BACKGROUND Urban health is a fashionable topic which generates a bulk of research work most often focused on particularities of health problems in urban settings. This focus distracts from the importance of research on how local urban health systems are organized and managed. OBJECTIVE To analyse the conceptual, managerial and technical problems faced by urban health system policy and organization in sub-Saharan Africa, in order to make recommendations. METHODS We report here on a research programme carried out to review the available evidence on health system policy and organization in urban areas, and to learn lessons from a number of case studies. RESULTS First, while the health district approach is usually regarded as a means of implementing primary health care in rural areas, we argue that it is likewise appropriate - theoretically and empirically - for the formulation and implementation of a coherent and effective health system in urban areas. Secondly, we concentrate on a number of contextual features that have to be taken into account in order to strengthen district organization and management in the urban context. Spatial, managerial and technical constraints which do not exist in rural areas, proliferation and fragmentation of uncontrolled health services in the private sector, lack of control over political power of the large national and university hospitals, insufficient governance and leadership of the urban health authorities are pointed out for attention. Having noted and thoroughly analysed these issues is not to suggest therefore that the health district approach has to be rejected but that it has to be modified and adapted in key respects. Thirdly, we outline district health system strengthening in the cities as a policy option less fashionable but more appropriate, including the World Bank agenda for reform, the sector-wide approaches for health development, the health promotion approaches based on the Ottawa Charter, and the poverty reduction approaches focusing on coping strategies of local actors. CONCLUSION Greater achievements could be reached by urban health systems in sub-Saharan Africa if they were organized and structured according to a health district policy. Key elements of such an organizational and managerial strategy should be realistically understood and assessed so as to provide health managers with a suitable tool for the successful development of primary health care in urban settings. Given the identified contextual constraints, implementation of a district health system in an urban context appears to depend mainly on political will and decision. It calls only incidentally for technical solutions. The following are among the most important requirements that have to be taken into account: ensuring appropriate allocation of resources to a legitimate urban health authority responsible for effective co-ordination of the many actors involved in urban health, setting out key developmental guidelines for the big city hospitals and effective communication channels with these institutions, ensuring development regulation and good governance of the private health sector. The role of the state remains crucial in this perspective.
