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OpenAI: ChatGPT Search Is About 20% of Google’s, 250 Million People Speak With ChatGPT, and Chat Is Merging With Work
OpenAI says ChatGPT growth is accelerating. The company added 200 million users over just the past two months, jumping from 1 billion to 1.2 billion weekly active users in 60 days. Its search volume, it says, is approximately 20% of Google’s. Its users create 1.5 billion images with it per week. And its voice mode, between dictation and speaking with ChatGPT, now has 250 million combined weekly active users. ChatGPT consumer product lead Adam Fry told me this during a brief fireside chat at an OpenAI-hosted dinner in New York City on Monday night. “The growth is just going big,” he said. During our conversation, Fry also revealed plans to merge ChatGPT’s Chat and Work modes (so that confusing toggle up top will soon go away), agreed with feedback that ChatGPT-created restaurant signage looks too uniform, and addressed the cost to serve its personal assistant Dots. Here’s a look at our full conversation, lightly edited for clarity and length. We also cover image generation, interactive interfaces, advertising, education, and public unease about AI: Alex Kantrowitz: OpenAI has analyzed ChatGPT’s search volume and compared it with Google’s. What did you find? Adam Fry: ChatGPT has been growing quite quickly. ChatGPT’s volume of search-like queries is now roughly one-fifth the volume of queries of Google. It’s a pretty amazing statistic when you think about it, mainly because we started just about a year and a half ago. It’s hard to remember this, but ChatGPT at a time didn’t have any up-to-date information. You’d ask a question, it would say something like, “It’s past my training date,” and nobody had any idea what that meant. You’re saying ChatGPT’s search volume is one-fifth of Google’s. Bing’s share of the search market is around 5%. Does that make you multiple times larger than Bing? To say that more directly, ChatGPT has gone from one billion to 1.2 in just the last two months. That’s roughly 100 million users in 30 days, and another 100 million in another 30 days. The growth is just going big, and we’re staying very focused on how fast ChatGPT is growing. What counts as a search? I might have 20 prompts back and forth in a ChatGPT conversation. Does each one count as a query? Story continues below… A MESSAGE FROM OUR SPONSOR Move upmarket without a rebuild Moving upmarket means saying yes to what enterprise buyers ask for first: SSO, directory sync, and audit logs. WorkOS gives you all three, so your team keeps building the product instead of the checklist. Get enterprise-ready. Continued from above…. Adam Fry: What people came to ChatGPT for to start, if you go back about two years, is really writing help and coding help. Those wouldn’t be things that you really search for. What we’ve seen over the last year is people have grown into all these other topics. Things like you’re looking up a person or people or a place or a thing, and it requires up-to-date information. That’s a key element. Another big part is finance questions or health questions, where you really want to make sure it’s up-to-date information that’s quite factual, and we’ll do a web search for those questions. It’s basically anything that a user would have traditionally gone to a traditional search engine for, but is now deciding to go to ChatGPT for. Does each conversation with a search embedded count as one search, or does every question that requires a web search count? Every time you ask a question and go search the web, that’s a search. You used to work at Google. How would you say the nature of search is changing? One of the things that people really love about ChatGPT is this personalization and this understanding of the broader journey. If you look in the past, people would go for a Q&A box, and you’d ask a one-off question, like how tall is the Eiffel Tower. But there’s so much context in our lives around, “Maybe I’m taking a trip to Paris.” It’s actually helpful for ChatGPT to respond, “Here’s how tall the Eiffel Tower is, but I know you’re going on a trip to Paris.” It’s that ability for people to actually maintain context over time that has led them to start using ChatGPT in this way. You’ve also announced 250 million weekly active users of voice input, including dictation and conversations with voice mode. We are at 250 million weekly active users. What’s amazing about this is, if you look at those 250 million, what we’re seeing is it’s actually also incremental to the product. It’s no longer just a novelty. People aren’t just trying out voice. We’re seeing them use voice input day to day in their daily life, and it’s grown so quickly. Those 250 million users are using voice input, and that could just be a quick question or a long conversation. We’re seeing both behaviors. We’re seeing people just not want to type. You just hold it and start talking to it, or it turns into a longer conversation where people just sit with it. The big reason for this is the frontier capabilities of our models that we’ve shipped. We shipped what we call GPT Live 1, and then we shipped GPT Live 1.1. The big change with this is that it’s much more natural to speak with. It’s something we call backchanneling and interruptibility. Mhhhm… What you just did there is what the model does, because it’s really good at having a bidirectional conversation. That push to the frontier—we were the first to really release this at scale—has made it so much more natural for people to chat. That’s still only about 20% of the user base. From the outside, that looks small. Why