Green Servitization in the Single-Use Medical Device Industry: How Device OEMs Create Supply Chain Circularity through Reprocessing

Abstract

Establishing a circular supply chain for single-use medical devices would make a significant contribution to reduce health care-generated emissions. One way in which this can be accomplished is to apply the possibility of device recovery through high-level disinfection and sterilization (a process referred to as ‘reprocessing’). As increasing emphasis is being placed on reducing health care-generated emissions, several major OEMs of single-use medical devices have extended their business to reprocessing services, taking a green servitization orientation. The present paper examines the trend towards green servitization in the single-use medical device industry. It uses interviews with industry experts, complemented with information from secondary sources, to explore how the green servitization phenomenon is supporting the transition of the industry to a more sustainable economic model. The findings provide insights into the green servitization endeavors of device OEMs as regards services offered, strategic intents, dominant business models, use of collaborative relationships and capability requirements. The paper reveals that single-use device OEMs may have started to understand the perspective and the long-term market share gains of combining a service model and a manufacturing model, making reprocessing an integrated part of how they think about how to design, produce and deliver their products.

1. Introduction

The health care sector provides an essential social function, but it is also one of the most polluting industries worldwide [1,2,3]. It is responsible for almost five percent of global carbon dioxide emissions [4,5]. Pollution from the health care sector is estimated to result in 614,000 disability-adjusted life years lost in the United States every year [4], 23,000 in Canada [6] and more generally in a considerable disease burden in all developed nations. Over 70 percent of health care emissions are generated within the supply chain, through the production, transport and disposal of goods and services purchased by health care facilities, such as pharmaceuticals, hospital equipment, instruments and medical devices [5]. Medical devices, in particular, are the major area of supply chain emissions in health care supply chains, which makes acting on their climate footprint a top priority to decarbonize health care.

Starting from the 1980s, single-use (or disposable) products have increasingly become the standard choice for medical devices. While they reduce liability and complexity for hospitals [7], single-use medical devices are emblematic of the ‘take, make and dispose’ model of linear economies, which results in vast amounts of waste and emissions, with associated environmental and public health damage [4,8]. Establishing a circular supply chain for single-use medical devices would make a meaningful contribution to reduce health care-generated emissions as part of the formal pledge by many countries worldwide to move towards a more sustainable health care [9]. In line with the circular economy framework, circular supply chains focus on “prolonging product, component and material life cycles through coordinated forward and reverse supply chains” [10] (p. 709). One way to drive circularity in the supply chain of single-use medical devices is to apply the possibility of hygienic recovery through decontamination, high-level disinfection, cleaning and sterilization, if required (a process referred to as ‘reprocessing’). Though labelled as single use by their Original Equipment Manufacturer (OEM), many types of single-use devices can be reprocessed one or more times, allowing to extend their life and generate environmental and economic benefits. Reprocessing is a permitted and a regulated practice in several developed nations, including the United States, Canada, Japan and Australia. It is currently regulated also in the European Union, though individual Member States may decide not to allow reprocessed single-use devices in their territory. Historically, reprocessing of single-use medical devices was performed in-house by hospitals until it became regulated; at that point, it moved to third-party reprocessors, who specialize in reprocessing capabilities and take over the risk of device reuse [4,11]. However, in the last few years, several device OEMs (including Stryker, Johnson & Johnson, Medline and Cardinal Health) have expanded into reprocessing, offering health care facilities the opportunity to purchase both devices and their reprocessing from the same provider. By doing so, these OEMs have taken a ‘green servitization’ orientation.

In general terms, servitization refers to a strategy where manufacturing firms extend their business into services as a way to develop new revenue streams and generate greater value for their customers [12,13]. Instead of focusing exclusively on developing and selling physical products, servitized manufacturers extend their business proposition to value-added services that support customer processes throughout the product life cycle [14]. The notion of green servitization has been recently introduced for servitization strategies of manufacturing companies that are based on the offering of green services; that is, services that are explicitly aimed at helping achieve ecological sustainability objectives [15]. The reprocessing services offered by OEMs of single-use medical devices clearly fall within the category of green services.

The extant literature on servitization indicates that manufacturers’ service offerings may include several types of green services related to product recovery, including maintenance, modernization and upgrade, retrofitting, remanufacturing, refurbishing and recycling (e.g., [16,17,18]). However, prior research has considered manufacturers’ service offerings to be aimed at facilitating customers in purchasing and using products or at improving product operational performance, and the delivery of green value has largely been overlooked. It is only recently that scholars have begun to refer to the notion of green servitization and to explore its implementation. In particular, Opazo-Basádez et al. [19] explore the interplay between green and digital servitization in the automotive industry. Marić and Opazo-Basádez [20] examine the implementation of green services in the area of reverse logistics by manufacturers in the electronics and computer industry. Paiola et al. [21] investigate how digital technologies may enable the delivery of green services by manufacturers of packaging machinery equipment and commercial refrigerators. Finally, the environmental potential of servitization has been touched upon by Agrawal and Bellos [22] and Örsdemir et al. [23], though in these latter studies servitization is assumed to imply the adoption of a pay-per-use business model (cf. [24]), which is not always the case. This study contributes to the emerging field of green servitization by examining the adoption of such business strategy by OEMs of single-use medical devices. Given the importance of reducing the environmental footprint of the health care sector and the potential of green servitization of device OEMs to foster the transition of the sector to a more circular economy model, this study seeks to address the following research question: what are the characteristics of green servitization implementation in the single-use medical device industry? This is a relevant question to raise as green servitization has proven to have different outlooks according to the industry in which it is implemented [25]. The medical device industry, in particular, presents particular challenges compared to other industries as strict infection control and quality requirements must be met in order to protect patient health [11,26].

The present paper uses interviews with senior executives at member companies of the Association of Medical Device Reprocessors (AMDR), complemented with information from secondary sources, to gain insights into the green servitization endeavors of single-use device OEMs as regards the services offered, the strategic intents, the dominant business models, the use of collaborative relationships and the capability requirements. The remainder of this section provides an introduction on the issue of sustainability in health care and on the circular economy opportunities offered by reprocessing of single-use medical devices. It further illustrates the notions of servitization and green servitization. Next, the method employed for the empirical research is presented, followed by a discussion of the empirical findings. The paper concludes with theoretical and practitioner contributions, and directions for future research.

