Supply chains represent the origin of the vast majority of greenhouse gas emissions in the health system. Nearly four‑fifths of the sector’s emissions can be traced back to its supply chains, making reducing emissions within them a critical step towards improving the environmental impact of health systems in OECD countries. This chapter reviews the impact of pharmaceuticals, medical devices and supply chains on the emissions of health systems and explores what steps countries can take to reduce the greenhouse gas emissions of these sectors and contribute to more environmentally sustainable health systems for all.
Decarbonising Health Systems Across OECD Countries
Abstract
Transforming health system supply chains is essential to significantly reducing emissions from the health sector. Scope 3 emissions comprised 79% of health sector emissions on average across OECD countries in 2018, indicating that the vast majority of health systems emissions originate from supply chains. Moreover, half of health sector emissions in OECD countries originate outside of the country of healthcare delivery, underscoring the deeply interconnected and global nature of health sector supply chains. This means that even if countries were to successfully implement low-emissions care delivery and reduce the emissions associated with their health facilities and care, an important share of health system emissions can only be meaningfully be reduced by tackling emissions associated with the production of pharmaceuticals and medical goods, and with health system supply chains.
Procurement offers an important opportunity for countries to push for more environmentally sustainable alternatives. On average across OECD countries, public sources funded nearly three‑quarters (73%) of health spending in 2021, making governments and social health insurance schemes the largest spenders on health systems in most OECD countries. Health further represents the largest share of public procurement on average across OECD countries, representing nearly one‑third (31.9%) of overall government public procurement spending in 2021. While not all government spending on health relates to publicly procured goods, there is enormous potential to harness green public procurement as a tool to mitigate health sector emissions.
Adopting guidelines and rules to encourage using public procurement as a tool to mitigate health sector emissions is growing, but many initiatives in the health sector remain in their infancy. The development of standardised cross-country environmental rules and guidelines for public procurement would provide suppliers with the clarity they need to make long-term changes that benefit mitigation efforts.
Pharmaceuticals and medical products drive an important share of health sector emissions. At least one‑quarter of health sector emissions in OECD countries come from the use of pharmaceuticals and other medical goods, and this value is likely an underestimate. Substituting away from some high-emissions products is already possible in certain cases. Researchers and clinicians have already begun to identify products that can be substituted when clinically appropriate. But few countries have translated this knowledge into policies that promote the use of lower-emitting alternatives.
Recent clinical developments mean lower-emitting alternatives for some products are coming to market. Pharmaceutical companies have invested substantial resources into developing lower-emitting alternatives for the propellants used in metered-dose inhalers. While the new products may offer significant reductions in emissions for products with high global warming potential, they may also come at a significant cost for health systems, which may be faced with deciding how much they are willing to pay for lower-emitting products.
Countries have taken steps to include environmental considerations in Health Technology Assessments (HTA), but a lack of high-quality empirical data, among other factors, has hindered the systematic inclusion of environmental factors into HTA decision making.
In recent years, the COVID‑19 pandemic drew attention to how complex, interconnected, and global medical supply chains have become. Trade in medical goods – including pharmaceutical products, medical equipment, orthopaedic equipment, personal protective equipment, and other products – rose by 38% between 2018 and 2022, to over USD 1.58 trillion (Drevinskas, Shing and Verbeet, 2023[1]). Nearly three‑fifths of the value of medical goods traded is made up of pharmaceutical products (Drevinskas, Shing and Verbeet, 2023[1]). Over the last 30 years, the global trade in pharmaceuticals has increased by more than 1 000%, representing 4% of global trade flows (OECD, 2024[2]).
New data from OECD emissions analysis indicates that supply chains make up an enormous share of overall health sector emissions. On average across OECD countries, emissions from supply chains represent 79% of overall health sector emissions.
Source: OECD analysis based on data from OECD Health Statistics 2025, System of Health Accounts and ICIO data.
Emissions from health sector supply chains occur in the production and preparation of medical products, as well as in the production and transportation of the raw and intermediate materials that go into making the final products. This includes emissions associated with the extraction of raw materials, transportation-related emissions, the emissions from the actual production process (such as energy for factories), and the emissions related to delivery, storage, and consumption of the products in their country of destination.
