are involved(complex).

RESPONSE

Domain 1: The condition or illness (risk factors)
Addresses how far the condition “small and nutritionally at-risk infants and their mothers” is a) wellcharacterised, well-understood and predictable, and b) how care is being affected by socio-cultural factors andco-morbidities.
1a. What is thenature of thecondition or
illness?

1a. Is the condition “small
and nutritionally at-risk
infants and their mothers”
well-characterised, wellunderstood and predictable?

1) Is the condition well-characterised, wellunderstood, predictable? OR 2) Not fully
characterised, understood or predictable?
OR 3)Poorly characterised understood,
unpredictable?

1b. What are
the relevantsocio-cultural
factors and comorbidities?

1b. Are socio-cultural factors
and co-morbidities relevant
for the condition “small andnutritionally at-risk infants
and their mothers”?

1) Are socio-cultural factors and comorbidities unlikely to affect caresignificantly? OR 2) To affect care andmust be factored in? OR 3) Pose significant
challenges to care planning and service
provision?

Domain 2: The technology
Addresses whether the methods (technologies) of the MAMI Care Pathway used for detecting, classifying,and supporting “small and nutritionally at-risk infants and their mothers” a) are newly introduced, b) need new
knowledge, c) need continued support, and d) need specific adaptations.
2a. What are thekey features of thetechnology?

2a. What are key features ofthe methods (technologies)
used to assess, classify
and support “small andnutritionally at-risk infants
and their mothers”? Are
methods known, do they
exist?

1) Are methods (technologies) used toassess, classify and support “small andnutritionally at-risk infants and theirmothers” already installed or existing,dependable? OR 2) Are they new and need
to be developed? OR 3) Do they need to beembedded in an existing (complex) system?

2b. What kind ofknowledge does
the technology
bring into play?

2b. Is new knowledge
generated or made visible
when applying the methods
to assess, classify and support“small and nutritionally at-risk
infants and their mothers”?
Has it the potential to detectchanges in health andnutrition status?

1) Do the methods used to detect, classify
and support “small and nutritionally at-risk
infants and their mothers” make risks orchanges in risks visible or measurable? OR
2) Partially or indirectly visible/measurable?
OR 3) Changes are unpredictable or can becontested.

‘Learning by doing’ case study series: Pakistan632c. Whatknowledge and/or support isrequired to use
the technology?

2c. What knowledge and/or
technical support is required
to assess, classify and support“small and nutritionally at-risk
infants and their mothers”?

1) No new knowledge is required to assess,classify and support “small and nutritionallyat-risk infants and their mothers”? OR
2) Detailed instructions and training areneeded. OR 3) Advanced training andsupport are necessary.

2d. What is thetechnology
supply model?

2d. Are the methods usedin the MAMI Care Pathway
generic and standardised?

1) Are the “small and nutritionally at-risk
infants and their mothers” methods usedin the approach generic, standardised andstraightforward to implement? OR 2) Are
significant organisational changes in the
management of health services needed?
OR 3) Is it highly vulnerable to support
withdrawal?

Domain 3: The value proposition
Explores whether the MAMI Care Pathway is considered a valuable intervention and for who it has value: a)the care provider and b) the user.
3a. What is thedeveloper’s
business case forthe technology(supply-sidevalue)?

3a. How do health workers
perceive the value of the
MAMI Care Pathway? Do
they understand the valueof the short-/mid-/long-term
benefits?

1) Is the perceived benefit of the MAMI
Care Pathway approach well-understood,
over the short/mid/long term? OR 2) Is it
undervalued (at risk?) OR 3) Is it unlikelythat it will be maintained (after the pilot
period), and at risk?

3b. What is its
desirability,
efficacy, safety,
and cost
effectiveness(demand-sidevalue)?

3b. How do the mothers(caregivers) perceive
the value of the MAMI
Care Pathway? Do they
understand the need, do they
appreciate the care, is theopportunity cost a barrier?

1) Is the MAMI Care Pathway approachconsidered needed, desirable, safe, costeffective by the user? OR 2) Is it unknown,
contested? OR 3) Is it considered notneeded, undesirable, unsafe, ineffective or
unaffordable by the user?

Domain 4: The adopter system
Explores whether the MAMI intervention has been adopted (accepted) and by who: a) health staff, b) mothers,c) lay support system of the mother.
4a. What changes
in staff roles,
practices, andidentities are
implied?

4a. Did important changes
have to be made for healthworkers (staff in the healthfacility) to take on their role in
the MAMI Care Pathway? Did
new skills have to be learned,
new staff be appointed, newtasks be taken on?

1) When adopting the care pathway,
were there no changes in staff roles andpractices? OR 2) Did existing staff haveto learn new skills and/or were new staff
appointed? OR 3) Did it pose a threat tocurrent professional identities, values andscope of practices (risk of job loss)?

4b. What is
4b. Were specific or new
expected of theactions expected of thepatient (and/mother?
or immediatecaregiver) – and is
this achievable by,
and acceptable to,them?

1) Nothing is expected of the mother(principal caregiver). OR 2) Routine tasks
and changes in behaviour are expected. OR3) Complex tasks are expected? Are theseachievable, acceptable?

