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

Response to Reviewer

1. Summary

Thank you very much for taking the time to review this manuscript also thank you for your valuable input in the article. Please find the detailed responses below and the corresponding revisions/corrections in the re-submitted file. I am grateful for the reviewers' thoughtful feedback, which has significantly improved the manuscript. The revisions address all points raised and enhance the depth, relevance, and applicability of the study. I believe these changes align the manuscript more closely with the journal’s standards and contribute meaningfully to the field of healthcare sustainability.

2. Point-by-point response to Comments and Suggestions for Authors

Comments 1: Removing some keywords that already appear in the title: sustainability; Romania; private medical sector.

Response 1: Thank you for your observation. I have carefully revised the keywords and removed those that overlap with terms in the title, ensuring the keywords list now provides added thematic precision and enhances the manuscript’s discoverability.

Comments 2: In the methodology, the authors present some results and even discuss these results. I believe that the methodology should be more summarized, presenting only the analyses performed.

Response 2: Thank you for this valuable suggestion. I have thoroughly reorganized the Methodology section to focus exclusively on describing the analytical methods and procedures employed, without prematurely introducing results or interpretations. All discussions and preliminary findings have been moved to the appropriate sections of Results and Discussion to improve the logical flow.

Comments 3: Statistical limitations should be discussed in the appropriate topic, not in methodology, as well as Relevance to the article.

Response 3: I appreciate this recommendation. The section discussing statistical limitations and the relevance of the analysis has been relocated to the Discussion section, ensuring that the Methodology chapter remains strictly methodological and aligned with best practices in research reporting.

Comments 4: In item 3.2.2. Regional and Country-Level Observations

The authors point out that: High administrative costs do not contribute directly to health outcomes. Why?

Response 4: Yes, it is very true that high administrative costs do not contribute directly to health outcomes because they primarily involve the expenses associated with governance, management, and bureaucracy, rather than the direct provision of medical care or patient services. Here’s why:

1. Resource Allocation to Non-Clinical Functions: High administrative costs are often spent on tasks like record-keeping, billing, insurance processing, and compliance with regulations. While these functions are necessary for running healthcare systems, they do not translate into direct improvements in patient care, such as better treatment or access to medical services.
2. Fragmented Financing Systems: In countries like the USA, where the healthcare financing system is fragmented, administrative complexity is higher. This includes managing multiple payers, insurance claims, and differing reimbursement policies, which increases costs without directly benefiting patients' health.
3. Opportunity Cost: Funds spent on administrative tasks could otherwise be invested in areas that directly impact health outcomes, such as hiring more healthcare professionals, purchasing advanced medical equipment, or improving healthcare infrastructure.
4. Inefficiencies and Redundancy: High administrative costs often indicate inefficiencies or redundancies in the system, such as overlapping tasks or excessive paperwork. For example, duplicative reporting requirements or poorly integrated IT systems lead to wasted resources that do not enhance patient care.
5. Comparative Evidence: The authors contrast countries like the USA, which has high administrative costs (~$295 billion annually in 2018), with countries like Japan and Nordic nations. These countries allocate fewer resources to administration and more to direct healthcare services, achieving greater efficiency and better health outcomes.

Thus, while administrative functions are necessary for maintaining healthcare systems, excessive costs in this area divert resources from patient-centred care, reducing the overall efficiency and sustainability of healthcare systems. This topic will be treated in a separate research / article that is already on my personal research agenda.

Comments 5: The topic “3.2.5. Recommendations for Improving Sustainability” should be moved from “Results” to “Discussion”.

Response 5: Thank you for your careful reading. I have made the requested structural change, relocating the recommendations section to the Discussion chapter where it logically integrates with the broader interpretation of findings and aligns with the journal’s standards.

Comments 6: The article presents several important and relevant points. For example, it mentions the use of artificial intelligence as a new tool; Waste Management Innovations and Renewable Energy Investments. Telemedicine, which has recently emerged and has shown good results in several countries, I believe is a highlight. It promotes access to people far from large centres, enhancing equity and social security. On the other hand, it does not mention Canada, a country considered by many to be a model of public health to be followed. But it would really be difficult to work with several different models. The public health model in Brazil, despite being inefficient, has a proposal considered socially sustainable. During the COVID-19 pandemic, people from neighbouring countries travelled to Brazil to have access to vaccines, which were distributed free of charge. New articles in the future could focus on other health models and compare them with the data from the current research.

