Journal of Cleaner Production 261 (2020) 121204

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Journal of Cleaner Production

journal homepage: www.elsevier.com/locate/jclepro

Review

Pharmaceutical industry riding the wave of sustainability: Review and

opportunities for future research
Matilde Milanesi a, Andrea Runfola b, *, Simone Guercini a
a
University of Florence, Department of Economics and Management, Via delle Pandette, 9, 50127, Florence, Italy
b
University of Perugia, Department of Economics, Via Pascoli, 20, 06123, Perugia, Italy

a r t i c l e i n f o a b s t r a c t

Article history: In recent years, the sustainability of the pharmaceutical industry has received growing attention from
Received 1 November 2019 consumers, policymakers, and organizations. Concerns about the introduction of sustainability practices
Received in revised form into the development of new delivery systems, new products that pose a lower environmental risk, waste
14 March 2020
recycling, the reduction of water usage, greener manufacturing methods, and recyclable packaging have
Accepted 17 March 2020
Available online 20 March 2020
intensified attention on this topic. The sustainability of the pharmaceutical industry has also aroused the
interest of scholars from various disciplines, such as chemistry, engineering, and environmental sciences.
Handling editor: Prof. Jiri Jaromir Kleme
s Even business and management studies are taking this topic into account. A higher degree of manage-
ment complexity is affecting pharmaceutical companies, in which the need to ensure environmental,
Keywords: economic, and social sustainability, as well as to control expenses, has led to the introduction of an
Pharmaceutical industry economic logic into the management of sustainability issues. Thus, we review existing business and
Sustainability management studies on sustainability in the pharmaceutical industry with the following aims in mind:
Health to depict the current status of the research, to delineate the main approaches to sustainability, and to
Sustainable development
identify possible gaps and subject areas to be investigated in future research. The analysis reveals that
Systematic literature review.
environmental sustainability has become a central focus of management studies, especially in terms of
cleaner production, green supply chain, green materials, and sustainable human resource management.
The paper proposes areas that remain unexplored and might represent opportunities for future research,
including waste management, the economic impact of new drugs, the contribution of pharmaceutical
companies to the economic sustainability of health systems, and the study of emerging vs. mature
markets.
© 2020 Elsevier Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2. Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2.1. Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2.2. Searching . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2.3. Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
2.4. Extraction, synthesis and reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
2.5. Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
3. Descriptive analysis of the selected papers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
4. Thematic analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
4.1. Environmental sustainability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
4.2. Social sustainability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
4.3. Economic sustainability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
4.4. Holistic approaches to sustainability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

* Corresponding author.
E-mail addresses: matilde.milanesi@unifi.it (M. Milanesi), andrea.runfola@
unipg.it (A. Runfola), simone.guercini@unifi.it (S. Guercini).

https://doi.org/10.1016/j.jclepro.2020.121204
0959-6526/© 2020 Elsevier Ltd. All rights reserved.
2 M. Milanesi et al. / Journal of Cleaner Production 261 (2020) 121204

5. Research gaps and challenges for sustainability in the pharmaceutical industry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

6. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Declaration of competing interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

