There is a growing impatience at national and international levels with the persistence of high burdens of ill health for which effective interventions are available. This has led to big political and financial commitments and the creation of large new international organisations with the aim of increasing access to health services.

The impact of these initiatives has not been consistently commensurate with these developments. It has become clear that the translation of these commitments into major improvements in the performance of health systems is not a simple task. One-size-fits-all approaches have had limited success in complex and rapidly changing contexts. Local innovations often do not spread quickly enough to have a major impact. Successful strategies need to combine large scale interventions and local adaptation and innovation. This paper explores alternative approaches for managing large scale health system changes in low and middle-income countries.