Nigeria: What Punjab Taught Zamfara About Safer Childbirth

A health facility may have a midwife, a labour ward and a woman ready to give birth – and still not be able to save her life.

Nigeria continues to face a severe maternal and child health crisis, with maternal mortality remaining among the highest in the world. According to the 2025 Nigeria Health Statistics report by the Federal Ministry of Health and Social Welfare, a total of 20,811 maternal, neonatal and under-five deaths were recorded between January and September 2025.

The crisis is part of a wider African challenge.

The World Health Organisation estimates that around 260,000 women died from causes linked to pregnancy and childbirth worldwide in 2023, with sub-Saharan Africa accounting for about 70% of those deaths. Research has estimated that Nigeria alone accounts for nearly 28.3% of global maternal deaths, while its maternal mortality ratio stands at about 1,047 deaths per 100,000 live births.

In Zamfara State in northwestern Nigeria, the problem is particularly stark. Skilled birth attendants were present at health facilities, but many lacked the equipment, medicines, and functional infrastructure needed to deal with life-threatening complications. Confronted with high rates of maternal and infant mortality, Zamfara State embarked on an ambitious health reform to strengthen its frontline primary healthcare centres.

Dr Nafisa Mohammed-Maradan, Zamfara’s Commissioner for Health and a maternal health specialist, said the state inherited what she described as a “very dysfunctional health system.”

“We have skilled birth attendants present at our facilities,” she said, “but they are unable to manage life-threatening complications,” not because of a lack of training, but because of dilapidated buildings, missing equipment, and a chronic shortage of essential medicines.

As the state’s Commissioner for Health and a maternal health specialist herself, Mohammed-Maradan described the weight of “the sad reality of Zamfara State” as “very worrisome to me, especially being a woman and a health leader in my state.”

“We realized that we needed to act fast,” she said.

“But the big question remained: where do we start from?”

Faced with the scale of the problem, the state did not begin by drawing up a new budget or building more facilities. Instead, it first set out to establish what was actually happening on the ground. The State Ministry of Health partnered with the World Health Organization and Acasus to launch an independent assessment of primary healthcare facilities, using Nigeria’s National Minimum Service Package as a guide. The goal, Mohammed-Maradan said, was to get honest baseline data and “know the true situation” on the ground.

“The result we saw was shocking,” she said.

What they found included a labor ward so degraded it made clear, as she put it, “we cannot continue like this.” The findings prompted the ministry to bring stakeholders together to mobilise resources and begin renovating and equipping facilities.

The assessment was followed by an effort to turn existing political commitment into action. Mohammed-Maradan said Dr. Dauda Lawal, Zamfara’s governor, had already declared a state of emergency in the health sector and made health one of the priorities in his six-point agenda.

She used that political momentum to bring together government officials, development partners and funders, including the Gates Foundation and Acasus, to agree on a roadmap for reform.

The state subsequently launched its Safe Delivery Initiative, focused on standardising delivery rooms. It also strengthened the state drug management agency and reactivated its sustainable drug supply system, which Mohammed-Maradan said led to a “drastic improvement” in the availability of essential medicines at health facilities.

The Zamfara Government has set up 23 safe delivery centers to improve maternal and child healthcare in 2025. The initiative aims to reduce maternal and infant mortality, provide quality healthcare services, and ensure safe childbirth across the state.

Transparency as a trust-building tool

Mohammed-Maradan described routine, real-time reviews of facility data as central to keeping the reform honest and moving. In one case, data from the assessment revealed equipment shortages at facilities in a local government area. She contacted the local government chairman, who subsequently procured and distributed the equipment.

The payoff wasn’t only operational; it reached frontline morale.

Health workers, she said, now “feel very happy” to come to work and “feel safe to bring their relatives and friends to our facility because they know that they will have the best of care.”

Within less than a year, facility infrastructure scores rose from 26% to 45%, and facility-based deliveries climbed steadily. She described the programme as a personal priority and said she was closely monitoring the indicators as the reforms continued.

Mohammed-Maradan said Zamfara’s biggest obstacle was not a shortage of resources, but fragmented efforts among partners working separately.

“We try to bring all the partners and all the funding in one place,” she said, adding that the approach faced resistance but that she insisted partners align with the state’s policy.

For Zamfara, she said, the starting point was ultimately simple: understand the problem before deciding how to solve it.

“We started with the problem,” she said, followed by leveraging political will and building transparency and trust.

Echoes From Pakistan

Zamfara’s experience points to a broader question facing health systems across Africa: when facilities exist but are not functioning properly, where should reform begin? Experiences from Pakistan offer some answers, but also show why successful reforms cannot simply be copied from one setting to another.

In Punjab, Ali Jan Khan, former Secretary of the Primary and Secondary Healthcare Department, recalled inheriting a system in which basic health facilities were operating limited hours. Many lacked doctors, essential medicines, electricity and basic equipment.

When he was posted to the province in 2015 – home to roughly 130 million people, comparable to the world’s 13th largest country – 42% of primary facilities had no doctor posted at all, and at another 21% where doctors were on the books, “with certainty we can say he was not used to visiting the health facility.”

At roughly two-thirds of facilities, he said, “a doctor never examined a patient.” Medicine, he said, “was just a luxury,” and even basic equipment like a stethoscope was often privately owned, “provided by the doctors themselves.”

The turnaround began with a structural decision: then-Chief Minister Shahbaz Sharif, now Pakistan’s Prime Minister, split the health department to give primary and secondary care their own dedicated leadership, a move Dr. Khan said “everybody resisted” at the time. It put primary healthcare “toward the center of things” for the first time, with the Chief Minister personally chairing regular stocktake reviews.

