What actually improves health outcomes and services in the long-run?  One huge way is through community mobilization.  But how can this be carried out successfully?  The PHASE project in Maila and Melchham in Nepal provides a great example.  In 2008, women in Nepal were giving birth in cowsheds and then spending their first month postpartum there with their baby.  This was due to cultural traditions that considered new mothers (and menstruating women) unclean, but considered cows to be holy and clean – so what better place for the new mother to reside?  This is a great example of the tremendous impact culture and beliefs have on health practices.  The two are integrated and can’t be dealt with separately.  Anyhow, cowsheds led to high levels of infection and a very high maternal mortality rate, with the adjusted UN estimate 850/10,000 in 2007. The four PHASE health workers involved the community in their entire process.  First, they went house to house getting to know the community and conducting surveys, and held community meetings and called together the Female Volunteer Health Workers who were trusted members of the community and thus could have a large impact.  Once some of the key issues were identified, such as the cowsheds, much discussion was held among themselves, with the FVHWs, with the community, and looking at how other parts of Nepal had dealt with this issue.  In the end, they decided to give women the incentive of a new set of clothes if they went to a primary care center to give birth and agreed not to live in the cowshed.  This came about after many discussions with the community about alternatives for where the mother spent her first month postpartum, and accepted the variety of options proposed, such a lean-to, or one room in the house.  Now, half of births there are attended by a skilled health worker and almost 100% agree not to live in a cowshed.  This is tremendous change, and it happened from the level of the community, and thus will be sustainable. Imagine is the PHASE health workers had simply gone in without extensively consulting the community and set up a birthing center.  Would it have been successful?  I don’t think so.  Likewise, I think this lesson needs to be applied to so many other projects in many parts of the world.  Using, there is a story behind resistance to change, and this needs to be explored and worked with!  I think this could even be very applicable to the situation with ebola in West Africa right now.  Just as one example, if the initial perception was that white people were bringing in the disease, then how likely is it that people would go to them when they got sick?