4c. What isassumed about
the extended
network of lay
caregivers?

1) Nothing is required from the extended
network of lay caregivers. OR 2) Caregivers
are assumed to be available. OR 3) A
network of caregivers is needed/expected tocoordinate their inputs.

64

4c. By offering MAMI, areother lay caregivers in themother’s network affected(e.g., family members,
volunteers, community
members), and are there newrequirements or expectations
for them? Is the wider
network requested to be
involved?

‘Learning by doing’ case study series: Pakistan

Domain 5: The organisation
Addresses whether the organisation of the MAMI intervention required important changes and inputs in thegiven organisational context: a) capacity, b) readiness to adopt, c) easiness of adoption and funding decision, d)changes in teamwork, and e) tasks to be undertaken (the work).
5a. What is theorganisation’s
capacity toinnovate?

5a. Did the organisational
setup have the capacity toinnovate, change, and adapt
ways of working, and did it
have the resources for doingso?

1) Local health system is well-organised(good managerial capacity, well-supported),
flexible and available resources, goodmanagement, risk taking is encouraged.
OR 2) Resources are inflexible, local
leadership is suboptimal and risk taking
is not encouraged. OR 3) Severe resourcepressure, weak leadership, weak resilience.

5b. How
ready is theorganisation forthis technologysupportedchange?

5b. Was the organisational
setup ready / open to
innovating, changing, andadapting ways of working,and did it have the resources
for doing so?

1) High tension for change, openness toinnovation, widespread support. OR 2) Little
tension for change, moderate innovation.
OR 3) No tension for change, poor
innovation, opponents to change.

5c. How easy will
the adoption andfunding decisionbe?

5c. How easy will the
adoption and funding
decision for the MAMI Care
Pathway be (resources, costsavings, new infrastructure
to manage by MOH, NGO or
donor lead)?

1) Single organisation with sufficient
resources; anticipated cost savings; no
new infrastructure or recurrent costs
required. OR 2) Multiple organisations
with partnership relationship; cost–benefit balance favourable or neutral; newinfrastructure found (e.g., repurposing staff
roles, training). OR 3) Multiple organisations
with no formal links and/or conflicting
agendas; funding depends on cost savings
across system; costs and benefits unclear;
new infrastructure conflicts with existingand significant budget implications.

5d. What changes
will be needed inteam interactions
and routines?

5d. What changes wereneeded in MOH, NGO,and health worker teamorganisation to adopt MAMI?
Did team interactions andteam routines change (new),align or conflict?

1) No new team routines or care pathways
needed. OR 2) New team routines or carepathways that align readily with existing
ones. OR 3) New team routines or carepathways that conflict with existing ones.

5E. What work
is involved in
implementation
and who will doit?

5e. What work is involved in
implementing and improving
the quality, and who will doit?

1) Established shared vision, few simple
tasks, uncontested and easily monitored.
OR 2) Some work needed to build sharedvision, engage staff, enact new practices,monitor impact. OR 3) Significant workneeded to build shared vision, engage staff,
enact new practices, monitor impact.

Domain 6: The wider context
Explores whether financial and policy requirements are in place nationally for rollout.
6a. What isthe political,
economic,
regulatory,
professional (e.g.,
medicolegal)
and sociocultural context
for programmerollout?

6a. Are financial and policy
requirements for MAMI inplace for programme rollout?
a) what was it like in theprevious context, b) what is it
like in the new context?

‘Learning by doing’ case study series: Pakistan

1) Financial and regulatory requirements arein place nationally; professional bodies andcivil society are supportive. OR 2) Are being
negotiated nationally; professional bodies
and lay stakeholders not yet committed. OR3) Raise tricky or legal or other challenges,
professional bodies and lay stakeholders areopposed.

65

Domain 7: Embedding and adaptation over time
Explores the feasibility of embedding and adapting the MAMI approach over time: the feasibility of a)continuing to adapt and evolve over the medium and long term, and b) building organisational resilience.
7a. How muchscope is there
for adapting andco-evolving thetechnology andthe service overtime?

7a. What is the feasibility ofcontinuing to embed andadapt the MAMI approach(intervention modalities)
over time (medium- to longterm)? Are you expecting
certain barriers?

1) Strong scope for adapting andembedding the MAMI approach. OR 2)
Potential for adapting and co-evolving the
MAMI services is limited and uncertain.
OR 3) Significant barriers to the further
adaptation or co-evolution of the MAMI
approach.

7b. How resilientis the organisationin regard tohandling
critical eventsand adapting
to unforeseen
eventualities?

7b. What is the organisation
resilience to detecting andovercoming critical issues
or barriers (barriers related
to embedding, handling
critical events, adapting to
unforeseen eventualities?)

1) Sense-making, collective reflection
and adaptive action are ongoing andencouraged. OR 2) Are difficult and viewed
as a low priority. OR 3) Are discouraged in arigid, inflexible implementation model.

66‘Learning by doing’ case study series: Pakistan

Annex 4d. Data tool: Planning forsuccessful scale-up of the MAMI Care
Pathway approach
Questions related to potential scalability
1.

