We have fewer than 500 days to the deadline of the Millennium Development Goals (MDGs). Since their launch in 2000, the goals have mobilised a wide variety of stakeholders for an inspiring journey. Despite some major success, Africa lags behind in many of the targets. Governments still aren’t spending enough on health: fewer than 10 countries in Africa budget at least 15% of their national budget for health in line with the 2001 Abuja Declaration. People aren’t getting the services they need, especially in rural areas, and financial hardship associated with ill-health worsens poverty. There is growing momentum that universal health coverage (UHC)—a goal that everyone should have access to the quality health services they need without risk of financial ruin—can transform health systems in Africa.