is it exciting from the inside? It’s very exciting for a few reasons. We see from the data that when people start using voice, they stay around using voice. One of the things, transparently, we can do a better job of is bringing more people into discovering it. We see that the number of people who discover it could be a lot higher. But once they do, it’s a really new way for people to interact with AI. We’ve made a lot of improvements to it too, where we’re just going to see the number go up. You have background mode, so now by default, if you close the app, it’ll show, “Hey, the conversation’s still going.” If you want to walk around the house or you’re putting away the groceries, you can still have a chat. That kind of continuity has also changed how much people use it. Dots launched on September 29 and is about a month old. How’s it doing? It’s doing great. We talk to people about their Dot, and the first thing that everyone says is, “I love my Dot.” One of the reasons we’re seeing this is the proactivity, its ability to reach out to you and figure out things. The biggest use case I see all the time is, “Did I forget something today that I was supposed to do?” You can just say to your Dot, “Remind me of things at the end of the day that I may have forgotten. Somebody emailed me or messaged me,” and it’ll do that. This Dot changes the paradigm of the relationship with AI, where it’s actually helping you and giving you time back. You’re more conservative with permissions than some competitors. I tried to give my Dot my credit card, and it wouldn’t take it. With the creator of OpenClaw in-house, why are Dots’ permissions more limited? This is a space where we want to be very thoughtful and conservative because it’s a new space where you’re entrusting your Dot to take care of things on behalf of you that matter and are meaningful. We’ve just talked about how you go to this 1.2 billion user growth and asking questions. Now we’re asking people, “Can you ask ChatGPT or your Dot to help get things done?” But when you ask it to help get things done, it’s a whole new level of trust. We’ve built up a tremendous amount of trust in giving the right answers to your questions, and we want to make sure that when we build this new product, it has a high degree of trust. It’s a long game. We think this is going to be a new market for a very long time, and we want to make sure that we’re being this trusted player in the market to start. I initially thought Dots would be available on my $20 plan, then realized I had to spend $100 a month to get it. I upgraded, but I’d like to downgrade at some point…. We hope to keep earning your business and make the value good enough. It’s a really good point. ChatGPT’s goal more broadly, which I think is unique for us in the market, is we are focused on bringing intelligence to everyone safely across the entire world. For Dots in particular, there’s no difference. We don’t have anything to share tonight about the date of when Dots will go to a broader set of users. But you can rest assured we’re working very hard, and there are a couple things we have to get right. Over time we’re going to work on more efficient, agentic models that are able and capable of doing things for you. The first one is, right now we wanted to make sure that your Dot is actually really helpful. We started with some of our best models, but over time we’re going to work on more efficient, agentic models that are able and capable of doing things for you. The second thing is around proactivity. We’re still dialing in: How much do I message you to help you get things done? We can always play around with that to understand how much usage should a user use to have a successful Dot. We’re going to work on both, and our goal and ambition is to bring it out to all users. How much background computing does a Dot require? I’ve read estimates that serving a $100 subscriber might cost OpenAI $3,000 in compute, and mine seems to read every email that arrives. How often is it checking connected data sources? Right now, Dots are on the compute-heavier side, and this is one of the things we want to make sure that we can dial back over time. But the goal is to give you the best product. This is our premium, always-on personal assistant. Once we nail that, we’ll figure out how to dial back the compute needs. The thing we’re seeing also from our models, as we train frontier models, is just how—I can’t even keep up with how quickly we have a new model, and each new model is more efficient. If you looked at 6.1 Sol when it came out relative to Astra, much more efficient. I’m very excited about the next set of models we have coming too that’ll be even more efficient that we can use. Elon Musk said the cost of serving Grok Bot was unsustainably high relative to revenue. Is efficiency the key to winning against competitors, or is there more to it? There are a couple of factors that go into it. One is the cost side, but the other is the revenue side. On ChatGPT and on our consumer business, we’ve been extremely proud of our ability to diversify different revenue streams in a way that’s growing really fast. To give you another stat, we announced several months back that we had passed 50 million subscriptions, and the number has grown considerably since then. On ads, within 200 days, we reached more than a billion in ARR, and that business is growing extremely quickly. We also have credits. Rather than paying for subscriptions, users can buy more credits. Between credits, subscriptions, and ads, I’m confident that the value of a Dot is going to be able to pay for itself. Elon has subscriptions too. This is clearly an expensive