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American Farmers’ Politics Are More Complicated Than Headlines Suggest | Nonprofit Quarterly | Civic News. Empowering Nonprofits. Advancing Justice.
Michael Shepherd studies the politics of rural communities. How does he think about farmers as voters?
Bear Hollow Zoo Mourns the Loss of Beloved Black Bear Yonah
Bear Hollow Zoo is mourning the loss of Yonah (16), an American black bear who was humanely euthanized on the evening of November 1 following complications from severe pneumonia. Yonah was surrounded
‘ResearchED’: Building the Case for Learning Science, One Saturday a Time
It started with a single gathering in London in 2013. Thirteen years later, it finally reaches the American heartland.
Six-Story Medical Office Building Tops Out At Broward Health North In Deerfield Beach
Florida YIMBY says "Yes In My Backyard" to positive new development in Florida.
Mineral separation facility coming to Eastman Business Park secures $54M; Aims to strengthen American supply chains
A rare earth mineral separation facility that's coming to Eastman Business Park has secured about $54.2 million.
CA-NINTENDO-OF-AMERICA
In this photo provided by Nintendo of America, fans line up to be among the first to buy The Legend of Zelda: Ocarina of Time for the Nintendo Switch 2
Vance Breaks With Trump and Steps Into Political Abyss | WSJ Politics Newsletter for Nov. 5
Plus, Democrats’ disciplined messaging on the economy paid off on Election Day, and how midterm results threaten America’s AI boom.
How Big Pharma Shapes Medical Science, Influences Doctors, and Undermines Patient Care
This week, Mad in America explores three new articles around pharmaceutical industry corruption. The first examines industry’s hidden influence over Three new studies expose the pharmaceutical industry's hidden influence over medical research, the use of ghostwritten academic papers to advance commercial interests, and the normalization of industry influence among future physicians.
Bryan Adams is thinking about war with America (in 1814)
"It's about respect," said Adams, whose new album reflects Canada's conflicts with President Trump. "Have have some respect for the past, and not just decide one day, 'Oh, this is better for America or whatever.'"
Holiday retail jobs are moving away from the sales floor
Americans are still buying plenty of stuff for the holidays, but they're getting more of it online. That calls for a shift in staffing.
Tiny Chihuahuas Hold a Big Surprise: A Sliver of Coyote DNA
The breed is descended from indigenous canines, which may have been intentionally mixed with wild coyotes long before Europeans arrived in the Americas.
Inflation pushes young voters to Democrats in 2026 midterms
Younger Americans are worried about the economy and high prices. They also swung Democrat in the midterms.
Trump Administration Delays Awards Slated To Improve Rural America’s Health
State leaders who scrambled to win and begin spending their first-year shares of Republicans’ five-year, $50 billion fund are in the dark about how much they’ll receive in the Rural Health Transformation Program’s second year after a federal office notified states that more time is needed to make allocations.
Many Americans have lost faith in science, but we can win them back
In July 2014, a man sick with Ebola flew from Liberia into Lagos, Nigeria, one of Africa’s largest and busiest cities. One imported case in a place like that could
Iranian Leaders Cheer Trump’s ‘Political Defeat’ as Republicans Blame War for Midterm Losses
Iranian leaders have hailed what they say is Americans’ rejection of the war, while Republicans look for answers and Democrats decide what’s next.
Dissecting Colorado’s Democratic sweep
Swoosh. Donald Trump came into his second term with a swoosh. He brought in Elon Musk and his tech bros with a swoosh. They swooshed out thousands of government employees across the nation. Then Trump’s ICE agents swooshed out thousands of recent immigrants, with some American citizens caught in the crossfire. Then Trump swooshed in […]
Longer reproductive lifespan and hormonal history may influence brain vascular health
A longer reproductive lifespan and a history of using birth control pills or menopausal hormone therapy were associated with certain signs of blood vessel health in the brain, according to a study published November 4, 2026, in Neurology, the medical journal of the American Academy of Neurology.
Famed Iron Age king was actually a woman
Meet Verica, ancient Rome's 'barbarian femme fatale.'
Mahoning Valley arts and entertainment
Art ASHTABULA ARTS CENTER, 2928 W. 13th St., Ashtabula: “Hope in Artistry: Suicide Awareness & Prevention,” through Nov. 21. Hours are 9 a.m. to 5 p.m. Monday through Thursday, 9 a.m. to 4 p.m. Friday and 9 a.m. to 1 p.m. Saturday. ashtabulaartscenter.org and 440-964-3396. BUTLER INSTITUTE OF AMERICAN ART, 524 Wick Ave., Youngstown: “In […]
‘Rent is due’: Mamdani on Americans rebuking Trump administration
New York Mayor Zohran Mamdani told CNN’s Jake Tapper that the midterm election results reflect working-class Americans’ frustration over the government’s failure to address their concerns.
America’s political landscape is shifting -- NBC Nightly News anchor Tom Llamas breaks down midterms
Trump Wrestles With New Reality: A Lame Duck With Two Years Left to Fight
After a decade at the center of American politics, President Trump is politically wounded, with diminished power. Those who know him say the next two years will be unpredictable.