Yes (+)No (–)

More information /action needed

Is input about the project being sought from a range ofstakeholders (e.g. policy-makers, programme managers,
providers, NGOs, beneficiaries)?
Are individuals from the future implementing agency involved in the design and implementation of the pilot?
Does the project have mechanisms for building ownershipin the future implementing organisation?

2. Does the innovation address a persistent health or service delivery problem?
Is the innovation based on sound evidence and preferable
to alternative approaches?
Given the financial and human resource requirements,
is the innovation feasible in the local settings where it is
to be implemented?
Is the innovation consistent with existing national
health policies, plans and priorities?
3. Is the project being designed in light of agreed-uponstakeholder expectations for where and to what extent
interventions are to be scaled up?
4. Has the project identified and taken into consideration community, cultural and gender factors that might constrain or
support implementation of the innovation?
Have the norms, values and operational culture of the implementing agency been taken into account in the designof the project?
Have the opportunities and constraints of the political, policy,
health sector and other institutional factors been considered
in designing the project?
5. Has the package of interventions been kept as simple aspossible, without jeopardising outcomes?
6. Is the innovation being tested in the variety of socio-culturaland geographic settings where it will be scaled up?
Is the innovation being tested in the type of service delivery
points and institutional settings in which it will be scaledup?
7. Does the innovation being tested require human andfinancial resources that can reasonably be expected to beavailable during scale-up?
Will the financing of the innovation be sustainable?
Does the health system currently have the capacity to implement the innovation? If not, are there plans to test ways toincrease health systems capacity?

‘Learning by doing’ case study series: Pakistan

67

8. Are appropriate steps being taken to assess and document
health outcomes, as well as the process of implementation?
9. Is there provision for early and continuous engagementwith donors and technical partners to build a broad base offinancial support for scale-up?
10. Are there plans to advocate for changes in policies, regulations and other health systems components needed to
institutionalise the innovation?
11. Does the project design include mechanisms to review progress and incorporate new learning into the implementation
process?
Is there a plan to share findings and insights from thepilot project during implementation?
12. Is there a shared understanding among key stakeholders
about the importance of having adequate evidence related to the feasibility and outcomes of the innovation priorto scaling up?

WHO ExpandNet (2011) Beginning with the end in mind: planning pilot projects and other programmatic research for successful scaling up.
Engage in a participatory process involving key stakeholders
Ensure the relevance of the proposed innovation
Reach consensus on expectations for scale-up
Tailor the innovation to the socio-cultural and institutional settings
Keep the innovation as simple as possible
Test the innovation in the variety of socio-cultural and institutional settings where it will bescaled up
7. Test the innovation under the routine operating conditions and existing resource constraintsof the health system
8. Develop plans to assess and document the process of implementation
9. Advocate with donors and other sources of funding for financial support beyond the pilot
stage
10. Prepare to advocate for necessary changes in policies, regulations and other health systems
components
11. Develop plans for how to promote learning and disseminate information
12. Plan on being cautious about initiating scale-up before the required evidence is available
1.
2.
3.
4.
5.
6.

68

‘Learning by doing’ case study series: Pakistan

Annex 5. Implementation materials
Table Annex 5. Summary of materials for implementing the MAMI Care Pathway approach at Indus
Hospital in Pakistan, 2021–2023
Materials from the 2021 MAMI
Care Pathway package

Description of change (what)

Method (how)Feeding form

Expanded points relating to good
latching and positioning

Adapted prior to implementation through consultation withthe core MAMI implementationgroup and further refined after
pilot testing

Initial visit form

Included use of the INTERGROWTH-21 growth charts in the“growth parameters” section

Adapted prior to implementation through consultation withthe core MAMI implementationgroup and further refined after
pilot testing

Follow-up form

Included use of the INTERGROWTH-21 growth charts in thein the “monitoring” section

Adapted prior to implementation through consultation withthe core MAMI implementationgroup and further refined after
pilot testing

Existing materials
IYCF – Pakistan counselling
cards

Unchanged

IMNCI treatment protocols

Unchanged

Materials newly developed
Checklist form for breastfeeding assessment

Developed for use during direct
observation of breastfeeding

Developed prior to starting
implementation and adapted
after pilot testing

Assessment of medical conditions form

Developed prior to starting
implementation and adapted
after pilot testing

Conversion of all forms in
REDCap software for datacollection

Developed prior to starting
implementation and adapted
after pilot testing‘Learning by doing’ case study series: Pakistan

69

Annex 6. Training sessions
Table Annex 6. Outline of training conducted at Indus Hospital in Pakistan, 2021–2023

Training(type and dates)

Participants
targetedThree workshops(2021–2023)

Medical docParticipants able to:tors, nurses, nu- •Identify danger
tritionists andsigns in infants
receptionists
u6m•
Plot anthropometric measurements on growth
charts•Identify incorrect
breastfeeding
methods•
Effectively counsel mothers onbreastfeeding
and complementary feeding•
Identify maternal
depression•
Provide preliminary mental
health counselling•
Perform correctreferrals

