Transformation Management of Primary Health Care Services in Two Selected Local Authorities in Gauteng

The transform ation o f health services in South Africa to­ day is governed by the political, policy and legislative frameworks. This article focuses on the transformation o f a primary health care service w ithin a local authority in Gauteng. The purpose with this article is to explore and describe the perceptions (expectations and fears) o f se­ lected managers em ployed in this prim ary health care serv­ ice. The results are utilised to com pile a strategy (fram e­ work) for transform ation m anagem ent and leadership within the primary health care service. A qualitative re­ search design was utilised and the data was collected by means o f individual interview s w ith selected m anagers in the service, followed by a content analysis. The expec­ tations and fears o f m anagers focus mainly on personnel matters, com munity participation/satisfaction, salaries and parity, inadequate stocks/supplies and m edication, the de­ terioration o f quality service delivery and the need for train­ ing and em pow erm ent. These results are divided into structure, process and outcom e dim ensions and are em ­ bodied in the conceptual fram ew ork for the transform a­ tion and leadership strategy. It is recom m ended that stand­ ards for transform ation m anagem ent be form ulated and that the quality of transform ation m anagem ent be evalu­ ated accordingly. Uittreksel M et die nuwe politieke, beleids-en wetlike raam w erk in S u id-A frik a , is o m v o rm in g /tra n s f o rm a s ie van gesondheidsdienslew ering noodsaaklik. H ierdie artikel fokus op die om vorm ing/transform asie van 'n prim êre gesondheidsdiens in 'n geselekteerde plaaslike ow erheid in G auteng. D ie doel m et die navorsing w as om die persep sies (v erw ag tin g e en vrese) van b estu u rd ers werksaam in hierdie prim êre gesondheidsdienste te verken en te beskryf. Vervolgens is die resultate benut om 'n strategic (raamwerk) vir transform asie/om vorm ingsbe-stuur en leierskap in die prim êre gesondheidsdiens op te stel. 'n Kwalitatiewe navorsingstrategie is gebruik en die data is by wyse van individuele onderhoudvoering m et g e se le k te e rd e b e stu u rd e rs w erk saam in die g e so …


Introduction
Local authorities traditionally rendered preventative and pro motive services and the provinces were responsible for the rendering o f curative services.This service delivery system was fragmented due to political policies and diversification.With the new political dispensation in South Africa, trans formation is necessary to counteract the duplication and frag mentation o f health care services.The transformation of health services in South A frica is guided by the W hite Paper on the Transformation o f the H ealth System in South Africa (South Africa, 1997), focusing on the following: equity, acceptabil ity, accessibility, affordability, availability and appropriate ness .The local authorities are involved in this process of transform ation with the integration o f prim ary health care services as a priority and by taking over some health care services that were previously rendered by the provincial au thorities.For this process to be successful, it is im portant that the local authorities and the provincial departm ents work together and have close co-operation in order to achieve the objectives o f transform ing health services and bringing about equity.The process o f transform ation is, however, com pli cated with m any external and internal factors im pacting on this process.The process o f transformation is challenging at all levels -national, provincial and local levels.A transfor mation m anagem ent strategy is therefore necessary to facili tate this process o f change in an orderly and acceptable man ner.This research focuses on the process o f transform ation o f prim ary health care services in two selected local authori ties in Gauteng.
The transform ation of primary health care services require that local authorities have to take over certain services that have previously been offered by the provincial adm inistra tions.The local authorities have to be prepared for this take over.Any process of change/transform ation could also lead to conflict and destabilisation o f existing services if not m an aged appropriately.The following research questions are rel evant: what are the expectations and fears o f managers in the local authorities in relation to the process of transformation and what transform ation strategy could be developed?The objectives of this research are to explore and describe the per ceptions o f managers in two selected local authorities in G au teng in relation to transformation and to formulate a strategy for transformation m anagem ent within the local authority.

Terminology Tran sform ation
Transformation is a process of planned change within a local authority, due to external and internal forces, in accordance with health policy and legislation in South Africa.

Tran sform ation m anagem ent
Transformation m anagem ent is a process o f strategic change managem ent (planning, organising, directing and control) by identifying the perceptions (views, expectations and fears) o f roleplayers and by strategising to meet these expectations and to counteract their fears in an acceptable and cost-effec tive manner to achieve a specific goal in relation to transfor mation.