product to serve. One thing we continue to bet on at OpenAI and ChatGPT more broadly is that the models will continue to get much better and much cheaper, way faster than any of us think. If you look back at the historicals on it, it continues to be true. From what I’ve seen, I see no slowing down of that. What is Meta doing right with Muse? It has spent a lot of time atop the App Store charts. There are a couple of things they’ve done well. The first is people have been craving simplicity in their products. One of the things we have stated publicly as well is, at times AI products can be too complex. We’ve announced we’re merging ChatGPT’s Chat and Work. We’re making it much more simple in the products. You don’t have as many toggles or sliders between efforts and different model pickers. One of the things they’ve done well is this simplicity. You just go in and you can ask a question. You don’t have to think too much about what you’re doing. That’s one thing that seems to have resonated with users, which we also believe in. Second, there’s something really nice about being able to access your agent across many different channels. We just announced and launched Dots on iMessage. Whether you talk to your Dot on email or iMessage or within the ChatGPT app, the ubiquity in getting your assistant out there is going to be key. Those are two things that, if I had to be nice to our competitors, I would say were two big ones. So Alexandr Wang’s meme-tweeting strategy isn’t something you’re going to emulate? I have a different tweeting style. ChatGPT still asks me to choose between Chat and Work, even though some people call this technology AGI. Will that distinction go away? Couldn’t agree more. We have to solve this. Asking users to choose — we’ve heard repeatedly from all of our users it’s too much to understand. When should you go to Chat? When should you go to Work? It’s solvable. There’s real research to solve to make sure the models can understand what your intent is. Are you asking for a fast, quick reply? Are you asking me to go do a long agentic task? We’re going to solve it, and the plan is to bring Chat and Work together. So one interface will work out whether I’m asking for a conversation or a task. When? Coming soon. You told me the majority of ChatGPT’s 1.2 billion users are using image functionality. What are they doing? Today, 1.5 billion images are created per week. It’s hard to even wrap my head around that number. They’re doing a wide range of things. One of the most interesting things they’ve started to do is really use it for productivity use cases. The first thing it started with—I don’t know if you saw the ’80s trend, but it was quite fun. You could take a photo of yourself and say, “Put me and my family in ’80s outfits.” I did this for my family, and it was a really fun poster. But what we’re also seeing is businesses for their menus, or posters for birthdays. People are using it almost in a productivity-like fashion to create visual diagrams of what they would like to see. We’ve actually brought the latency down on images as well, so it’s gotten a lot faster. It went from a very high number of seconds to getting much faster. As it comes down even further, the number of images people are creating and the number of use cases is going to grow a lot. My feature request: When a restaurant makes a menu or sign, prompt it for more specificity so it doesn’t look like every other AI-generated restaurant sign. Or offer a shuffle button for a different style. I agree with the feedback, and we’ll take it to the team. I’m seeing ChatGPT generate little interactive interfaces within its answers. What’s the direction for Intelligent UI, and how are people using it? I am extremely excited about Intelligent UI. If you go back a couple years, these chat apps were all text, and now that’s changing. They’re going to be visuals. Intelligent UI and our first attempt at this with GPT-6 Intelligent UI is really just the beginning. As you go to the extreme, what you can imagine is, let’s say you’re using voice mode, and you just say, “Show me how offside works.” Immediately it should show you a visual diagram, and you say, “No, I don’t quite understand it.” It should just repopulate. That’s where the future of this technology goes. It’s almost like you’re talking to a canvas that will update and change. People are finding it helpful for a lot of things. My favorite one is—it’s hard to admit that I had no idea how hearts work. The last biology course I took was in high school. I just asked it, “How does the heart work?” and it instantly gave me a beautiful interactive diagram of where blood flows and how it goes through. I’m really, really bullish on this for learning in particular. You’ve described useful applications in finance, health, and learning, and ChatGPT has 1.2 billion users. If people are getting so much value, why is public polling on AI so negative? The reality with AI is it is going to change the nature of how work gets done. For a lot of people, that is something that can feel scary at times, and we’ve all felt that. But I remain confident that when people actually use the product and they use AI, it very quickly changes how they perceive it. We’re at 1.2 billion, but there are still a lot of people who haven’t used it. The more people use it, get familiar with it, how it can actually help you in your life, it’s going to feel a lot less scary. Big Technology is a reader-supported publication. To receive new posts and support our work, please consider becoming a paid subscriber. Thanks!! Subscribe
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The Last Disney+ Original?
