Resources, Conservation & Recycling 141 (2019) 418–430

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Resources, Conservation &

Recycling
journal homepage: ​www.elsevier.com/locate/resconrec

Full length article

A proposed healthcare supply chain management framework in the ​T

emerging economies with the sustainable lenses: The theory, the practice,
and the policy
b​,​⁎​
Annibal Scavarda​a​, Gláucya Lima Daú​ , Luiz Felipe Scavarda​c​, André Luís Korzenowski​d
a​
Production Engineering School Federal University of the State of Rio de Janeiro – UNIRIO – Brazil 458, Pasteur Ave., Rio de Janeiro City, RJ, 22290-240,
Brazil b​ ​Nursing School Federal University of the State of Rio de Janeiro – UNIRIO – Brazil Health Economic and Technological Evaluation Laboratory of the
Federal University of the State of Rio de Janeiro 290, Dr. Xavier Sigaud St., Rio de Janeiro City, RJ, 22290-180, Brazil
c​
Industrial Engineering Department Pontifical Catholic University of Rio de Janeiro – Brazil 225, Marquês de São Vicente St., Rio de Janeiro City, RJ,
22451-000, Brazil d​ ​Production and Systems Engineering Program Unisinos University, Rio Grande do Sul–950, Unisinos Ave., 93022-750, São Leopoldo City,
RS, Brazil
sus tainable application perspective. The healthcare institution, based on the
Triple Bottom Line, must implement the educational program, develop the
corporate social responsibility, and interact with the community.
ARTICLE INFO

Keywords:
Supply chain
Sustainability
Healthcare
Emerging economy
Corporate social responsibility Education

1. Introduction
ABSTRACT them social, economic, and political, are capable of being analyzed,
considering two different perspectives. The first perspective reflects a
Some studies have emphasized the sustainable applications in the emerging Some studies have emphasized the sustainable applications in the
countries on the environmental, social, and economic improvement action
emerging countries (​Table 1​), becoming the integrating part of many
development. Establishing the Triple Bottom Line initiatives based on the
countries’ goals. Particularly in the emerging countries, there are pro
healthcare supply chain becomes a sustainable management strategy. This
grams with the population initiatives, involving not only the educa tional
research is a healthcare supply chain analysis in the emerging countries and it
proposes, through the sustainable lenses, a management fra mework. The study
sphere, but also aggregating value into the design of a better society
was development in a private healthcare institution in Rio de Janeiro (Brazil). The (​Cesaro et al., 2015​). The Corporate Social Responsibility (CSR) is
main objective is the analysis of the central sterilization service department and discussed in the studies with focus in the emerging countries (​Cruz and
the stockroom in the supply chain through the sustainable lenses. The Boehe, 2010​; ​Hah and Freeman, 2014​; ​Muller and Kolk, 2009​).
observation period is between December 2016 and June 2017. The research Thus, the healthcare institution needs to assume their CSR use
study presents four materials in the results: the cardboard, the paperboard, the (​Russo, 2016​) when creating the sustainable development possibilities,
plastic, and the nonwoven sterile barrier system. The study shows the theory, the instituting the ideas and the projects.
practice, and the policy. The theory presents data on the Brazilian reality related The crisis moment lived by some countries (​Ham and Kim, 2017​),
to the waste disposal, the unsanitary activity, and the stimulation for the correct
seg regation. The practice proposes the recycling activity implementation. The
policy aims at emphasizing the corporate social responsibility in the philosophy of
the healthcare institution. The conclusion is that the healthcare supply chain
management is capable to improve the population’s quality life and to offer new
 be ⁎​ ​Corresponding author.
burden of suffering on the population of any country in different points.
The second perspective allows the society to implement the innovative
and entrepreneurial actions, putting into practice new reinvention
possibilities (​Martin et al., 2017​), in the emerging countries like Brazil,
China, India, and Thailand. Brazil, a BRIC member (Brazil, Russia,
India, and China), is presently undergoing a restructuring period. This
period allows the Brazilian population to perform this reinvention
through the creativity and the resiliency.
Being the world’s fifth ranked country in geographic size and also in
the population, Brazil relies on a cultural diversity that contributes for
the sustainable application generation (​Barros et al., 2013​; ​Lino and
Ismail, 2013​). The Brazilian population needs to be increasingly

​ nnibal.scavarda@unirio.br ​(A. Scavarda), g

E-mail addresses: a ​ laucyadau@gmail.com ​(G.L. Daú), ​lf.scavarda@puc-rio.br ​(L.F.
Scavarda), ​akorzenowski@unisinos.br ​(A.L. Korzenowski).

https://doi.org/10.1016/j.resconrec.2018.10.027
Received 12 May 2018; Received in revised form 19 October 2018; Accepted 22 October 2018
0921-3449/ © 2018 Elsevier B.V. All rights reserved.
A. Scavarda et al. ​Resources, Conservation & Recycling 141 (2019) 418–430

Table 1
Some studies have emphasized the sustainable applications in the emerging countries.
Title Author Emerging country Year
sustainable supply chain performance A.; Afrifa, G.A.; Yamoah, F.A.; Oppon, E. 2018
A quantitative model for environmentally measurement Brazil, Russia, India, China, and South
Acquaye, A.; Mohammed, T.I.; Genovese, Africa (BRICS)
through Sustainable Supply Chain Management
Application of DEMATEL approach to identify the influential indicators towards Pathways for Sustainable Supply Chain Performance-Evidence from a
sustainable supply chain adoption in the auto components manufacturing Developing Country, Malaysia
sector Li, Y.; Mathiyazhagan, K. India 2018
Dual Institutional Pressures, Sustainable Supply Chain Practice and
Performance Outcome
Empirical Research on Influencing Factors of Sustainable Supply Chain Lu, Y.; Zhao, C.; Xu, L.; Shen, L. China 2018 Wu, J.; Zhang, X.; Lu, J. China 2018 Padhi,
Management-Evidence from Beijing, China
Framework for selecting sustainable supply chain processes and industries S.S.; Pati, R.K.; Rajeev, A. India 2018 Jakhar, S.K; Rathore, H.; Mangla, S.K. India 2018
using an integrated approach
Is lean synergistic with sustainable supply chain? An empirical investigation from Wang, J.; Zhang, Y.; Goh, M. China 2018 Thong, K.C.; Wong, P. Malaysia 2018
emerging economy
Moderating the Role of Firm Size in Sustainable Performance Improvement
Sustainable supply chain collaboration: incentives in emerging economies Pakdeechoho, N.; Sukhotu, V. Thailand 2018
Sustainable supply chain collaboration with outsourcing pollutant reduction Ding, H.; Huang, H.; Tang, O. China 2018
service in power industry

Sustainable supply chain management practices and performance Wang. J.; Dai, J. China 2018
Sustainable supply chain management practices in Indian automotive industry: performance: Lessons from Indian organizations
A multi-stakeholder view Mathivathanana, D.; Kannana, D.; Haq, A.N. India 2018 Hong, J.; Zhang, Y.; Ding, M.
Sustainable supply chain management practices, supply chain dynamic
capabilities, and enterprise performance China 2018 Das, D. India 2018
The impact of Sustainable Supply Chain Management practices on firm
Unveiling barriers to sustainable public procurement in supply chain initiative in Latin America A.B.L.S.; Renwick, D.W.S.; Thomé A.M.T.
emerging economies: Evidence from a leading sustainable Delmonico, D.; Jabbour, C.J.C.; Pereira., S.C.F.; Jabbour, Brazil 2018
an emerging economy’s context
When strategies matter: Adoption of sustainable supply chain management practices in Luthra, S.; Mangla, S.K. India 2018

