Those working within the South African (SA) District Health System (DHS) have various roles in addressing population health and wellbeing needs. These include motivating and co-ordinating local providers offering community, primary healthcare facility and district hospital services, including prevention and promotion services, and facilitating whole-of-government and whole-of-society collaboration with other government and social actors. These roles cannot be fulfilled by exercising traditional, command-and-control public sector managerial authority. Instead, distributed system leadership is required: a form of leadership practised by individuals and teams that enables the collective action needed to address complex health needs, and that is supported by wider organisational structures and processes. Based on a range of experience, this in-practice article presents the rationale for, and description of, system leadership within the DHS; appraises current approaches to leadership and management development in South Africa from this perspective; and outlines a system leadership development approach that offers promise for DHS and health system strengthening.