This study summarizes the findings of three assessments of Central Medical Store (CMS) reform and performance in Francophone Africa. The study aims to document and characterize the organizational reform of the CMSs and the impact of the reform on CMS management and performance in Cameroon, Burkina and Senegal. It seeks further to assess the extent to which increased autonomy brought about by such 'marketizing' reforms has had an impact on intermediate CMS results, service quality, product quality, and access to medicines. The findings indicate that organizational reform did contribute towards improving operational performance which, in turn, influenced service quality, product quality, and access to CMS-supplied medicine in these countries. However, improvements in these areas were premised not simply on increased autonomy, but on a whole variety of drivers, both internal and external to a CMS. These include a strong regulatory framework, the conventions, laws, regulations, and administrative acts that increase the flexibility of some decision making rights, whilst constraining others, with an emphasis on social obligations, accountability, and transparency, as well as external factors, such as technical assistance, government subsidies, and relevant external policies, institutions and regulations. The paper ends by proposing a framework that could be used both for the design as well as for the analysis of marketizing reforms in CMSs and other public sector commodity supply entities in developing countries. The framework is sufficiently general that, with some modifications, it could also be applied usefully to the design and analysis of such reform in other public sector institutions delivering social services.