1. Introduction lively debate in different fields, especially in management and

marketing studies (Dyllick and Hockerts, 2002; Ketola, 2008; Choi
Why the pharmaceutical industry and sustainability? It is and Ng, 2011).
known how the evolution of the pharmaceutical industry has had The first dimension of sustainability is the environmental one.
an impact on people’s lives, both because it has contributed, and Since the 1980s, environmental issues have become dramatically
still contributes to generating well-being in terms of health and relevant at the local and global levels. In 1992, scientists at the
quality of life for individuals, and because it is one of the most World Bank first used the term environmentally responsible devel-
relevant sectors for the economy at a global level (EFPIA, 2019). The opment. Soon after, Serageldin and Streeter (1993) employed the
pharmaceutical industry is responsible for researching, developing, term of environmentally sustainable development. Two years later,
producing, and marketing pharmaceutical drugs, vaccines, and Goodland (1995) coined the phrase environmental sustainability to
treatments for common and rare diseases. An aging world popu- refer to the safeguarding of human welfare by protecting sources of
lation and improved healthcare systems are driving demand for a raw materials and ensuring that the capacity to deal sustainably
pharmaceutical industry that is increasingly aware of the need to with human waste products is not exceeded. Since then, the term
pursue sustainable development while delivering a wider range of environmental sustainability has gradually become established and
pharmaceutical products. Therefore, the pharmaceutical industry employed by scholars, practitioners, scientists, and also policy-
has been the subject of growing attention for the impact in terms of makers (Moldan et al., 2012). Environmental sustainability con-
sustainability of its activities (e.g., Schneider et al., 2010). The cerns the impacts of processes, products, and services on the
inequality in access to medicines and treatments, in the various environment, biodiversity, and human health; it is a condition of
countries of the world (Petryna and Kleinman, 2006), the pollution balance, interconnectedness, and resilience that allows the satis-
generated by drugs in the entire life cycle of the product faction of human needs without compromising the supporting
(Kümmerer and Hempel, 2010) are just some of the issues that call ecosystems and the biological diversity (Morelli, 2011).
for a reflection on how the pharmaceutical industry is changing its The social dimension of sustainability is concerned with the
behaviors in running the business. Furthermore, the images of the well-being of people and communities, workplace health and
environmental and social impacts of the pharmaceutical sector are safety, working conditions, human rights issues, and labor rights
now used by the media all over the world to draw attention to the (Moldan et al., 2012; Bom et al., 2019). Social sustainability also
need for change, and there is no lack of claims from non-profit entails a tension between the interests of society and business
organizations and activists from the Z generation for a shift to- (Mohr and Webb, 2005). However, when companies respond to
wards sustainable management of pharmaceutical companies. If, sustainability issues at the micro-level, they are also protecting
on the one hand, the empirical world calls attention to these issues, habitat and contributing to the quality of life at the macro-level
how does the academic world stand instead? What are the main (Choi and Ng, 2011). Littig and Griessler (2005) maintain that a
topics of study? What is the contribution made? What are the clear theoretical concept of social sustainability still lacks as the
research gaps? This article provides an overall view of how man- definitions of the concept are manifold. To cite a couple of exam-
agement literature has addressed the topic of sustainability in the ples, Torjman (2000) discusses social sustainability in terms of
pharmaceutical industry. Indeed, there are several systematic human well-being, which is as difficult without a healthy envi-
analysis of the literature concerning how sustainability has been ronment as it is in the absence of a dynamic economy, while
addressed in specific industries, such as, to cite a few, the recent McKenzie (2004) defines social sustainability as a condition in
studies on construction industry (Araújo et al., 2020) or cosmetics which ‘the formal and informal processes, systems, structures and
(Bom et al., 2019), the pharmaceutical industry, despite its rele- relationships actively support the capacity of current and future
vance, has not been the subject of a specific study. This represents a generations to create healthy and livable communities’ (McKenzie,
research gap that the article intends to fill. 2004: 18). Despite the lack of a unique definition, it is widely
This work, therefore, forms part of the wider debate on sus- recognized that the social dimension of sustainable development is
tainability, which is a broad issue that has received increasing critical for the long-term survival of societies (Diamond, 2005).
attention among scholars and practitioners. Despite its multiple Finally, the economic dimension of sustainability has received
definitions and interpretations over the years, a widely accepted much attention, especially in the last two decades. The Global
initial definition was set forth in the United Nations’ report ‘Our Reporting Initiative (GRI) highlights the external impacts of a
Common Future’ in 1987, in which the idea of sustainability origi- business on economic systems. It defines economic sustainability as
nated from the concept of sustainable development, meaning ‘to the impact of an organization on its stakeholders and economic
meet the present needs without compromising the ability of future systems at the local, national, and global levels (GRI, 2002). A
generations to meet their own needs’. Since then, multiple di- contrasting perspective views the internal impact of economic
mensions of sustainability have been further developed and dis- sustainability on a company, while external economic contribu-
cussed. In the late 1990s, Elkington coined the phrase triple bottom tions are allocated to social sustainability in terms of financial
line, which refers to a method for measuring sustainability by health, economic performance, potential financial benefits, and
integrating three dimensions of sustainability e economic, envi- trading opportunities (Labuschagne et al., 2005). Sheth et al. (2011)
ronmental, and social e with the aim of guiding development to- have identified two different aspects of the economic dimension of
wards a sustainable global economy (Elkington, 1997). The multiple sustainability. The first concerns conventional financial perfor-
dimensions of sustainability have increasingly been the subject of mance, such as cost reductions, and the second aspect relates to the
 M. Milanesi et al. / Journal of Cleaner Production 261 (2020) 121204
economic interests of external stakeholders, including the
improvement of well-being and standards of living (Sheth et al.,
2011). Bom et al. (2019) synthesize the aspects of economic sus-
tainability: reduction of operating costs through systematic man-
agement, expenditures on research, labor productivity, investments
in training, and other forms of human capital.
Within this context, different actors contribute to improving the
chances of success of this ambitious challenge; among these, a
leading role is certainly played by pharmaceutical companies. Over
the years, the pharmaceutical industry has attracted the attention
of both the academic world and practitioners due to not only its
importance but also its relationship with a theme, namely health,
which is crucial to human existence. Among the related aspects
investigated in the economic-managerial literature, the ability to
generate continuous innovation in the treatment and defeat of
pathologies has been the target of numerous studies, some of
which take into account the efficiency and the economic-financial
return of new products (Graves and Langowitz, 1993; Roberts,
1999; DiMasi et al., 2016). The study of intra-organisational
(Cardinal, 2001) and inter-organizational processes (Bianchi et al.,
2011; Hess and Rothaermel, 2011) for the generation of in-
novations, such as new molecules and new drugs, have been the
subject of an in-depth debate that recognizes the key role of R&D
activities (Garnier, 2008).
In recent years, one stream of literature has emphasized the
relevance of sustainability issues in the pharmaceutical world (e.g.,
Schneider et al., 2010). In fact, in recent decades especially, the
economic and managerial literature has devoted increasing atten-
tion to the way in which pharmaceutical companies operate, both
by addressing issues related to the ethical dimension of their ac-
tivities (Komesaroff and Kerridge, 2002; see also Nussbaum, 2009;
Shaw and Whitney, 2016) and their environmental impact (Veleva
nez-Gonza
et al., 2003; Jime lez et al., 2012). However, sustainability
in the field of health has room to take on more facets that derive
from the perspective of multiple stakeholders operating at macro-
and micro-levels. In fact, at the macro and political-institutional
levels, numerous organizations, both international and national
(such as the UN, the European Commission, and the Food and Drug
Administration) set themselves the general objective of pursuing
sustainable development in the field of health, which they then
interpret with their own more or less binding policies for phar-
maceutical companies. For example, the World Health Organiza-
tion, the reference agency at the global level, targets as one of the
greatest challenges of sustainable development today the
achievement of ‘universal health coverage (UHC)’ that ensures the
access to essential health services for all people (WHO, 2018). The
European Commission, in its strategic plan 2016e2020, states that a
balance must be achieved between rapid market and patient access
to pharmaceutical products, and safety, quality, and efficiency
guarantees. At the micro-level, for the single players operating in
the health sector, sustainability is understood as taking into ac-
count the social, environmental and economic dimensions of the
operations of individual companies, where issues of corporate so-
cial responsibility (CSR) are now pervasive in the pharmaceutical
industry (Nussbaum, 2009; O’Riordan and Fairbrass, 2008).
However, the dimensions of sustainability highlighted above
must be considered as a whole: to address sustainability effectively,
a combination of the macro-dimension of sustainable development
in terms of health pursued by institutional actors at different levels
as well as the micro-level of individual companies is required. This
is another clear expression of the management complexity
affecting both the pharmaceutical companies and the health sys-
tems as a whole, namely a trade-off between effectiveness, effi-
ciency, and sustainability goals (Aquino et al., 2018).
Thus, this paper systematically reviews existing business and
3
management studies on sustainability in the pharmaceutical in-
dustry with the aim of depicting the current status of the research,
the main approaches to sustainability, possible gaps, and subject
areas to be explored in future research. The novelty of the paper lies
in proposing a comprehensive review of extant studies on phar-
maceutical sustainability in its broader conceptualization within
the managerial domain. To the best of the authors’ knowledge, no
other reviews have systematically dealt with this topic. Further-
more, the paper considers cleaner production issues by analyzing
them in the wider sphere of sustainability and its dimensions in the
pharmaceutical industry. The paper is structured as follows. The
methodology adopted in the paper is presented in the next section.
Section 3 concerns a descriptive analysis of the articles included in
the review, and Section 4 presents a thematic analysis. The paper
concludes with a discussion of the main results and a future
research agenda.
2. Methodology
In order to achieve its stated aim, this paper employs a sys-
tematic approach to review the literature on sustainability, with
specific reference to the pharmaceutical industry. A systematic
literature review has been defined as objective, transparent, and
complete, and it should allow replicability (Cook et al., 1997;
Tranfield et al., 2003). More specifically, a systematic literature
review consists of a thorough search for prominent contributions
on a specific topic that are appraised and synthesized according to a
pre-determined explicit method. A series of specific stages should
be carefully carried out to ensure validity and reliability. To achieve
this aim, four main steps pointed out in the literature e ‘planning’,
‘searching’, ‘screening’ and ‘extraction/synthesis/reporting’ e were
followed (Tranfield et al., 2003; Zhang et al., 2019). They are
described in further detail in the following subsections.
2.1. Planning
We began by planning the review and establishing a procedure
in order to develop a systematic, transparent, and replicable pro-
cess. This first step implied narrowing the focus of the review by
discussing the research questions. Hence, the following research
questions were defined:
RQ1. What is the current status of research on sustainability in
the pharmaceutical industry?
RQ2. What are the possible subject areas to be explored in future
research?
2.2. Searching
For the search stage of the research, the Scopus database was
adopted as the data source. Scopus is the largest abstract and
citation database of peer-reviewed literature and is widely recog-
nized as a complete database used to conduct systematic literature
reviews (Zhang et al., 2019; Gorraiz and Schloegl, 2008). The initial
identification of papers was conducted using a structured keyword
search. The central topic of this paper is sustainability, and the
pharmaceutical industry is the context of the research. Thus, the
initial keyword search included the search string ‘sustainab* AND
‘pharmaceutical’, limited to the article title, keywords, and abstract.
The use of the Boolean term* in the word sustainability allowed us
to broaden the search and include words with different suffixes.
The choice of keywords is consistent both with the topic of this
study and with other systematic literature reviews that analyze
sustainability in relation to other sectors (see, for example, Araújo
et al., 2020; Bom et al., 2019). The search was not delimited to
any specific period (with the only exclusion of the year 2020) in
4 M. Milanesi et al. / Journal of Cleaner Production 261 (2020) 121204

