Pakistan has been facing many challenges, both at national and international levels, since long. These include poor governance, the poor performance of the economy, the fragile relationship between state and society, the poor service delivery in education, health and urban amenities among many others. Intensity and complexity of these challenges have increased manifold over time but our approach to cope with these challenges has remained the same. As a result, our governance has become incompatible with modern times. Many reasons are cited for this deterioration in governance. Some of the most often cited reasons are excessive political interference and erosion of both capacity and integrity of civil bureaucracy over time. Whether these arguments hold merit or not has not been tested. Besides many other factors, one main factor is that bureaucracy trained to deal with challenges of late1960s and 1970s has limited capacity to deal with various issues of our time no matter how dedicated or committed they are. Lack of capacity of bureaucracy to deal with multiple challenges has resulted in a slowdown in decision making which cost dearly to the institutions/society. As a result, a vicious cycle of problems has set in, which has made it difficult, if not impossible, to come out of it. Things get worse and chaotic situation to arise and protests take place. If one looks into governance, rule of law and eradication of corruption indicators from World Bank Development indicators database over the past 2 decades, there seems hardly any improvement. Our institutions are suffering from multiple problems so any single recipe or solution in isolation can’t fix the problem. There is a need for a clinical approach to deal with the problems our institutions are facing. Poor health of an organisation is like a patient who is suffering from multiple diseases. For such patients, decisions by medical specialists are made in consultation with other fellow specialists to decide whether to go for surgery first or control sugar and then go for surgery. Or first to deal with very low creatinine value due to kidney malfunctioning, control sugar and then go for surgery and then inject blood to maintain hp level above nine. A single specialist doctor usually finds it very difficult to find the order of priority of treatment for such patients, practice is to refer such cases to a board meeting (a group of medical specialists) and discuss all such cases at length and reach a decision. Medical doctors reach a conclusion not only based on their opinions but also look into medical record/history (data of patients). This networking of doctors and fact-based approach is not only beneficial for the patient but also these doctors learn from each other and share all aspects with their young colleagues after leaving the board room. This networking is helpful both for patient and doctors. They not only change their decisions depending upon patient conditions but think differently in case problem aggravates. Any delay or wrong diagnostic cost the patient very dearly both in terms of health and money. Poor health of an organisation is like a patient who is suffering from multiple diseases Such practice is either missing in our governance structure or if it is adopted, there is no mechanism in place that the problem is taken seriously. Recent rains in Karachi city are an ideal case where each department was simply putting the responsibility on the other department. Moreover, decisions about critical issues are based on the just experience of individuals and fact-based decision making finds very little space for a particular problem under consideration. Gut instincts without hard-core evidence can hardly be helpful given the complexity of the issues the country is facing. There is a need to promote the culture of evidence-based solutions besides strengthening the networking of experts in the field. Due to lack of coordination among institutions and practice of decision making based on anecdotal evidence instead of facts, ill-conceived/ad-hoc/poor decision-making has now become a norm. This has resulted in further aggravation of the problems. Decision making is in silos without having coordination and learning from each other’s’ experience. Instead of having well-though diagnostic in consultation with other(s), institutions/authorities get engaged in the blame game and transfer some of the officers in the hope to get problems fixed by having a new officer. Blame instinct does not need any evidence. In blame instinct, we find a simple, clear reason for the problem which occurred and as a result, we stop thinking about the issue in depth. There is a need to rethink our governance issues in clinical ways so that issues can be prioritised and resolved accordingly. Quality governance is key to service delivery and common masses now not only demand delivery of various services, which were non-existent in the 20th century, but also concerned about the quality of the service. Without improving governance quality and intra and inter-department harmony, it is not possible for the government to fulfil its commitments it has promised. There is a need to have a constructive dialogue by engaging all the stakeholders on how to improve governance structure having the capacity to lead the country in the 2020s. It should not be a one-off event, but it should be considered as a continuous learning process. To progress and develop, there is not only a need for strong and creative bureaucracy but also need to construct a balance between state and society. There is a general perception that the state has tried to dominate the society during the last seven decades. The state must learn how to live in harmony with society. Without the support of society, it is difficult for the state to deal with issues it is facing. The writer is a faculty member of Quaid-i-Azam University, Islamabad