Be here for your patients and communities not only in this generation but for their children, grandchildren and beyond.

--BY VAIJAYANTI KHARE

Many would still consider ‘sustainability’ to be little more than a popular buzzword, but for those in healthcare, it is a concrete imperative. Either we establish healthcare on an environmentally, socially and economically sustainable basis, or we resign ourselves to a system of ‘sick care’ that serves neither patients nor communities!

The circular economy is the concept of keeping resources in use for as long as possible through their recovery and re-use. For healthcare, this might be more than just buying refurbished MRI scanners or sharing under-utilised surgical equipment. 

For a sustainable economy, and of course, smart business models, we see the transition from a linear to a circular economy as a necessary boundary condition. A circular economy aims to decouple economic growth from the use of natural resources and ecosystems by using those resources more effectively. By definition it is a driver for innovation in the areas of material, component and product reuse, as well as new business models such as solutions and services. In a circular economy, the more effective use of materials creates more value, both by cost savings and by developing new markets or growing existing ones.

Healthcare is no different from any other industry like manufacturing, retail, tourism, hospitality and such, in fact as healthcare is more an ecosystem comprising primary- secondary-tertiary-quaternary industry, it has that many more challenges of sustainability.  

Healthcare today is an end-to-end system, offering multi-specialty services and inter-disciplinary approaches. It prides on being a ‘wellness industry’ now as opposed to ‘care for the sick’ of yesteryears. Can this industry then be blind, oblivious or ignorant of the responsibility it has towards making itself ‘circular’ and sustainable? Also note, that our country, Nepal, can no longer hide behind its LDC status or any such economic, political or social excuses in this matter, especially not the Healthcare providers. In fact, I would go further to say that perhaps this sector can be the ‘driver’ of circular approaches for other industries too, as Health of the Individual, the Community, the Environment, the City and the Village – is the Wellness of all.  Prevention and Cure and all in-between, all around, needs to be the focus, rather than a self-centered, tunnel vision approach to ‘making money’.

Let us look at some key concerns and then at some smart approaches to manage and move to a more circular healthcare.  

Health care is resource intensive with significant input of materials, water, and energy that results in an output of waste, effluents, and emission pollution. Health care generates material in almost every category of waste and emissions. Hospitals consume two-and-a-half times more energy than other commercial buildings. 

Waste and Recycling
•    Cardboard alone makes up 15-20 percent of the waste stream of a typical hospital
•    Cardboard is used to ship 70 percent of all products in our country
•    Recycled cardboard (sometimes called old corrugated containers—OCC) only takes 75 percent of the energy needed to make new cardboard and lessens the emission of sulfur dioxide that is produced when making pulp from wood trees
•    Recycling 1 ton of cardboard saves 9 cu. yards of landfill space and 46 gallons of oil
•    While OCC is very recyclable, finding opportunities to reduce it is a priority
•    Beverage containers (glass, plastic, aluminum containers) make about 6-10 percent of healthcare waste
•    Sterilisation wrap accounts for up to 20 percent of waste generated in the Operating Room 

A standard recycling programme in a hospital consists of cardboard, confidential paper collection, mixed fibres (magazines, newspapers, non-confidential mixed office paper, boxboard), beverage containers, metal, recyclable construction/building materials and some non-traditional mixed plastics. Such a programme can reduce waste by 30–40 percent.

Water
•    Hospitals (50-75 bed) use an average of 130,000 gallons of water per day
•    Water is finite; it cannot be created or manufactured. What is available on the planet is all there is. Only three percent is fresh water, and only a fraction of that is available for our water consumption needs. Water conservation has two main categories: using less waste through better technologies in systems and fixtures, and capturing rainwater and other “used” water for other purposes. 

Supply Chain
Supply chain professionals are tasked to contribute to the overall value in the lifecycle of goods, services and equipment for health care organisations. Hospitals are environments for healing but many of the products and materials used may be harmful if they contain/release during production, use or disposal, carcinogens, reproductive toxins or other materials that may be hazardous to human health and/or the environment.

Ninety percent of [all sector] companies that perceive sustainability issues as significant have developed a comprehensive sustainability strategy, 60 percent have included sustainability on their senior leadership’s agenda and 69 percent have addressed a sustainability business case.

