Abstract
The global pandemic has taught us that we can focus the attention of the healthcare system on a clear intention when there is a looming threat. Climate action is required from multiple stakeholders particularly private sector suppliers in order to achieve the net-zero carbon emission by 2050 goal established by the Canadian government. Also building climate resilience among healthcare institutions and their supply chains is urgently needed, as they are already affected by a changing climate. By adopting a circular economy framework, the industry can move away from the current damaging take, make waste economic model and adopt a more sustainable model characterized by designing out waste and pollution, keeping products and materials in use, and regenerating natural systems. Health leaders can adopt sharing platforms, view product as a service, reduce single use products, encourage extended producer responsibility, and encourage value-based procurement in order to further these aims.
Introduction
“The goals of healthcare are multiple and ambiguous and the technology indeterminate” is a caution Carl Meilicke, founder of the Master’s Program in the Health Services Administration at the University of Alberta, would give, to new students each year. Indeed, in the 50 years since the program (now a Master’s Program in Public Health) was established, healthcare in Canada has become more ambiguous and the technologies have become more complex. Competing incentives, stove-piped professions, and constant reorganizations have all characterized a Canadian health system that has over the years defined the Canadian identity even more than hockey or beaver tails. But the pandemic has changed all that.
It is no longer business as usual; the goal is clear. There has been a new level of cooperation among all levels of government, institutions, and the private sector. Procurement rules have become more flexible, processes have become more efficient, and resources have been freed up. Public-private partnerships have been central in the development of new vaccine technologies and the acquisition of Personal Protective Equipment (PPE) and essential equipment. A sense of urgency prevails. Importantly, we know how we are doing in the fight against COVID-19: daily case counts, intensive care unit admissions, deaths, vaccination rates all tell us whether or not we are winning the fight.
We need to adopt this same focused intention and innovative private sector collaborations to fight the more far-reaching threat of climate change. We need the same level of cooperation among all levels of governments and healthcare institutions; we need the same sense of urgency. And we need to know whether or not we are winning the fight.
Measuring the impact of healthcare on the environment
There are clear ways to measure whether or not we will make the moonshot of a net-zero, climate-resilient health system. In the early 1990s, Mathis Wackernagel and William Rees at the University of British Columbia developed a method, the ecological footprint, to measure human demand on natural capital, in other words, the quantity of nature it takes to support people or an economy. In short, it is a measure of human impact on the environment. 1 Although the ecological footprint compares the total resources people consume with the land and water area that is needed to replace those resources, a carbon footprint also deals with resource usage, but focuses strictly on the greenhouse gases released due to burning of fossil fuels.
Many companies are starting to use the Global Reporting Initiative (GRI) standard for sustainability to report on their transition to a net-zero carbon footprint and their exposure to climate risk. 2 The GRI standards are separated into three material topics—economic, environmental, and social. Organizations can report on the three standards for a complete understanding of their material topics or choose to be more targeted in their reporting.
The net-zero climate-resilient challenge
In October 2018, the Intergovernmental Panel on Climate Change (IPCC) issued an alarming report that found that staving off the worst impacts of climate change by limiting global warming to 1.5 °C, the ambition of the Paris Agreement, would “require rapid, far-reaching and unprecedented changes in all aspects of society.” 3 Such thorough ongoing change, according to the IPCC, would need to include transitions in land, energy, industry, buildings, transport, and cities, that reduced global net human-caused emissions of carbon dioxide (CO2) “by about 45% from 2010 levels by 2030, reaching ‘net zero’ around 2050.”
In November 2020, the Government of Canada tabled the Canadian Net-Zero Emissions Accountability Act in the House of Commons. 4 The Act will legally bind the Federal Government to a process to achieve net-zero emissions by 2050, set 5-year rolling targets and improve accountability for achieving results. Canada is not alone in taking these steps. It has joined over 120 countries in pledging to be net zero by 2050, including several other G7 nations such as the United Kingdom, Germany, Italy, France, and Japan as well as hundreds of cities around the world, including Guelph, Halifax, Hamilton, Montréal, Toronto, and Vancouver. 5
Resilience and adaptation to climate change must also occur simultaneously as we pursue a net-zero goal. The climate is already changing, so we need to take immediate steps to mitigate risks and reduce the severity of the impact of growing threats to health and healthcare institutions.
