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

August 2024

Authors
Emergency Nutrition Network (ENN): Hedwig Deconinck, Stephanie V. Wrottesley, Marie McGrath
Adventist Development and Relief Agency (ADRA) Yemen: Ahmed Aljabi, Million Markos Mena, Gamal
Saleh Ali Mohammed and Aina Ahmed Kareef Mahmood
ADRA International: Emily Hirata

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, Ahmed Aljabi, Million Markos Mena, Gamal Saleh Ali
Mohammed, Aina Ahmed Kareef Mahmood, Emily Hirata, and Marie McGrath (2024) Implementing
care for vulnerable infants under six months and their mothers. ‘Learning by doing’ case study series:
Yemen. 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 more about the Yemen case study and to discuss how this work can be taken forward, pleasecontact Ahmed Aljabi at ahmed.aljabi@adrayemen.org.

ADRA’s Health and Nutrition MAMI assistantconducting a home visit.

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. Thiscase study investigates the process of implementing, adapting, normalising and embedding an integrated care pathway approach for the management of small and nutritionally at-risk infants undersix months (u6m) and their mothers (the MAMI
Care Pathway) in the Yemeni context to inform sustainable scalability.

MethodIn the Yemen case the MAMI Care Pathway approach was applied as an implementation pilot integrated within a health and nutrition emergency
programme operated by the Adventist Development and Relief Agency (ADRA) in Yemen. In thecase study, mixed methods were used to provide
a detailed description of the planning and implementation processes, to explore influences on the
adoption of the approach, and to appraise the potential scalability and sustainability of care. Different lenses examined health workers’ experiencesof implementing the MAMI Care Pathway, which
enhanced their capacities through ‘learning by doing’. Reflective discussions generated transferable
insights into implementation.
The case study did not paint an exhaustive or exclusive picture of the implementation of the MAMI
Care Pathway approach. For example, it did 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 Yemen, policies and guidance on providing comprehensive continuity of care for vulnerable infants
u6m outside of hospital settings are limited. ADRA’s
health and nutrition emergency programme provided an opportunity to introduce the MAMI Care
Pathway approach to fill gaps in providing continuity of care for vulnerable mother–infant pairs,
because of its favourable organisational environment and established relationships.

‘Learning by doing’ case study series: Yemen

The MAMI Care Pathway approach was implemented in nine Ministry of Public Health and Population- (MOPHP-) run health centres supported
by ADRA in four districts across three governorates
in Yemen. Following consultation with MOPHP,
start-up was quick and required minimal financial
and technical support. The brief infusion of external
expertise was sufficient for ADRA staff and MOHPH
health workers to acquire the knowledge and skills
needed for implementation.
ADRA’s support to health and nutrition services onbehalf of MOPHP included making the necessary
adaptations in generic materials; training and mentoring health workers; providing supportive supervision; and collaborating within and across healthservices. The support included a small remuneration to motivate MOPHP health workers to take on
the additional workload.
Comprehensively addressing vulnerability factors
for “small and nutritionally at-risk infants and theirmothers” with a person-centred and continuity ofcare approach required good skills and continuous
mentoring. The intentional shift from disease-focused care to comprehensive person-centred careof the infant and the mother was appreciated by
the health workers but its implementation was not
fully realised, nor were tasks shared or alignment
between services encouraged to streamline careand reduce workload.
Since ADRA focused on implementing and expanding the MAMI Care Pathway approach within theemergency portfolio to reach a wider population, no
major attempts were made to advocate for healthpolicy changes or to seek development funding tosupport further expansion. However, changes inpolicies and practice and wider local stakeholder
engagement were envisaged to mainstream theapproach in routine services at scale, including afeasible monitoring, learning and evaluation system.

Conclusion
The Yemen case study provides insights into thefeasibility of implementing the MAMI Care Pathway approach in an existing emergency health andnutrition intervention by building on ongoing support for maternal and child health and nutrition services. Showing by example, the success of ADRA’s
work has sparked the interest of other health andnutrition actors, who have begun making plans to
implement and expand the MAMI Care Pathway in
Yemen.

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

13

4.1. Understanding the health system

13

4.2. Planning for service delivery

14

4.3. Implementing services

17

4.4. Monitoring, improving quality and collaborative learning

20

4.5. Making suggestions for improving planning and implementation

23

5. Embedding the MAMI Care Pathway in routine services

24

5.1. Exploring adoption

25

5.2. Overall appraisal of the adoption process28

6. Considerations for scalability and sustainability

30

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

30

6.2. Exploring readiness for scale-up

33

7. Learning to inform practice and scale-up of the MAMI Care Pathway
approach in Yemen (summary findings)

35

7.1. Planning and implementation

35

7.2. Normalisation and adoption

36

7.3. Considerations for scalability and sustainability

36

7.4. Collective learning and suggestions to strengthen potential for scale

37

8. Conclusion

38

9. References

39

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: YemenAbbreviations

BHA		

Bureau of Humanitarian Assistance

CHNV

Community health and nutrition volunteer

CHW		

Community health worker

CMAM

Community-based management of acute malnutrition

CMW

Community midwife

DHO		

District Health Office

ENN

Emergency Nutrition Network

GHO

Governate Health Office

GNC-TA

Global Nutrition Cluster-Technical Alliance

IYCF

Infant and young child feeding

IMNCI

Integrated management of neonatal and childhood illness

JSI

John Snow Inc.

LBW

Low birthweight

M&E

Monitoring and evaluation

MAMI

Management of Small and Nutritionally At-Risk Infants Under Six

		Months and their Mothers

MANR

Multisectoral Assistance and Nutrition Response

		(USAID-BHA-funded project)

MEAL		

Monitoring, evaluation, accountability and learning

MOPHP

Ministry of Public Health and Population

MUAC

Mid-upper arm circumferenceNGO

Non-governmental organisation

OTP 		

Outpatient therapeutic programme

TFC

Therapeutic feeding centre

u6m

Under six months of age

UNICEF

United Nations Children’s Fund

USAID

United States Agency for International Development

WAZ

Weight-for-age z-score

WHO

World Health Organization

WLZ

Weight-for-length z-score

YEMLI

Yemen Emergency and Multisectoral Lifesaving Interventions

		(USAID-BHA-funded project)‘Learning by doing’ case study series: Yemen

5

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 babies (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 six 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), paediatric6

health (integrated management of neonatal andchildhood 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 deliverat scale (10). Care is therefore complex at both theindividual level and the service delivery level.
Connecting within and across services is ideal but
is elusive in practice. One critical barrier is a lackof 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.

‘Learning by doing’ case study series: Yemen

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 Managementof 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 IMNCI and United Nations Children’s Fund
(UNICEF)/WHO breastfeeding counselling materials and frameworks, as well as integrated continuity of care for at-risk infants u6m and theirmothers across health and nutrition services. It
has been used 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 the potential for replicability and sustainable delivery at
scale. Learning from small-scale implementation
is essential before expanding, which requires active planning from the outset. As a collective, theMAMI Global Network is an active forum practitioners around the world use to collaborate, exchange experience and support each other incaring for at-risk infants and mothers throughpolicy, research and practice. Activities are guided by a five-year strategy (9) that aims to achievesustainable, 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 ofthe MAMI Care Pathway and examine implementation models and delivery systems in different
contexts.

‘Learning by doing’ case study series: Yemen

MUAC of infant measured.

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.

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 the planning and implementation process in eachcontext.
Exploring the sequential steps of ‘normalisation’ (adoption) of care, spread, scalability andsustainability by applying 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.

The Yemen case was selected as an example ofapplying the MAMI Care Pathway approach as animplementation pilot integrated within a healthand nutrition emergency programme (started
in the Multisectoral Assistance and Nutrition Response project [MANR II] and continued in the
Yemen Emergency and Multisectoral Lifesaving Interventions project [YEMLI]) managed by
the Adventist Development and Relief Agency(ADRA) in Yemen and funded by the United States
Agency for International Development’s (USAID)
Bureau of Humanitarian Assistance (BHA). The
country health context (section 3) described
the implementation environment for our phased
investigation:
•

•

•

•

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).

‘Learning by doing’ case study series: Yemen

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

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 asservice users or decliners, and only involved a
few clinical health workers. Nor did it evaluate
the cost effectiveness, acceptability, or feasibilityof the Care Pathway approach, or compare it toalternative approaches.

Community health and nutrition volunteers with their MAMI kits.

‘Learning by doing’ case study series: Yemen

9

3.

Country healthcontext

Yemen is a low-income country that faces ongoing protracted crises. The current conflict began
in 2015, devastating the economy and resulting
in fragile health systems and severe food insecurity. In 2023, an estimated 24.1 million people
were at risk of hunger and disease, and roughly
14 million were in acute need of assistance.
The health system in Yemen in fragile areas issupported by international financial and technical partners, whose actions are coordinatedby the Ministry of Public Health and Population(MOPHP) and the Health Cluster, coordinated by
WHO, and the Nutrition Cluster, coordinated by
UNICEF and funded by USAID’s BHA. Data on theprevalence of LBW and preterm births in Yemen
are not available, but neonatal and infant mortality rates are high (Table 1). Skilled birth attendants
assist less than half (45%) of deliveries and only
10% of infants u6m are exclusively breastfed.

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

34.4 (2023) (20)

Fertility (births per woman)

3.4 (2023) (21)Live birth (births per 1,000 people)

28 (2023) (21)Neonatal mortality (neonatal deaths per 1,000
live births)

28 (2023) (20)

Infant mortality (infant deaths per 1,000 live
births)47 (2023) (20)Skilled birth attendance

45% (2023) (20)Exclusive breastfeeding

10% (2023) (20)

Wasting (children 6–59 months)

18% (2020) (22)

Stunting (children 6–59 months)

35% (2022) (20)Severe wasting and nutritional oedema (children
6–59 months)

1% (2020) (22)10‘Learning by doing’ case study series: Yemen

The MAMI Care Pathway approach was introduced in the Yemen case in 2021 through the
MANR II emergency programme on maternaland child health, nutrition and water, sanitation and hygiene, which facilitated embeddingof a MAMI pilot within the programme in nine
MOPHP-run heath facilities in four districts acrossthree governorates (Figure 1, Table 2). MAMI implementation through MANR II continued until
July 2022 and was carried over and extended un-til August 2023 as part of ADRA’s YEMLI project.
Additional staff were recruited to implement the
MAMI Care Pathway approach at the nine facilities. Over a 12-month period (June 2022–July2023), 891 mother–infant pairs were enrolled andsupported. Implementation of the MAMI Care
Pathway approach will continue in the nine sites
and expand to 24 fixed health facilities and fivemobile clinics through YEMLI II later in 2024.

