Abstract
Abstract
Introduction
Cross-border collaboration in healthcare has become increasingly important in the context of European integration, particularly in border regions where institutional and health system interactions are most pronounced. These regions offer opportunities for joint healthcare provision, patient and workforce mobility and shared use of resources. However, healthcare governance largely remains a national responsibility, introducing administrative, legal and institutional barriers to coordinated care. This review will examine the structures and mechanisms in place for cooperation and will map the available evidence relevant to the functions of cross-border healthcare in Europe using the Health System Performance Assessment framework.
Methods and analysis
This scoping review will follow the Joanna Briggs Institute methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Eligibility will be determined using the Population–Concept–Context approach. A three-step search strategy will include an initial limited search, comprehensive searches across six databases (PubMed, Web of Science, Medline, Embase, Global Health, Scopus) and grey literature searching. Two reviewers will independently screen studies via Covidence. Data will be extracted using a standardised form and synthesised descriptively. AI tools can assist with specific steps in the Responsible AI in Evidence Synthesis framework, provided they are supplemented by manual verification.
Ethics and dissemination
Ethical approval is not required as this review uses publicly available literature. Findings will be disseminated through an open-access publication, conferences and policy briefs targeting cross-border healthcare stakeholders.
Keywords: International health services, Organisation of health services, HEALTH SERVICES ADMINISTRATION & MANAGEMENT
STRENGTHS AND LIMITATIONS OF THIS STUDY.
Within the European context, cross-border healthcare (CBHC) has gained increasing policy relevance through the European Union’s efforts to improve access to high-quality and equitable healthcare across borders. This scoping review aims to map and synthesise the current evidence on the implementation of CBHC in Europe using the WHO Health Systems Performance Assessment Framework.
Our scoping review recognises the interdisciplinary and varied nature of health research in cross-border regions, allowing for the inclusion of a broad range of study types beyond just those focused on specific health outcomes.
A multidisciplinary and international research team from different disciplines of health research and public health contributed to the protocol.
To minimise language bias, articles in all languages will be included.
In line with scoping review guidance, a quality appraisal of the included studies will not be conducted.
Introduction
Up to 40% of the European Union’s (EU) territory consists of border regions, home to nearly one-third of the EU population. Compared with central areas, these regions often face structural disadvantages, yet they also offer considerable potential for growth and innovation.1 Across Europe, some border regions have experienced stagnation, whereas others have evolved into dynamic spaces of interaction and integration, partly due to the advantages arising where national systems intersect.1 Border regions represent important settings for cross-border cooperation, particularly in the provision of public services such as healthcare. Their increasing relevance in European policy has contributed to the development of new forms of integrated service delivery. Among these, cross-border healthcare (CBHC) constitutes a complex field shaped by diverse regulatory, institutional and socioeconomic factors.1–3 CBHC can refer to immediate border regions where care is accessed in the vicinity of neighbouring areas across a national border, or more broadly if healthcare is obtained outside a patient’s home country such as planned treatment abroad.
Within the EU, border regions are defined by the nomenclature of territorial units for statistics as regions located along land borders or where more than 50% of the population resides within 25 km of a border.2 For analytical purposes, two main types are distinguished: internal border regions (between EU member states) and external border regions (between EU and non-EU countries). This typology captures differences in border intensity and dynamics, particularly in relation to regional and cross-border policy frameworks.2 Border regions are characterised by frequent cross-border movement of people, goods and capital, alongside the interaction of legal systems and cultures, resulting in unique social, economic and cultural spaces that often require tailored governance or integration approaches.2
An increasing number of eligible areas are designated as ‘cross-border regions’, a concept embedded in the Lisbon Treaty of 2007.3 Within the EU, these regions serve as spaces of integration and benefit from EU programmes promoting regional development and cross-border collaboration.3 4 The EU currently comprises 40 internal borders with neighbouring countries in the European Free Trade Association, and European integration has transformed many border regions from peripheral areas into zones of economic and social opportunity.1 Despite reduced barriers, healthcare governance remains largely national, and institutional differences continue to hinder CBHC delivery. Cross-border cooperation addresses these challenges through synergies and cross-border public services (CPS), where authorities jointly provide services, including healthcare.5–7 CPS involve actors from different systems or countries and enable the exchange of patients, professionals, services, products, funding and healthcare-related knowledge across borders.
