Sustainability In Health Technology Assessments

The healthcare sector, while dedicated to human well-being, paradoxically contributes significantly to global environmental degradation. Its substantial carbon footprint, extensive waste generation, and chemical pollution necessitate an urgent re-evaluation of its operational paradigm. Health Technology Assessment (HTA), traditionally focused on clinical effectiveness and economic efficiency, is increasingly recognized as a crucial lever for integrating environmental sustainability (ES) into healthcare decision-making. This report synthesizes current knowledge on the integration of ES into HTA through a multisectoral lens, highlighting nascent efforts by HTA agencies, the complex methodological challenges, and the imperative for cross-sectoral collaboration.

Current integration efforts, though growing, are in early stages, marked by methodological diversity and a predominant focus on carbon emissions and waste, with less attention to the ecotoxicological impacts of pharmaceuticals. Key barriers include data scarcity, limited interdisciplinary expertise, and the inherent complexities of balancing clinical, economic, and environmental trade-offs. To advance ES in HTA, this review underscores the critical need for standardized methodologies, a strategic prioritization of technologies with intrinsic environmental harms, enhanced multisectoral partnerships, and the robust integration of circular economy principles. Achieving environmentally sustainable and resilient health systems requires HTA to evolve into a more holistic and proactive tool, fostering a future where healthcare truly heals both people and the planet.

1. Introduction: The Critical Nexus of Health, Technology, and Environment

The intricate relationship between human health, technological advancement, and environmental integrity has become increasingly apparent. As global health systems strive to deliver comprehensive care and achieve universal health coverage, the environmental consequences of healthcare operations and the technologies they employ can no longer be overlooked. This report delves into the evolving role of Health Technology Assessment (HTA) as a mechanism to address these environmental impacts, advocating for a multisectoral approach to foster a truly sustainable healthcare future.

1.1. Defining Health Technology Assessment (HTA) in a Broader Context

Health Technology Assessment (HTA) serves as a systematic and multidisciplinary evaluation of health technologies and interventions. Its core purpose is to determine the value of a health technology by examining its properties and effects, encompassing both direct and indirect consequences, thereby informing guidance on its optimal use within health systems globally. This process is transparent and accountable, providing evidence to decision-makers and stakeholders to support policy-level choices in healthcare. The World Health Organization (WHO) aptly describes HTA as a "bridge that connects the world of research to that of policy making," underscoring its pivotal role in evidence-informed decision-making for the development of sustainable and effective health systems.

Historically, HTA has primarily focused on clinical effectiveness, patient safety, and economic implications. However, its scope has progressively expanded to incorporate broader dimensions such as ethical, social, legal, and organizational considerations. Crucially, in recent years, environmental dimensions have gained increasing prominence within HTA frameworks, reflecting a growing societal recognition of healthcare's wider footprint. This expansion of HTA's mandate signifies a fundamental shift in what constitutes "value" in healthcare. The traditional calculus of clinical efficacy versus cost-effectiveness is now being augmented by considerations of environmental and societal impact. This evolution implies that policy decisions are increasingly expected to balance not only immediate health outcomes and financial expenditures but also the long-term ecological and social consequences, leading to a more holistic, yet inherently more complex, decision-making landscape for healthcare systems.

The policy relevance of HTA extends to guiding investments in health technologies and contributing to the realization of universal health coverage. This strategic position makes HTA an indispensable tool for integrating environmental considerations. While HTA predominantly assesses new technologies , its multidisciplinary nature and its capacity to inform policy position it as a powerful lever for systemic change. By consistently incorporating environmental criteria into its evaluations, HTA can influence not only the adoption of novel technologies but also, indirectly, incentivize manufacturers to design more sustainable products from their inception. This proactive influence can ripple through the entire supply chain, gradually impacting the environmental performance of the existing "stock" of technologies over time, even if HTA does not directly assess technologies already in use. This represents a shift from a reactive to a proactive approach in managing healthcare's environmental impact.

1.2. Conceptualizing Environmental Sustainability within Health Systems

Environmental sustainability, in the context of health systems, is defined as the capacity to improve, maintain, or restore health while simultaneously minimizing negative environmental impacts and actively seeking opportunities for environmental restoration. This endeavor ultimately benefits the health and well-being of both current and future generations. The foundational principle of sustainability in healthcare posits that human survival and well-being are intrinsically dependent on the natural environment, advocating for a "productive harmony" between human activity and nature. Achieving this harmony involves a multifaceted approach, including reducing carbon emissions, minimizing waste and hazardous chemicals, promoting sustainable procurement practices, and ensuring efficient resource management across all healthcare operations.

