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The African Health Initiative (AHI) is the Doris Duke Foundation’s (DDCF) response to the need to improve the knowledge base on how to strengthen health systems. As this Initiative began, African leaders already had set the stage for a focus on the health system through a series of high level meetings, all with accompanying declarations, beginning in 2004. African leadership, in committing governments to strengthening health systems, seemed likely to support AHI efforts to improve population health in ways that could be sustained by governments in the focus countries after the program ends. Elements of the program designed to assure sustainability included alignment with national and local health priorities, ownership and participation by the national Ministry of Health and affected communities, building of local capacity, and effective African leadership. But, as is often the case, challenges to African leadership and sustainability continue to emerge. This comment reviews progress and prospects in achieving sustainability. I argue that sustainability lies at the core of country ownership and will require a reshaping of how both countries and funders engage to improve population health.

African leadership for sustainable health policy and systems research