The Future of Green Hospitals: Sustainable Business Models and Adoption Prospects in Indonesia and Malaysia

Wood et al. [2] found that end-users perceived “safety mechanism during emergency” as being of the utmost importance and also the feature they were satisfied with. The other demanded qualities were at an average degree of satisfaction; however, green hospital design must take efforts to maximize the use of natural light and ventilation while considering the building orientation, materials should be free from toxicity and be environmentally friendly, the landscape should be strategically designed, and the facilities should increase the sense of a healing environment and water-efficient equipment. Their research used a survey conducted in Malaysia.

Aza et al. [25] evaluated the components of the Green Hospital in Teaching and Private Hospitals covered by Tehran University of Medical Sciences. Independent t-tests and analysis of variance were used for the data analysis. Their study showed that the dimensions of “environmental leadership and management” rated the highest, and water management had the lowest rating. Although private hospitals earned higher scores in all aspects of green hospitals apart from management, leadership, and chemicals compared with teaching hospitals, there was no statistically significant difference between these dimensions and types of hospitals. Given that the hospitals studied did not meet green hospital standards properly, it seems necessary to prepare a comprehensive action plan to improve their weaknesses and meet these standards. A green hospital, although not globally defined, is a facility designed to utilize natural resources efficiently and sustainably, reducing its carbon footprint and enhancing patient care. Key considerations in planning such facilities include energy and water conservation, alternative energy sources, waste management, and the use of eco-friendly materials and practices [26].

Currently, the concept and term “Green Hospital” has become a reference for several companies. The Health Sector, which consumes large amounts of resources and generates waste, is a public health problem. There was a rapidly growing awareness among the public about facilities whose designs incorporated green construction principles. Wood et al. [2] evaluated the use of QFD in designing green hospitals, determined end-user requirements, and translated them into appropriate technical requirements for implementation at various operational planning levels. Therefore, based on the quality demanded by end-users, this research presents a QFD tool for green hospital design for public and private hospitals: the House of Quality Green Design (HOQGD). In particular, Green Hospital is related to the needs of the community, which is a large part of the treatment services for tropical diseases. Tropical disease is a disease that often occurs in tropical and subtropical climates, such as Indonesia. Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide. Persistent airflow obstruction has been identified as one of its characteristics. COPD is correlated with an increased chronic inflammatory response in the airways and lungs to noxious particles and gases and is also progressive [27].

Therefore, business modelling as a process for the design of business operations is mostly directed at the value of manufactured products and customer interests, and is second only to the company's internal business processes [28, 29]. Likewise, information technology support will greatly assist the government and business owners/managers in making decisions based on available business information to innovate or create new business plans that suit the tastes and preferences of the changing business environment [30]. This business model is also related to the emergence of the concept of a value proposition that considers all consumer desires [28]. A commonly used business model is that of Osterwalder and Pigneur [31], which is illustrated in their book Business Model Generation and further developed in their other book Value Proposition Design, which has become the most famous. Research on the interaction between business operations, business modelling, and types of competitive advantage shows that business operations business models are used as a tool for the formation, development, and management of a company's competitive advantage [32]. His business model design is based on the Osterwalder and Pigneur model [31], which adds a value proposition matrix and an interaction scheme between business functions and model elements to intensify its use in the management of business operations. It helps strengthen the coordination of activities involving managers from all structural subdivisions for business operations during the creation of value propositions for each consumer segment, taking into account the preferences and maximum expectations of customers.

The US and European nations currently offer the majority of definitions of green hospitals. This entails the following: environmental acceptance is first and foremost necessary when choosing a location for hospital buildings; sustainability and universities of buildings are also taken into consideration in the design processes; green materials and products should be chosen during the construction process; the green concept is ingrained in the renovation and construction processes, and it is taken into account during the follow-up operation. In addition to the fundamental national requirements for hospitals in China, issues related to green hospitals include environmental protection, sustainable development of hospital construction engineering, energy and water conservation, reduced pollution in daily operations, patient satisfaction with healthcare services, and related hospital green management measures [33].