His approach centered on independent, facility-level monitoring and relentless performance reviews. Around 200 monitors visited every primary facility at least monthly, feeding data up through a “cascade model” of district-level accountability. “If people know they are being watched and asked,” he said, “15% to 20% of service delivery improvement happens simply through discipline, accountability, and reliable data.”

Crucially, the reform introduced round-the-clock emergency obstetric care at facilities that had previously closed by early afternoon, “everybody thought Basic Health Units (BHUs) were just basic primary healthcare open until afternoon,” he said.

“Labor is a natural process taking place at any odd time.” Conversion happened in stages, and today around 1,800 of Punjab’s 2,500 basic health units operate as 24/7 facilities. The province also introduced low-cost rural ambulances, priced at no more than $10,000 each, to cut delays in getting mothers to care.

The results followed: electricity availability rose from 64% to 99%, medicine availability from 72% to 99%, and skilled birth attendance climbed from 61% to 86% – gains achieved, Dr. Khan said, “without massive new capital investment,” through fixing supply chains and management discipline rather than a major injection of funding.

The experience in neighbouring Sindh showed why such reforms cannot simply be copied from one setting to another.

Acasus project director Sherry Manzar cautioned against simply copying that model. Having served on Dr. Ali Jan’s own team in Punjab in 2016–2017, he recalled arriving in Sindh around 2021–2022 to find baseline conditions that “practically mirrored Punjab’s initial state.” But Sindh’s population was roughly a third of Punjab’s, and its resources were far more constrained “in Sindh, resources were a real constraint we had to contend with,” he said, raising the question of how to match Punjab’s pace of progress with less money to work with.

The province found its champion in Health Minister Dr. Azra Pechuho, who set an unambiguous mandate: “My priority number one is MNCH, number two is MNCH, number three is MNCH.” Her instruction to the team was practical rather than ideological. She wanted to know “what’s missing where, and whether staff we pay for are showing up,” frustrated that routine data systems arrived 45 days late.

Sindh adapted, rather than copied, Punjab’s monitoring model. The team calculated that Sindh’s smaller footprint meant just 0.05% of the health budget could fund an independent monitoring system, Manzar said, to give “full visibility over the entire health budget,” since staff salaries are typically the largest line item and random-sample data on attendance could maximize the value of money already being spent.

“We learned in Punjab that resources aren’t the only constraint,” he said. “But in Sindh, resources were a real constraint we had to contend with.”

Unlike Punjab, where monitoring began as a donor-supported unit before being absorbed into government, Sindh funded it domestically from day one, with the Minister personally approving every indicator to keep the system tightly focused on maternal and newborn priorities.

That discipline held even through crisis.

In 2022, two-thirds of Sindh was submerged for months in catastrophic flooding. But Dr. Azra “didn’t miss a single monthly stocktake meeting” at the peak of the disaster. When a district manager argued the floods made reform impossible, her response became one of the defining lines of the reform: “Mothers are not stopping giving birth just because there is a flood. We still need to fix facilities and work harder now.”

The results were significant: population access to 24/7 labor rooms within 5 kilometers grew from 17% to over two-thirds of Sindh’s population in three years, and by 2024 more than 400,000 women were delivering annually in public facilities, nearly half of all births in the province, up from just 20% in 2018.

Quality of care is the missing piece

Dr Farhana Zareef said that the reforms in Zamfara, Punjab and Sindh demonstrate that there is no single formula for improving maternal healthcare. What matters is adapting solutions to the realities on the ground.

“We know what the problems are. We know what the solutions are,” she said. ‘But until and unless the solution is context-specific, things will not work.”

She also cautioned that functional facilities, medicines and health workers are not enough on their own. The quality of care and the ability to recognise complications and refer women quickly are critical.

“If the skilled provider sitting at that primary healthcare facility is not skilled enough to recognize what he or she can treat and what requires an immediate referral,” she said, delays can put the lives of mothers and children at risk. Timely referral saves more lives in the context of maternal mortality, she added, calling for referral systems that work in real time.

The question of financing remains, particularly for health systems operating under tight budgets.

Maria Antonieta Alva, former Minister of Economy and Finance of Peru, laid out four things she’d want to see before approving funding for maternal health.

“First, the language has to shift from inputs to outcomes,” she said. Rather than focusing on how many supplies or vehicles would be purchased, she said health leaders should show how many maternal deaths could be prevented and how many healthy births could be enabled. “Don’t tell me how many items you’ll buy, but tell me how many maternal deaths you’ll prevent.”

Second, she wants clear evidence the intervention works in comparable contexts. Third, proof that funding – not implementation or logistics – is the actual bottleneck. And fourth, a credible framework showing how results will be measured and how quickly.

Pilot data, she said, changes the entire conversation: it turns a request from “funding a hypothesis” into funding something that scales a proven result. She adviced health leaders to stop talking to finance ministries about “funding supplies or inputs, and start talking about funding results.”

Fenton Whelan, founder and chair of Acasus, said that one of the broader lessons from the three cases is that resources matter, but they are not the only determinant of whether health systems improve.

“The cost of not investing in the system or not investing in data is greater than the cost of doing it,” he said.

He also pointed to the intensity of leadership required to turn reforms into results, arguing that these were not changes achieved simply by signing a policy document. They required sustained attention and follow-through over weeks and months.

“The transferable thing here is both the belief in what can be possible, but also the learning that you need to have that intensity to really be willing to follow through,” Whelan said.

For Zamfara, the work is still underway.

“Whenever faced with a challenge, do not rush to make a budget. Know the problem first.”

Muhammad-Maradun gave a striking warning against reflexively throwing money at deep-seated structural issues.

“Whenever faced with a challenge, do not rush to make a budget. Know the problem first. Know the extent of the damage first. And I believe with persistence and determination, anything is possible,” she said.