order to obtain a broad view of the topic and its development in a

chronological sense. Based on this search process, 1918 papers were
identified as potentially relevant to the aim of the paper.

2.3. Screening

The researchers followed certain inclusion and exclusion criteria

to select papers for in-depth analysis (Table 1) carefully. We
selected full papers and reviews published in peer-reviewed jour-
nals in the business/management/accounting area. Duplicates were
excluded. Additionally, we conducted a qualitative analysis aimed
at assessing the eligibility of papers (Moher et al., 2010), based on
the researchers’ reading of the titles and abstracts of each paper in
order to decide whether the identified articles actually addressed
our targeted issue. When abstracts did not allow for comprehensive
coding, the content of the paper was also considered. When the
keywords used in the search string were only mentioned in the
abstract but were not the main topic, the paper was eliminated
from the list.
Finally, based on the searching and screening process, 59 papers
were selected for this systematic literature review and were
included in an Excel workbook, where some basic data describing
them were recorded (authors, year of publication, journal, abstract).

2.4. Extraction, synthesis and reporting

As suggested by Tranfield et al. (2003), clear reporting is a

fundamental step in a systematic literature review. More specif-
ically, a two-stage report is proposed in the paper, including
descriptive and thematic analysis. The descriptive analysis provides
in the form of descriptive information. The descriptive analysis
proposed in this paper includes the body of research on sustain-
ability in the pharmaceutical industry published over time, type of
study, the journals that have addressed this topic, and a citation
overview. In terms of thematic analysis, the focus is on the ap-
proaches (theoretical/empirical) to the study of sustainability, the
main subject areas, and the dimensions of sustainability (social/
environmental/economic) taken into account with reference to the
pharmaceutical industry. Thus, our approach to the analysis of ar-
ticles is qualitative, consistently with the qualitative systematic
review that is a strict systematic review process “used to collect Fig. 1. Steps of the systematic literature review.
articles, and then a qualitative approach is used to assess them”
(Snyder, 2019: 335). The steps of the systematic literature review
are summarized in Fig. 1. The data analysis is detailed in the led to the non-identification of relevant studies. Lastly, the meth-
following sections. odological approach was a manual literature review technique that
excluded other methods, such as cognitive mapping or concept
clustering; also, the screening and analysis were manual, which
2.5. Limitations
may have led to unintended bias. Despite these limitations, the
results of the literature review provide evidence for the relevant
There are some limitations in the methodology that need to be
dimensions of sustainability in the pharmaceutical industry and
considered while interpreting the findings. First, book chapters,
open up new research opportunities in this field.
conference papers, editorials, books, short surveys, notes, confer-
ence reviews, and letters have been excluded. Although common to
similar systematic reviews, the exclusion might generate inter- 3. Descriptive analysis of the selected papers
pretation bias due to the reduced number of reviewed literature
pieces. Second, the selected keywords and strings, which may have The search process identified a total of 59 articles on

Table 1
Inclusion and exclusion criteria for paper selection.

