How Can HTA Shape a More Sustainable Future for Healthcare?

Melissa Pegg

Senior Research Consultant, YHEC

YHEC is pioneering new methods and approaches for incorporating and evaluating the environmental sustainability of healthcare interventions. This is especially important given the current uncertainties around trade tariffs affecting international medical supply chains and environmental protections being rolled back in the US. YHEC Senior Research Consultant, Melissa Pegg, is the inaugural chair of the new Environmental Sustainability in Health Technology Assessment (ESHTA) Working Group. She gives us some background to ESHTA, the importance of the group’s work, and her hopes for how the group might provide expert guidance and insight for health technology assessment in the future.

Tell us a bit about yourself and your role, both at YHEC and as the new chair of ESHTA.
I am a Senior Research Consultant at YHEC, and I lead the Environmental Sustainability in Health Technology Assessment (HTA) team. I have 18 years’ experience working with a broad range of health technologies, including pharmaceuticals, medical devices, AI and digital health technologies, in both primary and secondary NHS services. Previously, I was a Fellow in Sustainable Surgery for the British Medical Journal (BMJ) Net Zero Commission and co-authored the landmark Green Surgery Report [1]. I also founded and chair the newly formed Environmental Sustainability in HTA (ESHTA) Working Group (WG) within Health Technology Assessment International (HTAi). 

Can you give us some background to the ESHTA WG – how did it develop?
The ESHTA WG was founded in November 2023, spurred by my Masters in HTA third-year project. I was researching methods to evaluate environmental sustainability in HTA, and one of my recommendations was to establish an HTAi WG focusing on developing a framework to incorporate and evaluate environmental sustainability in HTA. Throughout my research, I spoke to many key stakeholders internationally who shared an interest in this topic. These conversations demonstrated that incorporating environmental sustainability in HTA is multifaceted and the perspectives of several important stakeholders should be considered. The ESHTA WG includes patient experts, healthcare professionals, HTA representatives, researchers, health technology developers, policy makers and regulators from all over the world. 

Why are you interested in environmental sustainability in HTA?
Climate and ecological breakdown are the greatest threat to our environment, predominantly because of human interaction with the world, known as the Anthropocene. The Intergovernmental Panel on Climate Change (IPCC) estimates that without massive progress in measures for reducing the human impact of global warming, Earth will reach 3.5°C above reference within the next 70 years [2]. This will have a devastating impact on human civilisation. The IPCC also stated that if we continue to produce the same amount of greenhouse gas (GHG) emissions, we could reach 5.7°C (global average) above pre-industrial temperatures within this century [3]. Modelling suggests that full implementation of all national government-pledged mitigation actions would limit global average warming to around 2.7°C by 2100. 

The global healthcare sector is responsible for 4.4% of total global GHG emissions, with 72% of its carbon footprint attributable to the supply chain [4]. More concerning is that since 2016, healthcare GHG emissions have increased by 36%, making health systems increasingly unprepared to operate in global conditions and propelling healthcare further from its guiding principle of doing no harm [5]. If we don’t act, climate change will soon overwhelm the world’s health systems. 

Efforts to improve the environmental sustainability of healthcare systems have been gaining traction, at local, national and international levels. At the COP28 UN Climate Change Conference, 143 countries committed to the urgency of acting on climate change to improve health and the need to transform health systems to be “climate-resilient, low-carbon, sustainable and equitable”.

Despite this, environmental sustainability is not formally included in HTA reference cases globally, and environmental sustainability criteria are not explicitly considered during the review process. However, HTA agencies, like the Scottish Health Technologies Group (SHTG), England’s National Institute of Health and Care Excellence (NICE), Canada’s Drug Agency (CDA-AMC), Zorginstituut Netherlands (ZIN), and Thailand’s Health Intervention and Technology Assessment Program (HITAP), are now beginning to consider environmental sustainability. For example, NICE has launched a project exploring methodologies to compare the environmental impact of health technologies and has incorporated environmental sustainability into its topic prioritisation framework. CDA-AMC has published a report on reducing the environmental impact of clinical care [6], and the organisation’s strategic plan [7] outlines goals to adapt methodology and analyses to include environmental perspectives. ZIN has committed to “national and European legislation to reduce the climatic and environmental impact of medicine use” as part of its international agenda for 2024 to 2025 [8].

What are the aims of the ESHTA Working Group?
The ESHTA WG provides broad stakeholder views about useful approaches, methods, techniques and tools to assess environmental sustainability in HTA, while considering potential facilitators and barriers. The ESHTA WG is also raising awareness of the environmental impact of healthcare pollution across the lifecycle of products and care pathways, which will support the optimisation of HTA guidance going forward. Our objectives are to:

• • • Define the role of HTA in relation to environmental sustainability.

• • • Define the scope for environmental sustainability in HTA.