Analyzing enablers of sustainable supply chain: ISM and fuzzy AHP approach Kumar, D.; Rahman, Z. India 2017
Development and validation of a scale for measuring Sustainable Supply Chain Emphasizing Social Issues Toward Sustainable Supply Chain: A
Management practices and performance Brazilian Perspective
Evaluating sustainable supply chain indicators using fuzzy AHP: Case of Indian Performance evaluation and a flow allocation decision model for a sustainable
automotive industry supply chain of an apparel industry
Key factors for truly sustainable supply chain management: An investigation of Das, D. China and India 2017 Kumar, D.; Garg, C.P. India 2017 Wu, J.; Santoso, C.;
the coal industry in Indonesia
Institutional pressures, sustainable supply chain management, and circular Roan, J. Indonesia 2017 Zeng, H.; Chen, X.; Xiao X.; Zhou, Z. China 2017
economy capability: Empirical evidence from Chinese eco-industrial park
firms
Assessing the economic performance of an environmental sustainable supply Ding, H.; Liu, Q.; Zheng, L. China 2016 Bhardwaj, B.R. India 2016 Hsu, C.C.; Tan, K.C.;
chain in reducing environmental externalities
Role of green policy on sustainable supply chain management: A model for Zailani, S.H.M. Malaysia 2016 Esfahbodi, A.; Zhang, Y.; Watson, G. China and Iran 2016
implementing the CSR
Strategic orientations, sustainable supply chain initiatives, and reverse logistics: Silva, M.E.; Nascimento, L.F. Brazil 2015 Jakhar, S.K. India 2015
Empirical evidence from an emerging market
Sustainable supply chain management in emerging economies:
Trade-offs between environmental and cost performance
Sustainable Supply Chain Engagement in a Retail Environment Berning, A.; Venter, C. South Africa 2015
Sustainable Supply Chain Management: a Literature review Brazil 2015 and sustainability trajectories
on Brazilian publications Silvestre, B.S. Emerging countries (in general)
Silva, M.E.; Neutzling, D.M.; Alves, A.P.F.; Dias, P.; Santos, Sustainable supply chain management in emerging 2015
C.A.F.; Nascimento, L.F. economies: Environmental turbulence, institutional voids
van Hoof, B.; Thiell, M. Mexico 2014
Collaboration capacity for sustainable supply chain management: small and
medium-sized enterprises in Mexico Sustainable supply chain management (SSCM) in Malaysia: A survey Zailani, S.;
 Jeyaraman, K.; Vengadasan, G.; Premkumar, R. At the same time, adequate disposal can be more present,
Malaysia 2012
creating a sustainable environmental proposal (​Sykes et al., 2007​) in
A project management prospective in achieving a sustainable supply chain for the health care sector, which, specifically in the healthcare
timber procurement in Banda Aceh, Indonesia institutions is a chal lenge. This challenge is associated to a deject
Zuo, K.; Potangaroa, R.; Wilkinson, S.; Rotimi, J.O.B. Indonesia 2009 variety, being disposed throughout the day by several individuals and
to a need for attention to determined resolutions of the Brazilian
Ministry of Health Guiding Collection. The waste segregation of leads
the healthcare institutions to
inserted into the sustainability. Although with several initiatives for the
selective collection in the public venues, some errors are noted in the
disposal on the everyday life of part of the population. An educational
movement must be strengthened to broaden the awareness of the so
ciety for adopting the sustainable applications (​Barros et al., 2013​).
Approaching the subject in the healthcare institution, the adequate
disposal demand is present, with the seek for a more controlled
venue.

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A. Scavarda et al. ​Resources, Conservation & Recycling 141 (2019) 418–430
plastic, and the nonwoven Sterile Barrier Systems (SBS). At the same
the development of committees for managing this healthcare solid time that the practices are broadened, the possibilities are emphasized
waste. for a more elaborate program. This program has attention for the
On the other hand, the opportunities offered by the challenges are planning, the identification, the organization, and the sustainable ap
plication action control (​Manga et al., 2011​).
many and provide for the materials capable of continuing in the
The researchers motivated in strengthening the sustainable appli
healthcare supply chain to be able to return to the market. Thus, the
circular economy concept opens doors for practices like the material cations in the healthcare supply chain of this research seek, from the
recycling, the environment impact reduction, the sharing economy, and proposed management framework, to answer the two following ques
the CSR. Presently, a competitive scenario is increasingly observed, tions. Is it possible to implement the sustainable healthcare supply
leading the healthcare institutions to the sustainable strategy develop chain management in the emerging economies? What are the possibi
ment. The strategy can aim at maintaining the healthcare institutions in lities that can be used for establishing the sustainable applications?
the market and in delivering better services to their customers. For
that, an attentive view towards the supply chain can bring a new idea 2. Material and methods
per spective (​Jacobs and Subramanian, 2012​; ​Liu et al., 2018​;
Scavarda and Scavarda, 2004​). The “material and methods” section is organized into two subsec
The intersection among the environmental, social, and economic tions named “the literature review” and “the details of the technique
used.” The “literature review subsection” shows the papers found
sustainability is featured (​Ahmadi et al., 2017​; ​Carter and Rogers,
during the search and their data. The “details of the technique used”
2008​) as a driver for the development in this research of the proposed
subsection presents the methods used to build this research.
healthcare supply chain management framework. Some products are
integrating the healthcare supply chain may aid in the perspective of
the new ideas and new products (​Carvalho et al., 2017​). As part of this
supply chain, two of the healthcare units, the Central Sterilization
Service Department (CSSD) and the storeroom, offer their
contributions (​Pinter and Jardim, 2014​). This research proposes a
circular economy framework, where some products are inserted at the
healthcare supply chain. For that, three awareness levels were
determined: the theory, the practice, and the policy.
The CSSD is complex, equivalent to many other healthcare units,
like the emergency, the intensive care, and the surgical center, due the
processing of the products and the diversity of assisted specialties.
This unit supplies for the whole healthcare institution, in the multiple ac
tivities provided to patients. The storeroom, likewise the CSSD,
supplies the whole supply chain, but the product received is the end
product issued to all the healthcare units. The variety of products in the
in ventory and the inward/outward control are extremely common char
acteristics to both units. These characteristics are also directly related
to the supported specialties, to the bed number, and to the surgery per
formed number.
Within the dynamics of both units, which practices would enable
the sustainable applications? For the storeroom unit the cardboard
used as transport packaging in the stocked product boxes is identified.
For the CSSD, the approach of these practices can be broadened, as
the observation of a variety of components, like: the paperboard, the
 2.1. The literature review