Response 6: Thank you for this excellent observation. You are right that the current manuscript focuses primarily on comparisons between Romania, the USA, Japan, and selected EU countries, driven by scope constraints. However, I fully acknowledge the importance of exploring other international models such as Canada’s publicly funded system and Brazil’s socially oriented public health approach, especially considering their performance during the COVID-19 pandemic. I intend to incorporate these comparative perspectives in future studies and appreciate your insightful suggestion for broadening the research scope in subsequent publications.

Comments 7: The topic “3.5. Recommendations for Romanian Hospitals” should be presented in discussion.

Response 7: Thank you for this structural recommendation. I have repositioned the recommendations targeted specifically at Romanian hospitals into the Discussion section, ensuring the manuscript’s organizational coherence and thematic consistency.

Comments 8: Throughout the text, the authors “overuse” the use of topics, sometimes considered unnecessary. For example: in the topic “4.1.4. Role of Technology – key findings” I believe it is unnecessary to mention “Interpretation:” and “Implications:”. If the authors opted for a more fluid text, I believe the reading would be more enjoyable.

Response 8: Thank you for this valuable feedback. I have revised and streamlined the text, reducing the number of headings and labels to improve narrative flow. The sections have been rephrased for smoother readability while maintaining clarity and analytical rigor.

Comments 9: I believe the authors use too many Abbreviations; which makes the text less fluid. It is often necessary to reread it to understand the context.

Response 9: 

Thank you for pointing this out. I have standardized the introduction and use of abbreviations throughout the manuscript. Each term is now introduced fully at its first mention within a section (e.g., Current Health Expenditure [CHE]) and subsequently referred to by its abbreviation. This adjustment improves clarity and minimizes interruptions in the reading flow.

Response to Reviewer

1. Summary

Thank you very much for taking the time to review this manuscript also thank you for your valuable inputs in the article. Please find the detailed responses below and the corresponding revisions/corrections in the re-submitted file.

I am grateful for the reviewers' thoughtful feedback, which has significantly improved the manuscript. The revisions address all points raised and enhance the depth, relevance, and applicability of the study. I believe these changes align the manuscript more closely with the journal’s standards and contribute meaningfully to the field of healthcare sustainability.

2. Point-by-point response to Comments and Suggestions for Authors

Comments 1: The manuscript would benefit from including more diverse and recent international examples, especially comparative case studies, to help frame the Romanian context within a broader global conversation."

Response 1: Thank you for this valuable observation. In the revised manuscript, I have incorporated a broader range of recent international examples, including comparative case studies from Canada, Switzerland and the United Kingdom. These cases highlight innovative sustainability practices relevant to Romania, such as telemedicine expansion, green hospital programs and advanced public-private partnership models. These updates are reflected in Sections 3.1.2, 3.1.3, and 3.1.4 of the revised manuscript and provide a richer contextualization of the Romanian private healthcare sector within the global discourse.

Comments 2:
"Some references related to statistical analysis or systematic reviews would benefit from a more apparent connection to the methods used in the manuscript. Ensuring that sources are directly tied to the research design would enhance transparency and allow for better study reproducibility."

Response 2: I fully acknowledge this point. To address it, I have strengthened the methodological section (Section 2) by explicitly detailing how the systematic review process, data sources, and statistical methods (including Pearson and Spearman correlation analyses) align with and are supported by prior studies cited in the manuscript (e.g., Topol, 2019; Purohit et al., 2021). This ensures a more transparent, traceable connection between the cited literature and the applied research design, thereby enhancing the reproducibility and academic rigor of the study.

Comments 3:
"There appears to be room for engaging with underexplored areas in the current literature. For example, incorporating emerging themes like the influence of digital health technologies on sustainability could highlight where this study adds new value and insight."

Response 3:
I appreciate this insightful suggestion and I agree that we can expand the discussion on emerging themes, particularly the role of digital health technologies in sustainability. In Section 3.4, we already included elements from the analysis of how digital health records, AI-driven operational optimization, and telemedicine contribute to environmental, social, and economic sustainability.

Comments 4:
"Because healthcare sustainability is a rapidly evolving field, it is essential to verify that all references are up-to-date. Verifying all references ensures that the manuscript remains relevant and credible in light of the latest developments."

