Sustainability Analytics and Modeling 1 (2021) 100001

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Sustainability Analytics and Modeling

journal homepage: www.elsevier.com/locate/samod

Measures of Sustainability in Healthcare

Rama Mehra∗, Milind Kumar Sharma
Department of Production & Industrial Engineering, M.B.M. Engineering College, Faculty of Engineering & Architecture, Jai Narain Vyas University, Jodhpur, Rajasthan,
India

a r t i c l e i n f o a b s t r a c t

Key Words: Under the context of the 2030 agenda of the United Nations, sustainability of firms has attracted growing at-
Healthcare tention. Sustainability and healthcare are intricately related since the quality of our environment affects pub-
Sustainability measures lic health. Based on the acknowledged sustainability practices in healthcare, a compendious theoretical model
Integrated analytic hierarchy process -
for sustainability in healthcare has been developed, grounded in appropriate theories. The model encompasses
interpretive structural modelling
twenty-seven sustainability practices under its triple bottom line (TBL), which have been subsequently reorga-
Sustainable healthcare
nized and arranged for analysis into twelve sustainability measures on recommendation from a set of experts.
This study investigates the measures of sustainability in Indian healthcare based on an integrated methodology of
Analytic Hierarchy Process (AHP) and Interpretive Structural Modelling (ISM). Expert elicitation was employed
for establishing the importance, as well as the interrelationships among, the measures. Consequently, a strategic
theoretical framework for sustainable healthcare is proposed on the basis of the findings of the ISM method and
Matrice d’Impacts Croises Multiplication Appliquee a un Classement (MICMAC) analysis. This work has studied the
key measures that emerged for policy, practice, and research. The results suggest that research & innovations and
indigenous production are significant drivers of sustainable healthcare. In addition, the mediating measures viz.
circular practices, waste reduction and management, integrated facilities design, sustainable procurement, em-
ployee satisfaction, and green growth may offer guidance and provide a strong direction to healthcare managers
and practitioners in achieving their sustainability goals.

1. Introduction
The year 2021 marked the sixth anniversary of the adoption of the
United Nation’s (UN’s) Sustainable Development Goals (SDGs) by the
global community. It also heralds our stepping into the final decade
of action wherein our collective efforts and collaborative partnerships
will determine the extent of our success in translating the 2030 Agenda
(United Nations General Assembly, 2015) into a national and global re-
ality. The SDG framework has redefined development policies, govern-
ment priorities, responsibilities of businesses and citizens, and metrics
for measuring development progress across the world. Sustainability has
essentially three components – environment conservation, social respon-
sibility, and economic development. Current patterns of economic and
social development are putting pressures upon natural resources, and
may threaten the continued health and prosperity of human societies
(Fiksel et al., 2012). The healthcare industry’s involvement in damaging
and degrading the natural environment has become increasingly clear
in recent years (Hensher and McGain, 2020). A 2019 estimate places
healthcare’s global carbon footprint at 4.4 percent of the world’s to-
tal greenhouse gas emissions, whereas health expenditure accounts for
some 10 percent of global economic output (Karliner et al., 2020). Sus-
tainability and healthcare are intricately related in view of the fact that
the quality of our environment affects public health. The international
business community has recognized the practical and economic conse-
quences of the sustainability challenge (WBCSD, 2011). Therefore, In-
dian businesses have also begun to adopt the Triple Bottom Line (TBL)
(Elkington, 1994) anticipating environmental, social, and economic tar-
gets in attaining pre-defined corporate objectives. Healthcare, a key
driver for economic growth, is one of India’s largest sectors in terms
of both revenue and employment. The Indian healthcare industry’s size
is estimated to have reached US$ 193.83 billion in 2020 and to reach
US$ 372 billion by 2022 (India Brand Equity Foundation report 2021).
The use of sustainability measures / indicators is essential for an in-
tegrated systems approach to address the challenges of sustainability in
healthcare. When carefully chosen and implemented, measures of sus-
tainability can help managers and policy makers to formulate strategies,
establish improvement goals, and track progress, as well as benchmark
against other systems. Interest is, therefore, growing in how healthcare
systems might better measure their sustainability performance. Consid-
ering the old adage, ‘what gets measured gets managed,’ measuring In-

∗
Corresponding author.
E-mail address: ramamehra8@gmail.com (R. Mehra).