1.1. Sustainability in the Medical Device Industry

Due to its size and processes, the health care sector has a major environmental footprint [1,3]. It has been reported that the carbon dioxide emissions from health care account for almost five percent of the global total [4,5]. Health care emissions have been estimated at 8.5 percent of the national-level greenhouse gas emissions in the United States [2], 6.7 percent in Switzerland, 6.4 percent in Japan [5] and 5.4 percent in the United Kingdom [27]. The health sector’s environmental footprint is under constant upward pressure from a growing global population, ageing demographics and improved access to health care services in emerging and developing countries, all of which increase the demand for health care [1,26,28,29]. This is compounded by the adoption of increasingly advanced medical technologies, equipment and procedures, which are often highly energy- and resource-intensive [1,5].

Sustainability initiatives in the health care industry have historically lagged behind those in other industries, overshadowed by a primary (and legitimate) focus on improving quality and efficacy of medical care [8]. Yet, attention to environmental aspects and other sustainability issues in health care has been growing considerably in recent years [29,30]. Achieving the so called ‘sustainable health care’ or ‘climate-smart health care’ has started to represent an important concern for research, practice and policy [1]. Research studies have focused on quantifying environmental emissions from the health care sector, showing how these emissions are trending over time and estimating the associated public health damage (e.g., [2,31]). There are several non-profit organizations (e.g., Health Care Without Harm, the Centre for Sustainable Healthcare, the Nordic Center for Sustainable Healthcare) that are dedicated to promoting a sustainable approach to the health care sector. Policy discussions have started acknowledging the need to steer the health care industry on a more sustainable path and 45 countries, including some of the biggest carbon emitters such as the United States, have recently made a formal commitment to take concrete steps to cut greenhouse gas emissions across their health systems [9].

The vast majority of health care emissions is attributable to supply chain activities (‘Scope 3’ emissions) associated with the production, transport and disposal of health care-related goods and services. Eckelman et al. [2] estimate that supply chain emissions contribute approximately 80 percent of the total greenhouse emissions from the health care sector in the United States. Parallel assessments from Health Care Without Harm [5] indicate that 71 percent of health care’s global carbon footprint is concentrated in the supply chain. Medical devices, in particular, account for a sizable portion of emissions from health care supply chains (e.g., [2,27,32]) and are, therefore, an important area for environmental improvements. It is reported that health care waste stands at 100 million tons per year globally, and about 10 percent of it concerns medical devices [26].

The application of circular economy principles to product life cycle management of medical devices is widely seen as the best approach for improving their environmental efficiency [8,28,33]. In contrast to a linear (or ‘take-make-use-dispose’) model, whereby the value of embedded materials and energy disappears with product consumption or use [4,34,35], a circular economy model is “designed to eliminate waste through cycles of assembly, use, disassembly and re-use, with virtually no leakages from the system in terms of disposal or ever recycling” [17] (p. 130). Rather than following a linear path from production to use and disposal, manufactured products flow in closed loops consisting of repair/reuse, refurbishing/remanufacturing, repurposing and recycling, ‘extending’ resource value and minimizing waste generation [36]. A circular economy system minimizes resource input and waste, emissions and energy leakages by making reverse cycles of reuse, remanufacturing and recycling of products and materials as normal and efficient as linear, forward flows [34,37,38]. In practice, a circular economy approach is aimed at keeping manufactured products and used materials in the economic system for as long as possible [35,39] by slowing and closing resource flows. This offers the promise of efficiencies and savings as the highest possible utility of products and materials is enabled at all times [33]. Therefore, in the circular economy model, there is also a promise to generate economic value in addition to reducing the environmental impact of resource use [34,39].

The transition to a circular economy can be pursued along two different directions: with an economy-wide focus (e.g., local, national, transnational); or with a focus on specific industrial sectors, products or materials [40]. When the focus is on the health care sector and on such products as medical devices, there are particular challenges compared to other industries and products as strict hygienic and quality requirements must be met to protect patient health [11,26]. Circulation of products and materials, i.e., the creation of environmental and financial value through closed-loop chains, must ensure that product functionality and hygienic condition are unaffected as any increase in risk may endanger patient health [28]. Strict regulations are in place that aim to minimize the risks associated with medical devices and provide assurance of safety and good functioning [11].

1.2. Medical Devices and Single-Use Medical Devices

Medical devices include all devices intended to be used specifically for medical (diagnostic and/or therapeutic) purposes that do not achieve their primary intended action by biological or chemical means. This definition covers a wide range of devices, that vary significantly in level of associated risk, design complexity and usage characteristics [8]. Examples range from low-risk, low-complexity devices such as stethoscopes, thermometers and compression hosieries, to high-risk, high complexity devices such as infusion pumps and prosthetic heart valves.

In the past, medical devices were typically intended for multiple uses; that is, most medical devices were designed to be reused after hygienic recovery through disinfection and sterilization [7]. However, starting from the 1980s, advances in materials science and manufacturing technologies have made it viable to manufacture many such devices using low-cost plastic materials (especially polymers, high-density polyethylene and low-density polyethylene), provided that they were discarded after one single-use on a patient [28]. If the devices are intended to be used once and then disposed, polyethylene-based plastics allow for limited device costs without being less effective than stronger, more durable materials [41]. Single-use medical devices have rapidly become widely utilized, particularly in high-income countries [28,35]. A primary driver for this has been a generalized perception that disposable devices reduce the risk of health care-acquired infections and are, therefore, safer than reusable alternatives [4,42]. Many health care systems have resorted to single-use devices with the purpose of minimizing liability and complexity [7]. In addition, as hospitals have increasingly moved to just-in-time ordering (a practice that is being heavily questioned after the COVID-19 pandemic for its lack of resiliency to demand and supply disruptions), single-use devices align with the purpose of cutting infrastructure and inventory costs [4]. Nevertheless, to label a device as reusable, in addition to devising validated cleaning instructions, the original equipment manufacturer (OEM) must provide evidence that the device can be safely and reliably cleaned, disinfected and/or sterilized after use on a patient, while there are no regulatory requirements for devices that are marketed as single use [43]. This has provided a strong incentive for device OEMs to label devices for single use because of the lower liability and regulatory burden [4]. Single-use medical devices are clearly emblematic of the ‘take, make and dispose’ model of linear economies, which results in vast amounts of waste and emissions, with associated environmental and public health damage [4,8]. They have been estimated to make up 90 percent of the waste generated by medical devices [32].

