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This paper addresses the consequences of reforming health policies on the practice of tropical medicine. It briefly reviews the historical development of health systems in poor, tropical countries before summarising current trends in the reform of financing and management. Reforms considered include decentralising management, broadening choices in health financing, particularly introducing user fees, introducing 'managed competition' principles, and working with the private sector. Experiences in different countries are used to highlight some of the dangers inherent in current reform trends. It is suggested that while monopolistic and centralised systems of public provision are unlikely to come back into fashion, much can be done to build on the more positive aspects of current reforms and to minimise their undesirable side effects. Key issues are developing mechanisms that ensure that services are responsive to users, avoiding polarisation of services between rich and poor, and improving systems of regulation, supervision and monitoring.