The maternal tax

This series examines tax justice through a feminist lens. Previous pieces asked who holds power over tax systems, how gender assumptions are baked into fiscal policy, what it means to be an economic ghost, how daily levies extract without recording, and what happens when the economic ghost reaches old age. This article asks what happens when she falls sick. When she gives birth. When she dies.

The voices in Kampala said: "I have never accessed free healthcare. Not once." They pay taxes their whole lives. VAT on everything. Market fees. Presumptive tax. They pay. When they fall sick, the public clinic has no drugs. The doctor is absent. They are sent to private pharmacies where they pay again.

They pay for healthcare twice. Once through their taxes. Once through their pockets.

This is not an accident. It is design. It is the redistribution of resources upward—from the women who need care most to the systems that fail them, from the poor who pay regressive taxes to the wealthy who fly out when they fall sick.

We start where the pattern is sharpest: with the women whose taxes fund a system that lets them die.

Who pays when a woman gives birth?

Idah Nantale had surgery. She was a new mother, recovering. But there was no space inside Mukono General Hospital. She spent four nights sleeping outdoors, on the ground, because the facility her taxes helped build was overwhelmed far beyond its capacity.

When the Prime Minister made an unannounced visit in September 2025, she found women giving birth on the floor. Patients lay on verandas. Others slept under trees. The hospital was operating at the level of a Health Centre III, yet expected to serve an entire district. Full story.

Inside the maternity ward, women recounted delivering on the floor because there were no beds. Others reported being charged unofficial fees for nursery services when their newborns developed complications. Paying twice. Always paying twice.

This is not an isolated failure. It is the system at work.

The maternal tax

A few years ago, I conducted research that revealed a devastating pattern. Many women died from excessive bleeding during childbirth because the maternal facilities they accessed lacked misoprostol. A drug that costs pennies. A drug that saves lives. Not available.

The maternal tax is not visible like VAT on sanitary pads. It is not debated in parliament. But it is paid in blood.

When a woman cannot access a facility because it is too far, she pays with her time, her strength, her life.

When a facility lacks drugs, she pays at a private pharmacy or pays with her life.

When a facility charges unofficial fees for nursery services, she pays from money meant for food, for school fees, for survival.

When she dies from excessive bleeding that misoprostol could have stopped, she pays the ultimate price.

This is a tax. A tax on being female. A tax on giving life. A tax paid in blood.

In Uganda, the maternal mortality ratio is 284 deaths per 100,000 live births. In South Sudan, it is 1,223. In Sierra Leone, 443. The average for sub-Saharan Africa is 536.

In Europe, the average is 13.

A woman in sub-Saharan Africa is forty times more likely to die in childbirth than a woman in Europe.

Why?

One reason is that she cannot access care she can afford. Another is that the care she can access is underfunded, understaffed, underequipped. Another is that she has paid taxes her whole life and received nothing back.

When she dies, the system will record a statistic. Maternal death. Preventable. It will not record that she paid taxes for twenty years and the clinic had no misoprostol. It will not record that she paid VAT on every purchase and the hospital had no beds. it will not record that the money that should have saved her went somewhere else.

What light costs when the system fails

She is sick. She lies on a concrete floor in a health facility. There is no electricity. The power is out, as it often is. The generator exists, but there is no money for fuel.

Someone brings a tadoba. A miniature lantern crafted from scrap metal, burning paraffin on a rag wick. This is what lights the sick. This is what passes for care.

If you need an ambulance, you pay for the fuel. You pay the driver. The vehicle your taxes bought, the driver your taxes employ—you pay again to make them move.

This is not failure. This is design. A design that extracts from women their whole lives and offers nothing in return—not light, not transport, not dignity.

The generator exists. The fuel does not. The ambulance exists. The money to run it does not. The taxes exist. The care does not.

She paid. She pays. She will pay again. For what? For tadoba light over a sick body on a concrete floor.

When the tadoba runs out of paraffin, what then?

What taxes are supposed to do

Taxation has a purpose beyond collection. It is meant to redistribute. To take from those who have more and fund services for everyone. Health. Education. Infrastructure. Social protection.

This is the social contract. You pay. The state provides. Everyone benefits.

In countries with functioning public health systems, this works. Progressive taxes fund universal healthcare. When you fall sick, you go to a clinic. You are treated. You do not pay. Your taxes already paid.

In countries where the contract is broken, the opposite happens. Regressive taxes fund nothing. The wealthy opt out into private healthcare. The poor are left with underfunded public services. They pay twice. They die younger.

The woman in the market pays VAT on everything. That tax is regressive. It takes a larger share of her income than it takes from the wealthy. Her money flows into a system that builds private hospitals for those who can afford them and leaves public clinics to rot.

This is redistribution in reverse. From the poor to the rich. From the woman who cannot afford private care to the system that ensures she never will.

Where do the rich go when they fall sick?

They fly out.