Aspect Inclusion criteria Exclusion criteria

Subject area Business, management and accounting Other subject areas (i.e. medicine, engineering, energy etc.)
Document type Article, review Book chapter, conference paper, editorial, book, short survey, note, conference review, letter
Source type Journals Trade publications, book series, book, conference proceedings
Language English Other languages
Publication stage Final Article in press
 M. Milanesi et al. / Journal of Cleaner Production 261 (2020) 121204
sustainability in the pharmaceutical industry published from 2001
to 2019 (articles up to the third quarter of 2019). As Fig. 2 shows,
after a very slow beginning, the bulk of studies on the topic started
to be published in top journals starting in 2016.
It is evident that academic interest in the subject has rapidly
increased in the last few years. Although we cannot fully explain
this trend, we can suggest at least two plausible reasons. On the one
hand, this trend corresponds to the more general trend concerning
renewed and increasing attention on sustainability-related topics
in the business and management literature (Orlitzky et al., 2011;
Epstein, 2018). On the other hand, the above-mentioned dynamics
of change in the pharmaceutical industry might have resulted in a
growing interest in both the industry, in general, and the related
dimensions of sustainability, in particular.
Table 2 provides an overview of the papers published by jour-
nals. The Journal of Cleaner Production is the dominant source title,
consistent with its aim of addressing and discussing sustainability
issues, followed by Benchmarking.
Regarding the methodologies applied in the selected articles,
there is a strong predominance of qualitative approaches, with 49
empirical studies that develop case studies. Among those remain-
ing, four papers develop literature reviews on bioenergy and
bioactive compounds, fisheries, pharmaceutical supply chains, and
food manufacturing waste. The other three papers are conceptual
in nature and deal with integrated sustainability in the pharma-
ceutical industry, reverse supply chain, and business model
innovation.
An analysis of the number of citations of the selected articles
allows us to identify some of the most ‘influential’ articles. With the
proviso that this analysis has limits due to the dimensions of the
sample (which are too limited for a scientometric analysis) and the
nature of this indicator, the total number of citations is 951, with 10
out of 59 articles having zero citations. The most cited article
(Mirabella et al., 2014) had 271 citations as of September 2019. Only
one other article has more than 100 citations (Andersson et al.,
2005), while three articles have at least 40 citations (Veleva et al.,
2003; Caligiuri et al., 2013; Blum-Kusterer and Hussain, 2001).
With regard to the country of origin of the research institution
(see Fig. 3), the highest number of contributions come from the
United States (25%), followed by India (19.6%). The academic in-
terest in the pharmaceutical industry in the United States can partly
be explained by the fact that the United States is the worldwide
leader in per capita prescription drug spending, the country of
origin of global leading pharmaceutical companies, and the
worldwide leader in pharmaceutical R&D expenditure. Among the
Fig. 2. Publications by year.
5
emerging countries, India enjoys an important position in the
global pharmaceuticals sector as the largest provider of generic
drugs globally. More generally, the top 10 include both emerging
(India, Iran, Malaysia) and mature markets, with the latter being
more prevalent.
4. Thematic analysis
The thematic analysis is organized around the three dimensions
of sustainability e environmental, social, and economic e pre-
sented in the introduction. For each dimension, the main topics and
findings are presented and then discussed in the following section.
4.1. Environmental sustainability
The environmental dimension of pharmaceutical sustainability
is particularly present in the articles analyzed, given that 24 articles
deal with this prevailing issue. The thematic analysis of the full
papers shows four distinct fields of study of the ecological dimen-
sion as follows: cleaner production, green supply chains, green
human resource management (HRM), and green materials.
With regard to the research stream concerned with the topic of
cleaner production, there are articles addressing ecological issues
that specifically point to production in the pharmaceutical sector
(Veleva and Cue, 2017). Kaenzig et al. (2011) address the issue of the
ecological impact of products in all phases of the life cycle, and how
this is communicated by companies, highlighting that in the
pharmaceutical sector, disclosure by companies does not allow to
provide an overall view of this impact. The article by Belkhir and
Elmeligi (2019), for example, highlights the need to pay attention
to the impact of emissions of pharmaceutical production, under-
lining the emergence of a research gap with regard to this specific
sector. Based on an empirical analysis of 15 of the leading phar-
maceutical companies, the authors observe that this sector remains
substantially behind the scenes and has received only minor
attention despite the fact that their analysis shows that carbon
emissions in this sector are even higher than those of the auto-
motive sector, which has been the object of much more significant
attention. From this observation, the need for measures that pro-
vide an exhaustive picture of the sector’s carbon footprint emerges.
This need is also recognized in other studies comprising not only
general articles that seek to understand how to measure efficiency
in ecological terms in pharmaceuticals (Veleva et al., 2003) but also
articles that analyze more specific topics. Among the latter, for
example, there are studies related to the role of ISO certifications (Li
6 M. Milanesi et al. / Journal of Cleaner Production 261 (2020) 121204

Table 2
Journals ranked by number of articles.

N. Journals Articles

1 Journal of Cleaner Production 13

2 Benchmarking 3
3 Business Strategy and the Environment 3
4 International Journal of Production Economics 2
5 International Journal of Supply and Operations Management 2
6 Journal of Business Ethics 2
7 Measuring Business Excellence 2
8 Business and Politics 1
9 Corporate Environmental Strategy 1
10 Corporate Governance 1
11 Corporate Ownership and Control 1
12 Corporate Social Responsibility and Environmental Management 1
13 Entrepreneurship and Sustainability Issues 1
14 Futures 1
15 Global Business Review 1
16 IEEE Engineering Management Review 1
17 International Journal of Business Innovation and Research 1
18 International Journal of E-Entrepreneurship and Innovation 1
19 International Journal of Innovation Management 1
20 International Journal of Learning and Intellectual Capital 1
21 International Journal of Logistics Systems and Management 1
22 International Journal of Pharmaceutical and Healthcare Marketing 1
23 International Journal of Procurement Management 1
24 International Journal of Production Research 1
25 International Journal of Productivity and Performance Management 1
26 International Journal of Supply Chain Management 1
27 Journal of Business Research 1
28 Journal of Commercial Biotechnology 1
29 Journal of Food Products Marketing 1
30 Journal of Industrial Engineering and Management 1
31 Journal of Management Development 1
32 Journal of Operations Management 1
33 Personnel Psychology 1
34 Problems and Perspectives in Management 1
35 Production and Operations Management 1
36 Supply Chain Management 1
37 Sustainability Accounting, Management and Policy Journal 1
38 TQM Journal 1
39 Transportation Research Part E: Logistics and Transportation Review 1

Fig. 3. Top 10 publishing countries.

