Towards a sustainable management of bio-hazardous healthcare waste in LMICs. Global and local perspectives on impact studies

Identifying the best solution in the complex field of healthcare waste management (HCWM) while considering the potential impacts on the three pillars of sustainability – environmental, economic, social – can be challenging. This thesis explores the various aspects to be considered when implementing a technologically improved HCWM system in a low- or middle-income context (LMIC). A considerable number of international cooperation projects in the field of waste management have focused on enhancing sustainable development through the implementation of treatment technologies that are regarded as "more sustainable" due to their innovative reduction of pollutant emissions, minimization of risk to workers and local communities, together with their adaptability to contexts with limited resources. Despite these ambitious and optimistic objectives, a significant question remains unanswered: are these alternative waste management systems genuinely sustainable, both in the short and long term? The investigation was directed towards two disparate contexts in which a comparable process of transition from the existing HCWM system to a distinct alternative was occurring. To address this question, two primary approaches have been explored: the establishment of a local state-of-the-art and the conducting of impact assessment evaluations. The thesis is organised into three chapters, each of which is designed to be a standalone paper with its own distinct objectives and methodological frameworks. The qualitative and quantitative methodologies employed in this study are complementary, with the choice of methodology primarily contingent on the availability of data. The first chapter illustrates the first case study in Beira, Mozambique. The study design is based on a qualitative approach, incorporating a cross-sectional study through interviews, a roundtable event, project meetings, information, qualitative on-site observations, and prolonged engagement with incinerator operators. The second and third chapters are linked, with the final aim of performing a Life Cycle Sustainability Assessment (LCSA) on two HCWM systems in the case study of Ulaanbaatar, Mongolia. The following two chapters are dedicated to the presentation of quali-quantitative methodologies. In the second chapter, a Life Cycle Assessment (LCA) and Life Cycle Cost (LCC) analysis are presented. The third chapter focuses on Social-LCA (S-LCA) and LCSA. This research underscores a pivotal transition from a more limited conception of environmental sustainability to a more encompassing paradigm of sustainable development. The two case studies revealed numerous advantages when transitioning from BSW incineration to FHT sterilisation. The conclusion of the thesis asserts that the development of comprehensive, state-of-the-art impact assessments prior to the implementation of projects could assist decision makers in selecting not only the optimal alternative but also in initiating a participatory process that takes into account a greater number of stakeholder groups.