https://doi.org/10.1016/j.samod.2021.100001
Received 16 January 2021; Received in revised form 10 November 2021; Accepted 10 November 2021
2667-2596/© 2021 The Authors. Published by Elsevier Ltd on behalf of The International Federation of Operational Research Societies (IFORS). This is an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)
R. Mehra and M.K. Sharma
dia’s performance for SDG-3 that states ‘Ensure healthy lives and pro-
mote well-being for all at all ages,’ on the SDG India Index and Dash-
board, the overall index score for the country is 61 on a scale of 0–100
(NITI Aayog’s VNR 2020). Therefore, it is time for the healthcare ecosys-
tem to be re-engineered with systemic and structural changes, keeping
ground realities in mind, through innovative and sustainable models of
care delivery as well as business processes. It means that progress to-
wards sustainability practices in healthcare needs to be strengthened
further. Besides environment conservation, leading healthcare practices
with elements of sustainability is important for efficient resource man-
agement, cost-effectiveness, and continuous improvement of healthcare
services (Marimuthu et al., 2016). However, for the transformation of
traditional healthcare to sustainable healthcare, investigation of inter-
actions among measures of sustainability can be used to identify the hi-
erarchy of actions to be taken. Concurrently, for efficient policy making
in healthcare, it is essential to determine the leading measures of sus-
tainability. Consequently, the following research questions have been
explored:
RQ.1. What are the various practices for sustainable healthcare?
RQ.2. What are the imperative measures of sustainable healthcare
and how do they interact?
RQ.3. How is sustainable healthcare attained?
This study intends to fill research gaps and challenges identified in
the extant literature on sustainability in healthcare reported later in the
paper. It appraises a conceptual model for sustainability in healthcare
that reflects the extent of sustainability practices in healthcare. It further
attempts to reveal significant measures for healthcare sustainability. Fi-
nally, it contributes to the existing literature by presenting a strategic
theoretical framework for sustainable healthcare.
1.1. Sustainability in healthcare: Environmental, social, and economic
Sustainability in healthcare is a multi-disciplinary subject having its
presence in the areas of medical science, operations management, and
sustainability itself. A systematic literature search was conducted fol-
lowing systematic literature review (SLR) guidelines found in opera-
tions management (Thome et al., 2016) and in healthcare [Preferred
Reporting Items for Systematic reviews and Meta-Analysis (PRISMA)
(Moher et al., 2009)]. Citation database Google Scholar and several aca-
demic databases viz. Elsevier, Taylor & Francis, Emerald, Springer, Re-
searchGate, Inderscience, MDPI, John-Wiley, MEDLINE, and Harvard
Business Review (HBR) were searched for relevant studies. The websites
of the World Health Organization (WHO) and United Nations (UN) were
searched for relevant articles. Keywords ’sustainability’ and ’health’ or
’healthcare’ or ’hospital’ or ’health services’ were used to search for ar-
ticles with no limitation on publication dates. Initially, the search was
performed up to the first week of May 2020 but later the review was
updated till October 2020. Subsequently, the ’Snowball’ technique was
employed on selected articles to locate additional articles, if any, that
could have elicited the original keyword search. Finally, after applying
exclusion and inclusion criteria and removing duplicates, the articles
published in peer-reviewed journals were selected for review. Addi-
tionally, in order to account for publication bias, proceedings of the
conferences of repute in the field and articles from trade and industry
magazines were included.
Since the release of the Brundtland report (WCED, 1987), the con-
cept of sustainable development has been increasingly applied in the
context of corporations, giving rise to corporate sustainability. Interna-
tional Institution of Sustainable Development (IISD) defines corporate
sustainability as “adopting business strategies and activities that meet
the needs of the enterprise and its stakeholders today while protecting,
sustaining, and enhancing the human and natural resources that will
be needed in the future” (IISD, 2002). This definition emphasizes the
importance of meeting the needs of social and non-social stakeholders
and balancing the economic, environmental, and social dimensions of
corporate performance.
2
Sustainability Analytics and Modeling 1 (2021) 100001
The establishment of more environmentally preferable healthcare
has gained momentum in industry. However, the healthcare industry
practices environmental sustainability (Marimuthu et al., 2016), mak-
ing it greener than many other industries. This focus has led to the
adoption of circular practices, integrated design of healthcare facilities,
reduction and efficient management of medical waste, and sustainable
procurement. Specifically, in healthcare, circular practices comprise re-
cycling, repair, re-use, remanufacturing, and refurbishment of medical
products (Jameton et al., 2002; Vogt et al., 2014); efficient usage of re-
sources; using electric vehicles for transport thereby reducing carbon
emissions attributed to this sector (Mackenzie, 2011); and conservation
of natural resources, such as water conservation (McGain et al., 2014;
Marimuthu et al., 2016). Hence, it has led to the extension of product
life (Ertz et al., 2019), treating products as services (Giusti et al., 2020;
Marimuthu et al., 2016), sharing of products (Elabed et al., 2019), and
prevention of waste including designing out waste in products.
The physical environment in which medical care is provided also
has an impact on health and well-being, and therefore, integrated
facilities design or green design (Bilec et al., 2010; Shepley, 2010;
Pinzone et al., 2012) systematically applies lean principles and con-
currently integrates the expertise of all stakeholders to achieve break-
through improvements when compared with traditional design. Green
design advocates for clean energy, for example, solar, wind, biomass,
tidal and efficient usage of energy (Franco et al., 2017). Moreover,
guidance on reducing and eliminating negative environmental impacts
from healthcare facilities is available in the form of evidence-based de-
sign aspects, LEED Healthcare, the Green Guide for Healthcare, etc.
(Stevanovic et al., 2017; Buffoli et al., 2015).
Reduction of medical waste and its efficient management
(Campion et al., 2015; Chauhan et al., 2017; Leite et al., 2019;
Singh, 2019; Lindsay et al., 2019) controls pollution through
reduction or prevention of healthcare emissions to air, land,
and water (Saad, 2003; Sherman et al., 2012; Thiel et al. 2014;
Eckelman et al., 2016 & 2018). Efficient waste management ensures
proper hygiene and safety of healthcare workers and communities.
Reducing waste in operations also helps to save operating costs. Envi-
ronmental efficiency often translates into economic efficiency to create
value for stakeholders (Messelbeck et al., 1999).
Finally, the potential contribution of sustainable procurement to
environmental sustainability is evident, considering the size and im-
pact of the healthcare sector in terms of its percentage share of the
gross domestic product (GDP) of a country (Gelderman et al., 2017;
Chiarini et al., 2017). Hence, green procurement initiatives focused
on procurement criteria help reduce specific environmental risks us-
ing existing tools such as product labeling (for example, ISO 14,001
series), energy efficiency of devices (for example, energy star rating),
chemical safety, and procurement scorecards. Through these actions,
environmental footprints of the healthcare industry can be minimized
(Messelbeck et al., 1999; Ossebaard et al., 2020).
Social sustainability, in the context of healthcare, relates to the
ability of a healthcare system to enhance quality of life and im-
prove well-being of a community. Occupational sustainability in health-
care services involves meeting the demands of changing healthcare
operations without compromising the health and wellbeing of the
healthcare workers (Balka et al., 2006). Several researchers have
contributed to the exploration of indicators of social sustainability
viz.:patient satisfaction (Faezipour et al., 2011; Marimuthu et al.,
2016; Aljaberi et al., 2017) embracing safety, security, and comfort
of patients (Jameton et al., 2002; Turcu et al., 2013; Celdran et al.,
2018), quality of services (Lifvergren et al., 2009; Turcu et al., 2013;
Celdran et al., 2018; Al Hammadi et al., 2018) and trust in the ser-
vices (Smith et al., 2015); employee satisfaction (Pinzone et al., 2019;
Aljaberi et al., 2017; Balka et al., 2006) covering workforce educa-
tion, training (Pinzone et al., 2019) and employment; accessibility
(Palozzi et al., 2020; Turcu et al., 2013; Celdran et al., 2018), avail-
ability (24 × 7), and affordability of services (Jameton et al., 2002;
R. Mehra and M.K. Sharma
Shaw, 2017; Turcu et al., 2013; Celdran et al., 2018); and sustainable
health (Yang et al., 2010).
Researchers have addressed the many social indicators through
numerous techniques, strategies, and practices through: collaborative
healthcare information exchange programmes (Maghsoudi et al., 2020;
Rajapakshe et al., 2020; Tsasis et al., 2019; Vest et al., 2013) for im-
proving the cost and quality of healthcare; home-based telemedicine,
home-based surgery, advanced healthcare technologies such as mini-
mal to non-invasive surgeries with online monitoring and alarm sys-
tems (Ferrando et al., 2017) using internet of things (IOT) technolo-
gies (Presti et al., 2019; Turcu et al., 2013; Celdran et al., 2018)
that addresses the issues of healthcare access, affordability, qual-
ity, and patient satisfaction and signals a progress towards Health-
care 4.0; personalized medications using 3D-printing technology for a
smarter and more sustainable healthcare (Aquino et al., 2018); funding
premium-priced medicines (Godman et al., 2014; Godman et al., 2016)
for universal access; vaccination accounting for sustainable health
(Largeron et al., 2015); sustainable medical education as a sustainabil-
ity implementation strategy (Teherani et al., 2017; Walpole et al., 2019;
Tun, 2019); appropriate workforce development (Ramadevi et al., 2016;
Ahmed et al., 2017; Srinivasan et al., 2014); ‘green’ human resource
management practices (Pinzone et al., 2016; Pinzone et al., 2019);
medical tourism accounting for cross-border access to healthcare