The World Health Organization (WHO) has outlined ten strategic avenues for action to foster environmental sustainability in health systems. These include the adoption of national environmental sustainability policies, the active engagement of the health workforce as agents of change, and the promotion of innovative models of care that are inherently more sustainable. Similarly, the American Hospital Association (AHA) emphasizes that pursuing sustainability aligns seamlessly with healthcare's core humanitarian and stewardship missions. Beyond ethical considerations, embracing sustainability offers tangible benefits, such as significant financial savings and improvements in patient care.

This recognition of environmental sustainability as a strategic imperative reveals a profound shift in the mandate of health systems. Traditionally viewed as healers, solely focused on human health, health systems are now increasingly tasked with a dual role: not only to improve human health but also to minimize environmental harm and actively contribute to environmental restoration. This creates a moral and strategic imperative for healthcare organizations to become environmental stewards, acknowledging the undeniable link between planetary health and human health. This expanded responsibility broadens the ethical and operational scope of healthcare. Furthermore, while environmental initiatives are often perceived as additional costs, the evidence suggests otherwise. The documented "financial savings" and "improved quality of healthcare delivery" that can arise from sustainable practices indicate that environmental sustainability is not merely a compliance burden. Instead, it represents a strategic opportunity for enhancing operational efficiency, reducing long-term costs, and driving innovation, particularly through the adoption of digitalization and lower-carbon alternatives. This reframing positions sustainability as a "must-have" for the long-term economic viability and quality of care within health systems.

1.3. The Imperative for a Multisectoral Approach to Health and Environmental Goals

A multisectoral approach is fundamental to addressing the complex interplay between health outcomes and environmental sustainability. This approach acknowledges that both are profoundly influenced by a wide array of social, economic, environmental, and commercial determinants that extend across various sectors of society. It moves beyond the traditional confines of the health sector, recognizing that optimal population health cannot be achieved through isolated interventions.

A cornerstone of this approach is the "Health in All Policies" (HiAP) strategic vision, which advocates for evidence-informed actions undertaken by multiple sectors. The objective is to systematically consider the health implications of decisions made in diverse areas such as urban planning, energy, agriculture, and trade. This framework enhances accountability for health impacts at all levels of policy-making and directly addresses the "causes of the causes" of ill health, including pervasive issues like air pollution, dietary deficiencies, and the overarching challenge of climate change. Effective implementation of HiAP involves several key components: establishing clear needs and priorities, identifying supportive structures (such as interdepartmental committees), framing planned actions, facilitating robust assessment and engagement with all relevant actors, building necessary capacity across sectors, and ensuring continuous monitoring and evaluation.

The intrinsic connection between a multisectoral approach and the Sustainable Development Goals (SDGs) is evident. The SDGs provide a comprehensive blueprint for human development, where population health is not only a precondition for sustainable development but also an outcome and an indicator of its success. This framework emphasizes the profound interdependence of all goals, illustrating how progress in one area, such as health (SDG 3), is reliant on advancements in others, like clean water (SDG 6) or sustainable cities (SDG 11).

The multisectoral approach, particularly through HiAP, positions the health sector as a proactive "champion of population health" , extending its influence beyond direct clinical care. This means that the health sector is called upon to advocate for health and environmental considerations in policy decisions made by

other sectors, such as urban planning, energy, and agriculture. This expanded responsibility necessitates the development of new advocacy and collaborative skills among health professionals. Furthermore, the increasing recognition of climate change impacts on supply chains and the critical role of hospitals as "cornerstones of aid and recovery" during crises highlight that environmental sustainability is not merely about mitigating harm but also about building resilience into health systems. A multisectoral approach becomes paramount here, as systemic vulnerabilities (e.g., in energy supply, water access, or transport infrastructure) often lie outside the direct control of the health sector. Consequently, environmental sustainability, when viewed through this multisectoral lens, emerges as a critical component of national security and disaster preparedness, demanding integrated planning and coordinated action across governmental and private sectors.

1.4. Purpose and Scope of this Systematic Review

This report aims to synthesize the current body of knowledge regarding the integration of environmental sustainability into Health Technology Assessment. It specifically focuses on identifying and evaluating multidisciplinary frameworks and the role of multisectoral collaboration in this evolving field. By systematically reviewing existing methods, identifying persistent challenges, and proposing actionable recommendations, this report seeks to facilitate the development and implementation of robust environmental sustainability frameworks within HTA, ultimately contributing to more sustainable and resilient healthcare systems globally.

