The agenda of ‘‘women’s reproductive health’’ expands the scope of population interventions to embrace a wide array of concerns centered on reducing morbidity and mortality. This eclectic agenda has been heralded as a step forward, moving beyond narrow contraceptive solutions to the population problem. But, both economic crises and their solutions have led to debilitation in the post-adjustment health sector, presenting formidable obstacles to successful
implementation of the reproductive health agenda. This article examines the links between the global population discourse, national health policy and the realities that confront women who seek services in local clinics. The case study of Tanzania exempli?es a reproductive health paradox: fertility is declining, yet so is access to basic reproductive health care. This paradox calls for a reassessment of the relationship between vertical donor-reliant development programs and health systems in developing countries.