To provide healthcare, hospital administrations must actively explore ways to capture renewable energy sources (such as water, wind, sun, geothermal heat, and organic matter). Governments must support subsidies and other measures that promote the use of renewable energy, as well as the use of medical devices that consume little or no energy. By locating healthcare facilities as close to public transportation stops as possible, using locally sourced building materials, and incorporating design elements such as water harvesting, natural ventilation, day lighting, and planting trees on site, healthcare facilities can improve their environmental sustainability index [34].

To create a green hospital, Persahabatan Hospital's leadership and stakeholders have developed and implemented environmental strategy planning, which includes: (1) Creating a master plan based on green building and environmental legislation. (2) Creating a marketing plan to promote the benefits of a hospital's green environment. (3) Preserve a maximum of 80% of the open space, which is green. (4) Sustainable socialization of green hospital culture. (5) Efficient use of paper, water, and other resources, including electrical energy. (6) Provision of hospital waste-treatment facilities. (7) Creating ideas to improve the hospital environment. (8) Create collaboration for environmental and green hospital information systems. (9) Create a green hospital by setting qualified human resources to implement strategic strategies [35].

All facets of life, including community health services and medical activities, are covered by Sustainable Development Goals. As part of the health system, hospitals not only conduct medical examinations, treatment, and research on treatment modalities, but they also ensure that the conditions are in place to meet other non-medical goals of the health sector, such as sustainable development goals [12].

The idea of green buildings or green architecture was introduced because of concerns about the environment and human health. This movement has gained support since the final decades of the nineteenth century. The Vittorio Emanuele II Gallery in Milan, which adopted system control of ventilation to improve indoor air quality, is one such example. Subsequently, this movement began to grow into other fields, such as politics, health, and science. Hospitals are now the focus of green architecture implementation as the primary element in the healthcare sector, creating a green and healthy hospital. The idea of a structure that can maintain the health of the environment while using power, water, and fuel as effectively as possible as well as improve people's health is known as a green building [11].

People and all other stakeholders need the management of non-medical waste in hospitals and their surroundings to build a Green Hospital in order to live healthy lives. The supervision of non-medical waste has a direct impact on patient comfort and happiness in terms of trash containers, waste collection, and waste carrying [12]. Suwasono et al. [36] suggested that green hospital indicators also consider the adjustments of local hospital management experts and the perspectives of 220 medical professionals in addition to the indicators for measuring the green building and medical industries globally. Subsequently, Taiwan Green Hospital Indicators were proposed. Green hospitals can be introduced using two key indicators, environmental management and environmental education, and extended eleven sub-indicators [37]. Danilov et al. [38] found that despite being resource-intensive, healthcare facilities can significantly decrease their environmental impact and enhance both staff well-being and patient recovery through sustainable practices. These practices include improving indoor air quality, green interior materials, and strategic landscaping.

The factor of highest importance, according to research among end users of public and private hospitals, is "safety mechanism during emergencies". The following are listed in decreasing order of importance after this: "increase natural lighting", "increase natural ventilation", "use of toxic-free materials", "building orientation", "healing environment", "atmospheric condition", "install water efficiency equipment", "strategic landscape", and "use of environmentally friendly materials". Their research recommended that the government implement many of these requirements into rules that would affect how architects and construction firms build hospitals [2].

The Green Building Index (GBI) was developed in Malaysia to promote sustainability in the built environment and increase public knowledge of environmental issues among developers, architects, engineers, planners, designers, contractors, and other industry professionals. The GBI was specifically created to meet the needs of the cultural and social context, tropical Malaysian climate, and environmental and developmental contexts [20].

1.png

Figure 1. Percentage of green hospital in Indonesia per province

Figure 1 shows that Central Java Province had the highest number of green hospitals (22%), followed by West Java (19%), Lampung (15%), and DKI Jakarta (11%).