2. The Environmental Footprint of Health Technologies: A Global Perspective

The healthcare sector, despite its life-saving mission, exerts a substantial and often overlooked environmental impact. Understanding and quantifying this footprint is a prerequisite for developing effective mitigation strategies and integrating environmental considerations into HTA.

2.1. Quantifying Healthcare's Contribution to Environmental Degradation

Global estimates reveal that the healthcare sector's carbon footprint accounts for approximately 4.4% of total global greenhouse gas (GHG) emissions. If the global healthcare sector were considered a country, it would rank as the fifth largest contributor to climate change worldwide. This significant contribution underscores the urgent need for systemic change within the industry.

National data further illustrate this impact. For instance, the National Health Service (NHS) in England's carbon footprint is equivalent to that of the entire country of Croatia. In Canada, studies indicate that the healthcare system generates 33 million tonnes of CO2e annually and over 200,000 tonnes of other pollutants. These emissions are directly linked to approximately 23,000 Disability-Adjusted Life Years (DALYs) lost per year due to healthcare-related pollution. Beyond direct greenhouse gas emissions, healthcare's environmental footprint extends to particulate matter, nitrogen oxides, sulfur dioxide, increased malaria risk, nitrogen runoff, and the consumption of scarce water resources.

The data starkly highlight a profound paradox: a sector fundamentally dedicated to improving human health is simultaneously a major contributor to environmental degradation, which, in turn, directly harms human health. For example, air pollution, to which healthcare contributes, is linked to over 9 million deaths globally each year. This creates an undeniable ethical imperative for healthcare to address its own environmental footprint, moving beyond a purely curative model to one that actively prevents environmental health risks. This paradox necessitates a fundamental re-evaluation of healthcare's operational model and its very definition of "health." Furthermore, the Canadian study linking healthcare pollution to DALYs lost reveals that the environmental impact of healthcare is not merely an ecological concern but a direct public health burden. This implies that the true "costs" of healthcare extend beyond financial expenditure to include significant health externalities borne by the population. This understanding strongly reinforces the argument for integrating environmental considerations into HTA, as failing to do so means underestimating the true societal cost of health technologies and potentially making decisions that inadvertently worsen public health in the long term.

2.2. Lifecycle Impacts: From Production to Disposal (Carbon Emissions, Waste, Pollution)

The environmental impacts of health technologies are not confined to their use within clinical settings but span their entire lifecycle, from raw material extraction and manufacturing to transport, clinical use, and ultimate disposal. Analysis of the NHS carbon footprint reveals that the supply chain accounts for almost two-thirds of its total emissions, with pharmaceuticals and chemicals contributing 20% and medical equipment 10%. This disproportionate impact of the supply chain underscores its critical role as an intervention point for sustainability efforts. "End of life" and "use phase" are frequently identified as particularly impactful stages within the lifecycle.

Specific environmental impacts observed across the lifecycle include:

• Carbon Emissions: This is the most frequently identified environmental impact, particularly associated with technologies such as inhaled anesthetic agents and metered-dose inhalers (MDIs) due to their potent greenhouse gas propellants.

• Waste Production: Healthcare generates significant waste, with plastics constituting 25-30% of total healthcare waste. The NHS in England alone produces approximately 538,600 tonnes of waste annually.

• Water Pollution: This includes contamination from various chemicals and pharmaceutical substances.

• Reduced Biodiversity: This impact is also recognized by agencies such as NICE as a consequence of healthcare activities.

The overwhelming proportion of the carbon footprint residing in the supply chain, accounting for two-thirds of the NHS's total emissions , clearly indicates that efforts focused solely on hospital operations will be insufficient to achieve meaningful environmental gains. This highlights the urgent need for HTA to influence procurement decisions and engage proactively with manufacturers to drive sustainability throughout the entire product lifecycle, from raw material sourcing to end-of-life management. This effectively shifts a significant portion of the environmental responsibility upstream to suppliers and manufacturers, necessitating the development of new regulatory frameworks and contractual mechanisms to enforce sustainable practices.

While carbon emissions from devices like inhalers and anesthetic gases are gaining necessary attention , there remains a notable absence of comprehensive work on the ecotoxicological impacts of active pharmaceutical ingredients (APIs). This represents a significant blind spot in current environmental assessment efforts within HTA. The long-term environmental and potential human health consequences of pharmaceutical pollution, such as the contribution to antibiotic resistance or endocrine disruption, remain largely unquantified and unaddressed within HTA frameworks. This unquantified burden represents a future wave of environmental health challenges that current assessment methods are ill-equipped to handle.