Figure 1. Location of implementation sites in Yemen (see blue dots

‘Learning by doing’ case study series: Yemen)

11

Table 2: MAMI sites in ADRA-supported health facilities in Yemen, 2021–2023

Governorate

District

Health facility

Referral hospital

Lahj

Tuban

Bir Nasser Health Unit

Ibn Khaldoon Hospital

Al-Hubil Health Unit

Abyan

Al Madaribah andRas Al Arah

Al-Majza Health Centre

Khanfer

Al-Kood Maternal and Child HealthCentreAl-Razi Hospital

Al-Gool Al-Shabia Health Unit
Al-Darjaj Health Unit
Al-Dhale’e

Al- Dhale’e

Al-Bajah Health Centre

Al-Nasser Hospital

Habil Al-Sowq Health Centre
Al-Fajarah Health Unit

Health worker counselling a mother with a young infant.

12‘Learning by doing’ case study series: Yemen

4.

Planning andimplementation

This section describes the inquiry into the planning and implementation of the MAMI Care Pathway in
the Yemen 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
•

•

•
•

In Yemen, policies and guidance on providing comprehensive continuity of care for vulnerable
infants u6m outside of hospital settings are limited. Community management of acutemalnutrition (CMAM) guidelines recommend inpatient care for all infants u6m identified withsevere wasting or oedema.
Ahead of the pilot, the capacity of the nine MOPHP-run heath centres in which the MAMI
Care Pathway approach was to be implemented was analysed, including staff availability,
their medical certifications and whether they had received CMAM and infant and young childfeeding (IYCF) training.
ADRA recruited additional staff to implement the MAMI Care Pathway approach.
Stakeholder meetings were held with representatives from MOPHP, heads of Governorate
Health Offices (GHOs) and District Health Offices (DHOs), community health workers (CHWs)
and community health and nutrition volunteers (CHNVs), to present the MAMI Care Pathway
approach and garner support.

‘Learning by doing’ case study series: Yemen

13

Burden and perceived health priority. ADRA in
Yemen recognised that many young children justover six months of age are enrolled in CMAM programmes, suggesting that malnutrition begins
earlier than this age. Since services to manage
infants u6m were limited in Yemen, the MAMI
Care Pathway approach was proposed to provide
timely support to at-risk mother–infant pairs forfeeding, child health, and maternal wellbeing.
Policy context. No formal policy analysis was
conducted before implementing the MAMI Care
Pathway approach, but it was understood thatthe approach would fill gaps in Yemeni healthand nutrition guidelines in regard to care for atrisk infants u6m and their mothers. ADRA suggested for the Nutrition Cluster to integrate the
MAMI Care Pathway approach into the national
CMAM guidelines, which upto then proposed torefer all infants u6m with severe wasting (weightfor-length z-score (WLZ) <-3 and/or oedema and/or danger signs (of the integrated managementof neonatal and childhood illness [IMNCI]) to inpatient care (in hospital-based therapeutic feeding centres [TFCs]). Infants u6m identified withmoderate wasting (WLZ <-2) or breastfeedingproblems were referred to IYCF counselling in
outpatient therapeutic programme (OTP) sites at
the health facilities.

Local health system capacities. ADRA used acapacity mapping questionnaire to assess theservices provided at health facilities and thenumbers of health professionals available at thefacilities. The tool assessed as well health workers’
capacities in assessing clinical signs and symptoms (IMNCI), CMAM and anthropometric measurement, and in providing IYCF counselling andsupport to caregivers. For community-level implementation, community health and nutrition
volunteers (CHNVs) were selected. All involvedin addressing vulnerable infants u6m and theirmothers were trained on the MAMI Care Pathway
approach.
Stakeholders. Stakeholder meetings were heldwith representatives from MOPHP, GHOs and
DHOs, community health workers (CHWs) and
CHNVs from selected health facilities, to present
the MAMI Care Pathway approach. Besides implementing the MAMI Care Pathway approach,
CHWs and CHNVs play an important role inchampioning the approach through community-based sensitisation. At the start, ADRA was the
only NGO to implement the MAMI Care Pathway
approach in Yemen, but others have since expressed interest or adopted it. For example, Save
the Children conducted a one-week training on
MAMI in Aden as part of its plans to implement
the MAMI Care Pathway approach in Taiz Governorate.

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

14

Early engagement with MOPHP, GHOs and DHOs, and the Health and Nutrition Clusters
facilitated approval for introducing the MAMI Care Pathway approach in targeted healthfacilities.
External guidance was sought from the Global Nutrition Cluster Technical Alliance (GNC-TA),
who assigned a MAMI Advisor to orient ADRA staff on the MAMI Care Pathway approach andto support adaptation in the Yemeni context.
Nine implementation sites were selected. Each site consisted of a MOPHP-run heath centre
supported by ADRA, its catchment population and district referral hospital.
MAMI Care Pathway Package materials and newly developed materials were adapted to
the local context and translated into Arabic. ADRA International and ADRA Yemen technicalteams approved the final versions used for implementation.
Facility- and community-based health workers were trained to implement the MAMI Care
Pathway approach, according to their level of care. MOPHP focal points attended the training
sessions and the MAMI Advisor played an advisory and supervisory role during the initialrollout.

‘Learning by doing’ case study series: Yemen

Agency’s preparedness, stakeholder engagement,
and approval. ADRA International discussed thepotential to implement the MAMI Care Pathway
approach internally, and then presented the ideaof incorporating a MAMI pilot in MANR II to ADRA
Yemen. As ADRA did not have expertise in the
MAMI Care Pathway approach, it sought externalguidance from the GNC-TA on integrating theapproach in its existing health and nutrition programme in Yemen.
ADRA held stakeholder meetings with representatives from MOPHP, GHOs and DHOs, andsought approval from MOPHP and the Yemen
Health and Nutrition Clusters to introduce the
MAMI Care Pathway approach in targeted healthfacilities.
The GNC-TA MAMI Advisor was assigned to ADRA
to prepare and facilitate an orientation (August2021), followed by a design workshop to discuss
adapting the MAMI Care Pathway approach to
the Yemeni context and to finalise the MAMI
country materials (September 2021). Both the orientation and design workshops were aimed at
ADRA’s country-level coordinators and managers
in Yemen, as well as ADRA’s globally based technical advisors supporting the project.

the National Nutrition Cluster and other MAMI
focal persons, who attended and supported theirfive trainings in Aden. ADRA also engaged with
International Medical Corps and John Snow Inc.
(JSI) to advocate for implementing the MAMI
Care Pathway approach and to provide advice
and support, as well as with JSI to discuss including the approach as part of the Yemen Momentum for Integrated Health Resilience project, andto support them. It also provided advice to the
Health and Nutrition Clusters on incorporating
the MAMI Care Pathway approach in the revised
CMAM guideline and Minimum Service Package
for Yemen (23).
Defining the target population. Criteria to be
used to define vulnerability in infants u6m andtheir mothers were generated with advice andsupervision from the MAMI Advisor (Box 1). Highrisk classification criteria were aligned with the2013 WHO guidelines on severe acute malnutrition and moderate-risk classification criteria wereagreed through consultation with the MAMI Advisor. Weight-for-age z-score (WAZ) for infants
u6m, which was not being used in the OTP sites
for children aged 6–59 months, was also added tothe agreed list of criteria.

ADRA met with Save the Children to discuss expanding the MAMI Care Pathway approach in
Yemen and to share its implementation experience. It linked Save the Children to the GNC-TA,‘Learning by doing’ case study series: Yemen

15

Box 1. Criteria used to identify small and nutritionally at-risk infants
u6m and their mothers during screening and assessment in the
Yemen case, 2021–2023
Criteria used to identify at-risk infants u6m and their mothers during rapid screening in
the community or at any contact with health services, for referral for in-depth assessment
Infant u6m:

Mother of infant u6m:

•
•
•
•
•

•
•
•
•

•

Maternal orphan or mother absent
Low birthweight <2,500 g
Premature birth <37 weeks
Multiple birth (twins)
Infant mid-upper arm circumference(MUAC) <110 mm (infant <6 weeks) or <115
mm (infant ≥6 weeks)
Excessive crying or sleep problems, colicand other concerns

Adolescent mother <18 years
Maternal MUAC <230 mm
Maternal diseases (HIV, TB, other)
Maternal mental health concern

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

Mother of infant u6m:

IMNCI general danger sign or sign and•symptom of severe disease, including nutritional oedema
WLZ <–3 or WAZ <–3

Severe maternal mental health concern

Note: High-risk mother–infant pairs are referred to hospital. After their problems have been resolved
they return for enrolment in the MAMI Care Pathway and continue to be supported until the infantreaches six months of age.

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

Mother of infant u6m:

•
•
•
•
•

•
•
•
•

•
•
•
•

16

Maternal orphan or mother absent
Low birthweight <2,500 g
Premature birth <37 weeks
Multiple birth (twins)
Excessive crying or sleep problems, colicand other concerns
WLZ <–2 but ≥–3 or WAZ <–2 but ≥–3
MUAC <110 mm (<6 weeks) and <115 mm (≥6
weeks)
Growth deficit (perceived low growth bymother, low weight gain (<5 mg/kg/day) atthree consecutive follow-up visits)
Feeding challenges

Adolescent mother <18 years
Maternal MUAC <230 mm
Maternal diseases (HIV, TB, other)
Moderate maternal mental health concern‘Learning by doing’ case study series: Yemen

Selecting implementation sites. The MAMI Care
Pathway approach was implemented in nine of
the 28 ADRA-supported health facilities providing reproductive health, IYCF and CMAM. Sites
were selected based on the catchment population, availability of skilled staff, capacity of thehealth facility, and presence of a district referral
hospital. Additional consideration was given to
the accessibility, availability and provision of integrated services, including whether World Food
Programme- and UNICEF-funded OTP and targeted supplementary feeding programme wereavailable at the pilot health facilities or in theirsurrounding areas.
Designing the implementation modus. The
implementation modus was tailored to the local
context and capacities during the MAMI orientation and design workshop involving ADRA Yemen and MOPHP, with support from the GNC-TA
MAMI Advisor. The MAMI Care Pathway approach
was implemented as a pilot to inform further adaptation and scale-up.
Adapting, aligning, simplifying, testing and using materials. All MAMI Care Pathway package
materials were used, with WLZ <-3 added as ahigh-risk criterion. The MAMI Care Pathway criteria were integrated with those used in CMAM. A

MAMI register and referral card for CHNVs werealso developed with support from the ADRA Monitoring, Evaluation, Accountability and Learning(MEAL) team. All materials were translated into
Arabic. Together, the ADRA International Technical Advisors and ADRA Yemen Technical Specialists approved the final versions of materials used
for implementation. Annex 5 provides more detail on the implementation materials.
Training for implementation. Two training
workshops were held, one for health workers andone for CHNVs in the nine selected health facilities. Details of the training workshops are provided in Annex 6. The MOPHP focal points for IYCF
and the CHNVs attended the trainings and the
GNC-TA MAMI Advisor provided mentorship support. The training equipped implementers (according to their roles) with the necessary skills to:(1) screen and assess health status, anthropometry and risks; (2) assess mental health; (3) enrol
at-risk pairs; (4) refer and trace absentees; and (5)follow up on treatment outcomes. As part of national guidelines, health workers and CHNVs also
received training on awareness messages (nutrition, IYCF, hygiene, and social and behaviourchange) to be used in their practice.

