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community midwife taking blood pressure

Giving Pakistan the tools to fix its public health system

At the start of this decade, Pakistan faced some of the starkest health and nutrition challenges in the region. In particular, poorer women and children suffered from low penetration of primary and preventative healthcare.

Despite being a middle-income country, Pakistan experienced worrying rates of maternal and under-five mortality, as well as nutritional stunting, with almost half (43.7%) of young children struggling to reach their growth and cognitive potential.

Following devolution in 2013, the provincial departments for health in Pakistan launched their health sector strategies, with ambitious plans to restructure and radically improve the country’s public health system. With funding from UK aid, Mott MacDonald provides technical assistance to the provincial governments of Punjab and Khyber Pakhtunkhwa (KP) in support of their strategies for maternal and child health, and nutrition.


The differences in access to quality healthcare between the poorer and more affluent members of society demonstrated the deep inequality in Pakistan. Just 1% of total GDP was invested in health, leading to chronic shortages of supplies and trained personnel for those communities that couldn’t afford private care.

Pregnant women, in particular, rarely had access to childbirth attendants. Hospitals frequently had no gynaecologists or obstetricians on call, no anaesthetists, no blood supplies, and no form of transportation. Most basic health units (BHUs) closed at night, barring care from women in labour. This led to severe reputational damage, as women believed healthcare centres were insufficiently stocked and that it was a wasted expense to visit them.

In rural villages especially, mothers were often cared for by traditional birth attendants who lacked the skills to cope with most complications – a relatively common occurrence in any setting, but especially given the high number of early marriages in Pakistan.

Poor communities were caught in a vicious cycle of malnutrition. Previously, the health system only recognised hunger in cases of severe wasting, where a child has low weight for height. Practitioners didn’t acknowledge the problem of stunting, where a child does not reach the expected height for his/her age due to various nutritional deficiencies (often starting with the mother’s health pre-conception), because it was so widespread and therefore deemed ‘normal’. Stunted girls are also more at risk of childbirth complications when older.

Culturally, women in Pakistan are often the last to eat in the family. Especially in poorer families, they may eat less protein rich foods, with staples (bread and rice) dominating their diets. Modern diets have become high in oil and calories, but nutritionally empty, leading to the paradox of stunted children but overweight adults. Reports have shown that a nutritious diet with sufficient fruit and vegetables is not affordable for 20% of the population.


There was no tipping point for Pakistan, but rather a realisation by the government that the country’s health system had fallen behind. Comparisons with neighbouring societies such as Afghanistan and the Indian Punjab put the situation in sharp focus.

International convergence around skilled birth attendance as the most positive difference for saving women’s lives and stagnating levels of child morbidity also prompted Pakistan to take action. Globally, nutrition has become a much more widely acknowledged development issue.
As part of a nationwide push to better health and nutrition, with aid from the UK government, Mott MacDonald is managing a programme of technical assistance that supports the provinces of Punjab and KP in their efforts to improve the access and uptake of reproductive, maternal, newborn and child health (RMNCH) and nutrition services.

The TRF+ programme (which builds on the success of the Technical Resource Facility which ran from 2009 to 2015) helps the government at provincial and district level to strengthen its system to deliver quality maternal and child health services, including its financial management systems with a view to mitigating fiduciary risks. Monitoring to ensure better results is another important pillar of the programme.

One of the driving forces behind TRF+ is its use of a roadmap approach to improve targeted areas of the health sector. In Punjab, this special taskforce sits above the health department and reports directly to the Chief Minister, who can then personally monitor targets. In KP, the model is slightly different, with the Provincial Minister of Health overseeing results.

A ‘real-time’ dashboard provides immediate progress reports around stock availability of medicines, whether blood banks are functional, numbers of pregnant women transported by rural ambulance services, as well as cases of absenteeism among staff. The live maps and biometric surveillance are powered by digital technology that allows management to clearly see the glitches in the system and then exert top-down pressure to have them fixed.

On administrative areas such as financial management, our team provides direct support with long-term technical experts who sit in the health departments and provide close assistance over several years. By embedding the right people, we can help make things happen in government much quicker than as an arms-length consultant.

This is a project that has made huge improvements in a short space of time. The departments of health in Punjab and KP deserve a great deal of credit and should be immensely proud of their people’s efforts

Lucy Palmer - Health Specialist, Mott MacDonald


The programme is enjoying real progress. The simplicity of the roadmap approach means the health departments can gauge the results of interventions in black and white terms. Have women in a certain area had 24-hour availability of gynaecological care in the last month: yes or no? Have hospitals suffered stock-outs in the last month: yes or no? Were more women taken to open-all-hours BHUs on the ambulance service this month: yes or no?

Results against the log frame indicators show that standards are improving significantly across all fundamental areas of maternal and child health services such as availability of blood, transport, staff and medicine including contraceptive stocks. The capacity of the health system to treat the population is building. Indications show that the roadmap approach has been institutionalised to some extent within the departments and will continue sustainably when the funding ends.

The activities of lady health workers (LHW), a field force that visit door-to-door, especially in remote rural areas, provides a good indicator of how the situation is turning around. The team carries condoms and contraceptive pills, and they have also started to administer contraceptive injections, as well as everyday drugs such as aspirin, paracetemol and oral rehydration therapy. In the past, they struggled for regular stocks, particularly of contraceptive supplies, but a recent assessment showed that 75% of LHWs had contraceptive supplies for the whole month without a stock out.

Likewise, the provinces are now better equipped to map out services strategically and manage resources so that even the most remote communities have access to healthcare.

The direct financial assistance has helped the departments of health to update their systems and to develop their own budgets moving forward. In particular, this has allowed the KP government to gain a better handle on its liabilities such as pensions. They now have the templates in place to see the full extent of the challenge and ways to tackle it, rather than fear it like a black hole in their finances.

Digital technology has brought quick wins to the provinces. Management can see on their dashboard where workstreams have fallen behind, and what needs to improve. For example, a collaboration with the Punjab Information Technology Board created a mobile phone tracking system, eVaccs, that allows immunisation teams to ensure all children are reached and that they complete their course of injections, while building a real-time centralised database.

We have created four policy briefs that provide insights into some of the learning that came out of the TRF+ work, whilst also considering the future direction of health policy in Pakistan as it aims to move towards universal health coverage and self-reliance. These were funded by Mott MacDonald as part of our wider learning and dissemination after TRF+ finished. Click on the links below to find out more.

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