More than a third of births in Punjab, Pakistan, are delivered in the absence of a skilled birth attendant (SBA), leading to high maternal and infant mortality. To increase the SBA rate, Punjab is upgrading many primary care facilities to provide 24/7 delivery service. However, a major challenge is ensuring that, once available, these facilities are well used by the communities they serve.

To address this challenge, we looked for positive deviants. A significant breakthrough came with the identification of one district, Sargodha, where facilities averaged 40 monthly deliveries compared to the provincial average of 22.

Field investigations found that Sargodha had implemented a set of management practices that led to rapid improvement in utilization. Outreach camps were held at the newly upgraded facilities to introduce the round-the-clock service to the community. Each facility was required to maintain a monthly ‘Estimated Delivery Date (EDD)’ list of expectant mothers in the facility’s catchment area. The monthly EDD list was used as a target to evaluate facility performance. In addition, the district health manager in Sargodha held a monthly performance meeting with all the facility heads to identify and troubleshoot the low performing facilities.

Sargodha’s practices were codified and distributed to other districts. A central team then worked to ensure prompt and uniform implementation across all districts. Districts significantly behind on utilization were individually mentored on implementation of these practices. This led to an increase in utilization from a monthly district average of 22 to 46 deliveries per facility, 10-months post intervention, reducing the cost of each delivery from USD 59 to 31.

At this utilization level, Punjab’s 700 up-scaled facilities are on track to manage 32,000 monthly deliveries by December 2015, equivalent to the total monthly deliveries in Canada. The rapid transformation shows that identifying the positive deviants and understanding what works, rather than focusing on what does not, may hold the key for successful scale-up of some global health initiatives.