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No catastrophic financial hit required to fight climate change, scientists say in landmark court case
Canada does not need to shut down its industries or take a catastrophic financial hit to effectively fight climate change, one of the country's leading climate scientists testified during a landmark trial in a Vancouver courtroom this week.
The Daily Hilario: Here to there, and here again
Your daily dose of off-topic shenanigans
Texas Democrats pull off the breakthrough they’ve chased for decades
For decades, Texas Democrats have dreamt of turning the state blue, rallying around exciting candidates who drew big crowds and big money but could not ultimately overcome the state’s stubborn conservative majority.
Silicon Valley‘s political spending spree meets a blue wave — and a data center revolt
Tech billionaires poured hundreds of millions into the midterms, but it didn’t buy them much.
Europa League lights in Brussels await!
Preview of RSC Anderlecht clashWith four points already on the board and plenty of momentum behind them, our Red Bulls head into a crucial phase of the UEFA Europa League this Thursday at 18:45 CET. I...
Meghan Markle ‘Doomed To Be a Hate-Watch’ on MasterChef Australia
Meghan Markle’s MasterChef Australia gig might grab attention for the wrong reasons. According to a source, the Duchess of Sussex’s appearance in next year’s Junior MasterChef could steal the spotligh...
Washington voters backing initiative to keep transgender girls out of girls’ sports
Washington state voters backing initiative to ban transgender girls from girls' sports, election results show
NYT Spelling Bee Answers for November 4, 2026
Feeling stuck on today’s puzzle? We can help.
Declining influenza vaccinations continue among health care workers
Despite often caring for patients at higher risk of severe outcomes from respiratory virus infection, health care workers in Oregon continue to lag in rates of vaccination against the potentially
It’s time to reunite
Election season is over. Most of us exercised our constitutional right to choose representatives for office who best reflected our values and those we believed were best prepared to lead and solve the very real challenges facing our state, nation and county. The 2026 election season was full of both extreme highs and extreme lows. […]
Democrats seize power in Texas, ending decades of GOP dominance
Texas’ governor, lieutenant governor, attorney general and every other statewide candidate fell, upending the state’s political power structure in one night.
New Children’s Entertainment Releases: What Families Can Watch Together in November 2026
Plan family movie nights with November 2026 kids' releases, featuring animated films, holiday stories and familiar characters.
🗞️ Jesús de Miguel remembered, Champions League Wednesday's front pages
Football is in shock. The death of Jesús de Miguel has stunned the entire sporting world on a Tuesday to forget.On days like this, there is little point in talking about the Champions League or the s...
AI Teammates Launches Ongoing AI Implementation Program for Mid-Market Business Owners
Program builds a working AI system in the first 6 weeks, then continues as an ongoing operating partnership for owners of $1M to $20M businessesSilicon Valley, California--(Newsfile Corp. - November 4, 2026) - AI Teammates, founded by Alice Y. Chen, has launched the AI Architecture Method, a structured implementation program that builds and operates AI systems on behalf of business owners rather than training them to build their own.Image Credit: AI TeammatesTo view an enhanced version of this..
‘This might just be the biggest defeat for big money in politics’: Billionaires poured hundreds of millions into Tuesday’s races and still lost
Elon Musk’s pick lost in Texas and billionaires Vivek Ramaswamy and Rick Jackson lost their own races, though California’s wealth tax is trailing.
Pacific Scientists Build a Regional Picture of a Changing Ocean
Understanding how ocean acidification is unfolding across the Pacific requires more than individual research projects or monitoring stations.
Gardner-Johnson released by Bills after spitting ban
The Buffalo Bills release safety CJ Gardner-Johnson after he serves a one-game suspension for spitting in the direction of an opponent.
“Good Old Days” – Chris Evert Gets Nostalgic as Billie Jean King Celebrates 51 Years Since Her Historic Rise to WTA No. 1
Chris Evert looked back on her tennis career as Billie Jean King marked the 51st anniversary of the WTA introducing its first official rankings and Evert becoming the first-ever World No. 1 in women’s tennis.