70

Objectives

Topics covered

Materials used

•
•
•

•

•

•
•
•

Danger signs
Breastfeeding
Growth monitoring
Identificationof children withmedical problems (cerebral
palsy, congenital
heart disease
and hypothyroidism)
Follow-up care
Referrals
Maternal nutrition and wellbeing•••

PowerPointinteractive
lectures
Breast models
Picture cards
Videos‘Learning by doing’ case study series: Pakistan

Annex 7. Appraising the adoption process
Table Annex 7. Findings on the degree of normalisation* of the MAMI Care Pathway approach at Indus Hospital in Pakistan, 2021–2023
Normalisation domainquestion

Summary of finding

1. Is the MAMI Care Pathway
easy to describe? Can you
describe how it differs fromcurrent ways of working, fromwhat you did before for at-risk
infants under six months ofage (u6m) and their mothers?

Before the MCH clinic for infants u6m and their mothers (aka MCH/
MAMI clinic) opened, they worked quite differently: examined thebaby, did not MUAC, and gave some counselling. Now they examine infants differently and in more depth: monitor height andweight and track growth across follow-up visits; also assess issues
related to mother’s health. Before, all infants with nutritional issues
were referred to the PCM clinic of the hospital for malnourishedchildren up to five to six years. Now, the MCH/MAMI clinic supports
the at-risk mother–infant pair.

2. Do you and your colleagues
have a common understanding of the aims, objectives andexpected outcomes of theCare Pathway?

There was a common understanding of the purpose. The large
burden of malnourished infants and their mothers needed counselling/support; e.g., on infant feeding.
A training workshop explained the need and taught staff how to
implement MAMI care and built enthusiasm. After being trained,
they understood how to do the work, and why they should do it. Refresher training is done every six to seven months.
“Our first impression was, why do we need to do this additional
clinic?” “We all have seen the difference since the MCH/MAMI clinic(after vs. before).”Participants collectively agreed about the purpose of the intervention: Grade 5

In the beginning it was new to routinely follow up mother–infant
pairs. After training and learning about the tasks, the clinic ran well.
Everyone was comfortable with the work once it was thoroughly
explained.
3. Do you understand what im“Health workers enjoy the work: two residents work as a team toplementing the Care Pathway
monitor and examine the patient and fill the forms. They enjoy
requires from you (specificcounselling the mothers, directly dealing with mothers and intasks and responsibilities)?
fants.”
Participants individually understood what the intervention requiredof them: Grade 5‘Learning by doing’ case study series: Pakistan71

4. Can you easily grasp the
potential value, benefits andimportance of the Care Pathway?

All involved understood that early identification of cases (in regard
to maternal and infant issues) through the MCH/MAMI clinic resultsin fewer malnutrition cases at older ages and fewer cases beingreferred to the PCM clinic. Children with other vulnerabilities (e.g.,
Down’s syndrome) could be identified and supported early on (including their parents and communities). The MCH/MAMI clinic wasconsidered an essential service in the hospital.
MAMI allowed clinicians to deal with the mother and infant together and to counsel mothers on how to best take care of their infants
at home (detailed counselling encouraged them to look after theirinfants, they were more interested, asked more questions and followed up on what to do; e.g., if they could not access medication).
Other clinics had a high burden of patients and minimal time toengage with these types of patients. In the MCH/MAMI clinic they
saw a limited number of patients per day (18) and had more time tocounsel the patients and answer their questions.
“MAMI enables us to do what is required and provides comprehensive care at the clinic. There is no more the need to go to various
other departments for input.”
Participants constructed the potential value of the intervention for
their work: Grade 5

The Chair of Paediatrics (MAMI manager) was very involved andavailable for consultation in case of issues.
Regular audits were performed; e.g., if patients did not attend.
5. Are you (or other key indiThe MCH/MAMI clinic had permanent additional staff, who werevidual(s)) able and willing to
fixed (not rotating like the residents in paediatrics): a feeding nurse
get others involved in the Care(senior nurse) who had been trained on providing guidance, anPathway? Are you actively
other clinical nurse monitored vitals, and triage. A nutritionist was
engaged in making the Carebased at the PCM clinic and could be involved in MAMI if needed
Pathway work in your setting?
(there was no nutritionist in the MCH/MAMI clinic).
Key individuals drove the intervention forward: Grade 5
6. Do you believe and agree
that being involved is right,
and that by accepting theCare Pathway as part of yourwork you contribute to its implementation?
7. Do you have the capacity
and are you willing to organise
yourself and your colleagues
and collectively contribute to
the work involved for implementing the Care Pathway?
8. Do you have the capacity
and are you willing to collectively define the actions andprocedures needed to keep
the practice ongoing (invest
your time and energy to keep
it going)?