Response:
I have thoroughly reviewed and updated the references to ensure their relevance and alignment with the latest research developments. Some citations have been replaced with more recent studies published between 2022 and 2024, particularly in areas such as renewable energy in healthcare (e.g., Karliner et al., 2022) and telemedicine adoption (e.g., Liu et al., 2023). Additionally, I have verified that all references directly support the article’s arguments.

Comments 5:
"The numerous inconsistencies in line spacing and paragraph breaks disrupt the text's flow, making it easier for readers to lose interest."

Response 5:
I have thoroughly reviewed the manuscript to ensure consistent formatting of line spacing and paragraph breaks throughout the document. This revision ensures that the text flows smoothly and maintains reader engagement.

Comments 6:
"Punctuation mistakes, including missing periods, an errant comma or two, and looking like some thoughts are unfinished, distract from the clarity of the writing."

Response 6: I have meticulously proofread the manuscript to correct all punctuation issues, ensuring the proper use of periods, commas and other punctuation marks. Additionally, we have revised any sentences or paragraphs that previously appeared incomplete or underdeveloped, ensuring clarity, logical flow, and completeness in the presentation of ideas.

Comments 7:
"If the headings and subheadings were formatted consistently, it would enhance the document's structure. Having a consistent style, such as bold type or consistently sized font, helps provide a clear indication of the hierarchy of the text."

Response 7:
I have reformatted all headings and subheadings to ensure consistency in style and hierarchy. A clear formatting structure has been applied:

• Level 1 headings are bold and in size 12 font.
• Level 2 subheadings are Italic and in size 10 font.
• Level 3 subheadings are Italic and in size 10 font.
• Level 4 subheadings are bullets

This consistent formatting provides a clear indication of the text’s hierarchy, making the manuscript more organized and easier to navigate.

Comments 8:
"When figures, tables, or diagrams are used, clearly label them with helpful captions that explain each figure and incorporate them into the text, so they contribute to the discussion; they should not distract from it."

Response 8:
All figures, tables, and diagrams have been reviewed and updated to include clear, descriptive captions that explain their purpose and relevance to the discussion. I have ensured that each figure is referenced explicitly in the text, integrating it seamlessly into the narrative.

Comments 9:
"In introducing acronyms that should be spelled out when first mentioned in the manuscript, there is a tendency to alternate back and forth in writing whether to use the abbreviation or write it out in full."

Response 9:
I have standardized the use of acronyms and abbreviations throughout the manuscript. Each acronym is now spelled out in full the first time it is introduced, followed by the abbreviation in parentheses. Subsequently, only the abbreviation is used. For example, "Current Health Expenditure (CHE)" is introduced in full at first mention, and only "CHE" is used thereafter. This ensures consistency and avoids confusion for the reader.

Comments 10:
"When referencing quotes, paraphrasing the work of other authors, or developing academic citations, adhere to the reference style requested by the journal."

Response 10:  I have carefully reviewed all references and ensured adherence to the specific reference style required by the journal. Where necessary, I will also be consulting with Journal Author Services to guarantee that all citations, paraphrased material and bibliographic entries are formatted precisely according to the journal’s standards, ensuring accuracy and professionalism in scholarly attribution.

Final Remarks

Once again, I express my sincere gratitude for your detailed and constructive feedback. Your insightful comments have played a crucial role in improving the overall quality and scientific robustness of the manuscript. I am confident that the revised version now meets the journal’s expectations and contributes meaningfully to the academic discourse on healthcare sustainability. Please do not hesitate to share any further comments or suggestions, as I remain committed to refining the manuscript to the highest standards.

Response to Reviewer

1. Summary

Thank you very much for taking the time to review this manuscript also thank you for your valuable inputs in the article. Please find the detailed responses below and the corresponding revisions/corrections in the re-submitted file.

I am grateful for the reviewers' thoughtful feedback, which has significantly improved the manuscript. The revisions address all points raised and enhance the depth, relevance, and applicability of the study. I believe these changes align the manuscript more closely with the journal’s standards and contribute meaningfully to the field of healthcare sustainability.

2. Point-by-point response to Comments and Suggestions for Authors

Comments 1: The objectives are mentioned but not clearly separated or emphasized. The author must clearly state the main objectives at the end of the introduction to guide the reader.

