The primary health center as a social system: PHC, social status, and the issue of team-work in South Asia

doi:10.1016/0277-9536(86)90077-8

Social Science & Medicine

Volume 23, Issue 4, 1986, Pages 347-355

https://doi.org/10.1016/0277-9536(86)90077-8 Get rights and content

Abstract

Primary health care ideology is considered from the vantage point of health center field staff in South India and Sri Lanka. It is argued that professional and organizational role conflicts are fostered by primary health care inspired programs introduced without regard to the status and motivations of existing cadres of staff. Attention is focused on the health center as a social system and the need for social systems analysis as a preliminary step in planning for team-work at the health center-community level. Inasmuch as team-work is the cornerstone of PHC implementation, more thought need be given to staff response to potential programs.

References (33)

W. Goode
Community within a community: The professions
Am. Sociol. Rev.
(1957)
M. Segall
The Politics of Primary Health Care
M. Skeet
Community health workers: Promoters or inhibitors of primary health care?
Wld Hlth Forum
(1984)
W. Zacher
Discussion: Health centres must be strengthened first
Wld Hlth Forum
(1984)
H. Heggenhaugen
Will primary health care efforts be allowed to succeed?
Soc. Sci. Med.
(1984)
O. Gish
The political economy of primary health care and health by the people: A historical exploration
Soc. Sci. Med.
(1979)
Z. Chowdhury
The good health worker will inevitably become a political figure
Wld Hlth Forum
(1981)
R. Stark
Lay workers in primary health care: Victims in the process of social transformation
Soc. Sci. Med.
(1985)
D. Pyle
From projects to program: The scaling up/implementation process of community-level, integrated health, nutrition, population intervention in Maharasthra
(1981)
C. Taylor
Reorientation of health personnel to meet the people's needs
C. Taylor
Health systems research: How can it be used?
Wld Hlth Forum
(1984)
D. Pyle
From projects to program: The scaling up/implementation process of community-level, integrated health, nutrition, population intervention in Maharasthra
(1981)
D. Rueschemeyer
Doctors and lawyers: A comment on the theory of profession
W. Goode
Encroachement, charlatanism and the emerging professions: Psychology, sociology and medicine
Am. Sociol. Rev.
(1960)
R. Bucher et al.
Professions in process
Am. J. Sociol.
(1960)

D. Banerji

Health Behavior of Rural Populations: Impact of Rural Health Services—A Preliminary Communication

M.B. Parlato et al.

An analysis of 52 AID-assisted primary health care projects

APHA

(April 1982)

M. Nichter

Patterns of curative resort and their significance for health planning in South Asia

Med. Anthrop.

(1978)

M. Nichter

Paying for what ails you: Sociocultural issues influencing the ways and means of therapy payment in South India

Soc. Sci. Med.

(1983)

B. Kinosian et al.

Report submitted to the Professional Studies Program

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The primary health center as a social system: PHC, social status, and the issue of team-work in South Asia

Abstract

Am. Sociol. Rev.

The Politics of Primary Health Care

Community health workers: Promoters or inhibitors of primary health care?

Wld Hlth Forum

Discussion: Health centres must be strengthened first

Wld Hlth Forum

Will primary health care efforts be allowed to succeed?

Soc. Sci. Med.

The political economy of primary health care and health by the people: A historical exploration

Soc. Sci. Med.

The good health worker will inevitably become a political figure

Wld Hlth Forum

Lay workers in primary health care: Victims in the process of social transformation

Soc. Sci. Med.

From projects to program: The scaling up/implementation process of community-level, integrated health, nutrition, population intervention in Maharasthra

Reorientation of health personnel to meet the people's needs

Health systems research: How can it be used?

Wld Hlth Forum

From projects to program: The scaling up/implementation process of community-level, integrated health, nutrition, population intervention in Maharasthra

Doctors and lawyers: A comment on the theory of profession

Encroachement, charlatanism and the emerging professions: Psychology, sociology and medicine

Am. Sociol. Rev.

Professions in process

Am. J. Sociol.

Health Behavior of Rural Populations: Impact of Rural Health Services—A Preliminary Communication

An analysis of 52 AID-assisted primary health care projects

APHA

Patterns of curative resort and their significance for health planning in South Asia

Med. Anthrop.

Paying for what ails you: Sociocultural issues influencing the ways and means of therapy payment in South India

Soc. Sci. Med.

Report submitted to the Professional Studies Program