'Hopefully things get done': Americans react to historic political shift
The BBC spoke to voters from different states for their reaction to Democrats taking control of both the Senate and the House of Representatives.
"Cars That Moved America" automotive exhibition coming to Griffin Museum of Science and Industry
The technological evolution of the automobile has been the subject of some kind of exhibition at the Griffin Museum of Science and Industry going back more or less forever, but next year, a new approach to the subject with a new collection is coming.
STRIPED fights to make eating disorders a public health priority | Harvard T.H. Chan School of Public Health
A new video from the American Public Health Association features the work of the Strategic Initiative for the Prevention of Eating Disorders (STRIPED).
Haaland won election. Now, how will she govern?
By Kevin Hendricks — New Mexico made history Tuesday night with Deb Haaland winning her campaign to be the first Native American woman to win a governor’s seat. Haaland, a Laguna Pueblo member and former U.S. Interior secretary, beat Republican Gregg Hull by 14 points to become New Mexico’s next governor. She takes office Jan. […]
Accused puppy thief tried selling stolen goods back to business: Redlands police
An Inland Empire man already in trouble with the law for allegedly stealing an American Bully puppy was arrested again last week after police say he broke into an electronics store and then tried to sell the merchandise back to the business to pay for repairs to his cellphone. Redlands police responded to a burglary […]
How a blue wave crushed the tech right
The Democratic wins that swept America on election night was a backlash against data centers, and a rebuke to Silicon Valley elites.
NYC Mayor Mamdani says Americans want 'change they can feel in their wallets
Mayor Zohran Mamdani says the election was a referendum on national politics and a sign that Americans want leaders focused on affordability and working families.
Peter Schrager attempts best Steve Kornacki impression
News coverage in America now looks a lot like sports coverage with its focus on horse races, battlegrounds, numbers, and analytics. So it was only appropriate that Peter Schrager paid tribute to America’s leading elections expert, Steve Kornacki, on Election Day. Kornacki has become a cultural phenomenon on NBC’s election coverage, thanks to his touchscreen…
Mavs, Stars Exit: What It Means for Dallas Business
An economist’s analysis finds the teams generate just $5,000 in additional spending per game at businesses closest to the AAC. The bigger loss may be something Dallas can’t put a price on.
CAIR Md. Welcomes Muslim, Pro-Justice Election Victories, Calls Results a ‘Decisive Rejection’ of Islamophobia, Politics of Hate
The Maryland office of the Council on American-Islamic Relations (CAIR), the nation’s largest Muslim civil rights and advocacy organization, today welcomed election victories by Muslim candidates and leaders committed to justice, civil rights and Palestinian human rights in legislative races across
Kraft Heinz to sell coffee business that includes Jacksonville Maxwell House plant for $650M
Kraft Heinz has agreed to sell its North American coffee business to an affiliate of One Rock Capital Partners for an enterprise value of $650 million, while keeping a 30% stake in the business.
Entertainment, Expanded: Cinema Entertainment Centers Redefine an Exhibition Standard
Since the dawn of the exhibition industry, cinema owners have been looking for ways to bring customers through their doors. Now regarded as essential to the cinema experience, things like air conditioning and concessions were once hot new amenities to expand audiences and further establish cinemas as a focal point in communities and American culture. […]
Trump’s billionaire-blue collar coalition has been smashed by class politics
As tech bosses get richer and ordinary Americans struggle, Democrats put the case against the US’s grotesque unfairness – and voters responded, says Guardian columnist Aditya Chakrabortty
Democratic women surge past 100 House seats as Republican women lose ground
Voters also elected the country’s first Black and first Native American female governors as women won a record number of governorships.
Science advocates react to Democrats' historic midterm rout: 'It's a new day in Washington'
Researchers and advocates say they hope the 'blue wave' could signal more accountability after two years of attacks on science
Incumbent DA reelected by 3 to 1 margin in Hancock County
Incumbent District 7 top prosecutor Bob Granger of East Blue Hill swept up nearly three times as many Hancock County votes as his challenger, Steven Juskewitch, a Dedham attorney, on
How Science and the Environment Fared in the 2026 U.S. Midterms
Science was on the ballot across the United States in Tuesday’s midterm elections. On federal, state, and municipal levels, hundreds of people with backgrounds in science, technology, engineering, mathematics, and medicine ran for office. Americans also voted on measures related to conservation projects, pollutant abatement, healthcare access, and environmental reviews.
Fidel Estrada Jr., East Austin business owner and community elder, dies at 90
Fidel Estrada Jr. spent decades running Estrada's Cleaners and helping lead an East Austin community network.
Hancock County votes In a new probate judge
There’s a new probate judge in town. Well, in Hancock County.
