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Harmony at craft fair
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Lions linebacker Jack Campbell says he has full movement in lower body after suffering neck injury
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Times are tough for the Chicago Bulls . On Wednesday, they suffered a 135-105 blowout defeat to the defending champion New York Knicks. The Bulls also saw Jalen Smith go down with a left-hand injury , leaving them vulnerable at center. However, though they lost again, Chicago still made some history. For the first time in franchise history, all 15 […] The post Bulls make some history despite blowout loss to Knicks appeared first on ClutchPoints.
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NFL Injury Report, Week 9: Latest news, updates on Bhayshul Tuten, Breece Hall, more players for fantasy football
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Marlins Prospect Discusses Playing in Fall League
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When papers become currency: a Chinese debate about trust in science
Last Saturday, 31 October, I went to the University of Hong Kong’s Beijing Centre for its Talent Forum. It was the fourth stop in the series this year, following events in Shanghai’s Zhangjiang, Shenzhen’s Qianhai, and on HKU’s main campus. The programme covered a remarkable distance in one afternoon. HKU’s Xiao-Jing Wang discussed computational neuroscience, intelligence, and the prefrontal cortex—before even delivering his inaugural public lecture to students back in Hong Kong. His colleague Bing Zhang took us from the Big Bang to artificial intelligence. Tsinghua’s Xue Lan asked how AI might reshape the institutional infrastructure underpinning higher education. There were lively panels featuring industry leaders from JD.com, Xiaomi, Haier—and Kaiser Y Kuo on the closing panel discussing innovation and international connections. I cannot pretend to have followed every detail of the brain models or the astrophysics. The talk that stayed with me was closer to something we have covered before: Zhou Zhonghe 周忠和 on papers, evaluation, and scientific trust. Zhou is a palaeontologist, an Academician of the Chinese Academy of Sciences, and an international member of the US National Academy of Sciences. He is also editor-in-chief of The Intellectual (知识分子), China’s leading science commentary platform. His subject was uncomfortable enough for a room full of successful academics: what happens when the system for recognising good science starts rewarding something else? Part of my interest came from our sister newsletter, The East is Read, which covered the controversy around “Geng Tongxue” in May. A PhD dropout from Beihang University, Geng has publicly challenged papers by prominent researchers through detailed online allegations of manipulated images and fabricated data. At Tongji University, an investigation into a challenged Nature paper found academic misconduct, and the dean of its life sciences school was removed. The affair brought doubts about academic integrity well beyond laboratories and university committees. How could someone outside the established hierarchy spot problems in papers that had passed through prestigious journals and institutions? And what, exactly, had all that prestige guaranteed? Zhou approached these questions through two essays published in July by The Intellectual: one by Wang Xiaodong, director of the National Institute of Biological Sciences, Beijing, and a response by Wang Liming, of Shanghai’s Shangsi Institute of Natural Sciences. Both began with the controversy over Geng. Their arguments deserve a wider audience, so I want to put parts of them alongside what Zhou said on Saturday. Wang Xiaodong’s starting point is evolution. A research system selects for the behaviour it rewards. Grants, jobs, journals, talent programmes, and prizes collectively determine which scientists prosper and which practices get passed down from advisors to students. “Whatever the system rewards is what it will evolve to produce,” he writes, citing the ancient Chinese saying: The King of Chu loved slender waists, and many in the palace starved to death. That is a more demanding diagnosis than saying there are dishonest people in science. Punishing a fraudster does not change the selective environment that made a particular kind of research profitable. His account also gives scientific success an awkward role in the story. As Zhou put it on Saturday, science became a victim of its own success. Once research became central to industry, national power, and economic growth, universities and laboratories expanded, and public money followed. That created an administrative need for rapid decisions: who should get the next grant, the next laboratory, the next appointment? The difficulty is that the true value of a discovery may take years or decades of testing and building to become clear. Resource allocation cannot wait that long. Publication counts, journal prestige, impact factors, and citations therefore become convenient ways to make an instant judgement. “The real problem is not that these indicators have no value,” Wang Xiaodong writes, “but that they are trying to answer a question that only time can answer.” Telling administrators simply to stop counting papers will never be enough. They still have budgets to distribute and appointments to make. Something has to replace the shortcut. Zhou described the consequences inside publishing. Papers acquire ever more requirements: