Tajikistan, a Central Asian state of 7.4 million inhabitants, is facing particular health policy challenges: not only is the country the poorest of the former Soviet republics, but its capacity to deal with post-communist transition and economic crisis has been further undermined through civil war and large-scale migration. This paper, examining the introduction of the basic benefit package and formal co-payments, elucidates how international involvement in Tajikistan's health sector has impacted on national health governance. Based on documentary sources and information provided by key informants, we find that external agencies have both strengthened and weakened national health governance. Although they have played a major part in supporting Tajikistan's health sector, these efforts have often been fragmented, as donor coordination was at times less than optimal. A key challenge for national health governance is the limited technical and institutional capacity of the Ministry of Health and further efforts are needed to build national capacity.