This research examines the relationships among Ministry of Health - (MOH) decision-makers, the MOH, and structural forces shaping the evolution of Burundi’s primary health care delivery. While WHO's goal of Health for All has shaped health strategies in Sub-Saharan Africa, how primary health care (PHC) is formulated and implemented over time is relatively unknown. Using a realist perspective that allows human agency to come through, multiple methods -- including in-depth interviews with senior MOH decision-makers (>90,000 word data base), content analysis, participant observation and policy document reviews -- were employed to assess the interaction between decision-makers’ PHC beliefs, the Ministry’s PHC approach and the structural factors in a Sub-Saharan African nation, Burundi. Field work was undertaken during a two and a half year period. Findings indicate that Burundi’s history of authoritarian rule and ethnic strife molded the country’s PHC approach over time. The 1988-1993 period characterized by government democratic transition, also witnessed a major in the Ministry’s approach shift towards decentralization and community participation. Decision-makers' PHC beliefs were strongly influenced by public health education, suggesting that long- and short-term education and training are prudent strategies for promoting primary health care in the Ministry of Health’s organizational culture. Collectively, these beliefs changed the top-down institutional approach to decision-making, moving the MOH to a consensus building model in its approach to PHC issues. Despite these changes, authoritarian organizational culture and ethnic conflict conditioned decision-makers to implement their PHC beliefs cautiously and indirectly. Advances in participatory approaches to health care planning have been placed on hold given the surge in ethnic violence in 1996.