Towards circular healthcare: A qualitative exploration of approaches and implementation factors in Dutch hospitals.

Background: Healthcare is a major contributor to environmental pollution, mainly due to high resource use and a linear supply chain. In the Netherlands, healthcare consumes 13% of all abiotic raw materials and produces 4.2% of national waste. Although optimizing resource use and minimizing waste through circularity seems the way forward, it remains poorly understood. This study (1) explores how hospitals in the wider Amsterdam region approach circularity, and (2) identifies factors influencing implementation. Methods: Semi-structured interviews, informed by an implementation framework, were conducted with hospital staff in roles relevant to circularity implementation. Interviews continued until data saturation. Verbatim transcripts were coded and thematic analysis was applied. Results: Nineteen staff from twelve hospitals were interviewed. Institutionalization of circularity varied widely, from structured approaches with strategies, coordination, monitoring, and budgets to more fragmented, project-based efforts driven by individual champions. Key factors influencing implementation included bottom-up motivation, top-down support, infection prevention, internal and external collaboration, supply-chain dependency, policies, and regulations. Conclusion: Hospitals in the wider Amsterdam region are motivated to contribute to the circular transition, with staff organizing green teams and other bottom-up initiatives with varying levels of organizational support. Yet bottom-up momentum alone is insufficient. Because environmental benefits of circularity accumulate largely at the societal level while hospitals bear operational, financial, and infection-prevention risks, progress requires stronger top-down engagement and system-level changes. Additionally, regulations and policies need to address the absence of affordable circular alternatives, dependence on incumbent linear-economy suppliers, and showcase co-benefits of circularity to hospital management, regulatory bodies, and health insurers.