Last year, the National Health System (NHS) in the United Kingdom developed a practical, evidence-based and quantified path to a Net-Zero NHS. 6 The plan provides a detailed account of the NHS’ modelling and analytics underpinning the latest NHS carbon footprint, trajectories to net zero, and the interventions required to achieve that ambition. It lays out the direction, scale, and pace of change. In his forward to the plan, Simon Stevens, NHS Chief Executive states: “The burden of coronavirus has been exacerbated and amplified by wider, deep-seated social, economic and health concerns. The right response is therefore not to duck or defer action on these longer-term challenges even as we continue to respond to immediate pressures. It is to confront them head on.” 6
Incremental progress on the environment
In the 20 years since the Canadian Coalition for Green Health Care (CCGHC) was established, awareness and action on environmental stewardship in healthcare has increased. Much has been said and much has been done. In 2009, many prominent Canadian national associations representing health professions, academic health institutions, and Non-Governmental Organizations (NGO's) came together with a joint position statement: “We envision the health sector as a leader in integrating environmentally responsible practice into the delivery of healthcare. We also see it as an advocate in sharing information, best practice and encouraging Canadians and Canadian organizations to limit their ecological footprint.” 7
Since then, while progress has been made, it has been incremental and increasingly diffuse. Institutions are starting to broaden their green agendas beyond energy, water, and waste management to consider how other factors can affect their ecological footprint. 8 But these considerations are made largely within an institutional context and with an institutional mindset. They typically have limited involvement of private sector partners. The CCGHC has advised numerous hospitals in the development of their green procurement policies and helped develop the Green Hospital Procurement Guide in 2016. 8 The guide is now under revision considering the new perspective of a circular economy.
Observations from the Green Hospital Scorecard
The Green Hospital Scorecard (GHS) is the comparative database sponsored by the CCGHC that benchmarks the environmental performance of participating hospitals in the areas of corporate leadership, energy, energy behaviour, water, waste, pollution prevention, transportation, food, anaesthetic gases, and climate change. 8 Scorecards provide both a retrospective view and comparative view of participating peer group hospitals. Close to 100 hospitals across Canada have been submitting data for the last 7 years.
Unlike the NHS, the Canadian healthcare sector does not have federal emission targets to reduce energy and carbon emissions. Some actions have been taken at the provincial/territorial level. For example, British Columbia has issued carbon emissions reduction requirements to the public sector, including hospitals and requires annual reporting on reaching carbon neutrality. Currently, most of the effort to reach carbon neutrality in BC is through carbon offsets paid by the hospital. Energy use reporting by the public sector (including hospitals) is required in Ontario. Through the GHS, we know that some healthcare organizations have established their own targets for reducing energy use; however, those targets are variable. Sixty (72%) participants said they have set energy conservation targets, and 61 (∼73%) participants said they have action plans for energy conservation. These individual targets, however, are inconsistent and so it is difficult to report on overall health sector progress.
Regulations in Quebec and BC require public sector reporting on progress in addressing climate adaptation. Quebec regulations require health authorities to develop sustainable development plans, and BC regulations will be requiring the public sector to develop adaptation plans. The BC Minister of Health, and the Chairs of the Health Authorities have all been issued mandate letters which include acting on climate resilience.
According to GHS responses in the 2019 report, only 17 (20%) of 83 respondents reported that they had implemented environmentally preferable procurement policies by 2019.