The sustainability applied to the supply chain is target to re

searchers ​(​Ghadimi et al., 2019​; ​Magon et al., 2018​) ​in the emerging
countries (​Silvestre et al., 2018​; ​Stindt, 2017​). The researcher’s con
tribution assists the proposal development for several segments, as
the industry (​Ahmadi et al., 2017​; ​Köksal et al., 2017​; ​Oelze, 2017​)
and the healthcare institutions (​De Vries and Huijsman, 2011 ​Reiner et
al., 2018). ​Mustaffa and Potter (2009) ​show a parallel between the
healthcare supply chain and the industrial supply chain. They empha
size that the first presents itself more complex than the later one for
involving the care generation in accordance to the needs presented by
each patient. Despite of the authors’ indication of this complexity, it is
significant to stress that the industries established in the emerging
countries seek proposals and programs aiming the environmental sus
tainability for the supply chain.
Another aspect involving the sustainable supply chain concept is
the circular economy (​Hong et al., 2017​). The circular economy guides
towards the sustainable growth and it provides the Triple Bottom Line
(TBL) contribution of the adding value to where it is established (​Hong
et al., 2017​; ​Seuring and Müller, 2008​; ​Zeng et al., 2017​).
The concerns at the world level proposed in the Agenda 2030 and
the United Nations (UN) bring questions to be debated with a more
holistic view by the society and its several segments. These questions,
centered in a sustainable growth, make a deep dive into the concerns
under this subject. Among the 17 Sustainable Development Goals
there are: the affordable and clean energy; the climate action; the
decent work and the economic growth; the good health and the
well-being; the clean water and the sanitization; the gender equality;
the industry, the innovation, and the infrastructure; the partnerships for
the goals; the life below water; the life and the land; the non-poverty;
the peace, the justice and the strong institutions; the quality education;
the reduce inequalities; the responsible consumption and the
production; the sus tainable cities and the communities; and the zero
hunger.
These 17 goals are connected to each other. One of the examples
of this connection can be based on the speech of the UN’s General
Vice Secretary A. Mohammed, listing the climate changes as one of
the factors affecting peace. Among the genders, the female is the most
af fected one, explaining that desertification requires women to cover
greater distances, attempting to obtain water and food. This lead them
to miss the educational and the economic opportunities on the long
term.
The authors, between July 2​nd ​and October 18​th​, 2018, searched for
the sustainable supply chain papers using as their selection criteria the
“sustainable supply chain” term in their titles without any restrictions of
their publishing years. The search included the following science
publishers: Cogent Business & Management, Council of Supply Chain
Management Professionals, Elsevier, Emerald Group, Gestão &
Produção (G&P), Hindawi, Independent Journal of Management &
Production (IJM&P), Institute of Physics Publishing (IOP), Mary Ann
Liebert Inc., Multidisciplinary Digital Publishing Institute (MDPI),
Poznan School of Logistics, Published by Tennessee State University
College of Business, SAGE, Springer, Wageningen University &
Research, and Wiley. This search used the “sustainable supply chain”
term resulting in 240 papers. ​Fig. 1 ​shows a chart with the total number
of papers per year. From these, the growing scientific production on
the theme, especially in 2017 and 2018, can be observed. The
analyses of the year of 2018 shows the production growth of 26%
when compared to the year of 2017.
The authors selected 33 papers applying the following inclusion
criteria: the English language, the Digital Objective Identifier (DOI),

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 A. Scavarda et al. ​Resources, Conservation & Recycling 141 (2019) 418–430 ​Fig. 1. ​The total number of papers per year about the “sustainable supply chain”.

and the research focusing in the emerging countries. The identification outsourced services was performed for the reduction of these
of the emerging countries has as basis the G20 group. Actually, the
United Nation appointed to the G20 group the total of the 23 emerging
countries: Argentina, Bolivia, Brazil, Chile, China, Cuba, Egypt,
Equator, Guatemala, India, Indonesia, Mexico, Nigeria, Pakistan,
Paraguay, Peru, Philippines, South Africa, Tanzania, Thailand,
Uruguay, Venezuela, and Zimbabwe. This literature review sought the
Sustainable Supply Chain (SSC) with a broader segmentation, that is,
it did not use as the inclusion factor only the researches involving the
healthcare.
Among these 33 papers, ten were from India, eight were from
China, three were from Brazil, three were from Malaysia, two were from
Indonesia, one was from Mexico, one was from the BRICS, one was
from South Africa, one was from Thailand, one was from the
Chinese-Indian partnership, one was from the Chinese-Iranian
partnership. Despite of Iran and Russia not being appointed among the
G20 countries, the authors considered their inclusion, because they
were analyzed in the papers selected. One of these 33 papers involved
the emerging countries in general.
The incorrect human attitudes bring gradual impact on the en
vironment. The changes in the attitudes and in the cultural adjustments
are some of the measures to be implemented. These measures can be
initiated with the educational programs for the social integration and for
the awareness. This framework proposes the reverse logistic im
plementation and the sustainable applications to reduce the environ
mental impact and to add the social and economic value. The
emergent and sustainable topics are presented around the world. The
use of the plastic materials is discussed, because their reverse logistics
and their erroneous disposal increase in the sea, in the river, and in the
lake. This erroneous disposal impacts on the local fauna and flora
destructions.
In face of the climate changes, ​Jakhar (2015) ​points to a trend of
growth for them. The author emphasizes the point of provision of the
water, the food, and the public health systems, as well as the global
supply chains for strategic commodities. Jakhar points the risks to
several concerns, among them the humanitarian and geopolitical ones.
Zuo et al. (2009) ​analyze the sustainable applications in all the supply
chain stages and consider the TBL concept. The view of this study has
as a mark the Tsunami in Banda Aceh, Indonesia, in 2004. The
findings are that the sustainable applications on the supply routes, on
the post-dis aster situation project management, on the supply chain
integration, and on the stakeholders add value to the reconstruction
project.
The contributions brought by ​Ding et al. (2018) ​point to a model
involving the environmental sustainability for the contaminant reduc
tion in accordance to the standards for the coal industries. They ana
lyzed a collaborative mechanism for reducing contaminants among
partners in the supply chain. The investigation on the pricing of the

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A. Scavarda et al. ​Resources, Conservation & Recycling 141 (2019) 418–430
applications in the supply chain. ​Delmonico et al. (2018) ​approach the
public sustainability with the analysis of the organizational barriers. The
authors refer the strong incentive for the investments to be per formed
by the government for greater initiatives with the sustainable
applications. ​Padhi et al. (2018) ​define that the main point for the
sustainable business in the supply chain improve the performance in
the three dimensions of this supply chain. They propose a framework
identifying in the study itself 17 sustainable supply chain processes
from the literature and using the stakeholder theory. The authors
classified them into six groups, with one of them being an analysis of
the sustainability and the regulatory concerns.
For ​Silva and Nascimento (2015) ​and ​Silva et al. (2015)​, the social
concerns deserve more attention. These can be considered all over
the world, but especially in the emerging countries. Thus, greater
attention to the social sustainability must be put into practice. Their
study in volved the discussion with the Brazilian perspective, where
the social dimension deserves attention. Likewise, the findings from
Kumar and Garg (2017) ​indicate the social and environmental
contaminants by the service providers. In parallel, the carbon emission
and the greenhouse effect are factors broadly discussed and which are
brought by the studies in the emerging countries (​Acquaye et al., 2018​;
Li and Mathiyazhagan, 2018​; ​Wu et al., 2017​; ​Zeng et al., 2017​).
Therefore, the adequate and rational use of the natural resources
as solar energy and water is considered. This can be possible by
replacing the electric energy with the photovoltaic energy panels for the
solar energy conversion. The wind energy use also provides benefits.
The clean energy generation may be revisited by the several
segments, in cluding the healthcare institutions. This way, the
industries with the sustainable supply chain management assume the
environmental re sponsibility.
The cost involved in repairing the environment and removing the
non-identified hazard result of the supply chain can become real pro
blems (​Ding et al., 2016​). Another aspect, mentioned by ​Zailani et al.
(2012)​, indicates that the recent world economic events create un
certainty in the business. This leads the companies to restructure and
to reorganize themselves.
Wu et al. (2018) ​contribute with factors that influence a sustainable
supply chain. These include the internal knowledge management es
tablished by the industries and the consumer pressure and also the
governmental participation. The authors show that the internal
knowledge management and the governmental participation have a
direct effect on the sustainable supply chain. The governmental parti
cipation exercise pressure on the industry. ​Lu et al. (2018) ​examine the
relationships between the institutional pressure and the sustainable
supply chain application and between the sustainable supply chain
application and the performance outcome. The authors present six re
sults, among them: that the institutional pressure have a significant
positive impact on the supply chain management and that the sus
tainable supply chain design has a significant TBL positive impact.
Jakhar et al. (2018) ​in their “Is lean synergistic with sustainable
supply chain? An empirical investigation from emerging economy”
paper say that the relationship between the lean management and the
sustainable supply chain management is not straightforward. The au
thors present that the positive impact occurs by the lean management
influence over the supply chain sustainable practices and that the ne
gative impact involves the delivery and the logistics.
Thong and Wong (2018) ​present the impact of the social and en
vironmental performances over the economic one. They state that the
lean management is a tool for the cost reduction and for the market
growth and that the sustainability is an innovation key driver. ​Luthra
and Mangla (2018) ​present a research study within an Indian context
approach, in which their model developed allows to identify the sus
tainable supply chain management implementation strategy.
Hsu et al. (2016) ​emphasize on their results the positive aspect in
the reverse logistic in the implementation of the sustainable
dimensions as con tribution for the sustainability. ​Kumar and Rahman
(2017) ​analyze three sustainable adoption stages: the favorable
environmental crea tion, the sustainable implementation, and the
sustainable culture de velopment. They highlight joint development,
after peer comparison, as the first point for the sustainable culture
development. The second point is determining and resolving the
problems. A positive relationship between the supply chain economic
and the social basis is part of the results from the ​Pakdeechoho and
Sukhotu (2018)​’s paper. The authors emphasize a high level of the
incentives in the relationship between the supply chain and the social
dimension.
Das (2018)​’s paper presents that the social inclusive practices of
the community have a negative impact when associated with the
compe titiveness points. A reverse effect can happen when this
relationship is accomplished in an indirect way. The positive effect in
this relationship can be provided by the term used by the author
"community centred social performance."
The information and educational proposal are highlighted on the
paper of ​Berning and Venter (2015)​, emphasizing a better access to
the quality information and the refocusing on the already existing
educa tion. They also mention the public awareness by the
organization as a first step for the consumers and the stakeholders on
the supply chain value generation. They include training the
stakeholders, the suppliers, and the staff. The adoption training of the
sustainable applications is indicated as one of the green supply chain
management guides. The ​Bhardwaj (2016)​’s paper also shows the
same concern.
Silvestre (2015) ​explains that two factors may affect the learning
processes: the innovation and the progress of an adequate pace for
the sustainable path in the emerging economies. These factors are de
scribed as the turbulent environment and the institutional emptiness.
They strengthen that the knowledge and the innovation are essential
and require changes by the members and the sustainable supply chain
process transformation.
Wang and Dai (2018) ​bring some aspects for attention: the en
vironmental management strengthening by the companies, the recycl
able product design, the emission reduction, the packaging recyclable
materials, and the ISO 14001 implementation. They also emphasize
the social responsibility, as well as the worker’s protection, safeness,
and health. ​Das (2017) ​identifies ten supply chain constructors: the
practice ones (the environmental management, the operations, the
supply chain integration, the socially practices for employees, and the
socially in clusive practices for the community) and the performance
ones (the environmental performance, the operational performance,
the compe titiveness, the employee centered social performance, and
the com munity centered on the social performance).
A condition that equally draws attention is the size of the
companies for the economic performance analysis. ​Wang et al. (2018)
propose a practical model for the implementation and the
recommendation of a Sustainable Supply Chain Management (SSCM),
according to the size of