72

The feeding nurse was fixed to the MCH/MAMI clinic and solely
assigned to these tasks (less clinical, provide guidance on infant
feeding) and will continue with this in future. MAMI was considered
a good idea and she accepted that this was a focus of her work.
Participants agreed that the intervention was part of their work:
Grade 5The hospital saw many older malnourished children who were bornwith LBW. Colleagues understood that dealing with their vulnerability early could reduce or prevent high numbers of cases after six
months of age.
Participants agreed to the intervention: Grade 4
Because the MCH/MAMI clinic was established and paediatric residents rotated in the MCH/MAMI clinic, investing time and providing
quality care was a requirement and doing things differently was not
an option.
Participants continued to support the intervention: Grade 3‘Learning by doing’ case study series: Pakistan

9. Are you and colleagues able
to carry out the tasks required
to implement the Care Pathway (to operationalise its components in practice)? (Interactional workability)

10. Do you maintain trust in
the intervention and in eachother’s work and expertise in
implementing the Care Pathway? (Relational integration)
11. Is the work required for
implementing the Care Pathway distributed to participants
with the right mix of skills andtraining? Did it impact on thedivision of labour, resources,
power, responsibilities between colleagues (tasks andskill sharing)? Was extensive
training needed before implementing the Care Pathway?
(Skill set workability)

Colleagues worked as a team and were adequately trained. However, their competence in the tasks depended on their level of experience (what stage of their residency they were at) and the completion of tasks was easier when a more senior resident was present.
Sometimes staff were overburdened, especially if the mother had
several challenges or concerns that needed attention. In these cases, early follow-up was given. The staff aimed to assess/counsel one
mother–infant pair at a time. If there was more than one, they could
ask the feeding nurse to counsel them.
Participants performed the tasks required by the intervention:
Grade 4
Colleagues were well trained, supported and supervised and therefore the quality of the services being monitored closely was (expected to be) high. Challenges were discussed with the feeding nurse inmonthly sessions.
Participants maintained their trust in the intervention and in eachother: Grade 4
A whole-day training workshop was used to discuss growth charts,
train participants on feeding counselling and support using mannequins, and provide participants with scenarios to respond to.
Every six months they had learning sessions on MAMI-related
topics for all the paediatric residents. Sometimes family medicine
residents were invited when they expressed an interest in the MCH/
MAMI clinic. There were around 30 paediatric residents and 25–30
family medicine residents who were not fixed to the MCH/MAMI
clinic but who could get involved if they were interested.
The work of the intervention was appropriately allocated to participants: Grade 4

The manager was motivating and supported them on why the
MCH/MAMI clinic was important (they constantly got boosters
about its importance) and how to implement practices. The staff
asked questions or provided inputs to support cases, particularly
for the more challenging ones. Red flag patients (problem cases)
12. Is the implementation ofwere discussed, and an investigation could be opened: for example,
the Care Pathway adequately
if infants were not gaining weight, an abnormal finding, a disability
supported by the advisor/man- or maternal mental health issue was identified. Red flag cases were
ager? (Contextual integration) referred for early follow-up to specialist care. The lead paediatrician
was the main person leading the clinic, but supervisors from otherunits were also involved and agreed on the clinic’s importance.
The intervention was adequately supported by its host organisation: Grade 5
The hospital had a paperless data system and there was a separate
data collection system (using REDCap) for capturing data on MAMI
implementation. The MCH/MAMI clinic data were managed by the
13. Do you have access to
MAMI manager for research purposes and evaluated on a regular
information on the quality ofbasis (weekly or every two to three weeks, depending on the numcare and outcomes of the Care ber of patients). Weekly meetings investigated ‘red flag’ patients
Pathway (monitoring and eval- and care in general, involving the feeding nurse. However, data on
uation information)?
the quality of care (performance) were not readily accessible.
Participants accessed information about the effects of the intervention: Grade 3‘Learning by doing’ case study series: Pakistan

73

Data on quality of individual care were accessible, but data on qual14. Do you collectively agree
ity of services were not.
on the quality of care and theParticipants collectively assessed the intervention as worthwhile:effects of the Care Pathway
Grade 1
because of formal monitoring?

15. Do you individually think
the Care Pathway is worthwhile?

16. Can you make changes tothe intervention as an individual or a group in response to
the appraisal?

The paediatric resident saw the impact of the care given; e.g., byidentifying infants needing specific support and being able to pickup cases for timely referral.
Data from REDCap showed how many babies were preterm or malnourished, and how many mothers were depressed, and allowed
for monitoring over time. Data also indicated how many mother–infant pairs were not returning for follow-up.
The quality of services was not monitored.
Participants individually assessed the intervention as worthwhile:
Grade 3
aking changes in the quality of individual care was possible; making
changes in service quality was not possible.
Antenatal care, nutritional support in pregnancy and lactation support should be added to the clinic to better cover the needs.
Participants modified their work in response to their appraisal of
the intervention: Grade 3* The findings were informed by normalisation process theory (13, 14) (see Annex 3: Methods andlimitations), adapted to the MAMI Care Pathway approach, to understand the path followed towards
adoption, including enablers and barriers, and the likelihood of the Care Pathway becoming routine inpractice. The quotes are from the participatory discussions with the paediatric resident.

74‘Learning by doing’ case study series: Pakistan

Annex 8. Appraising readiness for scale
Table Annex 8a. Appraising challenges to scale-up, spread and sustainability of the MAMI Care Pathway approach at Indus Hospital in Pakistan, 2021–2023

Domain 1:
The condition (including risk
factors)

Addresses a) how well the condition “small and nutritionally atrisk infants and their mothers” is characterised, understood andpredictable, and b) how care is being affected by socio-cultural
factors and comorbidities.