• • • Propose value frameworks that incorporate environmental sustainability and its operationalisation.

• • • Foster consensus on these approaches, providing feasible and comprehensive solutions that can be piloted and implemented to achieve environmental sustainability recommendations in HTA.

Overall, we aim to support the development of frameworks and best practice recommendations to incorporate and evaluate environmental sustainability in HTA. For example, integrating CO2 equivalent measures alongside quality-adjusted life years (QALYs) and disability-adjusted life years (DALYs). We also hope to educate, and be educated by, a broad range of stakeholder groups and provide support tools for developing appropriate frameworks across diverse HTA communities globally. Linked with this goal, the ESHTA WG recently created an online central repository for resources in the field of sustainable healthcare development. We hope to develop further on this by collaborating with transdisciplinary teams across healthcare system governance, aligning with healthcare environmental targets.

What are you hoping will change because of the group’s work?
The (new) definition of HTA from HTAi [9] emphasises the inclusion of environmental criteria in the assessment of health technologies. However, there is an absence of clear and transparent guidance and regulation regarding the incorporation of environmental sustainability in HTA. A lack of regulation and standardised methods contribute to divergent practices and disagreement between experts, stakeholders and industry. The outputs of the ESHTA WG should have important implications for HTA organisations, guidance and global decision making. We are aiming to provide resources, widen perspective inclusivity, support best practice, look towards multidisciplinary techniques and multi-stakeholder collaboration, and achieve consensus when developing frameworks that will support global healthcare sustainability.

What do you see as the biggest challenges in the field?
There is an urgent need to develop more transparent global healthcare supply chains to enable a better understanding of and accountability for supply chain pollution. Identifying a suitable common communication channel for this will be useful. Furthermore, it is widely accepted that health economics aims to maximise health gains. However, overuse of health technology is contributing to environmental unsustainability. How should we consider the impacts of ecological and environmental damage in healthcare decision making that contribute to human ill health and also affect the availability of healthcare resources and resilience of healthcare? On this topic, interestingly, an ecological economics debate is stirring up amongst health economists. 

It is critical we take a planetary health perspective considering the health of human civilisation and the state of the natural systems on which it depends. The real challenge will be how we ’use’ data on human health impact, biodiversity impact, and resource use within the decision-making framework, especially when considering the need for and resources required to use the health technology. How much should we integrate environmental sustainability into decision-making frameworks? If environmental sustainability is integrated, should we establish and set thresholds to help support HTA metrics in reference cases?

There are also known challenges when establishing methods to assess environmental sustainability in HTA. There can be difficulties in defining the scope and boundary of environmental assessment, data quality issues, differing HTA perspectives and priorities, and potential ‘trade-off’ considerations between financial and environmental objectives. Notwithstanding this, HTA resource availability and jurisdictions’ political agendas are adding further challenges in the sustainable development of healthcare systems.

Are there other important considerations for HTA?
It is estimated that climate-intensified natural disasters may lead to $1.1 trillion in extra costs to healthcare systems globally and over two billion healthy life years lost by 2050 [10]. Currently, leading HTA organisations do not directly involve public opinions within economic evaluation decision-making processes. It is anticipated that HTA organisations will want to understand societal preferences because the environmental impact of health technologies contributes towards population ill health. For example, how much are people willing to pay, monetarily or in forgone health, for environmental gains? Nonetheless, a lack of empirical evidence on societal willingness-to-pay has not prevented NICE from establishing a cost-effectiveness threshold on which to base its current analysis methods and value framework. 

Recently, YHEC published the first concept paper [11] exploring public opinion about potential trade-offs in healthcare decision making that involves environmental outcomes, through a discrete choice experiment. The pilot study found that members of the UK public were willing to accept a reduction of approximately 0.75 years in life expectancy to achieve a 5% reduction in CO2-equivalent emissions. Conversely, the public would require an additional 1.59 years of life expectancy to tolerate a 5% increase in CO2-equivalent emissions. In a sub-analysis, the strength of trade-off was reduced when the impact of environmental changes was limited to countries outside the UK. The results suggest that trade-offs between healthcare and the environment are possible to quantify and that the public is willing to tolerate health losses to reduce harm to the environment. We hope this will form the basis of a larger study to leverage crucial regulatory and policy development in this space. 

If you wanted people to take away one thing from this blog post, what would it be?
Optimising resource use / using less healthcare that prioritises patient outcomes can be approached through the triple bottom line framework, which considers financial, social and environmental sustainability. The Sustainability in Quality Improvement (or SusQI) framework recognises that there are finite environmental, social and financial resources available to deliver a high standard of patient care. The overall goal of incorporating sustainability into quality improvement is to maximise sustainable value. This means delivering the best possible health outcomes with minimum financial and environmental costs, while adding positive social value at every opportunity. If we start here and look to develop a hierarchy of health technologies from the perspective of low value (financial, social and environmental), there will be sizable advancement in healthcare sustainability and net zero goals. We could utilise the SusQI framework to support HTA developing a screening process to consider current and new technologies for environmental evaluation.

