Environmental impacts of the health system Waste management is a key factor in health system environmental sustainability and resilience. Each year, millions of tons of waste are generated from across all sectors. A recent health sector study found that hospitals produce 1.7kg of hazardous medical waste per bed and 6.8kg of municipal solid waste per bed, while PHC clinics produce approximately 0.029 and 0.116 kg of hazardous medical waste and municipal solid waste per visit, respectively (Climate Transparency (2020). Moreover, it is estimated that public hospitals dispose of 27,000 tons of paper, 15,000 tons of plastic, 10,000 tons of food, 8,000 tons of glass and 7,000 tons of metal annually. (Alharb NS et al., 2021). These waste materials are not recycled and ultimately end up in land ﬁll. Indeed, there is an urgent need to empower the recycling sector in Saudi Arabia as it lacks ﬁrm direction, with recycling rates below 10% overall. Waste management companies in Saudi Arabia primarily use microwave, autoclave and thermal incineration technologies to treat medical waste. However, they are confronted by signi ﬁcant challenges to improving outcomes due to limitations around waste training, limited coordination among operators and lack of social responsibility. Therefore, in order to enhance sustainability and environmental protection, an integrated approach to waste reduction, management, recycling and reuse is needed. Waste from Saudi Arabia’s health facilities is managed through a combination of policies, regulations and practices. In 1998, the MoH passed regulations de ﬁning healthcare medical waste (HMW) handling, treatment and disposal. These regulations were later endorsed by the GCC as a uniﬁed HMW regulation among all member states. To promote good practice in hospital and health facility waste disposal, the Saudi Arabian government established the National Centre for Waste Management, which regulates and supervises waste management activities and promotes the principle of the circular economy. This includes recycling, resource retrieval and safe disposal to achieve better environmental and economic results. In addition, in 2022, the government allocated $50 billion to municipal services, including health facility waste management. Key stakeholders in the waste management sector, such as the Ministry of Environment, Water, and Agriculture (MEWA), Saudi Investment Recycling Company, National Environmental Recycling Company and others, collaborate to ensure the proper disposal of health facility waste. These combined efforts help to reduce waste and promote good practice in hospital and health facility waste disposal, contributing to the overall goal of an environmentally sustainable health system. Developing sustainable built infrastructure is another critical aspect of health sector environmental sustainability. Globally, health sector resilience and environmental sustainability assessment frameworks, known as sustainable green hospitals or green health facilities, are increasingly common. WHO has developed guidance for resilient and sustainable healthcare facilities (World Health Organization, 2020) and Global Green and Healthy Hospitals has developed a 10-goal framework (Global Green and Healthy Hospitals, website)) that includes guidance for sustainable design and use of health service buildings. In Saudi Arabia, ten health service projects applied for international Leadership in Energy and Environmental Design (LEED) certi ﬁcation from 2011 to 2020. The Saudi Mostadam (meaning sustainable) rating system for existing and new buildings, with categories that include site sustainability, e ﬃcient use of energy and water and the transportation of materials and waste, was recently introduced to improve sustainable building standards. However, this rating system does not include international standards for sustainable hospitals and green healthcare. Thus, a new domestic rating system for healthcare facilities needs to be developed in Saudi Arabia. Air quality is a key environmental sustainability and resilience factor and is also critical to the health sector’s focus on wellbeing. Air quality data show that average NO 2 concentration in Saudi Arabia is 95 μg/m, which is lower than the 100 μg/m set by the General Authority of Meteorology and Environment Protection (GAMEP). It is, however, much higher than the 40 μg/m recommended by WHO. In cities such as Riyadh, average yearly O 3 concentrations of 160 μg/m 3 surpass standard levels. However, due to decreases in the sulphur content of diesel, SO 2 exposure rates in major cities have fallen to within acceptable limits (Ministry of Environment, Water and Agriculture, 2017). Major 76 Sustainability and Resilience in the Saudi Arabian Health System The Partnership for Health System Sustainability and Resilience

PHSSR Saudi Arabia 2025