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This case can be used in a graduate level public management and leadership course to allow students to consider different approaches for Vice Minister Quesada in implementing major organizational change and how he handles the pressures upon him as a person and leader. This case can also be used in a leadership and organizational performance course to evaluate Quesada’s restructuring approach in managing rural health implementation and how to monitor and focus attention. Finally, this case could be used in a management course related to international development in the health sector to analyze the complex environment public manager’s face in implementing sweeping organizational changes in the developing world as well as his tactics for dealing with institutional opposition.

The case narrator is doing research on the health sector in Portobello—an alias for a Central American country—and follows Vice Health Minister Jose Manuel Quesada as he implements several major po