50% of health sector emissions on average come from sources outside of the country
Nine of the top ten countries making up the largest exporters and importers of medical goods globally are made up of OECD countries, underscoring the central role OECD economies have in both the production and consumption of medical products (Drevinskas, Shing and Verbeet, 2023[1]). The production of medical products is extremely complex and variable, with the exact production and delivery process dependent on the medical goods being produced. Pharmaceuticals and medical devices, for example, have markedly different supply chains, with many medical device supply chains more closely resembling supply chains from non-medical products than those of pharmaceuticals (OECD, 2024[2]). Nonetheless, supply chains across many medical products, both pharmaceutical and other, have become extremely international, with many products crossing three or more borders during the production phase before reaching their final market destination.
The globally interconnected nature of healthcare systems today is further underscored by the relatively high proportion of health systems emissions that originate from supply chains abroad. On average across OECD countries, 50% of health sector emissions stem from supply chain processes that occurred outside the country.
The international nature of the healthcare sector supply chain further emphasizes the importance of joint international efforts. In October 2024, the WHO and UNITAID convened global health organizations, including OECD and non-OECD governments, as well as other key stakeholders to discuss strategies for achieving climate-resilient and environmentally sustainable health supply chains (World Health Organization, 2024[3]). There is growing demand to address environmental and climate risks linked to health sector operations both within health systems and international agencies. Global initiatives such as the Alliance for Transformative Action on Climate and Health (ATACH) and the Global Framework on Chemicals for a planet free of harm from chemicals and waste (GFC) emphasize the need to work towards climate-resilient, low-carbon health systems, and responsible chemical management globally (World Health Organization, 2024[3]).
Source: OECD analysis based on data from OECD Health Statistics 2025, System of Health Accounts and ICIO data.
Pharmaceuticals and other medical goods represent a quarter of health systems emissions
While care facilities and direct care delivery play an important role in contributing to emissions, the production and consumption of medical inputs, in the form of pharmaceuticals and other medical good, represents an important share of overall healthcare emissions. In 2018, an estimated one‑quarter of overall health sector emissions related to the pharmaceuticals and other medical goods.
Source: OECD analysis based on data from OECD Health Statistics 2025, System of Health Accounts and ICIO data.
The significant contribution of the pharmaceutical sector to greenhouse gas emissions is large not only in the context of health systems, but of economic sectors globally. One study looking at the emissions intensity of the pharmaceutical sector exceeded that of even the automotive sector, though the exclusion of Scope 3 emissions arguably complicates drawing a conclusive picture of the comparative sizes of the sectors (Belkhir and Elmeligi, 2019[4]). The study further drew attention to the difficulty of assessing and comparing environmental performance between companies, even where public disclosures are made.
While research on the greenhouse gas impact of specific pharmaceuticals and medical products has so far captured only a fraction of the hundreds of thousands of products that are used in healthcare, policymakers and healthcare practitioners have identified certain types of products that can be fairly easily substituted for other widely available products, which deliver care of similar clinical value and efficacy with markedly lower greenhouse gas emissions.
Despite growing momentum and understanding around the environmental impacts of healthcare, the information available to practitioners, as well as policy action to promote products and procedures with lower environmental impact, remains limited. Where there has been attention, it has focussed – as below – on specific products for which there is a clear environmental benefit of one product over another, without patient impact. However, in far more cases, the evidence base for an environmentally-informed choice remains limited.
Anaesthetic gases: Desflurane use remains high in some countries – but policies to reduce its use have been effective
Analgesic products and anaesthetic gases have been identified as having an outsize role in the greenhouse gas emissions of the health sector, with lower-emission alternatives also identified. Anaesthetic gases and products have been estimated to represent 2% of the NHS’s overall carbon footprint in the United Kingdom (England) (Watts, Moonesinghe and Foreman, 2023[5]).
Not all anaesthetic gases have similar greenhouse gas emissions, however. Among volatile anaesthetic gases, sevoflurane and isoflurane can be used with significantly lower environmental impact than desflurane, for example, with sevoflurane contributing the least to greenhouse gas emissions. Estimates suggest that the global warming potential of desflurane may be nearly 20 times higher than sevoflurane, and more than three times as high as isoflurane (Friedericy et al., 2024[6]).
In the majority of cases, desflurane can be substituted for isoflurane or sevoflurane without impacting quality of care and patient outcomes. A number of countries have taken steps towards reducing the use of – or banning entirely – the use of desflurane in hospitals and surgical centres. The United Kingdom (Scotland) became the first country to ban the use of desflurane in 2023, with desflurane decommissioned for general use by NHS England in 2024. In Australia, the state of Western Australia similarly removed desflurane from its Medicines Formulary in 2023 while across countries in the European Union, desflurane will be banned from general use beginning in 2026. In Western Australia, removing desflurane has been estimated to have delivered both emissions and cost reductions, reducing an estimated 1 800 tons of CO2‑equivalent emissions annually, while driving down costs by AUD 750 000 (Department of Health and Aged Care, 2023[7]).