4.3. Implementing services
Key information••••

The pilot was implemented from December 2021 to August 2023 in nine facilities in five
districts across three governorates in Yemen.
Services were provided free of charge at all facilities. If referral was needed, severe acutemalnutrition vouchers were provided to cover the associated costs, paid for and organised
through ADRA’s USAID-BHA-funded project.
Sufficient skilled MOPHP and ADRA-recruited staff were available at all facilities and supportive
supervision and mentoring were provided to health workers monthly.
CHNVs received a monthly top-up to their transportation subsidy to motivate their adoptionof new tasks in their routine practice.

‘Learning by doing’ case study series: Yemen

17

Access: availability, geographic accessibility,
affordability and acceptability. The MAMI Care
Pathway approach was implemented in nine facilities in five districts across three governorates
in Yemen (Table 2 above). All services were provided free of charge in all facilities. If referral wasneeded, severe acute malnutrition vouchers of
US dollars (USD) 250 maximum were issued tomothers/caregivers to assist with the associatedcosts, including transport and accommodation
during inpatient care. These vouchers were paid
for and organised through ADRA’s YEMLI project,under which the MAMI Care Pathway was piloted.
Organisation of care. In the community, CHNVs
and CHWs conducted screening as part of weekly
visits, during which they also provided IMCI, IYCF
and CMAM services. They screened mother–infant pairs using a rapid screening guide. If they
were identified as at risk according to community-based screening, mother–infant pairs were referred to the health centre for an in-depth assessment. Initially, CHNVs received USD 15 per monthfor transport, but this was increased to USD 100,
which incentivised them to absorb the new tasks
into their routine practice.
In the health centres, mother–infant pairs wereassessed using the IMCI ‘ask, listen, look, feel’ approach adopted by the MAMI Care Pathway, andtheir level of risk was classified according to criteria in the MAMI Care Pathway. If in-depth assessment indicated low risk for the mother–infantpair, CHNVs provided general nutrition counselling and reassurance during household visits.
Pairs identified as ‘high-risk’ with infants aged
one month or older were referred to the TFC at
the hospital for inpatient care. High-risk pairs
with infants below one month of age were referred to the hospital for paediatric care.

18

If in-depth assessment indicated moderate risk
in either the infant or mother, the mother–infant
pair was enrolled in outpatient MAMI care at thehealth centre. Once enrolled, health workers provided management and follow-up according to
the adapted MAMI Care Pathway, consisting of
tailored counselling and actions to address specific problems (including clinical care, feedingcounselling and support, and mental health andpsychosocial support for mothers), and monitoring of progress, with adjustments to follow-up
as needed. Staff responsibilities included thefollowing: (1) clinical assessment and care by a
medical assistant or nutrition worker; (2) tailored
IYCF counselling by a midwife or nutrition worker; (3) mental health and psychosocial support
for mothers by a medical assistant or midwife; (4)monitoring of progress by midwives or nutrition
workers.
Mother–infant pairs remained enrolled in outpatient MAMI care until the infant reached six
months of age, after which the pairs were assessed (outcome review) by a midwife or nutrition worker. If further care (beyond six months)
was required, malnourished cases were referred
to ADRA’s supported CMAM activities, feedingproblems were referred to IYCF activities, andclinical issues were referred to IMCI activities in
the respective health centres. Table 3 lists thecomponents of the Care Pathway across healthactors at the community and health centre levels,with minimal variation by site.

‘Learning by doing’ case study series: Yemen

Table 3: MAMI Care Pathway components unpacked for integration into health services in the
Yemen case, 2021–2023
Activity

Detailed activities

What

Where

Who

Sensitisation

Sensitisation on risks

Information, educationand communication

Community

CHNVs

Health and nutrition
promotion

Social and behaviourchange communication

Community and healthfacilities

Health andnutrition
officers, healthworkers, CHNVs,
CMWs

Screening

Screening (rapid
assessment)

Through MAMI forms,
mid-upper arm
circumference tapes

Community and healthfacilities

Health workers,
CHWs, CHNVs,
CMWs

Assessment

In-depth assessment Through MAMI forms

Health facilities

Health workers

Follow-up

ReferralUsing severe acutemalnutrition referral
vouchers

Hospitals, health centres,
health units

Health workers

Follow-up in thehome during
enrolment

Home visits

Every household

CHNVs, CMWs,
CHWs

CMW= community midwife; CHNV= community health and nutrition volunteer.

Organisation of staff. Sufficient skilled MOPHP
and ADRA-recruited staff were available at all facilities. The MOPHP staff consisted of six nutrition
workers and six midwives in each governate ofLahj, Abyan and Al-Dhale’e, as well as 12 CHNVs in
Lahj, 20 in Al-Dhale’e and 26 in Abyan. ADRA staff
consisted of one MAMI coordinator and three
MAMI assistants recruited for the duration of thepilot. Implementation was supported by adapted
MAMI Care Pathway materials. Supportive supervision and mentoring were provided to healthworkers on the MAMI Care Pathway approachand other health-related activities at least once amonth in each health facility.

‘Learning by doing’ case study series: Yemen

Participation. Because the MAMI Care Pathway
approach targeted at-risk mother–infant pairs,
mothers were inherently involved in care. Caregivers’ perceptions of the need for and interestin the MAMI Care Pathway approach were notspecifically assessed, but pairs that met criteria
for enrolment were invited to join if they were interested.

19

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

•
•

Data on implementing the MAMI Care Pathway approach were consolidated from CMAM
reports, baseline and endline pilot data, and six-month age review forms to monitor the
impact of implementing the MAMI Care Pathway approach in the nine facilities.
Primary qualitative data were collected from GHOs and local authorities, as well as community
members, to complement the quantitative data. ADRA’s implementation research is ongoingand findings from the pilot are being used to improve existing service delivery and to planfurther expansion and scale-up.
Virtual platforms (e.g., WhatsApp, Skype, virtual meetings, emails and YouTube) were used toshare information and learning.
The MAMI implementation team were held accountable internally (ADRA) and externally(Government of Yemen, Health and Nutrition Clusters, USAID-BHA) for providing quality
services.

Monitoring and reporting. The indicators selected to monitor the impact of implementing the
MAMI Care Pathway approach were the following: (1) the percentage of infants admitted to OTP
or targeted supplementary feeding programme
who were six to eight months of age; (2) the percentage of infants u6m referred and admitted toTFCs; and (3) the percentage of infants u6m identified with wasting and/or underweight. These indicators assumed that implementing the MAMI
Care Pathway approach at the selected healthcentres would reduce the number of admissions
to TFCs and the proportion of infants identified
with wasting and/or underweight. Outcome datafor infants enrolled in the pilot were also collected
when they reached six months of age.

20

Sources of data included CMAM programme reports, baseline and endline pilot data, and sixmonth age review forms. Qualitative data werealso collected through focus group discussions
and key informant interviews with representatives of GHOs, local authorities, and community
members to complement information on thequantitative indicators. Table 4 summarises consolidated data (for all facilities) describing MAMI
implementation (screening, assessment, enrolment, and outcomes for MAMI pairs) as part ofthe pilot in Yemen over a 12-month period (June2022–July 2023).

‘Learning by doing’ case study series: Yemen

Table 4. Screening, assessment, enrolment, and outcomes of mother–infant pairs, 12-month period(July 2022–June 2023), Yemen
Key indicators:
Pairs screened

4,615

Pairs screened identified at risk

2,749

Pairs assessed

1,866

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

891 (47,7%)

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

60 (3.2%)

Pairs assessed boy/girl ratio

0.84

Key reasons infants’ moderate risk

LBW, slow weight gain

Key reasons mothers’ moderate risk

Adolescent motherhood

Pairs enrolled in care

891

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

402 (70.3%)

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

170 (29.7%)

Pairs missed before or at infant aged 6 months(died, absented, did not return, lost to follow-up)(% of pairs enrolled)319 (35.8%)

LBW= low birth weight; MUAC= mid-upper arm circumference.

‘Learning by doing’ case study series: Yemen

21

Improving quality and disseminating informationand learning. ADRA experienced several implementation challenges during the pilot rollout,
including the following: (1) delays in approvals forstarting and trainings; (2) turnover of key staff;(3) safety concerns in the field; (4) a lack of statistics on infants u6m; (5) a lack of mechanisms
to trace referred cases to verify the impact of theimplementation; (6) a lack of services for motherswith mental health conditions; and (7) traditional
practices that contradicted MAMI guidance. Several of these challenges made data collection difficult and led ADRA to continue the pilot implementation within the nine health facilities in its
follow-on project, YEMLI, rather than scale up to
all ADRA-supported health centres. This allowed
more time for data collection and analysis.
In-country sharing of information on MAMI was
facilitated by virtual platforms (such as Zoom,
MS Teams, Skype, email, YouTube, LinkedIn andWhatsApp). Outside the country, information
was shared through YouTube, LinkedIn, email,and webinars. ADRA Yemen was involved in the
MAMI Global Network (sharing learning andseeking input from peers through the Implementers Working Group) and ADRA International
was involved in the Infant Feeding in Emergencies (IFE) Core Group. ADRA’s evaluation of thepilot is ongoing, and its outcomes will be used to
improve and scale up implementation in ADRA’s
future programming. No national research insti-

tutions were involved and no national learningand information sharing entity (e.g., communityof practice, Country Chapter1) was established.
The MAMI implementation teams were accountable internally to ADRA International and ADRA
Yemen for provision of quality services. Externally,
they were accountable to USAID-BHA (donor),
MOPHP and the Health and Nutrition Clusters.
Stakeholders who were engaged with different phases of MAMI planning and implementation included the Health and Nutrition Clusters, MOPHP, and other implementing partners
interested in adopting the MAMI Care Pathway
approach. Activities and tools used to advocate
for MAMI with key stakeholders included the following: (1) presentations on the progress of MAMI
pilot implementation at Nutrition Cluster meetings; (2) a webinar on the MAMI pilot project; (3)sharing experiences, and lessons learned with
Save the Children, International Medical Corps
and JSI; (4) advocating for including the MAMI
Care Pathway approach in the revised Yemen
CMAM guidelines and the Minimum Service
Package; (5) expanding the implementation of
the MAMI Care Pathway approach in the de-facto
authority areas in the north of Yemen; and (6)training health workers, CHNVs, and ADRA staff
on the MAMI Care Pathway approach.

