Green-Certified Healthcare Facilities from a Global Perspective: Advanced and Developing Countries

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

1. The reference list contains several dated sources (before 2015). Please incorporate recent publications (2021–2025) that discuss low-carbon hospital design, resilient healthcare infrastructure, and carbon management in medical facilities, particularly those aligned with ISO 14067 and PAS 2080 standards.
2. It is recommended that the authors acknowledge and analyze existing sustainability rating systems that already include dedicated healthcare modules, such as LEED for Healthcare (U.S.), BREEAM Healthcare (U.K.), CASBEE for Hospital (Japan), Green Star Healthcare (Australia), DGNB Hospitals (Germany), and GBI Hospital (Malaysia). Discussing how these frameworks integrate medical operational requirements would add depth and contextual relevance to the comparative analysis.
3. The English writing is overall fluent, but could be further polished for conciseness and consistency, Such as “green healthcare facility system” and “green hospital certification” are recommended to be standardized.

Author Response

RESPONSE TO REVIEWER

 

Green-Certified Healthcare Facilities from a Global

Perspective: Advanced and Developing Countries

Preprints ID: preprints-181488

 “We would like to express our gratitude to the editorial team and reviewers for their insightful comments and efforts in improving our work. We believe that the revisions have addressed all concerns and enhanced the overall quality of the paper. We kindly await your final evaluation and decision.”

 

REVIEWER 1:

Comment 1:

The reference list contains several dated sources (before 2015). Please incorporate recent publications (2021–2025) that discuss low-carbon hospital design, resilient healthcare infrastructure, and carbon management in medical facilities, particularly those aligned with ISO 14067 and PAS 2080 standards.

Response 1:

Thank you for this valuable comment. Upon reviewing the reference list, we found that six sources were published before 2015. References 58, 68, 70, and 71 have been replaced with recent publications addressing topics such as low-carbon hospital design, resilient healthcare infrastructure, and carbon management in medical facilities. References 58, 68, and 71 have been enriched with more up-to-date sources on CASBEE and GREENSHIP certification systems. For reference 70, as suggested by the reviewer, an additional citation was included to ensure stronger thematic alignment (Lines 463-469 of the revised manuscript).

“Furthermore, these certification systems have recently become more coordinated for healthcare facilities, prioritizing low-carbon hospital design, providing robust healthcare infrastructure, and integrating carbon management approaches in medical facilities in line with ISO 14067 and PAS 2080 standards [70].”

Although references 41 and 72 were published before 2015, they remain relevant and were therefore retained in their current form.

 

 

 

Comment 2:

It is recommended that the authors acknowledge and analyze existing sustainability rating systems that already include dedicated healthcare modules, such as LEED for Healthcare (U.S.), BREEAM Healthcare (U.K.), CASBEE for Hospital (Japan), Green Star Healthcare (Australia), DGNB Hospitals (Germany), and GBI Hospital (Malaysia). Discussing how these frameworks integrate medical operational requirements would add depth and contextual relevance to the comparative analysis.

Response2:

We appreciate the reviewer’s valuable suggestion. In the revised manuscript, we have expanded the discussion in Section 4 to include a comparative evaluation of certification systems that feature dedicated healthcare modules, such as LEED for Healthcare, BREEAM Healthcare, CASBEE for Hospital, Green Star Healthcare, YeS-TR, IGBC, GREENSHIP, and GBI Hospital. The two new paragraphs highlight how these certification systems integrate medical operational requirements such as infection control, patient flow optimization, resilience, hygiene, and waste management into their sustainability assessment criteria. This addition provides greater contextual relevance and depth to the comparative analysis, aligning with the reviewer’s recommendation (Lines 431-441 of the revised manuscript).

“Beyond sustainable performance, these certification systems also incorporate operational elements specific to healthcare services. For example, LEED for Healthcare guarantees 24/7 operation thanks to advanced ventilation and contamination control, while BREEAM Healthcare emphasizes infection prevention and patient flow. Green Star Healthcare promotes staff well-being and productivity, while CASBEE Hospital prioritizes resilience and emergency preparedness.

YeS-TR, IGBC, GREENSHIP, and GBI adapt sustainability to local contexts through energy management, hygiene, and waste reduction. The inclusion of medical operational criteria in all the aforementioned certification systems increases the contextual relevance of comparative analysis and demonstrates how sustainability intersects with healthcare performance.”