Angry Voters Usher in Beginning of the End to the Trump Era
The electoral backlash extended even into deep red states and indicated that President Trump has lost his hold over the coalition that lifted him to the White House twice.
Ex-UK political aide Steve Hilton loses bid for California governor
Hilton, who was endorsed by President Trump, faced an uphill battle as a Republican in the widely liberal state.
Arizona voters poised to approve restrictions on transgender athletes
A ballot measure that would restrict transgender athletes from participating in girls’ sports appeared headed to approval Tuesday night.
WATCH: Democrat Troy Jackson speaks after Maine Sen. Susan Collins concedes
Jackson won election Wednesday to the U.S. Senate representing Maine, defeating Republican incumbent Sen. Susan Collins.
“I Don’t Know If I’m Willing to Do It Just to Fight” – UFC Fans May Have Seen the Last of Beneil Dariush Inside the Octagon
Fans may have already seen the last of Beneil Dariush inside the Octagon. The veteran lightweight has endured a difficult stretch lately, losing four of his last five UFC fights, with all four defeats coming by knockout. Most recently, Dariush was stopped by Quillan Salkilld at UFC Perth in May 2026. Before that, he suffered …
WATCH: Sen. Chuck Schumer speaks after Democrats win control of Senate
The longtime Democratic leader told reporters in Washington that “Americans voted for change” and that there had been a “generational remake of the Senate map.”
Lewiston’s mayor faces runoff after a tumultuous year in city politics
Challenger Rick LaChapelle had 45.7% of votes to 35.3% for Mayor Carl Sheline, according to unofficial results.
WATCH: New York Gov. Kathy Hochul speaks after winning reelection
This is Hochul's second time being elected governor. She was serving as lieutenant governor when Andrew Cuomo resigned in 2021, and she ascended to take his place.
Democrat J.D. Ford wins election to U.S. House in Indiana's 5th Congressional District
In an upset that many analysts did not see coming, Democratic nominee J.D. Ford defeated three-term Rep. Victoria Spartz in Indiana’s 5th Congressional District in Tuesday's election.
Democrats win control of the U.S. House
Democrats win the U.S. House and take unified control of Congress as voters deliver resounding rebuke to Trump.
WATCH: Democrat Annie Andrews' full victory speech after flipping South Carolina Senate seat
Andrews' victory in a state President Donald Trump won three times by double digits is a stark defeat for the Republican Party.
Charity donates mental health packs to primary schools
Amy Watson is offering support through a charity she set up after the death of her partner Joe Phipps.
Flats plan for aparthotel in Reading after business changes
City Wall House's apartments are used less following the pandemic, the building's owner says.
Democrat Troy Jackson wins election to U.S. Senate from Maine
Jackson wins election to U.S. Senate from Maine.
Problems at health trust buildings could cost additional £20m
The maternity building on the Royal Victoria Hospital site is already tens of millions of pounds over budget.
PJHS Halloween
Students and staff at Pleasanton Junior High shared their Halloween spirit, dressing up in spooky and fun costumes and characters.
Democrat Christina Bohannan wins election to U.S. House in Iowa's 1st Congressional District
The third time was the charm for Bohannan, who lost by just 799 votes in her second race against Miller-Meeks two years ago.
Political analysts discuss Wisconsin governor's race results
Democrat David Crowley defeated a Republican with close ties to President Donald Trump on Tuesday, rising from a childhood in one of the nation’s poorest neighborhoods to become the first Black person to lead the battleground state.
The Unlikeliest Democratic Win of All
Few thought South Carolina was really in play until it had already flipped.
WATCH: Republican Ken Paxton speaks after losing Texas Senate race
"I will commit that I will be praying for him, that he will do good for Texas and this nation," Paxton said about Talarico.
