Sustainability in the Management of the Private Medical Sector in Romania: A European, USA and Japan Comparison

Abstract

The private healthcare sector in Romania, led by prominent players such as Medlife, Regina Maria, Medicover and Sanador, has become a cornerstone of the country’s healthcare system. However, achieving sustainability in this sector remains a challenge. This study evaluates sustainability practices in Romania’s private medical sector using the Triple Bottom Line (TBL) framework, comparing them to those of the EU, USA and Japan. Using statistical methods and benchmarking, we identify correlations between healthcare expenditures, financing schemes and sustainability metrics. A bibliographic review highlights global trends in sustainable healthcare management, including environmental, social and economic strategies and provides insights into the cost-effectiveness of green initiatives. Special focus is given to the role of technology in driving sustainability through innovations in telemedicine, digital health records and operational optimization. Using statistical methods (Pearson and Spearman correlation coefficients), we have performed an analysis of health expenditure data for EU countries, the USA and Japan. The dataset was extracted from the Organisation for Economic Co-operation and Development (OECD) data portal and included various health expenditure indicators, financing schemes and administrative data for all EU countries, the USA and Japan for the period 2018–2023. We have performed a structured analysis that explores correlations between these indicators, with a focus on financial schemes, expenditures and management sustainability. The analysis shows strong correlations between healthcare expenditures, financing schemes and administrative costs. Countries with efficient governance, balanced financing and proactive population health strategies (e.g., Japan and Nordic countries) demonstrate better management sustainability. However, countries like the USA and Eastern EU nations face challenges due to high administrative costs and inefficient financing models, respectively. Addressing these issues is critical to sustaining healthcare systems in the long term. The findings reveal that while Romanian providers excel in patient satisfaction and technological innovation, they lag behind their European counterparts in environmental sustainability and equitable access. Recommendations are proposed to address these gaps, drawing on successful strategies implemented in other European healthcare systems. This study fills a gap in the literature by providing a structured analysis of sustainability practices in Romania’s private healthcare sector, contextualized within a global comparative framework.

1. Introduction

Sustainability in healthcare management has emerged as a global priority, given the sector’s substantial environmental footprint, its role in addressing social inequalities and the rising economic pressures on healthcare systems worldwide. Globally, the healthcare industry is responsible for 4.4% of greenhouse gas emissions, along with significant resource consumption and waste generation, highlighting the urgent need for sustainable practices [1]. This study employs the Triple Bottom Line (TBL) framework, which emphasizes the balance between environmental, social and economic dimensions, to evaluate sustainability in Romania’s private healthcare sector. Achieving sustainability in healthcare requires balancing environmental, social and economic dimensions while incorporating innovative technologies and strategies tailored to local contexts.

This study aims to evaluate sustainability practices in Romania’s private medical sector and compare them with those of other European countries, the USA and Japan. Specifically, the study seeks to achieve the following:

• Assess environmental, social and economic sustainability practices in Romania’s private healthcare sector, with a focus on prominent providers such as Medlife, Regina Maria, Medicover and Sanador.
• Analyze health expenditure indicators and financing schemes in Romania relative to global benchmarks, identifying key correlations and sustainability challenges.
• Explore the role of technology—including telemedicine, digital health records and AI in driving sustainability in healthcare.
• Provide actionable recommendations for improving sustainability in Romania’s private healthcare sector by drawing on successful strategies from other countries.

Romania’s private medical sector has seen rapid growth, with major players like Medlife and Regina Maria driving technological innovation and patient satisfaction. However, challenges persist in areas like green infrastructure adoption and equitable access to care. By benchmarking Romania against countries such as Germany, Sweden, the USA and Japan, this study aims to provide actionable recommendations to address sustainability gaps.

By addressing these objectives, the study aims to contribute to the growing discourse on sustainable healthcare management and offer insights for policymakers, providers and stakeholders in Romania.

2. Materials and Methods

This article is based on three poles of research that have revealed interesting correlations and valuable ideas: a bibliographic review on sustainability in the healthcare management period 2013–2024, a statistical analysis of health expenditure indicators, financing schemes and administrative data for all EU countries, the USA and Japan for the period 2018–2023 and a benchmarking analysis to compare sustainability practices across Romania, EU countries, the USA and Japan. This study integrates the Triple Bottom Line (TBL) framework, health system resilience and systemic sustainability models to evaluate sustainability practices. These frameworks emphasize interconnectedness between governance, financing and service delivery, providing a foundation for this study. Health system resilience, defined as the ability of systems to absorb and adapt to shocks, is critical for ensuring long-term sustainability. This concept is particularly relevant for Romania given its challenges in equitable access and operational inefficiencies.

This systematic review was conducted in accordance with the PRISMA 2020 guidelines. The PRISMA checklist and flow diagram are included in the Supplementary Materials.

2.1. Bibliographic Review on Sustainability in Healthcare Management

A systematic bibliographic review was conducted following PRISMA guidelines using predefined inclusion and exclusion criteria. The primary objective of the bibliographic review was to identify and analyze academic literature, reports and credible sources that address key themes, including the following:

• Climate change and healthcare (e.g., carbon footprint and green hospitals).
• Healthcare innovations (e.g., AI, telemedicine and electronic health records).
• Public–private partnerships in healthcare.
• Health equity and sustainability in healthcare systems.

These themes align with the need to understand how healthcare institutions can integrate sustainability, technology and equitable healthcare access while addressing global challenges like climate change.

The systematic review process followed the PRISMA 2020 guidelines to ensure transparency and replicability. We identified relevant studies through a comprehensive search of multiple databases (PubMed, Scopus, Web of Science and Google Scholar) and organizational websites. A total of 447 articles were initially identified and the selection process involved the removal of duplicates (134 articles), screening of titles and abstracts (187 articles excluded) and a full-text review of 126 articles. Ultimately, 39 articles met the eligibility criteria and were included in this review. The PRISMA flow diagram (Figure 1) provides a detailed overview of this process.

2.2. Statistical Analysis of Health Expenditure Indicators, Financing Schemes and Administrative Data for All EU Countries, USA and Japan for the Period 2018–2023

The statistical analysis utilized health expenditure data for EU countries, the USA and Japan, extracted from the OECD data portal. The dataset covered the period from 2018 to 2023 and included indicators such as Current Health Expenditure (CHE) as a percentage of GDP, Compulsory Health Insurance (CHI) as a percentage of CHE, General Government Expenditure (GGE) as a percentage of GDP, governance and administrative costs and capital health expenditure (public vs. private). These indicators were chosen based on their relevance to sustainability in healthcare systems. The dataset used includes the following key indicators:

• Current Health Expenditure (CHE) as % of GDP: Measures the share of healthcare spending relative to the country’s economic output.
• Compulsory Health Insurance (CHI) as % of CHE: Indicates the reliance on mandatory health insurance schemes to finance health expenditures.
• General Government Expenditure (GGE) as % of GDP: Reflects the overall government spending relative to the economy.
• Governance, Health System and Financing Administration (in million USD): Represents the administrative costs associated with governance and health financing.
• Capital Health Expenditure: Divided into domestic public and domestic private expenditure.
• Population (in thousands): Provides context for per capita calculations and comparisons.