Prim ary health care services
A primary health care service is the first level of health care rendered by a local authority in accordance with the author ised national, provincial and district health care policies."Primary health care is essential health care based on prac tical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and fam ilies in the com m unity through their fu ll participa tion and at a cost that the com m unity and country can afford to maintain at every stage o f their developm ent in the spirit o f self-reliance and self-determination.It fo rm s an integral part o f both o f the country' s health system o f which it is the central function and main focus, and o f the overall social and economic developm ent o f the community.It is the first level o f contact o f individuals, the fa m ily and com m unity with the national health system, bringing health care as close as possible to where people live and work, and constitutes the first element o f continuing health care process" (World Health Organization, 1985).

Lo c a l au thority
A local authority is the service unit within a community in accordance with the national policy and legislative require ments.

Perceptions
Perceptions are the perceived views, expectations and fears of roleplayers within a selected local authority.An expecta tion in this study refers to the perceived and expressed needs and desires o f the m anagers within a local authority in rela tion to the transform ation o f prim ary health care services.A fear is a negative psychological emotion perceived, experi enced and expressed by managers when they feel threatened by unknown situations within a local authority in relation to the transformation of primary health care services.

S trate g y
A framework for transformational management and leader ship within a primary health care service in Gauteng.

Research design
A qualitative, exploratory and descriptive research strategy was used within the context o f a local authority in Gauteng, based on the premise that there is not just a single reality and that reality is based on perceptions that are different for each person and that these perceptions change over time.W hat we know has meaning within a given situation or context (Burns & Grove, 1993:61).Primary health care services had to be taken over by the local authority and there are certain dynam ics (view s, expectations and fears by the different roleplayers) impacting on the process of transformation.
The population consisted o f the health care professionals employed by the local authority in a total o f 11 clinics in one of the following managerial positions: M edical Officer of Health, Deputy M edical Officer of Health, Nursing Service Manager, Chief Community Health Nurse and Assistant Chief Community Health Nurse.A stratified purposive and theo retical sampling method was used (Bums & Grove, 1993:239-246) to include the managers who were employed at the lo cal authority during the time o f the study.The following inclusion criteria were stated: * managers are in a full time and permanent post for at least three years with active involvement in the process of transformation during the time of the study and interviews; * availability for the interviews with proven proficiency in English.
A sem i-structured interview was used as data-collection method (Cassell & Symon, 1994:14-16 The interviews were conducted by an independent consult ant.Informed written consent was obtained from the M edi cal Officer o f Health as well as from the individuals them selves prior to the interviews.The rights of the participants were respected in relation to privacy, confidentiality and ano nymity, self determ ination during the interview, fair treat ment with protection from discom fort and harm.The quality o f the research was facilitated by adhering to the ethical prin ciples o f nursing research (Denosa, 1998).
Tape recordings o f the interviews were transcribed, followed by a content analysis in accordance with the principles de scribed by Kerlinger (1986:447-483).
Trustworthiness of the research was ensured by counteracting the threats (Woods

Results
The results are discussed in relation to the sample realisa tion, the perceptions (expectations and fears) of managers (table one) and a strategy for transform ation management within the local authority (see figure one).

Sample realisation
A total of ten individual interviews were conducted, repre sentative of all five areas within the local authority and rep resenting all categories of managers within the population.
It appeared as if the data was saturated on com pletion of these ten interviews.