and Hamblin, 2016) and system standards (Marinkovic et al., 2016).
In their study of the Chinese market, for example, Li and Hamblin
(2016) highlight how ISO14001 certifications are one of the most
important determinants to understand the employment of cleaner
production practices by pharmaceutical companies. In similar
ways, there are also studies that try to understand the determinants
of the entrepreneurs’ orientation to the execution of green activ-
ities in the pharmaceutical industry (Blum-Kusterer and Hussain,
2001; see also Rezai et al., 2016).
The second area of research we examine that is concerned with
the environmental dimension focuses on the supply chain. There
are general studies that emphasize that one of the main aspects to
consider is the need to address the green issue (Singh et al., 2016;
Kumar et al., 2019). In their study, Singh et al. (2016) argue that
there is growing attention to issues related to pharmaceutical
product waste management and means of remedying some of the
problems related to, for example, the management of expired drugs
or the danger of water pollution by pharmaceutical products. A
 M. Milanesi et al. / Journal of Cleaner Production 261 (2020) 121204
particularly relevant area in these studies, obviously, pertains to
decisions regarding the selection of suppliers (Hashim et al., 2017;
Moradi and Jolai, 2018) and other actors in the supply chain based
on their contribution in terms of ecological impact. For example,
Gardas et al. (2019), in their study of the Indian market, propose an
empirical investigation aimed at understanding the criteria for
choosing third-party logistics service providers. The authors high-
light the contribution in terms of CO2 of logistics, in general, and of
these actors, in particular. They highlight a particular gap in
research into the pharmaceutical sector and propose a scheme of 14
criteria and emphasize the need to integrate other dimensions of
sustainability.
One of the areas on which recent literature on pharmaceuticals
has focused is the importance of a green perspective in HRM that
emphasizes green HRM practices. Veleva et al. (2017) underscore
the role of employee engagement and the centrality of human re-
sources in order to implement a zero-waste culture in business.
Saeed et al. (2019) address another relevant issue, namely the use of
green HRM practices (such as selection or training) that can support
pro-environmental behavior by employees. In particular, the au-
thors relate those practices and compare the pharmaceutical sector
with other sectors with regard to their implementation. The results
show that the implementation of sustainable behaviors, from the
environmental point of view, is more likely in cases where green
HRM practices are placed within a more general perception of the
importance of sustainability in the company. In other words, they
seem to be linked to a general and overall approach to sustain-
ability. Similarly, Masri and Jaaron (2017) study green HRM prac-
tices and their impact on workers’ ecological performance in the
specific case of pharmaceutical companies in Palestine. Empha-
sizing the need to bridge a research gap regarding the construction
of measurements of the carbon footprint of workers, the authors
compare the pharmaceutical sector with other sectors and high-
light the crucial importance of personnel selection phases
(compared to those, for example, of training) among different HRM
practices. Andersson et al. (2005) instead focus on the role of su-
pervisors in stimulating environmental behavior in workers. The
authors argue, in particular, that ‘perceived corporate commitment to
sustainability’ (p. 302) is the factor capable of explaining the
behavior of supervisors and their ability to guide employees to-
wards sustainable behavior. However, these latter studies assume
the centrality of a corporate vision of sustainability in convincing
employees to adopt green behaviors.
A final line of research concerns the evolution of green materials
that the pharmaceutical sector can exploit for production. These are
broader studies that, by analyzing materials and their potential
applications, also highlight opportunities for the pharmaceutical
sector. In this area of study, there are articles that propose the use of
sustainable products such as algae, which can be used in the pro-
duction of therapeutic agents (Sudhakar et al., 2019), or the use of
waste from the production of marine resources, such as fish (Dave
and Routray, 2018), rather than other food waste (Mirabella et al.,
2014). To eliminate pharmaceutical refuses from water, Manda
et al. (2014) propose the use of innovative membranes.
Within this category, there are very few studies investigating
the interplay between environmental and social sustainability (two
articles) and environmental and economic sustainability (two ar-
ticles). Among these, Azim and Azam (2013) study both social and
environmental disclosure, addressing the specific case of pharma-
ceutical companies in Bangladesh. The authors highlight how the
pharmaceutical sector is backlogged in this regard. The article by
Weraikat et al. (2016) proposes a study aimed at verifying ways to
encourage consumers to return unused drugs. The authors high-
light how this is not only beneficial for the environment, given that
drug dispersion is reduced (in accordance with a vision of
7
environmental sustainability), but also allows the possibility of
allocating these unused drugs to sectors of the population that do
not have access to them (following a perspective of social re-
sponsibility). With regard to the interplay between environmental
and economic sustainability, the analyzed studies reveal an opti-
mization model for the integrated production and distribution
planning of a supply chain, with the two (economic and environ-
mental) objectives of cost minimization and greenhouse gas
emissions minimization(Jabbarzadeh et al., 2019) and themes of
reverse logistics, which stands for all operations related to the reuse
of products and materials, in the supply chain (Narayana et al.,
2019).
4.2. Social sustainability
Regarding the social dimension of sustainability, the articles
emerging from the review are of a more limited number: six articles
in total. This relative paucity reveals a substantial research gap for
this dimension of sustainability. With reference to this topic, the
analysis focuses on various issues, including the role of employees
(Caligiuri et al., 2013), access to pharmaceutical products by sectors
of the population (Quak et al., 2019; Sahu and Kohli, 2019), aspects
related to supply chains (Mani et al., 2016; Nematollahi et al., 2018),
product packaging (Lorenzini et al., 2018) and consumer behavior
(Chaar and Lee, 2012).
Regarding the role of employees and their attention to social
issues, Caligiuri et al. (2013) study the participation of employees in
company volunteering programs promoted with the collaboration
of NGOs. The article explores how these activities, in the case of
pharmaceuticals, increase employee engagement, and how this has
benefits not only for setting up CRS policies but also for employee
identification with company values. The article by Quak et al. (2019)
proposes the use of indicators to measure the ability of pharma-
ceutical companies to guarantee access to medicines by the pop-
ulation. In particular, in their study on drug access in emerging
markets, the authors highlight opportunities for using the AtM
Index, a tool considered able to sensitize pharmaceutical com-
panies towards the issue of guaranteeing greater access to drugs.
However, the research highlights the need to study sharing
mechanisms between the various pharmaceutical stakeholders in
order to facilitate higher access performance. Lorenzini et al. (2018)
highlight the importance of innovation with regard to pharma-
ceutical packaging and the role this plays in opening up greater
possibilities for patients to obtain adequate and correct therapies.
The necessity of responding to the needs of patients by affording
them centrality is also evident in the study by Sahu and Kohli
(2019), which deals with the connection between pharmaceutical
companies and hospitals, and in the study by Chaar and Lee (2012),
which investigates consumer behavior with respect to different
drug prescription systems.
4.3. Economic sustainability
Only a limited number of articles (4) deal with economic sus-
tainability. As observed by Aquino et al. (2018), in many healthcare
systems, the need to cope with two aims, namely the control ex-
penses and the need to ensure sustainability, has led to the
development of an economic logic into management. On the one