Cost of supplies is second only to that of labour. As technology continues to advance, supply costs may overtake labour costs.

Medical devices - materials may account for as much as 40 percent of total spending.

A recent study identifies areas for potential savings as:
•    Reduce medical waste through better segregation
•    Reduce landfilled waste through recycling
•    More efficient purchase of operating room supplies
•    Switch to reprocessed devices in the operating room over single-use devices
•    Material choices matter when purchasing
•    It is estimated that Styrofoam is responsible for a significant volume of material in a landfill and it will never, ever decompose
•    Paper accounts for approximately 40 percent of the solid waste clogging up our landfills. Use of recycled paper in place of virgin paper also significantly reduces costs towards wood, energy, water and solid waste

Surely and truly, the healthcare industry is an all-pervasive industry and hence calls for a right-round approach to sustainability. But, surely and truly, one has to start somewhere. Making this industry circular, and more so the operations of individual healthcare providers, especially the big hospitals like Norvic, Vayodha, the mid-and-small nursing homes like Om, Kirti Bal, Bir and of course the Govt / Mission ones like Patan, Bhaktapur Cancer, and many that have mushroomed all around, has to be on the agenda of the senior management.  Let us note here that, it is a matter of pride that relevant policies, regulations, quality norms and standards are in place at the national level, however, it is a matter of concern that most healthcare providers are short on strict and persistent implementation. Even the appellation of being ‘ISO certified’ is at most a mere marketing by-line than a validation of actual quality and /or circular practices. 

In discussions and debates in the organisational forums on how circular economy principles might take root in the healthcare sector there emerge seven key observations and areas that could guide this paradigm shift.

1. Healthcare sharing platforms may become the norm
An example can best illustrate this: One hospital had purchased a piece of surgical equipment and only used it sparingly. A sister facility of the same health organisation about 50km away wanted access to the same technology but did not have the capital nor patient volume to justify the purchase and so were either renting at a costly rate or not doing the procedures at all. Healthcare systems are so challenged right now, both financially and clinically. Doing more with less is becoming an important maxim.

2. It is about changing buying processes
Progress could be accelerated by reviewing purchasing policies, where agreements for service based solutions (for example, where a hospital buys a pre-owned, refurbished MRI machine which is maintained and upgraded by the manufacturer) are preferred over the simple acquisition of goods. 

3. Poor finances may be the mother of invention
New models have a chance to take hold as hospitals look to ways of working that they might not have considered when finances were stronger. Philips Healthcare, for example, recently asked more than 100 stakeholders in South Asia if they were willing to explore the possibility of refurbished systems and new business models. Of the 92 that responded, 80 appeared interested in the opportunities.

4. People have already bought into the idea of a sharing economy
A sharing marketplace for healthcare organisations, is also hopeful. The success of sharing economy models like Ola, AirBnb suggests consumers are getting comfortable with the concept of access over ownership and that eventually this will transfer to a professional setting.

5. We need better design
While those procuring equipment have to change the way they see healthcare equipment, so too do the manufacturers making and selling it.

6. Some healthcare areas remain a big challenge 
While the circular economy presents clear cost saving opportunities for healthcare equipment there are areas of healthcare where circular economy principles will have a harder time taking off. Drapes, gowns and other textiles we use are almost always cheaper, even with disposal costs included, than those we can reuse. Pharmaceutical waste is another problem area, as most unused drugs are thrown away by patients at home.

7. Developing markets may have different needs
One of the challenges Philips is facing in developing markets is perception, with customers and users reluctant to believe that pre-owned equipment is as good as new.  In developed countries the effort is to change a system that has existed and grown for decades, which is more difficult than building something from the ground up. However, it is possible to implement circular systems as corner stones of the healthcare system in developing countries without having to break down existing walls.

There is no choice. It is time, that healthcare, in its entirety and especially at the level of its individual ‘hospital’ healthcare delivery organisation, move to ‘transition from linear to circular’ economy models. Global trends, local resources’ crunch, better business sense and socio-environmental sensitivities call for all stakeholders to take bold steps towards this paradigm shift. The time is Now.

Vaijayanti Khare is known for her dynamic engagements in the corporate, academic, social and development fields in Kathmandu over the past decade. Her writings are a reflection of her hands-on work, insights, studies, success and challenges.