Waste from anaesthetic gases can also contribute to higher greenhouse gas emissions within the health sector, with no clinical benefit. Many hospitals, for example, use pipes to transport nitrous oxide across their buildings. Recent studies have suggested that the vast majority of nitrous oxide piped through hospitals is lost to leakage without being delivered to patients. The inefficiency of piped anaesthesia is underscored by estimates suggesting that more than three‑quarters – and in some cases, close to 100% – of nitrous oxide delivered through via hospital pipelines is lost, normally due to leaks within the pipe system (Morgan et al., 2025[8]).
Guidelines to help clinicians move away from using high-emission anaesthetic gases in favour of lower-emission alternatives have been developed in a number of countries. In the United Kingdom, a report on Green Surgery aims to provide guidance on practices that can help reduce the environmental footprint of surgical care. The report includes recommendations on reducing the impact of anaesthesia, including recommending the decommissioning of desflurane and substituting piped nitrous oxide with cylinders (Brighton and Sussex Medical School, Centre for Sustainable Healthcare and UK Health Alliance on Climate Change, 2023[9]).
Data from a number of OECD countries indicates that there is significant scope for many countries to drive down the use of the highest emitting anaesthetic gases in favour of lower-emitting alternatives, without clinical impacts. In the countries that have made reducing desflurane a priority in recent years, dramatic declines in the use of desflurane as a share of total anaesthetic gases has been observed, suggesting that reducing the overall use of anaesthetic gases or substituting desflurane for sevoflurane or isoflurane is possible. Countries report a wide variation in the use of desflurane, ranging from nearly three‑fifths of anaesthetic gases in Japan to no or nearly no use in the United Kingdom, Norway and Latvia.
Desflurane as a share of overall volume of isoflurane, sevoflurane and desflurane
Note: Overall volume should not be equated with patient case share.
Source: OECD Health and Climate Data Collection on High-Emission Clinical Inputs, 2025.
Inhalers: Lower-emission alternatives are already possible for many patients, and new clinical developments may provide even more
Inhalers used as treatment to support people with respiratory conditions offer another low-cost opportunity for countries to meaningfully reduce the greenhouse gas emissions associated with their health sectors. Metered-dose inhalers, which employ a high-emissions propellant to release the medication, have a dramatically higher emissions impact and warming potential than alternatives including dry powder and soft-mist inhalers. For many patients, switching from a metered dose to a dry powder or soft mist inhaler should be relatively straightforward and cause no clinical differences in outcomes, if patients are able to use new devices correctly However, switching inhaler may not be an option for others, such as young children or very old patients, for whom existing products may be more clinically appropriate.
Previous studies have suggested countries could markedly reduce the emissions associated with inhalers at little or no cost, and potentially even reduce expenditure on inhalers. A study in the Netherlands estimated that pressurised metered dose inhalers deliver about half of total doses of inhaler medication, and that reducing the number of doses delivered through metered-dose inhalers by 70% could reduce greenhouse gas emissions by 63 million kg CO2‑equivalent annually (ten Have et al., 2022[10]). In Japan, researchers have estimated that replacing 10% of prescribed pressurised metered-dose inhalers with dry powder alternatives for all patients aged 15‑74 would reduce the greenhouse gas emissions associated with inhalers by 6.1%, with an increase in costs of about 0.7% (Nagasaki et al., 2023[11]).
The potential impact of switching from high-emitting metered dose inhalers to low-emission alternatives in terms of costs to the health system is less clear. Should metered dose inhalers be substituted for low-cost dry powder alternatives, multiple studies have found that health systems would experience important cost savings for prescription inhalers. In the Netherlands, researchers found that substituting 70% of prescribed metered dose inhalers for low-cost non-propellant alternatives would save more than EUR 49 million per year (ten Have et al., 2022[10]). In the United Kingdom (England), researchers have estimated that every 10% of metered dose inhalers substituted for the lowest cost equivalent dry powder inhaler would save GBP 8.2 million per year (Wilkinson et al., 2019[12]).