1a. Is the condition “small
and nutritionally at-risk
infants and their mothers”
well-characterised, wellunderstood and predictable?

Medical staff were well equipped and skilled (trained) tounderstand the condition, and therefore to detect (e.g., used
growth charts based on WHZ, MUAC tapes) and classify theseverity. More challenging were the multiple steps/components of
the assessment and the care.

1b. Are socio-cultural factors
and comorbidities relevant
for the condition “small andnutritionally at-risk infants
and their mother”?

Probably more than half of malnutrition (vulnerability) in infants
is caused by social factors, e.g., poverty. Clinicians were used todetecting common social factors that interact with the condition;
they were used to assessing these (e.g., demography or infant care
aspects). However, for “small and nutritionally at-risk infants andtheir mothers”, factors were assessed in much more depth, which
was more challenging. For example, questions related to familyplanning or mental health were influenced by socio-cultural
factors and were not easy to talk about, and more time and effort
was required from the examiner to explore these. An experienced
clinician can handle these questions better than a junior clinician.
Paediatricians were not used to dealing with issues related to themother. Therefore, referral to services may be needed, but thisbrings in other challenges, but it is not impossible since mostservices are available at the hospital.

Domain 2:
The technology

Addresses whether the methods (technologies) of the MAMI
Care Pathway used for detecting, classifying, and supporting“small and nutritionally at-risk infants and their mothers” are a)
newly introduced, b) need new knowledge, c) need continued
support, and d) need specific adaptations.

2a. What are the key featuresof the methods (technologies)
used to assess, classify
and support “small andnutritionally at-risk infants
and their mothers”? Are
methods known? Do they
exist?

Clinicians were familiar with the assessment and classification
tools and knew how to use them. The hospital used a digitised
information system that was in the process of being updated
to include the MAMI assessment and treatment information.
The updated system would make it easy to insert and appraiseassessment data (e.g., height and weight, plotting weight on thegrowth curves). As such, the adapted 2021 MAMI Care Pathway
package materials could be integrated into the care system of thehospital.

2b. Is new knowledge
generated or made visible
when applying the methods
to assess, classify and support“small and nutritionally at-risk
infants and their mothers”?
Has it the potential to detectchanges in health andnutrition status?

Screening and assessing nutritional status of infants u6m initiallyused weight-for-length z-score. WAZ or MUAC was not done andhad to be initiated. Also, assessing and addressing maternal risk
factors was new. Initially, it was not thought feasible to assessmaternal mental health, anaemia and malnutrition (because they
were not trained on this), but once introduced and trained, theclinicians have developed the skills to assess and counsel mothers.

‘Learning by doing’ case study series: Pakistan

75

2c. What knowledge and/or
technical support is required
to assess, classify, support“small and nutritionally at-risk
infants and their mothers”?

New knowledge was required for implementing the Care
Pathway, and, as such, training became a continuous process,because residents rotated in the MCH/MAMI clinic and every
year new residents arrived. Annual training sessions took place(like November this year). Also, if anything changed in the Care
Pathway or was updated (e.g., introducing a digitised systemfor data analysis, such as REDCap, to have information readily
available and accessible), specific training sessions took place.

2d. Are the methods usedin the MAMI Care Pathway
generic and standardised?

The Care Pathway approach could be replicated in new sites(satellite health centres of the hospital), but it would be too taxing
to fully implement MAMI. Therefore, there is a plan to focus on
three to four key aspects (e.g., breastfeeding support, feedingcounselling, basic medical support) and, as such, develop a
simplified approach, modified to having a 10-minute encounter
based on ‘look, assess, adopt’. It is expected that it will take timeand effort to do this, because a solid programme will be neededthat can be sold to the donors.

Domain 3:
The value proposition
3a. How do health workers
perceive the value of the
MAMI Care Pathway? Do
they understand the valueof the short-/mid-/long-term
benefits?

The contribution of the MAMI Care Pathway to improving thehealth of infants showed a positive impact that was appreciated.
Picking up issues early helped to reduce future complications, andthe burden on the hospital care system. Rotation of residents in
the MCH/MAMI clinic offered a good opportunity for them to be
trained and to use the MCH/MAMI learning in future positions/placements.

3b. How do the mothers(caregivers) perceive the valueof the MAMI Care Pathway?
Do they understand theneed? Do they appreciate thecare? Is the opportunity cost abarrier?

Mothers were initially satisfied with the care and attention, butmany mothers did not come for follow-up visits because theyfelt the infant was okay or for other reasons (e.g., mothers were
working, could not afford the transport, had to be accompanied).
When mothers were in the clinic, they were happy andappreciative; after they left the clinic, other contextual factors
come into play that may have interfered with care.

Domain 4:
The adopter system

76

Explores whether the MAMI Care Pathway is considered avaluable intervention, and for who it has value: a) the careprovider and/or b) the user?

Explores whether the MAMI intervention has been adopted(accepted) and by who: a) health staff, b) mothers, c) the lay
support system of the mother.