422
the company. ​Van Hoof and Thiel (2014) ​stress out that the colla
 boration capacity for a sustainable supply chain must be built in the
new organization. Another aspect is the identification of the capacity of
the company in establishing the supply chain connection and the en
vironmental project implementation.
The sustainable supply chain applicability shows the high perfor
mance level at the environmental basis, according to the ​Esfahbodi et
al. (2016)​’s paper, but this applicability does not necessarily improve
the cost performance. They reiterate that in the SSCM measure
adoption in the emerging countries a financial analysis must be made
based on the budget and cost performances. ​Mathivathanan et al.
(2018) ​point out the strategic decision making TBL approach
incorporation and the sustainable management commitment practices.
Berning and Venter (2015) ​and ​Silva and Nascimento (2015) ​highlight
the CSR use.
2.2. The details of the technique used
The present research is an analysis of the healthcare supply chain
in the emerging countries and proposes, through the sustainable
lenses, the management framework. Brazil puts forward several order
pro blems, among them environmental, social, and economic. These
pro blems may develop a benefit generating network, where the
education can encourage and touch the society for the sustainable
applications. The environmental and economic concern adjustments
provide and enable the improvement implementation basis in the
social field (​Lozano, 2008​).
The present study was developed in a private healthcare network
institution, located in the city of Rio de Janeiro. The authors are not
connected to the institution and they obtained authorization from the
ethics committee for the data collection period. All professionals ob
served authorized via a consent document. The institution operates 24
h per day and provides approximately 200 beds and 11 operating
rooms with one of them considered hybrid. The hybrid operating room
A. Scavarda et al. ​Resources, Conservation & Recycling 141 (2019) 418–430
Fig. 2. ​The healthcare units and other external services involved in the
healthcare supply chain.
for the SBS;
- The internal and external nonwoven SBS used for the packaging of
the surgical boxes and other healthcare products, which shall be
sterilized. Each hip arthroplasty surgical box needs two overlays (an
internal one and an external one). In general, ten overlays are
placed in the plastic package and then into the cardboard box.
The cardboard, the paperboard, and the plastic sale prices were
extracted from the public domain information found on the recyclable
material commercialization websites. On the other hand, the nonwoven
SBS purchase price were obtained from price survey via the product
manufacturer and the distributor interview in the State of Rio de
Janeiro. The search for the nonwoven SBS purchase price by the re
has the imaging equipment, allowing the minimally invasive surgery
perfor mance. The surgical center performs approximately 12,000
surgeries per year and the CSSD processes around 108,000 critical
items, which shall be in contact with the sterile bodily tissues.
The research comprises the Brazilian private healthcare sector
perspective, the CSSD analysis, and the storeroom in the healthcare
supply chain through the sustainable lenses, as main objectives. The
observation period comprehended the surgical kit processing mon
itoring between December 2016 and June 2017. The authors observed
the processing of approximately 400 surgical kits supporting 50 hip
arthroplasty surgical procedures. The average observation time for all
kits was 140 h. The surgical kit processing comprised five stages: the
receipt, the cleaning, the inspection, the preparation, and the ster
ilization. The cardboard, the paperboard, the plastic wrappings, and
the internal and the external nonwoven SBS materials were used for
the preparation and sterilization stages. The observation period for
these two stages was of approximately 100 h.
The collected data were inputted into an instrument designed for
organizing the information. The information regarded the time of each
stage, the number of the surgical kits processed for each hip ar
throplasty procedure, and the amount of the materials used.
Consequently, the proposed healthcare supply chain management fra
mework is developed with those four materials, which are used by the
CSSD and which are delivered by the suppliers to the storeroom.
- The cardboard, the primary transport packaging for the nonwoven
SBS and the Process Challenge Device (PCD), even not being di
rected to the CSSD, was included for being delivered to the store
room by the suppliers along the other three materials;
- The paperboard, the PCD component, used for monitoring the
sterilization cycles with the biological and chemical indicators
monitoring;
- The plastic wrappings, used as the secondary transport packaging
cycling companies was performed, but this information was not found
in the public domain. In the next section, results obtained will be
analyzed.
Within each proposal, there shall be approached the sustainable
applications, focused on the healthcare supply chain. The logistics of
product delivery and the reverse logistics support are presented. The
sustainable applications possess incentive as much to the reverse lo
gistics as to the waste reduction strategies (​Connor and O’Donoghue,
2012​; ​Khayatzadeh-Mahani et al., 2017​). ​Ma et al. (2019) ​state that the
individuals with the most resource consumption are those who have the
greater recycling practical involvement. The authors propose the en
vironmental self-identity and the pride feeling for those individuals who
present a waste reduction focused behavior.
Fig. 2 ​exemplifies the healthcare units and other external services
involved in the healthcare supply chain. The healthcare supply chain
strengths the connection among the purchase units, which order the
products to the company of the supplier; the storeroom, which receives
the product for the verification, the storage, and the distribution to the
several healthcare units; the CSSD, which is between the clients of the
units and of the storeroom; the surgical center, which is the CSSD lar
gest client; and the recycling cooperatives, which collect materials as
well as transform them into the different new products.
3. The proposed healthcare supply chain management framework
The proposed healthcare supply chain management framework
shall approach the four materials presented. These are discussed
under the sustainable lenses, considering the connection of the three
aspects: the theory, the practice, and the policy. ​Fig. 3 ​shows the three
aspects.
The proposed healthcare supply chain management framework
presents the healthcare supply chain from the purchase unit, followed
by the several suppliers. From delivery to the storeroom, the
connection
 Fig. 3. ​The connection among the theory, the practice, and the policy.