At the same time, over 80% of participants reported that their healthcare facilities have experienced climate-related weather events. An average of four types of climate-related events were reported per facility. The most frequent climate-related events reported were extreme heat (59%), extreme cold (58%), and extreme rain and floods (52%). The majority (over 80%) also indicated that these events challenged their ability to deliver health services. The primary impact was damage to healthcare facility infrastructure, reported by 42% of respondents. The next most frequent impacts were reduced access to critical services (including dialysis, testing procedures) at 31%; healthcare worker impacts such as stress, exhaustion, and mental health (30%); and reduced access to medical supplies and products (25%). An average of three types of impacts were reported per facility. 8
A stronger sense of urgency is needed, if the health system is to do its part in reaching Paris Agreement commitments by 2030 and Net Zero by 2050. We have to do the things that have the greatest impact in the shortest period of time. Leveraging the supply chain does not require the same level of consensus among clinicians and the public to reduce service utilization or change models of care that might positively impact the environment. Other longer term strategies include reducing demand for health services and matching demand with appropriate supply, as well as reducing emissions from the supply of health services through decarbonized transport, infrastructure, food, and pharmaceuticals.
Role of the private sector in achieving net-zero climate resilience
According to Health Care Without Harm, a global leader promoting environmentally responsible healthcare, the sector contributes to greenhouse gas emissions through energy consumption, transport, and the manufacture, use, and waste disposal of products. Emissions emanating directly from healthcare facilities and healthcare owned vehicles (scope 1) make up only 17% of the sector’s worldwide footprint. Indirect emissions from purchased energy sources such as electricity, steam, cooling, and heating (scope 2) comprise another 12%. However, the lion’s share of emissions—71%—is primarily derived from the healthcare supply chain (scope 3) through the production, transport, and disposal of goods and services, such as pharmaceuticals and other chemicals, food and agricultural products, medical devices, hospital equipment, and instruments. 9
It is clear that we need to adopt a more collaborative approach to working with the private sector to reduce healthcare’s carbon footprint and help healthcare facilities to become more resilient. After all, the supply chain is the ball, heel, and big toe of its carbon footprint. According to the Government of Canada, it: “…cannot achieve net-zero emissions on its own. This goal will require support and engagement from all parts of society, including provinces, territories, Indigenous Peoples, youth, and businesses.” 5 So what new economic model needs to drive economic progress and environmental sustainability toward net zero and climate resilience?
The circular economy
The circular economy is an economic model that looks beyond the current take-make-waste model and aims to create a new economy that operates in a continually evolving cycle. The circular economy is an environmentally, financially, and socially sustainable model following three key principles: design out waste and pollution; keep products and materials in use; and regenerate natural systems. 10 This new economic model enables productive and sustainable financial and social growth while at the same time fostering sound environmental considerations. At the same time, elements of the circular economy can also help the health sector become more climate-resilient through, for example, the use of more reusables, more direct arrangements with local manufacturers, and warehousing of the products closer to the user.
Alignment of policy and financial interests to advance the circular economy
Governments, as policy-makers and funders play a key role in regulating and incentivizing the provision health services. An increasing number of civil society organizations are advocating for policy changes that promote a green recovery. Assigning green conditions to business support programs makes sense for governments. At the same time, health service providers are ideally positioned to rethink the nature of relationships with suppliers, to encourage innovation, and to leverage the supply chain to achieve better environmental performance. Suppliers can take advantage of more flexible procurement rules and propose new business models that can reduce costs as well as improve access to goods and services.
Resolve framework: regenerate, share, optimize, loop, virtualize, and exchange
The Ellen MacArthur Foundation and the McKinsey Centre for Business and Environment developed the ReSOLVE framework that goes beyond the 3Rs (Reduce, Reuse, Recycle) and identifies six actions that can be taken to transition to a circular economy. 11 These include the following steps:
Regenerate and shift to reusables and reprocessed products;
Share by using on-line sharing platforms and extend the life of products through redesign;
Optimize procurement by purchasing durable products, removing waste from the supply chain, and leveraging innovative technologies using value-based procurement models;
Loop products by remanufacturing, recycling, extracting biochemicals from organic waste, and digesting organic waste anaerobically;
Virtualize by reducing the quantity of paper-printed material and moving to on-line platforms to acquire new assets; and
Exchange old products for newer products with advanced design or production.