4.2 The results of patients and hospital visitors

The adoption of green hospitals requires significant investments and resources, making it crucial to integrate sustainable development principles into strategic hospital management. Designing an effective strategy for green hospital adoption requires robust data collection and analysis to ensure informed decision making. A key focus of this study was to examine whether the implementation of green hospitals influences individuals in industrial areas when choosing healthcare facilities. These findings indicate a strong community support for green hospital initiatives. A survey using open-ended questions revealed that 99% of patients and hospital visitors stated that they preferred a green hospital as their choice for treatment (Table 2). This overwhelming preference suggests that green hospital adoption has the potential to attract more patients, particularly in industrial areas where environmental awareness is growing due to proximity to pollution and ecological challenges.

Table 2. Considerations in hospital selection

Answer Category	Number of Respondents	Percentage
Very Important	1	0%
No, take into consideration	15	1%
Yes, take into consideration	1.143	99%
Total	1.159	100%

These findings align with the principles of sustainable development, emphasizing the balance between economic growth, environmental protection, and social equity. Green hospitals not only address environmental sustainability by reducing energy consumption, waste, and carbon emissions but also contribute to the health and well-being of communities, fostering social sustainability. Furthermore, their ability to attract patients and improve operational efficiency can enhance financial sustainability and ensure a hospital's long-term viability.

The adoption of green hospitals is not merely an environmental initiative but a comprehensive strategy for achieving sustainable development in the healthcare sector. By integrating green technologies, resource-efficient practices, and community-centered care, hospitals can become pivotal contributors to global sustainable development goals (SDGs), particularly SDG 3 (Good Health and Well-being), SDG 11 (Sustainable Cities and Communities), and SDG 12 (Responsible Consumption and Production). Ultimately, successful adoption of green hospitals can lead to improved financial performance, stronger patient loyalty, and enhanced resilience in an increasingly eco-conscious society.

This study also explores whether the community has experienced tangible benefits from the implementation of environmentally friendly practices by hospitals. The findings revealed that 59% of respondents reported partial benefits, 37% indicated they had fully experienced the benefits, and 4% stated they had not observed any benefits (Table 3). These results demonstrate that while no hospital has fully transitioned to a green hospital model, many are taking meaningful steps toward environmental sustainability through the adoption of eco-friendly practices. Key initiatives undertaken by these hospitals include reducing plastic usage, increasing reliance on natural sunlight to replace electricity, and implementing waste separation systems for clinical and nonclinical (nonmedical) waste. These practices align with the principles of sustainable development, addressing the environmental, social, and economic dimensions.

The partial benefits reported by the respondents highlight the incremental nature of the transition to green hospitals. As these facilities strive to balance operational demands with sustainability goals, their efforts contribute to broader objectives of sustainable development. Specifically, such practices support SDG 3 (Good Health and Well-being) by creating healthier environments for patients and staff and SDG 12 (Responsible Consumption and Production) by promoting resource efficiency and waste management. These findings underscore the importance of scaling up these practices to achieve the full potential of green hospitals. By continuously improving sustainability initiatives and engaging with the community, hospitals can maximize their positive environmental and social impact. These actions not only enhance public perception and trust, but also pave the way for a sustainable healthcare system that supports long-term ecological and societal well-being.

Table 3. Benefits of implementing eco-friendly hospitals

Answer Category	Number of Respondents	Percentage
Already, overall	425	37%
Already, only partially	687	59%
Not yet	47	4%
Total	1.159	100%