Expectations
The expectations of managers were classified into the follow ing categories: staff, community satisfaction, salaries/parity, stocks/supplies/m edicines, jo b satisfaction, quality service delivery, consultation, community participation, support/re lationship with regional office and the devolution of power and responsibility.M ost o f the participants (N=9) identified adequate staff as an im portant expectation and pre-requisite for the transformation o f primary health care services.Se lected direct quotations are as follows: "One thing we cer tainly expect is to have extra staff.""We can't be expected to render more services with less manpower.""W hat I am an ticipating is to have more resources; staff to man these serv ices -enough staff.""N aturally this would mean to have adequate staff."Transformation and quality service delivery is just not possible w ithout adequate and com petent staff.
There is a great need for the appropriate redistribution of human resources to ensure successful implementation o f the primary health care strategy and this is confirmed in the White Paper on the transform ation o f the health system in South Africa (1997:42) and in the Policy for the development o f a district health system in South Africa (1995:14).
Community satisfaction was highlighted (N=8 ) as an impor tant expectation for successful transformation of the clinic: "W hen we take over, all the health needs of the community should be met.""The problems of the clients -the patientsshould be addressed holistically.""The service should be acceptable to the community.""Wehave to accommodate the needs o f the people we serve."The service providers need to meet the health needs o f the community and monitor the level o f com m unity satisfaction (Oakley, 1989;South Africa, 1995:2-5;South Africa, 1997:64).An emphasis was also placed on equal salaries and parity and was viewed by the participants (N=7) as a serious concern during the take-over process as there were differences in salaries, not only on ra cial grounds but also in terms o f provincial versus local au thority service delivery authorities: "There are vast differ ences between the salaries paid by the local authorities and the salaries paid by provinces and this is gonna create big problem s." "If we could only get to the point of equal salaries and equal conditions o f service, people would settle down.""The salary issue is a very serious problem -not only the disparities between racial groups, but also betw een province and local authority."One o f the legacies o f the past can be seen in the disparities in relation to salaries and conditions of service that need to be rectified and be compliant with the labour rights and labour legislation of the country (South Africa, 1995:13).
Adequate stocks and supplies, especially enough medication, for successful transformation was also highlighted (N=7) as  Job satisfaction was also raised as an expectation by six par ticipants: "We really expect to start with, that there will be jo b satisfaction.""We m usn't forget the staff that will be exposed to all o f this -jo b satisfaction is therefore im por tant.""Transform ation is good if it brings about m ore job satisfaction."This desire m ight have been expressed as a fear due to uncertainties during the process o f transform a tion.M cM ahon, Barton & Piot (1992:45) states that pri mary health care service providers need to receive special at tention due to the circum stances they w ork in and extra effort should be made to facilitate jo b satisfaction am ongst these service providers.Some participants (N=5) were o f the opinion that transfor mation can only be successful if the quality o f service deliv ery was im proved: "High standard o f care is im portant.""M any staff m em bers are not capable o f rendering quality care.""The idea is good, provided quality is what we want to achieve.""We should be fully equipped to render quality care."Quality service delivery is dependent upon structure, process and outcome.Adequate structure standards should be in place (both human and material resources) to enable q u a lity p ro fe ssio n a l se rv ic e s to be ren d e re d (M u ller, 1998:242).Q uality is never negotiable.
Staff training was viewed (N=5) as an important aspect of transformation: "The training for primary health care nurses is too slow -we need well trained primary health care nurses.""The staff need to be adequately trained for the take-over proc ess -especially in primary health care.""I just hope that they will speed up the training o f prim ary health care nurses."Appropriate, adequate and timeous human resource develop ment is im portant (South Africa, 1997:54; M cM ahon et al., 1992:89).
C u ratio n is Decem ber 20 0 0 H alf of the participants (N=5) were o f the opinion that con sultation was important as part of the take-over process: "They must come to the people who are supposed to deliver the serv ices in this take-over.""Like free health services -it was just decided without any consultation at the level o f service deliv ery." "We had a lot of problem s when free health services was announced because there was no consultation.""We are ju st told to take over w ithout knowing what we have to do." Appropriate communication, which includes consultation with the service providers, is a prerequisite for any process o f change/transform ation.This should be seen as one o f the most im portant principles o f change/transform ational m an agement.Likewise, com m unity participation is also viewed as important (N=4): "We have to encourage com munity par ticipation.""Adjustments will be necessary for us if we are really going to get com m unity participation.""The com m u nity is being told to go to a clinic and you will get free service -they don't have a say in all o f this."Consultation with all stakeholders are important during the process o f transform a tio n o f p rim a ry h e a lth c a re se rv ic e s in S o u th A fric a (M cM ahon et al., 1992:57;South Africa, 1995:41).
The support from and a sound relationship with the Regional Office was also identified as an expectation (N=3): "We were told that the Regional Office will be there temporarily and their purpose is ju st to see us into the transform ation process.""We will need help in the restructuring o f a dis trict.""We really hope the M EC will really look into the problem s we foresee."The support o f district-based manage ment by the Regional M anagem ent is confirm ed in the policy docum ent on D istrict Services (South Africa, 1995:57), es pecially in relation to the financial and adm inistrative re sources.The devolution and developm ent o f pow er and re sponsibility was expressed as an im portant expectation by the participants -they have to be em pow ered to fulfill their ob ligations: "Presently we are experiencing a problem ... it ap pears as if the province is not ready to devolve yet, not really letting go but to control everything as they d on't seem to have m uch faith in the local authorities.""The other thing isprimary health care is now devolved to a local authority and it should be easier to m onitor and m anage ... it will be easier to run -but we must be given the pow er and authority to do it."The devolution o f pow er is confirm ed by the Policy for the development of a district health system in South Africa (1995:46) and this principle should therefore be executed with the necessary em pow erm ent o f the m anagem ent at the local authorities.The decision m akers at grassroots level should be authorised to make decisions.This is also con firmed by M cM ahon et al. (1992:22).The devolution of pow er is a prerequisite for successful transform ation o f pri mary health care services.

