Health reform is a complicated process which usuallyincludes simultaneous decentralization of the health system, a transition from vertical to integrated programs, an emphasis on six health thrusts, and the creation of public/private and community partnerships. With so many things going on at the same time, one is sometimes left with an impression that the health reform process is more chaotic than systematic.

In this context, a conceptual framework may be helpful to maintain the overall vision of a developing integrated health system. One possible framework which has been adapted from a 1987 WHO technical report to reflect country-specific terminology. This framework consists of a 3-dimensional cube which includes a matrix of program interventions and support components at various system levels. Examples of this framework are shown for the countries of Haiti and Zambia.

The first dimension is that of the package of PHC services or interventions. This may include the eight essential elements of primary health care as outlined at Alma Ata in 1978. These are Immunization; Maternal and Child Health and Family Planning; Nutrition and Supplemental Feeding; Curative Care; Essential Medicines; Water and Sanitation; Endemic Disease Control; and Health Education. Many variations and "minimum packages of care" are possible. For example, Zambia has developed them as six program thrusts - safe motherhood, child health, malaria, tuberculosis, HIV/STD and water/sanitation.

The second dimension is that of the system support components required to facilitate and support the delivery of the PHC interventions. Typically these systems include such things as planning and management; information systems; logistic and supply lines, infrastructure and equipment; training and continuing education, financing and user fee systems; community participation and partnerships, Iinformation, Education and Communications (IEC), and Operations Research.

The third dimension recognizes that the above support systems are required, to some degree, at each level of the health system , i.e., household; community; health center; district; region and central level. Within each level, the integration of PHC services and the integration of support components needs to occur. The degree of integration will, however, vary with the system level, e.g. full integration of services and support components at the health center level by a few multipurpose health workers. There are often differing views about whether health system reform should be a top-down, bottom-up or middle-out process. In general, experience has shown that there is no one best approach, and that each country must find its own mix of development strategies. In this case, the integrated health system framework may be useful to help people visualize that health reforms will result in a cohesive integrated system while simultaneously working at various levels of the health system, e.g., community level partnerships, district level strengthening of DHMTs and national level development of a health information system.