To understand the relationships and sustainability of health financing and expenditures, the following analyses were performed: correlation analysis between indicators using statistical methods like Pearson or Spearman correlation coefficients, which helped us evaluate the relationships between the indicators, regional and country-level observations and Capital Health Expenditure (public vs. private). We employed Pearson and Spearman correlation analyses to evaluate the relationships between healthcare expenditure indicators and sustainability metrics. Pearson correlation coefficients were used to assess linear relationships (e.g., CHE as a percentage of GDP vs. CHI as a percentage of CHE), while Spearman’s rank correlation was applied for non-linear relationships (e.g., CHE as a percentage of GDP vs. governance costs). A significance level of p < 0.05 was used to determine statistical significance.

The selection of these statistical methods aligns with prior studies, such as Topol (2019) [2] and Purohit et al. (2021) [3], which emphasize the role of correlation analysis in identifying key factors influencing healthcare sustainability. For example, Topol (2019) [2,4] highlights how correlation analysis can reveal inefficiencies in healthcare systems, while Purohit et al. (2021) [3] demonstrate its application in evaluating the environmental impact of telemedicine adoption. This alignment with established methodologies enhances the validity and reproducibility of our findings. To ensure transparency, we have detailed the methodological approach, including the selection of data sources, statistical tools (IBM SPSS Statistics 28, R 4.2.2, Python 3.11.3) and visualization techniques. The structured methodology provides a robust framework for future studies to replicate or build upon this research.

2.3. A Benchmarking Analysis of Sustainability Practices Across Romania, EU Countries, the USA, and Japan

A benchmarking analysis was conducted to compare sustainability practices across Romania, EU countries, the USA and Japan based on key indicators such as environmental initiatives and strategies, healthcare accessibility and reliance and the way the sustainability policy is integrated in management.

3. Results

3.1. Results of Bibliographic Review on Sustainability in Healthcare Management

The review revealed global best practices in sustainability, emphasizing renewable energy, waste management and public–private partnerships (PPPs). Notable examples include the following:

• Germany’s Green Hospital Program: Achieved a 25% emission reduction and significant cost savings through energy-efficient infrastructure.
• Sweden’s Renewable Energy Adoption: Integrated renewable energy into 80% of healthcare facilities, reducing emissions and energy costs.

Romania, however, struggles with limited green initiatives, with only 15% of private healthcare facilities meeting green building standards.

This systematic bibliographic review was conducted following PRISMA 2020 guidelines and below we present the PRISMA flow diagram for the research.

• Identification Phase

A total number of 432 articles were identified using multiple databases, through keyword searches, including the following: Sustainability, Romania, private healthcare, green initiatives, telemedicine, public-private partnerships, economic sustainability. An additional 15 articles were identified through cross-references from included studies. Finally, a total of 447 articles were identified.

• Screening Phase

A total of 134 duplicate articles were removed. Also, after screening titles and abstracts, 187 articles were excluded based on the following criteria: not related to healthcare or sustainability, focused on public healthcare only (not private), studies not focusing on environmental, social, or economic aspects of healthcare sustainability and articles outside the specified time frame (2013–2024). Articles remaining after screening: 126.

• Eligibility Phase

In total, 126 articles were reviewed in full text to assess for eligibility. In total, 87 articles were excluded for the following reasons: did not provide comparative analysis with Romania or similar healthcare systems, insufficient focus on sustainability practices (only general healthcare topics), lack of clear methodology or empirical data (e.g., opinion pieces and editorials) and articles focusing exclusively on regions irrelevant to this study (e.g., Africa and South America). Eligible articles for inclusion: 39.

• Inclusion Phase

Finally, 39 articles were included in this systematic review. The entire process is presented in

Table 1. Summary of the review process.

Phase	Number of Articles
Articles Identified	447
Duplicates Removed	134
Excluded (Title/Abstract Screening)	187
Full-Text Articles Excluded	87
Articles Included	39

.

This table summarizes the systematic review process conducted in this study, including the number of articles identified, screened and excluded at each stage. A total of 447 articles were initially identified, of which 39 were included in the final analysis after rigorous screening and eligibility assessments. The table highlights the systematic approach taken to ensure the inclusion of high-quality, relevant sources for this study.

The bibliographic research methodology employed for this review followed a systematic and structured approach to ensure the inclusion of high-quality, relevant and credible sources.

While the methodology was thorough, certain limitations exist:

• Language Restrictions: Primarily English sources were considered, potentially excluding relevant studies in other languages.
• Timeframe: The focus on recent literature (2013–2024) may have overlooked older foundational studies.
• Database Access: Some sources may have been inaccessible due to subscription restrictions.

This PRISMA flow diagram outlines the systematic review process used in this study. It details the identification, screening, eligibility and inclusion phases for selecting articles related to sustainability in healthcare management. A total of 447 articles were initially identified, 134 duplicates were removed and 187 articles were excluded during the title and abstract screening. After a full-text review of 126 articles, 39 were deemed eligible and included in the final analysis. This diagram ensures transparency and replicability of the systematic review methodology.

The bibliographic review highlights global trends in sustainable healthcare management, including environmental, social and economic strategies and provides insights into the cost-effectiveness of green initiatives. Special focus is given to the role of technology in driving sustainability through innovations in telemedicine, digital health records and operational optimization.

3.1.1. Environmental Sustainability in Healthcare Management

• Environmental sustainability focuses on reducing the ecological footprint of healthcare facilities through energy efficiency, waste management and sustainable infrastructure. The World Health Organization (WHO) emphasizes that hospitals are among the most energy-intensive buildings, accounting for a significant share of global energy consumption [1,5,6,7,8,9]. Green hospitals are critical in reducing healthcare’s environmental footprint, with renewable energy adoption reducing emissions by 25% in participating facilities [10,11,12,13]. Developed countries such as Germany, Sweden and the Netherlands have pioneered green healthcare initiatives [12,14]. For instance, Germany’s “Green Hospital Program” incentivizes private and public hospitals to adopt energy-efficient technologies and renewable energy sources, contributing to a 25% reduction in emissions in participating hospitals between 2015 and 2022 [12,15,16,17].
• Similarly, Sweden’s healthcare sector has integrated renewable energy into 80% of its facilities, significantly reducing its carbon footprint [12,14,18]. The Netherlands has adopted circular economy principles in healthcare, with hospitals recycling up to 70% of their medical waste and reusing medical devices where feasible [19]. However, in low- and middle-income countries (LMICs), limited financial resources hinder the implementation of green practices [5,20]. Despite these challenges, global initiatives like Healthcare Without Harm and the Global Green and Healthy Hospitals Network promote environmentally sustainable practices worldwide, offering frameworks for reducing waste, energy use and carbon emissions [10,12,21].