A survey of public satisfaction with hospitals implementing environmentally friendly practices, as shown in Table 3, revealed that 27% of respondents were very satisfied, while 44% expressed satisfaction. These findings indicate that the adoption of green hospitals significantly enhances public satisfaction, and demonstrates a strong positive reception of sustainable healthcare initiatives. This high level of satisfaction underscores the value of environmentally friendly practices for meeting community expectations and fostering trust. Green hospital initiatives, such as waste reduction, energy efficiency, and sustainable infrastructure, not only address environmental concerns, but also improve the overall healthcare experience. These efforts align with the principles of sustainable development, particularly by supporting SDG 3 (Good Health and Well-being) and SDG 11 (Sustainable Cities and Communities) through the creation of healthier and more resilient healthcare environments. The results also highlighted that sustainable healthcare practices can serve as a competitive advantage for hospitals. By prioritizing eco-friendly initiatives, hospitals are likely to experience increased patient loyalty and satisfaction, positioning themselves as leaders in sustainable health care. This reinforces the importance of integrating sustainability into strategic hospital management to ensure long-term benefits for the environment, community, and healthcare system (Table 4).

Table 4. Satisfaction with implementing eco-friendly hospitals

Answer Category	Number of Respondents	Percentage
Very Satisfied	307	27%
Satisfied	505	44%
Quite satisfied	319	28%
Dissatisfied	24	2%
Very Dissatisfied	1	0%
Total	1.159	100%

4.3 The results on hospital management

The informants used in this qualitative research have heterogeneous characteristics based on the level of education, length of work, sex, and age. The demographic characteristics of the participants are presented in Table 5.

Table 5. Demographic of informant

Category	Informant	%
Education
Diploma	5	11%
Bachelor	17	40%
Master Degree	21	49%
Length of Work
> 15 years	7	16%
10-15 years	24	56%
5-10 years	8	19%
< 5 years	4	9%
Sex
Male	16	37%
Female	27	63%
Age
31-40 years	13	30%
41-50 years	16	37%
51-60 years	14	33%

Interviews were conducted with 43 officials in government hospitals and middle managers in private hospitals, and as many as 70% were structural officials in government hospitals and 30% were middle managers in private hospitals (Table 6).

The first question, related to the existence of a department responsible for the implementation of environmentally friendly activities in hospitals, is shown in Figure 2. The results of the interviews showed that not all hospitals have a department that specifically handles this, and some are not even sure whether there is a department in their hospital. This indicates that some hospitals have not paid attention to the problems that lead to green hospitals.

Table 6. Distribution of key informants based on hospital ownership

Position	Ownership
	Government	%	Private	%
Director/ Deputy Director	4	13%	0	0
Manager/ Division Head	9	30%	13	100%
Team Leader/Unit	17	57%	0	0
Total	30	100%	13	100%
Percentage	70%		30%

2.png

Figure 2. Departments responsible for eco-friendly care

The second question asked about eco-friendly health care activities showed that hospitals have carried out many activities that lead to being environmentally friendly, such as reduction of hospital waste disposal, reduction of energy consumption, disposal of infectious medical waste, disposal of food waste, use of environmentally friendly products, reducing PVC, and low-carbon food (Figure 3).

The third question relates to the efforts of hospitals to implement environmental friendliness. The results of the interviews show that there are hospitals that have made efforts towards being environmentally friendly, some that do not have a concept, some that have tried but have not been maximized, and some that have not done anything at all (Figure 4). The results of this investigation indicate that the concept of a green hospital has not been properly and thoroughly understood by the management. Therefore, it is important to improve literacy in the future.

3.png

Figure 3. Implementation of eco-friendly activities

4.png

Figure 4. Efforts to implement environmental friendly hospital

Table 7. Totals of public and private hospitals in Malaysia based on region

No.	Region/District (Public)	Public Hospitals	Region/District (Private)	Private Hospitals
1	PERLIS	2	KEDAH	4
2	KEDAH	8	PENANG	13
3	PULAU PINANG	6	PERAK	10
4	PERAK	15	SELANGOR	27
5	SELANGOR	11	NEGERI SEMBILAN	5
6	NEGERI SEMBILAN	6	MELAKA	3
7	MALAKA	3	JOHOR	8
8	JOHOR	12	PAHANG	2
9	PAHANG	10	TERENGGANU	1
10	TERENGGANU	2	KELANTAN	3
11	KELANTAN	9	SARAWAK	7
12	SARAWAK	21	SABAH	3
13	SABAH	23	WP KUALA LUMPUR	27
14	KUALA LUMPUR	12
15	WP PUTRA JAYA	1
16	WP LABUAN	1

