Science Talk: Why a greener medication box matters to your health

The paper box your medication comes in seems an unlikely place to start a conversation about the future of healthcare sustainability. But it is exactly where one started at Tan Tock Seng Hospital (TTSH), the flagship hospital of NHG Health.

Until recently, that box could not be recycled. The small plastic window on the front, the kind that lets the pharmacist and patient glance in to check the pills, meant the packaging mixed paper and plastic and had to be thrown away.

A team of TTSH’s pharmacists redesigned it into a single-material paper box, while keeping it compatible and sturdy enough to run through automated pharmacy-dispensing machines.

The change was modest. Its impact is not.

With every hospital and polyclinic in Singapore progressively adopting this new design, an estimated 4.36 million boxes can be recycled annually at home in the blue recycling bins located in housing estates and public spaces.

This is expected to reduce about 4,600kg of carbon emissions. That is like 24 round trips between Singapore and Bangkok. It also removes the use of about 1,837kg of plastic each year, equivalent to 122,000 plastic bottles, and trims packaging costs across the healthcare system without compromising patient safety or pharmacy operations.

This example matters because the idea came not from a boardroom or hospital operations blueprint. It came from our front-line pharmacists asking a simple question about something they handled every day. This sets the context of what sustainable healthcare should be.

For healthcare organisations, sustainability is not a future concern. It is already shaping the way we work today. Energy costs are rising, pushed up by carbon taxes and by fragile global fuel supply chains. Ageing healthcare infrastructure needs to be retrofitted without ever disrupting services like ACMV (air-conditioning and mechanical ventilation) systems that keep patients safe.

And the changing climate itself and environmental events are contributing to disease burden, population vulnerability and inequity, and healthcare demand. The young, elderly and those who work outdoors are particularly vulnerable to the impact of extreme heat and air pollution.

This means sustainability is not solely an environmental issue but also a healthcare and financial one, and ultimately about patient care.

Healthcare sits on both sides of these challenges. We treat the harms of a warming climate, yet we also add to the problem, through the energy we use, the buildings we operate, the supplies we buy and the waste we produce.

This gives us both a responsibility and an opportunity to lead. By improving how we use resources, reduce waste and redesign processes, we can strengthen operational resilience, manage costs and improve outcomes.

More than a collection of projects

Meaningful progress requires more than a handful of one-off projects. It requires a system-wide approach.

In Singapore, healthcare facilities are among the most energy-intensive buildings in society. Hospitals operate around the clock and must maintain strict standards for ventilation, infection prevention, temperature control and patient safety.

A large share of that energy goes to the air-conditioning and ventilation systems that keep these spaces safe. Making them more efficient and resilient, renewing older facilities and tapping renewable energy where we can, well-supported by improved monitoring and management of energy use is necessary in maintaining the quality and reliability of care.

But a great deal of healthcare’s carbon footprint lies beyond buildings – in medicine, medical devices, consumables and logistics. We have measured such impact, and high-volume consumables and pharmaceuticals stand out as the biggest sources of waste and emissions.

Addressing them means working more closely with suppliers, industry partners and healthcare institutions to adopt more sustainable solutions and build the habit of weighing the environmental impact when deciding what to purchase.

None of this happens through technology alone. It is our nurses, clinical teams and facilities personnel who turn sustainability goals into daily practice, as the pharmacists at TTSH showed.

Other examples include improving waste segregation at source, reducing avoidable clinical waste and piloting recycling initiatives for selected materials. We are also exploring opportunities for reuse and reduction in high-volume consumables.

We have found that small improvements can accumulate into significant system-wide impact.

Better care and a lighter carbon footprint

The most promising opportunities lie within clinical care itself. For a long time, improving care and caring for the environment were viewed as separate goals. Increasingly, we see that they can pull in the same direction.

Through an approach known as sustainability in quality improvement, teams in NHG Health now weigh three questions together whenever they consider a change: Does it improve patient and population health outcomes, does it reduce cost or use fewer resources, and does it lower environmental impact?

The medication box illustrates how environmental and cost benefits can be achieved while maintaining patient safety and quality of care. So do surgical teams who have redesigned surgical supply kits and streamlined workflows.

Other initiatives, such as appropriate prescribing and teleconsultation for suitable patients, have demonstrated how improvements in access, patient experience and resource efficiency can be achieved alongside environmental benefits.

These examples show that better care, responsible resource use and environmental sustainability need not compete with one another. When clinical teams consider all three together, improvements in one area can often reinforce the others.

These innovations are not compliance exercises handed down from the top. They are led by clinicians and are grounded in evidence and focused on delivering high-quality patient care.

Often, the most sustainable healthcare is care that a patient never needs. Prevention, population health management and keeping people well reduce avoidable demand on the whole system, which is why sustainability and getting better value from healthcare are the same pursuit.

Preparing for a changing climate

Reducing our environmental footprint is only half the task. We must also prepare for a climate that is already changing, rapidly.

Healthcare organisations increasingly face risks associated with extreme heat, haze, evolving disease patterns and potential disruptions to supply. We are integrating these risks into our long-term planning, strengthening resilience of our infrastructure and our ability to keep our services running without disruption.

One effort reduces future risks; the other prepares us for those that we cannot avoid.

The road ahead

As healthcare systems face rising demand, finite resources and a changing climate, sustainability can help us make better decisions about how we deliver care, steward resources and build resilience for the future.

The transition to sustainable healthcare will require more than new technologies or greener infrastructure. It calls for sustained commitment and a willingness to learn and rethink how care is designed and delivered, from the planning of infrastructure and the purchase of supplies right down to the bedside.

This means considering sustainability not as an additional priority, but as part of the everyday work of healthcare. From designing facilities and procuring supplies to improving clinical pathways and strengthening population health, the question is increasingly the same: How can we achieve the greatest value for patients while using resources responsibly and reducing environmental impact?

The pharmacists who redesigned that medication box were not tasked with solving climate change. They simply paid attention to something they handled every day and asked if it could be done better. The answer demonstrates how small improvements, multiplied across a healthcare system, can generate meaningful impact.

If this mindset of curiosity, continuous improvement and action becomes second nature to every healthcare professional in each ward, clinic, and operating theatre in Singapore, the cumulative effect will be far greater than what any top-down sustainability programme could achieve.

Healthcare is about protecting and improving lives. Sustainability, at its core, is no different. Our aspiration for healthcare is not to run a sustainability programme alongside the work of care, but to make this way of thinking inseparable from it.

• Jeannie Tey is senior consultant in the department of epidemiology and preventive medicine at Tan Tock Seng Hospital and also serves as the hospital’s director of corporate planning and chief sustainability officer. Jason Cheah is deputy group chief executive officer of strategy, planning and resourcing at NHG Health and chair of the NHG Health environmental, social and governance council.