2.3. Differentiated Impacts Across Technology Types: Pharmaceuticals, Medical Devices, and Digital Health

The environmental footprint of health technologies varies considerably across different categories, necessitating tailored assessment approaches.

• Pharmaceuticals: These products contribute substantially to healthcare's environmental impact, accounting for 20% of the NHS's total carbon footprint. Specific examples of high-impact pharmaceuticals include inhaled anesthetic agents and metered-dose inhalers (MDIs), primarily due to the greenhouse gases used as propellants. Despite this, a significant gap exists in the assessment of the ecotoxicological impacts of active pharmaceutical ingredients (APIs) and their metabolites in the environment.

• Medical Devices: Medical devices contribute approximately 10% to the NHS carbon footprint. Their environmental impact is often measured in terms of carbon emissions and materials waste, particularly the distinction between single-use plastics and reusable alternatives. The reprocessing of single-use medical devices presents a promising avenue for achieving both economic and environmental benefits. However, the medical technology sector encompasses over two million diverse products, meaning a "one-size-fits-all" solution for circularity is not feasible. Instead, various circularity principles, such as maximizing product lifetime, material substitution, recycling, and refurbishment, must be explored depending on the specific product and business model.

• Digital Health: Digital health technologies (DHTs), including telehealth, artificial intelligence (AI), the Internet of Things (IoT), and electronic health records (EHRs), are increasingly being explored for their potential to reduce healthcare's carbon footprint. These technologies can lessen environmental impacts by reducing patient transportation needs, decreasing paper consumption, and minimizing the use of toxic chemicals. Case studies have demonstrated significant reductions in CO2e emissions from virtual consultations due to avoided patient travel. However, digital health is a double-edged sword for sustainability. While offering clear benefits, it also carries its own environmental footprint related to the energy consumption of devices, networks, and data centers, as well as the growing challenge of electronic waste (e-waste). Without careful design, implementation, and end-of-life management, digital transformation could inadvertently shift environmental burdens rather than eliminate them, creating new sustainability challenges.

Given limited resources, a crucial strategic consideration is the differentiation between "intrinsic" and "generic" environmental impacts, as highlighted by Hensher. HTA efforts should prioritize technologies with "intrinsic" environmental harms—those where the environmental impact is inherent to their chemical nature or function (e.g., specific anesthetic gases, propellants in pMDI inhalers). This targeted approach allows for maximum impact from scarce assessment resources, preventing their dilution on "generic" impacts (e.g., general manufacturing energy use) that might be more effectively addressed through broader policy instruments. This necessitates the development of robust environmental screening mechanisms early in the HTA process to identify these high-priority technologies.

Table 1: Key Environmental Impacts of Health Technologies Across Lifecycle Phases

This table provides a structured overview of the diverse environmental impacts associated with health technologies, categorized by their nature and the lifecycle phases where they predominantly occur. This comprehensive perspective is essential for HTA agencies to develop targeted assessment strategies and for policymakers to identify critical intervention points across the healthcare supply chain. By mapping specific impacts to lifecycle stages and technology types, this table facilitates a more nuanced understanding of where environmental assessment efforts should be concentrated to achieve the greatest benefits. It underscores that environmental considerations must be integrated throughout the entire product journey, from design to disposal, to truly achieve sustainable healthcare.

3. Current State of Integration and Methodological Approaches

The integration of environmental sustainability into Health Technology Assessment is an evolving field, characterized by growing interest but also significant challenges in implementation and methodological standardization.

3.1. HTA Agency Initiatives and Progress

Globally, HTA organizations are increasingly recognizing the imperative of incorporating environmental sustainability into their assessments. An international survey of HTA organizations across 20 countries revealed that while most acknowledge the value of environmental sustainability, only a minority have implemented concrete strategies, and those that have exhibit significant methodological diversity. This indicates a nascent stage of integration, despite a growing effort in recent years, with the majority of relevant documents published since 2022.

Leading agencies, such as the National Institute for Health and Care Excellence (NICE) in the UK and the Canadian Drug Agency (CDA) alongside the Institut national d’excellence en santé et en services sociaux (INESSS) in Canada, have demonstrated clear commitments to this agenda. Their activities can be broadly categorized:

• Strategic Visioning: Both NICE and CDA have articulated visions for incorporating sustainability. NICE aims to be a global leader in reducing healthcare's carbon footprint, while CDA focuses on integrating broader perspectives, including environmental impacts, into HTA.