How does the role as ESHTA chair complement your work at YHEC – do you think YHEC will get involved with more projects on environmental sustainability?
I feel honoured to be currently chairing the HTAi ESHTA WG made up of over 100 passionate stakeholders from across the world. I am also working closely with the ESHTA leadership team including Debjani Mueller, Nicola McMeekin and Anke Peggy-Holtforf.

At YHEC, we are leading efforts to integrate sustainability into healthcare lifecycle assessments, pioneer research methods, and educate a wide range of stakeholders on how to do the same. Within the Environmental Sustainability in HTA team at YHEC, we combine expertise in measuring environmental impact with economic modelling, amongst other evaluation techniques, and we use existing frameworks and validation checklists to standardise methodologies that support data generation in this space.

In collaboration with health economics colleagues, we recently developed a novel cost-carbon calculator model that supports reporting financial and environmental data, something which will be crucial for NHS decision-making processes going forward. This work was published by the International Journal of Health Planning and Management, and a key finding was that pharmaceuticals were a key contributor to carbon emissions across the care pathways evaluated. 

Further information
There are lots of opportunities to find out more about Mel’s work in this important space.

Sign up to YHEC’s online training event, Environmental Sustainability in Health Technology Assessment, on Thursday 26 June 2025 where Mel will be joined by YHEC Director, Professor Matthew Taylor, to provide an overview of current methods for quantifying the environmental impact of healthcare interventions.

Mel will also be presenting in Buenos Aires, Argentina at the HTAi Annual Conference in June. Delegates can hear Mel’s talk about the main theme NextGen Evidence: Diversifying And Advancing HTA To Meet Global Demands during plenary two.

To find out more about the ESHTA Working Group and to follow how their work evolves, visit their website or connect with them on LinkedIn.

References
[1] Brighton & Sussex Medical School, Centre for Sustainable Healthcare, and UK Health Alliance on Climate Change, 2023. Green surgery: Reducing the environmental impact of surgical care (v1.1). Available at: https://ukhealthalliance.org/sustainable-healthcare/green-surgery-report/ [Accessed 28 March 2025].

[2] World Resources Institute. 2024. What Would Cities Look Like With 3 Degrees C of Warming vs. 1.5? Far More Hazardous and Vastly Unequal. Available at: https://www.wri.org/insights/climate-change-effects-cities-15-vs-3-degrees-C#:~:text=Global%20average%20temperatures%20are%20now,suffer%20disastrous%20levels%20of%20loss%20 [Accessed 07 April 2025].

[3] The Intergovernmental Panel on Climate Change. 2023. AR6 Synthesis Report. Available at: https://www.ipcc.ch/report/ar6/syr/ [Accessed 07 April 2025].

[4] NHS Supply Chain. 2016. Sustainable Development Report, 2015-2016. Available at: .https://shorturl.at/fMHsW [Accessed 07 April 2025].

[5] Romanello M, Walawender M, Hsu SC, Moskeland A, Palmeiro-Silva Y, et al. 2024. The 2024 report of the Lancet Countdown on health and climate change: facing record-breaking threats from delayed action. Lancet; 404(10465):1847-1896.

[6] Canadian Agency for Drugs and Technologies in Health. 2023. CADTH Horizon Scan: Reducing the environmental impact of clinical care. Available at: https://www.cda-amc.ca/sites/default/files/pdf/htis/2023/EH0112%20v.7_%20Final.pdf [Accessed 15 April 2025].

[7] Canadian Agency for Drugs and Technologies in Health. 2022. Ahead of the curve: shaping future-ready health systems: 2022-2025 strategic plan. Available at: https://www.cda-amc.ca/2022-2025-strategic-plan. [Accessed 15 April 2025].

[8] National Healthcare Institute. 2025. International agenda, 2024-2025. Available at: https://english.zorginstituutnederland.nl/binaries/zinl-eng/documenten/reports/2024/03/01/international-agenda/International+Agenda+2024-2025.pdf [Accessed 15 April 2025].

[9] O'Rourke B, Oortwijn W, Schuller T; International Joint Task Group. 2020. The new definition of health technology assessment: A milestone in international collaboration. International Journal of Technology Assessment in Health Care, 36(3):187-190.

[10] World Economic Forum. 2024. Climate Crisis May Cause 14.5 Million Deaths by 2050. Available at: https://www.weforum.org/press/2024/01/wef24-climate-crisis-health/ [Accessed 07 April 2025].

[11] Pegg M, Mistry C, Barker E, Taylor M. 2024. Eliciting trade-offs between population health and environmental outcomes: A pilot study. European Journal of Environment and Public Health, 8(4), em0163.

Posted: 16 April 2025