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Holiday market brings Southern California vendors to Escondido as small businesses face rising costs
A holiday market at Rancho Guejito Vineyard in unincorporated Escondido is showcasing 30 Southern California vendors navigating higher costs and tighter spending this season.
Sony Pictures Home Entertainment to Release Horror Thriller 'Crawlers' Digitally Nov. 10, Disc Dec. 22
Sony Pictures Home Entertainment, together with Saban Films, Nov. 5 announced the retail release of horror thriller Crawlers on digital retail platforms on Nov. 10, and on packaged media Dec. 22. The movie generated more than $1.1 million at the global box office, including $688,000 across North American screens. In the movie, a catastrophic infestation … Continue reading "Sony Pictures Home Entertainment to Release Horror Thriller ‘Crawlers’ Digitally Nov. 10, Disc Dec. 22"
El-Sayed’s message to voters on Election Day: ‘Two very, very different visions’ between him, Rogers
Explore the Grand Theft Auto VI Launch Gallery
Grand Theft Auto VI is now officially only two weeks away. Today, enjoy a stunning look at Vice City and beyond with a collection of new screenshots on the official site.
Ratchet & Clank: Ranger Rumble Shutting Down Less Than a Year After Launch
It was announced less than a year ago, but Ratchet & Clank: Ranger Rumble — a mobile spin-off of the flagship PlayStation series — has been canceled.
Western Washington farmers brace for impacts after bird flu detected in Pierce County
Farmers across western Washington are bracing for potential impacts, after bird flu was detected at a commercial poultry facility in Pierce County.The Washingt
Distracted Eating Linked to Higher Odds of Heart Risk Factors in Kids
A Brazilian study found eating with screens on was linked to higher odds of stacked heart and metabolism warning signs.
United Airlines introduces personalised Spotify streaming through inflight entertainment
United Airlines is partnering with Spotify to let passengers stream their personal accounts directly through seatback screens.
New Mexico Health Care Authority prepares benefit recipients before sweeping changes
NEW MEXICO (KRQE) – More than 20% of New Mexicans depend on SNAP benefits to feed their families, and more than 40% depend on Medicaid for health care, including Jineene Jaramillo. “When you …
Sioux Falls development firm joins national agricultural advisory company
Sioux Falls-based A1 Development Solutions has joined Pinion, a national food and agriculture business advisory and accounting firm.
Patriot Support Programs of UHS and Wounded Warrior Project Join Forces to Connect Veterans with Specialized Behavioral Healthcare and Ongoing Support - Florida Hospital News and Healthcare Report
Collaboration creates a connected continuum of care and long-term support tailored to the needs of Veterans, Service members and their families. November 4, 2026 — Universal Health Services’ Patriot Support Programs […]
The surprisingly complicated science of perfect curling ice in Wisconsin
From Olympic lucky coins to microscopic imperfections, making curling ice requires an extraordinary level of precision. Just ask the ice crew in Wausau.
EA producer tells the inside story behind new Wing Commander remasters
It's mostly bad news from EA lately but preservation efforts are nice to see.
Armed suspect allegedly robs man outside business in North Columbus
A person was robbed at gunpoint on Nov. 3, after a suspect allegedly followed a victim out of a business in the 2800 block of Osceola Avenue and demanded money
Private equity-backed equipment rental business opens seventh New England location
The sales and service center in Bourne on Cape Cod is aimed at landscapers, arborists and homeowners.
Rockstar shares 38 new screenshots of Grand Theft Auto 6, showing off Vice City, Jason and Lucia, and much more
Rockstar Games have released an album of new in-game Grand Theft Auto 6, which offer perhaps our final peak at the game before its launch later this month.
Zelda: Ocarina of Time Remake Has Two Native PC Recompilations with Frame Generation and DLSS, While a Switch 2 Emulator Fork Runs It on Jailbroken PS5s
The Legend of Zelda: Ocarina of Time remake now has two native PC ports, while a fork of the Eglantine emulator runs it even on PS5 consoles.