(Jadhav et al., 2014) along with fostering a culture of sustainabil-
ity (Ramirez et al., 2013;Galpin et al., 2015) in healthcare organi-
zations as an implementation strategy, that can help achieve social
sustainability.
Economic sustainability refers to practices that support long-term
economic growth without compromising other dimensions of sustain-
ability. The economic aspect covers strategies that promote cost savings,
profits, research, and development. Under this dimension of sustainabil-
ity, most researchers have concentrated on the financial self-sufficiency
of publicly funded healthcare systems (Olsen, 1998; Birch et al., 2014;
Hearld et al., 2018; Giusti et al., 2020) and have observed that it is a
challenge to policy-makers in many countries. Although economic sus-
tainability is a direct and indirect outcome of many environmental and
social efforts (Erdil et al., 2018), such as energy conservation, recy-
cling, purchasing, providing job opportunities, supporting educational
institutions, attempts to promote it have been suggested. Promotion
has been through limiting the range of services offered or the groups
of population covered (Birch et al., 2014), and introduction of man-
aged equipment service particularly for diagnostic imaging technologies
(Giusti et al., 2020).
Outsourcing non-medical processes to third party suppliers
(Parmar, 2015) and the emerging model of private & public part-
nerships (PPP) have been recommended as a possible solution
(Giusti et al., 2020) for earnings and growth in the industry. Green
hospitals, adopting environment-friendly products, practices, and
construction, have become strategic and critical to the healthcare
industry. With 24/7 operations, they remain among the biggest energy-
users and waste generators (Zhu et al., 2018). Savings in operational
costs of healthcare is also a pressing goal (Lifvergren et al., 2009;
Jadhav et al., 2014; Faezipour et al. 2011; Saghazadeh et al., 2016;
Marimuthu et al., 2016). According to an All India Management Associ-
ation (AIMA) conference note, innovations could be a way forward for
large number of people to get quality care at a cost that the nation can
afford. Innovation is increasingly being seen as the currency of the 21st
century because it possesses the potential to contribute to fundamental
changes towards sustainability (Gupta et al., 2011; Hovlid et al., 2012;
Aquino et al., 2018; Shaw, 2017).
In the extant literature, few studies report the absence of a
structured framework for sustainability in healthcare (Erdil et al.,
2018; Al Hammadi et al., 2018; AlJaberi et al., 2017 and
Marimuthu et al., 2016). Though Marimuthu et al. (2016) has ex-
panded the concept with the delineated goal of sustainability as quality
and financial improvements for healthcare, it appears to be partial
3
Sustainability Analytics and Modeling 1 (2021) 100001
and practices under an economic dimension might be considered to
be derelict. However, AlJaberi et al. (2017) proposed a framework
for measuring sustainability in healthcare systems using Analytic
Hierarchy Process (AHP). But this study varies in objective and scope
as it has measured aspects of sustainability beyond the TBL. Inter-
estingly, an exponentially distributed stochastic model developed by
Khosravi et al. (2019) assesses and measures the sustainability of
any healthcare system based on actual statistical distribution of its
sustainability factors. Distinctively, extant literature does not provide
any evidence of a study that introduces a theoretical model for sustain-
ability in healthcare. Correspondingly, no significant studies seem to be
present that have investigated holistically the interactions among the
healthcare sustainability measures using the integrated methodology
of AHP and Interpretive Structural Modelling (ISM). Chauhan et al.
(2016) developed a hybrid method comprising ISM, fuzzy AHP, and
fuzzy technique for order preference and similarity to ideal solution
(TOPSIS) approaches for selecting a sustainable location of healthcare
waste disposal facility. While few studies have employed AHP / Fuzzy
AHP (Carnero, 2015; Romero and Carnero, 2017) and ISM method
(Chauhan et al., 2017; Leite et al., 2019) individually for assessing
specific dimensions or the related indicator within the considered
dimension of sustainability. Moreover, this study identifies a gap in the
literature in realizing economic sustainability in healthcare. Further-
more, a scarcity of knowledge is observed in the Indian context. Last,
contrary to this study, most of the studies of this domain have focused
on public healthcare settings only.
1.2. Conceptual model for sustainability in healthcare
Sustainability practices should be an essential element of health-
care’s strategic business plans. Therefore, based on the review of the
literature and theories of sustainability in firms, in particular, corporate
social responsibility, stakeholder theory, corporate sustainability, and
green economics, this work appraises a compendious theoretical model,
shown in Fig. 1, for sustainability in healthcare that reflects the extent of
sustainability practices in healthcare. These practices under the TBL in-
stigate the healthcare system to trace and manage value-added through
them. The model accommodates an assortment of environmental, social,
and economic measures and sub-measures deduced from these practices
and proposes the following:
1 For furthering the environmental sustainability of the healthcare
industry, from the policy perspective, it is imperative for develop-
ing nations to implement circular economies and green economies
like developed countries, such as the United States of America and
China, have. Circular practices comprise recycling, repair, re-use, re-
manufacturing, and refurbishment of medical products, and efficient
utilization of resources including conservation of natural resources.
Such practices ensure extension of product life, products treated as
services, product sharing, and prevention of waste including design-
ing out waste in products. Green or sustainable design of health-
care facilities optimizes environmental, social, and economic perfor-
mance of healthcare. The environmental foot print generated during
the life-cycle of healthcare could be minimized through practices
of appropriate site selection, green energy, water conservation, en-
ergy efficiency, recycled and low-emitting materials, reduced waste
generation, increased use of day lighting, local food, green cleaning
materials, and deployment of electric vehicles for transport. Reduc-
tion and efficient management of medical waste ensures healthcare
hygiene and safety of employees and communities, and controls pol-
lution through reduction or prevention of harmful emissions, such
as chemicals and gasses to land, water, and air. In addition to social
and economic benefits, sustainable procurement initiatives help in
reducing specific environmental risks through product labeling, en-
ergy efficient devices, chemical safety, and procurement scorecards.
R. Mehra and M.K. Sharma
Fig. 1. Conceptual model for sustainability in healthcare.
Moreover, greening of healthcare reduces associated emissions mak-
ing environment cleaner that directly affects public health.
2 The emergence of health outcomes, health consumerism, and cost of
care should be treated as the key performance social indicators of a
sustainable healthcare system, underpinned by a quest for ‘health’
care and not just ‘sick’ care. Hence, the spotlight needs to focus
on sustaining health. Explicitly, universalizing preventive healthcare
through personal hygiene, awareness, vaccination, regular check-
ups and promotive healthcare through exercise, yoga, meditation,
and healthy food is fundamental. Along with fundamental tenet of
‘Do no harm’, maximizing the reach of quality care and optimizing
the cost of delivered care can lead to greater patient satisfaction.
Further, beyond productivity and quality of work, there is a general
belief that healthcare employee satisfaction has a significant impact
on patient satisfaction.
3 Green growth of the healthcare sector, a pre-requisite for building
a green economy, representing less environmentally damaging and
resource-efficient healthcare activities, supported by green policies
could change the environment for healthcare. Secondly, it becomes
imperative for developing economies to indulge in extensive indige-
nous manufacturing of medical instruments, devices and diagnos-
tic equipment with international quality standards resulting in cost-
effectiveness of healthcare services. Furthermore, the healthcare sec-
tor should reinvent itself faster than ever and work on evolving,
innovating, and modifying care delivery models for integrated and
value-based care using such concepts as ‘bouquet hospital,’ ‘budget
hospital,’ and PPP models, which are gaining popularity in develop-
ing economies and are shaping the future of healthcare.
4
Sustainability Analytics and Modeling 1 (2021) 100001
1.3. Measures of sustainability in healthcare
The proposed conceptual model of sustainability in healthcare has
provided a foundation for subsequent analysis through AHP and ISM
techniques. Based on the TBL, this hierarchical model is comprised of
various practices, activities, and strategies. The model is then placed for
assessment by healthcare experts who advised the grouping of twenty-
seven sustainability practices into twelve measures for analysis. A few of
the experts were owners of private healthcare and of several segments
comprising healthcare services industry, therefore, were extensively ex-
perienced with regular sustainability practices. Sustainability measures
were created by grouping few practices and providing a broader tax-
onomy for them, where possible, yet preserving the sustainability di-
mension under which the considered practice resorts. Likewise, twenty-
seven practices have been reorganized and arranged into twelve mea-
sures on the recommendation of the experts. It is noteworthy to mention
that no single practice was added or dropped. Based on their properties
and attributes, Table 1 summarizes the twelve measures grouped into
three dimensions of sustainability viz. environmental, social and eco-
nomic.
2. Research methodology: integrated AHP-ISM
In the context of Indian healthcare, vital measures of sustainabil-
ity have been identified by utilizing AHP. The AHP method was used to
compute the weight and prioritize the measures while the ISM technique
was used to identify the indirect interrelationships among the mea-
sures. The ISM technique helped in understanding inter-dependencies
R. Mehra and M.K. Sharma Sustainability Analytics and Modeling 1 (2021) 100001