4a. Did important changes
have to be made for healthworkers (staff in the healthfacility) to take on their role in
the MAMI Care Pathway? Did
new skills have to be learned,
new staff appointed, newtasks be taken on?

No extra staff were hired, but new paediatric residents rotated in
the MCH/MAMI clinic. Some reorganisation of tasks had to happen
to enable coverage of the MCH/MAMI clinic activities, to ensurethat enough clinicians were available to cover the clinic activities.
At the start, the additional tasks and longer working hours createdsome resistance, but this mostly disappeared when the benefitsof the clinic were understood. Also, other departments wereaffected as they were asked to integrate the MAMI Care Pathway(e.g., accepting referrals). Overall, it took four months to put all
MAMI activities into place to start the clinic activities, and fromthe fifth month onwards data were being uploaded into REDCap.

4b. Were specific or new
actions expected of themother?

Before, mothers would go to the nursery to attend vaccinationand then go home. With the MCH/MAMI clinic, mothers andinfants at-risk received more attention and were asked to returnfor regular follow-up visits. Targeted counselling engaged themin a process to strengthen (or change) behaviours on feeding andcare practices.

‘Learning by doing’ case study series: Pakistan

4c. By offering MAMI, wereother lay caregivers in themother’s network affected(e.g., family members,
volunteers, community
members), and were there
new requirements or
expectations for them? Is thewider network requested to
get involved?

Domain 5:
The organisation
5a. Did the organisational
setup have the capacity toinnovate, change and adapt
ways of working, and did it
have the resources for doingso?

It is unknown if other family members were affected when
applying the MAMI Care Pathway approach because this wasnever directly asked. However, the mother was accompanied
by a family member when attending the clinic, including forthe return visits, or she was replaced if she was working. The
opportunity costs were, for example, time investment andpayment for transport. On the other hand, some mothers brought
other mothers and their infants if they noticed a problem, whichshowed that mothers networked with each other, were able toidentify risks and to act upon this (often these infants indeed
needed support). Also, relatives or in-laws could influence mothers
or interfere with feeding and care practices (e.g., dilute formula
milk to reduce the cost), who then ideally had to be included inbehaviour change messaging.
Addresses whether the organisation of the MAMI intervention
required important changes and inputs in the given
organisational context: a) capacity, b) readiness to adopt, c)easiness of adoption and funding decision, d) changes inteamwork, and e) tasks to be undertaken (the work).
The initiative of starting and maintaining the MCH/MAMI clinic
was driven by the Chair of Paediatrics, who received approval andsupport from the senior hospital management to adopt the new
approach, and who had relatively easy access to financial andhuman resources (so far).

5b. Was the organisational
The Chair of Paediatrics championed the innovation as a need
setup ready / open toto fill a care gap and took responsibility for making the clinic
innovate, change, adapt ways operational, then acting as the MAMI manager.
of working, did it and have theresources for doing so?
5c. How easy will the adoption
and funding decision for
the MAMI Care Pathway be(resources, cost savings, newinfrastructure to manage
by MOH, non-governmentalorganisations or donor lead)?

All organisational steps were managed by the Chair of Paediatrics/
MAMI manager, receiving the support and trust from superiors
and colleagues, and the financial resources through the hospital’scharity system. It was mentioned that other colleagues face muchbigger challenges in implementing their activities.

5d. What changes wereneeded in MOH, nongovernment organisation,
health worker teamorganisation to adopt MAMI?
Did team interactions andteam routines change (new),align or conflict?

Staff (paediatric residents and nutrition nurse) were available
through adapting the rotation system and trained to take on their
specific tasks. Sustaining the new team routines was challenged
by motivation because it needed to be sustained.

5e. What work is involved inImportant knowledge and efforts were invested to put operations
implementing and improving in place, e.g. developing evidence-based guidelines, obtaining
the quality, and who will do it? additional resources, sourcing additional tools, accessing
counselling skills, and introducing REDCap for monitoring
implementation and quality. To sustain quality of care, a more
simplified implementation approach would be required,especially for the expansion to satellite sites, and then it would benecessary to learn how it ‘survives’ over time.
Domain 6:
The wider context

Explores whether financial and policy requirements are in placenationally for rollout.

‘Learning by doing’ case study series: Pakistan

77

6a. Were financial and policy
requirements for MAMI inplace for programme rollout?
a) the past context, b) the
future context for expansion?

Domain 7:
Embedding and adaptation
over time

78

There was interest in expanding the learning to beyond the MCH/
MAMI clinic or hospital premises and efforts were made and were
continuing but needed to be regularised; e.g. involve cliniciansin training, involve nutritionists/dieticians in managing infantsu6m (as well as above six months), reach out to the Paediatric
Association of Pakistan for their engagement, expand to two othermain hospitals of Karachi with a high burden of undernutrition
but no services, reach out to WHO for their involvement andlearning. The MOH was committed to addressing malnutritionin children but there were disparities in service provision acrossprovinces and risk stratification/gap analysis would be required toensure that human resources and funding are provided according
to the level of need.
Explores the feasibility of embedding and adapting the MAMI
Care Pathway approach over time: the feasibility of a) continuing
to adapt and evolve on the medium and long-term, and b)
building organisational resilience.

