Developing Sustainability Rating System for Healthcare Facilities: Focus on Egypt

Healthcare is one of the core operating sectors all over the world with a designated Goal 3: Good Health and Well-being of the international Sustainable Development Goal (SDG), while three other goals addressed the eradication of causes of healthcare problems. The World Health Organization (WHO) estimated the increase of healthcare expenditure to be $2 - $4 Billion USD by the year 2030 as a result of Climate change. As a developing country, Egypt has a fast-growing healthcare sector, which is a good opportunity to direct the sector towards a more sustainable development scheme to reduce the cost of the service, while maintaining a high service level for the patience and reducing the environmental impacts of operation, which are the pillars of sustainable development. The aim of the work presented is to develop sustainability rating system for new and existing healthcare facilities suitable to the Egyptian context that encourages the facilities to operate more sustainably using the concept of cradle-to-cradle resources management. The rating system developed is based on a points system with the awardable levels of achievement: Bronze, Silver, Gold and Platinum. The points divided among three main categories: Energy, Water and Habitat, and additionally, two general prerequisites are added for the top management commitment towards sustainability and developing an environmental management plan. The system divides the facilities into new and existing, with each type having different awardable points that take into consideration the differences in applicability between the two types of facilities.


Introduction
Healthcare is one of the basic human rights, and to emphasise that importance, the Global Sustainable Development Goals (SDGs) directly addressed the issue in Goal 3: "Good Health and Well-being", while three other goals represented in Goal 2: "Zero Hunger", Goal 6: "Clean Water and Sanitation" and Goal 7: "Affordable and Clean Energy", target providing a better life for all humans and as a result the removal of the cause of diseases from source [1].
In general, the environmental risks are estimated to cause 12.6 million deaths per year, approximately 23% of the total annual deaths, with children under five years old and older adults being the most affected groups [2]. An estimated 5.5 million deaths per year are reported to currently have the root cause as the air pollutants causing climate change [3]. As climate change is considered one of the main causes of adverse health issues, with the expected increase in effect especially in countries of low income, the World Health Organization (WHO) estimates a USD 2 -4 billion increase in the healthcare expenditure by the year 2030 due to climate change alone [4].
Considering that the healthcare sector is one of the contributors to Green House Gas emissions, and taking into account the complexity of healthcare facilities, it is important for the sector to lead the path towards global sustainability as the main sector that deals with the consequences of business as usual actions [3].

Health Sector Overview
In 2015, the global healthcare expenditure was reported to be almost USD 1000 per capita, with a share of more than 6% of the world average Gross Domestic Product (GDP) [5]. The 2019 data showed that the expenditure ranged from 16.8% of GDP in North America, followed by 10.5% in Western European countries to only 5.5% in the Middle East and North Africa [6]. From the year 2000 to 2015, the annual healthcare expenditure growth rate reached 4% in comparison to the economic growth rate which only reached 2.8% for the same time period [7].
With the projected increase of average life expectancy from 73.5 in 2018 to reach 74.4 in 2022, the healthcare services expenditure is expected to also increase in the future due to the continuous increase of elderly population, in addition to the technological advancements that are currently being utilized by the sector and the accompanied rise in service providers cost [6] [8].
In the process of offering the healthcare service, the healthcare facilities consume a significant amount of resources to maintain the required service level, starting with the construction materials, and including electricity, water, food and other materials. A fully operating hospital, for example, usually functions 24 hours per day all year long, and some of the services that operate with it include: space cooling, indoor air quality control, lighting, cold and hot water supply, steam supply in addition to the core clinical activities taking place [9].

Health Sector in Egypt
On the regional level, the Eastern Mediterranean countries, including Egypt, have around 22% of the deaths attributed to environmental caused diseases [2].
The cost of healthcare services in Egypt reached USD 131 per Capita in 2016 with 4.6% share of GDP, yet 62% of the total cost was attributed to out-of-pocket expenditure. Although the expenditure figure seem to be much lower than the world average, the out-of-pocket spending can be considered high compared to the governmental health expenditure level [17].
Until 2014, Egypt had around 2600 fully operating hospitals with more than 130 thousand beds. The ownership of these facilities is 68% to the private sector, and 32% public sector distributed between governmental and semi-governmental institutions. However, the number of beds distribution is only 43% for the private section, while the rest are served by the public sector hospitals [18]. The current number of bed availability is reported at 1.5/1000 persons in comparison to the world average of 2.7/1000, which means that there is a high potential for the sector to grow still [19].
Although no comprehensive studies were published to date to report the overall share of energy consumption or greenhouse gas emissions by the healthcare sector independently, a case study done on a hospital in Egypt has found out that applying energy efficiency measures can result in a 2.5% to more than 40% reduction in energy consumption per year depending on the intervention level whether small measures to an existing facilities or a possible early intervention in the design stage [20].
The main objective of the work presented is to develop a Sustainability Rating system for healthcare facilities in developing countries having prevalent hot dry conditions, taking the Egyptian Conditions as an example. The proposed system is based on the international standards and follows the cradle-to-cradle concept, which is considered a new approach for facilities to manage their resources in a method that targets closing the life cycle of the materials consumed over the life-

