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What's in the box?

Community and acute care pharmacy have buying choices to help the climate, but how can procurement support?

by Ethar Alali


Medicines come in all shapes and sizes. Traditional procurement and regulation has concentrated on the efficacy and cost of medicines. In the case of generics, manufacturers with different blister packaging and boxes are considered the same. A prescription of one, is substitutable for the other.

While this is clearly true in its purity, there is a invisible problem that health services are only now beginning to understand through their sustainability initiatives.

Box Sizes: The Climate Impact

The relationship between volume and surface area is a staple of applied mathematics. If you double the sides of a cube, you multiply the volume by 8 but the surface area only by 4. In card, that quadrupling of surface area, quadruples the energy and water required to process even recycled card.

The difference doesn't stop there. An 8-fold volumetric increase means a conveniently sizes space has 8x less items in it. Yet crucially, it doesn't reduce the freight and logistics cost due to the fixed weight of container, vehicle and pallets.

Traditional health-economics has ignored these effects, despite the fact it adds as much as 2kg CO2 per km on each lorry load per pallet (180kg on the average logistics journey from warehouse to site). Requiring more pallets and even more lorries.

Health-climate-economics ensures these factors are included by accounting for the volume consumed by the box in transit. A traditional procurement will consider the above two boxes of Atorvastatin 40mg as equivalent. So a typical "Do Nothing" solution would not change to a better, more climate friendly supplier. While the application of a health climate evaluation, would consider the manufacturing and transit impacts of the drugs on the carbon footprint, patient respiratory conditions and heatstroke in turn.

How do you evaluate it? Several evaluations must apply.

Step 1: Box & Blister Pack

Boxes are cut from nets on large industrial machines. They are also printed beforehand and currently use virgin cardboard. The are of the box should be calculated to determine the energy for print, cut and stock pulp usage. These figures are available in aggregate through the kWh and wattage of the machines, associated manufacturing overheads (heat, light etc) etc. Step 2: Packing, Freight & Distance Freight emits a substantial amount of emissions simply moving things around. Shipping and Rail freight have a significantly lower carbon footprint than air freight, which also carried less cargo. The volume of packaging may vary but container spaces are fixed. Allowing you to calculate the amount of space boxes take and how many containers are needed for the load. Step 3: Logistics

From port to target site, the footprint of transit cannot be ignored. On average, 144km are driven by lorry (at 190g/kg/km) to hospital and primary care. Don't forget to add this to the total. Step 4: Storage and Waste The average lifetime of products on-site should be multiplied by any energy required to maintain humidity and the condition of the products. Add to that the unused products which have been disposed of, including the disposal.

Step 5: Use and Dispose Equipment disposal should be calculated. The weight of the waste is taken to disposal facilities by refuse collection lorry, with similar footprint to logistics. If the final disposal is incineration, this must also include the chemical reactions with oxygen in the air. 16g of Methane induced from items, that is burnt in air, releases 44kg of CO2.

Added together, this is the footprint of the medicine. Where recycling has occurred or reduced carbon processes are used, the calculations should be modified accordingly. When done, this can be incorporated into the utility equations to find out whether the costs justify the change. Since the health outcomes are constant.


In such a case, smaller boxes are clearly better for the environment and reduce the longer term emissions impact. Considering the lifecycle effects also provides a means to introduce circularity and ensure the most optimal proportions of up and downstream impacts are considered in their entirety. It also shows why health-climate-economics is a much better measure of the effect of boxes. So now, Earth trusts you'll deliver the smaller box.


Need help calculating the difference? Want help introducing health-climate-economics into commissioning. We're open to working on projects to introduce HCE into acute, primary and social care settings. Get in touch for a no obligation chat.

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