• Methodological Development: Agencies are engaged in outlining high-level plans for including environmental impacts. For example, NICE's 2024 manual incorporates environmental sustainability within its topic prioritization framework, and CDA's 2021 framework, though not yet operationalized, signals a commitment to methodological adaptations.

• Technology Guidance: A substantial number of documents from these agencies include environmental information related to specific health technologies. However, this data is often presented as published research or manufacturer claims, leveraging an "information conduit" approach, rather than being formally assessed or used to develop recommendations. This approach, while useful for raising awareness, may have minimal impact without a clear framework for data utilization.

• Policy Guidance: Agencies are also providing substantive support to decision-makers on environmental issues. NICE's public dialogue, for instance, found strong public support for sustainability initiatives that do not compromise care quality. CDA's Horizon Scan identifies opportunities to reduce healthcare's environmental impact.

• Communications: Public-facing materials, such as webpages and seminars, are used to communicate sustainability efforts. NICE has a dedicated "Sustainability" webpage, while CDA's public website does not explicitly address sustainability.

The progression of HTA agencies from simple information sharing to more complex integrated evaluations reflects an evolving methodological sophistication. Initially, the "information conduit" approach served to introduce environmental data. However, the move towards "parallel evaluation" and "integrated evaluation" signifies a deeper commitment to embedding environmental considerations within the core HTA decision-making process. This progression, while promising, also highlights the ongoing tension between achieving methodological rigor and ensuring practical feasibility given resource constraints. The development of robust, standardized methods is critical for consistency and comparability, yet the complexity and cost of implementing comprehensive assessments like Life Cycle Assessment (LCA) pose significant challenges.

3.2. Methodological Frameworks for Environmental Assessment in HTA

The systematic evaluation of environmental sustainability in HTA relies on a variety of methodological frameworks, each with its strengths and limitations.

• Life Cycle Assessment (LCA): LCA is a systematic methodology for evaluating the potential environmental impacts of a product throughout its entire life-cycle, from raw material extraction and production to use and end-of-life disposal. It involves a Life-Cycle Inventory (LCI) to quantify resource consumption and emissions, followed by a Life-Cycle Impact Assessment (LCIA) to analyze potential environmental impacts such as climate change, acidification, and toxicological stress. The "One Health extended" LCA framework, utilizing advanced software like SimaPro LCA, has been identified as addressing the greatest methodological needs for HTA. While LCA offers a comprehensive perspective, it is labor-intensive, costly, and faces challenges in data collection and ensuring consistency of functional units.

• Multi-Criteria Decision Analysis (MCDA): MCDA, also known as Multi-Criteria Decision-Making (MCDM), is a powerful tool for making decisions when multiple, often conflicting, objectives need to be considered simultaneously. It supports multifaceted technology decision-making, particularly where trade-offs between financial and environmental considerations are necessary. MCDA involves structuring the problem, specifying criteria, measuring alternative performance, scoring alternatives, and weighting criteria based on stakeholder input. The Analytical Hierarchy Process (AHP), often used in conjunction with circular economy frameworks, is a reproducible technique that supports MCDA. Benefits of MCDA include transparency, replicability, generalizability, and the ability to explore trade-offs. However, a full consensus on model structure, criteria selection, and weighting is still lacking.

• Circular Economy (CE) Principles: The CE framework represents a fundamental shift from a linear "take-make-waste" business model to a regenerative system that aims to maximize the lifetime value of products and minimize material and resource use. In the MedTech sector, circularity can take various forms, including design optimization, material substitution, recycling, refurbishment, and reprocessing. For digital health, CE principles focus on extending product lifetime and maximizing recovery of components and materials from e-waste. Successful implementation requires meeting patient safety requirements and addressing significant barriers such as regulatory hurdles, fragmented definitions, lack of harmonized tools, and financial/technological constraints.

• Other Methods: Other methods proposed for incorporating environmental impacts into HTA include "enriched" cost-utility analysis (CUA), cost-effectiveness analysis (CEA) using carbon dioxide emissions, cost-benefit analysis (CBA) where all outcomes are monetized, and environmental damage schedules. Environmentally Extended Input-Output Analysis (EEIOA) is also used to estimate carbon emissions or hidden environmental impacts.

3.3. Approaches to Integrating Environmental Considerations in HTA

HTA agencies are exploring several approaches to integrate environmental considerations, ranging in their depth of integration and impact on decision-making:

• Information Conduit: This is the simplest approach, involving the republishing of publicly available environmental data or manufacturer-submitted claims without further formal assessment by the HTA agency. While it raises awareness, its impact on decision-making is minimal without a framework prescribing how the data should be used.