between the sectors target of the present framework, the storeroom

itself and the CSSD are established. ​Fig. 4 ​shows this connection. After
the storeroom remove of the materials from the inside of the cardboard
box, it must be separated and sent to the shelter for the storage. The
storage must be performed in an adequate place and the
transportation must allow the boxes to remain dry and clean. In the
CSSD, the paperboard and the plastic must also be separated, trans
ported, and stored to keep the material integrity.
The nonwoven SMS must be adequately organized in a clean con
tainer. The container, for the purpose, will be separated and after sent
to the shelter. From the correct storage, the materials are sent and
collected by the registered and authorized recycling institution. These
institutions can be the waste collectors and the seamstress
cooperatives, created by the healthcare institution, which will be
responsible for transforming this material.
Establishing the reverse logistics and its integration is aggregated
to the proposed healthcare supply chain management framework. The
healthcare supply chain completion in the final user must create a not
so holistic view for the situation, but the supply chain can be improved
with the recycling and the transformation material (​Gaur et al., 2017​).
The waste reduction is possible through a careful analysis of the ma
terials that can be reused (​Lino and Ismail, 2013​; ​Oliveira et al., 2018​).
Le Hesran et al. (2019) ​address the reuse as the measure of the
resource maximization and of the waste reduction. However, they
emphasize that this opportunity is reuse dependent on the product
assessment.
This entire healthcare supply chain is laterally supported by the
three aspects: the theory, the practice, and the policy. Above the whole
healthcare supply chain there is the TBL, allowing the analysis of the
proposed framework under this view. The value is added to the action
through the CSR use (​Hah and Freeman, 2014​; ​Russo, 2016​) and
through the waste reduction passive of recycling (​Lino and Ismail,
2013​). The educational program implementation, involving the
healthcare institution employees and the local community, enables the
social sustainable establishment (​Crifo et al., 2016​; ​Lepoutre et al.,
2007​; ​Palazzo and Richter, 2005​). ​Geissinger et al. (2019) ​propose a
research model with the sustainability highlighted in the motivation, in
the efficient resource design, and in the new idea. In this research, the
TBL and the sharing economy are influencing the sustainable model.
The healthcare supply chain management framework is presented
under the sustainable lenses. The social and economic sustainability
are emphasized through the financial return and the sharing economy
along the cooperatives. The waste reduction environmental concern is
highlighted in this framework, providing the proposals for new papers
on the theme. ​Fig. 5 ​shows the proposed healthcare supply chain
management framework.

423
​ ig. 4. ​The connection among the units.
A. Scavarda et al. ​Resources, Conservation & Recycling 141 (2019) 418–430 F
4. Results
The current section presents the four materials and it emphasizes
their specific participations in the healthcare supply chain. The four
materials were selected from the observation performed by the authors
of the healthcare products processing in the CSSD in the recycling
practices performed by some Brazilian healthcare institutions. These
institutions reinforce that the implementation of the actions involving
the CSR and the sustainable applications is possible (​Cruz and Boehe,
2010​; ​Hah and Freeman, 2014​; ​Muller and Kolk, 2009​; ​Russo, 2016​).
Among the four materials mentioned, some points related to their
function and participation in the healthcare supply chain shall be
analyzed.
4.1. The cardboard used as the primary packaging
The cardboard has its entry into the healthcare institution through
input suppliers. The storeroom delivers the greater amount of this
material, stores following the organization of its content, and sends to
the depot and the discards. The CSSD does not receive these
cardboards due to the need for inspection of materials contained in this
packaging. The cardboard boxes cannot be stocked in the CSSD,
because the cardboard passes through several storage places with the
possibility of bringing a dust layer with this material. The cardboard
boxes must be opened for the verification and the stored separately
from the products, which shall be sent to the healthcare units. Thus,
even with the material not being delivered to the CSSD, the cardboard
was considered for
Fig. 5. ​The proposed healthcare supply chain management framework.
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A. Scavarda et al. ​Resources, Conservation & Recycling 141 (2019) 418–430
4.2. The paperboard of the process challenge device component
The paperboard must be sterilized for the sterilization process
monitoring of the healthcare products destined to the surgical center
and other healthcare institution units. The PCD is an item designed to
constitute a definite resistance to the sterilization process and used to
evaluate the performance of this process (Association for the
Advancement of Medical Instrumentation,(​Association for the
Advancement of Medical Instrumentation (AAMI), 2017​).
The PCD may contain three types of indicators (biological,
chemical integrator, and chemical emulator) and an association of
these (biolo gical and chemical integrator), according to their purpose
for the monitoring of loads with the implantable and non-implantable
being one of the products integrating packaging supplied to this
healthcare supply chain.
This material sale price for the companies operating with the re
cycling, according to the public domain information gathered in web
sites, is US$ 0.05 per kilogram. In accordance to the groups disposed
by the Brazilian Ministry of Health National Program, this material can
be recycled, allowing the promotion of strategies for sale to the
recycling cooperatives. Therefore, if is considered that ten kilograms of
card board is taken daily from the healthcare institution to its depot, the
obtained savings at the end of one year shall be US$ 132.00.
On the other hand, an aspect that does not involve the product sale
may be the effective participation of the company at the neighboring
community, that is, in the local community (​Berning and Venter, 2015​;
Silva and Nascimento, 2015​). The participation of the healthcare in
stitution in the community can be one of the opportunities approached
in the discussion section. The CSR use is, thus, brought to the
reflection for the social aspect improvement (​Mathivathanan et al.,
2018​) and as institution brand in the corporate scenario. Another topic
approached is the waste reduction as one of the key measures for the
environmental impact reduction.
The Brazilian studies from ​Lino and Ismail (2013) ​and ​Oliveira et al.
(2018) ​demonstrate the sustainable concern, enhancing of the
selective collection, of the waste management, and of the education as
practice for the environmental, social, and economic improvements.
The higher the dissemination of the possibilities and the discussion for
fomenting the sustainable applications, the better the condition of life
for the population in the near future.
devices. Therefore, each load with material sterilized must contain the
PCD for monitoring the sterilization process. After the PCD use, the
paperboard returns to the hamper (the recipient used for the stowage
of dirty clothes and of the waste disposal) and remains piled over a
bench for many Brazilian healthcare institutions for reuse like the
message an notation.
The paperboard has the same sale price as the cardboard, US$
0.05 per kilogram. The PCD composed of the paperboard sheets may
weight 284 g and its participation in the reverse logistics is similar to
that of the cardboard. The difference is the cardboard remain allocated
in the storeroom and the paperboard follow to the CSSD.
Only after going through the sterilization process, the PCD is dis
membered in the paperboard sheets and, thus, shall have its reverse
logistics completed. Considering an average number of ten sterilization
of the loads per day in the CSSD, the savings, with the reuse of the
cardboard, of US$ 121.44 per year.
The healthcare institution itself performs the investments in the
sterilization many times. The savings mentioned previously may not
have the economic representation against the need of the new tech
nology incorporation investments for the CSSD. The reflection must fall
not only upon the monetary value, but also over the sustainable ap
plication performed and the social values (​Pakdeechoho and Sukhotu,
2018​). The paperboard also creates other possibilities for the co
operatives of the craftsmen and it can be converted into several other
products, like: the earring, bracelet, and necklace boxes.