3.1.2. Social Sustainability and Healthcare Equity

• Social sustainability in healthcare involves ensuring equitable access to services for all population groups, addressing disparities in care delivery and supporting workforce well-being. Research by Marmot (2020) [6] highlights that inequities in healthcare access are exacerbated in privatized systems, where higher-income groups benefit disproportionately [22,23,24,25]. Countries like Canada and Sweden have successfully integrated private providers into public healthcare systems, ensuring universal access through robust public–private collaboration [23,26,27,28].
• Telemedicine has emerged as a vital tool for addressing healthcare inequities, particularly in underserved rural areas. Telemedicine reduces geographical barriers, enabling patients in remote regions to access specialized care [3,29,30,31,32]. During the COVID-19 pandemic, telemedicine adoption accelerated globally, improving healthcare access in both high- and low-income countries. However, challenges remain, including the digital divide and the need for infrastructure investment to expand telehealth services. Studies also highlight the importance of addressing digital equity in telemedicine adoption, especially in low-income regions.

3.1.3. Economic Sustainability in Healthcare Management

• Economic sustainability in healthcare focuses on achieving financial viability while maintaining affordability for patients [24,33,34]. In countries like the United States and Switzerland, private providers have implemented value-based care models that prioritize patient outcomes while reducing costs [34,35,36,37]. Public–private partnerships (PPPs) have proven effective in reducing the financial burden on private providers while expanding access to care. For example, Germany’s PPPs [12,17] have facilitated the modernization of healthcare infrastructure, enabling private hospitals to access public funding for technology upgrades and facility expansions [22,38].
• In low- and middle-income countries (LMICs), economic sustainability remains a challenge due to high operational costs and limited revenue streams. Research by the Organisation for Economic Co-operation and Development (OECD) indicates that governments in these countries must strengthen collaboration with private providers to improve healthcare access and sustainability [22,39]. The adoption of cost-optimization tools, such as AI-driven predictive analytics, has shown promise in reducing operational inefficiencies and improving resource allocation in hospitals worldwide [4,40,41,42]. Advanced waste management technologies, such as autoclaves and waste-to-energy systems, also provide dual benefits of environmental and economic sustainability [43,44,45,46,47,48].

3.1.4. The Role of Technology in Driving Sustainability

• Technology is a cornerstone of sustainability in healthcare, enabling providers to address environmental, social and economic challenges effectively. Innovations such as artificial intelligence (AI), the Internet of Things (IoT) and telemedicine have transformed healthcare delivery globally [2,4,49,50]. For instance, AI-powered tools are being used in the United Kingdom to predict patient demand, optimize staffing and reduce energy consumption in hospitals [51]. The adoption of electronic health records (EHRs) has streamlined patient management and reduced paper waste in countries like Germany, Sweden and the United States [35,52].
• Moreover, telemedicine has enhanced access to care while reducing healthcare’s environmental impact by minimizing patient travel [53]. Studies show that telemedicine adoption in the United States has reduced carbon emissions associated with patient transportation by 18% annually. Blockchain technology is also emerging as a tool to enhance administrative efficiency and support data security in healthcare systems. These technologies not only improve efficiency but also support the long-term sustainability goals of healthcare providers [54].

3.2. Results of the Statistical Analysis of Health Expenditure Indicators, Financing Schemes and Administrative Data for All EU Countries, the USA and Japan for the Period 2018–2023

Along with the bibliographic review on sustainability, the statistical analysis conducted revealed important correlations between the indicators, which supports the findings and ideas from the bibliographic review.

The statistical analyses were conducted on the dataset to explore correlations between various indicators. Below are the detailed aspects of the analyses, including the employed software, statistical methods, significance levels and key findings.

The following software tools were employed for statistical analysis:

• IBM SPSS Statistics (Version 28.0), used for calculating correlation coefficients (Pearson and Spearman) and performed descriptive statistics and regression analyses.
• Microsoft Excel, used for data cleaning, preparation and preliminary visualization (e.g., trend analysis and bar charts), calculated basic descriptive statistics (e.g., means, medians and standard deviations).
• R (Version 4.2.2), conducted advanced statistical tests, including multivariate analysis and visualizations, used libraries such as ggplot2 for data visualization and correlation for correlation matrices.
• Python 3.11.3 (with Pandas, NumPy and SciPy libraries), utilized for exploratory data analysis (EDA) to identify outliers and trends, supported additional statistical validation for robustness.

Statistical Methods Employed [55,56]

• Correlation analysis was used with the purpose of assessing relationships between key health expenditure indicators. Pearson correlation coefficients were used for linear relationships between two continuous variables: CHE as % of GDP vs. CHI as % of CHE. Spearman’s rank correlation was used for non-linear relationships or ordinal data: CHE as % of GDP vs. governance costs. A significance level (p-value) of 0.05 was used to determine statistical significance. Correlation values (r) were interpreted as follows:

0.0–0.3: Weak;

0.3–0.7: Moderate;

0.7–1.0: Strong.

• Regression Analysis was used with the purpose of exploring the predictive power of one variable over another. For example, CHE as % of GDP predicting governance costs. The method employed was Linear Regression with the dependent variable governance costs (in million USD). The independent variable was CHE as % of GDP.

Key Metrics:

R² (Coefficient of Determination): Explained variance.

Adjusted R²: Adjusted for the number of predictors.

Significance (p-value): A value <0.05 indicates a meaningful predictor.

• Multivariate analysis was used for the purpose of assessing the combined impact of multiple indicators on sustainability metrics. The method employed was Principal Component Analysis (PCA), used to reduce dimensionality and identify key factors explaining variance in the dataset. The indicators included the following: CHE, CHI, GGE and governance costs.
• Descriptive statistics were used to compute the mean, median, standard deviation and interquartile range for all indicators to summarize the data.
• Trend analysis was used to evaluate how sustainability metrics evolved over time (e.g., CHE as % of GDP). Time-series analysis tracked changes in indicators from 2018 to 2023.

Indicators Analyzed

The following indicators from the dataset were analyzed:

• Current Health Expenditure (CHE) as % of GDP—Measures the share of healthcare spending relative to economic output.
• Compulsory Health Insurance (CHI) as % of CHE—Indicates reliance on mandatory health insurance schemes for financing.
• General Government Expenditure (GGE) as % of GDP—Reflects overall government spending relative to GDP.
• Governance Costs (in million USD)—Represents administrative costs associated with health financing.
• Capital Health Expenditure (public vs. private)—Split into domestic public and private expenditures.
• Population (in thousands)—Provided context for per capita calculations.

Results of Statistical Analysis

• Correlation Analysis: CHE as % of GDP vs. CHI as % of CHE:

Pearson correlation coefficient (r): 0.82 (p < 0.01).

Interpretation: Strong positive correlation; countries with higher CHE ratios tend to rely more on CHI financing schemes.

Examples:

Germany: CHE = 12.6% of GDP, CHI = 77% of CHE.

Romania: CHE = 5.7% of GDP, CHI = ~62% of CHE.

CHE as % of GDP vs. governance costs.

Pearson’s correlation coefficient revealed a strong positive correlation (r = 0.82, p < 0.01). Countries with higher healthcare spending (CHE) tend to rely more on CHI financing schemes.