• Parallel Evaluation: In this predominant approach, environmental impacts are considered during the HTA deliberation process and/or reported and discussed alongside other data and analyses (e.g., economic evaluation). A committee might use environmental evidence alongside clinical and economic evidence, similar to how inequalities or innovation are considered. While offering flexibility, this approach can lead to inconsistencies due to a lack of transparency regarding when environmental impact should or should not alter a decision, potentially increasing the risk of legal appeals.

• Integrated Evaluation: This is the most comprehensive approach, where environmental data are fully incorporated into the assessment, often within an economic evaluation. For example, environmental data can be monetized (e.g., social cost of carbon) and included as an additional cost in a cost-effectiveness analysis. This approach requires a clear decision rule for trade-offs between different outcomes, such as defining how much health loss is acceptable for a unit of environmental benefit.

The evolution of these approaches, from simple information dissemination to more complex integrated evaluations, reflects a growing maturity in HTA's engagement with environmental sustainability. This progression signifies a deeper commitment to embedding environmental considerations within the core HTA decision-making process. However, this advancement also brings to the forefront the inherent tension between achieving methodological rigor and ensuring practical feasibility, especially given existing resource constraints. While comprehensive methods like LCA offer detailed environmental impact assessments, their labor-intensive and costly nature can pose significant barriers to routine implementation. This necessitates a strategic balance, where the pursuit of robust, standardized methods is tempered by the need for approaches that are proportionate in complexity and cost to implement across a variety of health technologies.

3.4. Case Studies and Practical Applications

Several case studies illustrate the application of environmental sustainability assessments within HTA, demonstrating both feasibility and the complexities involved across different technology types.

• Medical Devices:

  • Reprocessed Single-Use Devices: Reports from Canadian agencies have discussed the growing interest in evaluating the clinical safety of reprocessed single-use semi-critical and critical medical devices, recognizing their potential for both economic and environmental benefits through reuse.

  • Inhaler Materials: Modelling methods have examined trade-offs between disposable and reusable inhaler materials, demonstrating that adopting reusable inhalers can reduce environmental burden (e.g., by decreasing the number of inhalers used) while potentially offering cost savings. Improved clinical outcomes can also be associated with improved environmental outcomes, suggesting that a clinical versus environmental trade-off is not always necessary.

• Pharmaceuticals:

  • Inhaled Anesthetic Agents: An INESSS report in Canada included an integrated evaluation of inhaled anesthetic agents, incorporating the social costs associated with their carbon footprint into an economic analysis. This analysis showed that desflurane was less efficient than isoflurane and sevoflurane due to higher acquisition costs and greater social costs related to its carbon footprint.

  • Metered-Dose Inhalers (MDIs): A CDA report highlighted the significant environmental footprint of MDIs due to their greenhouse gas emissions, emphasizing the critical need for appropriate and necessary use.

  • Insulin Treatment: An existing health economic model was adapted to incorporate environmental impacts, assessing the health and environmental impacts of insulin treatment for type 2 diabetes mellitus (T2DM).

• Digital Health Interventions:

  • Telehealth: Numerous studies have assessed the carbon footprint of telehealth, primarily focusing on travel-related emissions. Case studies from the UK, France, and the USA have demonstrated significant CO2e reductions (e.g., 99% decrease in emissions for teleconsultations compared to in-person) due to saved patient travel time and distance.

  • Electronic Health Records (EHRs): Studies have modeled the environmental impact of EHR systems, identifying CO2 emission reductions from decreased paper consumption, discontinuation of X-ray film, and reduced water consumption for X-ray processing. However, they also noted energy consumption from personal computers and data centers as a contributing factor.

  • Robotic Surgery: One study assessed the carbon footprint of robotically assisted laparoscopy (RA-LSC), finding a higher carbon footprint per patient compared to conventional laparoscopy due to energy consumption and waste.

These case studies collectively demonstrate the feasibility of integrating environmental sustainability considerations into HTA, and importantly, they often reveal significant co-benefits beyond environmental preservation, such as cost savings and improved patient care. For instance, the appropriate use of metered-dose inhalers can lead to cost savings, improved patient care, and reduced environmental impact simultaneously. This evidence indicates that environmental sustainability is not merely an external burden but can be a strategic driver for efficiency and value within healthcare. However, the varied methodologies and outcomes across these case studies also underscore that successful integration often depends on the specific technology and context. This necessitates tailored approaches rather than a universal, one-size-fits-all solution, highlighting the importance of developing flexible yet robust frameworks that can adapt to the diverse landscape of health technologies.

