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Expanding 24/7 Maternal Care in Punjab, Pakistan

Hi, I’m Sherry Manzar, Project Director in Pakistan. This is These Three Things from Acasus. The rules are simple: I’m sharing three, and only three, critical things that helped us scale 24/7 Basic Health Units across Punjab. It’s a complex story of the resourcefulness and ingenuity of the government, which we were fortunate to be a part of.

In 2014, Punjab’s public birth facilities essentially closed outside the hours of 8am to 2pm. This lack of access cost lives. In just four years, the government with Acasus support:

Increased the number of fully functional 24/7 Basic Health Units from 77 in 2014 to 1,000 in 2018.
Enabled an additional 350,000 safe births each year, with the total volume surpassing even the UK’s NHS.
Reduced infant mortality by 35 percentage points, with momentum continuing to grow.

Since our support ended, the government added nearly 900 facilities, ensuring 89% of Punjab’s population now lives within 5km of 24/7 care.

Looking back, three things made the difference.

Prioritise what works

Having clinics open round-the-clock sounds obvious in hindsight, but at the start we were caught between two competing ideas. Conventional wisdom favoured investing in community midwives for home deliveries, but there was also an opportunity to expand existing 24/7 labour rooms. Instead of getting stuck in a theoretical debate, we supported the government in testing both.

In the early days we were not sure which model would work, but staying open-minded meant we could bring others along with us, including experts, practitioners, and health workers who all believed in the Chief Minister’s vision for saving mothers’ lives, but disagreed initially on the best way to do it. Within months, the data settled the debate: the facility-based model showed better results and was more scalable for the government.

The Chief Minister pivoted quickly, backing what could deliver safe births fast.

Say difficult things

One of our toughest moments was deciding to tighten the criteria for what counted as a ‘functional’ facility. If a labour room lacked even one essential medicine or staff member, we marked it as a failure. After all, what good was a labour room without a delivery table or a midwife, even if it had the other 19 out of 20 items? The pushback was immediate; some worried about appearances and others feared demoralising the teams. But our champions in the government agreed and helped us stand our ground. They shared our belief that women who need fully functional rooms aren’t in the room to speak for themselves, so we have to. Presenting the uncomfortable, honest truth built trust with political leaders. They backed the stricter standards, shifting the entire system from just ticking boxes to ensuring facilities were genuinely safe.

Build to outlast

It’s tempting to go fast by only working with the Minister, but that’s a fragile and unsustainable strategy. Instead, we built coalitions, spread ownership, and gradually built capacity throughout the entire system. We let public expectations do some of the work for us. As facilities improved, citizens began demanding 24/7 labour rooms in their own neighborhoods, making the service too popular to cut when leadership changed. By the time we stepped back, the system was ready to lead and the momentum never slowed.

In four years, we helped shape a stronger system using a toolkit of proven methods. It involved sparking early wins, accelerating what works, and embedding routines so the system knows how to deliver on its own. These lessons were learned in Punjab, but they’ve since been applied by Acasus to drive progress across Pakistan, including in Sindh and Balochistan, as well as in Afghanistan, Nigeria, and Ethiopia. You can read the full story and dive into the data here.

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AUTHOR

Shaheryar Manzar

ROLE

Project Director, Pakistan

shaheryar.manzar@acasus.com

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Expanding 24/7 Maternal Care in Punjab, Pakistan

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