Since its transition to democracy, Mongolia has undergone a series of reforms, both at national level and in the health sector. This paper examines the pace and scope of these reforms, the ways in which they have impacted on sexual and reproductive health services and their implications for the health workforce. Formerly pro-natalist, Mongolia has made significant advances in contraceptive use, women's education and reductions in maternal mortality. However, rising adolescent pregnancy and sexually transmitted infections, and persisting high levels of abortion, remain challenges. The implementation of the National Reproductive Health Programme has targeted skills development, outreach and the provision of resources. Innovative adolescent-friendly health services have engaged urban youth, and the development of family group practices has created incentives to provide primary medical care for marginalised communities, including sexual and reproductive health services. The Health Sector Strategic Masterplan offers a platform for coordinated development in health, but is threatened by a lack of consensus in both government and donor communities, competing health priorities and the politicisation of emerging debates on fertility and abortion. With previous gains in sexual and reproductive health vulnerable to political change, these tensions risk the exacerbation of existing disparities and the development by default of a two-tiered health care system.