This paper demonstrates that fundamental to lack of progress towards universal coverage in sub-Saharan Africa is an elitist post-colonial political economy that dominates the social organisation in the sub-region. Too often, it seems that analyses of these issues ignore history and take no or little account of these post-colonial influences that today still have a bearing on policy in various sectors, especially in health care. We conclude that the achievement of this objective has to be a long-term process but one that cannot forget history. Various influences are, however, already moving societies in the right direction. Copyright © 2012 John Wiley & Sons, Ltd.