Reflective Learning from Implementing Care Pathways for Vulnerable Infants and Their Mothers: Case Studies from Pakistan, South Sudan and Yemen.

Many infants are born vulnerable or become vulnerable in the first 6 months of life, putting them at risk of poor growth and development, long-term ill-health, and increased mortality. Many policies and practitioners aim to integrate care across services for at-risk mother infant pairs, but this is challenging in practice given individual, setting, and policy complexities. The MAMI Care Pathway, an integrated care pathway approach, frames and guides implementation of WHO nutrition and health guidelines within health and nutrition systems. Local contextualization is a pre-requisite for evidencing national policy uptake of relevant global recommendations. To gain insight into such contextualization, we undertook three in-depth country case studies to investigate planning, implementation, adoption, and scalability of the approach with practitioners in Pakistan, South Sudan, and Yemen. Our mixed methods using theoretical frameworks explored planning, implementation, normalization, and sustainable scalability of the care pathway. We explored healthcare workers perspectives through in-and cross-country reflective learning discussion. Initiatives were prompted by perceived but unmeasured need. Planning and starting implementation required substantial time and stakeholder consultation. Healthcare workers needed skills to perform existing tasks (reflecting shortfalls in routine care capacity and quality) as well as new ones (e.g. maternal mental health). Shifting from disease-focused to person-centred care required (and did not always get) buy-in from healthcare workers (where it was not embedded in service duties and pay), and from communities and mothers to adopt it (practical and competing priorities). It was possible to be system-supportive and scale-sensitive in emergency contexts. Identified commonalities in implementation realities heighten transferable learning potential. Health system strengthening is needed for impactful scale. A paradigm shift towards person-centred care is needed in policy framing and implementation guidance. Deeper localized case study development is a critical type of evidence to inform policy navigation, development and practice. TEASER KEY MESSAGEReflective learning from adapting, implementing, and normalizing the MAMI Care Pathway in Pakistan, South Sudan, and Yemen health systems highlighted the need for system-supportive, scale-sensitive approaches and financial and technical support to align with national policies and implementation realities. KEY MESSAGESO_LIInfants born vulnerable or becoming vulnerable early in life risk poor growth and development, ill-health, and mortality. Integrated care for at-risk mother-infant pairs is the goal of many policies but is challenging in practice. Case studies in Pakistan, South Sudan, and Yemen investigated the process of adapting, implementing, and normalizing the integrated MAMI Care Pathway approach by putting WHO guidelines on outpatient care of at-risk infants and their mothers into practice to inform feasible, sustainable care. C_LIO_LIThe cases in these diverse contexts demonstrated that system strengthening, and early healthcare provider engagement were crucial for impactful and sustainable scale of the MAMI Care Pathway approach. Identifying commonalities in implementation realities enhance transferable learning. C_LIO_LIEmbedding a sustainable approach in existing health services requires financial and technical support aligning with national health policies, planners, and implementation. Achieving comprehensive care also demands investment in routine service capabilities. C_LIO_LIA paradigm shift toward person-centred care is needed in policy and implementation guidance. Deeper localized case studies are critical evidence to inform policy navigation, development, and practice. C_LI