Can Japanese efficiency help cut out waste in African healthcare?

Although Africa’s health sector continues to be hit by declining financial resources, it is important to identify and eliminate waste in the system, which can amount to 20% of health spending. Can the application of a Japanese efficiency methodology sharply reduce waste?

The perennial issue of healthcare financing in Africa has long been discussed and debated as a question of insufficiency: there is not enough government funding, private-sector investment, or foreign aid. Yet, in a region where resources are already stretched, another question deserves equal attention: how much of what we already have is lost through inefficiency?

The WHO posits that up to 20% of health spending in Africa is lost due to inefficiency. This could have calamitous consequences for a region already plagued by fragile health systems.

The recent reduction in foreign Official Development Assistance (ODA) makes the issue even more urgent, with the Africa CDC reporting a 70% drop in ODA between 2021 and 2025. The immense need to optimise existing funding streams lends credence to the old English proverb which says, “A bird in the hand is worth two in the bush”.

As a medical doctor, public health practitioner and occasional patient, I have interacted with African health systems all my life. As a clinician, I recall having to carefully manage needles and syringes, as there were never enough. Doctors were scarce, so we were always overworked. Hospital beds were in short supply, so we often had to treat people on stretchers. But as much as these realities would consume me one minute, by the next I would rehearse to myself what I had been told in school: “This is medicine in Africa.”

My public health experience added another layer to this familiar story. What I had seen in tens and hundreds would become thousands and millions at the continental level. Health-worker shortages, medication scarcity and equipment insufficiency would often be discussed through the same prism: the scarcity reality of healthcare in Africa.

And while it is important to face reality, the focus on scarcity often leads down a single road: a desire to invest more to cover existing gaps, while ignoring the waste and inefficiency embedded within the system. It is akin to someone trying to carry water in a basket; he will do much work, but get little done.

Lean Six Sigma methodology

This is where Lean Six Sigma comes in, offering a structured path to reducing waste, improving processes and optimising outcomes. It could produce tremendous benefits in Africa, a region battling equal parts resource underutilisation and insufficiency.

Lean Six Sigma is a fact-based management methodology that combines ‘Lean’ waste-reduction principles with ‘Six Sigma’ defect and variation-reduction tools to improve overall business efficiency and quality. Though developed within the Japanese automobile industry, both have since been successfully applied across different sectors, including healthcare.

Starting with Lean, waste does not refer only to unwanted final products; it can exist in inputs, processes and outputs. One form of waste is inventory: unnecessary accumulation of materials or supplies before the next step in a process. An example is the Covid-19 vaccine wastage in African countries whose storage and distribution systems could not absorb supply. Nigeria, Malawi, South Sudan, DRC, Liberia, Mauritania, Gambia, Sierra Leone, Guinea and Comoros destroyed over 1.5m expired Covid-19 vaccine doses in 2021. While near-expiry deliveries compounded matters, an exclusive focus on scarcity risks overlooking losses the inefficient healthcare systems produced.

Another type of waste is caused by delays. Long waits at healthcare facilities are often merely the tip of the iceberg. There are delays in diagnosis, treatment, referrals, procurement and public-health responses.

These delays can allow disease progression and increase medication use, hospital stays and treatment costs. A study by Walker et al. (2020) found that advanced disease increased treatment costs by 177% in HIV patients in South Africa.

A further source of waste is motion and conveyance: the unnecessary movement of people, materials, or information. In procurement systems, for example, drugs and medical equipment may pass through multiple administrative layers and approval processes before reaching the end user, creating avoidable delays. This is often compounded by over-processing, such as repeating laboratory tests when recent and reliable results are already available, sometimes within the same healthcare facility, simply because the patient’s managing physician has changed. These inefficiencies lead to duplication, unnecessary expenditure, and delays in care, ultimately increasing the cost of treatment.

On the Six Sigma side, there is the drive to reduce process variation. Consider malaria programmes across sub-Saharan Africa. National programmes often operate alongside multiple partner initiatives. This programme proliferation is translated into divergent reporting requirements and datasets. Without coordination, competition for funding ensues, aggravated by duplication, rework and waiting as staff reconcile competing monitoring systems.

Variation is also manifested in inequitable healthcare quality, access to medicines and the availability of health personnel across rural and urban areas, regions and socioeconomic groups. Such variation threatens the achievement of universal health coverage, a component of the Sustainable Development Goals (SDGs).

Principle of continuous improvement

So, what can be done? Value Stream Mapping offers a powerful starting point. Policymakers can map the journey of a health service, medicine, payment or patient, examining each process and resource. Which steps add value? Which create delay? Where are the duplications and bottlenecks? Once visible, opportunities for redesign become harder to ignore.

Root-cause analysis can move policymakers beyond symptoms to ask why patterns exist. Was forecasting inadequate? Was procurement delayed? Was distribution poorly planned? Furthermore, the Pareto principle (also known as the 80/20 rule, which states that roughly 80% of outcomes arise from 20% of causes) can identify the causes responsible for the largest share of the problem, allowing scarce resources to be prioritised.

Kaizen, the Japanese concept of continuous improvement, offers another starting point. Policies and programmes should not be treated as finished products, but as systems requiring continual assessment, harmonisation and refinement. Proper evaluation should precede new interventions. The objective should be to improve what works, discard what does not and prevent resources from funding pet projects that lead nowhere.

Finally, there is the Voice-of-the-Customer (VOC) and the identification of Critical-to-Quality requirements (CTQ). In healthcare, the customer is the patient, and patients’ priorities are critical. Policy must therefore extend beyond disease treatment to the experience of receiving care: Is it safe? Timely? Clear? Accessible? Multiplied across millions of patients, these become heavy policy questions.

None of this can happen without data. We cannot reduce waste that we cannot see, or improve a process that we cannot measure. Better data on expenditure, procurement, claims, waiting times, stock-outs, medicine expiries and outcomes would engineer the better use of available resources.

Yet Lean Six Sigma should not become another pathway to austerity. There is a real danger that the language of efficiency could be misused to justify cutting already inadequate health budgets or reducing the workforce.

Efficiency is not the same as spending less. It is about obtaining more value from what is spent. Another danger lies in overregulating an already tightly regulated health system, and worsening
bureaucratic delays and bottlenecks. To avoid this, it is
important to actively involve the patients and health workers, and feedback should be used for continuous improvement.

In conclusion, Lean Six Sigma cannot independently solve Africa’s health-financing crisis or replace urgently needed funding. It can, however, help health systems maximise available income by reducing waste and prioritising efficiency. As ODA declines and alarm bells ring, now is the time to ensure every dollar on the ground is yielding commensurate healthcare benefits.

Dr Praise O. Adedeji is a medical doctor and public health professional with experience in health policy, health diplomacy, quality improvement, research, and programme development across Africa.