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The demographic and epidemiological transition which is under way in most developing countries is leading to very significant changes in the pattern of disease. Where in the early stages of the transition, a few diseases caused the majority of deaths, now the disease pattern is more varied, requiring at least fifteen different health interventions at the primary level. The characteristics of health program clients have also become more varied, as the transition takes place at different rates in different population groups within countries. Some clients now mainly suffer from the chronic diseases which are becoming more common as populations age; some suffer also from the communicable diseases typical of the early stages of the transition. Several of the problems and diseases which are now important have not traditionally been the target of primary health care (PHC) programs. And most of the health interventions which are now required are harder to manage than, say, the immunization programs which have been PHC's main success to date. Growing diversity and growing implementation difficulty together present a major new managerial challenge for PHC programs, but one which is not being systematically analyzed and planned for. One reason the management issues are not being thought through is the absence of an accepted methodology for discussing management approaches in PHC programs. This paper therefore attempts to develop a conceptual framework suited to analyzing an environment of dynamic change. The framework is based on the concepts of "strategic management", in which organizational structures and processes are systematically adapted to changing tasks and environments; and "organizational economics" in which careful analysis is made of the potential managerial costs as well as benefits of organizational change. The paper applies this framework first to the management of primary health care programs provided by governments, and then to the role of the non-government sector in primary care. The paper draws broad conclusions about how the design of PHC programs needs to evolve to meet the changing needs of their clients. If the general approach adopted seems useful, the conceptual framework needs next to be applied to a series of specific country cases to test its validity and refine it, and to adapt the general conclusions to local cultural, administrative, and political conditions.

Publisher: World Bank

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