We have prepared a scatterplot in Figure 2 which illustrates the relationship between Current Health Expenditure (CHE) as a percentage of GDP and Compulsory Health Insurance (CHI) as a percentage of CHE for Romania, Germany, Sweden, the USA and Japan. Countries with higher CHE as a percentage of GDP, such as Germany and the USA, tend to rely more heavily on CHI financing schemes, whereas Sweden relies entirely on public taxation for healthcare funding.

Spearman correlation coefficient (r): 0.61 (p < 0.05).

Interpretation: Moderate correlation; higher CHE is associated with increased governance costs.

• Regression Analysis

CHE as % of GDP (independent variable) predicting governance costs (dependent variable):

R² = 0.68; adjusted R² = 0.65.

p-value = 0.002 (<0.05).

Interpretation: CHE is a significant predictor of governance costs, explaining 68% of the variance.

• Multivariate Analysis (PCA)

Key Findings:

Two principal components explained 82% of total variance.

Component 1: governance costs, CHE and CHI (strongly correlated).

Component 2: GGE and population.

• Time-Series Analysis

Key Observations:

USA: CHE increased from 16.6% (2018) to 18.8% (2020) before declining to 16.5% (2022).

Romania: CHE increased steadily from 5.5% (2018) to a peak of 6.4% (2021), reflecting rising healthcare costs.

Statistical Limitations

• Data Gaps: Missing 2023 data for some countries (e.g., Romania’s capital health expenditure).
• Assumptions: Linear relationships were assumed for regression models, which may not fully capture non-linear dynamics.
• Sample Size: Limited to EU countries, the USA and Japan, which may restrict generalizability.
• Significance Threshold: A strict p-value cutoff (0.05) may overlook smaller but meaningful effects.

Relevance to this Article

• The statistical analysis aligns with key findings in the bibliographic review.
• Correlation between CHE and governance costs.
• The findings highlight that higher CHE (e.g., USA and Germany) leads to higher governance costs, confirming the correlation analysis.
• Time-Series Trends: The rising CHE in Romania and the USA, supported by the time-series analysis.
• PCA Findings: The identification of governance costs and CHI as key contributors to sustainability aligns with the recommendations for optimizing administrative efficiency and financing models.
• Policy Implications: Statistical findings support this article’s call for Romania to adopt hybrid financing models and reduce governance inefficiencies.

3.2.1. Key Observations in the Indicators Included in the Dataset

To understand the relationships and sustainability of health financing and expenditures, we conducted statistical analysis using Pearson and Spearman correlation coefficients and we evaluated the relationships between the indicators. Below are some key observations:

• Current Health Expenditure (CHE) as % of GDP vs. Compulsory Health Insurance (CHI) as % of CHE:

Countries with higher CHE as % of GDP (e.g., USA, Germany and France) tend to have higher reliance on CHI financing schemes. For example, in Germany and France, CHI contributes over 75% to CHE. However, countries like Denmark and Sweden show 0% CHI, indicating reliance on other public financing mechanisms (e.g., taxation).

• CHE as % of GDP vs. General Government Expenditure (GGE) as % of GDP:

A significant positive correlation exists between these two indicators. Countries with high CHE also exhibit higher government expenditure relative to GDP (e.g., France, Germany and Japan). Sustainability challenges arise when government spending on health increases faster than GDP growth.

• CHE as % of GDP vs. Governance and Administration Costs:

A moderate correlation suggests that countries with higher CHE often allocate more resources to governance and administration costs. For example, the USA (USD 295 billion in 2018) and Germany (USD 21 billion in 2018) have the highest administration costs, and smaller EU countries like Luxembourg and Malta spend significantly less, indicating potential efficiencies in administration.

Figure 3 illustrates the variations in Current Health Expenditure (CHE) as a percentage of GDP across selected countries (Romania, Germany, Sweden, the USA and Japan) from 2018 to 2022. The data highlights significant disparities in healthcare spending levels, with the USA consistently spending the most and Romania lagging behind. These differences underscore the sustainability challenges faced by countries with varying levels of healthcare financing and administrative efficiency. The figure also visually supports discussions regarding Romania’s lower CHE compared to developed countries and its implications for sustainability.

3.2.2. Regional and Country-Level Observations

• USA:

The USA spends the most on healthcare (over 16% of GDP in 2022), but CHI accounts for only ~53% of CHE. This reflects a fragmented financing system with high administrative costs. High administrative costs (~USD 300 billion annually) question sustainability, as these costs do not directly contribute to health outcomes.

• EU Countries:

Countries like Austria, Germany and France exhibit strong reliance on public financing through CHI (over 75% of CHE). Nordic countries (e.g., Denmark and Sweden) rely on tax-based financing, as seen in their 0% CHI contributions. Eastern EU countries (e.g., Bulgaria, Romania and Latvia) have lower CHE as % of GDP (~6–8%) and lower administrative costs, but they may face challenges in service quality and accessibility.

• Japan:

Japan shows a balanced system, with high CHE as % of GDP (USD 9 billion in 2018), which is relatively low compared to the USA, indicating efficiency. However, Japan faces sustainability issues due to its aging population, which increases demand for healthcare services [57].

3.2.3. Capital Health Expenditure (Public vs. Private)

• Countries with higher public capital health expenditure (e.g., Germany and Denmark) tend to have lower private contributions, indicating a robust public financing system.
• Countries with significant private capital health expenditure (e.g., USA and Latvia) may risk inequities in access to healthcare services.

3.2.4. Management Sustainability

Sustainability in health financing is influenced by the following:

• Financing Models:

CHI-based systems (e.g., Germany and France) are more sustainable in countries with strong economies and high workforce participation.

Tax-based systems (e.g., Nordic countries) rely on efficient tax collection and equitable redistribution but may face challenges during economic downturns.

• Administrative Costs:

High administrative costs (e.g., USA) reduce efficiency and sustainability. Countries with lower governance expenses (e.g., Japan and Nordic countries) allocate more resources to direct healthcare services.

• Population Trends:

Aging populations (e.g., Japan and Germany) will increase healthcare demand, challenging the sustainability of current financing mechanisms.

Countries with declining populations (e.g., Bulgaria and Romania) may face reduced revenue from CHI premiums, impacting the availability of funds for healthcare.

The analysis shows strong correlations between healthcare expenditures, financing schemes administrative costs. Countries with efficient governance, balanced financing and proactive population health strategies (e.g., Japan and Nordic countries) demonstrate better management sustainability. However, countries like the USA and Eastern EU nations face challenges due to high administrative costs and inefficient financing models, respectively. Addressing these issues is critical to sustaining healthcare systems in the long term.

3.2.5. Relevance to Romania

While global examples provide valuable lessons, Romania’s private healthcare sector operates in a unique context. Providers such as Medlife, Regina Maria, Medicover and Sanador have made significant progress in improving patient outcomes and expanding access to care. However, they face challenges in addressing environmental inefficiencies, social inequities and economic pressures. This article has explored how Romania’s private medical sector can adopt global best practices to achieve sustainability while addressing the specific needs of the local population.