However, the situation is evolving rapidly and the possibility of hygienic recovery through cleaning and sterilization (a process referred to as ‘reprocessing’) has been applied to many types of single-use medical devices [4,7,28]. Though labelled as single use by their OEM and intended “to be used on an individual patient during a single procedure and then disposed of” [44] (p. 63), several types of single-use devices can indeed be reprocessed one or several times; i.e., they can be made hygienic once again after use on a patient through cleaning and high-level disinfection or sterilization. Reprocessing allows for circularity in the production–consumption process of disposable medical devices. This offers an opportunity to decrease procedure costs, enable clinical providers to provide high-quality care for more customers, as well as reducing the environmental footprint of health care supply chains [41,45]. For example, use of reprocessed single-use electrophysiology catheters may enable savings as high as $3000 per procedure. In addition, a recently published Life Cycle Assessment (LCA) analysis has found that the environmental impact of using a reprocessed single-use electrophysiology catheter is about 50 percent of the impact of using a newly manufactured one [33], despite reprocessing causes the environmental burden of transporting used devices to the reprocessing plant and back to hospital customers, using chemicals and energy to clean them, and packaging reprocessed devices before transportation to customers.

Single-use devices that may currently be reprocessed include both Class I devices, such as pressure infuser bags and ECG cables, and Class II devices, such as pulse oximeter sensors and ultrasound catheters [7]. (Classes of medical devices are recognized by regulatory authorities in each region or country by order of increased risk and level of testing that the devices are required to undergo. In the United States, the Food and Drug Administration (FDA) recognizes three classes of devices: (i) ‘Class I’ devices, which are subject to general controls; (ii) ‘Class II’ devices, which are subject to general controls and require a 510(k) premarket review process to assure that the device is substantially equivalent to an existing device that is not subject to premarket approval; and (iii) ‘Class III’ devices, which require a Premarket Approval (PMA) application including sufficient valid clinical information and scientific evidence to demonstrate that the device is safe and effective for the intended use [7]). Reprocessing of single-use medical devices is a permitted and regulated practice in several developed nations, including the United States, Canada, Japan and Australia [46]. It is currently regulated also in the European Union (Regulation EU 2017/745 (MDR)—Article 17), though individual Member States may ‘opt out’ and not allow reprocessed single-use devices in their territory or introduce national rules that are stricter than the EU regulation. Regulatory standards for single-use device reprocessing currently require the entity that reprocesses a device (health care facility, third-party or commercial firm, etc.) to devise detailed reprocessing protocols, validated operating procedures and associated quality controls to ensure that the reprocessed device is as safe and effective (i.e., able to perform the technical function) as its original version [44]. In the European Union, for example, reprocessing must be performed in accordance with ‘common specifications’ (Commission Implementing Regulation (EU) 20/1207) detailing requirements concerning risk management procedures, validation of procedures for each step of the reprocessing cycle, quality management system and reporting of incidents and traceability of devices. Full conformity assessment is required also if (as will be clear from Figure 1) a ‘pure’ service model is adopted, and reprocessed devices are in their entirety returned to the health institution from which they were collected. The reprocessor must assume the same obligations as a device OEM and take responsibility for device quality and performance [47,48,49]. In the United States, for example, reprocessors must obtain device-specific clearance from FDA and, like OEMs, are required to submit a 510(k) notification to reprocess a Class II device and a PMA application, including validation data regarding cleaning, disinfection and sterilization, to reprocess a Class III device. They must meet adequate standards of safety and documentation to reprocess a Class I device.

The trend toward reprocessing reusable devices has matched recent developments in the health care industry. These include the rise in minimally invasive surgery, where single-use devices find common use and spiraling costs of such devices due to increasing technological content and complexity [7,35,45]. These developments have been compounded by increasing financial pressures on health care providers and, particularly in the United States, managed care placing limits to the costs of procedures and treatments [43]. Public consciousness of the environmental consequences of relying on single-use medical devices is also playing a role in leading health care facilities to entertain the possibility of reprocessed alternatives [11,43].

In the current landscape, reprocessing of disposable medical devices is most commonly performed by third-party or commercial firms, who specialize in reprocessing capabilities and take over the clinical risk of device reuse [4,11]. Leaning on third-party reprocessing, hospitals and other health care facilities can avoid the cost and complexity of developing and managing the reprocessing infrastructure (sterilization equipment, trained staff, quality assurance, process documentation) and obtain the necessary clearances from the relevant regulatory agency [50]. Figure 1 is drawn from a report recently issued by the Association of Medical Device Reprocessors and illustrates the provision of reprocessing services for disposable devices by third-party firms [46]. Used devices are pre-cleaned and placed by hospital staff in collection boxes following specific preparation and handling protocols. Collection boxes are collected by the reprocessor’s logistic service and taken to the reprocessing facility. At the reprocessing facility, devices are inspected to isolate those that are reprocessable from those that are damaged or unsuitable for reprocessing. Devices are labelled with a unique identification code that allows to track each device through the whole process until it is re-delivered to a health care facility. Then, devices undergo cleaning and disinfection; this may involve disassembling the devices prior to the cleaning and reassembling afterwards, inspecting individual parts and replacing parts that are found defective. Once cleaned, devices undergo testing and inspection to confirm safety and functional performance. Depending on their criticality as per the Spaulding classification system, devices are then subjected to high-level disinfection or sterilization [51]. (The Spaulding classification identifies three levels of criticality of medical devices based on device invasiveness and type of contact with the patient: non-critical, semi-critical and critical devices. As the criticality presented by the device increases, the level of reprocessing necessary for hygienic recovery also increases. Non-critical devices are those that do not enter the patient body and come in contact only with intact skin (e.g., oximeters, ECG leads, blood pressure cuffs); in general, cleaning followed by low- or intermediate-level disinfection is sufficient for recovery. Semi-critical devices may contact mucus membranes or non-intact skin during use on a patient (e.g., endoscopes); reprocessing through cleaning and high-level disinfection or sterilization is necessary. Critical devices enter the vascular system or normally sterile tissues (e.g., cardiac catheters, surgical instruments); reprocessing requires cleaning followed by sterilization). Finally, devices are shipped back to hospitals and health care facility customers. Devices may be returned to the same hospital from which they were collected, or they may be sent to a different hospital. Since the reprocessors’ ability to supply reprocessed devices is limited by the availability of used devices to reprocess, health care facilities are allowed to buy reprocessed devices only in quantities that match their returns.