Fears
The fears related mainly to the following: conditions o f serv ices, shortage o f m edication and staff, lack o f supervision, resistance to change, inadequate space and facilities, as well as the existing positions.M ost of the participants (N=9) were afraid to loose what they have in terms o f conditions of service:"We have different conditions o f service and salaries.""People are afraid o f loosing their benefits -w aiting to see w hat is going to happen.""The problem is integration -not only integration o f services, but us -what will happen?"Short age of medication was once again m entioned as a specific fear that results in a feeling o f frustration and powerlessness."We are not happy with the EDL." "The biggest logistical problem is drugs -we ju st don't have enough.""The com munity were told that they can get free health services -but we d o n 't have the drugs.""They should seriously consider this thing o f drugs.""M y fear is now -patients com e to the clinic but we don't have drugs to treat them ."Shortage of staff was also expressed as a fear (N=7): "Yes -we have lots o f fears -especially shortage o f staff.""My heart is palpitat ing because my first fear is I don't have enough staff.""We now have more work and less staff."M ost o f the participants (N =6 ) also expressed the lack o f supervision/authority, as well as the resistance to supervision, as a fear."The people from the province -they w on't listen to us; they don't want to work under us.""They are afraid o f loosing their positions and their pow ers."Fears w ere also expressed towards inad equate space and facilities to deal with all the demands.
Resistance to change was obviously also expressed as a fear by many o f the participants (N=5): "There is this resistance -people don't want to com e together.""They are afraid of now being inferior and resist the change.""There is a lot o f resistance from the other parties."Resistance to change is not a new phenom ena and has to be managed with sensitiv ity.M ost o f these fears are addressed in the W hite Paper on the transform ation o f the health system in South A frica (1997:57) and the Policy for the developm ent o f a district health system in South A frica (1995:14).It is clear that many o f the expectations were mirrored in the fears.

Transform ation strategy
The views o f the participants on the strategy for transform a tion m anagement, focused mainly on the following: m eet ings/consultation, conditions o f service and salaries, training of m anagers, adequate m edication/stocks, additional space, com m unity participation and evaluation.M ost o f the expec tations and fears that were expressed, were addressed as ex pectations and recom m endations to be included in the trans formation strategy.A few direct quotations are given: "The staff will have to sit down and workshop how they would like the services to be run.""Involve the people at grass root level.""Frequent m eetings and consultations are im portant.""The possible loss o f positions and existing conditions o f serv ice will have to be addressed."Trainingo f staff to cope with the changes ..." "Adequate facilities -mobile clinics, com munity health centres ... and o f course enough drugs.""We need to involve the com m unity more." A lthough the internal factors im pacting on the transform a tion o f primary health care services in a local authority were explored, there are also external factors, such as the political strategies, legislation, economy, national policies, o f which the W hite Paper on the transform ation o f the health system in South Africa (1997) and the Policy for the developm ent of a D istrict system in South A frica (1995) are m ost signifi cant.

Concluding statem ents: perceptions
The expectations and fears o f the m anagem ent, as w ell as their perceptions on the transform ation strategy, can be clas-sified as structure, process and outcom e (see figure one): * structural dimensions: there should be systems in place to enable quality service delivery, com m unity participation and effective comm unication, adequate facilities and equip m ent is necessary, adequate m aterial resources (especially m edication) and adequate hum an resources (num bers and competencies); * process dimensions: there should be quality processes in relation to the m anagem ent o f prim ary health care serv ices, com m unity participation (consultation/com m unication), quality hum an resource m anagem ent and quality change/ transform ational m anagem ent; * outcom es dim ensions relate to: quality prim ary health care service delivery m anagem ent (accessibility, acceptabil ity, equity, appropriateness, efficiency/effectiveness), com m u nity satisfaction and evidence o f im proved health care out comes, quality hum an resource m anagem ent (fair labour prac tices and jo b satisfaction) and to achieve the underlying phi losophy of transform ation in South Africa.