Table 1
Measures of sustainability in healthcare.

Dimension Measure Explanation References

Environmental Circular Practices It is the concept of keeping resources in use for as long as possible through their Jameton et al. (2002), Vogt et al. (2014).
recovery and re-use following cradle to cradle approach.
Facilities Design It refers to the architectural design of a hospital facility including its technology and Bilec et al. (2010), Pinzone et al. (2012),
equipment & its effect on patient safety. Need to create a truly healing environment Buffoli et al. (2015), Franco et al. (2017),
that comprises of nature, daylight and fresh air. Fonseca et al. (2018).
Waste Reduction and The goal of waste minimisation is to reduce to the greatest extent possible, the waste Sherman et al.(2012) Campion et al.
Management that is destined for ultimate disposal by means of re-use, recycling & other (2015), Chauhan et al. (2017),
programs. Eckelman et al. (2016), Eckelman et al.
Approx. 80% of all HCW can be disposed of through regular municipal waste (2018), Leite et al. (2019), Singh (2019),
methods. The other 20% can create health threats if not disposed of properly. Lindsay et al. (2019).
Disposal methods vary according to type of waste, local environment, available
technology, costs and financing & social acceptance.
Sustainable Procurement It is about combining social and environmental factors with financial considerations Messelbeck et al. (1999), Geldeman et al.
when making purchasing decisions. It involves making decisions based on life-cycle (2017), Chiarini et al. (2017),
costs and associated environmental & social risks & benefits. These include mercury Ossebaard et al. (2020).
& PVC plastic phase-out as well as substitution of toxic chemicals.
Social Patient Satisfaction It is the extent to which patients are happy with their healthcare. A measure of care Faezipour et al. (2011),
quality, it gives providers insights into various aspects of medicine, including the Marimuthu et al. (2016),
effectiveness of their care & their level of empathy. Its level is directly linked to key Aljaberi et al. (2017)
success metrics for hospitals.
Employee Satisfaction Job satisfaction has been identified as an important factor in healthcare staff Pinzone et al. (2019),
retention. It has been found to affect quality of care, patient satisfaction & turnover. Aljaberi et al. (2017), Balka et al. (2006).
Affordability Fundamentally, affordability is a function of income, spending and judgments about Palozzi et al. (2020),
the value of goods & services for their price. A healthcare facility should be available Celdran et al. (2018),
(24 × 7), accessible & affordable to all. Jameton et al. (2002), Turcu et al. (2013),
Shaw(2017),
Sustainable Health Focuses on prevention of diseases and promotion of healthy lifestyles through Yang et al.(2010).
vaccines, exercise, yoga, meditation, healthy food etc.
Economic Green Growth The incorporation of environment friendly practices into healthcare delivery such as Franco et al. (2017), Zhu et al. (2018).
a green hospital. In its simplest expression, a green economy is low carbon, resource
efficient and socially inclusive.
Research & Innovations Research & innovations are the critical factors to realize radical change because they Shaw (2017), Aquino et al. (2018),
possess the potential to contribute to fundamental changes towards sustainability. In Gupta et al. (2011), Hovlid et al. (2012)
the context of healthcare, improvement programmes such as in clinical practice,
nursing practice, reducing the cost of healthcare etc. falls in this category.
Savings in operational Reducing the total cost of care delivery is of vital concern to healthcare providers Parmar (2015), Lifvergren et al. (2009),
costs and enhanced worldwide as this is the only way to improve the bottom line. This economic aspect Jadhav et al. (2014),
profits covers strategies that promote cost savings, profits and research & development. Faezipour et al. (2011),
Savings in operational costs may be achieved through green growth of the sector, Saghazadeh et al. (2016),
indigenous production of medical instruments & devices, non-invasive approaches, Marimuthu et al. (2016).
telemedicine etc.
Indigenous Production India’s medical technology industry is primarily import dependent; only 30% of the –Suggested by authors
country’s requirement of medical devices is being met through indigenous
production; that too of low end category. However, India is called the pharmacy of
the world & is fast becoming the hub for innovation & manufacturing.

between measures, as well as the significant measures. Due to the com-
plexity of interactions between measures, whether they are direct or
indirect, and for establishing all linkages, whether hierarchical or non-
hierarchical, among the measures, the proposed integration of the AHP
and ISM methodology provides an appropriate technique for holistic in-
vestigation. This integrated methodology offers advantages of simplic-
ity and ease of understanding for both the users and the target respon-
dents/evaluators. Finally, a framework for sustainability in healthcare
was suggested on the basis of the results of the ISM and Matrice d’Impacts
Croises Multiplication Appliquee a un Classement (MICMAC) analysis. MIC-
MAC analysis helps to classify the measures and recognize driving and
dependent measures. The methodological flow of this study is illustrated
in Fig. 2.
3. Results and discussion
dents were doctors and two respondents were senior managers. Nine
doctors were from government teaching tertiary care hospitals repre-
senting academia and practitioners. The remaining four doctors were
owners of tertiary care private hospitals, pharmaceutical, medical sup-
ply and equipment, and diagnostic companies. They were also involved
in their management. Hence, the experts represented prominent stake-
holders of the healthcare system. All the experts had more than fifteen
years of work experience giving credibility and reliability to their judg-
ments. Nearly one-third of the experts were from the unregulated pri-
vate sector, increasingly engaged in sustainability practices and repre-
senting healthcare services industry. For reaching an agreement, on the
importance of measures and relationships among the measures, several
rounds of discussions on a one-to-one basis were carried out. Addition-
ally, AHP results were verified using ‘Super Decisions’ software. For as-
suring transitivity in the ISM procedure, the ‘Tranzy Closure’ program
was employed.