Regulated reprocessing threatens the traditional business model of device OEMs, which is strongly based on selling as many new, single-use devices as possible. As health care facilities turn to reprocessed single-use devices, commercial reprocessing companies take away orders for newly manufactured devices from OEMs. However, with few exceptions (e.g., Innovative Health in the cardiology field, Northeast Scientific in the intravascular field, Vanguard AG in the electrophysiology and endoscopy fields), third-party reprocessors have come to be subsidiaries of device OEMs. In practice, several major device OEMs have entered the reprocessing industry by acquiring third-party reprocessors. For example, Stryker acquired Ascent Healthcare Solutions (the then largest company in the reprocessing market) in 2009 and Hygia Health Services in 2018. Johnson & Johnson acquired the second largest reprocessor in the U.S. medical device market, Sterilmed, in 2011. Medline acquired MEDISISS in 2012 (Figure 2).

Such OEMs as Stryker, Johnson & Johnson and Medline have expanded the scope of their activities from an exclusive focus on manufacturing new devices to an expanded focus on manufacturing new devices and reprocessing used ones. They have, in actual facts, embraced green servitization into reprocessing services.

1.3. Servitization and Green Servitization

Servitization refers to a strategy where manufacturing firms extend their business into services as a way to develop new revenue streams and generate greater value for their customers [12,13]. Instead of focusing exclusively on developing and selling physical products (and, if anything, some basic product support services), servitized manufacturers leverage both product and service offerings to enhance and expand customer value. The resultant effect is greater customer orientation of market offerings and better value propositions since there is a shift in emphasis from improving product technical characteristics to streamlining and enriching the customer value creation process when using the product to address a specific need [52]. In short, the notion of customer value is expanded to include value-added ‘life cycle’ services as opposed to products alone [53,54].

The extant literature on servitization indicates that manufacturers’ service offerings may include several types of services related to product recovery, including maintenance, modernization and upgrade, retrofitting, remanufacturing, refurbishing and recycling (e.g., [16,17,18]). A classic example would be the manufacturer of heavy machinery Caterpillar. Caterpillar is often seen as leading in using digital technologies to provide data-driven maintenance and repair services. In addition, Caterpillar has an extended remanufacturing program, in which it remanufactures engine parts, drivetrains, electronics, hydraulics and other components for its construction equipment [55,56]. Notably, key Caterpillar products are designed and built to be remanufactured a number of times [57]. Despite such evidence, research has traditionally considered manufacturers’ service offerings to be aimed at facilitating customers in purchasing and using products or at improving product operational performance, and the delivery of environmental value has largely been overlooked. The main value for customer organizations lies in the possibility of obtainting support from the manufacturer in dealing with their service needs. It is only very recently that the notion of ‘green servitization’ has been introduced and has started to receive research attention.

The topic of green servitization lies at the intersection between the servitization and ecological sustainability domains. ‘Ecologically sustainable services’ or ‘green services’ are services that are explicitly intended to help achieve ecological sustainability objectives [15]. At the product level, green services are meant to offer opportunities to drive ecological sustainability throughout the product life cycle (e.g., by reducing resource consumption and amount of emissions). As such, green services represent a business proposition that may support product manufacturers in aligning their operations with environmental regulations. As a case in point, the End of Life Vehicle (ELV) Directive and the Waste Electrical and Electronic Equipment (WEEE) Directive of the European Union hold manufacturers of cars and electrical and electronic equipment responsible for end-of-use treatment of their products, for the amount and degree of product recovery, and the environmental impact of waste materials [58]. Prior studies have suggested that, in such settings, services associated with collection, remanufacturing, repurposing, recycling and disposal of product components represent green services (e.g., [19,20]). In other settings, which include the field of single-use medical device products, green services addressing ecological sustainability throughout the product life cycle are meant to support customer organizations that use the products rather than product manufacturers. Reprocessing services for single-use medical devices, in particular, enable health care facilities to improve their ecological sustainability performance by reducing the environmental footprint of their operations. In the broader view of Cocca and Ganz [15], which considers as green services also services that target social objectives, such reprocessing services deliver ‘green value’ also because, by means of reducing the cost of medical procedures, they may enable clinical providers to provide better care for more customers. More in general, green services may serve as a strategy to address environmental pressures and increasing public consciousness of environmental issues. They may further serve to improve the corporate reputation for environmental performance and corporate social responsibility which, in turn, creates sustainability-based differentiation [19,20,21]. Nevertheless, practical implementations of green services may, quite obviously, involve economic considerations. Allowing customers to achieve cost savings or revenue increases may be an important requirement or result associated with green service offerings [15].

The offering of green services drives product manufacturing firms towards green servitization, whereby services related to product recovery are provided with the explicit aim to improve the ecological sustainability of product functioning and use [19,20,21]. Therefore, green servitization refers to a business strategy that aims at providing ecological sustainability value to customers through the provision of green services.

2. Methods

2.1. Data Collection

This study is exploratory in nature as it focuses on a very specialist field, green servitization in the single-use medical device industry, in which very little research has been conducted to date [28]. Therefore, the study employs interviews with industry experts as the primary method of data collection [59]. When the research domain is still at an exploratory stage, conducting expert interviews offers a more effective approach to data collection than, for example, surveys or direct observation. This type of data collection strategy has also been acknowledged and adopted by several prior studies of servitization, including Storbacka [60], Kohtamäki et al. [61], Naik et al. [62], Raddats et al. [63] and Münch et al. [64]. A main concern expressed by prior research regarding the use of expert interviews is the question of what constitutes an expert. This study aligns with Gläser and Laudel [65] and identifies as ‘experts’ individuals who have special knowledge, competence, skills, training or role regarding the situation or process of interest. As a result, the interviewees were senior executives at four member companies of the Association of Medical Device Reprocessors (AMDR), who could provide extensive, detailed and deep insights into how the medical device industry is moving towards green servitization strategies. To minimize key informant bias, a preliminary introduction to the study and its intended purpose was circulated within AMDR to identify suitable interviewees who were willing to participate. Experts identified hold senior executive positions such as marketing director or business development manager. Of the four companies at which the interviewees were employed, two were servitized device OEMs and two were independent reprocessors. One of the independent reprocessors was based in the European Union, while the remaining companies were all U.S.-based.

