This week we published Building a Healthier Africa. An exploration of the healthcare value chain paints a clear picture of just how much of a wicked problem healthcare is.

All this season we've been looking across the value chains to better understand what's happening behind the scenes. It's allowed us to focus on the problems, not the solutions. And it's an especially useful exercise when looking at wicked problems which, by definition, don't have a solution.

One major problem is that the large majority of healthcare spend is out of pocket. Healthcare is expensive, in general, so anyone paying out-of-pocket anywhere in the world is a problem. And it's an especially large problem in the context of high rates of poverty, high unemployment, high food prices, currency devaluation, and so on.

So who pays, and how do you get more payers in the system?

The UN's Sustainable Development Goal 3 is "good health and well being", and a specific target within that goal is to achieve universal healthcare. But are the governments going to be able to find or allocate the money to implement these programs? What about donors?

Let's say that every government on the continent finds the money to implement a universal healthcare program in their country - which, you know, is a pretty big hypothetical - that still won't directly lead to a healthier constituency.

Another problem is access to quality healthcare.

In an environment of fragmentation, there are tens of thousands of small, nurse-led clinics or pharmacies that act as the first point of care for millions of patients around the continent. While they may be able to disburse medication or conduct basic tests, they may otherwise lack the ability to provide more robust services.

On one hand, the fragmentation of the last-mile healthcare system is a function of different factors, such as an increasing rate of urbanization of African cities (which in itself is caused, in part, by lack of rural employment opportunities), lack of car ownership, lack of infrastructure, and more. On the other hand, the limited treatment options at these clinics is a function of a lack of payers in the ecosystem and an inability for the clinics to afford various diagnostics tools.

When patients aren't getting proper diagnostics, it makes it harder for doctors to prescribe the right course of treatment for their patients. And patients aren't receiving diagnostic tests not only because of an unavailability of tests, but also because of their limited ability to pay for tests, and therefore, a preference to use what money they do have on symptom-relieving medication (which, again, without proper diagnoses may be ineffective).

This preference creates a culture in which healthcare is reactive. Preventative medicine and testing is limited. When I'm sick, let me exhaust the limited resources I have on empiric treatment, the patients tell themselves, before escalating to a doctor, whose care may be beyond my means. What this then does is create an environment in which doctors are treating diseases in their later stages, where treatment is both less effective and more expensive.

And because of all of these problems, African patients have generally been left out of clinical drug trials, which also means that some pharmaceutical drugs may be less effective for Africans than patients of other ethnicities.

That's some of the problems. There are undoubtedly more. And of course, it raises the question - how do we solve this?

With wicked problems, it's recommended to focus on strategies, not solutions. In particular, Nancy Roberts, PhD and Professor in the Department of Defense Analysis at Naval Postgraduate School, writes of three coping strategies depending on the degree of conflict that exists over the solutions, as well as the degree power held by each stakeholder group to identify the problem and implement a solution. The three strategies are either authoritative, competitive, or collaborative.

It is my firm conviction that people have to fail into collaboration. Experiences with authoritative and competitive strategies and personal knowledge of their disadvantages are great teachers. People have to learn what does not work before they are willing to absorb what they perceive to be the extra ‘costs’ associated with collaboration...

We learn to take care in attempting to tame wicked problems by turning them over to experts or some center of power for definition and solution. If we are truly dealing with wicked problems when no one is “in control,” then it is unlikely that the experts and leaders will be able be able to act unilaterally to define the problems and their solutions. In fact, their insistence in doing so may impede the problem solving process... And given the constraints and complexity of crisis situations, social learning is more likely to be successful if it remains a self-organizing, complex adaptive system that co-evolves as stakeholders meet, interact, and inform one another’s actions. Ultimately, we learn that to lead, facilitate and participate in such collective undertakings requires an act of faith. It begins with the hope that there is a better way of doing things, a recognition that failure is possible, and a willingness to ‘trust the process’ without guarantees of a particular outcome. It is sustained on personal reserves that enable people to remain calm and centered in the face of the unknown and the unknowable. These are important lessons for all of us to learn.

My sense is that this is where we are today - especially in assessing the startup and tech ecosystems' role to play in all of this. We've learned that top-down approaches won't necessarily work, nor will models copied and pasted from other markets. Technology can play a critical role in helping with distribution, or in garnering vital data from the last mile, and in better organizing and utilizing that data.

But to get healthcare in Africa to a more desired end-state, it's going to take technology plus governments plus multinational organizations plus development agencies plus pharmaceutical companies plus insurers plus local practitioners (plus more, I am sure!), coupled with more patience and more failures and more learning.

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✌️ Justin

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