This paper begins by summarising the evidence that proactive management of the political dimensions of reform is feasible and beneficial, making particular reference to the field of sexual and reproductive health. It then addresses two questions: 1) to what extent are donor agencies, directly or through the health sector strategies they support, already undertaking and applying political-economy analysis to processes of policy change? and 2) what adjustments need to be made to the case for proactive management of the politics of reform when the geographical context is sub-Saharan Africa, and the institutional context includes the complex set of aid relationships now typical of that region, including sector programme support and global health initiatives?