Cross-border care

Cross-border cooperation in border regions

HOPE has worked for many years on the topic of cross-border cooperation and identified and contributed to several activities in this field.

Co-operation in border areas has a positive impact on patients, providers, those who pay for health insurance and the whole healthcare system. The areas of cooperation are very diverse, involving local resources with the aim of better serving the needs of the local community, for example, emergencies, care, telemedicine, sharing of equipment, research, human resources, networking/sharing practice, funding or common structures.

HOPE set up in 2001 a working party on cross-border cooperation to work on a mapping of all hospital projects in border regions. Two questionnaires were designed, one for individual hospitals, one for health authorities at a regional level. The replies were compiled in the paper “Hospital co-operation in border regions in Europe” published in June 2003. This was then followed by a series of projects and conferences.


HoNCAB Final Conference, 18 February 2016, Brussels (Belgium)

HoNCAB project Final Conference represented the opportunity to present project’s main results and discuss them with the audience, including policymakers and health stakeholders. During the event one of the project’s outcomes, the Hospital Network for Care Across Borders in Europe, was also launched.

Cross-Border Territories: Day-To-Day Europe, 8-9 November 2007, Lille (France)

This conference was co-organised by HOPE and the Mission Opérationnelle Transfrontalière (MOT) with the objective to discuss the political and operational issues of cross-border cooperation. The 12 workshops provided opportunities for topic-by-topic debates and share of projects, good practices, etc., leading to concrete proposals in the form of recommendations, which were collected early in 2008 in a white paper addressed to national and European institutions. The two plenary panel discussions showed that cross-border territories meet real needs, are an effective means of boosting Europe and must receive greater support from national and European authorities. More than 800 people from all European borders participated to the event.

Cross-Border Cooperation in Border Regions, 25 October 2005, Venice (Italy)

This workshop was co-organised by HOPE, Veneto Region and the Local Health Authority of Feltre (Italy), gathering participants representing local authorities and healthcare institutions involved in cross-border activities in border regions. The workshop presented best practices as well as obstacles faced in the concrete work of cross-border actors. All types of cooperation were presented from collection of medical data to organized mobility of patients.

An important part of the workshop was devoted to the work done on Italian borders (Italy-Austria, Italy-France). Experiences from other border regions such as the Republic of Ireland and Northern Ireland, one or the Euregio Meuse-Rhine (Germany, Belgium and the Netherlands) were presented as well as cooperation between Germany and Austria, Portugal and Spain. Finally, also the innovative first steps for a “cross-border hospital” on the Spanish (Catalan region) and France were described.

Free Movement and Cross-Border cooperation in Europe: Practical experiences in hospitals, June 2003, Luxembourg

During this workshop various areas of cooperation were discussed, e.g. emergencies, care, telemedicine, sharing of equipment, research, human resources, networking/sharing practice, funding or common structures. The event gathered a wide range of professionals – nurses, managers and doctors – from different European countries.


Cross-border Directive

The Directive 2011/24/EU on Patients’ Rights in Cross-Border Healthcare adopted in March 2011 codifies patients’ rights to reimbursement for Healthcare received in another EU Member State and obliges Member States to provide information about access to such care through their National Contact Points. During the transposition period from 2011 to 2013, HOPE worked intensely on drafting the Directive and raised awareness about its content. Since then, HOPE has been monitoring the implementation of the directive.

In order to assess the impact of the Directive, a questionnaire was sent to all Member States in 2015, 2016 and 2017 to collect information on patient mobility in the preceding year. The report ‘Member States data on cross-border patient healthcare, published on 18 July 2018, provides an overview of the data on patient Mobility in 2016.

On 21 September 2018 the Commission published its report on the implementation of the Cross-Border Healthcare Directive. Patients mobility and its financial dimensions within the EU remain relatively low and the Directive has not resulted in a major budgetary impact on the sustainability of the national health systems. The report also shows that patients are increasingly aware of their rights under the Directive. In the last reporting period (2015-2018), the National Contact Points (NCPs) have been trained and supported to interact daily with citizens in a proactive way. The quality of information through dedicated national websites and other means has also improved.

On 30 January 2019, the Rapporteur Ivo Belet released its report on the application of patients’ rights in cross-border healthcare to which HOPE has contributed. The report intends to analyse the current shortcomings in the implementation of the Directive and to make recommendations for the improvement of the Directive. The report was widely welcomed by the Parliament and was adopted in a resolution on 12 February 2019 with 512 votes in favour, 32 against, and 62 abstentions. The report stressed out the issue of patients living in border regions, for whom it is often cheaper to get medical care in the closest hospital, which can actually be across a border. The Commission estimated that 40% of the EU population lives in what can be defined as cross-border areas and that less than 27% are aware of the right to healthcare across borders. It was also reiterated that national information offices are important for citizens, and there is a need to improve their implementation in all Member States. The European Commission welcomed the Parliament report and fully agreed with the views expressed.

The Commission also examined the transposition of the Directive into national law and launched 26 infringement procedures. The Directive allows Member States room for manoeuvre when it comes to transposition, but the Commissioner acknowledged that there is evidence of discrimination against EU citizens, as well as too-complex administrative procedures. The Commission has launched two cases on reimbursement and is now taking discussions with EU countries to find ways to simplify procedures. In the meantime, the Commission agrees that Member States should provide sufficient funding for the national contact and information points already mentioned.

On 12 April 2019, the European Commission released the report ‘Member States data on cross-border patient healthcare’ for the year 2017.

On 20 December 2019, the European Commission released a toolbox of cross-border healthcare intended for patients and National Contact Points.

On 3 April 2020, the European Commission issued practical guidance to Member States to support and encourage cross-border healthcare cooperation between national, regional and local authorities in the context of the COVID-19 outbreak.

The Commission Work Programme 2021 includes the Evaluation of the Directive 2011/24/EU on the application on patient rights in cross-border healthcare. The evaluation aimed to look into the approaches implemented by Member States in practice, how effectively these are working and what areas still act as barriers to patients seeking healthcare across borders.

On 15 January 2021, the Commission published the Roadmap on the Evaluation of Patients’ Rights in Cross-border Healthcare, open until 11 February 2021. On 4 May 2021, a public consultation was opened by the European Commission for 12 weeks (until 27 July 2021).

In May 2021, HOPE released its Position Paper on the evaluation of the directive 2011/24/EU on the application of patients’ rights in cross-border healthcare.

On 8 October 2021, the European Commission published the outcome of the consultation which received 193 responses.

On 9 November 2021, HOPE took part in virtual stakeholder workshop organised by the European Commission and Tetra Tech to discuss and gather feedback on the results of the evaluation of the Directive on patients’ rights in cross-border healthcare. Tetra Tech which was mandated by the Commission to conduct the study, presented the findings and discussed them with about 90 stakeholders. Among the main findings, the barriers to access cross border healthcare and to use ERNs were underlined: language, lack of information, red tape, and lack of interoperability. The future needs of patients were also stressed and particularly the challenges of telemedicine and how it should be reimbursed.

On 24 February 2022, the European Commission released two reports:
Study on Enhancing implementation of the Cross-Border Healthcare Directive 2011/24/EU to ensure patient rights in the EU
Study – Cross-border patient mobility in selected EU regions


EU projects

Support creation of a pilot network of hospitals related to the payment of care for cross-border patients

Evaluation of cross border activities in the European Union

Solutions for improving health care cooperation in border regions

Mapping Health Services Access: National and Cross-border Issues

Europe for Patients

Methods of Assessing Response to Quality Improvement Strategies

EURopean wide Innovative Procurement of Health Innovation