(Welcome to my weekly streaming ratings report, the single best guide to what’s popular in streaming TV and what isn’t. I’m the Entertainment Strategy Guy, a former streaming executive who now analyzes business strategy in the entertainment industry. If you were forwarded this email, please subscribe to get these insights each week.) Before we get going, I wanted to remind readers about how I plan to keep your trust while I add advertising to this newsletter. As you’ve no doubt noticed, I’m running ads now, but the danger is that it could impact my analysis and writing. I have a list of sponsors on my About Page, so if you think I’m biased, you can check out who’s sponsored this newsletter! This is something that I’m not sure anyone else in digital media does (if you’re a writer or media outlet and you do this, let me know and I’ll shout you out!) but it’s something I’d love to see embraced by the entire industry. Sunlight, i.e. transparency, is often the best disinfectant. Okay, on to this week’s issue. We (finally) have another major Disney+ TV show to talk about, so that’s my main focus for today. Plus, we had a lot of new shows come out, including the fourth seasons of The Diplomat and Tulsa King! And Love is Blind! The Lowdown! Also, four (four!) straight-to-streaming films came out this week, featuring a lot of big names and celebrities, so I’m going to look at those. All that, mixed news for the WNBA, Reacher ends its run on the charts, Skydance does well in September viewership, NYU’s Sundance dominance, all the flops, bombs and misses, and a whole lot more. Let’s dive right in! (Reminder: The streaming ratings report focuses on the U.S. market and compiles data from Nielsen’s weekly top ten viewership ranks, Luminate’s Top Ten Data, JustWatch and Reelgood interest data, Samba TV household viewership, company datecdotes, Netflix hours viewed data, Google Trends, and IMDb to determine the most popular content. While most data points are current, Nielsen’s data covers the weeks of October 12th to October 18th, 2026. You can find a link to my terminology here.) Subscribe Television - Disney+’s Porridge Problem Listen, per my headline, VisionQuest isn’t the last Disney+ Original. At least, I’m pretty sure it’s not. They have other MCU shows in development. Well, maybe one: But it sure feels like the end of an era. I’d call it their “porridge too hot” era, to quote myself from The Ringer. I told Ben Lindbergh that Disney+ seemingly couldn’t figure out the right amount of content. In the heights of the Streaming Bubble Era (circa 2019 to 2022), they started releasing an insane amount of TV shows. After their growth slowed, they’re down to two or three shows a year, and that might be down to 1 by 2027. Here’s my TV shows by year chart: Even at the time, I thought Disney was making too many shows (that cost too much). Today? They’re definitely making too few shows (though the budgets are more in check, at least according to the reporting). Porridge too hot, porridge too cold; too many shows, now not enough. Which makes evaluating VisionQuest so interesting. This show didn’t have a great lead-in, whether it be a Marvel Cinematic Universe film (the last non-Sony-produced-Spider-Man flick came out The Fantastic Four from July of 2025) or Marvel Cinematic Universe TV show (the two this year were Wonder Man back in January and _Daredevil: Born Again_in May, both of which underwhelmed). And so far, VisionQuest hasn’t quite recaptured the MCU Originals glory, but it has some signs of sparks. First, it made Samba TV, though at a lowly ninth place. At least it made it, a feat some other Marvel shows didn’t accomplish. (Ironheart landed on the Samba TV charts one week at tenth place, but Wonder Man and Daredevil: Born Again both missed.) VisionQuest also made Luminate, though with only 3.0 and 7.6 million hours. But it missed Nielsen in its first week. The best news might be its 7.8 on IMDb, on 12K reviews so far, great numbers, even for a superhero show. Looking at those numbers, this show will really need to pick up in future weeks—and it may since it’s coming out weekly—or Disney will have another disappointment on its hands. Disney+ binge-released their last few shows to try