7a. What is the feasibilityof continuing embedding
and adapting the MAMI
Care Pathway approach(intervention modalities) overtime (medium to long term)?
Are you expecting certain
barriers?

The current setup showed that there was good potential to adopt
the MCH/MAMI clinic as a routine service. Challenges included
further simplifying the approach, ensuring ongoing learning andimplementation support, and solving financial challenges relating
to staff, training, and medicines. Also, the whole approach was
carried forward by one influential person.

7b. What is the degree oforganisational resilience
in regard to detecting andovercoming critical issues
or barriers (barriers related
to embedding, handling
critical events, adapting to
unforeseen eventualities?)

Having a (stricter) system of accountability for embedding MAMI
into IMCI – supported by WHO – may increase the importance of
MAMI and commitment for MAMI services.

‘Learning by doing’ case study series: Pakistan

Table Annex 8b. Appraising the potential scalability of implementing the MAMI Care Pathway approach at Indus Hospital in Pakistan, 2021–2023, and suggested actions
Steps in the scale-up appraisal – questions

Suggestions for more information or
action needed

1. Is input about the project being soughtfrom a range of stakeholders (e.g., policy-makers, programme managers, providers, non-government organisations,beneficiaries)?

No

Support was sought from senior hospitalmanagers and paediatric colleagues, but
not from outside of the hospital. Links
were established with the MAMI Global
Network and MAMI Implementers Group.

No

There was a desire to establish links withother health facilities and adapt the design to their level, but this has not yet
happened.

Does the project have mechanisms forbuilding ownership in the future implementing organisation?

No

There was a desire to link in-country with
the MOH, United Nations organisations
and implementing partners.

2. Does the innovation address a persistent
health or service- delivery problem?

Yes

The identified health needs drove the efforts to start the MAMI clinic.

Yes

Implementation in the tertiary hospitalenvironment, driven by the Chair of Paediatrics, underlined the need for, and benefits of, this evidence-based approach.

Are individuals from the future implementing agency involved in the design
and implementation of the pilot?

Is the innovation based on sound evidence and preferable to alternative
approaches?
Given the financial and human resource requirements, is the innovation feasible in the local settings where
it is to be implemented?

Yes

Is the innovation consistent with existing national health policies, plans andpriorities?

Yes

3. Is the project being designed in light ofagreed-upon stakeholder expectations
for where and to what extent interventions are to be scaled-up?
4. Has the project identified and taken
into consideration community, culturaland gender factors that might constrain
or support implementation of the innovation?
Have the norms, values and operational culture of the implementing
agency been taken into account in thedesign of the project?
Have the opportunities and constraintsof the political, policy, health-sector andother institutional factors been considered in designing the project?
5. Has the package of interventions been
kept as simple as possible without jeopardising outcomes?
6. Is the innovation being tested in the variety of socio-cultural and geographic
settings where it will be scaled up?
‘Learning by doing’ case study series: Pakistan

No

No

Yes

The tertiary hospital had sufficient resources to implement the innovation.

The innovation was aligned with existing
paediatric services; however, person-centred implementation is new or ‘different’.
Scale-up was not an objective of implementing the MAMI Care Pathway approach.
They were very aware about the community and socio-cultural factors, but thehospital setting was constrained in regard
to further addressing these outside thepremisses.
Norms and values dictated what was feasible in the hospital setting.

NA
No

Yes

No

The existing package was contextualised
and adapted/simplified or expanded. Further simplification was perceived as needed for future action.
NA79

Is the innovation being tested in thetypes of service delivery points andinstitutional settings in which it will bescaled-up?

NANo

7. Does the innovation tested require human and financial resources that canreasonably be expected to be available
during scale-up?

No

Will the financing of the innovation besustainable?

No

Does the health system currently have thecapacity to implement the innovation? If
not, are there plans to test ways to increase
health systems capacity?
8. Are appropriate steps being taken to assessand document health outcomes as well as
the process of implementation?
9. Is there provision for early and continuous engagement with donors and technical partners to build a broad base of financial support for scale-up?
10. Are there plans to advocate for changes inpolicies, regulations and other health systems components needed to institutionalise
the innovation?

NA

NA
No

Yes

No

No

11. Does the project design include mechanisms to review progress and incorporate
new learning into the implementation process?

Yes

Is there a plan to share findings and insights from the pilot project during implementation?

Yes

12. Is there a shared understanding among key
stakeholders about the importance of having adequate evidence related to the feasibility and outcomes of the innovation priorto scaling up?

80

NA

Yes

Data were collected for research purposes andlearning.
The hospital was self-funded by zakat donations.

No plans, but a desire to be in touch with WHO
and the state MOH was expressed, but noprogress has been made yet.
Discussions and learning between clinicians
are ongoing.

Research was planned to consolidate learning.

Within the hospital system there was a sharedunderstanding, but not beyond it. There washope to expand to partner health facilities using the learning from the hospital context.

‘Learning by doing’ case study series: Pakistan

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