Infant’s weight, MUAC and length measured by health workers withthe assistance of the mother.

1 A MAMI Country Chapter is a network that may be formed at national or sub-national level to enhance capacity, bridge disciplines, highlightevidence gaps or champion the MAMI Care Pathway approach according to local needs and demand.

22‘Learning by doing’ case study series: Yemen

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

Implementers underlined the potential benefits of implementing the MAMI Care Pathway
approach for the growth and health of vulnerable infants and were eager to involve otherpartners in providing outpatient care to infants u6m in Yemen.
Capacity building and context-specific adaptation of the MAMI Care Pathway approach reliedon external guidance and support.
Buy-in and approval from local and/or national authorities was viewed as crucial to successful
implementation.
Inadequate referral services for specialised care (e.g., mental health services) was proposed asa potential barrier to continuity of care.

Preliminary MAMI pilot data suggest that implementing the MAMI Care Pathway approach has
promising benefits for infant growth and healthand wellbeing and should be considered by otherpartners interested in providing outpatient carefor infants u6m in Yemen. From its experienceof implementing the MAMI Care Pathway approach, the ADRA Yemen team suggested that
future planning for implementation incorporate
the following elements: (1) the use of external
MAMI guidance and support when implementing MAMI for the first time to facilitate capacity‘Learning by doing’ case study series: Yemen

building and context-specific adaptation of the
MAMI Care Pathway approach; (2) securing buyin and approval of local and/or national authorities; (3) establishing services for specialised care(such as mental health services) alongside MAMI
Care Pathway implementation, rather than relying on referrals to services managed by otherpartners, to ensure smoother continuity of care;and (4) routine collection and analysis of data
during the piloting stage to continuously inform
implementation.

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5.

Embedding the MAMI
Care Pathway in routine
services

Key information:
•
•
•
•

•

Adequate training, orientation, and adaptation to their context helped health workers understand how the MAMI Care Pathway approach built upon and strengthened existing services
for at-risk mother–infant pairs.
Assigning health workers clearly defined tasks and providing incentives ensured their commitment to providing this care as part of their routine practice.
Training, context-specific tools, continuous mentorship (supportive supervision), review of individual records for mother–infant pairs and participatory discussion were critical for effective
implementation and improving quality of care.
Person-centred care for mother–infant pairs was a new approach for health workers and required a broad skill set and adequate time. This was challenged by high workload and relianceon trained individuals (midwives and nutrition workers) to provide services, therefore preventing task sharing and skills transfer.
An M&E system was in place to assess service performance, but data were not available forreflective monitoring for quality improvement and learning.

This section describes whether and how clinicalhealth workers in the Yemen case understoodand adopted (normalised) the MAMI Care Pathway approach and embedded it in routine practice in primary care (13, 14). (See Annex 3 for methods and their limitations and Annex 7 for detailed
findings.) We interviewed one ADRA MAMI coordinator and two MOPHP health workers–one nutritionist and one midwife–assigned to the healthcentres to support and directly implement the
MAMI Care Pathway approach.

24First, 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 the health workers’ perspective was appraised.

‘Learning by doing’ case study series: Yemen5.1. Exploring adoption
The health workers participating in the inquiry were asked 16 questions to explore whether they:••

Understood the components of the MAMI Care Pathway approach (coherence, or what it is about);
Were 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 clinical health workers understood and saw thevalue of the MAMI Care Pathway approach. Theysaw how care had improved when implementing
the MAMI Care Pathway compared to before, including how it facilitated early detection of growth
faltering, and filled gaps in routine health andnutrition care for infants u6m and their mothers.

They also articulated how the MAMI Care Pathway
approach helped provide continuity of care for infants and their mothers. After training, the clinicalhealth workers were able to implement their assigned tasks. They also appreciated the benefits of
the approach: in particular, the early identificationof problems, close monitoring of growth, the identification and prevention of severe child illness, andsupport for mothers’ own health and wellbeing
and care practices.

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

Training built a base of understanding and created openness to being involved in improved
practices.
An advisor with international experience shared the new knowledge and supported the adaptation of materials to the local context.
Most components of the MAMI Care Pathway were familiar, and practical guidance was provided on combining care for the infant and mother.
Participants discussed the tasks and decided on the roles and responsibilities together basedon local capacities.

Barriers•

Health workers were initially uncertain about how to operationalise the MAMI Care Pathway
in existing services and care pathways.

‘Learning by doing’ case study series: Yemen

25

Engaging with the MAMI Care
Pathway (cognitive participation)
The MAMI Care Pathway approach was implemented as part of an emergency response programme in ADRA-supported health centres. Staff
were assigned clearly defined tasks as part of theirjob descriptions and were incentivised to performthem. Training and ongoing supportive supervision by the MAMI coordinator built the knowledge
and skills clinical health workers needed, and fos-tered collaboration among them. Clinical healthworkers were interested in the MAMI Care Pathway
approach as they appreciated how it integrated
with existing services and enabled continuity ofcare for infants u6m and their mothers, who had
been previously ignored, and could prevent more
severe conditions at older ages. While enthusiasm
for the MAMI Care Pathway approach was evident, commitment to sustained implementation
will require ongoing support and incentives fromADRA or other implementing partners.

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

Involvement in the care pathway was mandatory and MAMI Care Pathway tasks were partof the job description of health workers, supported by the emergency response programme.
Incentives were given for the extra work the MAMI Care Pathway approach required.
Access to supportive supervision and mentoring increased health workers’ interest in implementing the approach.
Being able to identify risks and provide care for this age group (previously ignored) was appreciated.
Health workers perceived that the care pathway fit well into established health and nutrition
practices (e.g., IMCI, IYCF, CMAM).

Barriers••

The MAMI Care Pathway approach introduced more and longer consultations.
Staff confirmed their commitment to engage in the future, but this commitment was speculative.

Health worker providing breastfeeding advice.

26‘Learning by doing’ case study series: Yemen

Organising changes andrelationships (collective action)
Operationalising the MAMI Care Pathway approachin primary care and community services required
collective action from all health workers, because
it built on or connected with other programmes(IYCF, TFC, CMAM, IMCI), which the ‘package of
MAMI’ helped frame, coordinate and strengthen.
Training, on-the-job mentoring and supportive supervision ensured that health workers could complete the tasks required at their level. ADRA pro-vided guidance on how to adapt operations at thehealth centre to work better together. While healthworkers acknowledged that the skills required to
implement the MAMI Care Pathway approach weresimilar to those they already used in their routine
practice, they felt that the initial three-day training
was too short to cover the many factors addressed
for infants and mothers through the person-centred approach. Substantial on-the-job mentorshipand support from the MAMI coordinator wereneeded to fill training gaps.

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

Comprehensive implementation records adapted to the context ensured standardised andquality actions (appropriated tools).
Competent well-trained health workers were enabled to collaborate and share tasks.
Competent managers and advisors ensured supportive supervision and provided good guidance.

Barriers••

The person-centred approach was new, covered many questions, and dealt with many issues
for both infants and mothers, which required a broad skill set.
Clinical health workers faced a high workload in the short timeframe available for consultations.

‘Learning by doing’ case study series: Yemen

27

Appraising the MAMI Care Pathway(reflective monitoring)
Implementing the MAMI Care Pathway approachrequired ongoing monitoring and reflection toensure and maintain quality of care and to monitor progress. Individual records of enrolled infant–mother pairs provided data for monitoring thequality of care and wellbeing of infants and theirmothers. Service delivery was monitored by the

MAMI coordinator and regular individual and teamdiscussions with health workers were held to provide feedback and solve problems; e.g., when enrolled pairs did not return for follow-up visits. The
Save the Children MEAL package for MAMI wasused for data collection, in parallel to existing datacollection systems at the health facilities. Data wereanalysed to appraise service performance but were
not available for reflective quality improvement orlearning.

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

The standardised individual records were a tool for ensuring the quality of individual care.
The efficiency of the Care Pathway provided to mother–infant pairs improved individual care.

Barriers•

Data were collected and analysed to appraise service performance but were not available forreflective quality improvement or learning.

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 fivepoint Likert sliding scale, with a score from 1 (“notadopted at all”) to 5 (“completely adopted”):

Cognitive participation, score 3.5. Clinicalhealth workers were engaged and saw the value of implementing the MAMI Care Pathway
approach but were not directly responsible foror involved in defining or adapting the ways ofworking.

Coherence, score 4.8. Confident managers
and advisors shared existing knowledge andexperiences and provided good guidance for
implementation. Several advancements madethis possible: specific recommendations on
outpatient care for this age group were included in the 2013 WHO guidelines on the management of severe acute malnutrition; materials for advocacy and implementation wereavailable (e.g., MAMI Care Pathway materials,
briefs and videos); learning experiences fromother settings were available (e.g., in the ENNs
publication, Field Exchange); and evidence
was published in medical journals. Externalguidance from the GNC-TA and continuous
engagement of the MAMI Advisor to support
implementation also helped.

Collective action, score 2.8. The positive involvement of health workers in their assigned
tasks as part of the pilot facilitated changes inrelationships and ways of working across implementing health teams. Implementation of
the MAMI Care Pathway approach occurredin parallel to, and was not integrated in, comprehensive child health care, but maintained
strong links with these.

28

Reflective monitoring, score 3.0. While an
M&E system was in place, health workers were
not aware of the appraisal of the quality of care,
did not get an overall understanding, and were
not involved in decisions on quality improvement.