4. Challenges and Barriers to Integration

Despite the growing recognition and nascent efforts, the full integration of environmental sustainability into HTA faces considerable challenges, stemming from data limitations, resource constraints, and complex methodological and policy issues.

4.1. Data Limitations

A primary barrier to comprehensive environmental assessment in HTA is the scarcity and quality of relevant environmental data. Granular and specific environmental impact data are often lacking, as such information is not yet routinely reported by manufacturers, included in clinical trial outputs, or submitted to regulators and HTA agencies. Collecting environmental data can be labor-intensive and time-consuming, and it is often difficult to trace impacts back to a specific technology. This data deficit hinders the ability to conduct rigorous and accurate assessments, limiting the scope and depth of environmental considerations in HTA reports.

4.2. Resource and Expertise Constraints

HTA agencies operate with limited resources in terms of both personnel and funding, especially when compared to the vast volume of technologies that require assessment. A significant constraint is the lack of interdisciplinary expertise, specifically professionals with backgrounds in environmental assessment (e.g., life cycle analysis specialists, climate change economists) within HTA teams. This shortage of specialized skills is a rate-limiting factor, constraining the ability of HTA systems to routinely incorporate environmental impacts into their evaluations.

4.3. Managing Trade-offs between Health, Environmental, and Economic Outcomes

One of the most complex challenges lies in the inherent need to manage trade-offs between potentially conflicting objectives: improving health outcomes, managing economic costs, and minimizing environmental harm. An intervention might improve health but cause environmental harm, or be less environmentally damaging but incur higher costs, diverting resources from other health-improving initiatives. Achieving societal consensus on how to weigh these disparate outcomes is exceptionally challenging.

These trade-offs expose fundamental ethical and societal dilemmas regarding the weighting of health benefits, financial costs, and environmental preservation. For instance, how much health gain is society willing to forgo for a certain reduction in carbon emissions, or vice versa? While pilot studies suggest it is feasible to elicit public preferences on such trade-offs , there is currently very little empirical evidence on societal willingness-to-pay for environmental benefits or willingness to accept health compromises for environmental gains. This lack of clear societal preferences complicates the development of robust decision rules for integrated evaluations, emphasizing the need for continued research in this area.

4.4. Methodological and Regulatory Gaps

The field currently suffers from a lack of standardized approaches and a consensus on the most appropriate methods for environmental impact assessment in HTA. This methodological diversity leads to inconsistencies, making it difficult to compare assessments across different technologies or jurisdictions. Furthermore, there are fragmented definitions and standards, a lack of harmonized tools, and challenges in ensuring regulatory coherence between environmental legislation and sector-specific medical device regulations. The absence of an agreed approach to quantifying certain environmental impacts, such as biodiversity loss, further complicates comprehensive assessment.

This fragmented methodological landscape significantly hinders consistent and comparable environmental assessments within HTA. Without standardized methods and metrics, it becomes challenging to establish a level playing field for evaluating the environmental performance of different health technologies or to track progress over time. This situation underscores the critical need for international harmonization efforts, perhaps led by global bodies like WHO or INAHTA, to develop and disseminate widely accepted guidelines and tools for environmental assessment in HTA. Such harmonization would not only improve the rigor and utility of assessments but also facilitate better data sharing and collaboration across national boundaries.

5. Future Directions and Recommendations

Advancing the integration of environmental sustainability into Health Technology Assessment requires a concerted, strategic, and collaborative effort across multiple sectors. The following recommendations outline key future directions to overcome current barriers and maximize HTA's contribution to sustainable healthcare.

5.1. Standardizing Methodologies and Data Collection

There is a pressing need to develop and adopt robust, standardized methodologies for environmental impact assessment within HTA. This includes refining and standardizing methods for Life Cycle Assessment (LCA) and Multi-Criteria Decision Analysis (MCDA) to ensure consistency and comparability across evaluations. Guidelines should be established for analytical scope, domains of environmental impacts considered, and how impacts are quantified and valued. Furthermore, efforts must focus on improving the availability and granularity of environmental data from manufacturers and clinical trials, potentially through new reporting requirements.

5.2. Prioritizing Assessment Efforts: Intrinsic vs. Generic Impacts

Given the limited resources for environmental assessments within HTA, a strategic prioritization of effort is crucial. HTA should primarily focus on assessing technologies that possess "intrinsic characteristics" causing specific, significant environmental harms or vulnerabilities. Examples include technologies with high carbon footprints inherent to their chemical composition (e.g., certain anesthetic gases, pMDI inhalers) or those sourced from at-risk ecosystems. Generic environmental impacts common to most products (e.g., general energy use in manufacturing) may be more effectively addressed through broader policy and regulatory mechanisms outside of individual HTA processes. This approach requires effective environmental screening assessments early in the HTA pipeline to identify high-priority technologies.

