Health system performance management is a dynamically complex problem, affected by a large number of factors which interact to produce health outcomes over time. A brief review of current health system performance assessment instruments, including the balanced scorecard, demonstrates only a limited ability to deal with the dynamic complexity of this problem. These are limitations that can be overcome with the incorporation of system dynamics methods. We propose a dynamic balanced scorecard for managing regional health system performance in New South Wales, Australia. Central to this scorecard will be an understanding of the dynamic interactions of cost, quality and access and how these affect population health.