to boost numbers, but that meant shows like Iron Heart and Wonder Man didn’t last long on the charts. _Daredevil: Born Again’s_last season missed entirely (though it came out weekly). Here’s the Disney+ Originals by totals: And for a fun new look, here are those same shows, rearranged by the years they came out: That really shows that, in addition to Disney+ releasing fewer shows, those shows just don’t hit like they once did. If I had to offer one main explanation, it’s that Marvel Studios moved away from characters who starred in the Avengersmovies (The Scarlett Witch, Vision, Hawkeye, Loki, Falcon, Winter Soldier) to characters who didn’t (Moon Knight, She-Hulk, Iron Heart, Wonder Man, Daredevil). It sounds trite, but more popular IP tends to do better than less popular IP. In Marvel’s case, beloved, decades-old characters trump newer ones. And yes, I think this is a problem for Disney. The failure of Marvel TV shows to linger for weeks on the charts, unlike in 2021 and 2022, explains why Disney’s share of the charts has plummeted: That’s a strategic issue. Yes, these shows are really expensive, but without them, Disney+ will struggle, especially if Disney+ keeps raising prices AND licenses out its shows non-exclusively. My recommendation? Return to the core value proposition, which is Disney+ as “genre HBO”. The goal is six shows a year, coming out weekly, spaced out throughout the year. When a show hits, keep it coming back. Make three to four of those shows Marvel or Star Wars, and fill out the rest with IP swings like Percy Jackson, Goosebumps or something like National Treasure. And make YA-skewing shows like Coven Academy to fill out the schedule. Disney, you can get this porridge just right, er, make the right number of shows. Quick Notes on TV Netflix’s sophomore, er, junior, er, senior season slump abated very, very slightly this week. I speak of The Diplomat, which returned for its fourth season on 15-Oct. Credit where credit is due, this show debuted in April of 2023, and has put out new seasons every year since. Has that helped the viewership? Not really. This season opened to 16.4 million hours, which is down significantly from the first season (21.7 million hours) and down somewhat from the second season (18.0 million hours), but it is up from last year’s 14.2 million hours opening. On Samba TV, it opened to third place; that’s also very good. On Luminate, it opened to 25.0 million hours, which is good, but over thirty million hours is a hit on that platform. Netflix wisely renewed it, since it’s steady and, frankly, Netflix needs hits.1 Paramount+ put out Tulsa King’s fourth season on a Friday. After putting out most of their big, usually-Taylor Sheridan-scripted shows out on Sundays last year, they’ve clearly moved to Fridays going forward. Was this a thought-out strategic change, Netflix mimicry, or a data-inspired move? Tough to say. Fridays are crowded with new movies, but so are Sundays with new shows. Anyways, this one is coming out weekly, and we haven’t seen it hit the Nielsen or Luminate charts yet. But it did make Samba TV at fifth place, which is a good opening. Still, if this doesn’t make Luminate or Nielsen next week, I’d call it a disappointment. Netflix had two unscripted shows hit the charts this week, one a docu-series and one a reality competition show. Tyson is a four-episode docu-series about one of boxing’s most popular fighters, and it made both the Samba TV and Luminate charts, but not Nielsen. That’s a solid run for only four episodes (assuming it didn’t cost an arm and a leg to produce). Netflix’s latest season of Love Is Blind also returned for its eleventh season, which opened to 10.0 million hours, down from previous seasons. It also had 11.0 million hours according to Luminate, roughly in line with the Nielsen numbers. Last issue, I analyzed the triple successes of Below, Carrie and Crystal Lake, noting that all three have done well. I mostly used Nielsen, but all three shows also made Samba TV (see above). Crystal Lake in particular did very well on Luminate, getting 35.0 million hours, top for Peacock among first seasons: The top “show” of the week would have been Thursday Night Football again, at 41.7 million hours. This