5.3. Fostering Multisectoral Collaboration and Capacity Building

Achieving comprehensive environmental sustainability in healthcare necessitates robust multisectoral collaboration. HTA agencies, academia, industry, payer organizations, patient groups, and professional societies must work closely to develop consistent and feasible methodologies and evaluate their practical application. This includes building capacity within the health sector and partner sectors by developing and fostering specific skills needed for cross-sectoral action, such as environmental assessment expertise. The health sector should embrace its role as a "champion of population health" by advocating for environmental considerations in policies across all government levels.

5.4. Integrating Circular Economy Principles

Shifting from a linear "take-make-waste" model to a regenerative circular economy is vital for sustainable healthcare. HTA frameworks should integrate principles that maximize the lifetime value of products, minimize material use through design optimization, and promote recycling, refurbishment, and reprocessing of medical technologies. For digital health, this means focusing on extending product lifetime, designing for repairability, and ensuring maximum recovery of components and raw materials from e-waste. Addressing regulatory, policy, and financial barriers is essential for successful implementation of circularity in the MedTech sector.

5.5. Leveraging Policy and Procurement Levers

HTA's policy-informing role can be significantly leveraged to drive environmental sustainability. This includes informing sustainable procurement policies, such as those implemented by the NHS, which mandate carbon reduction plans for suppliers and link contract qualification to sustainability progress. HTA can provide evidence to support decisions that prioritize technologies with favorable environmental impacts in health policy choices. Furthermore, HTA can contribute to national net-zero targets by identifying and promoting cost-effective, low-carbon interventions.

5.6. Capacity Building and Research on Societal Preferences

Investment in training and education for HTA professionals and stakeholders on environmental assessment methods is critical. Furthermore, empirical research is needed to understand and quantify societal preferences for trade-offs between health outcomes, economic costs, and environmental impacts. Discrete Choice Experiments (DCEs) have shown promise in eliciting these preferences, which are vital for developing robust decision rules in integrated HTA evaluations. Such research will provide a more informed basis for balancing competing objectives in healthcare decision-making.

Conclusions and Recommendations

The evaluation of environmental sustainability in Health Technology Assessment reveals a critical juncture for global healthcare. The sector's substantial environmental footprint necessitates a fundamental shift towards sustainable practices, with HTA emerging as a pivotal mechanism to guide this transformation. While HTA agencies worldwide are increasingly acknowledging the value of integrating environmental considerations, current efforts are largely in their nascent stages, characterized by methodological diversity and significant implementation challenges.

Key findings underscore the disproportionate environmental impact of healthcare's supply chain, the specific contributions of pharmaceuticals (especially anesthetic gases and MDIs) and medical devices (particularly plastics), and the dual nature of digital health as both a solution and a potential source of new environmental burdens. The persistent challenges, including data scarcity, limited interdisciplinary expertise, and the inherent complexities of balancing clinical, economic, and environmental trade-offs, highlight the need for a more structured and collaborative approach.

To advance this crucial agenda, the following recommendations are paramount:

1. Standardize and Harmonize Methodologies: Develop and widely adopt robust, standardized environmental assessment methods, particularly Life Cycle Assessment (LCA) and Multi-Criteria Decision Analysis (MCDA), tailored for HTA. This will ensure consistency, comparability, and rigor across evaluations.

2. Strategically Prioritize Assessments: Focus HTA resources on technologies with intrinsic environmental harms, where the environmental impact is inherent to the product's nature, to maximize the impact of assessment efforts. Generic impacts should be addressed through broader policy instruments.

3. Strengthen Multisectoral Collaboration: Foster deep partnerships among HTA agencies, industry, academia, government, and civil society to build capacity, share data, and co-develop solutions that transcend traditional sectoral boundaries.

4. Embed Circular Economy Principles: Actively integrate circularity into the design, procurement, use, and end-of-life management of health technologies, moving away from linear models to minimize waste and maximize resource recovery.

5. Leverage Policy and Procurement: Utilize HTA findings to inform and strengthen sustainable procurement policies and national environmental targets, driving systemic change across the healthcare supply chain.

6. Invest in Research and Capacity: Fund research into societal preferences for environmental trade-offs and invest in training programs to build the necessary interdisciplinary expertise within HTA bodies.