The paper discusses strategies for meeting the needs of the poor in a pluralist health sector. It argues that the first step in defining such strategies must be a realistic assessment of the complex and unregulated market for health services that exists in many parts of Africa. It suggests that simplistic calls for government and donors either to cease or substantially increase funding for existing public health services are misguided in a situation where even the labels ‘public’ and ‘private’ require careful analysis. Instead it proposes that governments should use their resources and influence to promote the substantial changes required to establish effective health services.

It also calls for a fundamental reassessment of the relationship between government, health services providers, civil society organisations, communities and households in the health sector. It concludes that a new vision for pro-poor health services will emerge from a process of listening to the needs of the poor, learning from mistakes and applying lessons from good practice models to address these needs.