Right to health: borders as opportunities

For citizens of border areas, accessing quality healthcare services can be difficult. Cross-border cooperation, also thanks to EU cohesion policy, can be effective in guaranteeing the right to health for all. An interview

In 2020, the Covid-19 pandemic highlighted the European dimension of healthcare, stimulating a strengthening of the EU's role in an area that has historically been the responsibility of the Member States. At the same time, the health emergency has exposed not only the fragilities of national healthcare systems, but also the inequalities in terms of accessibility and quality of services among the 27 countries of the Union.

Against this backdrop, cross-border health cooperation can make a difference in reducing disparities between European regions and the resulting risk of discrimination and marginalisation. In fact, there are several cases in which two or more neighbouring territories have decided to join together and experiment with forms of cooperation with the aim of offering what can in all respects be called "border public services".

The book “La cooperazione sanitaria transfrontaliera: sfide ed esperienze ” ("Cross-border health cooperation: challenges and experiences"), published in 2022 by CNR-ISSIRFA, is dedicated to this topic.

The volume - the result of collaboration and exchange between various stakeholders, including representatives of the Department of Cohesion Policies, the Ministry of Health, teachers, researchers, experts in health law and territorial cooperation - is divided into two parts: the first part frames the right to health and the principle of freedom of care within the European legal system, while the second analyses studies and concrete cases of healthcare collaboration initiatives in various cross-border areas of the EU.

We interviewed Raffaella Coletti and Gabriella Saputelli, authors and editors of the volume.

Healthcare does not fall within the exclusive competences of the EU: in this sector the Union can only coordinate and possibly integrate the policies of the Member States. Is there a reference regulatory framework at European level?

The theme of health is already present in the treaties: article 168  of the Treaty on the Functioning of the EU states that the EU encourages collaboration between Member States to improve the complementarity of health services in border regions and to provide adequate response to any cross-border health threats.

There is also a common framework of reference consisting of two regulations relating to social security systems (987/2009  and 883/2004 ) and a directive on patients' rights in the context of cross-border care (24/2011 ). The latter, implemented in Italy in 2014, aims to protect the citizens' right to be able to access treatment in countries other than their country of origin.

In any case, this is a constantly evolving regulatory context. With the pandemic, the issue of European health has become even more important, we know for example that there have been many cases of patients transferred not only at national but also European level. The pandemic has had a double impact in this sense: on the one hand, it has stimulated attention towards the topic, on the other it has slowed down some pre-existing processes in order to be able to respond to the ongoing emergency.

A passage of the introduction to the volume reads that "cross-border areas are confirmed as essential laboratories for strengthening health protection and healthcare at a European level". Why are border areas so important for strengthening the right to health in the EU?

The emergency due to Covid-19 has not only brought attention to the importance of health protection at all levels, but also pushed the European Commission to launch the first evaluation of the directive on cross-border health cooperation. It should be specified that in this directive the word "cross-border" is not used to indicate neighbouring cross-border areas; the meaning is rather that of the right to health which transcends borders and which therefore must be guaranteed in every country.

However, the Commission's study  revealed that this directive is mainly applied in border areas and the reason is quite clear: although in theory it is possible to go anywhere to receive the necessary care, it is also true that it is more difficult to go to a place where you have never been, where you do not speak the language and, above all, which is very far away. This explains why border areas have become places in which to experiment with new forms of integration. Even in border areas, reality is not so easy, because  healthcare systems are different from each other and bureaucratic-administrative obstacles often emerge.

The book presents several examples of good practices and cases of fairly successful cross-border health cooperation. Can you name a few?

Throughout the EU there are various examples of virtuous and successful healthcare collaboration experiences. Some of them are presented in the book, for example between France and Belgium, France-Germany-Netherlands, France and Germany, Italy and France.

A chapter, edited by the European Group of Cross-Border Cooperation EGTC GO, is dedicated to the Italy-Slovenia case, one of the flagships of cross-border health cooperation experiences involving Italy. As part of the EGTC-GO and through the support of the Interreg Italy-Slovenia programme, the cities of Gorizia and Nova Gorica have made a real investment in healthcare, there is even talk of experiments for a cross-border Single Booking Center (CUP).

How is cross-border health cooperation intertwined with cohesion policy?

In general, the enormous impact of the pandemic meant that the issue of health had a central position in the planning phase of the funds for the seven-year period 2021-2027. Among the main innovations of the current programming there is, for example, the EU4Health programme, whose funds serve to strengthen national systems and encourage collaboration also at a European level. This choice undoubtedly signals an effort to harmonise the various healthcare systems and, in general, a greater investment in the healthcare sector than in the past.

Health is also a very relevant theme in cohesion policy, supported within the ERDF resources (to improve healthcare infrastructure) and ESF+ (to help vulnerable groups access healthcare). For several years, the European Territorial Cooperation (ETC) - Interreg programmes have been among the main tools used to promote cross-border healthcare cooperation initiatives. In the acute phase of Covid-19, Interreg resources - as well as cohesion policy resources intended for the investment for growth and employment objective - were also used to respond to the emergency.

In the 21-27 programming, currently underway, there are various tools to develop cross-border cooperation in the healthcare sector. The challenge in the near future will be to make the most of the results achieved with the ETC programmes in the context of regional policies. In our country this is particularly relevant, given the competence of the Regions in the field of "health protection".

Are there promising development prospects in this sense?

As mentioned, the pandemic has turned the spotlight on the topic, which in any case had already been attracting a lot of attention for a few years ; the growing interest in the topic of cross-border healthcare cooperation is confirmed by the number of studies  published recently. As CNR ISSIRFA we have just published another volume on the topic, edited in collaboration with colleagues from EURAC Research (Institute of Comparative Federal Studies), which focuses specifically on the Tyrolo Alto Adige Trentino area .

From a practical point of view, the need to operate on different levels is increasingly apparent: starting from the European regulatory framework, which will have to be implemented better, to the need to strengthen bilateral relations between States, especially with reference to administrative management (think for example of the issue of reimbursement of healthcare expenses).

In general, the need to overcome bureaucratic obstacles to cross-border cooperation does not only concern the healthcare sector, but is a central challenge in the current Interreg programming period; another extremely current challenge is linked to the aforementioned need to better connect cross-border cooperation programs with regional policies. These are areas in which the European Commission is investing in with the 2021-2027 programming, in terms of resources and reflection. Overall, cross-border cooperation in healthcare is certainly an open field of study and experimentation with good development prospects.