Why has Uganda not enacted its national health insurance law after 35 years? An evidence brief for policy action

In many parts of the world, paying for a doctor's visit or a hospital stay can feel like a gamble. If a family member falls ill, the cost might be so high that it wipes out savings or forces a family to sell their land just to get care. To stop this financial panic, many countries use a system called health insurance. Instead of paying only when you get sick, people pay a small, regular amount into a shared pool of money. When someone needs treatment, the pool pays the bill. This spreads the risk so that no single person has to face the full cost alone. The goal is to make sure everyone, rich or poor, can access quality care without going bankrupt. For decades, Uganda has tried to build such a system. The country has a long history of promising to create a national health insurance scheme, yet despite repeated attempts over thirty-five years, the law has never been passed. Understanding why this promise remains unkept reveals a complex mix of fear, politics, and practical hurdles that go far beyond simple math.

A team of researchers from Makerere University in Uganda set out to uncover the reasons behind this long delay. They did not just look at old laws or statistics; they engaged directly with the people who would make the system work or break it. Between 2013 and 2024, the team held a series of meetings, interviews, and discussions with government officials, doctors, union leaders, business owners, and community representatives. They also reviewed dozens of official documents, including past bills, election promises, and parliamentary debates. Their goal was to map out the history of the idea and identify the specific concerns that have kept it from becoming a reality. By listening to these stakeholders and analyzing the documents, the researchers found that the failure to pass the law was not due to a lack of money or a lack of need, but rather a deep-seated distrust and a fear that the system would hurt the very people it was meant to help.

The researchers identified five main themes that explain why the national health insurance scheme has stalled. The first is simply the sheer length of time it has taken. The idea was first proposed in 1987, and since then, it has been revisited in almost every election cycle. Despite the government increasing its spending on health over the years, the country still struggles to fund its health services fully. The second and perhaps most powerful barrier is the fear of corruption. Many stakeholders believe that if a new fund is created to collect money, it will become another place where public funds are mismanaged or stolen. This fear is rooted in Uganda's past experiences with how public money has been handled. There is a specific worry that the Ministry of Health, which would oversee the fund, might have a conflict of interest because it is also responsible for running the hospitals that would use the money. Furthermore, some people see a form of hypocrisy, noting that while the government promises free care to the poor, many high-ranking officials use public tax money to pay for their own private health insurance or to travel abroad for treatment.

The third major concern is that the proposed insurance scheme feels like it is only for the wealthy or those with formal jobs. The initial designs of the law focused on people who earn a regular salary, leaving out the vast majority of Ugandans who work in the informal sector, such as farmers, market traders, and daily laborers. These workers often do not have a steady paycheck, making it difficult for them to pay regular premiums. Critics argued that the plan was an "elitist" project that ignored the rural poor and the non-monetary economy. Even when the law was revised to try to include these groups, the proposed fees were seen as too high for people with very little income. The fourth barrier is the reaction from employers, particularly business owners and manufacturers. They viewed the insurance contributions as a new tax that would increase their costs of production. They argued that if they had to pay more for their workers' insurance, they would have less money to hire new people or expand their businesses, which could hurt the economy.

Finally, the researchers found that political calculations played a huge role in the delay. The ruling political party has long campaigned on a promise of "free primary health care." Many political leaders feared that introducing a health insurance scheme, which requires people to pay premiums, would look like a betrayal of that promise and could cost them votes. They worried that their supporters would see the insurance payments as a new burden rather than a benefit. This political hesitation meant that even when a bill was passed by the parliament, the President and the party leadership would not sign it into law, especially during election years. The researchers noted that in other countries, such as Thailand, health insurance reforms were used as a way to win votes and build trust with citizens, but in Uganda, the political risk was seen as too great.

The study concludes that while the need for a national health insurance scheme in Uganda is urgent and long overdue, the path forward is blocked by these deep perceptions of corruption, exclusion, and political risk. The researchers suggest that to move past these barriers, the government and its partners need to rebuild trust. They propose starting with a smaller, independent fund that is managed separately from the Ministry of Health, similar to how the country's social security fund has operated successfully for decades. They also recommend that political leaders and business groups need to come together to find a design that protects the poor without hurting the economy or the voter base. The evidence shows that the technical solutions exist, but the political will and the public trust required to make them work are still missing. Until these fears are addressed and a new consensus is built, the promise of a national health insurance scheme in Uganda will likely remain just that—a promise.