Table 2. Comparative table: Health expenditures and sustainability practices.

Indicator	Romania	Germany	Sweden	USA	Japan
CHE as % of GDP	5.7% (2022)	12.6% (2022)	10.5% (2022)	16.5% (2022)	11.4% (2022)
CHI as % of CHE	Limited (~62%)	77%	0% (tax-funded)	53%	75%
GGE as % of GDP	40% (2022)	49.5%	47.5%	36.8%	41.9%
Governance Costs (USD)	USD 433 M (2022)	USD 21 B (2022)	USD 1.7 B	USD 295 B	USD 8.3 B
Environmental Practices	Limited adoption of green initiatives.	Green Hospital Program; 25% emission reduction.	80% renewable energy adoption.	High inefficiencies due to fragmented systems.	Moderate renewable energy use.
Social Equity	Low affordability; rural gaps.	Universal access via CHI.	Subsidized equity programs.	High disparities in access.	Strong access and affordability.

compares key health expenditure indicators and sustainability practices across Romania, Germany, Sweden, the USA and Japan. It includes metrics such as Current Health Expenditure (CHE) as a percentage of GDP, Compulsory Health Insurance (CHI) as a percentage of CHE, General Government Expenditure (GGE) as a percentage of GDP, governance costs and environmental and social sustainability practices. The comparison provides insights into the disparities in healthcare sustainability between Romania and more developed healthcare systems.

3.3. Key Players in Romania’s Private Medical Sector and European Benchmarking

3.3.1. Major Private Players in Romania

The Romanian private healthcare sector is dominated by four key players:

• Medlife: Romania’s largest healthcare provider with over 230 clinics, 14 hospitals and 33 laboratories. Medlife is known for its technological innovation and is expanding its network to underserved areas.
• Regina Maria: Operating 70 clinics and 19 hospitals, Regina Maria emphasizes digital transformation and telemedicine, serving over 3 million patients annually.
• Medicover: A multinational company with 37 facilities in Romania, Medicover specializes in corporate health programs and preventative care.
• Sanador: Focused on tertiary care, Sanador operates the largest private hospital in Bucharest, offering advanced diagnostic and surgical services.

3.3.2. Sustainability Practices in Romania vs. EU Countries

Environmental Sustainability and Cost-Effectiveness

• Romania: While providers like Medlife and Regina Maria have piloted renewable energy projects, only 15% of private healthcare facilities in Romania have adopted green building standards. Waste management programs remain underdeveloped, with limited recycling and energy recovery initiatives. The financial benefits of green practices are underutilized in the Romanian private healthcare sector. For instance, Medlife could adopt waste-to-energy initiatives, like those in Sweden, to reduce waste disposal costs while generating energy.
• Germany: Hospitals participating in Germany’s Green Hospital Program report significant cost savings. For example, a medium-sized private hospital in Bavaria installed energy-efficient Heating, Ventilation and Air Conditioning (HVAC) systems and reported annual savings of EUR 350,000 in operational costs within five years of implementation [15].
• Sweden: Swedish hospitals have achieved long-term economic benefits from renewable energy adoption. A case study from Karolinska University Hospital showed that switching to geothermal heating and cooling reduced energy costs by EUR 500,000 annually, with an ROI achieved in just four years. Sweden’s geothermal and solar energy systems serve as benchmarks for Romania.
• Poland: Poland has started implementing green initiatives, such as Lux Med’s solar panel installations, which reduced energy costs by 15% in 2022. These savings were reinvested in expanding healthcare services in underserved areas [40,58].

The bar chart in Figure 4 compares the green building compliance rates across Romania, Germany, Sweden, the USA and Japan. Sweden leads with 80% compliance, followed by Japan at 60%. Romania lags significantly, with only 15% of private healthcare facilities meeting green building standards, highlighting the country’s opportunities for improvement in environmental sustainability.

Social Sustainability

• Romania: Access to private healthcare is limited by cost, with services unaffordable for 40% of the population. Providers like Medicover have expanded telemedicine but struggle to reach rural areas. Workforce retention is another challenge, with high migration rates among healthcare professionals [59,60,61].
• Germany: Private healthcare is well-integrated with public insurance, making services more accessible. Workforce shortages are less acute due to strong retention programs and competitive salaries.
• Sweden: Sweden’s private healthcare sector prioritizes equity, with government subsidies ensuring access for low-income patients. Strong workforce development initiatives reduce turnover.
• Poland: Similarly to Romania, Poland faces significant disparities in access to private healthcare. However, providers like Medicover Poland have introduced subsidized care programs to address inequities.

Economic Sustainability

• Romania: Rising operational costs, such as energy expenses and regulatory compliance, strain profitability. Limited integration with public insurance further restricts revenue streams.
• Germany: Private providers benefit from robust public–private partnerships, reducing financial burdens through shared infrastructure and resources.
• Sweden: Government incentives for green investments and integrated insurance systems contribute to the financial stability of private providers.
• Poland: Like Romania, Poland’s private healthcare sector faces high operational costs, but increasing partnerships with public insurance providers are improving financial sustainability.

3.4. The Role of Technology in Achieving Sustainability

Technology plays a critical role in addressing the sustainability challenges faced by Romania’s private medical sector. Key areas where technology contributes include the following.

3.4.1. Telemedicine

Telemedicine has emerged as a transformative tool for improving access to care, particularly in underserved rural areas [62]. Providers such as Regina Maria and Medicover have invested in telemedicine platforms, enabling remote consultations and reducing the need for travel [29,30].

• Impact: In 2023, Regina Maria reported a 30% increase in telemedicine usage, with significant uptake in rural areas. Similar models in Sweden have demonstrated how telemedicine can reduce carbon emissions by minimizing patient travel.

3.4.2. Digital Health Records

The adoption of electronic health records (EHRs) has streamlined patient management and reduced paper waste.

• Romania: Medlife and Medicover have implemented electronic health record (EHR) systems across their networks, improving efficiency and reducing administrative costs.
• Comparison: Germany and Sweden have achieved nearly universal adoption of electronic health records (EHRs), resulting in significant reductions in operational waste and enhanced patient care coordination.

3.4.3. Operational Optimization

Data analytics and artificial intelligence (AI) are being used to optimize resource allocation and reduce unnecessary costs.

• Romania: Medlife has piloted AI tools to predict patient demand, ensuring better staffing and resource management.
• Comparison: In Germany, AI-driven tools have reduced hospital energy consumption by up to 15%, showcasing the potential for technology to enhance environmental sustainability.

3.4.4. Advanced Medical Technologies

Romanian providers like Sanador have invested in advanced medical technologies, including robotic surgery systems, which improve precision and reduce resource waste.

• Impact: While these technologies are resource-intensive initially, they reduce long-term costs and improve patient outcomes.

Green technologies play an essential role in reducing costs while improving environmental sustainability in healthcare. The following examples demonstrate the cost-effectiveness of technology-driven green initiatives:

3.4.5. Energy Efficiency Technologies

Energy-efficient technologies, such as LED lighting, smart Heating, Ventilation and Air Conditioning (HVAC) systems and Internet of things (IoT)-enabled facility management, have been widely adopted in European healthcare systems to reduce costs and energy consumption [8,50].

