The need for sustainable performance in the healthcare supply chain is becoming acute. The healthcare industry currently has to contend with multiple competing pressures alongside the new challenges of sustainable performance. The aim of this research is to explore the challenging factors of green supply chain initiatives from the view of the institution theory. This research tries to assess the actual sustainable performance resulting from the adoption of green supply chain initiatives in healthcare industries. As part of the research, the explanatory frameworks based on the institution theory are explored and discussed. Interviews with healthcare industry experts in Malaysia through the four case studies were conducted. The results provide in-depth insight and strong empirical evidence on how the institution pressure for green supply chain initiatives that contributes to the sustainable performance in healthcare industries. The findings of this research are intended to be used: a) to identify the green supply chain initiatives in healthcare industries; b) to build on a comprehensive picture of what challengers' factors for green supply chain initiatives in healthcare industries, as perceived by institution pressure. Additionally, the research offers propositions on how green supply chain initiatives could be better achieved through a range of institution perspective.