In developing nations, diverse health reform programs are affecting the design, financing and delivery of health care services as well as public health practice. This paper summarizes the characteristics of major reform strategies seeking to improve efficiency, equity and quality. Opportunities and risks for TB control are identified, as are responses in managing the reform transition. Recommendations are provided to advance TB control in this dynamic environment. These include participation in the planning process; demonstration of synergy between reform objectives and TB control; articulation of core functions to be protected; technical, managerial and leadership capacity-building; documentation of effects and best practices; and collaboration with those pursuing other public health priorities and reform analysis.