As previously mentioned, the study sought to explore the trend towards green servitization in the single-use medical device industry, and how the green servitization of device OEMs is supporting the transition of the industry to a more sustainable economic model. Interviewees were, therefore, asked about their views and perceptions regarding the tendency of device OEMs to complement their product offerings with reprocessing services, market dynamics and other developments that are related to this trend towards green services and circular economy solutions. A set of open-ended questions, rather than structured queries, were used to encourage respondents to elaborate their own ideas, so as to gain access to naturally occurring data. To increase consistency, all interviews were conducted by the author. The interviews took place between February and May 2022 and lasted from 60 to 90 min. As a general rule, interviews were audio recorded and later transcribed. In one case, however, this was not possible. The interview took place as an informal conversation designed to discuss also participation in the study, and so it did not appear appropriate to ask for permission to record in this case. A total of six interviews were carried out involving five executives, since one of the interviews took place with two interviewees, and two of the interviewees were interviewed twice to deepen and extend the interpretation of the interview data. There was also one executive who shared internal company documents between the first and the second interview to help the author understand the type of contracts that are most commonly in place between OEMs or independent providers of reprocessing services and their hospital customers. Further, information from multiple secondary sources, such as the academic literature, company websites, research and consultancy reports, trade press and newspapers, was used to complement, contextualize and triangulate the primary interview data.

2.2. Data Analysis

Data analysis was conducted using the thematic analysis method [66]. This method relies on researcher judgement, rather than on quantifiable measures (e.g., number of instances across the data set that are attributable to a theme), to determine predominant or important themes in the data. The thematic analysis method has been previously used in the servitization literature by Raddats and Burton [67], Gremyr et al. [68], Salonen and Jaakkola [69], Burton et al. [70] and Naik et al. [62], among others. A deductive approach to coding was favored in order to better direct the analysis of interview transcripts and other documentation towards the study’s specific areas of interest [71]. The themes used to analyze and interpret the data are presented in

Table 1. Themes used to analyze and report the interview data.

Theme	References	Examples
Green service portfolios	Oliva and Kallenberg [72] Rabetino et al. [54] Benedettini and Neely [73] Mathieu [74]	“Sometimes the manufacturing contract does not allow for the customers to buy back products, but they still want the green, environmental piece. So, at that point, … [company X] does work for the customers and it does still collect … [Company X] does not charge for any of those collections. That is part of its service model and value proposition to customers.”
		“… [company X] sends out to its customers on a monthly basis data that shows how many devices did you collect, which kinds of devices were collected, how many devices that came from your plant were rejected because of kicks or other damage, how much money did you save, how many pounds did you divert from the landfills, and … what savings you did not realize because you either mishandled the devices or did not buy back to the quantity that you could.”
PSS business models	Reim et al. [75] Tukker [76]	“… that is our program where we do new products and reprocessed products at one fixed cost”.
		“The delivery of a total service model is typically advantageous to the buyer but just as frequently organizations are pushing back on it... So, because of this mechanism, there is a limit to how much we can go in and take over an entire activity area such as the acquisition of devices for procedures.”
Strategic intent	Aguste et al. [77]	“There is such a growing cost of healthcare, as you know… There is also significant waste and at that time reprocessing was one of the fastest growing markets in single-use devices here domestically… So, for … [company X] to acquire … [company Y] was more of a growth acquisition in a market disruptive type of play.”
		“I think that… [company X] acquired … [company Y] to curtail or control, even minimize, the impact of reprocessing.”
Collaborative relationships	Kowalkowski et al. [78] Weigel et al. [79] Benedettini and Neely [80]	“… [company X] has agreements with some OEMs to reprocess their devices. These OEMs share with … [company X] complete information about their products.”
		“… [company X] partners with logistic providers for device collection and delivery. It also defines OEMs for which it reprocesses devices as business partners.”
Capabilities	Ulaga and Reinartz [14] Parida et al. [81] Wallin et al. [82] Raddats et al. [83]	“When we analyze new products, we may have to make material analyses, have to identify the specification based on the standards and on original products and that takes of course quite a long time and quite a high effort to do to identify and to define the specifications of the products.”
		“We have extremely sophisticated data capabilities and in the end that is probably one of our core competences when it comes to producing the best results.”

. They were derived from the literature and existing servitization theory.

3. Results

Before illustrating the findings, it may be useful to discuss one theoretical assumption underlying this study. By referring to device OEMs that have entered the reprocessing business as servitized OEMs, this study makes the implicit assumption that reprocessing is a service activity. An alternative line of reasoning would be to consider reprocessing as a manufacturing activity on the grounds that reprocessors must assume legal responsibility for all applicable manufacturer requirements when the reprocessed devices are marketed. Technically, indeed, health care facilities do not purchase from reprocessors the recovery of their used devices, but purchase recovered devices (i.e., physical products). The assumption made in this paper is driven by two main considerations. First, from a customer engagement and value creation perspective, reprocessing of medical devices follows a service rather than a manufacturing logic. Reprocessing activities rely on the influx of used devices as the primary input to the production process. Therefore, value is actually co-created with the customers because customers will not be able to obtain as many reprocessed devices as they need if they do not collect enough used devices, if they return damaged devices, or do not place orders for as many reprocessed devices as they would be entitled to do based on their returns. Second, reprocessing involves extended service encounters as opposed to ordinary product sales. Service encounters come into play because reprocessors must teach hospital staff how to preclean, handle, package and store used devices so that the fallout due to damaged devices is minimized and how to always pick up the reprocessed devices first. Reprocessors must also talk with clinicians about the safety of the devices and make them comfortable with using reprocessed devices, as well as working with hospital administrators to ensure that they buy back as many reprocessed devices as they are entitled to do based on their returns. It is these encounters that, by contributing to the achievement of environmental and financial savings, make up the value creation process and make it essentially a service process.