AMC Entertainment Q3 Earnings Call Highlights
AMC Entertainment (NYSE:AMC) reported record third-quarter revenue and adjusted EBITDA as a stronger box office, higher attendance and demand for premium screens helped the theater operator return to a quarterly profit. Revenue rose 31.6% from a year earlier to $1.711 billion, while net earnings we
How A Syrian Hospital Is Achieving 76% Childhood Cancer Survival Despite War And Shortages
Speaking on the latest episode of Global Health Matters, Ghanem joined Dr. Zainab Shinkafi-Bagudu, founder of Nigeria’s Medicaid Cancer Foundation and
Buffalo Academy of Science celebrates new middle school on former Medaille campus
BUFFALO, N.Y. (WIVB) — The Buffalo Academy of Science Charter School celebrated a milestone on Thursday at the former Medaille University campus. Years after the college has closed, the Buffa…
Hundreds receive free health care at Columbus pop-up clinic, highlighting gaps in access
More than 475 people received free health care Saturday as a two-day pop-up clinic returned to Columbus, offering dental, vision and medical services.
After nearly 2 years sober, Kansas City man loses truck and his business
After nearly two years of sobriety and hard work rebuilding his life, Michael Edwards was finally turning his dreams into reality.
Rapper Kodak Black Will Be in NPC in GTA 6, Creating Speculation Over Other Artists Appearing In-Game
Rapper Kodak Black has been confirmed to be featured as an NPC in GTA 6 via a new batch of screenshots.
Artist pulls popular screensaver from Roku OS because of Fox acquisition
Developer: “I can’t be part of the Fox world.”...
Councilmembers demand DA drop charges against Queens man shot by police during mental health crisis
Over a dozen city councilmembers this week called on Queens District Attorney Melinda Katz to drop the felony charges her office has brought against Jabez Chakraborty, the 22-year-old who was shot by police in his family’s home while experiencing a mental health crisis in January.
Cuyahoga County’s health and human services levy passes
Voters went to the polls and approved Issue 11, a levy for the Cuyahoga County Department of Health that sought to increase funding to keep essential services running.
New GTA6 Screenshots have released comparing real life cars to in Game Cars
Just moments ago, brand new Grand Theft Auto VI screenshots were released showing off some of the in game vehicles, with a side by side comparison to the real life versions of the cars. The Iconic…
Political Analyst: Midterms in Virginia were a rebuke of Trump
Randolph-Macon Political Science Professor Rich Meagher says Tuesday’s midterm elections in Virginia were a rebuke of President Donald Trump and his record on the economy.
Burglars hit Eugene home linked to Asian American business owners in second break-in since
HEADLINE: A resident asleep at home during recent Asian-American business owners targeted burglaryWEB SCRIPT:EUGENE, Ore. —The Eugene Police Department has con
Downtown Mesa businesses thrive as city keeps vacancy rate below 10 percent, leaders say
Businesses are filling up fast in downtown Mesa, according to city leaders who say their downtown sector has more than 500 individual properties. All but 6.9% of them are filled.
macOS 27.3 includes cool-looking ‘Pro’ screensaver from new touchscreen MacBook Pro
Included in today’s macOS 27.3 beta 1 is a great-looking screensaver featuring an animated version of the new MacBook Pro with PROLED XDR Display wallpaper.
Hawaii political trailblazer Pat Saiki remembered, honored in final farewell
A final farewell to a trailblazer in Hawaii politics took place on Saturday.
Young voters want less combat, more compromise in politics after midterms
Voters under 30 made up about 10% of midterm voters, according to AP VoteCast.
I don't give my toddler screens, sometimes I envy parents who do
I've kept my almost-3-year-old mostly screen-free. It isn't always easy, but I love seeing the ways he engages with the world.
How the midterms shook up Senate delegations for 2027
The changing political map is also a good reminder that American politics are more elastic than many people realize.
Letter to the Editor: When does a cultural affinity group become a political advocacy group?
I am writing in response to The Daily article on the cancellation of this year’s Spoon Cultural Food Fest following the withdrawal of other student organizations due to the inclusion of Wildcats for Israel. By my senior year in high school, 1971-72, I came to the conclusion that I was not a Zionist and I...
