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Journal of Environmental Accounting and Management
António Mendes Lopes (editor), Jiazhong Zhang(editor)
António Mendes Lopes (editor)

University of Porto, Portugal


Jiazhong Zhang (editor)

School of Energy and Power Engineering, Xi'an Jiaotong University, Xi'an, Shaanxi Province 710049, China

Fax: +86 29 82668723 Email:

Environmental Assessment of Healthcare Facilities in the Global South -- A Case Study from Pakistan

Journal of Environmental Accounting and Management 9(3) (2021) 285--297 | DOI:10.5890/JEAM.2021.09.006

Mustafa Ali$^{1,2}$, Silvio Cristiano$^{3,4,5 }$ , Yong Geng$^{6,7,8}$, Francesco Gonella$^{4,5}$, Sergio Ulgiati$^{9,10}$

$^{1 }$ School of Environmental Science and Engineering, Shanghai Jiao Tong University, Shanghai, China

$^{2 }$ The Pentland Centre for Sustainability in Business, Lancaster University, Lancaster, United Kingdom

$^{3 }$ Department of Environmental Sciences, Informatics and Statistics, Universit`{a} Ca' Foscari Venezia, Venice, Italy

$^{4}$ Research Institute for Complexity, Universit`{a} Ca' Foscari Venezia, Venice, Italy

$^{5 }$ Department of Molecular Sciences and Nanosystems, Universit`{a} Ca' Foscari Venezia, Venice, Italy

$^{6}$ School of International and Public Affairs, Shanghai Jiao Tong University, Shanghai, China

$^{7}$ China Institute for Urban Governance, Shanghai Jiao Tong University, Shanghai, China

$^{8}$ Shanghai Institute of Pollution Control and Ecological Security, Shanghai, China

$^{9}$ Department of Science and Technology, Universit`{a} degli Studi di Napoli ``Parthenope'', Naples, Italy

$^{10 }$School of Environment, Beijing Normal University, Beijing, China

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Pakistan is a resource-constrained country, poor in municipal and healthcare facilities. Existing healthcare structures in the country are often over-crowded, and an effective monitoring and assessment of their sustainability is therefore crucial. In this study, a systemic approach is outlined to evaluate the environmental sustainability of the largest and sole public hospital in the major city of Gujranwala, in the Punjab region of Pakistan. The Emergy (spelled with ``m'') Accounting (EMA) method is applied. Its operationalization allows to keep track of the amount of energy that was consumed in direct and indirect transformations to make a product or service. Relevant data include the hospital requirements in terms of energy, water, products, labor, and services. The EMA results offer a supply-side geobiosphere-oriented perspective. Emergy indicators show that the hospital is indirectly responsible for a significant stress on the environment, that might be decreased by an increased efficiency in the resource use. On the other hand, a hospital is a complex system, depending on skilled laborforce as well as on several fine imported medical products and related services, making it dependent on external socio-economic systems. The presented results address the geography dependent characteristics of the hospital, and can be used for benchmarking and future evaluation of similar hospitals within and across the region.


