Dec 4, 2025
by the Purpose Foundation
A question floated to us this week – not from a boardroom, not from a business case, but from a podcast episode that, to borrow the host's words about “where those bottles wash up on shore,” suddenly washed up on ours.
In the latest episode of his podcast What Now? podcast, Trevor Noah, former TV host and author, his co-host Eugene Khoza and author and journalist Tom Mueller dive deep into the U.S. dialysis industry – and open a much bigger conversation about incentives, accountability and what happens when life-and-death services drift away from the people they’re meant to serve.
We found ourselves nodding along, smiling the kind of smile you smile when someone else says the thing you’ve been thinking about and working on for years. Not because the story is uplifting (it isn’t), but because the episode pokes directly at questions we orbit around daily with steward-ownership.
What stood out to us is something we notice often: throughout the episode, the three of them circle around the topic of ownership in a structural sense, but without going much deeper. This is an interesting pattern, as ownership often remains invisible in public conversations, even though it quietly shapes much of the system they’re describing. And that’s precisely what makes this episode so compelling: it opens the door to a pivotal question that usually sits just beneath the surface. So we’d love to pick up that thread and invite Trevor, Eugene and Tom to join the conversation: let’s talk about ownership!
The podcast paints images that linger, drawing on examples that demonstrate that in the health and especially dialysis industry, most business models are not about health care but about shareholder-value extraction: dialysis centres run like drive-throughs, workers torn between ethics and efficiency targets, patients referred to as “units”. Podcast host Trevor Noah jokes, “I guess this is great if you’re trying to get fries out quickly. But these are human beings.”
Tom Mueller adds the line that’s funny for a second … until it isn’t: “People are not burritos.”
Beneath the jokes sits a topic that is anything but funny: it points to an industry in which two companies control roughly 80% of the market – a duopoly that shapes incentives, prices, and ultimately patient outcomes. In such a system, when patients become numbers and incentives are mainly driven by maximising shareholder returns, responsibility is easily lost, and the logic of financial markets tends to overshadow the logic of care. Of course, the issue isn’t efficiency itself, but what it is organised for, and where the line is to be drawn when efficiency begins to compromise care.
We hear how a once-miraculous technology became a structure centred on generating value for shareholders, how financial frames started to shape clinical decisions, and how innovation has flatlined for 40 years because, in their words, “there’s no money in it. They have their cash cow, and they're milking it relentlessly. They're not interested in a new milking machine. They're not interested in the cow.”
Again and again, the conversation circles back to responsibility – or rather, the absence of it. Trevor Noah captures it in a line that lingers long after the episode ends:
If everyone gets to say they’re not responsible,
then who is responsible?
And as Tom Mueller notes, the most unsettling part is how quickly we learn to accept these dynamics, summed up in his reflection: “We’ve been tricked into believing there is no common good anymore.”
We find that this podcast raises a quiet but crucial insight: how quickly we get used to the structures around us, how easily misalignment becomes “normal”, and how often it feels too hard, too complex, or too entrenched to change anything at all.
And from there, another layer becomes visible — the limits of the usual binaries we tend to fall back on: Public vs. private. Capitalism vs. socialism. Profit or purpose. (To name but a few.)
These frameworks feel familiar, but they often flatten the complexity of what’s actually at stake – as if most choices fit neatly into two opposing buckets and not much meaningful existed in between. Yet, listening to their conversation, the research done and insights presented into this particular industry, it becomes clear that the most important questions (and answers) don’t sit at the poles.
They often live in the spaces in between: How do we structure responsibly? Who is accountable when things go wrong? What should the role of investors be? And what happens when market power concentrates and quietly form duopolies, or even monopolies, especially in markets that are literally about life and death?
But it doesn’t have to be that way.
The questions that are being raised are not about ideology. They are questions of structure – of design – and, at their essence, of ownership.
Steward-ownership offers an important building block and answer to many of the tensions the podcast exposes.
At its core, steward-ownership is a simple idea: Profits are a means to an end, not an end in themselves. They serve the company’s mission and development or can be used to fund charitable activities. The value created within the company cannot be extracted by the company owners for their personal benefit. In addition, the company cannot become an object of speculation but remains self-determined and independent in the long term. The steering wheel always remains in the hands of people who are connected to the company and its mission.
Listening to Trevor, Eugene and Tom, we couldn’t help asking:
Would the innovation stagnation look different? Would workers be less trapped between ethics and efficiency targets? Would patients experience care rather than treated as “fries”? And how might this reshape the wider ecosystem — from supply chains to community health outcomes?
Well, staying in the health care industry for the sake of the argument we’ve seen hints of what’s possible: BuurtzorgT is a provider of community-based mental healthcare in the Netherlands, working with self-steering local teams to support patients with complex psychiatric and social issues in their homes. In 2020, BuurtzorgT transitioned to steward-ownership after the founders decided to adopt an ownership model that mirrors the organization’s self-steering nature and focus on patients. The new structure allowed BuurtzorgT to secure the necessary external capital while preserving the organization’s set-up and values.
Even at larger scale, we see examples proving the viability of steward-ownership. Novo Nordisk, for instance, is the largest insulin producer, leading diabetes-care company and most profitable company in Europe – and, it is steward-owned through a foundation model: the Novo Nordisk Foundation controls the company, anchoring its strategy in long-term purpose, research, innovation and societal impact.
And going back to our daily boardrooms and business cases – or, more realistically, inboxes and Zoom calls – we often hear from healthcare providers and executives who are exploring steward-ownership as a way to reclaim decision-making power in how their organizations are run. They’re looking for a structure that allows them to stay both profitable and mission-oriented, putting patients and care quality at the centre rather than letting short-term pressures dictate decisions.
Steward-ownership doesn’t claim to fix every healthcare challenge. It won’t magically redesign entire sectors overnight. But it can give a framework to run companies with clarity, long-term thinking, and accountability, without having to compromise between being profitable and being purpose-driven.
So imagine zooming out. If the picture drawn above applies to one sector or company … what does that suggest for others?
Housing. Energy. Food. Infrastructure. And, of course, AI — a domain with the potential to transform society and economy in a way we cannot yet predict and whose ownership and governance is crucial not only at the corporate level.
Ownership isn’t just a technical detail.
It’s a company’s DNA.
It quietly shapes everything else.
Ownership matters.
Here you'll find the respective episode of Trevor Noah's podcast.