Motorola's $1,599 Signature 27 Is the 'World's Fastest Android Smartphone'
Best camera system on a phone this year? DxOMark says so.
The scores are in. Who received low, high scores in health inspections?
Check out the most recent health inspection scores for restaurants in Bryan County.
Discord is killing its Electron app that can eat 4GB of RAM on Windows 11, and the Rust rebuild uses just 290MB
Discord is finally getting rid of Electron! Co-founder and CTO Stanislav Vishnevskiy has confirmed that Discord is rebuilding its client in Rust, and it’ll be using GPUI to handle the desktop interface. Discord also shared an early Windows 11 screenshot of the new app written in Rust, listed as “Discord Phoenix,” and it’s using just […]
PHOTOS: Chesterfield Coffee Con unites business owners, coffee lovers
Coffee aficionados and business owners united for coffee, sweets and more on Saturday morning at the Chesterfield Coffee Con.
Zelda: Ocarina of Time Switch 2 could be getting Master Quest DLC
Zelda: OoT remake datamine suggests a remixed adventured could be in the works…
Filipinnovation Forum Explores Filipino Contributions to Life and Environmental Science Research and their Impact on Communities
Filipinnovation Forum Explores Filipino Contributions to Life and Environmental Science Research and their Impact on Communities Attendees gather for a group photo after an insightful panel discussion during the forum […]
Best of Santa Cruz County entertainment, arts & food events this weekend, Nov. 5-8
With the weekend nearly here, check out things to do around Santa Cruz County, with a recommendation from Lily Belli and a specially curated list from Lookout’s BOLO events calendar.
Rockstar Reveals Even More GTA 6 Screenshots as PS5 Release Draws Closer
Check them all out here
New Tacoma tutoring center focuses on ‘the science of learning’
Local teacher Breanne Willard believes things like full-spectrum lightbulbs and a de-emphasis on screens can help students learn better.
Apple May Phase Out Non-Touch High-End MacBook Pros
Apple will likely consolidate its high-end MacBook Pro lineup around touchscreen models, according to Bloomberg's Mark Gurman. Writing in his latest "Power On" newsletter, Gurman questioned whether Apple would keep updating its high-end MacBook Pro models without touchscreens. The company has retained the mini-LED M5 Pro and M5 Max models alongside the new touchscreen versions, which cost $400 more.
From science experiments to “exploration at scale”
Panellists from State Street, SIX, Standard Chartered, Calastone and BNP Paribas explain why the industry is moving to tokenisation, and take stock of regulation, technology and infrastructure. Regulators are now a springboard for growth, but client interest still isn’t turning into live products. What’s missing is a use case that pays for itself quickly.
Experts question tactics, lack of mental health response in Columbia Pike police shooting
Overly aggressive tactics combined with an apparent lack of mental health responders may, according to policing experts, have contributed to a standoff on Columbia Pike escalating into a fatal officer-involved shooting. In interviews with ARLnow, two public safety experts questioned a series of decisions leading up to officers’ final confrontation with 33-year-old Shawn Valn, who
Texas Tech Health Sciences Center launches CenteringPregnancy program in Amarillo
iPhone Duo ‘crackgate’ could be at an end, as leaker claims Apple has figured out why some screens have been randomly breaking
The good news is it may not be a design flaw
Hundreds receive free health care at Columbus pop-up clinic, highlighting gaps in access
More than 475 people received free health care Saturday as a two-day pop-up clinic returned to Columbus, offering dental, vision and medical services.
Ocarina of Time remake datamine suggests Master Quest is on the way
Dataminers have found references to Master Quest in the Ocarina of Time remake's files, suggesting the tougher, mirrored mode could arrive as DLC.
Ashland Place Health & Rehab employee on leave after reporting alleged patient abuse
An arrest after allegations of patient abuse at Ashland Place Health and Rehabilitation, LLC. in Mobile is now raising questions about another employee's future
Police: Man killed in shooting near Fort Walton Beach towing business, no charges filed
FORT WALTON BEACH, Fla. -- A man was shot and killed in the parking lot of a Fort Walton Beach towing business on Saturday, accoridng to the Fort Walton Beach P
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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