Decarbonizing the Spanish Health System: A Qualitative Study on the Implementation of Environmental Regulations and Management Strategies in Health Institutions

<b>Background/Objectives</b>: The healthcare sector, despite its mission to protect health, is a major consumer of resources and emitter of greenhouse gases, giving rise to an ethical and governance paradox: how to reconcile the duty of care with the environmental impact of its activities. In the Spanish healthcare system, which is highly decentralized and regulated at multiple levels, this tension shapes the implementation of environmental policies. This study analyzes the governance and implementation of environmental regulations in Spanish healthcare institutions and the associated experiences. <b>Methods</b>: A qualitative, exploratory, descriptive study was conducted using effective meetings and semi-structured interviews with 20 participants, working in healthcare provision and environmental management within health institutions, across different regions of Spain, between September 2024 and November 2025. In addition, a documentary analysis of relevant regulations was undertaken. <b>Results</b>: The results indicate that Spanish healthcare institutions improve their environmental performance through the implementation of standards such as ISO or EMAS, although their adoption varies according to each institution's level of development in environmental management. In addition, differences were observed in the environmental dynamics of healthcare institutions, linked to the decentralization of the Spanish healthcare system, as well as administrative barriers to accessing funding and gender disparities in environmental leadership. <b>Conclusions</b>: The standardization of environmental regulations and measures across the country, along with strengthening organizational capacity, could strengthen progress toward more sustainable healthcare.