How the Stock Market Is Reacting to the Midterm Elections
U.S. stock futures fell as the first results came in, but later traded higher as investors assessed the outlook for artificial intelligence and other key sectors as the balance of power shifts in Washington.
Democrats flip four governorships, extending the party’s inroads into red states
Republicans entered Tuesday’s midterms with a 26-24 advantage in governor’s offices across the country.
Trump says Democrats 'did a good job,' blames Republican candidates for midterm losses
Voters delivered a significant rebuke to President Donald Trump on Tuesday by handing Democrats control of the Senate, rejecting his handpicked candidates while airing widespread concerns about high costs in the wake of his war against Iran and his punishing tariff policy.
Michele Tafoya Loses Senate Race Amid Nationwide Democratic Rout
Tafoya came up short against Democratic Lt. Gov Peggy Flanagan.
Declining influenza vaccinations continue among health care workers
Despite often caring for patients at higher risk of severe outcomes from respiratory virus infection, health care workers in Oregon continue to lag in rates of vaccination against the potentially
WATCH: Democrat James Talarico speaks after winning Texas Senate seat
Talarico's victory represents the first time a Democrat has won a statewide office in Texas since 1994, a shakeup for a state long dominated by Republicans.
Democrat Denise Powell wins election to U.S. House in Nebraska's 2nd Congressional District
Powell flipped a district that Democrats have been targeting for several election cycles.
Susan Collins concedes race to Troy Jackson in stunning political upset
The election all but ends the political career of one of Maine’s most famous and scrutinized elected officials.
Issue 3 trails; voters approve other constitutional amendments
A proposed constitutional amendment that would allow cities and counties to form economic development districts to attract retail businesses and other operations was at slightly below 50% as of 11...
Issue 3 trails; voters approve other constitutional amendments
A proposed constitutional amendment that would allow cities and counties to form economic development districts to attract retail businesses and other operations was at slightly below 50% as of 11...
SC secretary of state wins 7th term leading office for business filings
South Carolina’s longtime secretary of state, Mark Hammond, won a seventh term in office.
El Camino Healthcare District’s Measure S gets the greenlight
A ballot measure to establish term limits for El Camino Healthcare District’s board members appears headed for victory.
Cannabis Legalization Prevails in Massachusetts; Repeal Question Soundly Defeated
Ten years after legalizing adult-use cannabis, the Bay State voters rejected a prohibitionist proposal, Question 8, which aimed to wipe out the industry.
The Midterm Election Was About Health Care
In the face of Trump’s destruction of public health and modern science, voters are putting candidates who support Medicare for All, doctors, and nurses into positions of power.
Accel Entertainment, Inc. 2026 Q3 - Results
2026-11-04. The following slide deck was published by Accel Entertainment, Inc.
Iconic country music act cancels LA show just hours before showtime: 'Flew in from Oklahoma for this!'
If You Can Get 5/5 On This History And Science Quiz, You're Smarter Than 98.4% Of People
Test your knowledge of science and history!
Connections: Sports Edition today: Hints and answers for Nov. 4, 2026, puzzle No. 772
Welcome to Connections: Sports Edition Coach — a spot to gather clues and discuss (and share) scores.
Yankees news: Skubal linked to Yanks
Yankees among several teams in on top FA; Murphy walks back taunt; Chisholm likely to walk
Region semifinal pairings finalized for Watertown, Aberdeen area teams
Semifinal pairings have been finalized in area Class A and B region volleyball tournaments.
US stock futures mixed as Democrats score key midterm election wins
Wall Street faces fresh uncertainty over what Democratic control of Congress could mean for taxes, government spending and regulation.
US stock futures tumble as Democrats score key midterm election wins
Wall Street faces fresh uncertainty over what Democratic control of Congress could mean for taxes, government spending and regulation.