is still above last year’s game, but it continues the season’s overall downward trend, which happens every year. (Though a big week is coming, based on the news stories I’ve seen.) As I said before, I’ll do a deeper dive on all the October games later this month, with comparisons to previous years. One company is quietly on a roll, when you consider the shows it makes and streams. I speak of Skydance—a point Variety made—noting that it produces Neagley and Reacher for Amazon, along with Paramount+’s Lioness, which means it produced three of the top four shows of September according to Nielsen. By the way, Neagley fell off the Nielsen charts after four weeks, which is a pinch short for how well it started, but it’s still a huge success. (Interestingly, it finished just 7.3 million hours ahead of the cancelled Ride or Die.) The point, though, which I’ve made before, is that Prime Video still has a problem with how many co-productions it buys, most notably _The Boys_from Sony and Reacher/Jack Ryan from Skydance. It’s not a critical flaw—everyone licenses shows—but Amazon still struggles to make its own hits. Reacher finally fell off the Nielsen charts, so here’s its final rank for season four: We’re just getting started with this issue, but the rest is for paid subscribers of the Entertainment Strategy Guy, so if you’d like to find out… ...An example of the algorithm NOT picking a film… …whether or not Netflix buys shows simply for the movie poster… ...if East of Eden is above the Obliterated Line... ...what four star-studded straight-to-streaming films didn’t chart... ...and a whole lot more... ...please subscribe! We can only keep doing this great work with your support. If you want an idea of just how much content you’d get in a full issue, check out this older issue.
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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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Alabama was just dealt some major news days before the team's showdown against LSU. The post Alabama Dealt Surprising News Days Before SEC Showdown vs. LSU appeared first on HEAVY.
‘This is not about politics. This is about people’: UN warns of impact of deadly drone strikes in Sudan
Intensifying drone attacks on civilian infrastructure across Sudan are disrupting electricity, water and fuel supplies, putting lives at risk and hampering the delivery of humanitarian aid, the UN’s top official in the country has warned.
Chiefs Must Target Colts WR Josh Downs Before Deadline
The Kansas City Chiefs need a wide receiver upgrade after a tough loss. Insider analysis shows why Josh Downs is the perfect trade target for Mahomes.
What is the zeptoverse?
BBC science correspondent, Pallab Ghosh, takes us into the zeptoverse and explains how it could change our ideas of how the universe works.
California voters could reshape the state's landmark environmental law with Prop. 45
California voters decide if Prop. 45 should set deadlines on environmental reviews and lawsuits for housing, water, broadband and transit projects.
‘Lot of Us Concerned About You,’ ‘Sending You Love’ — NFL World Reacts As ESPN Reporter Announces She’s Stepping Away Due to Health Issues
Jenna Laine has been a familiar face on the Tampa Bay Buccaneers beat for years, so her absence from the press room did not go unnoticed. The ESPN reporter has now explained that she needs time away to deal with medical issues, though she has not said when she will return.
Small Business Saturday marketing ideas for 2026: 15 tips to help you sell more
By Mary Beth Eastman for ERGO NEXT Small Business Saturday (Nov. 28, 2026) is more than a shopping day. It’s a chance for retail shops, restaurants and
Moroccan-Belgian Superhero Picture ‘Atoman’ Secures North American Release
EXCLUSIVE: Disrupt Entertainment has acquired all North American distribution rights to North African superhero picture Atoman ahead of an international sales push for the film at the AFM. The Pennsyl...
The million-dollar bull business: Forget the cowboys, the bulls are making big money, too
From six-figure prize money to lucrative breeding deals, elite bucking bulls have become the stars of a booming, multimillion-dollar business.