‘Learning by doing’ case study series: Yemen

The scores for the four adoption components
were plotted on a spider chart showing the degree 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: Interpretating the adoption of the MAMI Care Pathway approach in the pilot in Yemen, 2023
(Adoption was scored on a sliding scale from 1 “not adopted at all” to 5 “completely adopted”)

We concluded that the overall adoption of the
MAMI Care Pathway had an average score of 3.5,
indicating that clinical health professionals successfully adopted the approach that resultedof receiving adequate initial training, ongoing‘Learning by doing’ case study series: Yemen

supportive supervision and monthly incentives.
Subsequent steps in quality improvement may
should consider overcoming the barriers identified in this section to improve implementation –and thus the effectiveness of the approach.

29

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:
•
•
•
•

•
•

•

Health workers understood the condition described as “small and nutritionally at-risk infants
and their mothers”, as adapted to their level of care, but they found some vulnerability factors
difficult to understand.
The technology involved in the MAMI Care Pathway required expanding from existingmaternal and child health and nutrition approaches, sometimes demanding different skills,
contextual adaptations and organisational changes.
Both healthcare workers 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. Mothers who attended care experienced an increasein their understanding, trust and appreciation, but there were challenges in these areas for
those who did not attend care.
Organisation of care needed good leadership, which was challenging in an environment withlimited resources.
Financial and policy support were faced with competing health priorities and were difficult
to anticipate or predict in the protracted emergency context. Dependence on external shortterm emergency funding limits the potential for sustainability and scale unless longer-term
funding is secured.
Interacting health system factors hindered the adaptation or co-evolution of the MAMI Care
Pathway approach into a routine service, and meant that collective reflection and adaptive
actions have been missing to date.

The first method identified challenges and generated insights to improve scalability to explore
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 MAMI coordinator and two clinicalhealth workers (one midwife and one nutritionist).

30

Reflective participatory discussions examined
the MAMI Care Pathway approach across sevendomains to identify challenges on scalability related to the condition (“small and nutritionallyat-risk infants and their mothers”), the technology (methods used in screening, assessment andcare), the value proposition, who are the adopters,
the health or care organisation, the wider system,and embedding and adapting over time. Next,
the case study investigators graded the chal‘Learning by doing’ case study series: Yemen

lenges as 1 (simple–straightforward, predictable,
few components), 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” waswell-described and well-understood by thehealth workers, when adapted to their level ofcare (primary care). However, some risks were
new and not easily detectable, understood, orpredictable (e.g., disabilities, congenital abnormalities, maternal mental health). The “mother–
infant pair” focus was a new way of describing a
condition when evaluating simultaneous conditions related to the infant and the mother. One
example here is the mother’s physical and mental health and socioeconomic situation affecting
the appraisal of the infant’s vulnerability of the
combined mother–infant condition.
We graded the vulnerable mother–infant condition as complicated (grade 2) because while
the condition was well-understood by the healthworkers when adapted to their level of care, somefactors of vulnerability were less clear, and wereoutside of the comfort zone of their expertise.
The technology. Methods and tools to assess,classify and support “small and nutritionally atrisk infants and their mothers” (technology) were
mostly known, as they expanded on or overlappedwith IMCI, CMAM and IYCF approaches. However, putting the mother–infant pair at the centreof care was new, and was a change from the habitual way of focusing on the infant’s condition.
Moreover, including maternal factors in the infant
Care Pathway required new skills. Assessing andsupporting the health and nutritional status of
the infant were known procedures, while thosefor mental health and sociocultural factors influencing feeding and care behaviours were lesswell-known. The detailed guidance and materials available in the generic MAMI Care Pathway
package helped implementers to adapt it to the
Yemen context, but it felt complicated to use.
We graded the technology involved in detecting
and addressing the vulnerable mother–infantcondition as complicated (grade 2) because it
required expanding from or adopting to various
existing maternal and child health and nutrition
approaches, some requiring different skills, contextual adaptations and organisational changes.
The value proposition (benefit, or unique selling point). Health workers appreciated the benefit of the MAMI Care Pathway approach for the
early detection of at-risk infants, monitoring andimproving the infant’s health and nutritional‘Learning by doing’ case study series: Yemen

status over a period, and addressing maternal
vulnerabilities that impact on care and feedingpractices. They also appreciated that the infants
were prevented from developing a more serious
condition. They valued that mothers who got theopportunity to understand the Care Pathway
by receiving care and support, appreciated themessages and increased care for their infants.
Without this opportunity, mothers often did notunderstand the value of how vulnerability factors (often invisible) affected their infant’s growthand health. Consistency in communication (i.e.,
health workers speaking the same clinical language) contributed to strengthening mothers’
understanding and confidence.
We graded the value proposition of the vulnerable mother–infant condition as simple (grade
1) because the benefit of the Care Pathway wasappreciated by both health workers and mothers
when care was provided.
The adopters. Staff roles changed and new staff
were sometimes allocated to implement or support the MAMI Care Pathway. Staff who took on
the Care Pathway alongside their regular tasks
found the increased workload a serious issue.
Some mothers found the assessment and support process burdensome and time-consuming,
though they were more receptive and confident
when the benefits became clearer. Household
and community support helped them to follow
recommended care and feeding practices ormanage conflicting messages.
We graded the adopters of the Care Pathway ascomplex (grade 3) because introducing the MAMI
Care Pathway threatened some health workers’
professional identities, values and scope of practice. Mothers’ understanding, trust and appreciation increased once they benefitted from care.
The impact of the recommended practices on
their support networks was important but thiswas beyond the reach of the Care Pathway assessment.
The health or care organisation. Importantchanges in the organisation of regular care wereneeded to integrate and implement the MAMI
Care Pathway, which were facilitated by the support from external technical and financial partners.
We graded the organisation of the Care Pathway
as complicated (grade 2) because many organisational factors interfered, and good leadershipwas challenging in an environment with limited
or insecure resources.
The wider system. National interest in rolling out
the MAMI Care Pathway approach grew but con31

siderable financial, technical and policy support
were necessary (including understanding risk
factors and the risk burden) to adapt it to the context and align it with existing programmes andservices.
We graded the wider system to adsorb the Care
Pathway as complex (grade 3) because competing health priorities were difficult to anticipate or
predict in the protracted emergency context.
Embedding and adapting over time. The pilot
spotlighted the feasibility of implementing the
MAMI Care Pathway in a fragile and dynamic
health system and provided a better understanding of how to embed and adapt it in an emergency programme. Making it a routine service
would require more learning than the pilot could
accommodate. The existing M&E system was too
fragile to support quality improvement or stimulate the national learning process for scale-up.

We graded the embedding and adapting of the
MAMI Care Pathway approach over time as complex (grade 3) because there were significant interacting health system factors, and the lack ofwider coordinated implementation and collective reflection constrained its further adaptationor co-evolution into becoming a routine service.
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 or controllable, thus less straightforward to address;
and grade 3 challenges (complex) are incomprehensible or unpredictable, thus systems dynamics methods are required to understand theirchanging or emergent behaviours. The area ofthe spider web in figure 3 appraises the overall
feasibility or ease of managing the challenges toimplementing the MAMI Care Pathway approachin the Yemen case at scale: the larger the area ofthe spider web, the more challenging the scalability.

Figure 3: Appraising challenges for scalability of the MAMI Care Pathway implementation in the
Yemen case, 2023
(Challenges were graded as 1 “simple”, 2 “complicated”, and 3 “complex” to address).

32‘Learning by doing’ case study series: Yemen6.2. Exploring readiness for scale-up

Key information:•

Actions the Yemen pilot took that could facilitate future sustainable scale-up of the MAMI
Care Pathway approach included the following:
Engaging key stakeholders in a participatory process.
Addressing a persistent health condition, or service.
Considering expectations for scale-up in the design.
Considering constraining or supportive sociocultural and gender factors.
Testing the intervention under existing human and financial resources constraints.
Engaging with donors and technical partners to support early and continuous scale-up.

•

Actions the pilot missed that could facilitate sustainable scale-up:
Keeping the intervention simple without jeopardising the outcome.
Testing the intervention in a variety of sociocultural and geographic settings.
Assessing and documenting health outcomes and the process of implementation.
Planning advocacy for changes in policies and regulations.
Designing mechanisms to review progress and promote learning.
Sharing understanding of the importance of evidence on feasibility and outcomes priorto scale-up.

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 for methods
and their limitations and Annex 8b for detailed
findings.) The case study team triangulated the‘Learning by doing’ case study series: Yemen

case study information to populate the table inAnnex 8b. They explored 12 key actions in thedesign of the pilot to provide useful insights forscale-up decision-making. Table 5 shows whether these actions were taken or missed.

33

Table 5: Appraising potential scalability of the MAMI Care Pathway implementation in the Yemen
case, 2023
Appraisal of actions for sustainable scale-up
1. Involved future stakeholders

Yes

2. Addressed a persistent health condition or service

Yes

3. Considered expectations about scale-up in the designYes

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

Yes

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

Missed steps (in orange):
•

•

•

•

34

Keeping the package of interventions as simple as possible, without jeopardising outcomes(step 5): The findings suggest that the MAMI
Care Pathway materials underwent only minorchanges to align the approach with existingcare. This may be explained by the emergency context, in which ADRA provided hands-on
support to MOPHP staff.
Testing the innovation in a variety of sociocultural and geographic settings (step 6): The
findings suggest that the emergency projectmade it possible to test the innovation in pilot
sites in ADRA’s impact area without making
changes to account for each specific contexts.
The site selection depended on where ADRA
provided support to health activities.
Not needing extra human and financial resources for implementation (step 7): The findings suggest that the emergency project was
flexible in its resource management, whichallowed for additional staff and a salary topup to compensate for the increased tasks andworkload.
Seeking early and continuous financial support from donors and technical partners for•scale-up (step 9): The findings suggest that all
activities depended on emergency funding,which could change or end when emergency
donor priorities shift. No sustainable development funding was sought.
Planning for advocacy for changes in policies
and regulations (step 10): The findings suggest that no plans were developed in this regard, although ADRA was aware of the needand expressed a desire to engage with thestate MOPHP.

Near-missed steps were assessing and documenting the implementation process and healthoutcomes (step 8), and instituting mechanisms
to review progress and incorporate new learning
into the implementation process (step 11). ADRA
recognised that the MEAL system was weak andplanned for external support to improve it. Nevertheless, ADRA succeeded in using time-limited
emergency funding to gain initial experiences in
implementing the innovative MAMI approach. By
sharing their learning and offering their expertise, they drove both the intentional and organic
spread of the approach to other emergency anddevelopment programmes and actors.

‘Learning by doing’ case study series: Yemen

7.

