The OHE published a podcast this week on whether environmental sustainability should be formally incorporated into health technology assessment. The participants — senior economists from OHE and NICE — made the case carefully and honestly. Healthcare is responsible for roughly 4–5% of national greenhouse gas emissions in high-income countries. In England, around 25% of NHS emissions come from medicines. The NHS has legally binding net-zero targets. It is entirely reasonable to ask whether the body that makes reimbursement decisions for those medicines should factor environmental impact into those decisions.
The problem is what the debate's own participants acknowledge in the final section: by the time a technology reaches HTA, most of the environmental decisions have already been made.
The lock-in problem
The largest share of healthcare's environmental footprint does not come from clinical decisions. It comes from the supply chain — procurement, logistics, manufacturing. These are scope 3 emissions, generated upstream in the production process, before a regulatory submission is filed, before a health technology assessment begins, before a reimbursement committee convenes. An anaesthetic gas with a high global warming potential, a pressurised inhaler with a high-emission propellant, a biologic manufactured through an energy-intensive process — by the time these technologies reach NICE, the formulation and manufacturing decisions that determine their environmental footprint are locked.
"By the time technology reaches HTA, many environmental harms are already baked in. The biggest gains will not come from saying yes or no at the point of reimbursement."
This is not a criticism of HTA. It is a description of where HTA sits in the decision sequence. HTA evaluates technologies as they arrive. It does not, and cannot, reach back into Phase 2 manufacturing design or formulation choices. The environmental wins that HTA can deliver — preferring a lower-emission inhaler where clinical equivalence exists, linking to carbon reduction plans in published guidance, running evidence reviews in high-impact areas — are real but bounded. They operate at the margins of an environmental footprint that was determined much earlier.
The lever that operates upstream
The European Corporate Sustainability Reporting Directive — which entered mandatory reporting for large EU-listed companies in 2025 — does something HTA cannot. It requires pharmaceutical companies to publicly disclose their environmental and access policies in a standardised format, at the corporate level, before any individual product submission is made. The European Sustainability Reporting Standard E1 covers climate and emissions. S4 covers consumer and end-user access and affordability. These disclosures apply to the whole company — to manufacturing decisions, supply chain choices, and pricing policies — not to individual technology assessments.
Where the Leverage Actually Sits
The mechanism matters. CSRD disclosures are not advisory. They are mandatory and standardised, which means institutional investors, payers, and governments can read and compare them. A company that publicly reports its access and environmental commitments under CSRD creates a disclosure baseline that reimbursement negotiations, investor ESG scoring, and patient advocacy scrutiny will all reference. That creates a commercial incentive to get the upstream decisions right — not because NICE will factor them into a reimbursement model, but because they are now visible in a standardised format to every stakeholder that matters.
The access dimension the debate is missing
The OHE podcast frames the environmental HTA question as a sustainability debate. It is also, underneath, an access debate — and that is where it connects most directly to the decisions pharma and biotech companies are making right now.
CSRD's ESRS S4 standard requires disclosure on whether and how companies ensure access to their products for all relevant population segments. For a pharmaceutical company, this is a direct question about pricing policy, reimbursement strategy, and the gap between list price and actual patient access across markets. The companies currently treating CSRD as a sustainability reporting exercise — managed by corporate affairs teams, disconnected from commercial access functions — are building disclosure architectures without understanding what they are committing to in their payer negotiations.
The access team isn't writing the CSRD disclosure. But payers will read it.
In most large pharma companies, CSRD compliance is being led by sustainability and investor relations teams. The commercial access function — which knows what the pricing policies actually are and what the real-world access gaps look like — is typically absent from the process. The disclosures being written may not reflect the commercial reality they describe. And when a European payer references those disclosures in a reimbursement negotiation, it is the access team that will need to explain the gap.
What this means in practice
The HTA sustainability debate will continue, and it should. There are genuine win-win cases — lower-emission inhalers with equivalent clinical outcomes, anaesthetic gases where environmental impact is a legitimate criterion — where HTA can and should take a view. NICE is right to explore this space carefully and experimentally through its HTA Lab.
But the structural change in pharmaceutical environmental accountability is not coming from reimbursement decisions. It is coming from mandatory disclosure. And the companies that understand this earliest will build the commercial and access architecture to deliver on their CSRD commitments — rather than discovering the gap between what they disclosed and what they negotiated when a payer or investor points it out.
- Is your commercial access function involved in drafting your CSRD disclosures — or will you inherit commitments that your pricing and reimbursement strategy cannot deliver?
- Have you modelled the gap between your ESRS S4 access commitments and your actual reimbursement outcomes across EU markets?
- Does your environmental sustainability team understand that a European payer can reference your CSRD access disclosure in a price negotiation?
- Are your manufacturing and formulation decisions — the ones that determine your product's actual environmental footprint — being made with visibility of what you will need to disclose?
The OHE debate asked the right question: should environmental impact factor into drug approval decisions? The more important question for companies acting now is different: who in your organisation is connecting the upstream decisions that determine your environmental footprint to the disclosure obligations that make those decisions public — before the reimbursement negotiation begins?
Pharma Is Treating CSRD as a Sustainability Reporting Problem. It's an Access Strategy Problem.
A deeper look at how CSRD's disclosure obligations intersect with pricing, access, and payer negotiations — and why most commercial teams aren't in the room when the disclosures are being written.
Read the full analysis →