The National Action Plan for Primary Health Care, a planning document of the Sierra Leonean Ministry of Health for the restructuring of the country's rural health services, is analyzed in its social, economic, and historical context. It appears to be an attempt of the national government to gain control over the highly devolved health care delivery system, but the state has neither the political will nor the power to achieve this goal. The utility of the document is therefore in doubt, which raises two important questions: Whose interests does this plan serve, and at whose cost?; Sierra Leone's National Action Plan on Primary Health Care (PHC) is prototypical of the failure of many national PHC plans. The main providers of health care in Sierra Leone are traditional medical services, allopathic private medical services, government medical services in rural health centers, public health programs in rural areas, and hospitals in urban areas. The national plan integrates most of these institutions and health workers into an administrative pyramid with the Provisional Medical Officer at the top and volunteer village health workers at the base. Also proposed is the designation of a new group of paraprofessional health workers--medical assistants--to supervise rural health centers. The basis of the National Action Plan is to recapture public control of a disorganized health care system by imposing an administrative hierarchy. Although operational and health care functions are decentralized, the power within the health care system remains highly centralized at the provincial level and sources of community power are ignored. Widespread mistrust of Sierra leone's central administration comprises a major obstacle to acceptance of any national plan. This lack of popular support could be overcome if one of Sierra Leone's elites was deeply committed to the PHC plan. However, physicians and nurses already enjoy lucrative private practices and the economic elite is profiting from drug importation and co-ownership of private hospitals. The main support for the PHC plan came from multinational donor agencies, in particular the World Bank. Its major purpose appears to have been to create positive publicity for international development aid and defuse political opposition. As such, the PHC plan is largely an academic exercise that is unlikely to be implemented.
