The odds were stacked against us. Yet great progress was made.
When we began work in Punjab, Pakistan in 2014, one in eleven children died before their fifth birthday – far worse than in Punjab, India, where focused efforts were already saving lives. The two Punjabs shared language, culture and geography, but not results.
And yet, within just three years, the situation improved. One of the main drivers of this progress was increasing the number of births taking place in the health system – by around 350,000 more each year – making childbirth much safer for both mothers and their children.
So how did the government get there? And what did we learn?
Start with What Matters Most
The turnaround in Punjab was the result of ruthless prioritisation. We asked: “What was the fastest way to save the most lives?” By focusing relentlessly on safer childbirths as one of three priorities, we avoided the trap of trying to fix everything at once.
Sequencing was equally important. The Punjab government began fixing the basics – staffing, supplies, and power – then extended services 24/7. We helped the government to define ‘functionality’ in very practical terms. A 24/7 facility needed a midwife and security guard present overnight, backup power, steriliser, delivery table, privacy screens, and the essential medicines to manage haemorrhage. If even one item was missing, the site was flagged as failing and district leaders were held accountable until gaps were fixed. This swiftly raised the standards of care.
Once those foundations were reliable, the government moved on to strengthen referral mechanisms, and finally introduced innovations like digital dashboards and established ambulance services to create momentum.
Make Facilities Work 24/7
Keeping primary health units open around the clock was one of the most significant changes. Trust was a major issue – women were avoiding going to a government clinic in favour of delivering at home with a traditional birth attendant. The breakthrough came after district managers and facility healthcare workers improved the look and feel of facilities (clean rooms, privacy and basic comfort). This was not cosmetic – it was essential for trust. When women saw that services were reliable and respectful, word quickly spread.
Soon, tens of thousands of women each month delivered in facilities, instead of at home. Making sure midwives were available day and night, saved countless lives.
Link Communities to the System
Safe delivery begins long before labour. The Punjab government expanded antenatal care by ensuring every pregnant woman was screened, received supplements, and was linked to her nearest 24/7 facility. This allowed risks to be detected early and facilities to prepare for each birth.
Punjab had an extraordinary resource: over 45,000 lady health workers across villages. They weren’t midwives, but they knew every pregnant woman in their community. By connecting them directly to the 24/7 birthing facilities, we created a reliable referral chain. Each month, these workers brought lists of pregnant women to their nearest facility, becoming the glue linking communities and healthcare facilities together.
Trust Government Leadership
The most critical decision we made was to trust government leadership. This wasn’t our reform – it was theirs. This required backing the government’s ideas – even when their success wasn’t guaranteed. For instance, when the Secretary of Health proposed outsourcing management of the maternal ambulance fleet, many donors and partners were initially skeptical and thought it was beyond the capacity of the government. Yet the decision to trust this vision and jointly work to make it a success proved transformational.
Today, that service transfers over 27,000 patients a month, cutting response times almost in half. Reforms succeed when governments take ownership and partners get behind them.
Use Data to Drive Relentless Improvement
Real-time, ground-level data was central to success. Independent monitors visited facilities, mobile apps tracked progress, and regular “stocktakes” with political leaders ensured accountability.
This regular rhythm of measurement and review created a culture of urgency, surfacing problems early and resolving them quickly – not glamorous, but game-changing.
Keep Political Leaders Engaged
None of this would have been possible without the committed Chief Minister who personally reviewed progress and demanded results, forcing the system to deliver.
Managing that pressure was a careful balancing act. Leaders want quick, tangible results – ambulances on the road, facilities open, immunisation rates rising. Early wins were essential to build confidence, yet deeper reforms take time. We learned to sequence: first fix the basics, then extend 24/7 services, strengthen referral and data systems, and only then innovate. By layering reform, progress was sustained without losing focus or depth – turning political pressure into lasting improvements.
Reforms often stall because health systems are mired in bureaucracy. By making health a top priority, Punjab turned the situation around.
Key Learnings
Punjab’s success resulted from:
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Prioritising ruthlessly – focusing on interventions that save the most lives.
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Fixing the basics – 24/7 services, reliable medicines, working referral mechanisms.
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Building feedback loops – harnessing data, creating community links, and political stocktakes that keep the pressure on.
Through smartly sequenced reforms and sustained political will, Punjab turned small wins into dramatic progress.
Punjab’s story proves that meaningful change is possible – fast. The barriers are real, but not insurmountable. With focus, clarity, and strong government leadership, even fragile health systems can save countless lives.