Learning to inform practiceand scale-up of the MAMI
Care Pathway approach in
Yemen (summary findings)

The process of accessing learning from the implementing the MAMI Care Pathway approach,as part of an emergency programme in nine
MOPHP-run heath centres supported by ADRAin Yemen, involved an empirical investigation in areal-life context. Interviewing members of the implementation team to collect their perspectives,using several sources of evidence, and discussing
emerging findings together, uncovered implicit
knowledge and expanded learning. Using different lenses to explore what was done, where, bywhom, and how, uncovered and heled further
generate a range of rich learning about implementing the Care Pathway approach in the given
context.

7.1. Planning andimplementation
In consultation with MOPHP and the donor, ADRA
identified (‘created’) the opportunity to introduce
this new intervention, which addressed a longstanding perceived need in a highly vulnerable
population, and for which the emergency programme had the appropriate organisational environment.
Because ADRA had many years of experience inmanaging an emergency health and nutrition
project in Yemen, they had a good understanding of the need and context, as well as established relationships in-country to leverage. This
made for a quick start-up, with minimal financial
and technical support needed. The brief infusionof external expertise was able to build the knowledge and skills needed for implementation. The
implementation focused on providing care to alarge population of vulnerable infants and theirmothers to prevent infants from slipping into a
more serious health or nutrition condition. The
health system had not previously addressed thisvulnerability for both infants and their mothers.

‘Learning by doing’ case study series: Yemen

Health worker taking MUAC measurement of mother.

35

7.2. Normalisation andadoption
Because the pilot in Yemen introduced the MAMI
Care Pathway approach as part of its ongoing support in an emergency context, in the interests ofsustainability it was useful to investigate whether
clinical health care providers, and their managers
or supervisors among MOPHP staff, understood,
adopted and embedded the approach in routine
practice after they were trained and coached.
ADRA’s support to health and nutrition services
on behalf of MOPHP ensured that the healthworkforce could provide the services, made thenecessary adaptations in generic MAMI Care
Pathway materials, trained and mentored healthworkers, provided supportive supervision, andensured collaboration within and across services.
Support included a small remuneration to motivate health workers to take on additional workload. Health workers in general were gratified
to offer care to a population that was previously
ignored or referred to hospital care if they wereable to access health services. The shift from disease-focused care to person-centred care of theinfant and the mother did not generate an immediately tangible or ‘felt’ decrease in workloads
or improved teamwork, but health workers appreciated the increased expertise.
The appraisal of the adoption process of the MAMI
Care Pathway approach generated detailed information on facilitators and barriers useful for improving health workers’ adherence behaviours toenable more sustainable health outcomes.

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.
The Yemen case study shows that the supportive
context of the emergency project and the ability of ADRA to garner external (sequenced short-36term) emergency funding and technical support
catalysed the introduction of an integrated careapproach in this context. This has formed a basis
which can be built upon. Changes in policies andpractice informed by more implementation evidence and wider local stakeholder engagement
would be necessary to mainstream and sustain
the approach in routine services at scale.
The experience of piloting the approach in theongoing emergency health and nutrition project
facilitated important learning on planning andbuilding capacities and readiness for service delivery that may be transferable to similar emergency settings and for continued service development in this setting. A strengthened feasible
MEAL system will be crucial to support this process. The admirable openness and enthusiasm of
the ADRA team in regard to mentoring and supporting other partners in starting up the MAMI
Care Pathway will encourage and enable others
to come on board and will maximise the potential
for learning.
ADRA used emergency funding as an entry point
to initiate the MAMI Care Pathway approach andused repeated short-term funding to expand
implementation and learning, in which they
involved key stakeholders, including MOPHP.
They did not make major attempts to advocate
for health policy changes or to access development funding to support further expansion of
the MAMI approach. However, disseminating the
success of the approach generated interest fromother health and nutrition actors, who have started planning to take up the MAMI Care Pathway
approach in Yemen.

7.4. Collective learning andsuggestions to strengthen
the potential for scale
The empirical investigation of the implementationof the MAMI Care Pathway approach in nine sites in
Yemen revealed both achievements and challenges in regard to implementing and adopting the approach, as seen through the eyes of health workers(members of the support team and the implementation team).
Learning from the Yemen case experience was valued as key to paving the way towards improved implementation and sowing the seeds for exploring
potential scale-up. ADRA shared the experience of
implementing the MAMI Care Pathway approachwith other implementing organisations in-country
and encouraged them to adopt the approach in‘Learning by doing’ case study series: Yementheir emergency health and nutrition projects, andoffered assistance to doing this. Systematic documentation could facilitate this process.
Regarding mothers’ perceptions, as understood byhealth workers, we learned the following:
•

•

•
•

•

Vulnerable mothers considered the integrated Care Pathway beneficial when they experienced and witnessed positive changes to thewellbeing of their babies, e.g., improved growth.
Various factors made it difficult for health workers/services to influence affected mothers; advice from health workers conflicted with household and community values and norms.
Mothers’ adherence to care improved when
there was clear communication across healthworkers and services.
Because risk factors of vulnerable mother–infant pairs were often invisible and because there
was no perceived tangible benefit for mothers(such as food supplements, drugs or soap), theylost interest in returning for follow-up visits orcomplying with care (the cost was too great forthe perceived benefit).
The cost of transport was perceived as a major
barrier to attending follow-up visits, as well as
being referred to hospital.

From service implementation, we learned the following:
•

•

•

•

•

While most of the MAMI Care Pathway components are part of a national policy or healthapproach, implementation was weak and the
MAMI Care Pathway strengthened and/or filledgaps and connected services (where existing)for vulnerable infants and their mothers.
Applying a “person-centred and continuity ofcare” approach in the MAMI Care Pathway was
new and needed leadership support across services and actors.
The “new or strengthened” activities in the
MAMI Care Pathway approach increased workload, which was possible to manage this within
the emergency programme that had the required financial and technical capacities.
ADRA’s direct support for service delivery allowed care to be provided smoothly, avoided
duplication of actions and encouraged and enabled compliance by health workers.
Harmonising communication about the aim
and importance of the MAMI Care Pathway
approach to address vulnerability factors stimulated confidence in and between service providers and users.

‘Learning by doing’ case study series: Yemen

From the health system, we learned the following:
•

•

•

•
•

•

•

MOPHP’s engagement from the start was important to create interest and understanding,and to eventually facilitate processes acrosssectors and actors.
The initial orientation of stakeholders and training of implementers targeted a small group,
which facilitated a quick start but failed to establish an adequate MEAL system for continuous learning.
ADRA simplified the approach and materials,
but adaptation was minimal and did not evolve
during implementation because of the limited
MEAL system in regard to informing adjustments.
A financial incentive made it possible to influence the health workers’ job descriptions to include the MAMI approach.
Vertical disease-focused programmes prevailed and overlapped with existing approaches (e.g., IMNCI, maternal, infant and young childnutrition, and CMAM), collaboration was locallymanaged and duplication for smarter service
delivery partially avoided.
Learning was limited to interested emergency stakeholders; adequate leadership would
be needed to expand interest in the MAMI approach.
ADRA expressed the desire to expand research
capacities and is seeking support for doing this.

37

8. Conclusion
The findings of the “learning by doing” case study are intended to improve practice for service delivery, encourage research, and drive mindful, sustainable approaches for scale-up. Guided by different
frameworks, the Yemen case study painted a rich, nuanced picture of the planning, implementation
and adoption of the MAMI Care Pathway approach in the implementation.
Comprehensively addressing vulnerability factors for “small and nutritionally at-risk infants and theirmothers” with a person-centred and continuity of care approach was complex and required goodskills and continuous mentoring. Improving readiness to successfully embed and scale up a sustainable approach within existing health services would require longer term funding commitment andconsiderable efforts from implementing partners to engage in aligning health and nutrition policies,
implementation plans and practices. In the Yemen case, these requirements were partially met byintegrating the approach within an existing emergency programme, building on ongoing support formaternal and child health and nutrition services, with good documentation of learning and an openness to sharing lessons learned.
Adopting and scaling up the MAMI Care Pathway approach learning experience in Yemen could build
a broad base of expertise to address a critical gap in perceived need and to provide comprehensive, respectful quality care to improve the health, growth and survival of vulnerable infants and their mothers.

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‘Learning by doing’ case study series: Yemen

39

Annexes

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

40‘Learning by doing’ case study series: Yemen

Annex 2. Definitions
Adoption. Implementing new ways of thinking, acting and organising in health care 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. Conscious adoption of the perspectives of individuals, families and communities 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, and 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). Quality of patient care focuses mostly on technical quality, appropriate referral, continuity of care and patient-centredness. (12)‘Learning by doing’ case study series: Yemen

41

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)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 a healthproblem after the termination of major financial, managerial and technical assistance from an external
donor. (15)
Sustainable. Able to be maintained or 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 realitythat helps design a research question, guide the selection of relevant data, interpret the data and propose 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)References
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10. Lohr, K.N. (Ed.) (1990) Medicare: A strategy for quality assurance, volume I. Institute of Medicine.
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‘Learning by doing’ case study series: Yemen

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: Yemen

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: Yemen

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: Yemen

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.

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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: Yemen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: Yemen

49

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: Yemen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: Yemen

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: Yemen

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: Yemen53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: Yemen

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: Yemen55

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: Yemen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: Yemen57

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: Yemen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?

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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: Yemen

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: Yemen

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: Yemen

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.

