Health services in the former Soviet Republics of Central Asia face many challenges, not least a rising burden of disease and severe economic constraints. Each government has developed proposals for reform. This paper describes the key elements of the proposals developed in each country. They have many features in common, such as financing based on social insurance, although they also have many differences, reflecting national political, economic and historical circumstances. While most attention so far has concentrated on the design of the proposed systems, it is argued here that there has been inadequate attention to the obstacles to implementation. These stem from the many adverse factors in the context within which reforms are taking place, weaknesses in the process of reform, and failure to involve the groups whose actions will be necessary for success. It is argued that governments and those advising them must place greater emphasis on the challenges of implementation, including the development of a much better understanding of the context within which change must take place.