hand, this need is, in many cases, interpreted in terms of cost-
cutting, with consequent reduction of services instead of
improved efficiency, reduced waste, etc. On the other hand, the
improvement of efficiency has been translated as the standardi-
zation of processes through the introduction of protocols and
standards in service delivery. Within this scenario, the study by
Aquino et al. (2018) specifically explores the possibilities offered by
8 M. Milanesi et al. / Journal of Cleaner Production 261 (2020) 121204
technology to reconcile standardization and personalization of
healthcare. More specifically, the work highlights the criticalities
and potentialities of the use of 3D printing by pharmaceutical
companies in producing personalized medications. Key findings
suggest the potential revolutionary role of the 3D printing of drugs
in pharmaceutical compounding and/or manufacturing as a tool of
smarter healthcare.
Economic sustainability is also discussed in terms of patent
activities. Azad et al. (2018) focus on large pharmaceutical com-
panies in Bangladesh and their expertise in process patent activities
rather than their product patents. The authors observe that
achieving sustainability, in the long run, using automation and
purchase of patents exclusively seems unsuitable. Thus, technical
efficiency is measured, and it is shown that the main source of
inefficiency in large pharmaceutical companies is scale inefficiency.
In fact, it is demonstrated that this type of inefficiency overcome
pure technical inefficiency. Focusing on SMEs instead, Nin ~ o-
Ame zquita et al. (2017) examine the Indian pharmaceutical in-
dustry, a highly fragmented industry with weak generic-based R&D
activities. The proxy for economic sustainability is growth. The
study shows that exports, R&D expenditure, and previous-year
profits exercise positive impacts on the growth of SMEs. However,
SMEs in the pharmaceutical industry should pay more attention to
internationalization and value-creation by means of R&D invest-
ment for their long-term growth and survival strategy.
Attention is also given to the financial performance of phar-
maceutical companies, particularly those adopting environmen-
tally friendly manufacturing. The managerial problem addressed
concerns the assessment of the costs versus benefits with respect to
green manufacturing and sustainable supply chain management.
Menzel et al. (2010) conduct a survey of annual and sustainability
reports published by companies along with recording changes in
their resource and financial performance. This study concludes that
there is no significant relationship between green manufacturing
and financial performance; thus, the expected result that greener
manufacturing by a company results in improved corporate per-
formance is not confirmed by the results obtained.
4.4. Holistic approaches to sustainability
A considerable number of articles (22) adopt an overarching
perspective by considering concurrently all the dimensions of
sustainability that contribute to corporate sustainability (Steger
et al., 2007; Yoon, 2017). Sustainability, which grounds in a global
framework, can be transposed to the business level as corporate
sustainability, defined as “meeting the needs of a firm’s direct and
indirect stakeholders (such as shareholders, employees, clients,
pressure groups, communities, etc.), without compromising its
ability to meet the needs of future stakeholders as well” (Dyllick
and Hockerts, 2002). Leonard and Schneider (2004) adopt a holis-
tic approach to sustainability in the pharmaceutical industry that
should consider profits but also people and the planet. They suggest
an alignment between integrated sustainability initiatives and
business goals so that sustainability initiatives in all their di-
mensions e environmental, social, and economic e are measured,
valued, and controlled like traditional business drivers. Chaturvedi
et al. (2017) discuss the approach of pharmaceutical companies to
environmental sustainability combined with the economic and
social welfare of the society. They propose a framework of orga-
nizational sustainability e to be considered as a synonym of
corporate sustainability e in which there is a balance between
growth and monetary profits and environmental and societal costs.
Vihari et al. (2019) add another dimension to organizational sus-
tainability, namely organizational learning. Business model inno-
vation, namely innovation in the value proposition, value creation,
and in the value capture system, is also discussed as a relevant
driver of corporate sustainability (see, for example, the studies of
Vihari and Rao, 2017; Heitzmann et al., 2018). Corporate sustain-
ability can also be enhanced via strategic alliances with non-
governmental organizations to guarantee that sustainable initia-
tives are meaningful (Hansen et al., 2010).
Within this heterogeneous category, there are also a number of
articles on sustainable supply networks that consider the economic
and social dimensions, not only the environmental one. As phar-
maceutical companies experience increasing pressure from in-
stitutions due to the demand for more sustainable products, they
need to focus on sustainability issues; further, their responsibility
for their activities should be extended from the production to the
whole supply chain, with the additional aim of avoiding economic
losses, environmental and social risks or scandals (Walker and
Jones, 2012; Kabir, 2013; Bravo and De Carvalho, 2015). Thus,
there seems to be a broad consensus regarding the idea that
pharmaceutical industries need to follow sustainable supply chain
processes such as sustainable design and development, strategic
sourcing, sustainable product returns, and recycling (Zahiri et al.,
2017; Padhi et al., 2018). Janatyan et al. (2018) maintain that
pharmaceutical companies need to select certain levels of
commitment to sustainability practices within their supply chains
and propose a multi-objective model to design a pharmaceutical-
distribution network according to the main dimensions of sus-
tainability. Villena and Gioia (2018) discuss the opportunity for
pharmaceutical companies to engage their suppliers in their sus-
tainability initiatives. Similarly, Villena (2019) examines how sus-
tainability requirements flow over global supply networks. The
study points out that, in order to flow a buyer’s sustainability re-
quirements, the buyer’s procurement unit has to connect the sup-
plier’s procurement unit as a lack of collaboration between
procurement and internal and external stakeholders limits a
company’s effort to promote sustainability throughout the supply
network. Not only strategic procurement and supplier engagement
but also green HRM is linked to green supply chain management
and positively impacts the triple bottom line of sustainability per-
formance (Zaid et al., 2018).
The three dimensions of sustainability are often included in
articles on corporate social responsibility (CSR). The first question is
how pharmaceutical companies deal with sustainability issues in
their CSR reporting. Min et al. (2017) observe that most pharma-
ceutical companies currently practice CSR by taking the triple-
bottom-line approach of environmental, social, and economic
strategies to manage their businesses and produce an overall pos-
itive impact. The authors conclude that CSR adds value to corporate
financial performance and should be viewed as a long-term in-
vestment, regardless of company size. They hold that CSR should be
implemented by pharmaceutical companies because it invests in
stakeholder management and creates positive relationships, which
improve reputation and profitability. Schneider et al. (2010) analyze
the evolution of reported sustainability activity in the pharma-
ceutical sector and show an increase in the scope and extent of
related activities across the sector. Demir and Min (2019) examine
the consistencies and incongruities in the CSR reporting of phar-
maceutical companies and observe that while disclosures on
mature areas such as environment and labor relations show some
level of standardization, those focusing particularly on sensitive
areas such as human rights and supply chain are far from being
standardized. When discussing CSR, attention is given to perfor-
mance measurement of CSR-related intangibles (Parisi and Kai,
2008; Parisi and Hockerts, 2011). Mistry (2018) proposes a perfor-
mance measurement system that includes the assessment of eight
pillars of sustainable operations: people, quality, safety, produc-
tivity, availability, environment and community, continuous
 M. Milanesi et al. / Journal of Cleaner Production 261 (2020) 121204 9

