An old cliché says that "all politics is local" - that people's votes are driven more by the quality of local services like garbage collection than by debates on big national issues. That phrase can also be applied to health, since poor health and illness are experienced in the course of daily life: a child lies sick, a pregnant woman needs care, a man is injured on the job, a young couple wants to learn about family planning. Health systems must offer care where people live. Failures may be caused by global or national forces, but the impact is profoundly local. Change, when it comes, occurs in individual lives, families and villages.
This doesn't mean that global and national politics - and health-care policy - are not important. As we in the global health community well know, they are. Policy matters a great deal, which is why so many of us put so much time and effort into our advocacy work. We know that UN, G8 and parliamentary resolutions express commitments to which governments can and must be held; that aid budgets are expressions (or, all too often, fail to be adequate expressions) of those commitments; that fiscal appropriations can represent concrete investments in saving lives. We know that national laws and health policies have profound impacts on the quality of people's lives, on their ability to exercise and enjoy their human rights, on their safety, security, health, survival.
But real success in ending the numerous health catastrophes that challenge developing countries will require us to walk the dusty village roads as well as the marble halls of power. We must "think globally, act locally," to borrow a phrase from the environmental movement.
To defeat the age-old scourge of maternal death - which is the focus of Family Care International's work - we need to seek solutions at both levels. Thinking globally, we and our colleagues argue, cajole and demand that national and international leaders use their power to save women's lives. This is some of our most important and effective work, and it will continue until women are no longer needlessly dying in pregnancy and childbirth.
But years of work in the villages of Africa and Latin America have taught us that, while crucial, policy alone will not solve the problem. Yes, too much of the developing world (and particularly Africa) faces fundamental gaps - not enough skilled health workers, clinics that are falling apart, commodities systems that cannot get even basic drugs and equipment to where they need to go. Yes, the remaining - and glaring - gaps are largely a result of too little money. Yes, it is urgently important to build health systems that can provide skilled care, emergency treatment, postpartum care, reproductive health services, and family planning for every woman everywhere.
But clean, accessible, professionally-staffed health centers can only save the lives of women who use them. Real solutions require a focus not only on supply, but on demand as well. And in many villages, in many countries, social and cultural barriers - traditional health practices, gender inequities, taboos and other beliefs, insensitive medical practices - keep women away from clinics. After all, women have always died from complications of pregnancy, unsafe abortion and childbirth: women and their communities need to see that these deaths are preventable. Communities - and the respected, influential local leaders who can be such powerful agents of change at the grassroots level - need the education and empowerment to take ownership of their local health services, to demand and create accountability (through structures like facility management committees), and to help change the social and cultural norms that stand between women and the skilled care that they need.
Strategies for engaging communities are strikingly missing from global discussions on effective maternal health interventions, and from national road maps for reducing maternal deaths. When they are mentioned, communities are generally envisioned as targets for behavior change information, but rarely as active partners in effort to improve the availability, quality, and utilization of the health services that can prevent women from dying. Building communities' capacity to overcome barriers to care - persuading women to use, and empowering them to demand, the care that can save their lives - will begin to unlock the demand side of the maternal health equation.
In a world in which all health care is local, communities are the missing partner in efforts to end maternal mortality.
Originally posted at Global Health Blogs.