Response 1: Thank you for this important observation. I have revised the Introduction section to clearly and explicitly list the main research objectives at its conclusion. These objectives now appear as distinct, enumerated points, making them easier to follow. They cover the evaluation of sustainability practices in Romania’s private healthcare sector, analysis of health expenditure indicators, assessment of the role of technology, and formulation of actionable recommendations based on global benchmarks. This enhancement ensures that the reader can immediately grasp the scope and aims of the study, improving the manuscript’s clarity and navigability.

Comments 2: There are several grammatical and spelling mistakes throughout the paper. Comprehensive proofreading or editing using a language tool is recommended.

Response 2: Thank you for highlighting this. I have undertaken an extensive round of proofreading to address all identifiable grammatical, spelling and stylistic issues. Additionally, if the manuscript is accepted for publication, I plan to engage the journal’s Author Services to conduct a final professional language review to ensure the highest editorial quality.

Comments 3: Is there room to further explore the impact of telemedicine and digital health technologies on healthcare equity, particularly in rural Romania?

Response 3: Thank you for this insightful and timely suggestion. Indeed, the impact of telemedicine and digital health technologies on healthcare equity in rural Romania is both crucial and underexplored. To address this, I have expanded the discussion in Section 4 (Discussion), where I now provide a more detailed exploration of how telemedicine platforms, mobile health applications, and AI-enabled diagnostics can bridge healthcare access gaps in underserved rural communities. This addition strengthens the study’s relevance and highlights an important area for future policy development and research.

Comments 4: The authors should highlight evaluating the economic feasibility (cost-benefit or ROI) of proposed green technologies in Romanian healthcare settings.
Response 4: Thank you for emphasizing this important dimension. I have expanded Table 3 (page 17) and its accompanying narrative to explicitly highlight the economic feasibility and return on investment (ROI) associated with adopting green technologies, such as solar energy, geothermal systems, and waste-to-energy solutions, in Romanian healthcare settings. This enhancement provides a clearer picture of the financial and environmental trade-offs, reinforcing the practical applicability of the recommendations.

Comments 5: Could the study provide a more detailed policy framework or roadmap for how Romania can implement the successful practices observed in Japan, the EU, and the USA?

Response 5: Thank you for this valuable suggestion. While the current manuscript provides high-level recommendations, I fully recognize the need for a detailed, structured policy roadmap. I would like to note that this topic is part of a forthcoming research project I am currently developing, which will specifically focus on creating a detailed implementation framework tailored to Romania, drawing from the successful practices observed in Japan, the EU and the USA. I look forward to sharing these findings in a future dedicated publication.

Comments 6: Is there potential to include stakeholder perspectives (e.g., healthcare managers, policymakers, patients) to enhance the practical relevance of the recommendations?

Response 6: Thank you for this excellent recommendation. At present, the manuscript is primarily based on systematic review and statistical analysis, and unfortunately, due to the current political and institutional context in Romania (including upcoming elections and governmental instability), it was not feasible to include stakeholder perspectives such as healthcare managers, policymakers, or patient representatives. However, I fully agree that incorporating these voices would significantly enhance the practical relevance and impact of the study. I am planning to conduct surveys and semi-structured interviews with these stakeholder groups as part of a future research phase, which will complement the current findings and help co-design context-sensitive sustainability strategies for the Romanian healthcare sector.

Final Remarks

I sincerely appreciate the reviewer’s detailed, constructive feedback, which has played a critical role in improving the depth, clarity, and scientific contribution of this manuscript. I trust that the revisions made align the study more closely with the journal’s standards and enhance its value to the broader discourse on healthcare sustainability. Should you have any further comments or require additional clarifications, I remain fully available to address them.

Response to Reviewer

1. Summary

Thank you very much for taking the time to review this manuscript again also thank you for your valuable inputs in the article. Please find the detailed responses below and the corresponding revisions/corrections in the re-submitted file.

I am grateful for the reviewers' thoughtful feedback, which has significantly improved the manuscript. The revisions address all points raised and enhance the depth, relevance, and applicability of the study. I believe these changes align the manuscript more closely with the journal’s standards and contribute meaningfully to the field of healthcare sustainability.

All the changes done are pointed in blue color.