Leading the Health Care Workforce Through Change: Leadership, Policy, and Innovation in Action
On Sept. 17, human resources (HR) and employee relations leaders from seven essential hospitals gathered in Washington, D.C., for “Leading the Health Care Workforce Through Change: Leadership, Policy, and Innovation in Action.” Hosted by America’s Essential Hospitals and Essential Hospitals Institute with support from the Robert Wood Johnson Foundation, the convening focused on strategies for […]
Holidays at Disney or Universal? What to do, how to choose
Park Pulse is USA TODAY's weekly guide to what's happening across America's national parks and major theme park destinations, including Disney and Universal.
Hannah Pingree wins governor’s race
Democrat and former Maine House speaker Hannah Pingree has won the gubernatorial election, beating out her Republican adversary Bobby Charles and Independent Rick Bennett.
An Opportunity for Renewal and Progress on Science and Democracy
The American people have spoken, and they clearly want a Congress that will prioritize their well-being over corporate interests; that will help ease the affordability crisis instead of worsening it; and most of all, a Congress that will stand up to the authoritarian, destructive impulses of Preside
AIG pulls back growth target amid mounting pricing pressure
American International Group is backing away from its prior expectation of low- to mid-teens premium growth in 2026 amid rising competition and declining rates across several lines of business.
Kraft Heinz to divest its North American coffee business in $650 million deal
Kraft Heinz will divest its North American coffee business to private equity firm One Rock Capital Partners as CEO Steve Cahillane works to revive the company.
CAIR, CAIR-MI Congratulate Sen-Elect Abdul El-Sayed on Defeating the ‘Politics of Hate’ to Become First Muslim Senator
Muslim civil rights and advocacy groups praise people of Michigan for rejecting hate and Muslim voters for record turnout The Council on American-Islamic Relations (CAIR), the nation’s largest Muslim civil rights and advocacy organization, and its Michigan chapter, CAIR-Michigan, today congratula
As Holidays Approach, No One Cares About Amazon’s Biggest Business
Amazon quietly became America's largest company by revenue, yet holiday shoppers and Wall Street investors seem far more focused on its AI ambitions than its massive e-commerce engine, and that split attention may be hiding a serious risk.
The Donald Trump Era in American Politics Is Ending
The takeaways from the midterms are clear: no amount of billionaire spending could overcome the fact that Donald Trump’s dominance is coming to a close, the Left has much more room to grow, and we have entered a period of new possibility in US politics.
Kraft Heinz Selling North American Coffee Business for $650 Million
Kraft Heinz is selling a controlling stake in its North American coffee business, including Maxwell House and Gevalia, to One Rock in a $650 million deal.
Aroma Joe's now open in Bucksport
Aroma Joe's has opened its new location, its 58th in Maine, at 80 US-1 in Bucksport. The newly built, 1,170-square-foot coffeehouse and drive-thru features coffee and espresso drinks, flavor infusions,
Commentary: Rural and religious Americans lost faith in science. We can win them back
In July 2014, a man sick with Ebola flew from Liberia into Lagos, Nigeria, one of Africa’s largest and busiest cities. One imported case in a place like that could
Two home health agencies in N.J. gain recognition from Newsweek
Valley Home Care and Atlantic Visiting Nurse have ranked on Newsweek’s list of “America’s Best Home Health Agencies 2027.”
Permanent daylight saving time has a dark side, scientists warn
A new study warns that permanent daylight saving time could force American children to make at least 2 billion additional school commutes in darkness, potentially increasing safety risks and disrupting their biological clocks. Researchers found that fatal crashes involving school-aged pedestrians were roughly twice as likely during dark mornings as after sunrise.
Trump’s Whole Theory of Power is in Ruins
More than any American president, Trump has used fear as a central tool of policymaking. He doesn’t look so fearsome today.
Winners and losers from the 2026 midterm elections
Millions of Americans voted in a midterm election with incredible consequences on billionaires, taxes, AI regulation, and data centers.
Three Trade Partners for the Detroit Tigers This Winter
With the team needing relief pitching and several teams needing outfield help, the Detroit Tigers have several potential trade partners. The Motown team allowed 11 walk-off hits in 2026 and blew 32 saves, both the most by an American League team. Although their offensive core and deep starting rotation will be back for next season, …
These 9 candidates for governor just made history
Voters on Tuesday elected the nation's first Black woman governor and the nation's first Native American woman governor.
El-Sayed Celebrates ‘an America Big Enough for All of Us’
In Michigan, Adbul El-Sayed outlasted former Representative Mike Rogers in a Senate campaign marred by ugly attacks.
Bioiberica makes Fi Europe debut by showcasing science-backed branded ingredients for next-generation functional foods and beverages
Bioiberica, Booth 51C69, Food Ingredients Europe (Fi Europe), Messe Frankfurt, November 17-19, 2026
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.”
Before the Dawn in America’s Heartland
With hardly a cloud in sight, astronauts had a sweeping view of nighttime lights in the U.S. Midwest.
Event to celebrate anniversary of ‘Gone With the Wind’
Ninety years after Margaret Mitchell introduced readers to a world that would become one of the most recognizable stories in American literary and cinematic history, the story is coming home.
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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