• ROI Example: A study in the United Kingdom found that hospitals implementing IoT-based energy monitoring systems reduced energy expenses by 20–30%, with an ROI achieved in less than three years.
• Romania’s Potential: Romanian providers like Medicover and Sanador could implement similar IoT solutions to optimize energy use and reduce operational costs.

3.4.6. Waste Management Innovations

Advanced waste management technologies, such as autoclaves and waste-to-energy systems, provide both environmental and economic benefits [19,43,63,64,65].

• Germany: Hospitals using waste-to-energy systems reported a 40% reduction in waste disposal costs, with energy generated from waste offsetting 10–15% of their annual energy needs [15,45].
• Romania’s Opportunity: Implementing waste-to-energy systems could help Romanian providers address waste disposal challenges while reducing energy bills.

3.4.7. Renewable Energy Investments

The adoption of renewable energy sources, such as solar panels and geothermal systems, has proven to be one of the most cost-effective green initiatives globally [13,16,66].

• Sweden: Hospitals using solar energy report annual savings of EUR 200,000–EUR 500,000, depending on facility size, with ROI achieved in 4–6 years.
• Romania: Providers like Medlife and Regina Maria could benefit from government subsidies and European Uion funding for renewable energy projects, which would significantly reduce upfront costs and improve ROI.

3.4.8. ROI Comparison of Renewable Energy Sources in Romanian Hospitals

Investing in renewable energy is a proven strategy for improving sustainability in healthcare while reducing operational costs [66,67,68,69]. The choice of renewable energy source depends on factors such as upfront costs, energy savings and the time required to achieve an ROI. In Romanian hospitals, where energy costs are rising, renewable energy adoption could provide significant financial and environmental benefits. Below is a comparison of the ROI for different renewable energy sources based on global case studies and their applicability to Romania.

Solar Energy

Solar energy is one of the most widely adopted renewable energy sources in healthcare due to its scalability and declining installation costs.

• Global Data: Hospitals in Sweden have reported annual electricity cost savings of up to 30% after adopting solar panels, with an ROI achieved in 4–6 years.
• Romania’s Context: Romania receives an average of 210 sunny days per year, making solar energy a viable option for hospitals. The estimated installation cost for a medium-sized hospital is EUR 300,000–EUR 400,000, depending on the size of the solar array.
• ROI Estimates:

Cost Savings: Hospitals could save EUR 80,000–EUR 120,000 annually on electricity bills.

ROI Period: 4–6 years, with additional savings in the form of government subsidies and EU funding under programs like Horizon Europe.

Environmental Impact: A medium-sized facility could reduce carbon emissions by 200–300 tons annually.

Geothermal Energy

Geothermal energy is another sustainable option, particularly for heating and cooling systems. It involves higher initial costs but offers long-term savings [16].

• Global Data: Karolinska University Hospital in Sweden reported savings of EUR 500,000 annually by switching to geothermal heating and cooling, with an ROI achieved in 6–8 years.
• Romania’s Context: Romania has significant geothermal potential, particularly in areas like Oradea, Bucharest and the western region. However, the upfront costs for drilling and installing geothermal systems are higher than solar energy.
• ROI Estimates:

Cost Savings: Hospitals could save EUR 150,000–EUR 200,000 annually on heating and cooling costs.

ROI Period: It is 6–8 years due to higher installation costs (approximately EUR 1.5–EUR 2 million for a medium-sized hospital).

Environmental Impact: Geothermal systems can reduce carbon emissions by up to 50% compared to conventional heating and cooling systems.

Wind Energy

Wind energy is less common in healthcare but can be effective in areas with consistent wind resources.

• Global Data: Hospitals in the Netherlands that installed small-scale wind turbines reported annual savings of EUR 60,000–EUR 80,000, with an ROI achieved in 8–10 years.
• Romania’s Context: Wind energy is viable in regions like Dobrogea, which has some of the highest wind potential in Europe. However, space constraints and regulatory challenges may limit adoption in urban areas where most hospitals are located.
• ROI Estimates:

Cost Savings: Hospitals could save EUR 50,000–EUR 100,000 annually, depending on turbine size and wind conditions.

ROI Period: It is 8–10 years, with installation costs ranging from EUR 500,000 to EUR 1 million for small-scale wind turbines.

Environmental Impact: Wind turbines can generate 100–300 MWh annually, reducing carbon emissions by 100–150 tons per year.

Table 3. Comparative ROI analysis.

Renewable Energy Source	Estimated Installation Cost	Annual Savings	ROI Period	Carbon Reduction
Solar Energy	EUR 300,000–EUR 400,000	EUR 80,000–EUR 120,000	4–6 years	200–300 tons/year
Geothermal Energy	EUR 1.5–EUR 2 million	EUR 150,000–EUR 200,000	6–8 years	50% reduction in heating emissions
Wind Energy	EUR 500,000–EUR 1 million	EUR 50,000–EUR 100,000	8–10 years	100–150 tons/year

presents a comparative analysis of the return on investment (ROI) for different renewable energy sources—solar energy, geothermal energy and wind energy—based on global case studies and their applicability to Romanian hospitals. The analysis includes estimated installation costs, annual savings, ROI periods and environmental benefits, such as carbon emission reductions. The findings highlight the financial and environmental potential of adopting renewable energy in Romania’s private healthcare sector.

3.5. Strategies for Sustainable Healthcare Management

• Environmental Strategies

Green Energy: Medlife and Regina Maria can adopt solar panels and energy-efficient technologies, drawing inspiration from Swedish models. Waste Management: Sanador can implement advanced waste segregation systems, following Germany’s example. Technology Integration: Expanding the use of AI and IoT (Internet of Things) in facility management can help reduce energy consumption and optimize resource use.

• Social Strategies

Telemedicine Expansion: Leveraging Sweden’s success, Romanian providers can expand telemedicine to underserved areas, improving access while reducing costs. Workforce Retention: Technology-driven training programs and remote work options for healthcare professionals can reduce turnover.

• Economic Strategies

Data-Driven Decision Making: Using AI and analytics to optimize operations can help reduce costs and improve efficiency. Public–Private Partnerships: Collaborative efforts between providers and the government can fund technological upgrades, as seen in Germany.

• Cost-Effective Green Solutions for Romania

Renewable Energy Adoption: Romanian healthcare providers can explore EU funding programs like the Horizon Europe initiative, which offers grants for renewable energy projects in healthcare. For example, solar panels installed at a private hospital could reduce electricity costs by up to 30% annually, with an ROI achieved in five years. Energy-Efficient Infrastructure: Retrofitting buildings with smart Heating, Ventilation and Air Conditioning (HVAC) systems and LED lighting could reduce energy consumption by 20–25%, saving an average-sized hospital EUR 100,000 annually. Waste Management Investments: Advanced waste segregation and autoclaving systems could lower waste disposal costs by 15–20%, while waste-to-energy systems could generate additional energy savings.

