This research examines the impact on health-care provision of advanced state failure and of the violence frequently associated with it, drawing from six country case studies. In all contexts, the coverage and scope of health services change when the state fails. Human resources expand due to unplanned increased production. Injury, threat, death, displacement, migration, insufficient salaries, and degraded skills all impact on performance. Dwindling public domestic funding for health causes increasing household out-of-pocket expenditure. The supply, quality control, distribution, and utilisation of medicines are severely affected. Health information becomes incomplete and unreliable. Leadership and planning are compromised as international agencies pursue their own agendas, frequently disconnected from local dynamics. Yet beyond the state these arenas are crowded with autonomous health actors, who respond to state withdrawal and structural violence in assorted ways, from the harmful to the beneficial. Integrating these existing resources into a cohesive health system calls for a deeper understanding of this pluralism, initiative, adaptation and innovation, and a long-term reorientation of development assistance in order to engage them effectively.