improvement, and engineering excellence. Table 3 provides a syn- industry could be studied from a twofold perspective: (1) in rela-
thesis of the thematic analysis organized by dimensions of sus- tion to market access to innovative drugs that contribute to gains in
tainability, main topics, author/year, and a number of papers for terms of well-being and (2) in relation to the accessibility of drugs
each dimension. to all sectors of the population among the different markets at a
global level.
A further emergent gap, partly linked to the previous one,
5. Research gaps and challenges for sustainability in the
concerns the relationship between mature and emerging markets.
pharmaceutical industry
The emphasis on emerging markets mainly concerns the produc-
tion of drugs by local companies or subsidiaries of multinational
Concerning the status of research on sustainability in the
companies, covering only one dimension of the production of
pharmaceutical industry, our review reveals that limited attention
pharmaceuticals globally. In fact, even if emerging markets repre-
to social sustainability in that industry. In fact, although the liter-
sent a significant share of the global production of drugs (an
ature review showed that even if management studies are
emblematic case is that of India, the leading global producer of
permeable to the issue of sustainability of the pharmaceutical in-
generic drugs), there is a concentration of production in some
dustry, the analysis mainly revealed the focus of such studies to be
mature markets that seems to be neglected in the literature. Taking
environmental sustainability, mainly in terms of cleaner produc-
as an example the case of Europe, the relevance of some countries,
tion, green supply chain, green materials, and sustainable HRM.
according to data from the European Federation of Pharmaceutical
However, a certain level of fragmentation and lack of convergence
Industries and Association (EFPIA, 2019), such as Italy and Germany,
towards major themes appears evident. In particular, the literature
would deserve examination aimed at understanding the productive
review suggests a lack of attention to social sustainability. This is
dynamics and the related implications for sustainability in all its
rather surprising, given the recognized role of the pharmaceutical
dimensions. Furthermore, as already highlighted, the analysis of
industry in creating social well-being. The call for a greater diffu-
emerging markets does not take into consideration the social
sion ‘healthy lives’ for all individuals expressed, for example, in the
dimension of sustainability, which is linked to market access to new
claims of international institutions such as the United Nations,
drugs and access to medicines by all sectors of the population.
seems to be less developed in the literature.
There seems to be a disconnect between the interest in emerging
As for possible subject areas to be covered in future research, we
markets from a production/environmental impact perspective and
identify some challenges emerging from the results of the sys-
the objectives of ensuring wider access to care. The potential bar-
tematic literature review. Fig. 4 shows the main challenges that we
riers to access to drugs, including cultural or regulatory ones, is a
describe below.
key topic to be explored.
The social impact of the pharmaceutical industry is self-evident:
Another under-investigated topic is the relationship between
drugs and vaccines (but also other pharmaceutical products, such
innovation and sustainability. On the one hand, the empirical evi-
as medical devices) play a fundamental role in disease prevention,
dence shows a change in the technological trajectory towards
diagnosis, therapy, and, fundamentally, in the continuous
research and the development of expensive molecules with
improvement of people’s quality of life. Despite this, we found few
disruptive effects on some diseases. For example, cases such as the
studies dealing with the social impact of the pharmaceutical in-
recent launch in May 2019 of a pharmaceutical product for gene
dustry. Hence, the social sustainability of the pharmaceutical