a complete story, polished presentation, extensive datasets, and accessibility to readers beyond the immediate field. Individually, those demands sound reasonable. Together, he warned, they produce formulaic “eight-legged” papers 八股文 and rigid reviewing, while genuinely original or non-consensus work struggles to get past journal editors—some of whom wield immense gatekeeping power despite having limited laboratory experience themselves. Meanwhile, the demands for sprawling, “complete” narratives have fuelled a wider replication crisis. Wang Xiaodong uses a mahjong metaphor to describe the result: put the complex papers published by the exact same lab over several years side by side, and they often look like “Thirteen Orphans” (十三不靠)—every tile completely unrelated to the next, and none of them reproducible by outsiders. Zhou also spoke frankly as an editor who has trouble finding reviewers. Everyone wants someone else to review their work; qualified senior researchers have little time to return the favour. The labour is anonymous, unpaid, and brings almost no institutional recognition, so it increasingly gets passed down to postdocs and graduate students. And while anonymity protects reviewers from rank and personal favours, hyper-specialisation means an author’s most qualified reviewer is often a direct competitor, shielded from accountability. The protection and the problem coexist. Wang Liming takes the argument a step further. The decisive change, in his essay, is the instant conversion of academic honour into material resources. Once a paper can be cashed in for funding, a job, students, commercial investment, or even a company valuation, scientists are alienated from their work: they must keep minting this “research currency” to keep their teams alive. He is careful not to romanticise the past. The old world of gentleman scientists—financially independent figures like Boyle and Darwin who needed nothing from external funders—was also a closed club that excluded people without inherited wealth, women, and much of humanity outside the West. Professional science allowed ordinary people, himself included, to become researchers. Nobody should want to undo that. The problem, in his account, is an exchange system that becomes too uniform and too difficult to correct. His most pointed Chinese example is the “hat” (帽子): the prestigious talent designation that brings continuing access to money, laboratory space, students, and institutional influence. “If papers are the circulating currency of the research system, then a ‘hat’ is a bond that pays interest over the long term,” he writes. A paper at least requires another round of peer review. A title in the Chinese context can lock in a judgement made years ago and turn it into permanent status rent, regardless of whether its holder is still doing good science. Here, official institutions hire, organise, and evaluate scientists. Unlike honours awarded by autonomous academic communities in the West, a Chinese “hat” blends non-scientist administrative power with state authority. Once granted, it turns a past judgement into permanent status rent that is nearly impossible to revoke—because taking a hat off would imply that official authority erred in putting it on. Both Wangs see China as experiencing, at compressed speed, pressures present across global science. Research expansion, rising investment, publication growth, and elaborate evaluation metrics arrived in China within two or three decades rather than two or three centuries. Zhou agreed with that international framing—noting that recent US White House science policy documents and the new president of the US National Academy of Sciences, a fellow palaeontologist who recently visited Zhou’s institute in Beijing, have raised strikingly similar warnings about consensus-bound peer review, short-term project grants, and the replication crisis. Still, Zhou emphasised that China’s traditional hierarchy, personal networks (guanxi), and the ethos that “a good scholar becomes an official” (学而优则仕) amplify those pressures at home. So what would change things? Here Zhou’s tone differed from the call for a revolution in scientific trust in Wang Xiaodong’s essay. As an evolutionary biologist, Zhou favoured patchwork repair (修修补补). Living systems survive through accumulated adjustments; dramatic mutations are usually fatal. Science cannot return to a small, slow-moving pastoral era, especially after the successive accelerations of professionalisation after the Second World War, the internet, and now artificial intelligence. But it can alter the local environment in which researchers work. He pointed to domestic experiments designed to support unconventional research and diversify funding, including Tencent’s New Cornerstone Investigator Program, the Xplorer Prize, and the Future Science Prize. He also mentioned participating in reviews for “major non-consensus projects” under the National Natural Science Foundation of China. One guiding principle he recalled was wonderfully direct: “Failure is allowed; corruption is not” (允许失败，不允许腐败). That distinction would mean quite a lot if taken seriously. An honest attempt that fails should not have to disguise itself as a success to survive an assessment. Wang Liming’s essay adds a sharp caveat to the optimism about new domestic funders. Multiple organisations do not automatically produce multiple ways of judging science. If the same pool of senior domestic scientists makes the decisions through the same two-round review procedures, it is still “fake