For execution of the integrated methodology to holistically inves-

tigate the measures of sustainability, expert elicitation technique was
utilized. Data were collected from mid-December 2019 to mid-March
2020 using two questionnaires (Appendix A) administered to a sam-
ple of twenty healthcare providers, out of which fifteen responded. The
respondents and the hospitals were located in the largest state of In-
dia, Rajasthan and in the second largest city, Jodhpur. Thirteen respon-
3.1. AHP
A three-level hierarchy structure for sustainability in healthcare il-
lustrated in Fig. 3 is the result of the proposed theoretical model. A
specific goal of identifying vital measures of sustainability lies on the
first level. Three dimensions of sustainability, environmental, social, and

5
R. Mehra and M.K. Sharma
economic, are placed at the criteria level. The sub-criteria level is com-
posed of sustainability measures under the three dimensions. There is
no alternative at the bottom. A pair-wise comparison of the sustain-
ability dimensions and then the sustainability measures under the three
dimensions was conducted using the standard 1 to 9 Saaty’s scale. A
geometric mean approach was used for combining the individual pair-
wise comparison judgments of fifteen experts. Finally, an assigned and
normalized weight of each measure was obtained as shown in Table 2.
At the criteria level, among the dimensions of sustainability, the en-
vironmental dimension is believed to be of highest importance. This
finding appears consistent with the recent studies concerning sustain-
ability in healthcare (Hensher, 2020; Sanchez et al., 2020; Guzzo et al.,
2020; Leiden et al., 2020). While at the sub-criteria level, among the en-
vironmental measures, circular practices and sustainable procurement
rank second and third, respectively. In line with the United Nations SDG-
6
Sustainability Analytics and Modeling 1 (2021) 100001
Fig. 2. Flowchart of the integrated methodol-
ogy.
13 requirements, minimizing the negative impact of healthcare opera-
tions on environment through adoption of various practices would assist
in achieving and improving sustainability in healthcare. Circular prac-
tices involve activities such as reducing the use of primary resources, uti-
lization of renewable energy sources, prevention of waste, maintaining
the highest value of healthcare-related materials and products, changing
utilization patterns, and sharing of healthcare products, while sustain-
able procurement helps reduce specific environmental risks attributed
to healthcare.
The economic dimension plays the second most important role in
sustainability in healthcare. Associated measures, research & innova-
tions, and indigenous production have obtained higher weights at the
sub-criteria level with first and fourth ranks, respectively. India is called
the ‘pharmacy of the world’ and is fast growing as a hub for inno-
vation and manufacturing. Therefore, sustained and coherent invest-
R. Mehra and M.K. Sharma Sustainability Analytics and Modeling 1 (2021) 100001

Fig. 3. AHP model for identifying the imperative measures of sustainability in healthcare.

Table 2
Local and global weights of all dimensions and measures.

Criteria (Dim.)

Sub-criteria Environmental Social Economic Consistency Index Consistency Ratio Global

(Measures) ↓ 0.3845 0.2430 0.3725 (CI) 0.0012 (CR) 0.0023 Weight Rank

CP 0.2975 0.0001 0.00011 0.1144 2

FD 0.1846 0.0710 7
WR & M 0.2228 0.0857 6
SP 0.2951 0.1134 3

PS 0.2857 0.0025 0.0028 0.0694 9

ES 0.1747 0.0425 11
A 0.2896 0.0704 8
SH 0.2500 0.0607 10

GG 0.0944 0.0050 0.0057 0.0352 12

R&I 0.3797 0.1414 1
SOC & EP 0.2357 0.0878 5
IP 0.2902 0.1081 4

CP: Circular practices, FD: Facilities design, WR & M: Waste reduction and management, SP: Sustainable procurement, PS: Patient satisfaction,
ES: Employee satisfaction, A: Affordability, SH: Sustainable health, GG: Green growth, R & I: Research and innovations, SOC & EP: Savings in
operational costs and enhanced profits, IP: Indigenous production.

ments in research & innovations may provide solutions to existing
healthcare challenges. India’s medical technology industry is primarily
import-dependent (Chakravarthi, 2013). It has become crucial for the
healthcare industry to engage in indigenous manufacturing of health-
care equipment that would make expensive advanced medical technol-
ogy affordable, enabling quality of care.
The social dimension has received the lowest importance ranking
among TBL. It is notable that sustainable health has occupied the tenth
rank among twelve measures, suggesting its relative importance. Nev-
ertheless, it has no mention in previous studies related to sustainability
in healthcare. Subsequently, the key result of the sensitivity analysis
indicates that the economic dimension has more impact on enhancing
sustainability in healthcare. Hence, research & innovations, and indige-
nous production demand greater attention. As for the consistency of
judgments, all consistency ratio (CR) values are less than 0.1, indicating
that the comparison matrices are of good consistency.
3.2. ISM
Direct relationships among sustainability measures have been ob-
tained from the expert judgments. Fig. 4 graphically presents thirty pairs
of direct-relationships that exist among measures with six bidirectional
relationships. However, indirect interrelations and how they influence
sustainability in healthcare remain obscure from this picture.
Along with Fig. 4, a structural self-interaction matrix (SSIM) is simul-
taneously generated based on expert judgments as shown in Table 3.
The SSIM is then converted into a binary matrix, called the initial
reachability matrix, substituting V, A, X and O by 1 and 0, accordingly.
Table 4 shows the initial reachability matrix.
For maintaining conceptual consistency, applying the concept of
transitivity, a basic assumption in ISM, enables the use of inference to
fill some of the cells of the initial reachability matrix. Transitivity can
be explained with the following example: if element i relates to element

7
R. Mehra and M.K. Sharma Sustainability Analytics and Modeling 1 (2021) 100001

Fig. 4. Direct relationships among sustainability mea-

sures CP: Circular practices, FD: Facilities design, WR & M:
Waste reduction and management, SP: Sustainable procure-
ment, PS: Patient satisfaction, ES: Employee satisfaction, A:
Affordability, SH: Sustainable health, GG: Green growth, R &
I: Research and innovations, SOC & EP: Savings in operational
costs and enhanced profits, IP: Indigenous production.

Table 3
Structural Self – Interaction Matrix (SSIM).

CP (1) FD (2) WR& M (3) SP (4) PS (5) ES (6) A (7) SH (8) GG (9) R & I (10) SOC & EP (11) IP (12)

CP (1) O V O V V O O X A V A
FD (2) V O V V O O X A V O
WR & M (3) O V V O O X A V O
SP (4) O 0 O O X A O O
PS (5) V O O A A A O
ES (6) O O X A V O
A (7) O O O A A
SH (8) O A O O
GG (9) A V A
R & I (10) V X
SOC & EP (11) A
IP (12)

CP: Circular practices, FD: Facilities design, WR & M: Waste reduction and management, SP: Sustainable procurement, PS: Patient satisfaction,
ES: Employee satisfaction, A: Affordability, SH: Sustainable health, GG: Green growth, R & I: Research and innovations, SOC & EP: Savings in
operational costs and enhanced profits, IP: Indigenous production.

Table 4
Initial reachability matrix.