  1. [1] Abel, T. (2010), Human transformities in a global hierarchy: Emergy and scale in the production of people and culture, Ecological modelling, 221(17), 2112-2117.
  2. [2] Agostinho, F., Almeida, C.M., Bonilla, S.H., Sacomano, J.B., and Giannetti, B.F. (2013), Urban solid waste plant treatment in Brazil: Is there a net emergy yield on the recovered materials?, Resources, Conservation and Recycling, 73, 143-155.
  3. [3] Ahmad, R., Liu, G., Santagata, R., Casazza, M., Xue, J., Khan, K., ... and Lega, M. (2019), LCA of hospital solid waste treatment alternatives in a developing country: the case of district Swat, Pakistan, Sustainability, 11(13), 3501.
  4. [4] Ali, M., Ashraf, U., Chaudhry, N., and Geng, Y., (2017a), Unsafe waste management practices and hepatitis C among hospital sanitary staff in Pakistan, Journal of Hospital Infection, 96(1), 95-96.
  5. [5] Ali, M., Wang, W., and Chaudhry, N., (2016a), Application of life cycle assessment for hospital solid waste management: A case study, Journal of the Air & Waste Management Association, 66(10), 1012-1018.
  6. [6] Ali, M., Wang, W., and Chaudhry, N. (2016b), Management of wastes from hospitals: A case study in Pakistan, Waste management {$\&$ research: the journal of the International Solid Wastes and Public Cleansing Association, ISWA}, 34, 87-90.
  7. [7] Ali, M., Wang, W., and Chaudhry, N. (2017b), Assessment of hospital waste management in a major city of Pakistan, International Journal of Environment and Waste Management, 19, 97-104.
  8. [8] Ali, M., Wang, W., Chaudhry, N., Geng, Y., and Ashraf, U. (2017c), Assessing knowledge, performance, and efficiency for hospital waste management---a comparison of government and private hospitals in Pakistan, Environmental Monitoring and Assessment, 189, 181.
  9. [9] Almeida, C., Santos, A., Bonilla, S., Giannetti, B., and Huisingh, D. (2013), The roles, perspectives and limitations of environmental accounting in higher educational institutions: an emergy synthesis study of the engineering programme at the Paulista University in Brazil, Journal of Cleaner Production, 52, 380-391.
  10. [10] Arbault, D., Rugani, B., Tiruta-Barna, L., and Benetto, E. (2013), Emergy evaluation of water treatment processes, Ecological Engineering, 60, 172-182.
  11. [11] Brown, M. and Buranakarn, V. (2003), Emergy indices and ratios for sustainable material cycles and recycle options, Resources, Conservation and Recycling, 38, 1-22.
  12. [12] Brown, M.T., Campbell, D.E., De Vilbiss, C., and Ulgiati, S. (2016), The geobiosphere emergy baseline: a synthesis, Ecological Modelling, 339, 92-95.
  13. [13] Brown, M.T., Protano, G., and Ulgiati, S. (2011), Assessing geobiosphere work of generating global reserves of coal, crude oil, and natural gas, Ecological Modelling, 222, 879-887.
  14. [14] Brown, M.T. and Ulgiati, S. (1999), Emergy evaluation of the biosphere and natural capital, Ambio, 28 (6), 486-493.
  15. [15] Brown, M.T. and Ulgiati, S. (2001), Emergy measures of carrying capacity to evaluate economic investments, Population and Environment, 22(5), 471-501.
  16. [16] Brown, M.T. and Ulgiati, S. (2004), Emergy Analysis and Environmental Accounting A2 -- Cleveland, in Cutler, J., Encyclopedia of Energy. Elsevier: New York, pp. 329-354.
  17. [17] Brown, M.T. and Ulgiati, S. (2012), A Geobiosphere Baseline for LCA--Emergy Evaluations, Proceedings from the seventh biennial emergy analysis research conference, Gainesville, FL, p. 481-492.
  18. [18] Brown, M.T. and Ulgiati, S. (2016a), Assessing the global environmental sources driving the geobiosphere: A revised emergy baseline, Ecological Modelling, 339, 126-132.
  19. [19] Brown, M.T. and Ulgiati, S. (2016b), Emergy assessment of global renewable sources, Ecological Modelling, 339, 148-156.
  20. [20] Burki, A.A., Memon, R., and Mir, K. (2015), Multiple inequalities and policies to mitigate inequality traps in Pakistan, Oxfam International: Nairobi.
  21. [21] Campbell, D.E. and Lu, H. (2014), Emergy evaluation of formal education in the United States: 1870 to 2011, Systems, 2(3), 328-365.
  22. [22] Chung, J.W. and Meltzer, D.O. (2009), Estimate of the carbon footprint of the us health care sector, JAMA, 302, 1967-1972.
  23. [23] Climate Data (2018), Gujranwala climate. Guiranwala Weather by month / averages, 1982-2012, (accessed April 2020).
  24. [24] Cristiano, S. (2018a), Systemic Thoughts on Ecology, Society, and Labour, in Cristiano, S. (Ed.), Through the Working Class Ecology and Society Investigated Through the Lens of Labour, Ca Foscari University Press: Venice, vol. 8, pp. 9-23 (ISBN 978-88-6969-297-0; 978-88-6969-296-3).
  25. [25] Cristiano, S. (2018b), Systemic assessment for sustainable design. LCA-based EMergy synthesis of an EMERGENCY NGO hospital in Sudan, PhD thesis in Architecture, City, and Design. Universit\`{a} Iuav di Venezia: Venice.