Comment 3:

The English writing is overall fluent, but could be further polished for conciseness and consistency, such as “green healthcare facility system” and “green hospital certification” are recommended to be standardized.

Response 3:

Although careful attention was paid to this issue during the writing process, a few instances were unfortunately overlooked. We appreciate the reviewer’s observation. To ensure consistency of meaning, the term “green healthcare facility system” has been adopted throughout the manuscript.

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

Reviewer comments

The manuscript (Green-Certified Healthcare Facilities from a Global Perspective: Advanced and Developing Countries) compares certification systems for green healthcare facilities implemented worldwide and investigates how healthcare facilities are complex structures designed to provide uninterrupted service while involving substantial resources, high energy consumption, and heavy human and material traffic. The research is fascinating, but it needs these improvements before being considered as an article.

 

1. The Introduction (L35-L157) does not specify why this research is necessary? Who will benefit from this research. Who are the stakeholders whose practice will be enhanced once this article is published?
2. The Introduction (L35-L157) fails to specify an outline statement providing a clear overview to the reader on how the article is structured.
3. In the Materials and Method section (L158-L197), which provides various green building certification systems, the authors must specify the reasons behind their selection in this section rather than the next one.
4. Section 4 presents an innovative analysis of various themes and areas that are related to the green building certification systems aligned with healthcare; however, the authors must provide more thematic insight and enhance Section 4.8 further to give the readers an evidence-based reflection on why and how some certifications focus on some factors and not others.
5. The authors have failed to present a Discussion section, which must (1) summarise research results; (2) compare research findings with academic literature; and (3) present research limitations.
6. The Conclusions (L823-L923) must specify in more detail the implications this research has for policy and industry.
7. Lastly, before completing the Conclusions (L823-L923) the authors must highlight and specify how this research can be taken forward and present ideas of future research.

Comments for author File: Comments.pdf

Author Response

Green-Certified Healthcare Facilities from a Global

Perspective: Advanced and Developing Countries

Preprints ID: preprints-181488

 “We would like to express our gratitude to the editorial team and reviewers for their insightful comments and efforts in improving our work. We believe that the revisions have addressed all concerns and enhanced the overall quality of the paper. We kindly await your final evaluation and decision.”

 

REVIEWER 2:

Comment 1:

The Introduction (L35-L157) does not specify why this research is necessary? Who will benefit from this research. Who are the stakeholders whose practice will be enhanced once this article is published?

Response 1:

We agree that the “Introduction” section did not clearly state the necessity for the research, the stakeholders who would benefit from the study, and the actors who would develop applications after the paper is published. Accordingly, the relevant section has been revised to elaborate on the rationale of the research, the target audience, and the areas of application. These clarifications have been updated in the paragraph below (Lines 159-172 of the revised manuscript).

“Although numerous certification systems specific to green healthcare facilities have been developed worldwide, research that comparatively and holistically addresses how these systems respond to the sustainability requirements of healthcare facilities in different socio-economic contexts remains limited. This study aims to fill this gap by comprehensively investigating the strengths and weaknesses of green healthcare facility certifications and contributing to the development of these systems. The findings of the research are expected to provide evidence-based guidance for policymakers, architects, engineers, hospital administrators, and researchers working in the field of sustainability on improving environmental performance, operational efficiency, and human well-being. Furthermore, this study will guide stakeholders such as certification bodies, national green building councils, and health and environment ministries in developing assessment criteria and implementation strategies sensitive to local conditions, thereby contributing to the widespread adoption of sustainable healthcare buildings at both the national and international levels.”

Comment 2:

The Introduction (L35-L157) fails to specify an outline statement providing a clear overview to the reader on how the article is structured.

Response 2:

Thank you for the comment about the lack of an outline statement that clearly presents the structure of the paper to the reader. A paragraph has been added at the end of the Introduction section to summarize the organization and content flow of the article (Lines 173-178 of the revised manuscript).

“The remainder of this paper is structured as follows: Section 2 presents the materials and methods used in the study. Section 3 provides detailed information about eight green certification systems applied to healthcare facilities. Section 4 discusses the comparative analysis of these certification systems, highlighting their similarities and differences. Finally, Section 5 concludes the paper by summarizing the key findings and providing recommendations for future research.”

