Healthcare systems face persistent pressure from rising demand, constrained budgets and widening expectations around equity and quality. At the same time, the environmental footprint of healthcare has become increasingly visible, with pollution and resource use now recognised as material factors shaping population health and system resilience. Priority setting, long used to guide fair and transparent allocation of scarce health resources, has traditionally focused on financial constraints and near-term health outcomes. Growing awareness of climate change and environmental degradation is reshaping this landscape. Environmental sustainability introduces new dimensions to decisions about which services to fund, expand or discontinue and how to balance efficiency with equity under planetary limits. Integrating environmental considerations into established priority-setting frameworks offers a structured way to align health system decision making with commitments to high-quality, low-polluting and climate-resilient care.
Principles of Priority Setting and Sustainability
Priority setting in healthcare emerged to address unavoidable scarcity by evaluating value for money through transparent and ethically grounded processes. Three principles are widely applied: cost-effectiveness, priority to the worse off and financial risk protection. These principles are rooted in egalitarian and prioritarian ethics, emphasising equal moral worth and additional weight for benefits accruing to those in greatest need. Priority setting also involves managing trade-offs, recognising opportunity costs and navigating tensions between coverage, service breadth and affordability.
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Environmental sustainability challenges some of these assumptions. Traditional approaches largely overlook pollution and resource depletion, even though environmental harms disproportionately affect vulnerable populations. Failing to account for these harms is inefficient, because prices do not reflect true costs and unfair, because impacts fall unevenly. Environmentally sustainable healthcare seeks to maintain and improve health and wellbeing while reducing unnecessary material consumption and pollution within finite ecological limits. This perspective shifts emphasis from efficiency under financial scarcity to sufficiency under environmental constraints, broadening the scope of concern from national health systems to global wellbeing across present and future generations. While both approaches share a commitment to equity, they differ in how responsibilities and benefits are distributed.
Evaluating Interventions with Environmental Criteria
In practice, priority setting relies on tools such as health technology assessment, which systematically evaluates the medical, economic, social and ethical consequences of medicines, devices and models of care. Environmental effects have historically been absent from these assessments, despite evidence that specific interventions and products carry substantial climate impacts. Lifecycle assessment methods now allow comparison of material and energy inputs across clinical modalities, highlighting opportunities for action without compromising patient safety and often with minimal financial impact.
Several approaches exist to incorporate environmental considerations into health technology assessment. Information conduit models present environmental data alongside existing analyses, integrated evaluations synthesise clinical, financial and environmental impacts into a single framework, and parallel evaluations report these dimensions separately. Each approach faces challenges, including limited availability of standardised emissions data and the relatively small influence of environmental costs on incremental cost-effectiveness ratios except in specific cases. Multicriteria decision analysis offers a complementary method by explicitly weighing multiple values, such as health gain, equity, safety and environmental impact, without requiring monetary pricing of pollution. By making value judgements transparent, this approach supports deliberation aligned with societal priorities, although it requires careful design to avoid diluting core health criteria.
Embedding Sustainability in Budgetary Processes
Beyond evaluating individual interventions, priority setting supports implementation through deliberative budgetary processes. Programme budgeting and marginal analysis is widely used to examine how resources are currently allocated and to compare marginal costs and benefits of alternative options. This framework brings together evidence inputs from health technology assessment and scoring tools from multicriteria decision analysis within a fair and transparent process.
Programme budgeting and marginal analysis enables comparison across services, technologies and organisational decisions, including investment in low-carbon infrastructure or disinvestment from low-value care. Environmental sustainability can be incorporated as an explicit criterion, allowing decision makers to consider health benefits, financial costs and environmental harms together. These approaches are marginal rather than zero-sum, focusing on incremental changes relative to existing practice. As many healthcare organisations now include sustainability within their mission and vision, integrating environmental criteria into established priority-setting processes can occur with limited disruption, particularly where evidence-based frameworks are already in place.
Environmental sustainability introduces unavoidable conceptual and practical challenges for fair resource allocation in healthcare. Pollution, climate change and resource depletion extend the ethical horizon of priority setting beyond immediate system boundaries and timeframes, highlighting responsibilities across populations and generations. Priority-setting frameworks offer structured tools to clarify trade-offs, articulate values and guide decisions under both financial and environmental constraints. By evolving to incorporate sustainability, these approaches can support health systems in navigating the transition towards care that protects health, reduces inequalities and operates within planetary limits.
Source: The Lancet Planetary Health
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