Measures i↓ ,j→ CP FD WR & M SP PS ES A SH GG R&I SOC & EP IP

CP 1 0 1 0 1 1 0 0 1 0 1 0
FD 0 1 1 0 1 1 0 0 1 0 1 0
WR & M 0 0 1 0 1 1 0 0 1 0 1 0
SP 0 0 0 1 0 0 0 0 1 0 0 0
PS 0 0 0 0 1 1 0 0 0 0 0 0
ES 0 0 0 0 0 1 0 0 1 0 1 0
A 0 0 0 0 0 0 1 0 0 0 0 0
SH 0 0 0 0 0 0 0 1 0 0 0 0
GG 1 1 1 1 1 1 0 0 1 0 1 0
R&I 1 1 1 1 1 1 0 1 1 1 1 1
SOC & EP 0 0 0 0 1 0 1 0 0 0 1 0
IP 1 0 0 0 0 0 1 0 1 1 1 1

8
R. Mehra and M.K. Sharma Sustainability Analytics and Modeling 1 (2021) 100001

Table 5
Final reachability matrix.

Measures i↓ ,j→ CP FD WR &M SP PS ES A SH GG R&I SOC & EP IP Driving Power Rank

∗ ∗ ∗
CP 1 1 1 1 1 1 1 0 1 0 1 0 9 II
FD 1∗ 1 1 1∗ 1 1 1∗ 0 1 0 1 0 9 II
WR & M 1∗ 1∗ 1 1∗ 1 1 1∗ 0 1 0 1 0 9 II
SP 1∗ 1∗ 1∗ 1 1∗ 1∗ 0 0 1 0 1∗ 0 8 III
PS 0 0 0 0 1 1 0 0 1∗ 0 1∗ 0 4 V
ES 1∗ 1∗ 1∗ 1∗ 1∗ 1 1∗ 0 1 0 1 0 9 II
A 0 0 0 0 0 0 1 0 0 0 0 0 1 VI
SH 0 0 0 0 0 0 0 1 0 0 0 0 1 VI
GG 1 1 1 1 1 1 1∗ 0 1 0 1 0 9 II
R&I 1 1 1 1 1 1 1∗ 1 1 1 1 1 12 I
SOC & EP 0 0 0 0 1 1∗ 1 0 1∗ 0 1 0 5 IV
IP 1 1∗ 1∗ 1∗ 1∗ 1∗ 1 1∗ 1 1 1 1 12 I
Dependence 8 8 8 8 10 10 9 3 10 2 10 2
Rank III III III III I I II IV I V I V

Table 6
Level Partition of Final Reachability Matrix Iteration – 1, Iteration – 2, Iteration – 3, Iteration – 4.

Measure Reachability Set Antecedent Set Intersection Set Level

CP (1) 1,2,3,4,5,6,7,9,11 1,2,3,4,6,9,10,12 1,2,3,4,6,9

FD (2) 1,2,3,4,5,6,7,9,11 1,2,3,4,6,9,10,12 1,2,3,4,6,9
WR & M (3) 1,2,3,4,5,6,7,9,11 1,2,3,4,6,9,10,12 1,2,3,4,6,9
SP (4) 1,2,3,4,5,6,9,11 1,2,3,4,6,9,10,12 1,2,3,4,6,9
PS (5) 5,6,9,11 1,2,3,4,5,6,9,10,11,12 5,6,9,11 I
ES (6) 1,2,3,4,5,6,7,9,11 1,2,3,4,5,6,9,10,11,12 1,2,3,4,5,6,9,11
A (7) 7 1,2,3,6,7,9,10,11,12 7 I
SH (8) 8 8,10,12 8 I
GG (9) 1,2,3,4,5,6,7,9,11 1,2,3,4,5,6,9,10,11,12 1,2,3,4,5,6,9,11
R & I (10) 1,2,3,4,5,6,7,8,9,10,11,12 10,12 10,12
SOC & EP (11) 5,6,7,9,11 1,2,3,4,5,6,9,10,11,12 5,6,9,11
IP (12) 1,2,3,4,5,6,7,8,9,10,11,12 10,12 10,12

Measure Reachability Set Antecedent Set Intersection Set Level

CP (1) 1,2,3,4,6,9,11 1,2,3,4,6,9,10,12 1,2,3,4,6,9

FD (2) 1,2,3,4,6,9,11 1,2,3,4,6,9,10,12 1,2,3,4,6,9
WR & M (3) 1,2,3,4,6,9,11 1,2,3,4,6,9,10,12 1,2,3,4,6,9
SP (4) 1,2,3,4,6,9,11 1,2,3,4,6,9,10,12 1,2,3,4,6,9
ES (6) 1,2,3,4,6,9,11 1,2,3,4,6,9,10,11,12 1,2,3,4,6,9,11 II
GG (9) 1,2,3,4,6,9,11 1,2,3,4,6,9,10,11,12 1,2,3,4,6,9,11 II
R & I (10) 1,2,3,4,6,9,10,11,12 10,12 10,12
SOC & EP(11) 6,9,11 1,2,3,4,6,9,10,11,12 6,9,11 II
IP (12) 1,2,3,4,6,9,10,11,12 10,12 10,12

Measure Reachability Set Antecedent Set Intersection Set Level

CP (1) 1,2,3,4 1,2,3,4,10,12 1,2,3,4 III

FD (2) 1,2,3,4 1,2,3,4,10,12 1,2,3,4 III
WR & M (3) 1,2,3,4 1,2,3,4,10,12 1,2,3,4 III
SP (4) 1,2,3,4 1,2,3,4,10,12 1,2,3,4 III
R & I (10) 1,2,3,4,10,12 10,12 10,12
IP (12) 1,2,3,4,10,12 10,12 10,12

Measure Reachability Set Antecedent Set Intersection Set Level

R & I (10) 10,12 10,12 10,12 IV

IP (12) 10,12 10,12 10,12 IV

j and element j relates to element k, then transitivity implies element i
relates to element k. Table 5 presents the final reachability matrix.
Table 6 presents a level partition matrix. Iterations were carried out
until all the measures were arranged.
Finally, based on the level partition of measures and connective in-
formation included in the final digraph, an interpretive structural model
is obtained for measures of sustainability in healthcare. The ISM model
is a four-layer hierarchy and is nearly symmetric as shown in Fig. 5.
Research & innovations, and indigenous production measures are at the
deepest layer of the ISM structure. Patient satisfaction, affordability, and
sustainable health are at the surface layer of the structure. The remain-
ing measures are in the middle. The ISM model also represents transitive
links and presents the actions that need to be pursued to achieve the de-
sired linkage as shown in Table 6.
Concerning the AHP-ISM integration, Fig. 6 depicts a four-layer hi-
erarchical structure with consideration of importance (weight) of each
measure in which different dimension measures are filled with different
shades of a color. Weights obtained at a sustainability dimension level
are reflected in the ISM model in order to gain an overall individual
significance of each measure. The higher the weight a dimension pos-
sesses, the darker the fill color is. It can be seen that the fill color of
sustainability measures become darker as they move to a deeper layer.
At the third level, all four environmental sustainability measures come
together validating the theory.