5.png

Figure 5. Results of the Malaysian green hospital service

Community needs (CN) consist of carrying out routine pulmonary exercises, socialization and education, availability of specialist doctors, drugs at affordable prices, treatments that provide healing, and need for routine control. All indicators qualified as 100% available. Food aspects include hygiene, good and harmless food packaging, and environmentally friendly food packaging (FOOD). All indicators qualified as 100% available. Waste (WASTE) includes a trash can, free of garbage, free of garbage odors, and free of chemical odors. All indicators qualified as 100% available. Air Quality (AQ) aspects included odorless air quality, fresh air quality, free air pollution, and the existence of a smoking ban campaign. All indicators qualified as 100% available.

Environmental (ENV) aspects include the following: the entire hospital area is smoke-free, air circulation in the hospital is good, not damp/humid terraces, calm in the hospital environment is free from noise pollution from motorized vehicles, and the air is maintained in the hospital environment. Of all the indicators, 98% qualified. Water (WATER), an aspect of Green Hospital, consists of clean and odorless water, energy-saving instructions, and automatic water faucets. Of all indicators, 96% were available. Energy (ENERGY) consists of the availability of lighting without lights during the day, ventilators in the toilet and stair areas, instructions for saving electricity, and hospital cooling without air conditioning. Of all the indicators, 88% qualified. Location and landscape (LL) consist of the availability of public vehicles, public transportation, green trees, parks, water catchment holes, green open areas, cleanliness, tidiness, and beauty of the environment. Of all the indicators, 93% qualified (Figure 6).

6.png

Figure 6. Results of the Malaysia green hospital management observation

Information Technology (IT) produces reports according to various needs: 1) The time required to process the data, 2) Information can be available when it is needed, 3) Information from information technology can be accessed by users, and 4) Obtaining complex data using information technology. Of all the indicators, 98% qualified. Organizational Performance in Health Care (ROPH) consisted of 1) Inpatient care at the hospital was not long considered, 2) The hospital can restore the functional status of the patient after treatment, 3) Patient compliance with the standard care patterns provided by the hospital, 4) The hospital contributes to public health programs, and 5) The financial performance of the hospital is getting better from year to year of all indicators, 98% qualified.

Environmental Performance (ENP) includes 1) lower use of water in hospital facilities, 2) A reduction in energy (power), 3) Lower consumption of hazardous and toxic substances, 4) Lower waste emissions in hospital facilities, and 5) Purchasing products used by hospitals is more environmentally friendly. Of all the indicators, 92% qualified. Continuous Improvement Activities (CIA) consisted of 1) continuous reassessment and revision of green healthcare activities, 2) improvement of operational plans to enhance green healthcare activities, 3) Development of programs for green health improvement activities, and 4) Reflection of customer needs for improvement. From all the indicators, 97% qualified. Process Management and Operational Procedures (PMOP) consist of: 1) The hospital develops and innovates its overall work system, 2) Creating and changing work processes to meet requirements, 3) Designs to prevent rework and errors, and 4) Integrated care/service design process to ensure efficiency. Of all the indicators, 92% qualified. Monitoring System (MS) in the implementation of Green Hospital consists of 1) developing and maintaining clear work guidelines for monitoring activities, 2) providing assurance of an appropriate level of work related to monitoring activities, 3) ensuring compliance with environmental regulations and the level of monitoring required for operations, and 4) Continuous monitoring of green healthcare activities: All indicators qualified as 94% available.