4.3. The plastic used as the nonwoven sterile barrier system packaging

The plastic is a secondary packaging for the nonwoven SBS, al

lowing the protection during the transportation to this SBS. The non
woven is packaged generally with ten units in the interior of the sealed
plastic bags. The storeroom sends the SBS protected by this
packaging to the CSSD. The professional in charge of preparing the
healthcare product opens the number of the SBS for a specific period
of the day and discards the plastic into the hamper. The plastic, in
many cases, will not be reused.
This reality can be changed, if the healthcare institution adopts
measures for the incorporation of the plastic to the recyclable group.
These measures may involve the discard reduction, enabling the waste
reduction the environment (​Pacheco et al., 2012​). According to data
presented by ​Guamá et al. (2008)​, the period for the plastic to undergo
degradation in the environment may take centuries. The plastic is not a
biodegradable material. ​Guamá et al. (2008) ​also refer that the plastic
incineration releases toxins harmful to the human body. Consequently,
the sustainable measures for the recycling materials with the plastic
components, when allowed, can be improved (​Pacheco et al., 2012​).
The selection initiatives of this material contribute not only to the en
vironmental application, but also to the social and economic ones.
Moving away from the healthcare institutions is to emphasize the
information received through the media and observed daily, regarding
the presence of the waste in the oceans, in the rivers, and in the lakes.
The waste, impact the environment, affecting the local fauna and flora.
In the sustainable economic dimension, the kilogram of the plastic can

425
be worth up to US$ 0.95. The CSSD of a large helthcare institution
 (between 151 and 500 beds) is capable of processing, for 1000
surgeries a month, an average of 9000 critical items. Thus,
approximately 18,000 nonwoven SBS can be used, producing a
monthly average quantity of 1800 plastic bags. The estimate was
performed based on the use of the SBS only for the critical items.
4.4. The internal and external nonwoven sterile barrier system
A sterile barrier system has the distinct purposes in the sterilization
process: of allowing the air removal from the interior of the packages,
of the penetration of the sterilizing agent, of the removal of the
sterilizing agent, and of the maintenance of the product sterility. Like
the PCD, the SBS is sterilized, but in this case, must maintain the
healthcare product sterility conditions. The healthcare institutions must
follow the manu facturer instructions for the develop their standard
operational pro tocol.
Presently, there are several types of the SBS, with some of these
being disposable, like nonwoven. After the sterilization, the kits and
other material are forwarded to the surgical center for the execution of
the several procedures. During the assembly of the operating room
and the surgery, the operating room professional has the task of
opening the packages for the exposure of their sterile content. This
action allowed handling by the surgical team, providing aseptic
transfer.
The nonwoven SBS shall then be disposed into a specific hamper,
if measures for the reuse of this material exist. If no measures for this
take place, the nonwoven SBS may be wet and contaminated due to
the inappropriate spill of the antiseptic solution and due to the con
tamination with patient’s bodily secretions. This is the reason why the
plan, control, and supervision measures for this waste in a surgical
center must be implemented.
From the arguments presented, the strategies can be established,
so that, a product susceptible to recycle is able to proceed in the cycle
A. Scavarda et al. ​Resources, Conservation & Recycling 141 (2019) 418–430
supply chain, through the three aspects: the theory, the practice, and
the policy. The theory presents data reflecting the Brazilian reality re
garding the waste disposal, as well as the unhealthy activities of the
families living off this condition. For the practical aspect, are proposed
the practical recycling implementation. These proposals aim at bringing
the individuals, who find the subsistence means in the waste collection,
for the educational programs. This proposal allows aggregate and im
prove the monthly revenue. The third aspect, the police, aims at em
phasizing of the CSR use in the philosophy of the healthcare institu
tions. The CSR uses allows the implementation of the practical aspect
and the collaboration for the waste reduction mentioned at the theo
retical aspect.
5.1. The first aspect applied with the sustainable lenses: the theory
According to data from the ​Brazilian Institute of Geography and
Statistics-IBGE (2000)​, the Brazilian waste production reaches
228.413 tons per day. The waste is sent to several final destination
units, like: the open-air dumps flooded area dumps, the controlled
landfills, the sanitary landfills, the composting stations, the triage sta
tions, the incineration, and the non-fixed venues. Among these, is
aimed at the controlled and the sanitary landfills, with the Southeast
region being the Brazilian largest producer. This is the reason why
special attention must be given for the initiatives seeking production
waste reduction and the waste transformation. These actions are able
to be implemented improving perspectives for the environment and the
future generations (​Leme et al., 2014​; ​Lino and Ismail, 2013​).
Ferrer et al. (2018) ​conduct a literature review involving the sus
tainable urban infrastructure and the waste disposal. This paper cor
roborates with the search for the sustainable practical implementation
strategy for the waste reduction.
The government, through greater incentives, must also promote the
sustainable application awareness. The tax reduction for the
responsible institutions must be a stimulus factor for the sustainability
and to return safely to the society, fulfilling its healthcare supply chain
path. The initiatives that bring the sustainable applications can involve
the CSR use (​Maas and Reniers, 2014​), activating the supply chain
and allowing the reverse logistic of these products to be implemented.
The purchase price of the nonwoven SBS, according to data from
three prices obtained along the manufacturers and the distributors,
were US$ 0.96 and US$ 0.75 for those used as respectively the
external and internal casings. If established a rationale for the
calculation based on the hip arthroplasty surgeries, using an average
of 20 surgical kits for a patient are used of 40 nonwoven SBS units (an
internal one and an external one).
The sale of the plastic may reduce the nonwoven SBS purchase
costs and the sale of the PCD paperboard may reduce the device
price impact in the budget. Therefore, the strategies must be
determined aiming at clarifying the cycle proposed by the
Environmental Protection Agency EPA (2000)​. The encouragement
and the incentive must be present in the daily lives of the companies,
the governments, the communities, and the citizens.
These sustainable strategies allow that the healthcare supply chain
cycle to be complete with an attentive management and a supervised
reverse logistics. This reverse logistics must also be based on the pre
cepts, involving the impact reduction cost and stimulating the unit
budget improvement. Many are the possibilities for adding value to the
business and to the brand, but the CSR reflection is emphasized.
Diabat and Govindan (2011) ​provide the EPA (2000) model in their
study for the four steps in implementing the green supply chain. These
steps are divided into identifying costs; determining opportunities;
calculating benefits; deciding, implementing, and monitoring.
5. Discussion
The present section considered, under the sustainable lenses, the
analysis of the four materials and their insertions into the healthcare
and the CSR use. This tax must take place not only for those
institutions seek to reduce the waste, like: the cardboard, the
paperboard, the plastic, and the nonwoven SBS, but also for those
companies working with the composting techniques. At the healthcare
institution, the composting can be performed in waste from the
healthcare institution kitchens, like: the fruits, the vegetables, and the
greeneries.
The waste decrease contributes for the reduction of the areas
called open air dumps. These areas are in the third position among the
col lected waste final destination units (48,321.7 tons/day) in Brazil
(IBGE, 2000). The information media shows that many individuals
make their living out of the waste, like the “collectors”. The second
largest Brazilian waste destination is the sanitary landfill with around
82,650 tons per day. The waste reduction can generate the social pro
blems in two distinct fronts. Then, when educational programs are
implemented for reducing the waste, the local communities are pro
vided with the improvement in their quality of life. For example, when
the intake of the waste is reduced to open-air dumps, the opportunity
for revenue is withdrawn from the group living off the waste collection.
Many Brazilian studies show the sustainable waste management stra
tegies (​Agostinho et al., 2013​; ​Coelho and Lage, 2018​; ​Lino and Ismail,
2013​; ​Pacheco et al., 2012​; ​Rocha and Satler, 2009​).
Many families live off this condition and they live nearby the
landfills. These families could take part in the social project, where
people learn a new activity in order to perform a new line of work. The
children would have the opportunity of leaving the open-air dump and
going to the school. These actions are not easy, but can be a
continuous process for the change in the search of a better society.
At these healthcare supply chain, in most cases, elements are dis
posed with no action for the reverse logistics. Some of them, as the
nonwoven SBS, for being in a surgical ambiance, can be incorporated
to the infect waste, if there is not the corporate decision making for the
planning involving the adequate solid waste segregation. Many times,
 this waste is mixed with other materials, like: the blood and the human
secretions with the SBS. The SBS lose their characteristics and don’t
to go forward in the reverse logistics. The infecting waste increases, im
pacting not only the deconstruction of a healthcare supply chain based
in the sustainable applications, but also the CSR implementation and
of the economy. This impact doesn’t allow the reinvestment in the
social and quality program improvement actions.
Thus, from the knowledge of the presented reality and based on
the four products, the sustainable applications incorporation aiming the
waste reduction in the healthcare institutions is targeted. ​Pinter and
Jardim (2014) ​provide data on the segregation and the solid waste
decrease in the surgical center. The authors work with the nonwoven
material and perform an estimate, which can be project for the
healthcare institution. Again, a surgical movement of 1000 surgeries
per month is considered and it is believed that around 2,760 g of the
nonwoven could be generated in the period of a year.
It is, thus, understood that the CSR begins inside the healthcare
institution, the homes of employees, and the clients themselves. The
social responsibility cannot be maintained for the community, if the
value is not representative on everyday life of the institutions and of
their employees. The movement must be inside out, with the con
structive actions. Consequently, this movement encourages the
healthcare institution employees to become integrating members of the
support commissions in their communities. The management at its
several levels, when sensitized and engaged, can be strong support
for the sustainable application fulfillment (​Cruz and Boehe, 2010​; ​Hah
and Freeman, 2014​; ​Muller and Kolk, 2009​; ​Russo, 2016​).
At the end of the theory aspect discussion, the attention is drawn to
the possibility of a holistic view on the sustainable applications inser
tion in the Brazilian healthcare institutions. Then, the practical aspect
brings to the discussion the individual’s view on the concern with the
environment and with the cost reduction possibilities and the sharing
economy stimulus.

