Green Hospital Implementation for Sustainable and Resilient Health Systems in Low- and Middle-Income Countries: A Scoping Review

Abstract

Introduction. Health care both protects population health and drives environmental harm through energy use, waste, and greenhouse-gas emissions. The Green Hospital concept links environmental sustainability with hospital resilience, but evidence from low- and middle-income countries (LMICs) is fragmented. Objective. To map evidence on Green Hospital implementation in LMICs; identify enablers and barriers; characterize measurement approaches; quantify reporting of health, economic, and equity outcomes; and synthesize a conceptual framework of pathways from governance to population health. Methods. Scoping review following PRISMA-ScR, registered on the Open Science Framework (https://doi.org/10.17605/OSF.IO/F2BR5). PubMed/MEDLINE, Scopus, and ScienceDirect were searched for English-language peer-reviewed empirical studies published from January 2009 to October 2025 from countries classified by the World Bank (FY2025) as low-, lower-middle-, or upper-middle-income. Screening and charting were performed in duplicate. Results. Twenty-nine studies were included, concentrated in lower-middle-income settings (20/29), Sub-Saharan Africa (11/29), and South Asia (7/29). Implementation clustered in waste management, water and sanitation, energy efficiency, and green infrastructure, with limited resilience integration. Leading enablers were leadership commitment, regulatory support, and institutional awareness; leading barriers were financial constraints, weak technical capacity, fragmented governance, and non-standardized indicators. Life-cycle assessment and multi-criteria decision-making predominated. Three gaps were quantified: one study reported a population health outcome, and only as a cross-sectional association; three reported cost data and none a formal economic evaluation; none disaggregated findings by occupational group, rurality or ownership. Conclusion. The literature maps a Green Hospital agenda concentrated in foundational environmental domains and weakly connected to resilience-oriented governance and performance systems. Because studies were predominantly cross-sectional, pathways from intervention to resilience and health are presented as hypothesized propositions requiring testing. The next priority is to align harmonized environmental key performance indicators with hospital accreditation.