The Baltic states Estonia, Latvia, and Lithuania regained independence in the early 1990s in the aftermath of the dissolution of the Soviet Union. Since then, they have had a rocky path to health reform. The reforms have been aimed at making a clear break with the Soviet-style Semashko model, which was characterised by central planning and universal access but which suffered from inefficiency, hospital overcapacity, and poor healthcare.1 Early reforms, similar across all the Baltic states, focused on improving quality, efficiency, and geographical and timely access to healthcare. Yet differences in size, language, politics, economy, and culture (fig 1) perhaps explain variations in the implementation of the reforms. In recent times, a difficult economic climate has required some tough austerity measures to balance public budgets. We discuss these reforms, the impact of the global financial crisis, and some challenges for the future.