9
R. Mehra and M.K. Sharma
In addition, research & innovations and indigenous production mea-
sures at the deepest hierarchy of the ISM model contribute significant
latent impact on other measures. Consequently, these two measures de-
mand greater attention. Moreover, affordability and patient satisfaction
are situated at the surface layer of the structure bearing lower weight.
Although sustainable health is isolated from other measures and has no
impact on them, it should be considered in establishing preventive ac-
tions and promotion campaigns for health.
3.2.1. MICMAC analysis
Further, MICMAC analysis was performed by classifying the mea-
sures into four quadrants on the basis of their driving power (along the
10
Sustainability Analytics and Modeling 1 (2021) 100001
Fig. 5. Interpretive Structural Model (ISM) CP: Circu-
lar practices, FD: Facilities design, WR & M: Waste reduc-
tion and management, SP: Sustainable procurement, PS:
Patient satisfaction, ES: Employee satisfaction, A: Afford-
ability, SH: Sustainable health, GG: Green growth, R & I:
Research and innovations, SOC & EP: Savings in opera-
tional costs and enhanced profits, IP: Indigenous produc-
tion.
Fig. 6. Interpretive structural model with the importance
of each measure.
Y-axis) and dependence (along the X-axis) as shown in Fig. 7. For this
purpose, a position coordinate matrix was developed.
MICMAC analysis integrated with AHP-ISM further suggests that two
economic measures, specifically, research & innovations and indigenous
production, are observed to be extraordinarily crucial. They have scored
higher weights in the AHP analysis, located at the bottom level of the
ISM model, while MICMAC analysis labels them as the driving measures.
The remaining two economic measures, green growth and savings in op-
erational costs & enhanced profits, occupied the second level in the ISM
model. MICMAC analysis finds green growth in a mediating role, while
savings in operational costs & enhanced profits is found to be a depen-
dent measure that conforms to reality. Moreover, all the environmental
R. Mehra and M.K. Sharma Sustainability Analytics and Modeling 1 (2021) 100001

Fig. 7. MICMAC Analysis CP: Circular practices, FD:

Facilities design, WR & M: Waste reduction and man-
agement, SP: Sustainable procurement, PS: Patient sat-
isfaction, ES: Employee satisfaction, A: Affordability,
SH: Sustainable health, GG: Green growth, R & I: Re-
search and innovations, SOC & EP: Savings in opera-
tional costs and enhanced profits, IP: Indigenous pro-
duction.

measures, specifically circular practices, sustainable procurement, waste

reduction & management, and facilities design are found to hold link-
age roles, each occupying the third level in the ISM model with 2nd , 3rd ,
6th , and 7th ranks, respectively. Social measures, specifically, affordabil-
ity and patient satisfaction are identified as dependent measures in the
MICMAC analysis and occupied the highest level in the ISM model with
8th and 9th ranks in the AHP analysis, respectively. Another social mea-
sure, employee satisfaction, occupies the second level in the ISM model
and plays a mediating role as per MICMAC analysis with the 11th rank
in the AHP analysis. Sustainable health is found to be an autonomous
measure in MICMAC analysis. Ironically, it is a fundamental measure
that has largely been ignored in previous studies.

3.3. Framework for sustainable healthcare

Several researchers have attempted to extend the alternative meth-

ods approach to built theory using the techniques of ISM and MICMAC
analysis. Sushil (2017) emphasized that ISM / Total Interpretive Struc-
tural Modelling (TISM) has extensively been adopted by researchers for
theory building, conceptualization, case analysis, and decision making.
Warfield (1994) and Mandal and Deshmukh (1994) mentioned that MIC-
MAC analysis is used to interrelate factors in complex systems. While
Dubey et al. (2015) argued that ISM / TISM model and MICMAC together
have great potential to generate testable theory. In line with these ob-
Fig. 8. Sustainable healthcare framework CP: Circular practices, FD: Facil-
servations, a framework for sustainable healthcare is presented herein
ities design, WR & M: Waste reduction and management, SP: Sustainable pro-
that integrates the findings of the ISM method and MICMAC analysis. curement, PS: Patient satisfaction, ES: Employee satisfaction, A: Affordability,
The proposed strategic theoretical framework for sustainable health- SH: Sustainable health, GG: Green growth, R & I: Research and innovations,
care, shown in Fig. 8, is a testable regression model in which the driving SOC & EP: Savings in operational costs and enhanced profits, IP: Indigenous
measures are independent variables, the linkage measures are mediat- production.
ing variables, and the dependent measures are dependent variables. Fur-
thermore, sustainable health as an autonomous measure does not find a
place in the framework. are further surrounded by government policies. Thus, stakeholders and
This framework integrates four powerful theories. According to policies influence sustainability in healthcare stressed by stakeholder
Chang et al. (2017), corporate social responsibility (CSR), stakeholder theory and green economics respectively. According to the stakeholder
theory, corporate sustainability (CS), and green economics form the approach, the healthcare industry while achieving their strategic objec-
leading theory landscape of sustainability in firms. In the context of tives should respond to, in addition to social stakeholders, the needs of
sustainability in healthcare, CSR and CS concern the balance of eco- non-social stakeholders for addressing environmental issues. From the
nomic, social and environmental dimensions of healthcare performance. policy perspective, it is imperative to implement circular economies and
Surrounding the healthcare system are the various stakeholders who green economies. It would help to make the healthcare industry more

