Sustainability is an important point of attention for the public at large, for governments, and for the healthcare system [1-3]. Previously, the term sustainability has been mostly related to environmental degradation [4]. Nowadays, the significance of sustainability has evolved and is related to other aspects, such as the well-being of patients, healthcare employees, and the community. Hence, a sustainable structure should be defined as a one that ensures preservation of resources, is practical from ecological, social, and economical perspectives, and meets the interests of different stakeholders. There is sufficient literature suggesting methods for improving sustainability in healthcare systems; however, there is no consensus on feasible strategies for implementing the proposed sustainability measures in clinical laboratories despite several opportunities [1-3].

In this review article, we present the state of the art in research on sustainability practices in the healthcare sector based on an exploration of the scientific literature and showcase the most suitable practices to support their hastened implementation. We also challenge conventional sustainability practices in the healthcare sector and remind managers of their responsibility not only to follow best practices but also to manage environmental and economic impact for the benefit of the larger community. Furthermore, we discuss the relation between laboratory strategies and sustainability, topics not discussed often enough in the scientific literature.

The meaning of sustainability is constantly evolving in this rapidly changing world. One of the very first official articulations of sustainable development was made in the Burtland Report, published by the United Nations in 1987, in which sustainable development was defined as “development that meets the needs of the present without compromising the ability of future generations to meet their personal needs” [2, 4]. However, this definition is largely open to interpretation, which has made it difficult to build a consensus on the topic of sustainability. The Swedish scientist Karl-Henrik Robert proposed a more practical definition [4]. According to him, an ideal society would strive to reduce the consumption of mineral and other natural resources.

The definition of sustainable development proposed by the European Union (EU) is broader and more holistic and considers the multiple facets of all sustainability policies, including economical, human, and environmental facets [4].

Healthcare structures serve to preserve and improve public health; however, their environmental impact can negatively affect wellbeing of humans and other organisms [5]. Therefore, sustainability of hospitals and healthcare structures is also key to promoting human well-being and health. However, the sustainability measures implemented in healthcare structures need to ensure that the quality of service provided by healthcare structures and access to and affordability of healthcare are not compromised, so that both businesses and customers benefit [4, 6, 7]. Another important issue to be tackled regarding sustainability in the healthcare sector is the management of waste disposal and air pollution [8]. Klangsin & Harding [9] showed how medical waste has become one of the top pollutant sources worldwide and is a major factor affecting disease spread and air, water, and soil quality in and around healthcare structures [9]. Thus, it has become imperative for healthcare organizations to have a multidisciplinary team addressing various aspects of sustainability in healthcare.

Moreover, as public healthcare has a huge impact on national economies and accounts for 23.7% of employment in the EU [10], sustainability measures in the healthcare sector are also needed to reduce its negative impacts on the national environment and economy [3].

Sustainable thinking has already been introduced in the laboratory community, and multiple means have been proposed, through which clinical laboratories can establish sustainable development goals and reduce their environmental impact (Table 1) [11].

Most industry analysists will understand that attaining optimal delivery while minimizing environmental risk requires substantial planning. Being environmentally aware and accountable is no longer a bonus or a status symbol; it is something that is increasingly being demanded by our society, making it a key component of rather than an added value to a service [2].

Hospitals, health practitioners, and the laboratory medicine community should lead the shift to carbon neutrality by decreasing their environmental footprint and implementing efficient approaches to address the effects of climate change and pollution without compromising the quality of healthcare [19].

Considering that healthcare accounts for approximately half of the EU government’s expenditure [10], sustainable procurement and sale of materials for the healthcare sector is an opportunity for EU government and healthcare users to strategically attain sustainable growth goals [19]. With more than 15,000 hospitals in the EU [20], the European healthcare industry can play a major role in affecting the supply and demand of healthcare products and in leading the shift to safer, more creative, and more viable goods and services.

The major focus of governments and the healthcare sector should be on the six domains of healthcare waste identified by the Institute of Medicine and by Berwick and Hackbarth, which include failure of care delivery, failure of care coordination, overtreatment or low-value care, pricing failure, fraud and abuse, and administrative complexity [21]. Recently, Shrank, et al. [21] estimated that the cost of waste disposal in the US healthcare system ranged from $760 billion to $935 billion, accounting for approximately 25% of the total healthcare expenditure; thus, sustainable practices in healthcare waste disposal should also be implemented.

Several actions are envisioned in the pursuit of sustainability (Fig. 1) [22, 23]:

The European Green Deal (EGD) Investment Plan, also known as the Sustainable Europe Investment Plan, will mobilize at least €1 trillion for sustainable investments over the next decade to achieve its objectives, which aim at making Europe the world’s first climate-neutral continent by 2050 [24]. To achieve this goal, renewable power sources should become the main sources of energy in the EU. However, the effectiveness of the EGD depends on the involvement of all EU stakeholders. The European Commission has already taken some initiatives focusing on hospitals and healthcare stakeholders, such as “Towards Zero Carbon Hospitals with Renewable Energy Systems” [25], which aim to reduce CO₂ emissions from the 15,000 hospitals in Europe by providing them suitable tools to achieve greater sustainability. Their relatively high energy requirements make hospitals an ideal subject for exploring non-technical barriers to energy efficiency measures and renewable energy systems. However, in contrast to new hospitals, which can be designed to be energy-efficient, existing EU hospitals will need to focus on reducing energy consumption and exploiting renewable energy sources to achieve the long-term CO₂-reduction targets set by the European Commission. Further, a high-quality “Guide for European Hospitals on Renewable Energy” targeting decision-makers and based on good practices and lessons learned from regional hospitals has been developed and widely distributed [26]. This initiative incentivizes the pursuit of sustainability in healthcare structures and promotion of environment-friendly attitudes among all healthcare stakeholders, which can benefit the whole system.

The relation between sustainability and healthcare is a current research topic and needs to be applied more deeply to laboratory medicine. We hope to increase awareness about sustainability in healthcare from a holistic point of view and grow the body of literature on this important topic. Maintaining a sustainable healthcare system while providing high-quality, effective, and safe healthcare is a major economic and social challenge for healthcare services and consumers. The cost-saving potential of a more efficient use of energy and other resources in healthcare systems is clear; yet, there is a long way to go for environment-friendly hospitals, healthcare structures, and clinical laboratories to become the norm. Good collaboration among the EU healthcare systems and a common vision for future actions would help achieve such goals. Due consideration should be given to the environment and healthcare in EU policies, and any strategy for achieving a sustainable future for Europe will have to consider their interconnectedness. In line with its values, the EU should seek to promote the well-being, security, and interests of European citizens, and sustainability will have to continuously inspire the European Commission’s political decisionmaking and guide the development of the post-EU2020 growth strategy.

The global environmental crisis will only worsen unless all societal implementors are held accountable for the true cost and risk of polluting nature and its consequences to the public and the environment. Too much responsibility for reducing environmental footprints is currently focused on citizens and waste management, and efforts made by individuals will remain insufficient unless action is taken across the entire value chain.. Acting too late in reducing our environmental footprint will pose major public health and environmental risks. Solutions, ranging from waste reduction to collection and recycling, to avoid the impending environmental crisis can be implemented only if all stakeholders are held accountable for their actions and the impact of these on the environment.