OBJECTIVES: A survey was conducted to establish the extent to which environmental factors impact payers and payer influencers, as well as macro-environmental policy and purchasing decisions. METHODS: Qualitative telephone interviews were undertaken with subjects in the UK, Germany, France, Spain and Sweden. RESULTS: Though still in their infancy, environmental consequences were confirmed as becoming an important dimension of health technology assessment (HTA).  Regulation and best practice guidelines designed to limit the environmental impact of purchasing strategy were identified at local, regional, or national level in Sweden and the UK. Poor data availability was identified as a major challenge, undermining the credibility of claims related to environmental factors. To avoid a “green-wash” of health technologies presented to decision makers along the value chain, environmental evaluations will need to provide robust, standardized information concerning a wide range of criteria, such as waste management, energy containment or Carbon footprints. Health technology development, as well as market access management will have to anticipate an evolving awareness for environmental matters, in both emerging and mature markets. Their ultimate translation into policy and regulation is anticipated to be a combination of regulatory control and progressive application of Pigovian costs. CONCLUSION: Regulatory control is likely to be rolled out through updated operating procedures in existing structures, such as public agencies in charge of homologation, HTA or reimbursement. This is not likely to happen in a consistent manner across the various national healthcare systems. Payers are expected to deal not only with evolving enhanced recommendations and standards, but might choose to pro-actively reflect environment-related viewpoints themselves, when defining future specifications. In such a scenario, strategic purchasers will encounter a framework of versatile requirements and incentives, and are likely to opt for health technologies that are able to present a solid environmental case.