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63

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: Yemen

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: Yemen

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: Yemen

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: Yemen67

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: Yemen

Annex 5. Implementation materials
Table Annex 5. Summary of materials for implementing the MAMI Care Pathway approach in the
Yemen case, 2021–2023
Materials from the 2021 MAMI
Care Pathway package v3

Description of change (what)

Method (how)All MAMI Care Pathway package materials

Adapted to context and translated into Arabic
Added weight-for-length z-score(WLZ) < -3 as a high-risk criterion

Integrated the MAMI Care
Pathway approach criteria with
CMAM criteria

Existing materials
None
Materials newly developed
MAMI CHNV training materials Developed for use by CHNVs
MAMI CHNV screening andfollow-up form
MAMI register for community
health and nutrition
volunteers (CHNVs)

Internal discussion between
ADRA Yemen MAMI team and
ADRA International Health andNutrition Advisor, with full coordination with MOPHP

Referral card

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69

Annex 6. Training sessions
Table Annex 6. Outline of training conducted in the Yemen case, 2021–2023

Training(type and dates)

Participants
targetedTraining for
health workers (3days, November
2021)

18 health workers

Objectives

Topics covered

Materials used•

Understand the
MAMI Care Pathway approach
Be able to use
the MAMI Care
Pathway approach to screen
infants u6m andtheir mothers
Know how andwhere to referat-risk infants
u6m and theirmothers•

The MAMI Care
Pathway approach and
MAMI in the
Yemen context
Screening andassessment
Management
Monitoring andreporting••

MAMI Guide
MAMI Tools

Understand the
MAMI Care Pathway approach
Be able to use
the MAMI Care
Pathway approach to screen
infants under six
months of age(u6m) and theirmothers
Know how andwhere to referat-risk infants
u6m and theirmothers•

Screening in thecommunity
Classification ofrisk and referral
pathways••

MAMI Guide
MAMI Tools••

Training for CHNVs (2 days, January 2022)

58 CHNVs

•
•

•

70

•
•
•

•

‘Learning by doing’ case study series: Yemen

Annex 7. Appraising the adoption process
Table Annex 7. Findings on the degree of normalisation* of the MAMI Care Pathway approach in the
Yemen case, 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 MAMI, anthropometric measurements were not taken for
infants u6m, only for children 6–59 months. If malnutrition in infants u6m was suspected, they were directly referred to the TFC
at the hospital, or the mother was counselled on breastfeeding.
When MAMI started, several benefits of the approach were noted:
increased knowledge on how to assess and follow up growth of
infants u6m, monitoring the mental health and nutritional status of
the mother, and improved counselling to prevent bad breastfeeding habits.
“MAMI filled a gap in dealing with the mother of the infant u6m,
before there was no concern given to these mothers. When meeting mothers in the vaccination room we couldn’t provide any services, unless we sent them to the TFC.”
Participants distinguished the intervention from current ways ofworking: Grade 4

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

3. Do you understand what implementing the Care Pathway
requires from you (specifictasks and responsibilities)?

Since the MAMI training and implementation, knowledge has
increased on how to deal with the infant and mother (including
for the mother’s mental health and nutritional status, and how tomonitor growth and development of the u6m group).
Quotes:“In Yemen, mothers below 18 years have no experience on how todeal with infants u6m. Now we understand why health and growthmonitoring is important; before we didn’t understand.”“MAMI is dealing with infants u6m and mothers together.”Participants collectively agreed about the purpose of the intervention: Grade 5
After receiving good training on why and how to implement theactivities, tasks were understood, and implementation was madefeasible. Roles and responsibilities were assigned.
Participants individually understood what the intervention requiredof them: Grade 5‘Learning by doing’ case study series: Yemen71

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

Several benefits of MAMI were identified: effective support ofinfants before they are six months of age (before they become
acutely malnourished cases); close monitoring and prevention, andidentification of illness early; benefits on weight gain. Mothers weregrateful for MAMI: they felt it gave them a benefit compared to experiences with children who developed severe acute malnutrition/
moderate acute malnutrition.
Mothers with bad habits (not exclusive breastfeeding/mixed feeding) changed their habits, listened to advice, and were more committed to coming to the health centre.
Before the MAMI Care Pathway approach, LBW infants, twins, orphans and adolescent mothers (u18) were ignored as vulnerabilities.
“Mothers come back more because their young infants need morecare, and the health centre can help to teach them how best tocare for their infants.”
Participants constructed potential value of the intervention for theirwork: Grade 5

5. Are you (or other key individual(s)) able and willing toEverybody had assigned tasks and supported each other. The MAMI
get others involved in the Care coordinator provided a lot of support to ensure collaboration.
Pathway? Are you actively
Key individuals drove the intervention forward: Grade 4
engaged in making the Care
Pathway work in your setting?
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?

In the beginning, health staff faced many challenges and did nothave a good model for implementing the MAMI Care Pathway. After training and follow-up/on-the-job training and visits from ADRA,
implementation became easier, and the Care Pathway was accepted.
Participants agreed that the intervention should be part of theirwork: Grade 4

Because MAMI had a lot of benefits and was already accepted by
the team, they were interested in it and asked many questions. Cas7. Do you have the capacity
es for MAMI were always there but they did not know how to deal
and are you willing to organise with them. MAMI integrated many services that were already there
yourself and your colleagues
for older children and that could also be used for infants u6m.
and collectively contribute to“MAMI is the superhero for the programmes on the ground, so
the work involved for implemany people are asking about MAMI (different people working on
menting the Care Pathway?
health outside of the health centre).”Participants accepted the intervention: Grade 3

8. Do you have the capacity
and are you willing to collectively define the actions andprocedures needed to keep
the practice going (invest yourtime, energy to keep it going)?

72

If ADRA was no longer supporting, the health centre would continue with MAMI. After two years of implementation, the health workers had good knowledge and skills in regard to completing MAMI
tasks.
“We would be willing to teach the colleagues, train in MAMI and
expand implementation.”
Participants continued to support the intervention: Grade 3‘Learning by doing’ case study series: Yemen

9. Are you and colleagues able
to do the tasks required to implement the Care Pathway (tooperationalise 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)

The MAMI work was considered as teamwork, and required working together. Across the team, they had both health and nutrition
people who provided care for at-risk infants/mothers together –integrated, cooperative working between colleagues. When themembers of the team provided the different services, they wereencouraged by the benefits and the outcomes of implementing
MAMI.
Participants performed the tasks required by the intervention:
Grade 1
There were eight other midwives in the same centre, but MAMI
cases would always be sent to the one MAMI focal point. However,
ADRA staff made sure that everyone working together was trained
and knew what the others were doing, and understood how to cover each other. However, only one midwife and one nutrition worker
were trained on MAMI per health centre so not all health centre
staff implemented MAMI. There was a plan to train all health workers on screening (not assessment or support) but this had not yet
been done due to limitations in the budget.
Participants maintained their trust in the intervention and in eachother because they were trained and supported: Grade 3

MAMI was considered a collection of other programmes (IYCF, TFC,
CMAM, IMCI), not something new.
Once health workers were trained and their capacity was built, they
worked as a team to implement the “package for MAMI”. The “pack11. Is the work required forage” helped to coordinate the activities.
implementing the Care PathThe MAMI Care Pathway was considered an integrated programme,
way distributed to participantsaligned with other programmes: ADRA, by means of a matrix,
with the right mix of skills andhelped health workers to understand how to work together andtraining? Did it impact on the
how to better deal with cases and change operations in the healthdivision of labour, resources,
centre.
power, responsibilities beA three-day training session at the start of MAMI was not enough totween colleagues (tasks andbuild skills: in the beginning, the training was thought to be similarskill sharing)? Was extensive
to other programmes, but after working on MAMI it was felt thattraining needed before implethere was not enough training because many new factors werementing the Care Pathway?
being addressed and it had to be pieced together in a way that had(Skill set workability)
never been done before, which needed more explanation.
The work of the intervention was appropriately allocated to participants with trained skills: Grade 3

12. Is the implementation of
the Care Pathway adequately
supported by the advisor/manager? (Contextual integration)

At the beginning of implementation, there was some misinformation and a lack of understanding, but after follow-up and supervisory visits the team felt well supported by the manager.
The intervention is adequately supported by its host organisation:
Grade 4

13. Do you have access to
information on the quality ofcare and outcome of the Care
Pathway (monitoring and evaluation information)?

Individual records of enrolled pairs provided data for monitoring
progress in the mother’s behaviour and the infant’s wellbeing.
However, data on performance of services were not available forclinical health workers.
Participants access information about the effects of the intervention: Grade 2‘Learning by doing’ case study series: Yemen

73

Regular team discussions were held to solve problems; e.g., aboutcases not returning for follow-up visits.
Monitoring of services was done by the coordinator, who met with
14. Do you collectively agree
the health workers to give feedback.
on the quality of care and the
The Save the Children MEAL MAMI package was used for data coleffects of the Care Pathway
lection.
because of formal monitoring?
Participants collectively assessed the intervention as worthwhile:
Grade 3

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

16. Can you make changes tothe intervention as individual
or group in response to theappraisal?

Multiple benefits of the Care Pathway were expressed (see above).
The comprehensive and quality of care promoted by the Care Pathway effectively addressed the risks to mother–infant pairs.
Participants individually perceived the intervention as worthwhile:
Grade 4
Feedback on the individual monitoring of care was provided to themother. Supervisory visits detected, corrected, or clarified this information for the mother. No structural changes were made.
Participants modified their work in response to their appraisal of
the intervention: Grade 3*Findings were informed by Normalisation Process Theory (13, 14) (see Annex 2: Methods and limitations), adapted to the
MAMI Care Pathway approach, to understand the path followed towards adoption, including enablers and barriers, and toassess the likelihood of the Care Pathway becoming routine in practice. The quotes are from the participatory discussions
with the MAMI implementation team.

74‘Learning by doing’ case study series: Yemen

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

Domain 1:
The condition (including risk
factors)

Addresses a) how well the condition “small and nutritionallyat-risk infants and their mothers” is characterised, understoodand predictable, and b) how far care is affected by sociocultural
factors and comorbidities.

1a. Is the condition “small andnutritionally at-risk infants
and their mothers” wellcharacterised, well-understood,
and predictable?

Clinicians were knowledgeable and skilled as regards addressing
the signs and symptoms of the condition. However, too manycases were identified if the description in the V3 Care Pathway isapplied, so it was amended.

1b. Are sociocultural factors
and comorbidities relevant
for the condition “small andnutritionally at-risk infants andtheir mothers”?

Before, many conditions were not considered; e.g., adolescentpregnancy, lactating women, family planning, close birth
spacing.

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 key features of themethods (technologies) used
to assess, classify and support“small and nutritionally at-risk
infants and their mothers”? Are
methods known, do they exist?

The MAMI Care Pathway approach laid out how to objectively
detect and refer vulnerable pairs early for care. Risk factors could
be expanded beyond the commonly used(e.g., all congenitalabnormalities that impact feeding). On the other hand, tools tocomprehensively assess congenital abnormalities that impact
feeding were missing.

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 and nutrition
status?

Implementing the Care Pathway worked well after contextual
adaptations were made and training was conducted by aninternational expert. Some risk factors were missed and further
contextual improvements need to be made. The MAMI Care
Pathway approach was cross-cutting with many programmesthat addressed a limited set of criteria. Therefore, there was felt
to be a need for additional criteria for risk factors. For example:
maternal physical and mental health was assessed, thus a newvulnerability had to be addressed; disability was detected, butthen follow-on care needed to be done in case it impacts on,
for example, feeding difficulties. Thus, the MAMI Care Pathway
could be improved.

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

If possible, training materials and guides could include lessons
and videos that help practitioners to work with this infant group.
Having access to more learning tools to better detect risks would
be useful. For example, the WLZ indicator was challenging,
and additional materials were needed to support taking thesemeasurements.