Sustainable Healthcare Facilities
In the efforts to promote Green Buildings, including healthcare facilities, several guidelines were prepared originating from different countries covering both, new and/or existing facilities, some with context more relevant to the country of issuing, similar to the proposed system that is discussed in this work, and some are prepared for international use regardless of the region of implementation.
One of the earliest established rating systems is the Building Research Estab- Although the number and titles assigned to the criteria categories differed from one rating system to the other, the rating system guidelines in general included 6 and to 10 different categories covering aspects such as: energy, water, materials and resources, site management, transportation, indoor and outdoor Developing a sustainability rating system based on the international best practices and fitting to the Egyptian local conditions, taking into consideration the weather, land use and availability of materials became a necessity with the increased risks due to climate change and water scarcity, as well as the need for elevated energy efficiency became core needs to guarantee the sustainable development of residential buildings, communities, schools and commercial areas [30].

Methodology
In order to develop the proposed rating system, first the applicable laws and regulations were studied to know the base which must be followed, especially concerning energy, water, waste disposal, and the indoor environment. These laws, regulations and guidelines can be viewed as the basis of any facility that should be abided by and the proposed sustainability measures are efforts exerted over these regulations to drive the road to sustainability.
Afterwards, several international standards were reviewed and consulted, varying from the most well-established standards namely LEED and BREEAM, and additionally including rating systems from developing countries that have nearly similar conditions to the Egyptian Context.
With the aim of facilitating the implementation of the system the proposed criteria are divided into three main categories only, namely: Energy, Water and Habitat, taking into consideration the inclusion of the aspects deemed applicable from the international rating systems. The criteria and its relvant weight is determined using the following methodology: • Action points that should be fulfilled by the facility as a basic requirement are defined as prerequisites; • Optional criteria are assigned a minimum score of 1 awardable upon the criteria implementation; • Criteria that are judged to be harder to implement or require high investment are assigned higher scores, which are divided into smaller milestones with the highest awardable the full score; and • The total score of all the optional criteria is kept at a maximum of 100 points. The proposed rating system encourages the sector to go above and beyond the measures dictated by the laws and regulations, towards a more sustainable design, build and operation aiming to close the loop of consumption through applying the Cradle-to-Cradle concept. The Cradle-to-cradle principal of resources management is a new approach used to ensure the maximum utilization of resources without directing any of it to landfills [31].

Proposed Sustainability Rating System for Healthcare
Facilities in Egypt

Proposed Criteria and Scorecard
The rating system' criteria are developed separately for both the New and Existing facilities, this is mainly due to the difference in the condition of each type of facility, for example the applicability of the HBRC design and construction guidelines as part of the new facilities permit process which was not applied to most of the existing facilities. For the proposed system application, the facilities will be categorized at the time of intent to follow the rating system criteria, where New facilities will be considered as projects that are still under planning with the ability to take into consideration the criteria in the design phase, and the same treatment will also be applied to extensions to already existing facilities, while Existing facilities are those already constructed whether operation is already proceeding or still in the commissioning stage of operation.
The differences in the expected intervention level during the transition towards sustainability deemed it necessary that some of the criteria are not equally weighted to account for the different implantation hardships between upgrading an existing situation and implementing a measure from the design phase. The proposed system is discussed below starting with the two general prerequisites, followed by the three criteria categories: Energy, Water and Habitat.

General Prerequisites
To begin the criteria general prerequisites that is overarching before the different assessment categories is developed which is the Top management sustainability commitment and having an environmental management plan in place, as shown in Table 1, and being prerequisites, these criteria do not award the facility any points. The top management commitment prerequisite can be accomplished in the form of a policy that is signed by the management representative to include the points of focus towards sustainability that will be undertaken by the facility and the associates, from the design and construction phase to the operation

Energy Category
Energy is the first section of the rating system that is designed to cover all the criteria related to electricity and other fuels consumption for the different facility activities including lighting, air circulation, cooling and hot water generation, as mentioned in Table 2. All these activities are considered essential for any healthcare facility operation, as well as being a major contributor to the greenhouse gas emissions from the facility makes them essential to be addressed, especially with the knowledge that a number of measures can have a great impact towards a more energy efficient operation [9]. which result in the total awardable points for this section are more for New facilities than they are for existing ones. In general, it is recommended to communicate the performance requirements as early on to allow for flexibility in applying the settled on measures, to reduce the cost and materials waste of alterations after construction, for example the credit E01 window-to-wall ratio, and E09 HVAC system efficiency and ventilation should be correctly designed from the beginning due to their large contribution to energy efficiency which can reach around 4% and 35%, respectively, compared to the conventional methods and in accordance to the building status [20].