London. India. South Africa. Dubai. The best hospitals, the best doctors, the best outcomes. Paid for with money that was never taxed fairly in the first place.

When a senior official falls sick, they do not queue at the public clinic. They do not wait for drugs that never arrive. They board a plane. Their treatment is funded by the same taxes the market woman pays. Or by money that should have been taxed but was not.

The same system that fails her serves them. The same government that underfunds her clinic approves their travel. The same taxes that buy nothing for her buy first-class treatment for them.

This is not a failure of resources. It is a failure of priorities. The money exists. It is just spent elsewhere.

The clinic that has nothing, the minister who has everything

The Prime Minister visited Mukono and found women on the floor. She went to Kayunga and inspected oxygen systems and improved facilities.

The contrast tells everything. Some hospitals receive attention. Some do not. Some women deliver on concrete. Some do not.

The minister travels for treatment. The permanent secretary flies for a conference. The director's child is delivered in a Nairobi hospital, at public expense.

The woman in Mukono delivers on a floor, using gloves she bought herself. Her taxes paid for the minister's flight. Her contributions funded the director's child. Her labour subsidised their comfort.

This is not an accident. It is the logical outcome of a system designed to serve some and extract from others.

Health as a right, not a privilege

The Universal Declaration of Human Rights, Article 25, says: "Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services."

The International Covenant on Economic, Social and Cultural Rights, Article 12, recognises "the right of everyone to the enjoyment of the highest attainable standard of physical and mental health."

These are not aspirations. They are obligations. Countries that have ratified these treaties are legally bound to realise this right. Progressively. With available resources.

If a woman dies in childbirth because the clinic has no misoprostol, the right has been violated. If a woman pays taxes her whole life and cannot access care, the right has been violated. If a government spends more on travel for officials than on medicine for its people, the right has been violated.

Idah Nantale survived. She slept on the ground, but she lived. Her right to health was violated. She was denied the dignity of a bed after surgery. But she lived.

How many did not?

What the State Should Provide

Universal healthcare. Funded by progressive taxation. Free at the point of use. Accessible to all, regardless of formal status, regardless of ability to pay.

This means:

• Antenatal care that costs nothing and requires no purchases

• Delivery in a facility with drugs, equipment, beds, and trained staff

• Postnatal care that supports mother and child

• Misoprostol available in every facility where women give birth

• Treatment for sickness without payment at the door

• Medicine available when prescribed

• Ambulances that come when called

• Clinics within reach, with staff who are paid and present

This is not a dream. It exists in countries that have decided that health is a right, not a commodity. It is funded by taxes on those who can most afford to pay—wealth taxes, corporate taxes, progressive income taxes. Not by VAT on food and cooking fuel.

The woman in the market already pays for this system. She pays every day. The question is whether she will ever receive it.

What would change if health were funded fairly?

If health were funded by progressive taxation, the woman in the market would pay less. VAT on essentials would be reduced or removed. Wealthy individuals and corporations would pay more. The money would fund services she could actually use.

If health were funded fairly, she would not pay twice. Her taxes would buy care. When she falsl sick, she would go to a clinic and be treated. When she gives birth, she would deliver in a facility with drugs, beds, and staff. When her child needs vaccines, they would be there.

If health were funded fairly, maternal mortality would fall. Women would not die because they could not afford misoprostol. Newborns would not die because there was no incubator. Families would not be pushed into poverty by medical bills.

If health were funded fairly, the minister would not need to fly out. The public system would serve everyone. The wealthy might still choose private care, but they would also pay taxes that fund public services. They would contribute, not extract.

If health were funded fairly, Idah Nantale would have had a bed.

The question that remains

Idah Nantale had surgery. She was a new mother, recovering. There was no space inside Mukono General Hospital. She spent four nights sleeping outdoors, on the ground.

She has paid taxes her whole life. She has paid for every stage of this pregnancy. She has paid for the delivery. She leaves with a baby and a memory of sleeping on concrete.

Other women delivered on the floor. Other women paid unofficial fees for their newborns' care. Other women died from bleeding that misoprostol could have stopped.

They paid. They died. The minister flew. The system that collected from them their entire lives offered nothing in return.

Why?

Why does a woman who pays taxes her whole life have to buy gloves to give birth safely? Why does she sleep on the ground after surgery? Why does she die from bleeding because a drug that costs pennies is not there?

Why does a government that collects from her every day provide nothing when she needs it most?

Why do ministers fly out for treatment while women die in facilities without drugs?

Why is her life worth less than their comfort?

The question is not whether she contributed. She did. Every day. Every purchase. Every fee.

The question is where her contribution went. And why, when she needed it back, there was nothing left—not even a bed.

Idah Nantale survived. She slept on the ground, but she lived.

How many did not?

She could not prove she existed when she needed a loan. She could not access a pension when she grew old. Now she pays to give birth and may die because the system that took from her gave nothing back. The next article examines what women build when the system fails them completely: the safety net they weave from poverty.