AFGHS co-signatory countries ask health care users to help fill the financing gap
Hundreds of thousands of Ugandans living with HIV on antiretrovirals could be targeted for user fees or community health insurance schemes requiring modest premium payments, according to the April 2026 version of the country’s America First Global Health Strategy implementation narrative.1 As part of the “sustainable financing for the private not for profit sector” strategy, 491 facilities will be targeted for a phased introduction of user fees and scale up of community health insurance programs.2 In the Ugandan context, PNFP facilities include faith-based hospitals and other health facilities, US missionary organizations and centers of excellence—services that are often co-located at government facilities but run with additional financial and technical resources. 402,000 people—or about 28 percent of the total Ugandan adult PLHIV population on treatment—get ART from the private not for profit sector. The selected facilities provide the majority of ART and prevention of mother to child transmission (PMTCT) services. The plan doesn’t give the total number of clients served by the 491 facilities, so it is not possible to give a precise number. But the majority of 402,000 is a figure in the hundreds of thousands—hence the estimate I’m using.3 The April draft of the Ugandan implementation plan narrative is the only one I’ve been able to review. But the government of Uganda is not alone in turning to health care users to help fill the financing gaps caused by the abrupt withdrawal of US funds. In July 2025, the Government of Liberia introduced user fees for previously free services including “registration, accommodation, patient feeding, hospitalization, and a wide range of surgical and diagnostic procedures.”4 Earlier that year, Liberia rolled out a revolving drug fund designed to stabilize drug supplies by “allowing patients to pay a small fee for standardized, quality medications,” according to a Ministry of Health press release.5 (Both of these approaches had been proposed in the National Health Policy 2022-2031; media coverage explicitly connects the launch with the US foreign aid cuts.) The health financing strategies proposed by Uganda and established in Liberia are qualitatively different from user fees officially adopted by specific health facilities to cover funding shortfalls caused by the new US approach.6 The latter is a stopgap, adhoc change. The former is a national governmental adoption of policies that pass costs on to health care users, despite evidence that such approaches can exacerbate inequities and leave deficits unfilled. Two countries does not make a pattern, but they do point to urgent questions: Have other countries, including Liberia, included user fees or community health insurance schemes in their implementation plans? If so, do any of these narratives have what Uganda’s lacks: a fall-back plan in place in case these strategies for sustainable health systems fail to deliver—as they have before? I wonder if you think about it Subscribe Predictable pitfalls Both community-based health insurance and user fees are as old as the hills. And after decades of people climbing up these hills, duking it out, climbing back down—neither strategy has shown the results the Ugandan implementation plan is counting on. This is, in fact, a hill some folks are willing to die on. (You knew I’d get there, right?) In November 2025, an African-led team of health system experts published a paper directed at low- and middle income country governments trying to figure out how to create self-sustaining health systems. The money wasn’t coming back. It had been more than nine months since the season of freezing, waivering and wood-chippering; two months since AFGHS tumbled into the world touting co-financing requirements and reductions in future US government health aid. Governments were looking for strategies for sustainable, self-financed health systems, the authors wrote. For countries considering user fees and community health insurance to fill the financing gaps, they had a simple message: Don’t. On user fees, the paper states: “Reliance on user fees is ultimately a regressive and inequitable approach. It places a disproportionate burden on the poor and undermines health system goals of equity and financial protection. […] There is overwhelming evidence that user fees mobilise very limited resources for the public health sector, making it an inefficient mechanism for revenue mobilisation.” On community health insurance: “Attempting to shift the burden of funding previously donor-funded services, such as HIV care and management, and TB treatment, onto contributory schemes would exacerbate their fragility and fail to protect the population.”7 The WHO says that community-based health insurance “cannot be expected to provide a major source of funding or coverage,” and