5.2. The second aspect applied with the sustainable lenses: the
practice

In the healthcare supply chain, each stage must be directly con

nected to the next stage and, thus successively, minimizing faults. At
this gearing, the actions must be implemented not only for the plan
ning, the execution, and the maintenance, but also for the introduction
the educational programs in each stage. These stages, once in
corporated, must contribute and facilitate the comprehension, trans
lating into greater security to those handling and acquiring a product.
This concern can be common in any of the four materials, but,
above all, it may be present in the internal and external nonwoven
SBS, as this material remains in the healthcare supply chain towards
the surgical center. These actions must have an educational
intervention, becoming auxiliary in the development of the knowledge
and the awareness of the society. The responsible and the
conscientious attitudes are welcome with the strategies that provide
safe return and the healthcare profes sional handling of these
materials, as well as the clean production (​Berning and Venter, 2015​).
The planning, the execution, and the supervision of the segregation
must be performed in a more adequate manner, guaranteeing that the
product is capable of maintaining a standard for the reuse. This way,
an adequate hamper in an operating room must be made available
and soon after the collected material must be forwarded to a depot,
where there is no contamination risk. The leaflet informing to
population about the healthcare supply chain and the attention with the
material may be used, prepared, and annexed to the recycled end
product. The measures aim at reassuring the society of acquiring and
using the converted end product. The measures may generate the
aggregate value, thus slowly building a movement of population the
awareness for understanding and for adopting the sustainable
applications (​Pinter and Jardim, 2014​).
All these measures can create movements that have for many years
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A. Scavarda et al. ​Resources, Conservation & Recycling 141 (2019) 418–430
 vocational courses can be a stimulus for other individuals to seek
been performed, but which need the drivers. The community agents refinement (​Donia et al.,
can guide and participate in the community education programs and
the institution directors can perform the seminars. The objective of
these seminars is creating an example, so that other institutions seek
similar initiatives, in other words, oriented to the best targeting through
the benchmarking. The disclosure of acts involving the CSR with the
sus tainable healthcare supply chain provides the movement favorable
to the new perspectives for the society (​Cesaro et al., 2015​; ​Mousa,
2015​).
Therefore, there is a search for making possible with greater visi
bility the possible practices already implemented by the Brazilian
health institutions. The stimulus for projects of this nature, that leave
the drawing board and of corporate ideals, strengthens the trend that
the healthcare institutions are able to implement these practices. Thus,
a view into the corporate future must be reinforced, considering the
new adepts of the sustainable application.
The creation of the recycling cooperatives can include those mem
bers of the society out of the work market and who perform selective
the waste collection activities (the cans, the cardboard, the paper, the
plastic, and the glass bottles) on the streets (​Barros et al., 2013​). A
registration program performed along the local communities can
identify the idle professionals and the people who wish to have a dif
ferent work activity. The seamstresses cooperative can be another ex
ample and encouragement to the manual labor. This may bring about
the creativity of those living in the communities, generating revenue
and promoting the insertion of the citizens into the society.
These actions contribute to the self-esteem increase of those living
there and taking part into these programs (​Crifo et al., 2016​; ​Lepoutre
et al., 2007​; ​Palazzo and Richter, 2005​). ​Meng et al. (2019) ​state that
the local population participation in the waste classification and in the
waste recycling is a factor that leads to the solid waste management
success. For ​De Almeida and Borsato, (2019), ​the material recycling is
one of the appropriate and of the recognized strategies to reduce the
environmental and social impacts.
Some creations may include the purses, the calendar covers, and
the coin bags, among other objects, which can be manufactured with
the nonwoven SBS. The plastic may compose the crochet techniques
ap plication in the manufacturing of the purses and the tablecloths.
The cardboard may serve as the package for the several handicrafts.
Thus, a series of the ideas can be applied to this reality, stimulating
the manual skills of those practicing them. The activities of these
nature insert the individual into the community and enable a
usefulness sense.
The creation of the local craft fairs, for the exhibiting, the pro
moting, and the selling the products manufactured by the cooperative
workers, strengthens the CSR idea. The CSR also promotes the need
for strengthening the sustainable applications. The community fairs
aim at developing three aspects: the professional who idealized and
manu factured the product, those interested in engaging in an initiative
and work in this profile, and the people leveraging new initiatives and
improvement in the economic field.
With the strengthening of these activities, the creation of an edu
cational framework stimulates the local community, inserting the in
dividuals into the healthcare institution. A register of the local com
munity residents assists in the knowledge of the necessities, of the
intentions of each individual, and of the instruction and education le
vels. The register can verify abilities and skills for better adaptation to
a new activity. Some examples of the educational programs that can
be implemented are the adult literacy, the qualification for the activities
in the healthcare institution hygiene field, and the development of the
partnerships with the schools, offering the vocational courses.
These educational initiatives intended that the offer of the voca
tional courses, in partnership with schools, is not free, but it’s offered
for a small fee, originating from services performed by the community
cooperatives themselves. This way, those working in craft
cooperatives, with the cans, the plastic, and the glass and even at the
healthcare in stitution itself can attend vocational courses. The
 2017​).
With the structuring and the educational programs implemented the
qualified professionals are inserted into the work market by the
healthcare institution. This initiative promotes a salary increase for the
population, allowing a change the lives, providing the social and eco
nomic opportunities, the valorization, and the improved self-esteem
(​Hemingway and Starkey, 2017​).
When educational practices are implemented, they directly change
the social and
economic dimension involved. The new perspectives are provided
to individuals, so that they are able to find the new employment, ob
taining a better work positioning. Influencing the local community in a
beneficial way may generate value to the healthcare institution brand
and may allow the visibility in the corporate world’s competitive market.
These educational initiatives generate credibility for the in stitution
(​Lee et al., 2017​) and may be strengthened by the social ac tions like
those analyzed previously.
The creation of a link between the theory and the practice is hoped
with the implementation of the institutional policies. This link allows the
incorporation, the maintenance, and the renewal of the sustainable
application. This enables rooting the actions into the institution values.