Recommendations for health leaders
Adopt sharing platforms
The most sustainable procurement is not procuring at all. Most of us are familiar with Kijiji, e-Bay, and Facebook marketplace. Health-Share.ca is a new on-line marketplace that enables asset sharing exclusively for the healthcare system. As a national initiative of the CCGHC and FLOOW2 Healthcare in The Netherlands, Health-Share.ca was developed primarily in response to the COVID-19 crisis. Health-Share.ca helps hospitals and healthcare suppliers to efficiently match supply of and demand for products, materials, excess stock, personnel, and facilities. Utilizing the platform users can swap, sell, rent out, or even give away items such as medical devices, furniture, IV bags, injection needles, gloves, masks, knowledge, skills and staff, transportation services, consulting, meeting rooms, parking spaces, storage facilities, and other unused assets. The result is improved efficiency, flexibility, less waste, cost reductions, and enhanced collaboration. And as we have witnessed during the COVID-19 pandemic, it improves climate resilience by relying less on a vulnerable supply chain. Although Health-Share.ca is currently a national platform focused mostly on pandemic-related items, the vision is that users will eventually develop their own local, in-house exclusive sharing platforms, based around the Health-Share.ca platform.
Adopt product as a service (servitization)
With the application of a circular economy model, “ownership gives way to stewardship.” 12 Under a servitization model, health service providers no longer own products or absorb the cost of their repairs. Manufacturers and suppliers are instead held responsible for performance. This creates a shift from volume of product sales to performance, reliability, longevity, and reusability of products. This performance-based model could have a direct impact on reducing overall costs of healthcare operations while improving healthcare service to patients and increasing climate resilience through reduced reliance on a vulnerable supply chain. Although concerns have been raised about corporate control, this model may prove to be very effective for a certain types of highly technical equipment items.
Reduce single use
There are several studies comparing Single-Use Devices (SUDs) versus reusable equipment that reveal SUDs typically result in several-fold higher petrochemical use and Green House Gas (GHG) emissions on a life cycle basis. 13 If business models are tied to a throw away culture in healthcare, manufacturers are not incentivized to conduct the studies to prove their products can be safely reprocessed. Moreover, they may be under the false impression that SUDs reduce hospital-acquired infections. 12 However, many third-party vendors are now emerging to allow hospitals to outsource liability and the infrastructure needed for reprocessing. Emphasizing reusable products over SUDs can also contribute to climate resilience, reducing healthcare dependence of on a potentially vulnerable supply chain.
Promote extended producer responsibility and take back programs
If an institution purchases equipment, it is typically responsible for its end-of-life disposal. Extended producer responsibility can be an effective means to support the creation of a circular economy. 12 Extended producer responsibility is a model where companies that produce products are responsible for the collection, reuse, recycling, and/or end-of-life management of their products and packaging. This shifts product design and distribution to suppliers and has the potential to reduce GHG emissions if the materials are reprocessed and fewer new resources are used. This includes programs where companies take back worn out or unused parts or components.
Adopt value-based sustainable procurement
Adopting a value-based model of procurement goes beyond lowest price and enables the creation of an organization culture that is more accepting of innovation, allowing for custom and sustainable designs, and cooperation across markets. 13 Adopting a sustainable procurement policy can move suppliers to a more proactive approach to sustainability. Total life cycle costing should become part of any important purchasing decisions.
Conclusion
Implementing these strategies is particularly challenging, given the current COVID-19 crisis and other competing priorities. Other social justice aims such as equity and inclusion are however, part of environmental justice. Moreover, adopting environmentally preferable approaches often go beyond “doing the right thing” and have strong financial pay backs. Energy management, for example, has shown significant year over year savings. What we need now is to build a national “Coalition of Leaders” representing government policy-makers, academics, healthcare organizations, professions, civil society, and industry leaders. And there needs to be a national accountability framework for the high-impact activities. 14 I once met a woman who had lived in London during the bombings in WW ll. When I mentioned how difficult that must have been, she told me that while it was terrifying at the time, she remembers it now as the happiest time of her life: “We did not know what tomorrow would bring, but we knew we were all in it together.” In these uncertain times, all we know is that the road ahead will be very challenging. If we adopt a common vision of a net-zero, climate resilient health system, the future could be better than we ever imagined.