diversity.” He argues for three distinct kinds of money: broad baseline funding governed by fair procedures; patient funding for questions that take ten years; and non-consensus funding based on individual taste, deliberately empowering a few genuine experts to make biased, contrarian bets on eccentric ideas that would inevitably be averaged out by a committee. Replacing one monopoly with another achieves little; a healthy ecosystem needs variance. Zhou’s proposals for publishing were similarly concrete: strip papers of their resource-allocation burden and return them to recording discoveries and establishing priority; separate dissemination from evaluation, as eLife and Peer Community In do; adopt more modular “micro-publications” and real-name endorsements; recognize the labour of editors and reviewers; and give replication work proper credit rather than treating it as an unpublishable dead end. AI makes every part of this debate more urgent—and Zhou wove it throughout his talk. In his own preparation, he used AI to survey the declining influence of academic monographs, noting how tools are already changing how scholars gather information. More fundamentally, he placed AI as the latest great acceleration in scientific history: just as the internet sped up the pace of research and tightened external resource pressures, AI is compressing the cycle again. In the essays Zhou cited, AI cuts both ways. Wang Xiaodong expects large language models to erase much of the English-writing disadvantage long faced by Chinese scientists, further swelling the flood of papers coming out of Chinese labs. Wang Liming sees AI accelerating both ends of the trust crisis: it lowers the cost of paper mills and fabricated images just as quickly as it lowers the cost of automated image forensics, data auditing, and code reproduction. “Whoever builds the verification layer wins,” Wang Liming writes. His proposed alternative to the static, packaged “story paper” is a continuously versioned “unit of discovery” containing a falsifiable claim, raw data, analysis code, experimental parameters, and an ongoing log of independent checks—where negative results and failed replications are recorded rather than buried. Zhou ended his keynote by bringing AI back to the question of scientific honour and credit. Citing a recent Intellectual discussion on “What AI Means for Mathematics” featuring Fields Medalist Deng Yu 邓煜—at a moment when AI is already batch-solving mathematical conjectures, as HKU Vice-President Lin Chen noted in his opening remarks—Zhou agreed that human researchers must remain the principal agents: AI is a tool that frees scientists from tedious calculation to think about deeper, messier real-world problems. Yet that partnership creates a thorny new evaluation problem. When a breakthrough is made with AI, what is the human contribution and what is the machine’s? And since AI models distil centuries of accumulated human scholarship, is it right that the credit and value flow so heavily to the private AI companies building the tools? The old struggle over how to assign scientific honour is acquiring a whole new layer. What I took away was a serious discussion of how science can remain trustworthy as its scale, incentives, and tools change. These were scientists with real standing inside China’s system questioning how that standing is produced, and proposing changes that would affect their own institutions and peers. That made the afternoon at HKU’s Beijing Centre worthwhile. At the close, Wang Feng, Director of Communications and Public Affairs at HKU, said the value of the forum series—which heads to Hangzhou in December and cities like Chengdu early next year—would lie in the real cooperation it helped bring about. The university has plenty to celebrate: this week it topped the QS Asia rankings for a second consecutive year, alongside its 11th-place position in the QS World University Rankings 2027. For me, bringing this debate to an audience beyond the people who review papers and allocate grants was a useful contribution. Share [ The East is Read PhD dropout’s exposé forces an academic fraud reckoning in China A former doctoral student turned blogger has shaken China’s academic establishment by publicly accusing prominent university scholars of fabricating data and manipulating papers, triggering investigations at several leading institutions and drawing rare attention from state media… Read more 5 months ago · 43 likes · 8 comments · Yuxuan JIA ](https://www.eastisread.com/p/phd-dropouts-expose-forces-an-academic?utm_source=substack&utm_campaign=post_embed&utm_medium=web&embedding_publication_id=47580)
DeVonta Smith still sidelined with injury
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Washington Commanders: 29-Year-Old Trade Candidate’s Injury Revealed
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Giants Announce Major Abdul Carter Injury Update Before Eagles Game
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Seahawks sign former UFL MVP quarterback following Sam Darnold injury
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Lions Linebacker Jack Campbell Shares Health Update After Major Neck Injury & Hospitalization
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Flutter Entertainment plc 2026 Q3 - Results
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Trial to test plasma treatment for burn patients
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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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