Taylor Red singer Nicole Taylor dies at 35 after ‘aggressive’ breast cancer diagnosis
Nicole’s identical triplet sisters and bandmates, Nika and Natalie, announced her death on social media.
Women Who Shape Schroon Lake: Local leaders gather for women in business panel
Women business leaders in the Schroon Lake region will gather to share ideas during a free panel discussion.
Chilling Health Update On Former Bruins Forward Jarome Iginla
While he isn’t known for his time with the organization, Hall of Fame NHL forward Jarome Iginla did spend one season of his illustrious career as a member of the Boston Bruins in 2013-14. Iginla, who was reportedly going to be traded to the Bruins from the Calgary Flames at the 2013 NHL Trade Deadline, […] The post Chilling Health Update On Former Bruins Forward Jarome Iginla appeared first on HEAVY.
Lakers predicted to trade for $150M high-intensity defensive menace to pair with Luka Doncic
The Los Angeles Lakers are slowly becoming a tough team to beat. They could get even tougher by getting this defensive pest in a potential deal.
Save Over $1,000 Off the Lenovo Legion RTX 5070 Ti Gaming PC With 32GB of DDR5 RAM for Black Friday
This first good deal I've seen on a Lenovo Legion gaming PC since the summer.
First U.S. bird flu death of the year after cattle exposure
A person in Washington state has died from complications of the bird flu, the AP reported yesterday. It’s the first such death this year in the U.S., and the third overall since bird flu became a major public health concern in 2024.
Death is big business in I.Coast, where funerals cost fortunes
Valerie Bli Lou is a shopkeeper from a modest family, but she is determined to give her late father the sumptuous funeral that Ivorian tradition demands -- whether she can afford it or not.- Tears and...
Trump says $4 billion in Israel military aid will end this year, citing political reasons
President Donald Trump on Tuesday said he made a deal with Israeli Prime Minister Benjamin Netanyahu that will see the U.S. "cut off" military aid to Israel this year.
Juan Atkins, Detroit techno music pioneer, dead at 64
LOS ANGELES — Juan Atkins, the Detroit club music producer who pioneered techno as a genre, has died. He was 64. Atkins' death was confirmed in a social media post
John Frieda, Celebrity Hair Stylist and Hair Care Business Entrepreneur, Dies at 75
The celebrity hair stylist’s death was announced by his salon on Tuesday, Nov. 3
Former Duke QB Daniel Jones Named as Surprise Trade Candidate
There could be a big surprise at the trade deadline involving a former Duke player.
Do you need a preventative rabies vaccine? Probably not.
It might seem like a good idea, but it could just complicate things for your doctor.
‘Lawyer up’: Democrats take the House, and warn Trump’s family businesses are first in line for subpoenas
Democrats can’t override Trump’s veto, but the incoming Oversight chair promised to probe the family’s crypto deals, and other family businesses.
NFL Power Rankings entering Week 9: Broncos are 6-2 but need to improve, perhaps with some pre-deadline trades
Popular Sherlock Holmes TV Show With Harry Potter Star Update Is a Great Sign for Season 2
A Sherlock Holmes show starring a Harry Potter actor has secured multiple international distribution deals after a strong U.S. performance. The development expands the show’s reach across several Euro...
Republic of Ireland to face Spain as NI draw Poland
The Republic of Ireland will face world champions Spain in the 2027 Nations League, while Northern Ireland take on Poland in League B.
Grading the Game: Nebraska
Last week I wrote that Nebraska would be a much stiffer test than Iowa, and that an offensive collapse in Lincoln could put bowl eligibility out of reach again. For 56 minutes, that’s exactly what it looked like. Then Washington scored 14 points in the dying moments and won 17-10, improving to 5-3 overall. Nebraska […]
LSU student cooks up her passion for comfort meals into a business out of her on-campus apartment
Sometimes, the best part of college is going home to a home-cooked meal and getting back to your childhood favorite foods. Eighteen-year-old Ziya Rosenthal, owner and chef behind Midnight Rouxx, understands the love for fresh, prepped comfort foods. Based out of Nicholson Gateway Apartments, Midnight Rouxx gave Rosenthal the chance to create her ideal school-and-work...