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Paper short abstract

Uganda’s healthcare relies on out‑of‑pocket payments, driving household debt and inequality. Structural adjustment and donor dependence constrain state capacity, with women bearing disproportionate burdens. A rights‑based, redistributive approach is needed.

Paper long abstract

Uganda’s health financing model illustrates enduring tensions at the heart of development studies: the legacies of structural adjustment, the persistence of neoliberal austerity, and uneven consequences of aid‑dependent systems. Despite decades of reform, healthcare provision remains heavily reliant on out‑of‑pocket payments, a mechanism that forces households to absorb costs directly and reproduces cycles of indebtedness and inequality. Drawing on policy documents and qualitative accounts, this paper situates Uganda’s reliance on user‑financing within broader debates on the political economy of development, showing how conditionalities and debt regimes have constrained state capacity to deliver equitable healthcare.

The analysis foregrounds the gendered dimensions of health financing: women, as primary caregivers and managers of household health, disproportionately bear the burden through unpaid labour, informal borrowing, and reduced consumption. This dynamic exemplifies how neoliberal development paradigms intersect with developmental feminism, where liberal frameworks such as gender mainstreaming and Women in Development expand programmatic visibility but often depoliticise structural inequalities.

By examining Uganda’s health system as a case of postcolonial development under constraint, the paper advances three contributions to development studies. First, it highlights how out‑of‑pocket financing entrenches inequality and undermines social citizenship. Second, it demonstrates the paradox of the postcolonial state, which remains central to legitimising healthcare provision yet is disciplined by external financial regimes. Third, it calls for a rights‑based and redistributive approach to health financing that prioritises universal health coverage, social protection, and debt relief. Uganda’s experience is situated within wider debates on the future of development, sovereignty, and justice in Sub‑Saharan Africa.