This case study aims to identify how Ethiopia has adopted and implemented strategies to improve health services, including the factors that enabled and inhibited success across a meaningful range of health services for the period 1996-2006. Particular emphasis has been given to the impact of utilized strategies on the poor. This case study reviewed one 'primary strategy', decentralization in the form of devolution of authority to the regional level in 1996 and to the district (woreda) level in 2002, and seven 'corollary strategies' in the context of decentralization implemented at the subnational level. The study concludes that decentralization in the health sector is likely to be more effective when it is implemented as part of a broader government decentralization policy across sectors. Sequencing in implementing Ethiopia's decentralization strategy made decentralization more manageable, although decentralization was rolled out prematurely. Moreover, the effectiveness of implementation was found to be driven largely by the institutional and management capacity at the subnational level. At the subnational level, decentralization was found to be more effective in those regions that increasingly strengthened their management and institutional capacity and where regional governments set priorities and adapted the strategies to local needs. However, decentralization was often influenced by the 'clientelistic' center, region power relationship, a problem compounded by the lack of community voice, making the available resources at risk of political capture by the local elite. Overall, the key lesson for implementing improvements in health service delivery (HSD) is that the lack of any critical inputs (facilities, health workers, and drugs) inevitably limits the overall impact of the strategy, and that the implementation of such key inputs should be carefully coordinated and properly synchronized.