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Seamless health care solutions to the ‘three delays'


Primary Healthcare Revitalization, Integration and Decentralization (PRIDE) project


Adequate health care is inaccessible to many pregnant women and mothers throughout Pakistan, resulting in high maternal and child death rates. Geographic distance, lack of personal agency, and transportation needs contribute to low rates of health care facility utilization, coupled with limited availability of skilled providers and emergency obstetric facilities. This situation was exacerbated in 2005 when an earthquake damaged nearly 80% of healthcare infrastructure in Pakistan. Large donor investments supported the strengthening of health system infrastructure to address these healthcare needs, however the missing link was demand creation to increase service utilization.


HDI pioneered  innovative demand generation initiatives that leveraged the well-documented ‘three delays’ and elicited local solutions from the target audience members. The delay in seeking care was addressed through an Interactive Voice Response mobile service that advised women on care-seeking. The transportation delay was addressed by an “Uber-style” network of branded cars that provided cashless transactions to bring women who were pregnant or with children under five to a health facility. Development of quality, branded basic health and emergency care centers addressed the delay of low-quality care. This multi-pronged approach to addressing structural as well as social norm constraints fostered service demand and uptake by:

  • Developing a telehealth system that connected women to health care by engaging community health management committee to identify pregnant mothers and women with children under 5 and leveraging household decision-makers:

  • IVR phone menu provided women with health concern options and were directed to appropriate advice from a female doctor advising her through recorded instructions whether or not to seek care. This message could be played for the household decision-maker (husband, mother in-law), providing needed credibility to encourage care seeking behaviors, if the condition warranted.

  • Creating a seamless branded healthcare network for maternal and child health that linked transportation to care to facility-based care:

  • Partnered with a local health management committee to provide transportation vouchers and a branded network of drivers for clients to access care facilities.

  • Identified and branded taxis to accept the vouchers and promoted their services to these targeted groups.

  • Restoring confidence in health systems by ensuring availability of quality services

  • Branded facilities provided reliable treatment services, ensuring that medical professionals were always available to meet with clients.

  • Social franchising and the associated mass media promotion of what the client can expect: skilled provider, available through an appointment with reduced wait time, clean facility, etc.  Creating these expectations through marketing materials not only created demand for quality services but gave providers pride in association with the brand that was promoted as having good quality of care and high standards.


Results show a 300% increase in service utilization once the facilities were branded and marketed. Increase in facility deliveries, reduction in maternal mortality and reduction in child mortality.

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