3.1. Green Service Portfolios

Figure 3 displays and classifies the types of green services that are typically offered by the reprocessing subsidiaries of device OEMs. ‘Device collection’ services refer to the collection of used devices. They concern collection agreements with health care facilities that do not use reprocessed devices but still seek to reduce the volume of their waste stream for environmental and/or cost reasons (the disposal of clinical waste is regulated and expensive for hospitals—Moultrie et al. [8]). OEMs train hospital staff to clean and handle used devices safely for collection and organize shipment to reprocessing facilities. Collection services are offered free of charge as OEMs retain the residual value of returned devices. ‘Device reprocessing’ services constitute the core of servitized OEMs’ service offerings. OEMs collect used devices from hospital customers and return them to their original single-use status. A reprocessed device may go back to the health care facility from which it was collected, or it may be sent to a different health care facility customer (Figure 1). Since OEMs’ ability to provide reprocessed devices depends on the availability of devices to reprocess, health care facilities are allowed to buy reprocessed devices only in quantities that match their returns. OEMs track all devices through the entire remanufacturing process and dispose of devices that cannot be safely reprocessed. Importantly, OEMs reprocess a range of their devices as well as devices from other OEMs, according to a ‘multi-vendor orientation’ of the service offering [84]. ‘Inventory management’ services consist of purchasing advice for reprocessed devices. Device OEMs provide suggestions concerning the number of devices of each kind that a hospital should purchase. Demand for devices in each product line is predicted based on utilization data that hospital customers agree to share with the OEM and based on regular meetings with hospital administrators. Hospitals can also see online what inventory of reprocessed devices is available at the OEM and how many devices they may order based on the returns that they have made. Inventory management services are offered free of charge. ‘Data analysis’ services refer to data concerning, e.g., how many used devices of each kind a hospital has collected, how many devices collected from the hospital were unsuitable for reprocessing or defective, how many reprocessed devices the hospital has bought back. These data are elaborated in periodic reports displaying the carbon and cost savings that a hospital has achieved through its reprocessing program, as well as the savings that the hospital did not realize because it either returned damaged devices or did not buy back as many reprocessed devices as it could. Periodic reports with sustainability and financial achievements are provided free of charge to help customers visualize what the value of the reprocessing program really is [14]. ‘Warranty’ services are provided in the form of guaranteed savings. OEMs elaborate savings models for potential new health care facility customers based on their unique profile (types and quantities of devices that they are using and how much they are paying for them). If a health care facility that has followed a set of proven steps with the OEM is unable to meet the estimated savings, the OEM compensates the difference. Finally, ‘consultancy’ services concern assessment of the overall opportunities to improve procurement of devices for procedures. Based on the analysis of purchase information provided by hospital customers, OEMs may provide consultancy regarding such aspects as whether a hospital has the right mix of device products, whether it is paying the right price to current OEM suppliers, whether there are opportunities for price negotiations that could give the hospital a more beneficial spot. Since core device purchasing decisions are involved, this service can only be offered if there is a well-established, trustworthy relationship with the customer organization.

The classification in Figure 3 adopts the well-known, two-dimensional model proposed by Oliva and Kallenberg [72]. The first dimension is the type of interaction between provider and customer, ranging from discrete, one-off transactions with specific/limited content to close collaborative relationships involving partnership arrangements over an extended time frame [73]. This dimension entails also different levels of value co-creation, from little or no customer engagement in the service process (transactional services) to highly interactive customer touchpoint journeys (relational services) [54]. The second dimension is the focus of the service, which may be either on the product or on customer processes related to the product. While product-oriented services focus on product availability and functionality, customer process-oriented services focus on improving customer processes related to the product [74]. Most of the services offered by device OEMs are relational, entailing high levels of customer input, communication and co-creation over extended time frames. Clearly, in their green servitization initiatives, device OEMs aim at being partners of their customers rather than generic suppliers of physical products (new or reprocessed). Consistent with this, most of the services are provided free of charge. Some of the services involve high levels of customization, such as data analysis or consultancy services. Reprocessing services, in particular, typically involve customized pricing (depending on the volume of purchases) and risk-sharing arrangements, whereby OEMs commit to provide enough reprocessed devices and health care facilities commit to continue to use enough devices.

3.2. PSS Business Models

A company’s business model describes the design or architecture of the mechanisms that the company employs to create, deliver and capture value [85,86]. Product-Service System (PSS) business models refer to the business models of manufacturing companies that support and complement their product offerings with a set of value-adding services; that is, are servitized [87]. Research and practice identify three general categories of PSS business models: product-oriented, use-oriented and result-oriented [75]. In a product-oriented business model, the OEM still sells the product in a traditional way, but also offers some extra services that are linked to the product. The sale of the physical product remains the basis of the economic relationship with the customers. This business model is largely dominant among servitized OEMs in the single-use medical device industry, whereby health care facilities have to place separate orders for new and reprocessed devices.

There are, however, some instances of use-oriented business models for device reprocessing services. With use-oriented business models, the product still plays a central role, but its ownership remains with the OEM. The customer purchases access to the product, which also includes a set of services that assist in product use. For example, Stryker Sustainability Solutions (Stryker’s reprocessing subsidiary) offers a ‘Save Simply Program’ where customers can purchase new and reprocessed devices for one single blended price. Orders are filled with reprocessed devices first and supplemented by new devices, as necessary. Used devices are collected by Stryker for further reprocessing or disposal. The program was first introduced in 2018 for some ECG leads manufactured by Philips through a partnership between the two companies and later extended to Stryker’s Prevalon mobile transfer mats. Sustainable Technologies (Cardinal Health’s reprocessing subsidiary), offers a similar program, labelled ‘Blended Code (B-Code) Solution’ across device categories including compression sleeves, ECG cables and transfer mats. A B-Code program is offered also by Medtronic (Sustainable Technologies’ former parent company) for some pulse oximetry sensors. In these examples, there are no actual sales of devices, but rather sales of product availability and use. Intriguingly, as the example above illustrate, this business model is adopted only for low-tech, high-volume devices. Profit margins for new and reprocessed devices tend to be closer for such devices than for complex, high-tech devices and OEMs can more easily afford to adopt a use-oriented business model as a tactic to gain market share through reducing costs and simplifying ordering for the customers.

Finally, a result-oriented business model is focused on the sale of a specific result or outcome that is guaranteed through a combination of products and services. The OEM not only retains product ownership, but also chooses the product to use for achieving the agreed-upon result. There appear to be no instances of this business model in the single-use medical device industry. Indeed, according to interviewed experts, this model is unsuitable for medical supplies. Decisions about what device and technology to use can hardly be outsourced to device OEMs, given their impact on quality and safety of patient care.

3.3. Strategic Intent

Aguste et al. [77] claims that product manufacturing companies servitize with the strategic intent to either ‘defend’ the product business from competition or ‘grow’ an independent business. In the single-use medical device industry, servitization is mostly pursued with a ‘grow’ intent. OEMs tend to view the reprocessing business as an opportunity to expand their addressable market in single-use medical device products by targeting new customer segments (i.e., hospitals and hospital departments that seek to achieve cost and carbon savings by reusing medical devices). What makes this strategy attractive is that, from an economic perspective, reprocessing services do not displace traditional sales of new devices [88] (p. 22). Compared to other industries, the risk that reprocessed versions of products may cut into sales of new ones is lower, since only certain customer segments are interested in reprocessed devices. On the contrary, the value of the product may be even higher for such customers if a reprocessed version is made available by the OEM. Nevertheless, a ‘grow’ intent is reflected in the fact that, as noted above, servitized OEMs significantly reprocess other manufacturers’ devices in addition to their own. Several OEMs actually mainly reprocess other vendors’ devices and only a few of their product lines.