The legal foundation for CBHC is anchored in the Treaty on the Functioning of the EU (TFEU), which promotes healthcare cooperation among member states. While healthcare remains primarily a national responsibility, Directive 2011/24/EU on patients’ rights in CBHC, aligned with the TFEU and Regulation on social security coordination, requires the European Commission to support patient mobility, promote CBHC collaboration and establish rules to ensure safe, high-quality care and access.8 The Directive grants EU citizens the right to access healthcare services in other member states. However, this is influenced by multiple factors, including geographical proximity, limited availability of specialised services, medical needs during travel, access to continuous treatment, efforts to reduce waiting times, preferences for familiar healthcare systems and care needs following relocation.6 8
Health systems aim to promote, restore and maintain health through core functions such as service delivery, financing, governance and the generation of resources. Their performance is commonly assessed by how effectively they achieve key objectives, including equitable access, high-quality care, population health improvement, financial protection, efficiency and sustainability.9–11 The WHO Health System Performance Assessment (HSPA) framework for Universal Health Coverage (online supplemental appendix 1) is a dynamic concept that is still being extended and provides a structured approach to evaluating how health systems deliver services, utilise resources and achieve results across dimensions such as effectiveness, efficiency, equity, access, quality and financial sustainability.10 This framework helps to identify strengths, gaps and opportunities for improvement, support accountability and guide reforms aimed at strengthening health system performance and resilience.10 11 Similar to public health, CBHC is an important direction from a European perspective where performance assessment methodologies also require advancement.12 The functions, objectives and goals outlined in HSPA frameworks therefore offer a useful analytical lens for examining CBHC initiatives. Despite the growing importance of CBHC in European integration, evidence remains fragmented across disciplines, policy domains and regions. Cooperation with non-EU neighbours adds complexity due to differing legal frameworks and limited institutional agreements, requiring context-specific approaches. Although numerous CBHC initiatives exist, no comprehensive synthesis has systematically mapped their operation, the health system functions and objectives they address, or the evidence available to assess their performance. Addressing this gap is essential to understanding CBHC’s contribution to health system performance and accessibility in border regions. A scoping review is, therefore, warranted to map existing evidence, identify institutional structures and cooperation mechanisms and examine how CBHC initiatives align with core health system functions, objectives and performance dimensions.
This scoping review will examine the cooperation and functioning of CBHC in Europe using the HSPA framework, to assess how institutional differences and collaborative mechanisms shape healthcare delivery in border regions. More specifically, we will (1) review and synthesise the available evidence and data sources regarding the performance, functioning and challenges of European CBHC. Therefore, we will identify key datasets, reports and evaluations, indicators of success, patient mobility, quality of care and cost-effectiveness and assess gaps in data availability and reliability. We will (2) identify and examine the key healthcare system functions, objectives and goals that have been addressed in European CBHC initiatives since 1992, when the Maastricht treaty was signed. This includes the analysis of core functions such as resources, financing, service delivery and intermediate objectives like accessibility, quality, efficiency and equity in consideration of the HSPA. We will explore how CBHC supports the objectives of national European and EU-wide health policies and how these functions are prioritised across different regions. We will (3) further assess the types of cross-border cooperation mechanisms and institutional structures (eg, CPS) that have been implemented to facilitate healthcare collaboration, categorise cooperation mechanisms (eg, formal agreements, networks, EU-funded projects) and examine legal, administrative and policy frameworks that support CBHC as well as the role of institutions and regional actors in enabling cooperation.
Methods
The procedures for this scoping review were developed in accordance with the JBI methodology for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) for reporting this review. This protocol has been prepared following the JBI best practice guidance for the development of scoping review protocols.13 14 Scoping reviews aim to systematically map the breadth of available literature in a given research area, identify key concepts, types of evidence and gaps in knowledge.15
This scoping review may methodically use AI tools such as Atlas.ti (https://atlasti.com) and/or Chat AI (https://academiccloud.de/services/chatai) in key steps to enhance the review efficiency under guidance of the Responsible AI in Evidence Synthesis (RAISE) framework,16 which will be accompanied by manual validation to preserve research integrity and quality. These tools may be used to identify search terms, organise and categorise extracted data, and support thematic synthesis. This structured integration streamlines data processing while maintaining critical expert oversight.
Eligibility criteria
The inclusion and exclusion criteria will be based on the PCC approach (see table 1) of the JBI method to assess study eligibility, which has been recommended for reporting scoping reviews.13 14
Table 1. Population, concept and context and types of content of the scoping review.
| Criteria | Description |
|---|---|
| Population | Residents of European countries including EU member states and neighbouring non-EU countries, including patients, healthcare providers, institutions and policymakers involved in CBHC cooperation |
| Concepts | Collaboration and functioning of cross-border health systems; differences in institutions, legal frameworks and cooperation mechanisms; existing structures, initiatives and challenges between neighbouring countries |
| Context | CBHC in Europe, including patients, healthcare providers, institutions and policymakers. This includes CBHC involving at least one country or territory located on the European continent, regardless of EU membership |
| Types of content | Peer reviewed studies, reports and grey literature such as newspaper articles from 1992 onwards |
CBHC, cross-border healthcare; EU, European Union.