‘Learning by doing’ case study series: Yemen75

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

Domain 3:
The value proposition

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

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

The MAMI Care Pathway approach was valuable and healthworkers were committed. It improved the teams’ skills to covervulnerable cases that were not being addressed before, helping
to make a change and decreasing the risk of severe illnesses
developing that need lengthy and expensive treatment. Midand long-term benefits mirrored preventative programmes(more so than any other programmes); e.g., detecting and acting
upon a health condition early to prevent more serious conditions
that need complex interventions later.

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

Mothers seemed to understand the benefit in regard to
reducing the risk of malnutrition to avoid needing CMAM or
being referred to higher-level facilities. MAMI attracted attention
to vulnerable infants and mothers.

Domain 4:
The adopter system
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, andnew tasks be taken on?

76

For the Care Pathway to be successful, MAMI-specific services
needed embedding in routine care. Some changes could
facilitate embedding the Care Pathway in routine care, suchas the use of the weekly growth chart, adapted for “small andnutritionally at-risk infants and their mothers”. The current tools
used do not reflect all risks and are not appropriate for infants
u6m as they are designed for children 6–59 months of age. For
example, existing weight-for-age growth charts do not follow
growth in weeks but in months, thus these were adapted. The
weekly growth charts were used when the support team waspresent; otherwise, the regular monthly version was used. Moresupport was needed to improve the organisation of MAMI,
with specific tools for use by MAMI. Until recently, context
adaptations were easy to make (one person’s decision), but inthe last few months, as more organisations have got involvedin MAMI implementation, there has been less liberty to makeadaptations. It was suggested that MOPHP have a national-level
discussion or working group across partners to make decisions
on context adaptation.

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.
ADRA staff supported the health centre team, who gained goodknowledge on implementing the Care Pathway. Refresher
training was needed (one training was received), when the
resources/tools were updated (see above). Many challenges wereexperienced in implementing the MAMI Care Pathway. At thestart, when it was new, there was little interest but now those
who have not directly implemented it are more interested in
MAMI and have started to inquire and ask questions about it;e.g., MOPHP and implementing partners.

‘Learning by doing’ case study series: Yemen

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

Mothers (caregivers) had traditional ideas on infants’ health,feeding and care practices that prevented them coming to
the health centre. MAMI brought new learning for mothers:
introduced changes in behaviours (e.g., use of cow milk, faltering
nutritional status of mothers due to repeated pregnancies),
provided support for identified problems, made linkages
between existing programmes, and gave more attention to theinfant, which was encouraging for mothers. Mothers said thatthey feel that there is now someone who is concerned about
them and their infant, and that care is well organised, without
them having to go to another health centre. Mothers asked
more questions, building their own confidence in care for theirinfant.

4c. By offering MAMI, areother lay care givers in themother’s network affected (e.g.,family members, volunteers,
community members), andare there new requirements or
expectations for them? Is thewider network requested to be
involved?

Mothers with infants enrolled tended to bring other mothers,
which created an increased interest in the MAMI Care Pathway;
this indicated more awareness since MAMI was put in place.

Domain 5:
The organisation
5a. Did the organisational setup
have the capacity to innovate,change, adapt ways of working,and have the resources fordoing so?

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).
ADRA Yemen started the MAMI Care Pathway approach as apilot and will further expand. ADRA leadership embraced the
expansion, asking for coaching support from MOPHP, andadvocated for others to join in the new project. MOPHP, which
was reluctant at the start, saw that the approach provided lesscomplicated support to earlier detected problem cases, andaccepted it.

5b. Was the organisational
Under ADRA’s leadership and guidance, building on theirsetup ready to innovate, change experience, and by engaging MOPHP, this would be possible.
and adapt ways of working, wasit open to doing so, and did it
have the resources to do so?
5c. How easy will the adoption
and funding decision for
the MAMI Care Pathway be(resources, cost savings, newinfrastructure to be managedby MOPHP, NGOs or donorlead)?

Resource inputs to strengthen capacities felt more like doing
what had been missed before. Now it was like waiting for MAMI
to deal with special cases better. The MAMI Care Pathway
approach built upon and profited from simple available
resources to gain knowledge and skills to address the vulnerable
age group.

5d. What changes were neededin MOPHP, NGOs, and healthworker team organisation
to adopt MAMI? Did teaminteractions and team routineschange (new), align or conflict?

MAMI brought changes to the health centre teams, andworkplans were adapted. MOPHP planned to support the ADRA
lead to further support the MAMI Care Pathway approach acrosspartners and health facilities.

‘Learning by doing’ case study series: Yemen

775e. What work is involved in
implementing and improving
the quality, and who will do it?

Domain 6:
The wider context
6a. Are financial and policy
requirements for MAMI inplace for programme rollout?
a) in the past context, b) in the
future context?

Domain 7:
Embedding and adaptation
over time78

The MAMI Care Pathway was a good resource package that, withadaptations made to account for the context, enabled qualitycare. Only improvements in expanding risk factors and tools
for training needed to be added. Many questions about MAMI
implementation evolved from a need to know more details
on the MAMI Care Pathway approach. A common vision andstronger leadership are needed to facilitate MAMI in the context
of emergency programmes.
Explores whether financial and policy requirements are inplace nationally for rollout.
There were no adequate financial and policy requirements inplace for MAMI. While MOPHP was open to adopting the MAMI
Care Pathway approach, engagement with donors needed to
be strengthened to expand interest with more case studies,more outcome studies, more discussions, more donors. It wassuggested to include donors in meetings to share learning. New
programmes on health and nutrition expressed an interest in
adopting MAMI but more evidence on effective implementation
with better adapted tools would be useful.
Explores the feasibility of embedding and adapting the MAMI
Care Pathway approach over time: the feasibility of a) continuing
to adapt and evolve over 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-long term)? Are
you expecting certain barriers?

The MAMI Care Pathway approach was an example of providing
comprehensive care. For example, LBW was a risk indicator that
had been neglected before. Before, there was no coordinatedcare system for this vulnerable population. More assistance fromthe Nutrition Cluster could offer opportunities to close gaps in
the existing programmes (CMAM, IYCF) for vulnerable infants
u6m.

7b. What is the level oforganisational resilience
in regard to detecting andovercoming critical issues orbarriers (barriers related toembedding, handling criticalevents, adapting to unforeseen
eventualities)?

ADRA built momentum among partners for rolling out MAMI.
They were asked to provide support to partner agencies basedon their knowledge and experience of MAMI (e.g., MOPHP and
NGO partners). The need to address care for vulnerable infants
was great and MOPHP was interested in embedding MAMI,
despite the challenges.

‘Learning by doing’ case study series: Yemen

Table Annex 8b. Appraising the potential scalability of the pilot on integrating the MAMI Care Pathway approach in Yemen, 2021–2023, and suggested actions

1.

Steps in the scale-up appraisal – questions

Suggestions for more information or actionneededIs input about the project being soughtfrom a range of stakeholders (e.g., policy-makers, programme managers, providers, NGOs, beneficiaries)?

Yes

MOPHP and national cluster member organisations were solicited for their involvementin the pilot from the start. They were not involved in the pilot’s design.

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

No

Health workers from outside ADRA were not
involved in the design or implementation of
the MAMI pilot.

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

Yes

The desire to involve partners and sharelearning enabled the strengthening of
in-country capacities.

Yes

Policies covered health needs, but a comprehensive approach was lacking in primarycare, with only very ill or severely malnourished infants covered (by IMCI and CMAM).

Yes

The innovation built upon the evidence andmaterials made available through the MAMI
Global Network.

Yes

If national policies were implemented correctly, then this innovation, which builds
upon them, would not require additional
resources. The innovation enabled continuityof care for vulnerable mother–infant pairs.

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 tobe implemented?
Is the innovation consistent with existing national health policies, plans andpriorities?
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, cultural andgender 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 design ofthe 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 sociocultural and geographic settings where it will be scaled-up?

‘Learning by doing’ case study series: Yemen

Yes

Yes

See above.

Expansion to new sites was ongoing, but thesustainability of the approach (beyond NGOled implementation) was not considered.

Yes

The primary care setting limits the ability tocomprehensively address community andsociocultural factors. There was more clarity
and scope about addressing these in thecommunity, but a limit to what they could
realistically do.

Yes

Norms and values dictated what was feasible, and built upon existing services, because
the facilities were already being supported
by ADRA.

No

There was a desire and efforts were made to‘knock on the door’, but there is no traction
yet. Design and implementation was led by
ADRA, not driven by national-level policies.

No

No

The package was contextualised but only
minor changes were made or added.
Expansion was agency-driven, and site selection depended on where ADRA was active.
ADRA has been in Yemen for many years
and knew the context well.
79

Is the innovation being tested in thetype of service delivery points and institutional settings in which it will bescaled-up?
7. Does the innovation tested require human and financial resources that canreasonably be expected to be available
during scale-up?
Will the financing of the innovation besustainable?

Yes

No

No

Does the health system currently havethe capacity to implement the innovation? If not, are there plans to test ways
to increase health systems capacity?

No

8. Are appropriate steps being taken to assess and document health outcomes, aswell as the process of implementation?

Yes

9. Is there provision for early and continuous
engagement with donors and technicalpartners to build a broad base of financial
support for scale-up?
10. Are there plans to advocate for changes
in policies, regulations and other healthsystems 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 andinsights from the pilot project during
implementation?
12. Is there a shared understanding among
key stakeholders about the importanceof having adequate evidence related to
the feasibility and outcomes of the innovation prior to scaling up?

80

No

The innovation was tested in health centres
supported by the emergency health and nutrition programme, and other similar healthcentres will be targeted for scale-up.
Implementation depended on emergency
funding.

The innovation was tested as part of a multiyear donor-funded and NGO-implemented
emergency health and nutrition programme
in response to protracted crises that had alimited life.
The agency engaged with MOPHP to takeon the innovation as a routine service buttransfer of learning has only started.
The agency requested external support toimprove on this.
Activities were driven and dependent on
emergency funding, which may change or
end over time.

No

There were no concrete plans but the agency was aware of the need, and had the desire
to engage with UNICEF, WHO and MOPHP.
They said they were “working on it”.

Yes

The implementers reported that there were
gaps in guidance to make implementation
easy, and that a robust learning system was
not yet in place.

Yes

Presentations on implementation andprogress were shared at various occasions
in-country and at the global level, but learning was not systematic.

Yes

The understanding to learn from the implementation process was well taken and plans
were being discussed.

‘Learning by doing’ case study series: Yemen

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