Lahore, Pakistan ? U.S. aid could have transformed Pakistan’s largest maternity hospital, where rats run through the halls, patients sleep three to a bed, women who require C-sections aren’t getting them because only one operating room is functioning, and premature babies risk death because of a shortage of incubators.

But the government of Pakistan’s most populous province, Punjab, turned down an American offer of $127 million for health care, education and municipal services following the U.S. raid that killed Osama bin Laden. Sixteen million dollars was earmarked for Lady Willingdon Hospital in the provincial capital of Lahore.

The government’s decision was thought to be an attempt to win votes by capitalizing on pervasive anti-American sentiment in a province with a significantly larger population than France and a bigger land area than Greece. Pakistan’s federal government and other provinces did not follow suit, but they may also find themselves with less U.S. assistance soon.

Pressure is growing in the U.S. Congress to reduce the billions of dollars in annual military and civilian aid because of the government’s alleged ties to Islamist militants. The money has failed to persuade Pakistan to target militants using its territory to attack U.S. troops in Afghanistan.

The experience in Punjab shows that the impact of an aid cut in this poverty-stricken country would be felt most acutely by the poorest citizens, not the army generals allegedly gambling with militant proxies in Afghanistan or wealthy politicians hoping to win votes with their anti-American gestures.

Pakistan’s elite does benefit from U.S. assistance, either through lucrative contracts for NGOs or by allegedly skimming off money funneled through the government. The loss of these funds may crimp their lifestyle, but it is unlikely to affect whether their families get adequate medical treatment or their children a decent education.

Like many government-run hospitals in Pakistan, Lady Willingdon struggles to provide even basic care. The hospital, built by the British in the 1930s before Pakistan’s independence, was meant to house 80 patients. The country’s population has since boomed, forcing officials to cram 235 patients into a facility that is now rundown. Paint peels off the concrete walls and black mold covers the ceilings.

Patients are forced to share beds, and sometimes women who are close to giving birth have to sit on the floor for lack of space, said nurse Kaneez Akhtar.