Water Category
Another major resource that is consumed in healthcare facilities is water, which is the second focus category with the assessment criteria discussed in Table 3.
Water is a very valuable resource, and especially with the rising freshwater scarcity problem, conserving every drop of water became essential. Healthcare facilities consume water similar to other buildings, but with the specific case of fully operating hospitals the consumption can be in many different areas for several purposes, for example: hot and cold water are used in clinical activities areas, patients' rooms, kitchen and cafeterias, laundry areas, as well as in the form of steam which is produced on site from boilers.  A category prerequisite is that the water and wastewater management actions that are designed or planned to be implemented within the facility should be recorded in the form of a plan to guarantee the official status of these actions. In order to address the water consumption amount, one of the points of focus is the use of water saving devices in all areas including faucets, showerheads and toilet flushing tanks in all installed areas is stressed upon through credit W07. A control tool that is recommended to be used by all types of facilities is W05 water metering that can be used to monitor the consumption and stand on the effectiveness of the implemented measures, as well as to detect any leaks as soon as they occur, with separate water meters installed according to the types of water streams and the size of the facility. As landscape areas can be considered a major water consumer, W02 irrigation efficiency addresses the use of weather resistant plants and efficient irrigation systems, the reuse of treated greywater for different activities is also encouraged through credits W04, on the condition that the reuse practice does not affect the overall service quality, which is monitored by credit point W06, as the patients well-being remains the main target of any healthcare facility.

Habitat Category
The third and last category is habitat, and to facilitate its use, the category covers all the other aspects that are not covered in water in energy, including: sustainable site management, indoor environmental quality and materials and resources use. Table 4 includes the rating criteria for habitat, which is, in contrast to the energy category, the awardable points ire more for existing facilities than for new buildings in this section, and that is due to the fact that existing facilities often need more monitoring and upgrading of their existing conditions to enhance the  The cradle-to-cradle management concept is stresses upon the most in this category, especially in the materials and resources related criteria, as they tackle the sustainable materials choice and use, and the management of all the waste types, whether municipal, clinical or chemical. As a prerequisite, a solid waste management plan should be prepared that includes the different assigned roles and responsibilities regarding the different stages of waste management within the facility, and states clearly the products purchasing policy adopted, and the acceptable level of waste disposal even if the actual action is to be taken outside the property itself. The achievement of credits H08 to H10 requires first the proper separation of all waste types from the generation source, and the close monitoring of these waste streams during handling and transportation to avoid contamination, specifically H10 medical waste which also includes chemical wastes and can cause a whole batch of waste to be considered as hazardous waste. Also, as an encouragement of the total material recovery content the facility is not only encouraged to use local materials (H12) as much as possible in all the construction and furniture acquisition, but to additionally use recycled materials (H13) whenever available. A specific criterion for healthcare facilities is H14 Persistent Bio-accumulative Toxic (PBT) chemicals reduction which requires the careful choice of materials that are low emitting of these chemicals, an issue that is considered essential to enhancement of the conditions to which patients are admitted.
Several critical operational categories are also covered in the habitat category, which addresses the general site conditions inside the facility building as well as outside, with the aim to promote the importance of maintaining the site in general through the project lifetime through H07 preventive and corrective maintenance, this category is awardable to new facilities based on developing a plan, but requires further tangible actions from existing facilities. Additionally, for the existing facilities, the indoor air quality and facility conditions are considered critical operational quality parameters which are targeted by credits H16 air quality indoors, H17 rooms overcrowding, H22 kitchen hygiene and food quality and H23 insect and pest control activities, which are all points that should exhibit good practice conditions within the facility.

System Awardable Levels
Healthcare facilities applying the proposed rating system, whether new or existing, can achieve one of four possible award levels through implementing the criteria with the credit points. These points however cannot be calculated without first complying with the general prerequisites and the prerequisites of each of the energy, water and habitat categories.  comparison to the LEED which awards the platinum level with 80+ points, this difference aims to make the level more achievable to encourage the implementation within the Egyptian context.

Conclusions
Universal healthcare is one of the focus points of the 2030 SDGs worldwide, and the eradication of the causes of health conditions deterioration is also clarified by several international organizations. Considering the potential for the Healthcare sector expansion to satisfy the service availability need, especially in developing countries like Egypt, it is recommended that the healthcare facilities lead to the way towards sustainable operation. Sustainability in relation to healthcare facilities aims to reduce the facilities' impact on the environment, without an added economic burden while maintaining or even improving the service quality provided to the society.
To support the healthcare facilities in this transition, a sustainability rating system is proposed addressing the three main issues of energy, water and habitat in a simplified form suitable for the current targeted implementation levels, and at the same time based on the lessons learned from the international Green buildings rating systems that have been long in operation. The rating system is prepared following the cradle-to-cradle concept of consumption with a focus on all materials life cycle maximization, which is different from the efficient buildings concept that is usually followed by existing systems.