However, there is at least one notable example in the industry where servitization may have been pursued with a ‘defend’ intent. Johnson & Johnson moved into reprocessing by acquiring Sterilmed in 2011. Sterilmed reprocessed mainly Johnson & Johnson devices; it was one of the biggest players in the reprocessing market at that time, whereas now it is significantly smaller than other top players’ reprocessing subsidiaries. These facts suggest that Johnson & Johnson might have actually acquired Sterilmed to curtail or control the impact of reprocessing, expecting that the uptake of reprocessing would cannibalize the sales of new devices and eventually cut down profits.

3.4. Collaborative Relationships

The extant literature entertains the possibility that servitized OEMs may rely on external partners for developing and delivering their services (e.g., [78,79,80]). Collaborative relationships with other companies in the industry can be leveraged to increase internal service capacity and access specialized competences in the service domain. In the single-use medical device industry, it is not uncommon for smaller OEMs to ‘outsource’ reprocessing activities to other OEMs or independent reprocessors. Health care customers are extremely reluctant to change suppliers and smaller OEMs often decide to bundle reprocessing services into their general offerings as a strategy to gain market share. While it would be unviable, or perhaps misaligned with their business objectives, for such OEMs to organize reprocessing services internally, they can ‘outsource’ reprocessing activities to a larger OEM or independent reprocessor that has already logistics infrastructure, regulatory knowledge, reprocessing technology, etc. Larger OEMs and market leaders have started to consider the idea of reprocessing in collaboration only in the past few years. In this case, the main driver has been customer demand, since most hospitals want to deal with very few suppliers that are able to provide a broad range of reprocessed devices.

3.5. Capabilities

Offering reprocessing services and circular economy solutions for single-use medical device products requires a specific set of technical capabilities. Firstly, OEMs need to be competent in reprocessing technologies. The medical device industry has been reported to be slow in the implementation of environmentally conscious design practices (e.g., [8,11]). The single-use medical device sector is no exception to this. The interviewed experts stated that, even within servitized OEMs, there is currently no design consideration for reprocessing. Therefore, R&D teams at OEMs’ reprocessing subsidiaries need to be able to track down what cleaning, disinfection and sterilization processes are available and figure out whether or not these are suitable to guarantee the hygienic recovery of the device. For those devices that cannot be cleaned using a standard process, R&D teams must be able to develop specific cleaning processes. In addition to that, servitized OEMs need to possess specific, expert knowledge to develop testing procedures (and often also testing equipment) ensuring that the technical function of the devices has not been impaired by previous use and reprocessing.

Secondly, in order to reprocess devices from other OEMs, servitized OEMs need to be competent in reverse engineering. An OEM has all the device specifications and updated design files concerning its products, but it has no access to such information for other OEMs’ devices. Hence, just like independent reprocessors, these OEMs need to recreate the original design specifications of the device by conducting reverse analyses of design elements including material properties, manufacturing methods, functional features and physical dimensions. Nevertheless, reverse engineering competences are necessary to detect and evaluate design changes that OEMs may introduce over time and to assess whether the current reprocessing protocols remain effective.

Thirdly, servitized OEMs often need software programming skills when strategies have been adopted at the device design stage to impede reprocessing and force obsolescence after a single use [4]. Increasingly, manufacturers include electronic chips and proprietary software in their high-cost, high-tech devices that lock them from being reused. As a consequence, servitized OEMs that are willing to reprocess such devices need to add to their portfolio software skills, which are primarily related to get around the obsolescence projected by device manufacturers.

Finally, offering reprocessing services for single-use medical devices requires logistics capabilities and data analysis capabilities. The optimization of logistics flows plays an essential role in increasing the availability of reprocessed devices and enabling the delivery of actual value to the customers. However, managing the logistics network for reprocessing activities is significantly more complex than organizing linear deliveries of new devices because just-in-time, intricate flows of devices from/to multiple health care facility customers need to be planned and managed. Servitized OEMs may develop the relevant logistics capabilities internally or outsource transportation and shipping of devices to third-party providers that specialize in logistics services. Data analysis capabilities are more difficult to outsource. They refer to the analysis of device usage and return patterns that allows OEMs to elaborate device purchase suggestions for their customers. Reprocessing activities are very data-intense [50]: regulatory requirements of process documentation mean that most devices have serial tags or bar codes in which detailed information on the reprocessing journey(s) is stored, collections and deliveries of devices are recorded, and inventory status information is exchanged continuously between providers and customers. These data represent a potentially unique asset for OEMs that seek to provide the best results to their customers, yet they need to be translated into opportunities to improve the management of the reprocessing program. Therefore, core capabilities for OEMs that, in particular, seek to contract for output and performance (e.g., take responsibility for guaranteed savings) include the ability to analyze, interpret, integrate and use device operational data for planning the logistics network and optimizing material flows.

4. Discussion and Conclusions

Growing knowledge of the role that health care activities play in relation to the global climate crisis has generated an important call for action towards the goal of setting the health care sector on a more sustainable path [5]. In line with this call, the recent literature has started to draw attention to reprocessing of single-use medical devices as an effective strategy to reduce health care-generated waste and emissions. Within the literature, several authors have pointed out that the trend towards green servitization, wherein several major OEMs of single-use devices have extended their businesses to reprocessing services, could stimulate and accelerate the uptake of reprocessing (e.g., [11,26,36]). This paper contributes to this discussion, using interviews with industry experts to draw insights into the implementation of green servitization in the single-use medical device industry.