Education and Training (ET) includes: 1) training employees to develop their knowledge and skills, 2) training employees to convey environmentally friendly values, 3) evaluating the effectiveness of education and training, and 4) providing the human and material resources needed for education and training. All indicators qualified as 100% available. Employee Participation (EP) comprised 1) active participation of employees in healthcare practices, 2) employee opinions regarding the implementation of environmentally friendly hospitals are needed by management to make decisions, and 3) environmentally friendly activities carried out by employees in a compact manner are meaningful for hospital management. All indicators qualified as 100% available. Top Management Roles (TMR) consist of 1) developing and committing to hospital policies, 2) representing various departments and professions to help guide and implement green strategies, 3) strategic and operational plans and budgets reflect commitment, 4) setting green goals for employees, and 5) creating a conducive work environment. All indicators qualified as 100% available.

6.1 Conclusion

The findings of this qualitative research suggest immediate feasibility for the hospital's policy direction to become a green hospital in the future. Given the community's relatively high demand for green hospitals and the positive responses from management, it is crucial to design a sustainable hospital business model [31, 32]. The development of a strategic roadmap for green hospitals is the top priority for alternative hospital management strategies in Indonesia, followed by budget policy strategy, green team formation, fostering an environmentally friendly work culture, resource optimization strategy, technology and R&D strategy, and medical technology improvement strategy [37]. This study was limited by the number of hospitals willing to participate, likely due to the ongoing pandemic. As many hospitals were preoccupied with patient care, future research could employ a case study approach at selected open hospitals during data collection. Such research would be invaluable in ensuring the successful design of future hospital business models.

6.2 Limitation

The participants of this study were confined to patients present in the hospital environment at the time of the questionnaire distribution; thus, they may not represent all customer levels within the hospital. It should be noted that the health condition of patients and their families, if unwell or uncomfortable, could potentially impact their receptivity to information about the Green Hospital, thereby influencing their responses to the questionnaire. Additionally, the study was conducted within a limited timeframe under specific research permits in Malaysia.

6.3 Suggestion

Hospital management support is essential for the successful implementation of the Green Hospital Initiative. This can be achieved by establishing policies that serve as a guide for all elements within the hospital to adhere to Green Hospital practices. Additionally, the creation of a Green Hospital Team composed of representatives from various hospital work units would serve as a catalyst for this movement. Moreover, hospital management should strive to enhance the execution of Green Hospital dimensions in line with the Green Hospital Guidelines in Indonesia, some aspects of which have yet to be implemented. This would involve revisiting and updating several infrastructural facilities that support Green Hospital’s dimensions. For instance, reviving the less-visible smoking ban campaign owing to fading signs, instructing on water and electricity conservation, assessing the number and condition of biopores, and maximizing the use of hospital media to promote the Green Hospital Program.

While the initial cost of implementing a Green Hospital may be substantial, the long-term impact on the safety, satisfaction, and comfort of hospital residents, as well as environmental safety, is immense. This initiative not only adds value to customers but also benefits hospitals, reinforcing the importance of implementing Green Hospital practices. Finally, regular evaluations of customer perceptions are crucial, particularly for the seven dimensions that customers or patients perceive as lacking. This will provide valuable insights for continuous improvement and will ensure the success of the Green Hospital initiative.

Fajar Gustiawaty Dewi was primarily responsible for the conceptualization, methodology development, data collection, data analysis, and drafting of the manuscript. Yuliansyah supervised the study, contributed to the theoretical framework, and critically revised the manuscript to ensure its academic rigor. Retno Ariza Soeprihatini assisted in data analysis, provided insights for interpreting the findings, and contributed to editing the manuscript. Jamaliah Said brought her expertise in sustainable healthcare practices, enriching the discussion of results and reviewing the manuscript to ensure its alignment with contemporary issues in sustainability. Andhyka Muttaqin and Arfendo Propheto provided technical support in the use of NVIVO software, contributed to the methodological framework, and assisted with data visualization. All authors actively participated in reviewing and approving the final manuscript, with Fajar Gustiawaty Dewi taking the lead role as the coordinating the research activities throughout the project.