A strategy for transform ation m anagement of primary health care services in a local authority
The conceptual framework for transform ation m anagement o f prim ary health care services in a local authority is illus trated in figure one.The strategy (fram ework for transfor m ation) is presented in relation to the context, the roleplayers, the goal/objectives and the process o f transform ation m an agem ent and leadership.

C o n te xt
The context is the prim ary health care services w ithin se lected local authorities in Gauteng.There are both external and internal forces and dynam ics to take into consideration.The local authorities function under the auspices o f local governm ent.Local governm ent in South A frica has been undergoing significant changes.The C onstitution (South A frica, 1996a) gives expanded responsibilities to local gov ernment and new policies are being implemented which should change the w ay m unicipalities function.The changes in lo cal governm ent will have a significant influence on the health sector, for local governm ent currently delivers some health services and will play an im portant role in the district health system.The local governm ent should m obilise communities and facilitate interaction betw een different roleplayers in the health sector, such as national governm ent, the provincial governm ent and the private sector (Fast & E ngelbrecht, 1999:45).Local governm ent will therefore play an im por tant role in the transform ation o f the local authorities.Dis trict municipalities are responsible for integrated development planning, provision o f bulk infrastructure w hich includes health services and the prom otion o f equitable distribution of resources (Fast & Engelbrecht, 1999:48).
The legislative and policy fram ew ork for the transformation o f local authorities to deliver quality prim ary health care serv ices, constitutes at least the following: C onstitution (South Africa, 1996a), the W hite Paper for the transform ation of the health system in South Africa (1997), Policy for the develop ment of a health district system in South Africa, (1995), the Local G overnm ent Transition Act (South Africa, 1996b), as well as the current various labour laws and policies.This framework will im pact on the structural transformation, i.e. resources (such as facilities, equipment, stocks/supplies and m edication, hum an and other m aterial resources, m anage ment systems and structures), the transformation of processes (primary health care service delivery, management processes, including resource managem ent), that will hopefully result in the required outcom es o f quality primary health care serv ice delivery, adequate community satisfaction with improved health care indicators, as well as fair labour practices, job satisfaction and productivity as far as the employees are con cerned.
A strategy for transform ation m anagement of primary health care services in relation to the context, includes at least the following: * the context o f the primary health care service is clearly identified and described in relation to the location of the serv ice, service delivery profile, com m unity profile and staff pro file; * the policy and relevant legislation framework is delin eated, listed and analysed, indicating the impact thereof on the primary health care service; * the contextual changes/transform ation required within the primary health care service, is clearly delineated in prepa ration for the strategic transformational plan to be designed.

Roleplayers
The roleplayers in this process of transformation are the m an agers and other service providers at national, provincial and local/district levels (the employers and employees) and the community.It is obvious that each group of roleplayers have certain expectations during the process of transformation.The nursing service m anagers have also expressed many fears.It is therefore im portant to counteract the fears and to meet/ address the expectations in accordance with the contextual circumstances and legislative/policy framework.
There is a strong trend towards decentralisation in South A f rica and tremendous demands are being placed upon the lo cal governm ent sphere, but local government cannot always meet these dem ands.It is in this context that the D istrict Health System is established.The process o f developing such a system m ust take account of the local government reality and the various processes that will impact on the health serv ice delivery.It is therefore im portant for people involved in the health sector at district/local level to participate in the formation o f integrated development plans, to explore new mechanism s for delivering o f services, to engage with the allocation o f health service functions to district and local municipalities and to continue and improve the rendering of high quality health care in an integrated m anner (Fast & Engelbrecht, 1999:49).
Role clarification o f roleplayers is necessary during the proc ess o f transformation.This role clarification should take into account the mission o f a transformed health service at local level (South Africa, 1997:13) to focus on the following: * to provide a primary health care service that is more appropriate, equal, acceptable and effective; * to provide leadership and guidance during the process of transformation and primary health care service delivery; * to promote and monitor the health of all people in South Africa.
The roleplayers should be em powered with regard to their role, the process and principles o f transformation and trans formational leadership, as well as to the quality related issues of structure, process and the outcomes that need to be achieved (Rathwell, et al., 1995;Streefland & Chabot, 1990).A strat egy for the transform ation o f prim ary health care services acco m m o d ates at least the fo llo w in g in re la tio n to the roleplayers: * all relevant roleplayers are identified and listed; * a profile analysis of the roleplayers is undertaken; * there is a strategy for em pow erm ent and leadership developm ent of the different roleplayers; * there is a clear role-clarification o f roleplayers during the process o f transformation; * there is evidence o f adequate em pow erm ent/develop ment o f the roleplayers in relation to their responsibilities during the process o f transformation; * there is a human resource transform ation managem ent strategy to facilitate fair labour practices during the process of transform ation within the primary health care service.