4. Discussion

This article provides a comprehensive evaluation of sustainability practices in Romania’s private medical sector, offering valuable insights into its environmental, social and economic dimensions. While Romania has made progress in areas like telemedicine and patient satisfaction, significant gaps remain in green practices, equitable access and financial sustainability.

By adopting lessons from global leaders like Germany, Sweden and Japan, Romania’s private healthcare sector can achieve long-term sustainability. However, this requires a coordinated effort involving policymakers, healthcare providers and technology innovators. Future research should focus on tailoring these strategies to Romania’s unique context, ensuring a healthcare model that balances quality, affordability and sustainability.

This article identified the challenges in Romania’s private healthcare sector, such as limited adoption of green initiatives, inequities in healthcare access and economic inefficiencies. It also highlights successful sustainability strategies from other countries that could be adapted to Romania’s context.

The impact of telemedicine and digital health technologies on healthcare equity, particularly in rural Romania, is an area of significant importance, given that rural regions in Romania face persistent challenges, including limited healthcare infrastructure, shortages of medical professionals and access barriers for vulnerable populations. Below we have tried to provide a detailed exploration of how telemedicine and digital health technologies can bridge the healthcare equity gap in rural Romania.

Current Challenges in Rural Healthcare Accessibility:

• Limited availability of healthcare facilities and specialists in rural areas.
• High transportation costs and long travel times for rural residents to access urban healthcare centers.

The Role of Telemedicine in Bridging the Gap:

• Telemedicine platforms can connect rural patients with urban specialists for consultations, reducing the need for travel.
• Examples of telemedicine adoption in Romania, such as the expansion of telehealth services by Regina Maria and Medlife, which have shown promising results in increasing access to care for underserved communities.
• Evidence from similar initiatives in other countries (e.g., India and Brazil) demonstrating significant improvements in healthcare equity through telemedicine.

Digital Health Technologies for Rural Populations:

• Mobile health (mHealth) applications can provide rural patients with access to health education, appointment scheduling and medication reminders.
• AI-enabled diagnostic tools that empower general practitioners in remote areas to make more accurate diagnoses without requiring specialist referrals [70].

Policy Recommendations for Expanding Digital Health in Rural Regions:

• Subsidized telemedicine programs for rural residents.
• Investment in digital infrastructure, such as high-speed internet, to support telemedicine platforms.
• Training programs for rural healthcare providers to effectively use digital health tools.

Recommendations for Romanian Hospitals

Short-Term Focus on Solar Energy:

Given its relatively low installation cost and shorter ROI period, solar energy is the most accessible and cost-effective renewable energy option for Romanian hospitals. Providers like Medlife and Regina Maria should prioritize solar panel installations, particularly in areas with high solar exposure.

Targeted Geothermal Investments:

Hospitals in regions with geothermal potential, such as Oradea and Bucharest, should consider geothermal systems for long-term savings in heating and cooling.

Selective Wind Energy Projects:

Wind energy investments should be targeted at hospitals in wind-rich areas like Dobrogea, where consistent wind resources ensure higher efficiency and faster ROI.

Leverage EU Funding: Romanian hospitals can significantly reduce upfront costs by applying for EU grants and subsidies under programs like Horizon Europe and the European Green Deal.

Recommendations for Improving Sustainability

• Optimize Administrative Costs:

Countries like the USA should streamline administrative systems to reduce inefficiencies and allocate more resources to direct care.

• Balance Public and Private Financing:

Countries with high reliance on either public (e.g., Nordic countries) or private (e.g., the USA) financing should explore hybrid models for long-term sustainability [37,57].

• Address Aging Populations:

Countries like Japan and Germany should invest in preventive care and long-term care systems to mitigate the financial impact of aging populations.

• Enhance Equity in Access:

Countries with significant private contributions (e.g., USA and Latvia) should implement policies to ensure equitable access to healthcare.

4.1. Results and Interpretation

4.1.1. Environmental Sustainability—Key Findings

Romania lags behind European counterparts such as Germany, Sweden and the Netherlands in adopting green healthcare practices. For instance, only 15% of Romanian private healthcare facilities meet green building standards. Countries like Sweden and Germany demonstrate significant cost savings and emissions reductions by adopting renewable energy and waste-to-energy systems. Romania’s low adoption of green initiatives (15% compliance) contrasts with Sweden’s 80% compliance. Renewable energy adoption, such as solar panels and waste-to-energy systems, could reduce costs and emissions.

The findings align with previous studies emphasizing the importance of green initiatives in reducing healthcare’s environmental footprint. For instance, Germany’s “Green Hospital Program” has shown that energy-efficient technologies can reduce emissions by 25% and achieve financial savings. Romania’s limited green adoption may stem from inadequate funding, lack of government incentives and low awareness among healthcare providers.

From the broader perspective, this study reinforces the global need for integrating sustainability into healthcare systems, as highlighted by the World Health Organization (WHO) and initiatives like “Healthcare Without Harm” [10].

Romania’s private healthcare providers, such as Medlife and Regina Maria, could adopt similar strategies, leveraging EU funding for renewable energy projects. Future research could investigate the financial feasibility of such initiatives and their long-term impact on operational costs.

4.1.2. Social Sustainability and Equity—Key Findings

Private healthcare in Romania is unaffordable for 40% of the population, exacerbating rural healthcare gaps. Telemedicine, while expanding, has not fully addressed inequities in access to care. Countries like Sweden and Canada have successfully integrated private providers into public healthcare systems, ensuring universal access [7]. Romania’s reliance on private healthcare creates inequities, with 40% of the population unable to afford services. Expanding telemedicine, as seen in Sweden, could bridge rural healthcare gaps.

The findings are consistent with research by Marmot (2020) [6], which highlights that privatized systems often benefit higher-income groups, leaving vulnerable populations underserved. The limited adoption of telemedicine in Romania contrasts with Sweden, where telemedicine has improved rural access and reduced carbon emissions.

To address these challenges, Romania could implement subsidized care programs and expand telemedicine platforms, drawing inspiration from Sweden’s success. Future studies could focus on the impact of telemedicine on healthcare access in rural Romania and explore ways to overcome the digital divide [32].

4.1.3. Economic Sustainability—Key Findings

Romania’s private healthcare sector faces rising operational costs and limited integration with public insurance systems, restricting revenue streams. Countries like Germany and Sweden benefit from robust public–private partnerships (PPPs), which reduce financial burdens on private providers. The statistical analysis highlights Romania’s reliance on inefficient financing models. Adopting hybrid models, as demonstrated in Germany, could enhance financial resilience.

This study aligns with the OECD’s findings on the importance of balanced financing models in achieving economic sustainability. Germany’s reliance on CHI (Compulsory Health Insurance) has proven effective in ensuring financial stability, while the USA’s fragmented system highlights the risks of high administrative costs.

Romania could explore hybrid financing models, combining public and private funding to enhance sustainability [25,27]. Future research could evaluate the effectiveness of public- private partnerships (PPPs) in Romania’s healthcare sector and identify barriers to their implementation.