2. Point-by-point response to Comments and Suggestions for Authors

Comments 1: The background section should include key theories such as the triple bottom line (TBL), health system resilience, and systemic sustainability models to strengthen the conceptual foundation.

Response 1: We appreciate the reviewer’s suggestion to enhance the theoretical grounding of the manuscript. The following changes have been implemented:

·       I have incorporated the TBL framework (economic, social, and environmental dimensions) as the foundational lens for evaluating sustainability in healthcare. This will be referenced in the introduction and background sections, with specific examples of how it applies to Romania’s private medical sector.

·       I included a discussion on resilience to contextualize the challenges faced by Romania in terms of governance inefficiencies, financing gaps, and inequities in access.

Comments 2:
Incorporating recent empirical studies and reports, especially those highlighting global or regional best practices, will help situate the current research within broader scholarly discourse.

Response 2: We agree with the reviewer’s suggestion and I have included the following:

• Global Best Practices:
• Examples such as Germany’s Green Hospital Program and Sweden’s renewable energy adoption have been discussed in detail.
• I have referenced studies such as Karliner et al. (2020) and German Health Alliance (2023) to showcase the financial and environmental benefits of green initiatives.
  
  
• Regional Comparisons:
• Findings from other Eastern European countries (e.g., Poland) have been highlighted to show how similar challenges have been addressed.
• Studies such as Nowak and Sokolov (2022) were included to contextualize Romania’s position within Eastern Europe.

These additions will demonstrate how the current study advances or fills gaps identified in prior research.

Comments 3:
The background should prioritize the most pertinent references and avoid overly detailed summaries of past studies.

Response 3: I have streamlined the background section as follows:

• Focus on key references that clarify the theoretical underpinnings and global best practices.
• Summarize past studies briefly, emphasizing their relevance to the current research.

Comments 4:
" Ensure that every key point in the conclusion is directly supported by specific data, results, or analyses presented earlier in the manuscript.

Response 4:

I have revised the conclusion to explicitly link each point to the data and findings presented in the results section. Examples include:
Technological Innovations:
Revised text:
“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:
Revised text:
“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.”

Environmental Sustainability:
Revised text:
“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 €500,000 annual energy cost savings, highlight opportunities for improvement.”

Comments 5:
Citing relevant peer-reviewed studies or reports that align with or support the research results can reinforce the credibility of the conclusions.

Response 5:
I have integrated additional corroborative references throughout the manuscript. Examples include:

• Environmental Sustainability:
  Reference studies by Al-Farsi and Tanaka (2020) on waste-to-energy systems to support the feasibility of similar initiatives in Romania.
• Social Equity:
  Reference Marmot (2020) to contextualize inequities in privatized healthcare systems.
• Economic Sustainability:
  Reference OECD (2020) on the importance of public-private partnerships in achieving financial sustainability.

These references will demonstrate thorough engagement with existing knowledge and reinforce the study’s findings.

Comments 6:
Include visual aids such as scatterplots and bar charts to enhance data presentation.

Response 6: I have created the following visualizations to enhance clarity:

1. Scatterplot: Showing CHE as % of GDP vs. CHI as % of CHE for Romania, Germany, Sweden, USA, and Japan.
• This visualization illustrates the correlation between healthcare spending and financing mechanisms across countries.
2. Bar Chart: Comparing green building compliance rates across the same countries.
• This highlights Romania’s lagging position in environmental sustainability.

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Comments 7:
Clarify how the current work advances or fills gaps identified in prior research

Response 7:
I have explicitly stated the contributions of the study in the introduction and conclusion:

• Introduction:
  “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.”
• Conclusion:
  “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.”

Final Remarks

Once again, I express my sincere gratitude for your detailed and constructive feedback. Your insightful comments have played a crucial role in improving the overall quality and scientific robustness of the manuscript. I am confident that this revised version now meets the journal’s expectations and contributes meaningfully to the academic discourse on healthcare sustainability. Please do not hesitate to share any further comments or suggestions, as I remain committed to refining the manuscript to the highest standards.

Dear Reviewer,

Once again, I express my sincere gratitude for your detailed and constructive feedback. Your insightful comments have played a crucial role in improving the overall quality and scientific robustness of the manuscript. I am confident that this revised version now meets the journal’s expectations and contributes meaningfully to the academic discourse on healthcare sustainability. 

Best regards,

Emanuel Mesteru