However, were metered dose inhalers to be substituted with dry powder inhalers at the average cost at the time of evaluation, researchers across multiple countries have found that the costs to the health system would increase. In the Netherlands, substituting 70% of metered-dose inhalers for average‑cost dry powder equivalents would increase the cost of inhalers by EUR 3.7 million per year (ten Have et al., 2022[10]). With an estimated 1.4 million patients prescribed inhalers for COPD or asthma annually, this would equate to an additional cost of EUR 2.64 per patient per year. In the United Kingdom (England), every 10% of metered-dose inhalers substituted with dry powder inhalers according to the brand prescribing patterns of 2017, costs would increase by GBP 12.7 million each year (Wilkinson et al., 2019[12]).
Not all pressurised metered dose inhalers are the same, and new propellants being developed offer the potential to deliver propellant-based inhalers with substantially lower emissions, potentially even lower than emissions offered by current soft-powder and dry powder inhalers. Some major pharmaceutical companies who produce propellant-based inhalers have committed to developing lower-emission alternatives to use in their metered-dose inhalers, with some products approved in 2025 and further regulatory submissions expected (Wittenberg, 2024[13]).
As with anaesthetic gases, OECD countries report a wide range in the use of different types of inhalers, with the share of metered dose (high-emitting) inhalers ranging from about 40% in Japan to more than 80% in Australia, the United Kingdom and the United States.
Metered dose inhalers as a share of all prescribed inhalers, 2023
Source: OECD analysis based on data from the 2025 OECD Health and Climate Data Collection on High-Emission Clinical Inputs.
Recent clinical developments in lower-emitting propellants may make policy decisions to substitute inhalers less straightforward. The development of lower-emission propellants and the likelihood that they will come shortly to market across many OECD countries also points to the nuance needed when making policy changes based on emissions considerations, particularly when they affect care delivery. While substituting metered dose inhalers for dry powder alternatives may reduce emissions given the products currently on the market, lower-emission alternatives that do not require significant policy changes and changes to prescribing practices could also emerge in the coming years. While in most cases the majority of patients can switch to an alternative inhaler without impacting clinical outcomes, they may also become accustomed to their treatment regimes and may have a preference to maintain practices they are already familiar with. At the same time, as new formulations, the products coming onto the market may be priced substantially higher than existing inhalers, and could require policymakers to grapple with the price they are willing to pay to drive down emissions as much as possible.
Similar increases in price have been seen in previous reformulations of inhalers that were undertaken to phase out the use of chlorofluorocarbons (Wouters, Feldman and Tu, 2022[14]; Jena et al., 2015[15]). Chlorofluorocarbons (CFCs) were previously used as the propellant in metered-dose inhalers, but were ultimately banned due to their impact on ozone depletion. Researchers have found that when generic albuterol inhalers containing chlorofluorocarbons were removed from the market in the United States at the end of 2008 in favour of on-patent hydrofluoroalkane (HFA) albuterol inhalers, out-of-pocket costs nearly doubled almost immediately, while the use of inhalers also slightly declined (Jena et al., 2015[15]). Given existing financial pressures facing many health systems, it is far from clear that stakeholders will be willing to purchase significantly more expensive products which deliver clinically equivalent care with lower emissions.
Reducing intravenous administration of medicines when oral alternatives are available can reduce emissions
Many medicines administered in hospitals and other care settings have multiple delivery formats available. Most notably, clinicians often have the choice between administering patients analgesic and other medicines intravenously or orally. Recent life cycle assessments from a range of countries have found that administering medicines orally is associated with significantly lower greenhouse gas emissions and can further reduce the amount of water used during the administration of the medication. In a study of the use of acetaminophen and ketoprofen in a French university hospital, intravenous administration of the medications was found to be associated greenhouse gas emissions more than 50 to 60 times higher than administering the same drugs orally (Bouvet et al., 2024[16]). Oral administration further reduced the water consumption associated with the drug by at least 8.6 litres per administration (Bouvet et al., 2024[16]). A study of practices in hospitals in Australia, the United Kingdom and the United States similarly found that switching away from intravenous paracetamol administration in hospitals in favour of oral administration would have reduced greenhouse gas emissions across the 26 hospitals evaluated by 5.7 kilotons of CO2e in 2019 and reduced associated costs by more than 98% (Davies et al., 2024[17]).
Improving measurement and data harmonisation for pharmaceutical and medical products
For practitioners and clinicians to be able to make informed environmentally-oriented decisions, clear information on the trade‑offs between different clinical options are needed. As momentum for greater public reporting and emissions requirements in procurement has grown, a number of initiatives to improve measurement, reporting and information have developed. The global Choosing Wisely initiative, which has worked to reduce low-value care by providing clear and actionable recommendations for practitioners, has begun to develop resources to help clinicians make informed choices around products and procedures with lower environmental impacts which do not impact patient care.