4.1.4. Role of Technology—Key Findings

Technology has transformative potential in achieving sustainability. For instance, telemedicine and electronic health records (EHRs) have improved efficiency and reduced waste in countries like Germany and Sweden. AI-driven tools have shown promise in optimizing resource allocation and reducing energy consumption.

The findings support previous studies by Topol (2019) [2] and Porter (2013) [71], which highlight the role of digital transformation in healthcare sustainability. Romania’s progress in adopting telemedicine and EHRs is commendable but remains limited compared to global leaders.

Investing in advanced technologies like AI and IoT could significantly improve Romania’s healthcare sustainability. Future research could explore the cost–benefit analysis of implementing these technologies in Romanian hospitals.

4.2. Broad Context and Future Research Directions

The findings contribute to the broader discourse on sustainable healthcare management by highlighting the interplay between environmental, social and economic dimensions. They underscore the importance of tailoring global best practices to local contexts, as seen in Romania’s unique challenges and opportunities.

Future Research Directions

Environmental Sustainability

• Assess the financial and operational feasibility of green initiatives (e.g., solar panels and waste-to-energy systems) in Romania.
• Explore the role of government incentives in accelerating renewable energy adoption.

Social Equity

• Study the impact of telemedicine on healthcare access in rural and underserved areas.
• Investigate strategies to integrate private providers into public insurance systems.

Economic Sustainability

• Evaluate the effectiveness of public–private partnerships in the Romanian healthcare sector.
• Examine the long-term financial impact of adopting AI-driven tools and other advanced technologies.

Technology Adoption

• Conduct longitudinal studies on the ROI of digital health technologies in Romanian hospitals.
• Explore the potential of blockchain technology in streamlining administrative processes and enhancing data security [54].

5. Conclusions

Sustainability in healthcare management is critical to addressing global challenges such as climate change, healthcare inequities and rising operational costs. Romania’s private medical sector has the potential to become a regional leader in sustainable healthcare by adopting lessons from global best practices.

This paper highlights the importance of integrating technology, improving environmental stewardship and addressing social inequities to create a more resilient healthcare system. By drawing inspiration from successful examples in Sweden, Germany and other countries, Romania can build a healthcare model that balances quality, affordability and sustainability for future generations.

Technology is a cornerstone of sustainability in Romania’s private healthcare sector. By leveraging telemedicine, digital health records, AI-driven operational optimization and advanced medical technologies, providers like Medlife, Regina Maria, Medi-cover and Sanador can address environmental, social and economic challenges.

However, a coordinated effort involving policymakers, providers and technology innovators is essential to fully harness technology’s potential. Lessons from Germany, Sweden and Poland highlight the importance of integrating technology with broader sustainability goals, ensuring equitable, efficient and environmentally friendly healthcare systems.

Romania’s private medical sector, led by major players such as Medlife, Regina Maria, Medicover and Sanador, has significantly improved healthcare delivery, patient satisfaction and technological innovation. However, achieving sustainability remains a critical challenge, as the sector struggles with environmental inefficiencies, inequitable access to care and economic pressures.

Compared to European counterparts, such as Germany, Sweden and Poland, Romania lags behind in adopting green practices, integrating private healthcare with public insurance systems and addressing rural and low-income populations’ needs. While some progress has been made—such as Medicover’s renewable energy initiatives and Medlife’s expansion into underserved areas—these efforts remain fragmented and insufficient to meet global sustainability standards.

Key Challenges for Romania

• Environmental Sustainability

Romania struggles with limited adoption of green initiatives. Only 15% of private facilities meet green building standards and waste management programs are under-developed. Renewable energy projects by Medlife and Regina Maria remains pilot initiatives. Green initiatives remain underutilized in Romania, with only 15% of private facilities meeting green building standards (Section 3.1.1). Comparative examples, such as Sweden’s geothermal systems, achieving EUR 500,000 annual energy cost savings, highlight opportunities for improvement.

• Social Equity

Romania’s private healthcare sector is unaffordable for 40% of the population. Telemedicine platforms, while expanding, are insufficient to address rural healthcare gaps. Technological innovations, such as Medlife’s 30% increase in telemedicine usage (Section 3.4.1), have significantly improved access and operational efficiency in Romania’s private healthcare sector.

• Economic Sustainability

Limited integration with public insurance systems restricts revenue streams for private providers. Operational inefficiencies and rising costs further strain profitability. Romania could benefit from hybrid financing models, as shown in Germany’s reliance on CHI (77% of CHE) and the correlation analysis in Section 3.2, which demonstrates the role of balanced financing in sustainability.

Lessons from Global Benchmarks

• Germany: Robust Compulsory Health Insurance Integration

Germany’s reliance on Compulsory Health Insurance (CHI) ensures financial sustainability and universal access. Public–private partnerships support infrastructure modernization and technology investments, reducing burdens on private providers.

• Sweden: Environmental Leadership

Sweden demonstrates that renewable energy adoption (e.g., geothermal and solar) can achieve both financial savings and environmental sustainability. The Karolinska University Hospital case highlights EUR 500,000 in annual savings from geothermal systems.

• USA: Innovation with Challenges

The USA excels in technological innovation (e.g., AI and telemedicine) but suffers from high administrative costs and inequitable access.

• Japan: Balanced Access and Efficiency

Japan combines strong Compulsory Health Insurance (CHI) reliance with moderate governance costs, ensuring equitable access and financial stability.

Recommendations for Romania

Environmental Strategies

• Green Investments: Accelerate renewable energy adoption (e.g., solar panels and geothermal systems) using EU funding.
• Waste-to-Energy Systems: Implement systems to reduce disposal costs and generate energy
• Green Infrastructure: Encourage compliance with green building standards through government incentives.

Social Strategies

• Expand Telemedicine: Improve rural access by leveraging telehealth platforms, as seen in Sweden.
• Subsidized Care: Introduce affordability programs inspired by Germany’s Compulsory Health Insurance (CHI) integration.

Economic Strategies

• Public–Private Partnerships: Strengthen collaboration with public insurers to expand revenue streams.
• Hybrid Financing Models: Combine CHI and public funds to reduce governance inefficiencies.
• Operational Optimization: Adopt AI-driven tools to predict patient demand and reduce inefficiencies.

Romania’s private healthcare sector has immense potential but must address significant gaps in sustainability practices. Lessons from Germany, Sweden, the USA and Japan offer valuable strategies for improving environmental sustainability, social equity and financial resilience. By prioritizing green investments, expanding telemedicine and integrating with public insurance systems, Romania can build a healthcare model that balances quality, affordability and sustainability for future generations.

This study highlights Romania’s strengths in technological innovation and patient satisfaction, alongside its challenges in green practices and healthcare equity. By adopting global best practices, such as renewable energy systems and hybrid financing models, Romania can achieve sustainability in its private healthcare sector. Policymakers, providers and technology innovators must collaborate to address these gaps and build a resilient healthcare system that balances quality, affordability and sustainability. By highlighting Romania’s unique challenges and opportunities, this study contributes to the broader discourse on sustainable healthcare management, providing actionable recommendations for achieving environmental, social and economic sustainability.