Planning for Primary Health Care in Nicaragua
JOHN M. DONAHUE
The changes in the Nicaraguan health system introduced after the revolution of July 1979 provide an arena in which to study the process by which a health system is made to conform to a new political environment. To study the process of change in a health system, Firth's distinction between structure and organization is useful ( 1). Structure implies ordered and predictable sets of social relationships which are related as parts to a whole. An example of a structural analysis in the comparative study of national health systems would be that of Roemer ( 2). He identifies five principal types of health systems from free enterprise to socialist. Typological approaches to the cross-national study of health systems rely on a structural-functional model of analysis. They are useful for identifying the points of change in health systems. A "before and after" structural analysis may indicate that change has taken place, but it does not address the process whereby the change took place.
Firth argues that a structural analysis alone cannot interpret social change. He concludes that "analysis of the organizational aspect of social action is the necessary complement to analysis of the structural aspect"( 1, p. 36). Social structure and social organization are reciprocal elements in the study of social change. A health system as a social structure can be described as a set of group relations or of ideal types. As a social organization, a health system comprises the concrete activities of individuals and groups as they pursue specific goals. A processual methodology focuses on the choices of actors within a structure or among various structures in a given field of activity. As a field of activity, a health system might contain several alternative goals among which actors might