Decentralized treatment of hospital and local wastewater is increasingly recognized as a necessary complement to centralized infrastructure. This approach effectively reduces pharmaceutical residues and other micropollutants entering the aquatic environment. This research aims to evaluate how advanced, compact treatment trains can effectively limit emissions of contaminants of emerging concern. These systems must remain technically robust and compatible with real operating conditions. We investigate combinations of biological and physicochemical processes to enhance water quality and efficient pharmaceutical degradation. Beyond treatment efficiency, the work examines how decentralized systems can be integrated into existing wastewater management and emerging water reuse strategies. Particular emphasis is placed on identifying design principles, monitoring needs, and control strategies that enable safe, reliable operation at hospital scale. By synthesizing experimental findings, the research seeks to define benefits, and limitations of decentralized approaches, and to provide guidance for regulators, utilities, and healthcare.