 

Comment 3:

In the Materials and Method section (L158-L197), which provides various green building certification systems, the authors must specify the reasons behind their selection in this section rather than the next one.

Response 3:

We agree. The suggestion regarding the need to explain the rationale behind the selection of the certification systems within the “Materials and Method” section has been carefully addressed. Accordingly, the paragraph describing the eight certification systems has been revised to include a clear justification for their selection. Specifically, a detailed explanation has been added, stating that these systems were chosen based on three main criteria: (1) the inclusion of healthcare-specific assessment tools or adaptations within their national green building frameworks, (2) their representativeness of both developed and developing country contexts that allow cross-regional comparison, and (3) the availability of comprehensive documentation and accessible data to ensure methodological consistency. In addition, geographical and cultural diversity was considered to ensure global representativeness (Lines 188-203 of the revised manuscript).

“2.      Four certification systems that are in use in advanced countries (LEED in the U.S., BREEAM in the U.K., Green Star in Australia, and CASBEE in Japan) and four certification systems that are in use in developing countries (YeS-TR in Türkiye, IGBC in India, GBI in Malaysia, and GREENSHIP in Indonesia) were selected for use in this study. These eight certification systems were chosen based on three criteria: (1) their inclusion of healthcare-specific assessment tools or adaptations within their national green building frameworks, (2) their representativeness of both developed and developing country contexts, allowing cross-regional comparison, and (3) the availability of comprehensive documentation and publicly accessible data to ensure methodological consistency. In addition, geographic and cultural diversity was considered to include examples from different continents, providing a balanced global perspective on sustainability practices in healthcare facility certification. Quantitative and qualitative data were collected about these eight certification systems from their official guidelines and relevant scientific publications. This selection approach provides an analytical basis for understanding how regional differences shape the models and strategies applicable to sustainable healthcare development.”

Comment 4:

Section 4 presents an innovative analysis of various themes and areas that are related to the green building certification systems aligned with healthcare; however, the authors must provide more thematic insight and enhance Section 4.8 further to give the readers an evidence-based reflection on why and how some certifications focus on some factors and not others.

Response 4:

We thank the reviewer for this constructive comment. In line with the suggestion, the manuscript has been revised to provide deeper thematic insight explaining why and how certain certification systems emphasize specific sustainability factors. A new subsection titled “4.9. Discussion” has been added, and this enhancement has been integrated with Comment 5- Response 5, which further elaborates on the contextual and evidence-based interpretation of the findings. The new paragraph clarifies that thematic differences among certification systems arise from regional socioeconomic conditions, environmental challenges, and policy frameworks shaping sustainability priorities (Lines 857-869 of the revised manuscript).

“These thematic differences can be explained by the contextual priorities and environmental challenges of each region. For example, certifications such as LEED, BREEAM, and Green Star emphasize energy performance, carbon reduction, and innovation, reflecting strong climate policies and advanced technological infrastructures characteristic of developed economies. In contrast, systems like IGBC, GREENSHIP, and YeS-TR place greater importance on water efficiency, local materials, and waste management due to resource constraints and rapid urbanization challenges common in developing countries. CASBEE, on the other hand, stands out for its focus on resilience, durability, and disaster preparedness, consistent with Japan's high exposure to earthquakes and climate risks. Altogether, these findings emphasize that the thematic focus of certification systems is not arbitrary but rather a reflection of the socioeconomic conditions, environmental pressures, and policy frameworks that shape sustainability priorities in each region.”

Comment 5:

The authors have failed to present a Discussion section, which must (1) summarise research results; (2) compare research findings with academic literature; and (3) present research limitations.

Response 5:

We apologize for this oversight. The “Results and Discussion” section was indeed predominantly results-oriented and lacking a thorough discussion. A new subsection titled “Discussion” has been added at the end of Section 4. In following are included in this subsection: (1) the key findings are summarized, (2) the results are compared with the results of previous studies such as those published by Kouka et al. [30], Yoon and Lim [31], and Li et al. [35], and (3) the study’s limitations are discussed in terms of scope and data sources, and recommendations are made for future research (Lines 828-856 and 870-882 of the revised manuscript).