noted that most schemes offer only moderate benefit to individuals paying into them, and exclude the poorest segment of the population.8 And yet, the US-Ugandan implementation plan says that community health insurance is “the central pillar of this [PNFP] sustainability strategy” and that this approach that will generate “pre-paid pooled funding at facility and community level [that] improves financial risk protection for households, reduces catastrophic out-of-pocket expenditure, and generates structured, transparent revenue streams that can progressively absorb recurrent costs including health worker salaries.” Unfortunately, Uganda’s own history suggests the pillar might not be able to bear this weight. Ugandans Have Been to this Rodeo Before—and Some Want Their Money Back Uganda introduced its first community health insurance scheme in 1996 with support from international donors.9 Thirty years later, somewhere between 0.2 and 0.3 percent of the population is covered by CHI; just over 1 percent has any kind of health insurance.10 User fees were universally introduced in 1993 as a condition of a World Bank loan.11 They were abandoned in 2001, and in 2004—the year I moved to Uganda to watch the free HIV program get underway—a definitive study found that the fees did not improve health systems and outcomes.12 In 2004, most clinics and hospitals had ‘free’ and ‘fee for service’ options for getting care.13 The fee for service, or “cash and carry” programs had often been established in the years prior to PEPFAR and the Global Fund to Fight AIDS, Tuberculosis and Malaria. People who could afford to paid for the drugs, often at facilities in the private-not-for-profit (PNFP) sector. When free drugs arrived, some people who’d been paying kept on doing so, perhaps because of shorter wait times, greater confidentiality, convenience or other factors. But in the year that I spent visiting the same clinics around the country week after week—including a “center of excellence” that maintained separate days for cash and carry clients and those accessing free ARVs—lots of people who had been paying tried to switch to the free option. They’d paid because they had no other choice. They’d sold pieces of family land, begged family members for loans, bought pills by the week, and sometimes by the day. Or they were just cash-strapped, like most of us, and wanted the funds for other things. 14 Twenty-two years later, this hasn’t changed. Ugandans pay out of pocket for 30-40 percent of their health care costs, leading one paper to declare that “falling ill is more than a health crisis. It is a financial emergency.”15 One recent study found that up to 48.5 percent of households dealing with tuberculosis sold something, took out a loan or dug into savings to defray the costs of TB care—which is supposed to be universally free.16 The Ugandan implementation plan does anticipate challenges. It proposes a phased approach, with 187 facilities introducing user contribution systems in Year 1, 152 in Year 2, and 153 in Year 3. Willingness to pay and feasibility studies will precede roll out; fees will be tiered by region, and a waiver system is proposed to ensure that no one has to pay who is unable to. Moreover, the plan provides for quarterly reviews of epidemiological data to “ensure that user contributions do not compromise epidemic control gains, ART continuity for the client cohort, TB case management, or PMTCT services.” Alt text: A screenshot of a table included in the implementation plan narrative that is the subject of this stack. It’s got a fetching pink bar at the top. It uses the abbreviation “CHI” which is Community Health Insurance, and FBO which is Faith Based Organizations, and it details the number of facilities that will implement user fees with waivers and community health insurance schemes over the five years of the agreement. As I said in the footnote, this is a super interesting document with a lot of other rich material. Tell me what you see—and what you would have focused on. And if you’ve seen something like this, or anything else that strikes you, in another implementation plan, tell me that too. You can use the Substack message platform or try me on Signal at @endaplague_again.25 (because @mercoonfan was, weirdly, taken). But the plan doesn’t fully explain what will happen if this approach doesn’t work out. Yes, progress will be monitored, and corrective action triggered. However, there is no specified funding replacement if premium and fee revenue prove inadequate. Instead, the authors write, “Currently, COEs serve a total client cohort of over 180,000 across 28 facilities. In the initial years, the U.S. Government (USG) will provide financial support for clients; over time, user fees generated by COEs will become the primary source of funding for sustaining their services.” Failure does not really seem to be an option. Health insurance schemes are