  26. [26] Cristiano, S., Falchetti, C., Miacola, F., Dinatale, V., Ronco, F., Savio, R., Schiavon, D.I., Bindi, V., and Deriu, M. (2018), Cooperation beyond development. Rethinking international aid for the self-determination of recipient communities, Journal of Universities and international development Cooperation, volume 1/2018.
  27. [27] Cristiano, S. and Gonella, F. (2019), To build or not to build? Megaprojects, resources, and environment: an emergy synthesis for a systemic evaluation of a major highway expansion, Journal of Cleaner Production, 223, 772-789.
  28. [28] Cristiano, S. and Gonella, F. (2019), Learning from hybrid innovative-vernacular solutions in building design: emergy analysis of Sudanese energy-saving technologies, Journal of Environmental Accounting and Management, 7(2), 209-223.
  29. [29] Cristiano, S., Gonella, F., Elia, C., Nannini, E., and Ulgiati, S. (2017), Downscaling the need for common resources while saving money. Lessons from an innovative socio-sanitary structure run by a humanitarian NGO: Emergencys Salam hospital in Khartoum, Sudan, 12th Conference of the European Society for Ecological Economics - Ecological Economics in action: building a reflective and inclusive community, Budapest, Hungary.
  30. [30] Cristiano, S., Ulgiati, S., and Gonella, F. (2021), Systemic sustainability and resilience assessment of health systems, addressing global societal priorities: learnings from a top nonprofit hospital in a bioclimatic building in Africa, Renewable and Sustainable Energy Reviews, 141, 110765.
  31. [31] De Vilbiss, C.D. and Brown, M.T. (2015), New method to compute the emergy of crustal minerals, Ecological Modelling, 315, 108-115.
  32. [32] Dietz, T., Ostrom, E., and Stern, P.C. (2003), The struggle to govern the commons, Science, 302, 1907-1912.
  33. [33] Garc\{\i}a-Sanz-Calcedo, J. (2014), Analysis on Energy Efficiency in Healthcare Buildings, Journal of Healthcare Engineering, 5(3), 361-374.
  34. [34] Gonella, F., Elia, C., Cristiano, S., Spagnolo, S., and Vignarca, F. (2017), From Head to Head: an Emergy Analysis of a War Rifle Bullet, Peace Economics, Peace Science and Public Policy, 23(3).
  35. [35] Gujranwala R&D Cell (2010), Research Thesis on Gujranwala District. (accessed December 2016).
  36. [36] He, S., Zhu, D., Chen, Y., Liu, X., Chen, Y., and Wang, X. (2020), Application and problems of emergy evaluation: A systemic review based on bibliometric and content analysis methods, Ecological Indicators, 114, 106304.
  37. [37] IEA - International Energy Agency (2016), Recent trends in the OECD: energy and CO2 emissions.{\_}Trends{\_}in{\_}the{\_}OECD.pdf (accessed April 2017).
  38. [38] IEA - International Energy Agency (2018), Pakistan, Key Energy Statistics 2018 (, accessed January 2019).
  39. [39] Jafri, S. and Khattak, A. (1995), Income inequality and poverty in Pakistan, Pakistan Economic and Social Review, 33(1/2), 37-58.
  40. [40] Japan International Cooperation Agency (2015), Project for integrated solid waste management master plan in Gujranwala: final report - Supporting report. http://open{\_}{\_}117{\_}12246336.html (accessed December 2018).
  41. [41] JICA (2012), Lahore Urban Transport Master Plan in the Islamic Republic of Pakistan, Final Report Volume I&II. {} (accessed March 2019).
  42. [42] Lou, B., Qiu, Y., and Ulgiati, S. (2015), Emergy-based indicators of regional environmental sustainability: A case study in Shanwei, Guangdong, China, Ecological Indicators, 57, 514-524.
  43. [43] Lupinacci, D.M. and Bonilla, S.H. (2018), Exploring approaches and dimensions of human transformity through an educational case, Ecological Modelling, 368, 336-343.
  44. [44] Kamp, A., Morandi, F., and {\O}sterg{\aa}rd, H. (2016), Development of concepts for human labour accounting in Emergy Assessment and other Environmental Sustainability Assessment methods, Ecological Indicators, 60, 884-892.
  45. [45] Kemal, A.R. (2006), Income Inequalities in Pakistan and a strategy to reduce income inequalities, Background Paper for PRSP-II, PRSP Secretariat, Government of Pakistan.
  46. [46] Kugelman, M. (2015), Pakistans Interminable Energy Crisis: Is there any way out? publication/pakistans-interminable-energy-crisis-there-any-way-out (accessed April 2017).
  47. [47] Malik, A., Mufti, A., Hiser, H., and Veziroglu, N. (1998), Solar mapping of Pakistan using visible images from geostationary satellites. Renewable Energy, 13, 1-16.
  48. [48] Marvuglia, A., Benetto, E., Rios, G., and Rugani, B. (2013), SCALE: Software for CALculating Emergy based on life cycle inventories, Ecological Modelling, 248, 80-91.
