Global Policies: Local Inequities The case maternal health services in rural Pakistan

The recent past has witnessed great interest in global maternal health. The Safe Motherhood initiative, the Cairo conference and Millennium Development Goals all played a key role in drawing policy attention to a historically invisible problem. Consequently maternal mortality rates have declined in many countries, but many have a long ways to go. A number of reasons exist for these countries’ failure to achieve their goals, but a common feature amongst them is role of distal global players in their maternal health policies. A key, yet unspoken policy thrust of these policymakers is a focus on privatization of maternal health service delivery. This presentation will draw attention to ways in which these global policies interact in unintended ways with local values and structures to further exclude poor, socially marginalised women from maternal health services.

A 10-month village ethnography in Punjab Pakistan showed patterns of maternal healthcare use were complex and were linked not only to material resources but also to the apparent social status associated with particular consumption patterns. The highest social group primarily used free public sector services; their social position ensuring receipt of acceptable care. The richer members of the middle social group used a local private midwife and actively constructed this behaviour as a symbol of wealth and status. Poorer members of this group felt pressure to use the aforementioned midwife despite the associated financial burden. The lowest social group lacked financial resources to use private sector services and opted instead to avoid use altogether and, in cases of complications, used public services. Han, Nunes, and Dreze’s (2010) model of status consumption offers insight into these unexpected usage patterns. Privatization of healthcare within highly hierarchical societies may be susceptible to status consumption, resulting in unforeseen patterns of use and persistent inequities. To date these influences have not been widely recognised, but they deserve greater scrutiny by researchers and policy-makers given the persistence of the private sector.