The size of government procurement across OECD countries represents an important share of the overall economy. Public procurement represented 12.9% of overall GDP on average across the 38 OECD countries in 2021, and represented more than one‑quarter (27.8%) of total government expenditures (OECD, 2025[18]). The important role of government spending in the economy has made public procurement an increasingly popular tool for driving policy objectives, including encouraging innovation, social outcomes, and the economic development of certain sectors.
Harnessing the influence of public procurement to shape environmental factors through “green” procurement strategies has become an increasingly important area of policy focus in recent years. As countries explore all possible avenues to foster an economy-wide transformation towards more environmentally sustainable practices, leveraging the power of public procurement has emerged as a key tool. Policymakers have recognised potential of public procurement policies to both drive demand for green products and services and to incentivise businesses to adopt more sustainable practices. This approach aims to tackle pressing environmental challenges, including mitigating greenhouse gas emissions, by encouraging sustainable development through strategic procurement choices. In this way, public procurement plays a crucial role in shaping environmental outcomes and influencing the broader market towards sustainability.
Nearly four-fifths of countries have adopted green public procurement policies, but policies are rarely health sector-focussed
OECD countries have taken a growing interest in green public procurement policies in recent years. Nearly four‑fifths (78%) of responding countries reported that regulations to include environmental considerations in procurement were in place. These policies do not automatically extend across all sectors of procurement, however, with many countries initially focussing on specific sectors for action, such as construction and the procurement of wood products. About one in six countries have developed procurement guidelines or regulations specifically for the health sector itself. This indicates a limited but growing recognition of the unique environmental impacts and needs within the healthcare sector.
Broader green procurement policies developed by the government can serve as an important building block in developing procurement requirements for the health sector specifically. In the United Kingdom (England), NHS England has applied and extended the environmental requirements in the government’s procurement policy to develop a roadmap for suppliers – both of goods and of services – to the NHS (NHS England, n.d.[19]).
Building on the broader procurement strategy of the UK Government, NHS England has developed a supplier roadmap intended to help the English health system achieve its goal to reach net zero by 2030. The roadmap outlines guidance and requirements for suppliers to the NHS system to develop plans to reduce their greenhouse gas emissions and measure their carbon footprint.
In order to support suppliers in developing their capacities for measuring their environmental performance, procurement requirements are being rolled out progressively, with new rules first applicable to larger suppliers before being rolled out to cover all procurement.
Beginning in April 2022, all procurement to NHS was required to include weighting for net zero and social value considerations. Carbon reduction plans have been required of for all suppliers of contracts worth more than GBP 5 million as of April 2023, and for all suppliers as of April 2024. Beginning in April 2027, public reporting of supplier emissions, targets, and carbon reduction plans will be required for all Scopes (1, 2 and 3) for all suppliers to the NHS, with individual product footprinting mandatory as of April 2028.
A number of countries have developed procurement processes and policies aimed at improving environmental considerations in for hospital purchasing. These policies often focus on improving environmental sustainability across a number of areas, including but not limited to greenhouse gas emissions. In Denmark, for example, the regional buyer responsible for the procurement of medicines in hospitals (AMGROS) has trialed public procurement tenders featuring environmental criteria including environmental considerations around the packaging and transportation of goods, return policies for devices, and the impact on antimicrobial resistance. In Norway, the Sykehusinnkjøp HF is responsible for all procurement for specialist health services and hospitals in the country. All procurement is required to meet certain standards of social responsibility, including environmental considerations. The group has also collaborated together with other Nordic countries on a set of criteria for more sustainable packaging for medical products. In the Netherlands, while procurement is decentralised, the government is in the process of developing an online portal for health facilities and procurement organisations that will provide them with information related to sustainable procurement, including guidelines around criteria for sustainable procurement.
The large share of government spending on health makes public procurement a powerful tool for shaping more environmentally sustainable production
Across OECD countries, a high proportion of overall government expenditure is spent on healthcare. Health expenditure as a share of GDP averaged over 9% across OECD countries in 2022, with the vast majority – 73% – coming from public sources in 2021 (OECD, 2023[20]). Previous analyses have suggested that close to three‑tenths of government public procurement is related to procurements for the health system.
Note: Countries with an asterisk* represent OECD accession countries. Data for Korea is from 2022. Data for Costa Rica is from 2021.
Source: OECD National Accounts Statistics (database), 2025.
The significant amount of public spending on healthcare underscores the potential positive impact well-developed procurement requirements could play in reducing the emissions impact of the health sector. Some of the structural characteristics of the health sector may influence how impactful procurement policy can be in shaping the environmental behaviours of its suppliers.