5.3. The third aspect applied with the sustainable lenses: the policy

The healthcare institutions are able to create strengths for their

brands in a competitiveness of the market is present. This view into
the future establishes challenges that must be encouraged and
transformed into opportunities. In both aspects, the theory and the
practice, the CSR use insertion was mentioned. Some authors have
discussed the CSR (​Hemingway and Starkey, 2017​; ​Reimer et al.,
2018​), as already em phasized at the introduction section, enabling the
corporate brand as sessment and showing the example of the
corporate commitment and the CSR. The CSR can contribute for the
engagement of the local communities into the recycling actions,
promoting continuous im provement to the population’s environmental,
social, and economic dimensions, besides of the education (​Hah and
Freeman, 2014​; ​Lino and Ismail, 2013​; ​Russo, 2016​).
With the present socioeconomic-political crisis in Brazil, a compe
titive situation may be created to the healthcare institutions. The
healthcare institutions seek to maintain their presences in this market,
where some institutions are capable of attaining the balance and
others are undergoing the financial stability loss periods. Bringing the
local community within the healthcare institution and vice-versa may
strengthen the CSR development with an effective look to the supply
chain (​Ciliberti et al., 2011​).
The CSR may be incorporated into the awareness as more
healthcare institutions bring their stories and realities. With the sharing
informa tion, the society becomes aware and understands that the
risks are highly controlled. This control is allowed by an environmental
re sponsibility, which seeks contributing for the waste reduction. The
booklet elaboration may also enable the society to understand the re
cycling practice, the materials that may be recycled, and how they can
be sold. The partnership can also be established with other
cooperatives and communities, creating newsletters on hygiene
practices, as well as an attentive view of the healthcare institution’s
psychologists group to waste accumulators.
The healthcare institutions must create a commission to manage
the healthcare solid waste. This commission must follow the provisions
of the Brazilian Healthcare Surveillance Agency and plan the structure
for the correct disposal and the selective waste collections. An
adequate storage until the disposal in an adequate venue and the
shipping to recycle must be two of the concerns of the commission.
The attention to the protocols on how to segregate, from the unit
that used the product and the transport at the healthcare institution up
to the depot, must be supervised (​Pinter and Jardim, 2014​). The pre
servation of the material conditions, not allowing the contamination
427
A. Scavarda et al. ​Resources, Conservation & Recycling 141 (2019) 418–430
and the humidity risks, must be the responsibility of all professionals of
the healthcare institution. For being the CSSD, the surgical center, and
the storeroom directly involved in the reverse logistics of these pro
ducts, the actions closer to the coordination of the healthcare units and
the work teams deserve special attention. The effective supervision of
these actions must be rigorous and daily. Besides the technical team,
the supervision of the healthcare institution’s hygiene team must also
be performed. This team have the responsibility for the transportation
and the adequate material storage. The integration between the risk
management work group and the commission for the healthcare in
fection prevention and control adds value in the healthcare supply
chain management.
The waste management commission can assist in the implementa
tion of the sustainable applications that also enables the CSR, as well
as the educational programs. The healthcare waste management is an
area still providing many gaps to be filled and challenges to be
overcome. The Brazilian Healthcare Surveillance Agency established
in the Resolution 306 (​Brazilian Ministry of Health, 2004​) and in the
Brazilian Environmental Council 358 (​Brazilian Ministry Environmental,
2005​), respectively on the internal and the external healthcare waste
man agement.
In this way, here are noted information for healthcare institutions to
incorporate multi-professional teams aimed at the health solid waste
management into their policies. This team work can also analyze the
several possibilities for the advancement of the sustainable applica
tions. The possibilities involve other materials integrating the health
care supply chain and those integrating this research. Surrounding all
these actions, the educational programs sensitize employees and they
contribute with the individuals who do not have access to the in
formation.
Analyzing the contributions presented of this research, im
plementing the sustainable supply chain management in the emerging
countries is possible. Also, possibilities are presented in the theory,
practice, and policy aspects for the sustainable applications to be es
tablished. In addition, the stimulus is reinforced for the future studies
development, which may bring contributions regarding the selective
collection and the reverse logistics of the healthcare supply chain
products. The educational actions involving not only the healthcare
institution employees, but also the local community inserted into the
social projects and the CSR use are proposed.

6. Conclusions

The supply chain analyzed by the sustainable lenses allows the

strategy reinvention and the possibilities of the new ideas for the
emerging markets. Above all, in moments of the environmental, social,
and economic crises in countries like Brazil, where a diversity of cul
tures can be found, the innovative initiatives bloom amongst the po
pulation and foster actions allowing changes. ​Kusi-Sarpong et al.
(2018) ​address the sustainable innovation. The authors present the
innovation use to solve the sustainable problems. The innovative
financial invest ment management vision is highlighted in the results.
Other highlights include the technical expertise, the green practical
research and de velopment investment, and the green manufacturing.
The healthcare supply chain established connections among the
storeroom, the central sterilization service department, and the
surgical center. A group of materials, which analyzed in light of the
Brazilian legislation, can be susceptible to be recycled. The research
analyzed the theory, the practice, and the policy under the sustainable
lenses.
The research also proposed the planning, the execution, and the
supervision of the actions involving the segregation of the healthcare
solid waste. The sale of materials to recycling cooperatives becomes
possible from the adequate and the controlled management. The edu
cational programs are strengthened, not only for better knowledge of
428
the population, but also for the awareness of the society for the ap
 propriate disposal. The educational proposal may be one of the lenses con tributions based on the TBL.
to generate the higher sustainable visibility. The CSR, besides contributing with the local community, also cre
The IBGE (2000) statistic data show that waste production in Brazil ates opportunities to the healthcare institution. The CSR use, when
and the existence of open-air dumps draws is the focus attention. This promoted and shared with other companies, via meetings, seminars,
disposal venue ranks third in the received waste in Brazil. The and workshops can contribute for the development the actions in
attention involving also the community living off waste collection and centive. These actions provide a supply chain of new possibilities and
living in the proximity of landfills. Therefore, some of the sustainable a network for the development of a harmonic movement capable of the
applica tion opportunities can be described as the waste reduction. environmental, the social, and the economic transformations.
The applicability of the contributions from the research comes to The opportunities are placed for the new studies execution and
assist in a holistic view into the healthcare supply chain. The creation seeking the discussion of the supply chain under the TBL light. The
of the commission for the healthcare solid waste management in ac healthcare institution should be encouraged to promote and to share
cordance to the Brazilian National Legislation is proposed for the its sustainable applications into the supply chain. The few Brazilian
healthcare institutions. The healthcare infection prevention and control studies about the SSC topic, particularly those with the healthcare
and the healthcare risk management can participate with the effective focus, were limitations of this research.
work.
The emphasis on the TBL is implemented is in that not only the
Declarations of Interest
sale of the material to be recycled is possible, but in that the actions
along the local communities must be performed. These actions can be
None
ex emplified through the development of the recycling cooperatives,
the local seamstress cooperatives, the craft fairs, the vocational
courses, and the insertion of the local community workers into the Acknowledgements
healthcare institutions. The CSR is strengthened as a path for
generating value to the company brand, as well as a stimulus to other The present study was developed at the Health Economic and
initiatives of similar characteristics. Technological Evaluation Laboratory of the Federal University of the
In conclusion, the healthcare supply chain management framework State of Rio de Janeiro. The authors would like to acknowledge the
is suggested, where the supply chain and the materials highlighted in support from the Rio de Janeiro State Foundation for Research
this research are united and involved into three aspects: the theory, Support, the Brazilian Network for Evaluation of Health Technologies,
the practice, and the policy. The key contribution of the research and the Brazilian National Scientific and Technological Development
comes via the implementation of the sustainable application in the Council (Grant Number 3131812014-4). The authors would like to
society. The educational programs and the CSR use are targets during thank the Editor in Chief Ming Xu and the anonymous reviewers for
the im plementation of the programs that may assist in improving the their con structive contributions and comments.
popu lation’s quality of life and established new perspectives for the
A. Scavarda et al. ​Resources, Conservation & Recycling 141 (2019) 418–430
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