Goal/objective
The goal is to transform the present delivery of health serv ices in order to be com pliant with the National Health Plan (South Africa, 1997).The objective is quality transformational m anagement to achieve the following: * quality m anagem ent o f prim ary health care service delivery (accessibility, equity, appropriateness, acceptability and efficiency/effectiveness) resulting in the im provement of existing health care indicators within the community; * quality community participation resulting in com m u nity satisfaction; * quality human resource managem ent resulting in fair labour practices, job satisfaction and productivity.
The goals/objectives of the primary health care service in re lation to the transformation process is therefore identified and clearly formulated for inclusion into the strategic/transfor m ational plan.

The process of transform ation m anagem ent and leadership
The process o f transform ation m anagem ent relates to the managem ent o f primary health care service delivery (struc ture, process and outcom e), com m unity participation and hum an resource m anagem ent.The principles o f planned change/transform ation management and leadership should be applied throughout (Brooke, 1990;Schulz & Johnson, 1990;Marriner-Tomey, 1993;Barker, 1990).

Managem ent of primary health care service delivery
A transform ational strategic plan is necessary to guide the process o f transformation and quality service delivery within the primary health care services.Successful transformation is also dependent upon the participation o f all the relevant roleplayers to facilitate ownership and accountability by all concerned.Therefore a decentralised m anagement system is necessary with adequate em pow erm ent o f all the relevant decision-makers (Schulz & Johnson, 1990).A functional inte gration o f comprehensive prim ary health care services is of paramount importance.This includes at least the following: a situational analysis o f the existing services rendered by the primary health care service and an analysis o f those services to be taken over by the primary health care service that were traditionally rendered by the provincial service.An analysis of the existing structures, processes and outcomes in relation to the transformational requirem ents also needs to be under taken.

Community participation
Creative strategies to involve the community at decision-making levels, have to be developed and applied.This would relate to at least the following: * an an aly sis o f e x istin g com m unity particip atio n , intersectoral partnerships and leadership practices; * a needs analysis o f com m unity expectations, leader ship, strengths and weaknesses; * the establishment and/or strengthening o f consultation/ decision-making structures within the community; * a strategy/operational plan to enable adequate com munity participation and com m unication between the com munity and the primary health care service; * adequate representation o f the various com m unity groups/roleplayers, such as non-governm ental organisations, youth groups, church/religious groups, ward councillors, tra ditional healers, civics, w om an's organisations, disabled groups, etc. * empowerment of the community; * implementation and evaluation o f community partici pation strategies/plans to result in adequate and effective part nerships betw een the community and the primary health care services.

Human resource management
The process o f transformation has created many fears in rela tion to hum an resource m anagem ent.A hum an resource management strategy should therefore be part of the strategic plan to facilitate appropriate staffing o f the primary health care services, adequate utilisation o f staff, relevant develop ment/empowerment o f the staff, as well as fair labour prac tices in accordance with the relevant labour laws o f the coun try.An adequate skills mix is necessary for the rendering of quality and cost-effective primary health care services.This will require a situational analysis o f the existing skills mix and the needs o f the primary health care service in accord ance with the national, provincial and local policy frameworks.

