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In most African countries, the district sphere of governance is a colonial creation for harnessing resources from the communities that are located far away from the centre with the assistance of minimally skilled personnel who are subordinate to the central authority with respect to decision-making and initiative. Unfortunately, postcolonial reforms of district governance have retained the hierarchical structure of the local government. Anchored to such a district arrangement, the (district) health system (DHS) is too weak and impoverished to function in spite of enormous knowledge and natural resources for a seamless implementation of universal health coverage (UHC). Sadly, the quick-fix projects of the 1990s with the laudable intention to reduce the burden of disease within a specified time-point dealt the fatal blow on the DHS administration by diminishing it to a stop-post and a warehouse for commodities (such as bednets and vaccines) destined for the communities. We reviewed the situation of the district in sub-Saharan African countries and identified five attributes that are critical for developing a UHC-friendly DHS. In this analytical paper, we discuss decision-making authority, coordination, resource control, development initiative and management skills as critical factors. We highlight the required strategic shifts and recommend a dialogue for charting an African regional course for a reformed DHS for UHC. Further examination of these factors and perhaps other ancillary criteria will be useful for developing a checklist for assessing the suitability of a DHS for the UHC that Africa deserves.

The Millennium Development Goals (MDGs) galvanised global-level, regional-level and country-level efforts to scale up health interventions and improve health outcomes for health-related MDGs. However, despite improvements in coverage and in the health status of the African people, there persist challenges, to which countries need to pay attention. The 2013–2016 Ebola virus disease (EVD) outbreak in West Africa revealed many weaknesses in the health system detection, preparedness and response systems of the three most affected countries (Liberia, Guinea and Sierra Leone). These pointed to major gaps in the implementation of Integrated Disease Surveillance and Response and the International Health Regulation (IHR) 2005, as well as the weakness of health systems overall.1 2 More importantly, it brought to the fore the importance of building resilient health systems that can withstand shocks and sustain provision of regular health services. Kieny and Dovlo underscored this point and asserted that ‘…we need to build systems that are grounded in primary healthcare principles and capable of responding to routine as well as unexpected challenges that might arise in the future….’3 In pursuant of this agenda, the WHO Regional Office for Africa developed a framework for ‘Strengthening health systems for Universal Health Coverage (UHC) and the Sustainable Development Goals (SDGs) in Africa’ which consolidates systems and services around a logical results chain with the …