Population
This scoping review will focus on populations residing in European countries and cross-border regions between countries. It will consider patients, healthcare providers, institutions and policymakers involved in CBHC cooperation. They often share a common cultural and historical background, characterised by distinct institutional environments (remote/rural regions of their countries), including their healthcare systems.
Concept
This review will examine the collaboration and functioning of cross-border health systems, specifically investigating how institutional differences, collaborative mechanisms and legal frameworks influence CBHC. The aim is to identify and map existing structures, related performance indicators such as workforce availability stratified by type or the number of existing health facilities within the border regions, associated challenges and cross-border cooperation initiatives between the health systems of two or more countries sharing a border. Key aspects will include cross-border integration of healthcare systems, cooperation initiatives, health system functions, objectives and goals addressed, and the availability of services and resources for cross-border populations. Furthermore, we will map differences in access and utilisation among EU commuters, non-EU commuters and resident populations across different jurisdictions. This includes examining whether and how potential disparities in healthcare access are addressed in the literature. Given the expected heterogeneity of available sources, healthcare equality or equity-related findings may emerge as an indirect outcome of the process.
Context
This scoping review will focus on cross-border health systems involved in CBHC in Europe. We will include CBHC collaboration involving at least one country or region located on the European continent regardless of EU membership. It also includes countries that are only partly located in geographical Europe, such as Turkey. The figure (figure 1) provides an overview of the included countries. We will include cooperation in border regions, at European or national level and patient mobility between singular European countries (eg, residents travelling abroad for treatment). However, cooperation taking place only outside of Europe, as well as overseas territories/colonies of European countries, will not be included.
Figure 1. Map of included European countries.
Types of content
All types of study designs will be considered such as reviews, cross-sectional studies, mixed method and qualitative studies. Opinion pieces and commentaries may be excluded. Additionally, we may consult the websites of regional, national and international governmental bodies to identify supplementary reports and publications. Only studies released from 1992 onward will be considered, as this timeframe aligns with the signing of the Maastricht Treaty in 1992, which came into effect in 1993. We will include literature that do relate to European healthcare systems.
Search strategy
We will conduct a three-step search strategy in alignment with the PRISMA-ScR (see table 2). These steps include, first, an initial limited search of databases, followed by an analysis of the text words contained in the titles and abstracts of the retrieved papers as well as the index terms used to describe them. Second, a comprehensive search will be carried out using all identified keywords and index terms across all included databases. And, finally, the reference lists of all identified reports and articles will be examined for additional sources, including relevant grey literature. The electronic databases PubMed, Web of Science, Medline, Embase, Global Health and Scopus will be searched using key terms related to cross-border health systems from inception onwards. We will undertake manual reference checks of full-text articles and search the websites of relevant organisations for articles and publications. Grey literature searches will be conducted using Nexis Uni (https://www.lexisnexis.com/) to identify relevant newspaper articles, alongside general searches on the websites of the European Commission and the European Observatory on Health Systems and Policies (WHO Regional Office for Europe) to retrieve policy documents, reports and other relevant materials.
Table 2. PRISMA-ScR-aligned three step search strategy.
| Steps | Description |
|---|---|
| Step I: initial search | Initial limited database search to identify keywords and index terms |
| Step II: adjusted search | Use refined search strategy with adjusted keywords and index terms across the databases PubMed, Web of Science, Medline, Embase, Global Health and Scopus |
| Step III: reference and grey literature search | Analyse reference lists of identified literature for additional sources of relevant data including grey literature |
PRISMA-ScR, Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews.
Key search terms and synonyms related to Europe, EU and bordering states such as Switzerland, United Kingdom, Ireland; health, health system; health system performance; border, cross-border and transnational will be searched in the listed databases. A preliminary search strategy was developed using the following search string: (cross-border OR “cross border” OR border region* OR transborder OR “trans-border” OR cross-frontier OR international border*) AND (Europe* OR EU OR “European Union”) AND (health OR healthcare institutions OR health systems). No restrictions regarding language or study design will be applied. Publication date will be restricted to 1992 onwards.
Selection procedure and data management
Following the comprehensive search of the above-mentioned databases, all citations will be collated and uploaded into Covidence, a software tool designed to streamline the management of systematic reviews (https://www.covidence.org/), for evidence synthesis. Duplicates will be identified and systematically eliminated within Covidence. Two reviewers will independently screen the titles and abstracts to verify their alignment with the inclusion criteria. The full texts of the selected articles will undergo a detailed evaluation by two or more independent reviewers. Reasons for exclusion following full-text review will be recorded and reported in the final scoping review. Any disagreements between reviewers will be addressed through joint discussion at each stage of the selection process and by an additional independent reviewer if required.