Principles of transform ation m anagem ent and leadership
Transform ation m anagem ent is the facilitation o f change within the individual, group and organisation/primary health care service to meet the transform ational needs and demands within the internal and external environment.This process consists of three steps, i.e. initiation o f the transformation process, the change strategy itself and stabalisation (Drake, 1993:72).The initiation phase focuses on the following: crea tion o f an awareness for transform ation/change by highlight ing the internal realities and external forces im pacting on the prim ary health care services.This necessitates the creation o f a dynam ic com m unication system and process betw een the various roleplayers within the prim ary health care service and externally (Flarey, 1995:4).This process is em bodied in the internal and external assessm ent phases during the design of a strategic and transform ational plan for the service.The change strategy would include a revision o f the vision/m is sion statements o f the prim ary health care service, the objec tives o f transform ation, as well as the operational plan for the attainm ent o f each objective (Schulz & Johnson, 1990:62)

Conclusions and recommendations
The following conclusions are made: * the m anagers have the follow ing expectations: ad equate hum an resources, com m unity satisfaction, adequate stocks, supplies, medication, space/facilities to deliver qual ity primary health care services, fair labour practices in terms of equity/parity o f salaries and other conditions o f services, job satisfaction, quality service delivery with appropriate devo lution o f power/authority, consultation with service providers and consultation with the community, adequate hum an re source developm ent, support from regional offices; * the fears relate to the identified expectations as well as to resistance o f change and loss of positions; * a transform ation strategy needs to focus on the expec tations and counteract the fears, in accordance with the prin ciples o f change/transform ational management; * the expectations and fears are classified within the di mensions o f structure, process and outcome; * a strategy for transformation management of primary health care services in a local authority was developed, focus ing on the context, the roleplayers, the objectives, the proc ess o f transform ation m anagement and leadership, as well as the outcomes.
The following recommendations are made: * the form ulation o f standards for transformation m an agement in health services; * the evaluation o f the quality of transformation m an agem ent within the primary health care service after im ple m entation o f the standards/strategy.

Concluding remarks
The transform ation o f primary health care services in a local authority is not only a very labour intensive process, but is also an em otional process resulting in lots o f expectations and fears by the roleplayers.This process o f transformation needs to be carefully designed, implemented and continuously evaluated.This article explored and described the percep tions (expectations and fears) of managers within a primary health care service in a local authority during the process of transformation.A strategy (transformational framework) was presented to accommodate the perceptions, focusing on a proc ess o f planned transformation management and leadership.

Figure 1 :
Figure 1 : Conceptual fram ework: Transformation management of primary health care services in a local authority . The transform ational/change strategy m ust focus on at least the follow ing (see figure one): * Structural transform ation: transform ation in rela tion to the systems, facilities/equipm ent, drugs/supplies and other material resources, as well as the human resources within the primary health care service; * Process transformation: in relation to the process of prim ary health care m anagem ent, com m unity participation and hum an resource management; * O utcom es: system s to enable the m onitoring and evaluation o f the outcomes in relation to the quality o f pri mary health care service delivery, com m unity and hum an re source outcomes.The process o f change is re-inforced by evaluation, m onitor ing, positive feedback, constructive criticism, encouragem ent and em powerm ent.The general principles o f transformation m anagem ent and leadership should accommodate at least the following (Schulz & Johnson, 1990); Marriner-Tomey, 1993; Drake, 1993) : * dynam ic com m unication w ith all roleplayers: the es tablishm ent, im plem entation and continuous evaluation of com m unication structures and strategies; * em powerm ent through participation of all the relevant roleplayers: the process o f transform ation; * m anaging resistance to change; * leadership development; * resource management.The third step in transform ation m anagem ent refers to the stabilisation phase (Drake, 1993).The process o f transfor mation is very labour intensive and em otional.It is therefore necessary to enter into a phase o f stabilisation once the objec tives have been attained.During this phase emphasis is placed on the successes and the less successful outcom es are ad dressed.The transform ation strategy in relation to the process o f trans form ation m anagem ent and leadership, should therefore in clude at least the following: * a transform ational/strategic plan on the structural di m ensions (systems, facilities/equipm ent, drugs/supplies and hum an resources); the process o f primary health care man agement, community participation and human resource man agem ent required for successful transform ation o f the primary health care service and the required outcomes; * a transform ation/strategic plan on the general m an agem ent o f change/transform ation to foster ow nership and C u ratio n is successful transform ation and to counteract resistance to change.

Table 1
Distribution of categories: expectations, fears and strategies

ealth Care M anagem ent Prim ary health care: POLICY FRAM EW ORK an
im portant expectation: "We ju st d on't have enough medi cation and other supplies to render a service.""Weshould get the resources -enough drugs, equipm ent, stocks etc." "We need adequate am ounts o f m edicine and other resources to be able to render a good prim ary health care service."Ad equate stocks and supplies is a obvious necessity for the de livery o f quality health care services.