The interviews evidence that the reprocessing services offered by device OEMs entail high levels of customer input, communication and co-creation over extended time frames; that is, relational interactions with customers [72]. Clearly, by offering reprocessing services, device OEMs aim at becoming partners of their key customers, entering into business relationships in which demand and supply risk may be shared. Device collection and reprocessing services are often complemented with services intended to support hospital customers in running their reprocessing programs, ranging from inventory management to data analysis, warranty and consultancy. Such services are mainly offered under product-oriented business models, meaning that reprocessing and other services are purchased separately from new devices [75]. However, there exist some instances of use-oriented business models for low-tech, high-volume devices, where customers obtain a mix of new and reprocessed devices and are charged a single blended price for each device they use. Most device OEMs servitize into reprocessing with the strategic intent to grow their business by reaching a new customer segment, that of hospitals and hospital departments that seek to achieve cost and carbon savings by reusing medical devices [77]. These endeavors entail not only making available reprocessed versions of own devices, but also reprocessing other OEMs’ devices. However, there are also examples of OEMs that have moved into reprocessing with the intent to defend their product business, expecting that the uptake of reprocessing would cannibalize the sales of new devices and eventually cut down profits. As in other industrial sectors (e.g., [79,80]), servitized OEMs in the single-use medical device industry resort to collaborative relationships with other companies (independent reprocessors or other servitized OEMs) to increase internal service capacity and access specialized competences in the service domain. This is especially important for small OEMs, who may want to offer both new and reprocessed versions of their devices as a strategy to gain market share, but do not possess the necessary logistics infrastructure, regulatory knowledge, reprocessing technology, etc. Reprocessing in collaboration has started to be considered also by large OEMs, motivated by customers’ desire to reduce their supplier base and move towards strategic relationships with few suppliers that can provide a broad range of devices. Regardless of the collaborative arrangements, reprocessing services require OEMs to develop or acquire specific technical capabilities in the areas of reprocessing technologies and reverse engineering. In addition, servitized OEMs often need software programming skills which are primarily related to getting around electronics and proprietary software that many OEMs include especially in their high-cost, high-tech devices to lock them from being reused [4]. Mainstream servitization research highlights the importance of data analysis capabilities for service provision (e.g., [14]). In the case of green servitization into device reprocessing services, the capability to analyze data concerning device usage and return patterns needs to be complemented with logistics capabilities in order to effectively plan and manage flows of devices from/to multiple health care facilities and increase the availability of reprocessed devices. While logistics capabilities are the farthest from traditional competences of device manufacturing, they are essential to optimize material flows and ensure the delivery of actual value to the customers.

This paper is one of the first to address the topic of green servitization and it is the very first to do so in the context of the single-use medical device industry. The extant literature on servitization indicates that manufacturers’ service offerings may include several services related to product recovery (e.g., [16,17,18]). However, previous research does not investigate instances in which the delivery of green value is central to servitization endeavors. Moreover, the very few studies that so far have dwelt upon the notion of green servitization have focused on industries that are very different from healthcare; that is, automotive [19], industrial equipment [21] and electronics and computer [20]. While in these industries all manufacturers have always offered at least some types of services (e.g., repair, technical support), manufacturers of single-use medical devices venture into a completely new territory when they servitize into reprocessing.

4.1. Managerial Implications

The expert interviews suggest that factors such as increasing costs of health care and growing concerns around environmental sustainability will inevitably change the single-use medical device space over time. Although developments in device technology will continue to play a fundamental role in the future, managers at OEM companies will increasingly need to deal with new demands concerning the economic and environmental performance of their devices.

As the service offerings of several OEMs seem to suggest, there may be some players in the industry that have started to understand the perspective and the long-term market share gains of combining a service model and a manufacturing model, making reprocessing an integrated part of how they think about how to design, produce and deliver their products. Clearly, the progress of the industry towards reprocessing will depend on the activity of governments and regulatory bodies and on how they will maintain and update regulations to ensure safety and functionality of reprocessed devices, promote more circular products in public procurement and create incentives for OEMs to design devices for reprocessing. Individual companies may also play a role. If more OEMs get into creating better economic and environmental value by integrating the service strategy into their product-based focus, this will generate a disruptive type of process and a systemic change in the industry. Managers at OEM companies should be aware of this and get ready for it.

4.2. Utilitarian Implications

This study highlights that the trend towards servitization in the single-use medical device industry may support the transformation of health care systems towards a circular economy. Given its focus on reprocessing services, the topic of servitization in the single-use medical device space is very closely connected with reusability. By offering a means of closing material loops and reducing waste, the green servitization of device OEMs paves the way for more environmentally friendly ways of providing health care services. Moreover, in addition to being associated with environmental benefits and the transformation of industries across the word in the direction of more environmentally friendly solutions, the servitization-enabled uptake of device reprocessing provides the added benefits of realizing resilient health care supply chains and creating social value. In terms of supply chain resiliency, reprocessing and reuse of disposables makes health care supply chains less vulnerable to disruptions from demand surges, shortage on certain devices or on certain materials used in the production of devices, and price shocks due to unexpected events [4,26]. The potential effects of these disruptions have been especially evident during the COVID-19 pandemic and are still visible, for example, in the global shortage of microchips. Similarly, social value originates from the cost savings that are generated by device reprocessing and reuse. The single-use model will ultimately become unaffordable given the constantly increasing technological content and spiraling costs of devices [7,35,45]. Against this backdrop, reprocessing single-use devices supports health care providers to use the best device technology, and hence provide the best possible care, for more patients.

In sum, the trend towards green servitization examined in this study can effectively support the restructuring of health care delivery towards outcomes (clinical, environmental, financial) that have the highest impact and are of most importance to patients; that is, it may contribute to the actual implementation and achievement of the concept of “high-value care”.

4.3. Limitations

As with any research, this study has its limitations. The use of expert interviews as primary source of data provided the opportunity to gain a broad and informed perspective about the developments that are taking place in the single-use medical device industry. However, while experts were carefully identified as individuals with in-depth knowledge of the industry, this approach presents limitations in terms of internal validity due to the smaller number of interviews that the study could draw upon. Although secondary sources (the academic literature, company websites, research and consultancy reports, trade press and newspapers) were also consulted, it was not always possible to triangulate and validate the interview data.

Further, the thematic analysis method relies on researcher judgement to determine predominant or important themes in the data. Therefore, despite the identification of the themes drew on careful examination of consolidated servitization theory, it cannot be excluded that other researchers would not have focused the analysis on different aspects.

4.4. Opportunities for Further Research

The insights obtained from this study underscore that servitization can be effective also as a green strategy, especially in industries that urge to take actions to reduce their environmental footprint, such as health care. The empirical findings uncover that a green servitization strategy may help manufacturers of medical devices be much more focused on the things that are in the political landscape around environmental sustainability and value-based health care. The study reveals the need for further analysis regarding regulatory and other incentives that may motivate device OEMs to integrate the green service strategy into their product-based focus, and to make their green servitization orientation broader and more strategically committed. Validating this study’s findings by reaching out industry experts from other geographical areas where reprocessing is a permitted and a regulated practice would increase the reliability of the conclusions. Further research might be directed to examining how single-use medical devices should be better designed to support reprocessability and reusability. Nevertheless, to provide a more comprehensive picture, the analysis should be extended to include the viewpoints and experiences of hospital customers.