11
R. Mehra and M.K. Sharma
environmentally sustainable, supporting green economics. The frame-
work further suggests that green healthcare initiatives practiced through
circular practices, integrated healthcare facilities design, waste reduc-
tion and management, sustainable procurement, together with green
growth and employee satisfaction strategies would result in savings in
operational costs, enhanced profits, increased patient satisfaction level
and affordability of healthcare services. Finally, one may infer that eco-
nomic sustainability practices in healthcare drive the social sustainabil-
ity practices mediated through environmental sustainability practices to
achieve sustainable healthcare.
4. Conclusion
Concerns regarding sustainability are at the forefront of societal
awareness. Globally, unsustainable development has contributed to eco-
logical degradation and human suffering while compromising the abil-
ity of ecosystems and social institutions to support human life. Recent
years have witnessed the healthcare industry’s role in damaging and de-
grading the environment but now leaders of change are emerging from
the healthcare arena. Health professionals are poised to serve as models
for sustainability and must facilitate necessary transformation toward
more sustainable practices. This study appraises a compendious theo-
retical model for sustainability in healthcare based on the triple bottom
line. The model reflects the extent of sustainability practices in health-
care. These practices instigate the healthcare system to trace and man-
age value-added through them. The model accommodates an assortment
of environmental, social, and economic measures and sub-measures.
On the recommendation of experts, twenty-seven practices have
been reorganized and arranged into twelve measures. Subsequently,
each measure is defined for better understanding (Table 1). Analytic
Hierarchy Process (AHP) and Interpretive Structural Modelling (ISM)
methods were used for modeling these measures. With assistance of an
expert elicitation technique, fundamental data for investigation were ob-
tained from fifteen experienced healthcare experts. The proposed con-
ceptual model provides a hierarchical structure that was validated by
AHP (by evaluators and consistency values). Weights of sustainability
measures were quantified using the AHP method and for understand-
ing their inter-relationships, the assorted measures were modelled using
ISM.
Due to the complexity of interactions between measures, whether
direct or indirect, and for establishing all linkages, whether hierarchical
or non-hierarchical, among the measures, integration of the AHP and
ISM methodology was identified as an appropriate technique for holis-
tic investigation. This study shows how the application of an AHP-ISM
based integrated method can lead to a better understanding of how vari-
ous measures influence sustainability in healthcare. Consequently, MIC-
MAC analysis was performed to understand the nature of dependencies
among the drivers and dependents of the structure. Finally, this work
proposes a strategic theoretical framework for sustainable healthcare
on the basis of ISM method and MICMAC analysis findings. The sug-
gested framework divulges strategic drivers of sustainable healthcare
that demands special attention by policy-makers.
4.1. Key findings of the study
This work studied key measures that have emerged for policy, prac-
tice, and research. The following are the key observations that emanate
from the study:
1 To achieve sustainable healthcare, it is inferred that economic
sustainability practices drive social sustainability practices linked
through environmental sustainability practices. Exclusively, the
framework for sustainable healthcare suggests practicing green
healthcare initiatives through circular practices, integrated health-
care facilities design, waste reduction and management, and sustain-
able procurement together with green growth and employee satis-
faction strategies would result in savings in healthcare operational
12
Sustainability Analytics and Modeling 1 (2021) 100001
costs, enhanced profits, increased patient satisfaction level and af-
fordability of healthcare services.
2 The main outcome of the proposed integrated methodology (AHP-
ISM) and suggested framework (ISM-MICMAC) divulges research
and innovations and indigenous production as the strategic drivers
of sustainable healthcare. Thus, these drivers demand special atten-
tion by the policy-makers. For improving sustainability in health-
care, it is imperative to instigate extensive manufacturing of medi-
cal technology equipment indigenously. Additionally, augmentation
of healthcare research could lead to innovations in the industry for
shaping better ways of generating value. Explicitly, environmental
innovations, social innovations, and technological innovations, to-
gether with green policies could deeply change the environment for
healthcare making it more sustainable and robust. Hence, sustained
and coherent investments would provide solutions to existing chal-
lenges of healthcare costs, quality, time, access, growth, and envi-
ronmental quality.
The research findings provide valuable insights into the perception
and knowledge about sustainability and its measures in healthcare.
4.2. Implications of the study
This study has tried to demystify the nuances of healthcare sustain-
ability by contributing to the theory and suggesting a framework for
it. The results of this research could lead to efficient policy-making in
healthcare. It may assist decision-makers in prioritizing sustainability
practices with an aim to establish or enhance sustainability in health-
care. It can also help in recognizing significant practices necessary for
sustainability achievement. The mediating measures through circular
practices, waste reduction and management, integrated facilities design,
sustainable procurement, employee satisfaction, and green growth may
offer guidance and provide a strong direction to healthcare managers
and practitioners in reaching sustainability.
The ISM-MICMAC based framework for sustainable healthcare may
be further tested with data collected using a structured questionnaire to
offer even deeper insights. This may also help to bridge the gap between
qualitative and quantitative approaches. In this way, the present litera-
ture on sustainability in healthcare can be utilized for validation of the
framework. This kind of study can further be extended to other service
areas and organizations. Finally, a healthcare sustainability index could
be developed that aims to institutionalize a focus on improving health
outcomes.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgement
The authors are grateful to the learned Editor-in-Chief, Reviewers,
and healthcare experts for their constructive comments and opinion. The
authors also thank Subhash Mehra, Consultant, Head & Neck Surgeon,
Shalakya Hospital, Rajasthan, India, for reading the initial draft of the
paper.
Appendix A. Appendix title
Questionnaire. ‘A’
Execution of the Analytic Hierarchy Process (AHP) requires generat-
ing pair-wise comparison matrices by utilizing experts elicitation tech-
nique using standard Saaty’s scale (1 to 9):
Goal: Sustainability in healthcare
R. Mehra and M.K. Sharma Sustainability Analytics and Modeling 1 (2021) 100001

Table B.1
Structural self-interaction matrix (SSIM).

Measures j→ IP SOC& EP R&I GG SH A ES PS SP WR& M FD CP

i↓ 12 11 10 9 8 7 6 5 4 3 2 1

CP 1

FD 2

WR & M 3

SP 4

PS 5

ES 6

A 7

SH 8

GG 9

R&I 10

SOC & EP 11

IP 12

CP: Circular practices, FD: Facilities design, WR & M: Waste reduction and management, SP: Sustain-
able procurement, PS: Patient satisfaction, ES: Employee satisfaction, A: Affordability, SH: Sustainable
health, GG: Green growth, R & I: Research and innovations, SOC & EP: Savings in operational costs and
enhanced profits, IP: Indigenous production.

Criteria level: Environmental: Social: Economic Under criteria: Economic

Concerning the goal of sustainability in healthcare:
Q 1. How important is environmental sustainability with respect to
social sustainability?
Q 2. How important is environmental sustainability with respect to
economic sustainability?
Q 3. How important is social sustainability with respect to economic
sustainability?
Under criteria: Environmental
Sub-criteria level: Circular practices: facilities design: waste reduc-
tion & management: sustainable procurement
Concerning the goal of environmental sustainability in healthcare:
Q 4. How important are circular practices with respect to facilities
design?
Q 5. How important are circular practices with respect to waste re-
duction & management?
Q 6. How important are circular practices with respect to sustainable
procurement?
Q 7. How important is facilities design with respect to waste reduc-
tion & management?
Q 8. How important is facilities design with respect to sustainable
procurement?
Q9. How important is waste reduction & management with respect
to sustainable procurement?
Under criteria: Social
Sub-criteria level: Patient satisfaction: employee satisfaction: afford-
ability: sustainable health
Concerning the goal of social sustainability in healthcare:
Q 10. How important is patient satisfaction with respect to employee
satisfaction?
Q 11. How important is patient satisfaction with respect to afford-
ability?
Q 12. How important is patient satisfaction with respect to sustain-
able health?
Q 13. How important is employee satisfaction with respect to afford-
ability?
Q 14. How important is employee satisfaction with respect to sus-
tainable health?
Q 15. How important is affordability with respect to sustainable
health?
Sub-criteria level: Green growth: research &innovations: savings in
operational costs & enhanced profits: indigenous production
Concerning the goal of economic sustainability in healthcare:
Q 16. How important is green growth with respect to research &
innovations?
Q 17. How important is green growth with respect to savings in op-
erational costs & enhanced profits?
Q 18. How important is green growth with respect to indigenous
production?
Q 19. How important is research & innovations with respect to sav-
ings in operational costs & enhanced profits?
Q 20. How important is research & innovations with respect to in-
digenous production?
Q 21. How important is savings in operational costs & enhanced prof-
its with respect to indigenous production?
Questionnaire. ‘B’
For executing Interpretive Structural Modelling (ISM) method:
The following table is intended to register the perception of pro-
fessionals from the healthcare industry to develop pair wise contextual
relationships between the measures of sustainability in healthcare:
Please fill in the white boxes of the Table B.1 using anyone of
the following symbols (V, A, X or O):
V = measure i will help to achieve / alleviate measure j
A = measure j will help to achieve / alleviate measure i
X = measure i and j will help to achieve / alleviate each other
O = measure i and j are unrelated
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