more acceptable to the Ugandan population than user fees. Members of Parliament and civil society traveled to Ethiopia to see how that country’s scheme worked. In a follow up report, a veteran civil society group recommended allowing the “health insurance ecosystem to grow organically and [to] keep reviewing the law and regulations as this growth takes root.”17 One study found that more than three-quarters of Ugandans were willing to join a health insurance program.18 However, coverage of community-based health insurance is minimal, as is coverage of any kind of insurance—including private plans.19 A national health insurance scheme bill has been stalled for several years and presently sits with President Yoweri Museveni.20 Community-based health insurance scheme that do exist are expanding in number, but losing enrollees. Between 2022 and 2026, the number of community-based health financing schemes across the country increased by 42 percent, while the number of people enrolled decreased by nearly 11 percent.21 None of this means that community-based health insurance should not happen in Uganda—or that people do not want insurance. It doesn’t even mean that user fees and waivers won’t ever work. But there is highly relevant evidence from Uganda and the surrounding region that it is quite optimistic to describe community health insurance and user fees as central supports for sustainable financing in any sector of the health system. And now for the best-case scenario In the best-case scenario22, the Ugandan approach does exactly what it sets out to do, and so does the Liberian fee structure and revolving pharmacy fund—though I’ve not confirmed that these are in the MoU. In one best-case scenario, Uganda is an outlier, and user fees and community health insurance are not recurrent pillars of self-sustaining financing in other countries’ implementation plans. In another best-case scenario, all countries that include these strategies enjoy success beyond anyone’s evidence-informed wildest dreams: reliable funding generated by health care users fees, great health care outcomes for everyone, no exacerbation of inequities, no crippling household debt. No sold land, repurposed school tuition or high-interest loans. In the best-case scenario, not one of the hundreds of thousands of Ugandans living with HIV receiving antiretrovirals from 491 PNFP facilities misses a refill or leaves care because of user fees or community health insurance premiums. This is the best-case scenario for these people for their own health, and for their families. It is also the best-case scenario if Uganda wants to stay on the path to eliminating HIV as a public health threat. According to the country’s most recent data, 96.5 percent of people living with HIV on antiretrovirals are virologically suppressed. Epidemic control depends ensuring that 95% of people living with HIV know their status, 95 percent of those individuals are on ART, and 95% of those individuals are virologically suppressed. Uganda is still struggling with the first “95"—a frankly abysmal 85.3 percent. If HIV epidemic control and the attendant prevention of new infections, avoidable suffering and premature death matter, the country cannot afford to lose any clients who are currently in care.23 As I write this a couple hours before the polls close for the US elections in the city I live in, I say with soul-deep sincerity: I am rooting for the best-case scenario. I think it’s safe to say that we all are.24 I think it’s also safe to say that if the US and co-signatory governments have inked plans that lead to successful expansion of community health insurance and strategic use of user fees, we all would like to know, now, so that we don’t miss the opportunity to celebrate when success happens. The implementation plan narratives have to enter the public domain. They are the fullest expression of a strategy co-created by two governments. There are assumptions and details that people living in the US and co-signatory countries need to understand that are not available in the MoUs or, to date, in the Congressional Notifications. Some of these details can help other countries that are, as I write this, still working on implementation plans. Others, like a solid count of how many other countries have plans for expanding user fees or health insurance, are important for regional and global health architecture reform initiatives. No matter how this election night turns out, there will be a slew of new Congressional member orientations, briefings and talking points papers in the next few months. Release of implementation narratives should be a bullet point in every context that AFGHS is discussed. These documents can be redacted so that procurement sensitive information isn’t disclosed. There is much more historical precedent for sharing such documents than there is for relying on user fees to fill health financing gaps. Let’s