ABSTRACT
One of the most fundamental issues challenging the implementation and thus viability of the primary health care concept in less developed countries (LDCs) is whether teamwork,
Although many national and international agencies claim to be committed to a participatory approach to helping rural poor, little is known about how to translate ambitious plans into effective action. The record of earlier community development and cooperative efforts is largely a history of failures, resulting more often in strengthening the position of traditional elites than in integrating poorer elements into the national development process. Current calls for involvement of the rural poor in the development process often seem little more than wishful thinking, inadequately informed by past experiences as to the investments in institutional innovation required to give reality to an important idea. (Korten 1979)
Just as the first concern of a bureaucracy is to ensure its survival and to protect itself against inroads from competing organizations, so it is the priority of the professional to protect his or her position within the organization…. Professionals jealously guard traditional prerequisites and privileges and do not willingly surrender something except in exchange for something as good or better. (Foster 1977)
A failure to make primary health care socially relevant by taking into account the existing health care system can render even the most logically conceived strategies virtually impotent or even counter-productive. (Mosley 1983)
an essentially democratic concept, can be operationalized within countries having complex hierarchical social structures.1 Collaborative teamwork between doctors, nurses, midwives, auxiliaries, and volunteers is central to primary health care implementation and outreach (Boerma 1987, Flahault 1976, Schaeffer and Pizurki 1984). While the path of primary health care rhetoric is inspirational, the path of primary health care operationalization is commonly that of the least social and political resistance. The distributional and equity aims inherent in primary health care are often paid lip service while programs implemented in the name of primary health care are accommodated to local power structures and health bureaucracies which are socially, administratively, and politically self-sustaining.2 This results in a glossed continuation of the previous policy in which health service is a commodity delivered by health professionals and their assistants (Segall 1983). The gloss is often a gesture toward greater “community participation” in the form of a community health worker-volunteer program.3 Active participation of community members in planning, implementing, and evaluating health services rarely occurs, as this would entail decentralizing the governmental bureaucracy and the devolution of power (Chowdhury 1981, Gish 1979, Heggenhougen 1984, Skeet 1984, Stark 1985, Zacher 1984). Community health workers are typically incorporated into a health infrastructure, and ultimately made responsible to the health bureaucracy and not to the communities they are to serve. Community representatives are asked to facilitate compliance to predetermined programs (Foster 1982).
