Which Factors are Holding up the Integration of the Environmental Impact of Health Technologies in Health Technology Assessment? Insights from a Multi-Stakeholder Interview Study

Objectives The integration of environmental impact into health technology assessment (HTA) is increasingly discussed, but its practical implementation remains uncertain. This study explores multi-stakeholder perspectives on the progress, challenges, and equity implications of incorporating environmental considerations into HTA. Methods As part of the Horizon Europe project HI-PRIX (ID: 101095593), 13 semi-structured interviews were conducted with experts across academia, HTA agencies, regulatory bodies, and industry in seven European countries. Interview transcripts were analyzed through a thematic analysis conducted manually, using a grounded-theory approach. From the interviews, 101 quotes corresponding to 37 codes were extracted and organized in eight analytical themes. Results Stakeholders agreed that environmental impact is relevant but under-addressed in HTA due to fragmented data, methodological uncertainty, and lack of regulatory guidance. Many emphasized that a health system perspective is too narrow, where methods conventionally used to assess health technologies are not necessarily appropriate to also assess environmental impact, calling for a societal approach that reflects lifecycle impacts. Equity consequences linked to the inclusion of environmental impact of health technologies in HTA were specifically recognized as both reasons for its incorporation and potential barriers. At this stage, procurement was identified as a practical approach to account for the environmental dimension. Conclusions Integrating environmental impact into HTA will require shifting toward a societal perspective, stronger collaboration across stakeholders, and development of EU-level guidance, expert panels, and standardized methodologies. Methodologies incorporating equity into economic analyses should be explored as a potential direction for future research. Until frameworks mature, environmental impact is likely to remain informative but not yet decisive in HTA.