  49. [49] Mehmood, A., Waqas, A., and Mahmood, H.T. (2013), Stand-alone PV system assessment for major cities of Pakistan based on simulated results: a comparative study, NUST Journal of Engineering Sciences, 6(1), 33-37.
  50. [50] Meng, F., Liu, G., Yang, Z., Hao, Y., Zhang, Y., Su, M., and Ulgiati, S. (2016), Structural analysis of embodied greenhouse gas emissions from key urban materials: A case study of Xiamen City, China, Journal of Cleaner Production, 163, 212-223.
  51. [51] Meo, M.I., Haydar, S., Nadeem, O., Hussain, G., and Rashid, H. (2014), Characterization of hospital wastewater, risk waste generation and management practices in Lahore, Proceedings of the Pakistan Academy of Sciences, 51, 317-319.
  52. [52] Miller, P., de Barros, A.G., Kattan, L., and Wirasinghe, S.C. (2016), Public transportation and sustainability: a review. KSCE Journal of Civil Engineering, 20, 1076-1083.
  53. [53] Minallah, M., Ghaffar, A., Rafique, M., and Mohsin, M. (2016), Urban growth and socio-economic development in Gujranwala, Pakistan: A geographical analysis, Pakistan Journal of Science, 68(2), 176.
  54. [54] Mohiuddin, O., Asumadu-Sarkodie, S., and Obaidullah, M. (2016), The relationship between carbon dioxide emissions, energy consumption, and GDP: A recent evidence from Pakistan. Cogent Engineering, 3, 1210491.
  55. [55] Naveed, A., Wood, G., and Ghaus, M. U. (2016), Geography of Poverty in Pakistan. PPAF{\_}SDPI{\_}Report{\_}%20Geography{\_}of{\_}Poverty{\_}in{\_}Pakistan.pdf (accessed December 2019).
  56. [56] Odum, H.T. (1973), Energy, ecology, and economics, Ambio, 2 (6), 220-227.
  57. [57] Odum, H.T. (1996), Environmental Accounting: Emergy and Environmental Decision Making, John Wiley and Sons: New York, NY.
  58. [58] Ohnishi, S., Dong, H., Geng, Y., Fujii, M., and Fujita, T. (2017), A comprehensive evaluation on industrial & urban symbiosis by combining MFA, carbon footprint and emergy methods---Case of Kawasaki, Japan, Ecological Indicators, 73, 513-524.
  59. [59] Punjab Bureau of Statistics (2015), Punjab Development Statistics. (accessed December 2016).
  60. [60] RAFTAAR (2016), Energy in Pakistan: chronic shortages, concrete solutions. img/DFID{\_}PDF.pdf (accessed April 2017).
  61. [61] Ripa, M., Fiorentino, G., Vacca, V., and Ulgiati, S. (2017), The relevance of site-specific data in Life Cycle Assessment (LCA). The case of the municipal solid waste management in the metropolitan city of Naples (Italy), Journal of Cleaner Production, 142, 445-460.
  62. [62] Ritchie, J. and Dowlatabadi, H. (2014), Understanding the shadow impacts of investment and divestment decisions: Adapting economic input--output models to calculate biophysical factors of financial returns, Ecological Economics, 106, 132-140.
  63. [63] Santagata, R., Zucaro, A., Viglia, S., Ripa, M., Tian, X., and Ulgiati, S. (2020), Assessing the sustainability of urban eco-systems through Emergy-based circular economy indicators, Ecological Indicators, 109, 105859.
  64. [64] Spagnolo, S., Chinellato, G., Cristiano, S., Zucaro, A., and Gonella, F. (forthcoming), Sustainability assessment of bioenergy at different scales: an Emergy Analysis of biogas power production.
  65. [65] Sustainable Development Commission (2009), NHS England carbon emissions carbon footprinting report. (accessed March 2017).
  66. [66] Sweeney, S., Cohen, M.J., King, D., and Brown, M.T. (2007), Creation of a global emergy database for standardized national emergy synthesis, Emergy Synthesis, 4, 483-497.
  67. [67] Tao, W. and Shen, Z. (2008), Heat flow distribution in Chinese continent and its adjacent areas. Progress in Natural Science, 18(7), 843-849.
  68. [68] Ulgiati, S. and Brown, M.T. (2012), Labor and services, Proceedings of the 7th biennial emergy conference. Center for Environmental Policy, University of Florida: Gainesville,pp. 557-562.
  69. [69] U.S. Energy Information Administration (2007), Energy Characteristics and Energy Consumed in Large Hospital Buildings in the United States in 2007. (accessed December 2019).
  70. [70] The Climate Data Factory (2019), Wind speed -- Gujranwala (Pakistan). (accessed April 2020).
  71. [71] The Nation (2017), Governmentt spends less GDP on health: Survey. (accessed December 2017)
  72. [72] Viglia, S., Civitillo, D.F., Cacciapuoti, G., and Ulgiati, S. (2018), Indicators of environmental loading and sustainability of urban systems. An emergy-based environmental footprint, Ecological indicators, 94, 82-99.
  73. [73] Wolf, D. and Lundholm, J.T. (2008), Water uptake in green roof microcosms: Effects of plant species and water availability, Ecological Engineering, 33(2), 179-186.
  74. [74] World Inequality Database (2020), Middle 40% national income share, Pakistan, 1990-2019. country/pakistan/ (accessed November 2020).