This paper focuses on the application of the analytical hierarchy process (AHP) technique in the context of sustainable development to establish and optimise health care waste management (HCWM) systems in rural areas of developing countries. This is achieved by evaluating the way in which the AHP can best be combined with a life cycle management (LCM) approach, and addressing a main objective of HCWM systems, i.e. to minimize infection of patients and workers within the system. The modified approach was applied to two case studies: the sub-Saharan African countries of South Africa and Lesotho. Quantitative weightings from the AHP are used to identify alternative systems that have similar outcomes in meeting the systems objective, but may have different cost structures and infection risks. The two case studies illustrate how the AHP can be used (with strengths and weaknesses) in environmental engineering decision support in developing countries.