“4.9. Discussion

Eight different green certification systems used in developed and developing countries were comparatively analyzed across seven main categories. The results indicate that these systems focus on similar sustainability dimensions of energy, water, waste management, indoor environmental quality, transportation, material selection, and project management, but do not fully address the specific needs of healthcare facilities. In particular, critical aspects of healthcare systems such as hygiene, infection control, medical waste management, and patient–staff safety are not sufficiently emphasized within the current certification frameworks. This finding suggests that healthcare facilities require a more specialized assessment system that integrates operational and social sustainability dimensions alongside environmental sustainability.

The findings of this study are generally consistent with previous comparative research on green building certification systems. Kouka et al. [30] emphasized that there are significant differences among certification systems in different countries, and that these differences are strongly shaped by local and socio-economic conditions that structure sustainability priorities. The present study supports these observations. It also shows that most healthcare-related certifications resemble adaptations of general-purpose green building frameworks rather than systems specifically designed for healthcare facilities. Similarly, Yoon and Lim [31] highlighted that healthcare certification systems should be developed based on regional geographic and cultural contexts and should prioritize patient safety and well-being. This aligns with the current study’s finding that indoor environmental quality and user-oriented criteria have not yet evolved into critically informed categories in most systems. Furthermore, the results support the arguments of Li et al. [35], who emphasize the need for comprehensive content analyses to improve the functionality and contextual applicability of existing green certification systems. Beyond confirming previous research, this study extends the literature by revealing a clear pattern: certification systems in advanced countries tend to prioritize carbon reduction and energy performance, whereas those in developing countries focus more on water efficiency and local resource management.

The findings of this study should be interpreted within certain limitations. First, the analysis is limited to eight certification systems; therefore, it may not fully reflect the diversity of regional applications. Second, since the research is based on the review of documents and guidelines, empirical performance data from certified green healthcare facilities (e.g., energy consumption, resource efficiency, and user satisfaction) were not included in the evaluation. This limitation restricts the ability to test the real-world impacts of the criteria. In addition, differences in the scoring methodologies of certification systems (for example, CASBEE’s BEE-based approach versus BREEAM’s percentage-based evaluation) partially hamper comparability. Future studies are recommended to develop hybrid models that incorporate real performance data, expand the scope to cover different climate zones and healthcare facility types, and strengthen interdisciplinary collaboration among architects, engineers, healthcare professionals, and policymakers.”

Comment 6:

The Conclusions (L823-L923) must specify in more detail the implications this research has for policy and industry.

Response 6:

As per the reviewer’s suggestion, the “Conclusions” section has been revised to present more clearly the potential implications of the research for policymakers and industry stakeholders. The newly added paragraph explains how the findings can contribute to the development of national standards in the field of sustainable healthcare facilities, the improvement of strategies of green building certification organizations, and the acceleration of green transformation within the construction industry (Lines 915-923 of the revised manuscript).

“The findings of this study serve as direct guidance for policy development and industry practices. Policymakers can use these results to formulate more comprehensive and context-specific sustainability regulations for healthcare infrastructure, thereby achieving stronger alignment with regional health and climate goals. For the construction and design industry, the findings provide a framework for integrating certification principles into the design, project management, and operational phases, fostering collaboration among green building councils, healthcare institutions, and developers. In this regard, the study supports the creation of resilient and low-carbon healthcare facilities that can serve as exemplary models for future policy and industry transformation.”

 

Comment 7:

Lastly, before completing the Conclusions (L823-L923) the authors must highlight and specify how this research can be taken forward and present ideas of future research.

Response 7:

In line with the reviewer’s constructive feedback, an explanatory paragraph has been added to the end of the “Conclusions” section to highlight how this research can be further advanced and which research areas should be prioritized in the future. This paragraph emphasizes the importance of interdisciplinary approaches, the integration of quantitative performance data, and the implementation of long-term monitoring studies (Lines 994-1003 of the revised manuscript).

“In future research, this study can be further advanced by utilizing real performance data obtained from certified green healthcare facilities to evaluate the measurable impacts of relevant sustainability criteria on energy consumption, resource efficiency, and user well-being. Expanding comparative analyses to include a greater number of certification systems and regional contexts will enhance the generalizability of the findings. Furthermore, developing hybrid models that integrate environmental, medical, and digital indicators could further strengthen the accuracy and reliability of sustainability assessments. Collaborative research among architects, engineers, healthcare professionals, and policymakers will be crucial for shaping the next generation of adaptive and evidence-based green healthcare certification systems.”

Author Response File: Author Response.docx