As countries begin to embed environmental standards into procurement regulations and purchasing agreements, ensuring rules are transparent and consistent and applicable to a large enough market share is critical for ensuring suppliers have incentives to comply with new standards. Companies may have little incentive to enter a market where the procurement rules require them to produce a product with different specifications – for example, with different packaging – than in other countries, particularly where the market is small. Moreover, in most cases, payers do not currently value or incentivise differentiation based on sustainability considerations. Developing cross-country standards and regulations is therefore important for incentivizing companies to respond to calls for tender, and for offering companies clarity in the actions they should take in both the short- and medium-term across markets.
Nordic countries have a well-established tradition of working across their markets to create certain environmental standards for medical products that apply across multiple countries. The Nordic Criteria for More Sustainable Packaging apply to the packaging of medical products across Denmark, Finland, Iceland, Norway and Sweden and were developed jointly by policymakers responsible for procurement at the hospital, regional, and national level. Building on initiatives developed at a university hospital in Denmark, the criteria provide guidance to procurement actors on developing criteria for reducing waste, promoting recyclability, and increasing the use of recycled or sustainable materials, with three levels of criteria (“basic”, “advanced”, and “spearhead”) that can be applied to tenders (Capital Region of Denmark, Region of Southern Denmark, Central Denmark Region, North Denmark Region and Region Zealand, 2022[21]). One reason cited for the development of the joint criteria was to persuade industry players to comply with standards by increasing the market size requesting such standards (Sookne, 2022[22]).
More recently, larger countries located across the world, rather than in one region, have begun working together to develop joint procurement standards. These efforts could provide even stronger incentives to large healthcare suppliers, including pharmaceutical companies and the medical device industry, by assuring a market size so important that companies would effectively be obligated to change their practices and supply chains globally to comply with the new guidelines set.
Countries including Australia, Ireland, Norway and the United Kingdom, have publicly committed to collaborating on decarbonising their healthcare supply chains. Initial discussions have focussed on setting joint standards for green procurement, public disclosure of greenhouse gas emissions from suppliers, and setting targets for emissions reduction among suppliers (Australian Department of Health and Aged Care, 2024[23]).
As awareness and concern about climate change and other environmental challenges has risen, many global initiatives to encourage more consistent and public reporting have been developed. Some have been developed to help guide the measurement and reporting of environmental impacts across economic sectors, while a more limited set have been developed targeting companies within the healthcare sector more specifically. These include the Greenhouse Gas Protocol and its associated Sector Guidance for Pharmaceutical Products and Medical Devices, developed by NHS England in partnership with pharmaceutical industry stakeholders in 2012, as well as various ISO standards (e.g. ISO 14 040, ISO 14 044, and ISO 14 067), a number of guidelines applicable to the chemicals sector (of which the pharmaceutical industry is a part), guidelines on measuring Scope 3 emissions in the pharmaceutical industry developed by the Pharmaceutical Supply Chain Initiative, and an approach to measuring the carbon footprint of specific medicines (ECOVAMED, 2024[24]; OECD, 2025[25]; Environmental Resources Management Ltd., 2012[26]) and to conducting environmental lifecycle assessments (PAS 2090). In addition to guidance on measurement of environmental impact, additional reporting standards provide guidance to companies who wish to publish information on their environmental, social and governance impact (“ESG” reporting) (Booth et al., 2023[27]).
Companies in the health sector have begun to make commitments and take action towards sustainability in their production and publicly reporting the environmental impacts of their production processes and products. Studies have found that the largest publicly traded companies are more likely to publicly report their greenhouse gas emissions and environmental footprint than smaller and privately held companies (Bade et al., 2023[28]). Trends toward public reporting are also relatively recent, with significant progress made in recent years.
While the development of public standards and guidelines for measuring environmental impact is intended to harmonise different approaches to evaluating such a complex issue, there remain significant differences in the ways companies measure, report and benchmark their environmental impact. In an analysis of the 20 largest medical device companies, 100% reported having Scope 1 and 2 targets, while a further 75% also included Scope 3 targets for their companies.
However, far fewer companies reported actual results for Scope 3 than for Scopes 1 and 2, with fewer than half (13 in 2022, 9 in 2023) reporting Scope 3 emissions estimates. Reporting approaches were also highly inconsistent, with the baseline and target years for companies inconsistent across companies.
Note: Based on top 20 largest medical device companies.
Source: OECD analysis based on public corporate reporting data.
