The EconomistFebruary 1st 2020 Middle East & Africa 412 torship of Saddam Hussein in 2003, the
cleric has sought power. He styles himself a
local hero who endured American sanc-
tions and Saddam, while other elites lived
the high life abroad. That has given him
clout on the street, which he occasionally
cashes in for a seat at the table. In 2016 he
led a large rabble that occupied parliament.
Last year the political bloc that he leads,
called Sairoun, won the most seats in par-
liamentary elections.
Mr Sadr is also eyeing two other impor-
tant positions. The commander of the Pop-
ular Mobilisation Force (pmf), Abu Mahdi
al-Mohandis, was killed in the American
drone strike on Qassem Suleimani, Iran’s
top commander, on January 3rd. The pmf
co-ordinates Iraq’s powerful Shia armed
groups; Mr Sadr would like to control it. He
has been meeting pmfcommanders. Last
month he made a show of his strength by
recalling his Mahdi Army.
But the post he most covets is head of
Iraq’s clergy. Currently Grand Ayatollah Ali
al-Sistani, a respected 89-year-old, sits
atop the clerical establishment. Mr Sadr,
half his age, has had a go at him before. The
Mahdi Army seized the holy city of Najaf,
the seat of Mr Sistani, in 2004—until Amer-
ica’s army forced it out. Today followers of
Mr Sadr predict he could mount a theologi-
cal challenge. Though just a hujjat al-islam,
or junior cleric, he has spent over a decade
in the cloisters of Qom, Iran’s clerical capi-
tal, improving his scholastic credentials
and ties with Iran’s rulers.
Mr Sadr may hope to become Iraq’s ver-
sion of a supreme leader. But it will be a
bumpy ride to the top. Some in his ranks
seethe at his betrayal of the protesters.
Sheikh Asaad al-Nasari, a close associate,
declared he would remain on the street.
The protesters, for their part, detect disar-
ray in the governing ranks. They sound em-
boldened. “Without Suleimani the militias
are sheep without a shepherd,” says Faiq al-
Sheikh Ali, a liberal parliamentarian who
claims to be the protesters’ choice for
prime minister. He wants American forces
to stay in Iraq to keep Iran out.
Both sides hope to exhaust the other,
but they might end up exhausting ordinary
Iraqis. Business is grinding to a halt. With
oil prices low, the budget deficit is widen-
ing. Fears are mounting about the govern-
ment’s ability to pay salaries. Meanwhile,
President Donald Trump threatens to seize
Iraq’s foreign assets and impose sanctions
if the government persists with its request
for American troops to leave. He has al-
lowed Iraq to bypass American sanctions
on Iran and buy its gas and electricity. The
waiver expires in mid-February. It might
not be renewed, particularly if militias
continue to lob rockets at America’s em-
bassy in Baghdad, as they did on January
26th. Iraq is desperate for some calm. But
continued unrest is more likely. 7
A
sickpersonwouldoncehavetosell
land or cows to pay hospital bills,
says Owen Orishaba, a teacher in the
Kigezi highlands of Uganda. But now “a
goat can solve your problem.” Four years
ago he joined a community health-insur-
ance scheme managed by Kisiizi Hospi-
tal, a church-run institution. With
45,000 members, it is the largest of its
kind in the country. Its success illus-
trates a wider truth: to deliver services to
poor, rural people, begin with the sys-
tems they have built themselves.
In principle, Ugandans can get free
health care at public clinics. In practice,
government health centres are short of
money, medicine and staff. The state
accounts for only 15% of health spend-
ing, with another 42% coming from
donor aid. Almost all the rest comes
straight out of people’s pockets at private
or faith-based facilities. Uninsured
patients sometimes run from their beds
to evade bills, says Moses Mugume, an
administrator at Kisiizi Hospital. Even as
he talks, a tearful woman, who is not in
the insurance scheme, is brought into his
office after being caught doing so.
How to reduce the burden on patients
while generating steadier funding for the
hospital? The answer lay in the hills. For
generations, villagers had carried the
sick down from the steep slopes and
thick banana groves on an engozi, a
stretcher made from vines and bamboo.
They also pooled their savings to cover
burial costs and to support bereaved
relatives. As Mr Mugume tells it, the
hospital went to these informal societies
and asked them a question: “Why do you
wait for death to occur? Why don’t youpreventdeath?”
In 1996 the hospital began enrolling
engozigroups in health insurance. Group
leaders register members and collect
premiums, which range from 11,000 to
17,000 shillings ($3-4.50) per person a
year. Members make a small co-payment
to access services, such as 3,000 shillings
for a basic examination or 40,000 shil-
lings to deliver a baby. Chronic condi-
tions are not covered, to keep costs
down. Group enrolment is a way to enlist
the strong alongside the sickly.
The impacts are not just financial.
Patients with insurance are less likely to
be admitted to hospital than those with-
out. That is because they show up earlier,
when their conditions are more easily
treated. A study by Emmanuel Nshakira-
Rukundo and colleagues at the Universi-
ty of Bonn estimates that child stunting
falls by 4.3 percentage points for every
year that a household is in the scheme.
The cost still puts off the very poorest.
Only about a quarter of the hospital’s
patients are insured. But Kisiizi shows
the potential to build on institutions
which, as Mr Nshakira-Rukundo puts it,
“emanate from a place of social sol-
idarity”. In neighbouring Rwanda five-
sixths of the population are enrolled in
state-run health insurance delivered
through local groups. By contrast the
Ugandan government’s plan for a nation-
al health-insurance scheme, currently
before parliament, says little about
community models. Schemes like that at
Kisiizi could continue alongside state
initiatives, says Walimbwa Aliyi, a health
official, but are too thinly spread to be
the basis for it.Whywaitfordeath?
Health care in UgandaKISIIZI
How a Ugandan hospital delivers health insurance through burial groups