The success of efforts to promote social protection in Uganda since the early 2000s has varied considerably, with cash transfers progressing much further than social health insurance. Using original primary research and a process-tracing methodology, we show that external actors were able to form a coherent policy coalition around cast transfers and promote them in ways that became aligned with the dominant ideas and incentives of powerful actors within Uganda’s political settlement. In contrast, proponents of health insurance struggled to mobilize a coalition capable of overcoming actors with greater holding power, particularly the President and private sector actors. Whereas ‘just giving money to the poor’ fits with Uganda’s increasingly personalized-populist political settlement, the hard work of building a credible health system, and formally requiring citizens to contribute to their own healthcare, requires a commitment and capacity to promoting a new social contract that seems to be lacking in Uganda.