look at the information together so we can hope for the best and prepare for, you know, the other thing. Alt text: A substack first: a bicep selfie! It’s my arm - peachy-white skin, black shirt (flannel, notch neck, too hot for this appallingly balmy November weather, if you’re wondering) and a sticker that says I VOTED 2026. Beige letters on red for I voted. Beige on blue for 2026. You bet I did.25 In your wildest dreams. Subscribe 1 This is a really, really rich 95 page document. There are fascinating ideas and detailed plans in it. It is all worth reading AND I have, in this post, highlighted an instance of content that could pose challenges and certainly posits success of strategies that haven’t worked before. I would love to hear what readers’ see that’s interesting and should be lifted up as something to check for in other implementation plans. I will also shortly be adding a static page to the substack site where implementation plan documents will live. I will put the url into this footnote and it will also be there on emilybass.substack.com by the end of the week. Uganda Implementation Narrative Section 4 April 22 2026 Draft 1.51MB ∙ PDF file Download Download 2 User fees are costs charged for visits, labs, medicines or other health services, usually at the time they are provided. Community health insurance, or community-based health insurance, is what the World Health Organization calls “micro insurance,” which is health insurance targeted at low-income people. 3 As usual (by which I mean always), please prove me wrong. 4 https://smartnewsliberia.com/liberias-ministry-of-health-announces-2025-hospital-service-fees-for-public-facilities/?utm 5 https://moh.gov.lr/news/2025/grand-cape-mount-leaders-residents-embrace-new-community-pharmacy-program/?utm 6 https://www.christianitytoday.com/2026/09/hiv-usaid-pepfar-africa-foreign-aid-cuts-mission-hospitals/?utm 7 https://gh.bmj.com/content/10/11/e021270 8 https://www.who.int/news-room/fact-sheets/detail/community-based-health-insurance-CBHI 9 https://pmc.ncbi.nlm.nih.gov/articles/PMC2827475/ 10 https://pmc.ncbi.nlm.nih.gov/articles/PMC10861328/#b3-jpmph-23-110 11 https://pmc.ncbi.nlm.nih.gov/articles/PMC527704/ 12 Same citation as the footnote 2 - the article is called “Learning from failed health care reform in Uganda.” To which I say: If only. If. Only. 13 There is a whole taxonomy of user fees to be aware of, if not commit to memory. Out of pocket costs are everything that someone pays for themselves. In this Stack, user fees are planned and policy-supported out of pocket costs. There are also out of pocket costs that people pay to buy drugs or receive tests or health care assessments that would be free if the drugs were on the shelves, or the machines or kits were available, or the staff were on site. A user fee is usually designed to be modest, pegged to willingness to pay, and may be waiveable at the point of care for anyone who is unable to do so. The costs for things that would otherwise be free are whatever the market will bear and people either have to pay them or go without. Out of pocket costs for services and stuff that aren’t available in public facilities are different again from bribes or unofficial fees that some health workers may impose, even though most are indefatigable, tireless and tired, and devoted to their clients. 14 For the record—which really is these footnotes—I would give a whole stack of fridge magnets for a systematic analysis of the economic and social impact of the Mass Unemployment Event in AFGHS countries among the very people who used to be able to afford and cover user fees, both for themselves and vast family networks. Locally employed USAID technical staff, house cleaners, caregivers, drivers and technicians were financial anchors for cousins, friends, friends’ children, friends’ childrens’ cousins, teachers, pastors, neighbors and so many other kinds of kin. Aid recipients lost direct funding; many other people who had not been aid recipients, but parts of the elaborate care webs that function as safety nets for so many people, lost crucial support too. And that’s even before we get to the people who worked at the hotels and restaurants and bars where people employed by the US and its implementing partners used to spend disposable income. Those businesses have lost revenue; those folks have lost jobs. It will be some time coming—and someone will have to fund this work—but I do hope it happens. And I hope, as usual, to be proven wrong. 