Table 3
The thematic analysis: a synthesis.

Dimensions of Main topics Authors/Year N.

sustainability Articles

1. Environmental Cleaner production Veleva and Cue (2017); Belkhir and Elmeligi, 2019; Veleva et al. (2003); Li and Hamblin (2016); 8
sustainability Marinkovic et al. (2016); Blum-Kusterer and Hussain (2001); Kaenzig et al. (2011); Rezai et al.
(2016).
Green supply chain Singh et al. (2016); Kumar et al. (2019); Hashim et al. (2017); Moradi and Jolai, 2018; Gardas 5
et al. (2019).
Green human resource management Veleva et al. (2017); Saeed et al., 2019; Masri and Jaaron, 2017; Andersson et al. (2005). 4
Green materials Sudhakar et al. (2019); Dave and Routray (2018); Mirabella et al. (2014); Manda et al. (2014). 4
1a. Environmental and Environmental and social disclosure Azim and Azam (2013). 1
social sustainability Reduction of drug dispersion Weraikat et al. (2016). 1
1b. Environmental and Environmental and economic impact Jabbarzadeh et al. (2019). 1
economic sustainability of greenhouse gas emissions
Reverse logistics Narayana et al. (2019). 1
2. Social sustainability Employees engagement Caligiuri et al., 2013 1
Access to pharmaceutical products Quak et al. (2019); Sahu and Kohli (2019). 2
Pharmaceutical packaging Lorenzini et al. (2018). 1
Consumer behavior Chaar and Lee (2012). 1
Socially sustainable supply chains Mani et al. (2016); Nematollahi et al. (2018). 2
3. Economic sustainability Sustainable manufacturing Aquino et al. (2018); Menzel et al. (2010). 2
Patent activities Azad et al., 2018. 1
SMEs growth Nin~ o-Amezquita et al. (2017). 1
4. All dimensions Corporate/Organizational Steger et al. (2007); Yoon (2017); Leonard and Schneider (2004); Chaturvedi et al. (2017); Vihari 8
sustainability et al. (2019); Vihari and Rao (2017); Heitzmann et al. (2018); Hansen et al. (2010).
Sustainable supply networks Walker and Jones (2012); Kabir (2013); Bravo and De Carvalho (2015); Zahiri et al. (2017); Padhi 9
et al. (2018); Janatyan et al. (2018); Villena and Gioia (2018); Villena (2019); Zaid et al. (2018).
CSR Min et al. (2017); Schneider et al. (2010); Demir and Min (2019); Parisi and Kai (2008); Parisi 5
and Hockerts (2011).
Performance measurement Mistry (2018). 1
Tot. 59
10 M. Milanesi et al. / Journal of Cleaner Production 261 (2020) 121204
Fig. 4. Challenges for future research on sustainability in the pharmaceutical industry.
therapy of SMA (spinal muscular atrophy), whose cost has been
approved by the Food and Drug Administration at 2.1 million dol-
lars per patient, raise new challenges in terms of sustainability. In
fact, these expensive molecules, in systems that have the objective
of offering access to drugs in accordance with a universalistic logic,
as in most European markets, are challenging the overall economic
stability of the system. On the other hand, the literature seems to
ignore this aspect for the most part. Therefore, a research gap has
emerged in the study of the relationship between innovation and
sustainability.
A topic that, surprisingly, lacks coverage is waste management.
Only a few studies in our review deal with this topic. As is well
known, the issue of waste management has attracted attention in
many industries. In the pharmaceutical sector, the study of waste
management concerns different levels. At the level of the user, the
recovery and disposal of expired or expiring drugs and their
packaging are the focus. At the production level, the management
of production waste and attention to water use are of interest. The
European Environment Agency has promoted very strict protocols
for waste disposal in the pharmaceutical sector. In fact, the best
manufacturing practices for the pharmaceutical industry almost
exclusively focus on the correct procedure to produce medicines.
However, medical devices, such as plasters, condoms, and diag-
nostic tools, deserve special mention, as they fall into several
product categories, from electronics to the plastic industry, due to
the integration of rubber. In addition to environmental pollution
itself, the issue of waste disposal also involves far more serious
implications, such as the proliferation in the environment of drug-
resistant bacteria, which are one of the main threats to global
public health. Therefore, it is not only a matter relevant to the
environment but also to social sustainability and the economic
impact of waste management.
The analysis also reveals that little attention has been paid to the
issue of economic sustainability and, above all, to the relationship
between pharmaceutical companies and the economic sustain-
ability of the health system. This area undoubtedly represents an
opportunity for academic research. In recent years, the economic
crisis has focused attention on the issue of health system sustain-
ability, mainly with reference to cost-effectiveness, quality of care,
and, lately, patient involvement. The trade-off between effective-
ness, efficiency, and sustainability reveals the complexity of health
systems management. Within this context, different actors
contribute to the chances of success by balancing the efficiency,
effectiveness, and sustainability of health systems e and a leading
role is certainly played by pharmaceutical companies. A key aspect
concerns the delivery of new drugs that, in universal health sys-
tems, such as most systems in the European Union, can be totally or
partially reimbursed by the public actor, thus affecting the total
health expenditure. Other aspects must also be taken into consid-
eration. In developed countries, average life expectancy has risen
above the age of 80, and health science, new drugs, and technolo-
gies have improved the quality of life. Although unquestionably
desirable, these aspects imply costs for the health system. Thus, the
economic dimension of sustainability and the relationship between
sustainable health systems and sustainable pharmaceutical com-
panies are in the spotlight.
6. Conclusion
Sustainability in the pharmaceutical industry represents an area
of research that academic literature has yet to deepen in its various
facets. How the change in the pharmaceutical industry can take
place, and the impact it can have on improving the quality of life of
individuals, and the hopes of leaving a better world for future
generations also depend on how academic research contributes to
generating new knowledge in this area. This is particularly impor-
tant if the issue of sustainability in the pharmaceutical sector is
addressed according to a managerial perspective, whose focus is
precisely on the business behavior of companies. Despite growing
interest from the academic world and other institutions, as well as
general attention on pharmaceutical issues by different stake-
holders, managerial literature was lacking in providing a systematic
picture of the current status of research in this field. As confirmed
by this review, sustainability was mainly addressed in terms of
specific areas and empirical investigations. Consequently, the pa-
per’s novelty lies in the merit of providing a systematic overview of
the extant literature.
The paper then identifies five gaps for future academic research
on sustainability in the pharmaceutical industry. Among these, the
paper proposes some gaps that are closely related to the topic of
cleaner production. In fact, despite all the gaps and related areas
identified may have a connection with the issues of cleaner pro-
duction, the aspects connected to waste management in the
pharmaceutical industry, the evolution of sustainable production in
mature markets as well as the implications in terms of economic
aspects of the cleaner pharmaceutical production, represent urgent
 M. Milanesi et al. / Journal of Cleaner Production 261 (2020) 121204
research challenges that require further investigation. Hence and
according to a general perspective, the issue of cleaner production
takes on a central role in the sustainability studies of the phar-
maceutical industry.
The article, therefore, proposes gaps that can be subject to future
empirical investigation, and which can also be analyzed consid-
ering how the topic of sustainability relates to other linked con-
cepts, such as the ethical dimension of the behavior of
pharmaceutical companies. In this sense, future research may be
aimed at understanding how the theme of sustainability in the
pharmaceutical industry relates to business ethics or corporate
social responsibility policies. To conclude, this article proposes
considerations that allow understanding how the theme of sus-
tainability in the pharmaceutical sector has been addressed in the
management literature, thus offering scholars some tentative food
for thought for the future study of the sector and of the issue of
sustainability.
Declaration of competing interest
The authors declare that they have no known competing
financial interests or personal relationships that could have
appeared to influence the work reported in this paper.
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