Note: Based on top 20 largest medical device companies.
Source: OECD analysis based on public corporate reporting data.
Pharmaceutical and healthcare companies have also become increasingly involved in efforts to improve the harmonisation of measurement related to environmental impact in the health sector. Public private initiatives, such as the Sustainable Markets Initiative and efforts through the British Standards Institute, have been launched to support companies and health systems to improve access to information about environmental impact, reduce environmental footprints and improve the harmonisation of measurement approaches.
Insufficient data and evidence hamper the inclusion of environmental criteria into health technology assessments
Health technology assessments (HTAs) serve as a critical tool for efficiently allocating limited resources to where they can have the biggest impact within health systems. By considering the clinical and economic implications of different healthcare and technologies, HTAs allow policymakers to make informed decisions on safety, efficacy and cost effectiveness when integrating new technologies, treatments and interventions into the healthcare system.
HTAs have traditionally focussed on the clinical and cost-effectiveness of new technologies, with additional considerations given to certain social or ethical considerations, such as the impact on patient quality of life and access to care. Until recently, these evaluations have not regularly considered the potential environmental impacts of the technologies being evaluated. This may be due to a combination of factors:
Health systems remain primarily focussed on delivering high-quality care in as financially efficient a manner as possible, especially as rising demands for care occur in an era of fiscal constraint. HTAs have been designed first and foremost to address these primary health systems goals.
HTAs depend on high-quality evidence and information. The strong evidence base upon which decisions are made is a hallmark of the HTA process. Information related to the environmental impact of healthcare technologies and interventions thus far remains extremely limited, complicating in many cases the ability for decisionmakers to make evidence‑based judgements based on environmental factors (Greenwood Dufour et al., 2022[29]).
Stakeholders participating in the HTA process may not be experts in or familiar with environmental impacts. This may complicate their abilities to make informed decisions about potential environmental effects, particularly where the evidence is limited or of poor quality (Greenwood Dufour et al., 2022[29]).
There is not yet consensus on the best approach on how environmental considerations should be incorporated into assessments. A range of options exist with different implications for how environmental factors would be weighed. Environmental impacts could be used as an additional input of information during the deliberative process. They could alternatively or complementarily be translated into extended measures of the economic impacts or potential health impacts of a new technology. A recent review identified a range methods that have been adopted to incorporate environmental considerations into HTA, including extending cost utility and cost effectiveness analyses to account for greenhouse gas emissions, cost-benefit analyses that evaluated the willingness to pay by CO2‑equivalent, and multicriteria decision analysis, but noted the lack of evidence around environmental impacts at the product or technology level complicates efforts to incorporate environmental considerations into HTA evaluations (Pinho-Gomes et al., 2022[30]).
As the evidence for the health system’s environmental impact grows, a number of countries have begun to explore or express interest in considering environmental factors in health technology assessments. The number of countries that have actively moved to systematically incorporate environmental considerations into HTAs remains extremely limited. In the United Kingdom, a recent (2023) feasibility analysis conducted by the National Institute for Health and Care Excellence (NICE) found that the evidence around environmental impacts at the product level was not suitably advanced to incorporate environmental impacts systematically across all NICE HTA evaluations (National Institute for Health and Care Excellence, n.d.[31]).
At the same time, environmental impacts – including a product’s impact on greenhouse gas emissions – have been considered ad hoc to the approval of some new technologies in the United Kingdom. A recommendation in early 2022 to use a certain product (sedaconda anaesthetic conserving device‑S) as a lower-cost alternative for inhaled anaesthetics, for example, that while there was a lack of evidence on its impact on greenhouse gas emissions, there was the “potential” that the device could help to reduce greenhouse gas emissions compared to other products (National Institute for Health and Care Excellence, 2023[32]). However, the environmental considerations were neither taken into account as evidence nor cited as a reason the product was recommended (Szawara et al., 2023[33]).
Other countries that have not formally integrated environmental considerations into HTA decision making processes have also considered other environmental impacts during at least some HTA deliberations. In Canada, for example, a number of dental interventions have considered environmental implications, such as the impact of water fluoridation on water and soil contamination and the environmental impact of mercury that could be released from fillings (Greenwood Dufour et al., 2022[29]). While environmental impacts are included as one of ten domains within the deliberative framework developed by Canada’s Drug Agency (CDA-AMC) Health Technology Expert Review Panel, not all domains are required to undergo a full evaluation during the deliberation process (Walpole et al., 2023[34]). CDA-AMC has identified adapting its approach to more broadly consider equity, patient perspectives and environmental factors as part of its 2022‑2025 Strategic Plan, including better identifying the environmental impact of health technologies as part of the health system (CDA-AMC, 2022[35]).