Patient and public involvement
We did not involve patients or the public while designing this protocol.
Data extraction
Following the selection process of the finally included studies, we will develop a data extraction form in Microsoft Excel to extract data that is relevant to our research question and objectives. Areas for extraction will include title, author(s), year of publication, the country of publication, study design, health system setting (eg, hospital, national or regional public health, primary or specialist care), border region being investigated, healthcare system functions that may be related to resources, governance, service delivery and/or finance and associated objectives. Other areas will be further determined following extraction, based on some initial pilot studies (see table 3). Data will be extracted by two independent reviewers. AI-assisted software may only be used to derive concepts and context where large amounts of information are presented in the included studies to improve efficiency. To ensure accuracy and reliability, any AI-assisted data extraction will undergo manual validation by the review team. Two reviewers will independently verify the extracted data against the original full-text articles and any discrepancies identified during the validation process will be resolved through discussion and consensus.
Table 3. Overview of variables.
| Variables | Description |
|---|---|
| Study/source characteristics | Covidence ID, authors, year of publication, title, type of study/source, aim of the study |
| PCC framework | Population or actors addressed, geographical scope, type of CBHC collaboration, healthcare setting |
| Health system aspects | Health system functions, subfunctions, objectives and goals addressed, guided by the HSPA framework |
| Barriers and facilitators | Reported barriers and facilitators to CBHC cooperation |
CBHC, cross-border healthcare; HSPA, Health Systems Performance Assessment; PCC, Population–Concept–Context.
Data analysis
The data charted in the extraction table will be analysed descriptively using frequencies, percentages or absolute numbers. The descriptive analyses will be conducted using appropriate software such as in Microsoft Excel or STATA (https://www.stata.com/). Relevant extracted data from the final included set will then be mapped thematically to the functions, intermediate objectives and final goals of the health system based on the HSPA framework.
Risk of bias assessment
No assessment of risk of bias or methodological quality appraisal of the included articles will be performed, as the objective of this scoping review is to broadly map the existing literature on cross-border cooperation rather than to evaluate the quality of data, methods or effects. Unlike systematic reviews, such assessments are not applicable to scoping reviews.
Presentation of the results
The results of the scoping review will be presented descriptively. Visualisation tools such as Flourish (https://flourish.studio/) will be used to display the findings. The collected evidence will be presented in formats such as tables, figures and maps based on the extracted data. In addition, a narrative summary of the included studies will accompany the tabulated and visualised results, describing how they relate to the objectives of the review.
Ethics and dissemination
This scoping review aims to draw exclusively on data and information from publicly available sources, including peer-reviewed publications, official reports and grey literature. As no primary data will be collected, and no human participants will be directly involved, formal ethical approval is not required. The findings of this review will provide a comprehensive mapping of existing evidence on the functioning and cooperation of European cross-border health systems.
The results will be disseminated through multiple channels to reach both academic and policy audiences. These will include submission to a peer-reviewed journal, presentations at relevant conferences, and sharing of key insights with researchers and stakeholders involved in CBHC. Summarised findings may also be made available through policy briefs or targeted dissemination to EU institutions, national ministries of health and cross-border regional cooperation platforms. By identifying gaps in evidence, indicators and institutional mechanisms, the dissemination of results will support future research agendas and inform the design and implementation of more effective cross-border health policies in Europe.
Supplementary material
Acknowledgements
This scoping review is conducted in partnership with the Cross-Border Institute of Healthcare Systems and Prevention (CBI), Groningen/Oldenburg. The Project Health4DE-NL is part of the Interreg VI A programme Germany-Netherlands (Grant number 31177).
Footnotes
Funding: This review is funded by the Interreg VI A programme Germany-Netherlands (Grant number 31177), which is supported by funds from the European Regional Development Fund (ERDF). Also, the regional provinces of the border regions, regional health authorities as well as the Carl von Ossietzky Universität Oldenburg, the University of Groningen (UG), the Aletta Jacobs School of Public Health and the University Medical Center Groningen (UMCG) are involved in the funding. Funders had no role in designing the protocol, conducting the review, analysing data or drafting the manuscript.
Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online (https://doi.org/10.1136/bmjopen-2026-117613).
Provenance and peer review: Not commissioned; externally peer-reviewed.
Patient consent for publication: Not applicable.
Map disclaimer: The depiction of boundaries on this map does not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. This map is provided without any warranty of any kind, either express or implied.
Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
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