Changes in the role of the state and private sector are seen as central to success of many health care reforms. The article argues for a more focused "stewardship" function of governments in securing equity, efficiency, and quality objectives through more effective policy making (steering), regulating, contracting, and ensuring that adequate financing arrangements are available for the whole population. At the same time, the author argues a strong case for greater private participation in providing health services (rowing). The article reviews related reform trends in health care financing, generation of inputs and service providers. It concludes that reforms often fail, not because of a flawed technical design, but because of other factors. These include a lack of political commitment to change, resistance from vested stakeholders who fear loosing some of their existing benefits, and a failure by policymakers to translate successful aspects of the reforms into something visible that ordinary people and the public can see with their own eyes when next they use the reformed services.