15 https://eprcug.org/blog/how-out-of-pocket-healthcare-costs-keep-driving-ugandans-into-poverty/ 16 Another straight-to-the-point journal article title. Households experiencing catastrophic costs due to tuberculosis in Uganda: magnitude and cost drivers. https://pubmed.ncbi.nlm.nih.gov/32938411 17 https://www.cehurd.org/download/technical-policy-brief-on-community-health-insurance-scheme/?wpdmdl=13661&refresh=6ae9122f5d4ed1793659439 18 https://pmc.ncbi.nlm.nih.gov/articles/PMC10125197/ 19 https://pmc.ncbi.nlm.nih.gov/articles/PMC10861328/#b3-jpmph-23-110 20 https://ugandapost.news/uganda-to-make-health-insurance-mandatory-by-2026/ 21 https://shu.org.ug/download/235 22 With a nod, tip of the stack hat, and wag of the Mercoon tail to a deeply valued reader who told me that I have a tendency to speculate about the worst-case scenarios a little too much of the time. 23 https://news.mak.ac.ug/2026/10/uphia-2025-shows-ugandas-hiv-status-awareness-gap-despite-strong-treatment-outcomes/ As you’ll see in the next footnote, I’ve already written a subSubstack on another topic, so I will be brief with regard to the study referenced in this article. The Uganda Population-Based HIV Impact Assessment, or UPHIA, will never happen in this way again. For more than a decade, PHIAs have been supported by the US government as a way to generate accurate estimates of country progress on key HIV indicators. They are a holdover from the PEPFAR program that was laser focused on ensuring US taxpayer dollars subsidized progress in pandemic control. There may be other population-level surveys and the data may even be publicly released, as the entire set of FY2026 MER data have not. But PHIAs will never happen again. If you’re wondering whether the estimates of HIV progress at country level might get less reliable….you’re not alone. 24 Ooh baby, I hate “we” in almost all forms. But sometimes I go there, when I am looking for company, which I am. Because this Stack moves into the somewhat-uncharted territory of assessing what the implementation plan narratives may suggest about co-signatory countries’ roles and responsibilities to the people living within their borders. The MoUs, specimen and data sharing agreements were templates. Countries’ answers fit into pre-specified questions that did not include, “how are you going to fill financing gaps and stabilize your health system as this plan unfolds?” In contrast, the implementation narratives are open form—the product of co-creation between the two governments. Co-creation can mean lots of things, but nothing leads me to believe that implementation plans are ghost-written by the US government, or that contents were imposed by the US counterparts. Instead, I think the parts of the plans that read like country government initiatives are endorsed, if not initiated by, those governments. For instance, the Ugandan implementation plan narrative describes plans for revenue-generation through fees charged for equipment calibration, repair and maintenance provided through Uganda’s National Equipment Calibration Laboratory, and laboratory accreditation through the Uganda National Accreditation Service (UGANAS), targeting private sector, PNFP, research and academic clients. That’s super specific and also quite ambitious. It doesn’t read like an American idea. There’s also a provision for solar panels, and other stuff that feels country owned and driven. This is where it gets interesting. If co-creation is the case, then both the US and co-signatory governments are accountable for the contents and the outcomes. Most discourse about AFGHS to date has focused on the decisions that America has made, or demanded that other countries make. The AFGHS architects have monopolized the hot seat. As they should, in so many ways. America absolutely created the conditions under which countries needed to come up with health financing strategies to fill unanticipated, catastrophic funding gaps. And with not-too-long a lens, we can look back and see that America is also on the hook for its role in the Bretton Woods institutions that made user fees and health system fiscal austerity conditions of loans during the era of structural adjustment. But in the here and now, it is not at all clear to me that the US is requiring Uganda or any other country to implement specific approaches to sustainable financing. Instead, it is as the authors of that paper up in footnote 6 suggest: African governments have agency. As implementation plans roll out—whether or not the narratives are shared—it will be important to understand what this agency looks like and what it means for people, including the poorest of the poor. And it will be important to figure out how to talk about it safely, respectfully and critically in places other than the literal and metaphorical footnotes. 25 This week’s song is “Once upon a time” by the Moody Blues. (I know, this is gonna be a weird, largely banger-free end of 2026 playlist. HMU with requests.) AND please do watch the video and appreciate the truly amazing opening sequence—a drum kit wasteland, a coupla plastic bags, a bit of sand. Sort of like the hill where fiscal austerity policies that put costs on health care users might go to perish. But then there’s a lady with amazing hair. It’s worth it.
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