Other OECD countries, including Poland, France, Sweden, Spain, and the Netherlands, are also considering how environmental impacts can be better incorporated into health technology assessments (Bobini and Cicchetti, 2024[36]). In the Netherlands, the Dutch National Healthcare Institute (Zorginstituut Nederland) has published an advisory report at the request of the Ministry of Health titled “Healthcare personnel utilisation and environmental sustainability taken into account when deciding whether healthcare can be reimbursed”. The report focuses on how the utilisation of scarce healthcare personnel and environmental impact can be taken into account when assessing whether or not to reimburse an intervention from the basic health insurance package. In May 2025 the advice was presented to the MoH in which the National Healthcare Institute sets out clear calculation methods for both subjects and advice on how to use them in the assessment and appraisal phases. It also indicates why labor input and environmental impact could, for now, not be incorporated in the criteria ‘effectiveness’ or ‘cost-effectiveness’. The Dutch National Healthcare Institute has commenced a 3 year trial period to gain experience with the proposed methods in the report.
How might environmental considerations be factored into HTAs?
While a lack of high-quality empirical data on the environmental impact of many new health technologies creates a significant barrier to better embedding environmental considerations into the assessment of new health technologies, there are many approaches to how environmental factors could be considered and weighted in health technology assessments if this information were to be made more consistently available. (Toolan et al., 2023[37]) identified four potential approaches to how HTA agencies could take on board environmental impact information in their assessments (Toolan et al., 2023[37]).
HTAs could serve as an information conduit for HTA agencies, using information on the environmental footprint of a technology that had been calculated elsewhere (such as by the company).
They could further be considered via an integrated evaluation that would quantify health, economic and environmental considerations into one model, such as through an extended cost-benefit or cost-utility analysis.
Alternatively, environmental impacts could be considered through a parallel evaluation that looked at the environmental impacts (positive or negative) of the new technology as a standalone consideration, without linking the environmental impact to health or economic factors, as in an integrated evaluation.
Lastly, environment-focussed evaluations could specifically evaluate the environmental impact of an alternative technology, where the health and economic benefits of the two products would be considered largely the same, with only an important difference in the environmental footprint. This would require an extension of what HTA agencies normally assess.
Williams et al. (2024[38]) have identified multiple methods to incorporate environmental factors into health technology assessments using these four approaches and identifies potential benefits – and risks – of implementing the different approaches.
Source: Adapted from Williams, J. et al. (2024[38]), “Methods to Include Environmental Impacts in Health Economic Evaluations and Health Technology Assessments: A Scoping Review”, https://doi.org/10.1016/j.jval.2024.02.019.
One additional challenge lies in identifying what constitutes environmental impact, and how to balance potential tensions between environmental benefits and harms that can be contained within one new product or technology. Some researchers have raised concerns, for example, which focussing too narrowly on reducing greenhouse gas emissions overlooks the additional and potentially negative impacts a technology that delivers care with lower emissions may also have on the environment in other ways. The same product, for example, may simultaneously release higher levels of harmful chemicals or other toxins into the ecosystem while also lowering emissions. At the same time, the comparatively straightforward approach to measuring greenhouse gas emissions when compared to other environmental impacts, combined with its more direct impact on climate change, have led some researchers to make the case that incorporating emissions footprinting into HTAs offers a good starting point for taking into account the environmental impacts of health technologies (McAlister, Morton and Barratt, 2022[39]; Williams et al., 2024[38]).
As countries begin to consider how and whether to incorporate environmental impacts into HTA, more clearly defining the scope of environmental impacts being considered and how adopting different approaches to environmental assessment would impact current HTA processes would help countries to best weigh the risks and benefits in doing so. Incorporating environmental considerations into health technology assessments offers countries a good opportunity to take seriously their commitments to reducing the environmental footprint of the health system. At the same time, making decisions based on incomplete or insufficient data could risk complicating a well-designed practice for unclear environmental benefit, particularly where there are tensions or trade‑offs between environmental impacts on different fronts.
Many of the data challenges facing health systems today will likely be reduced in the coming years. The data barriers that may currently prevent environmental factors from being more systematically considered in HTAs and other healthcare assessments will not necessarily represent the same obstacles that they do today. Even if the available information is insufficient today, countries have a good opportunity to begin proactively thinking through how environmental considerations could be more systematically included so they are ready to respond effectively once the necessary data is more widely available.
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