When we began working with the Government of Sindh on maternal and newborn health, the challenges were daunting – overstretched facilities, unreliable data, and women giving birth without skilled birth attendants.
What struck me most wasn’t the scale of the problem in a province of 55 million people, but the urgency to act. Sindh’s leaders wanted results – and fast. That urgency became their greatest strength. It turned bureaucracy into action, and created momentum that saved lives, inspiring change far beyond the province.
The Turning Point: Ambition Meets Accountability
Right from the start, Dr. Azra Pechuho, Sindh’s Minister for Health, set the tone: “We don’t have the luxury of time – women and children are dying now.” She wanted results within weeks, not years.
Rather than cutting corners, her demands forced us to focus on what mattered most. If her ambition was high, the systems supporting it had to be just as strong.
But first, we needed to understand the reality on the ground.
We began by mapping every health facility – not just on paper, but in practice. Was it open? Staffed? Powered? Equipped?
Once the picture became clear, change followed fast. District health officers could finally see which facilities worked, which improved, and which needed more intensive help. That clarity brought accountability and created momentum.
Fixing the Basics, Building Trust
In Sindh, as elsewhere, families judge the health system by what they experience at the facility. If the lights are off, the midwife is absent, or medicines are missing, trust is lost.
So the government worked to fix the basics: staffing, power, water, and medicines. Every Basic Health Unit had to be truly 24/7 – open, functional, and ready to deliver safe, respectful care, day or night. It wasn’t about building new facilities. It was about making existing ones work all of the time.
Not every idea worked. Early models that looked promising – such as training community midwives to set up their own clinics – proved difficult to scale. What mattered was not perfection but pace: the ability to learn fast and pivot toward what saved lives fastest.
Before long, small improvements started rippling outwards. A mother arriving at midnight was greeted by a midwife ready and equipped to help. The midwife had power and equipment that worked. There was a designated female toilet in the labour room. As word spread, women began returning to facilities they had once feared.
Learning Fast, Fixing Forward
Early learning taught us to be humble. Success in Punjab couldn’t simply be transplanted to Sindh. The province’s diversity – in geography, economy, and culture – demanded its own solutions. What worked in relatively well-organised Lahore didn’t always work in the sprawling megacity of Karachi, and could fail entirely in the sparsely populated, arid districts of Tharparkar.
So instead of creating a rigid plan, we made a flexible one. Each district team used local data to identify where to act first. Some increased the numbers of midwives, others re-designed referral systems and organised transport.
Technology changed everything. Real-time dashboards gave provincial leaders a clear view of each district’s needs, turning problems that once took months to uncover into issues resolved within days. The system cost just 0.05% of the health budget, yet provided visibility over the other 99.95%. That visibility built momentum, and with momentum came trust.
Champions of Change
One of the most powerful lessons we learned was that accountability travels faster through relationships than through reports. When a district officer knows that the Minister herself will call to ask why a facility’s power is out, they make change happen.
But it wasn’t just top-down pressure. Empowering local teams and giving them the data, tools, and recognition they needed proved just as vital. Many of Sindh’s most dramatic improvements came not from new money, but from new management approaches.
As one district officer put it, “For the first time, we weren’t just reporting problems – we were solving them.”
Results and Reflections
The results have been striking. In less than two years, the number of 24/7 functional facilities has risen sharply, ambulance response times have fallen, and more women are choosing to deliver in safe, staffed facilities. Maternal and newborn survival rates are improving, too.
Success didn’t come from luck or from single silver-bullet interventions. It came from hundreds of small improvements – the power supply that stayed on, the midwife who showed up, the dashboard that highlighted a gap before it became a crisis. Even in complex, resource-constrained settings, we can make rapid progress when we meet ambition with evidence.
Learnings for Others
Three lessons stand out:
- Start with visibility. You can’t fix what you can’t see. Real-time data is not a luxury – it’s a prerequisite for action.
- Diagnose before scaling. Every district is different. Listen first, adapt fast, and let results guide investment.
- Build momentum through early wins. Visible improvements earn trust and create the energy that sustains reform.
Sindh’s journey is far from over, but it has already redefined what progress can look like.
With committed leadership and a willingness to learn fast, even the toughest problems can be solved – and for every mother who returns home safely with her baby, that leadership has made all the difference.
