Methods for evaluating environmental sustainability in health technology assessment: views of stakeholders

Abstract Incorporating environmental sustainability into health technology assessment (HTA) is increasingly important for aligning with government targets, healthcare policies, and healthcare professional bodies endorsing the use of more sustainable health technologies, while maintaining clinical effectiveness and value for money. Although proposals exist to include environmental criteria in HTA, methodological development in this area remains limited. This study explored stakeholder perspectives on useful methods, frameworks and challenges for assessing environmental outcomes in HTA. Semi-structured interviews were conducted with eight stakeholders including HTA decision makers, industry representatives, sustainability professionals, and academics from different jurisdictions to ensure diverse views and cross-setting applicability. Data were analysed thematically to identify opportunities, barriers and facilitators for methodological development. Stakeholders broadly supported integrating environmental outcomes into HTA, with carbon footprint highlighted as a key measurable and decision-relevant indicator. Environmental life cycle assessment was considered useful for quantifying emissions and identifying hotspots, but barriers included limited environmental data, lack of methodological consensus on scope and boundaries, and resource and expertise constraints. Broader environmental outcomes, such as impacts on resource use, biodiversity, and health, were also seen as important where evidence is available. Suggested approaches included carbon costing within economic evaluation, multi-criteria decision analysis, expert consensus, and weighting of highly polluting technologies to address trade-offs. Stakeholders emphasised the need to understand societal preferences for environmental gains, including willingness to pay or trade-off health benefits. This novel research provides the first qualitative insights into multidisciplinary stakeholder views on environmental sustainability in HTA, identifying both opportunities and challenges for methodological innovation and policy development.