Citizenship and the right of access to health care

1) Recognition of citizenship for those born on the other side of the border.

According to Brazilian legislation, if a pregnant woman goes to the other side of the border to be attended to in the last stages of labor, either due to the lack of services in the twin city or other needs, those born a few kilometers from the border will not obtain the certificate of live birth in Brazil.⁵ Therefore, citizenship is not guaranteed from birth. This situation negatively impacts demographic statistics (birth rate and population growth). It is necessary to explore a legal solution and introduce technical standards to avoid unnecessary displacements of the mother to seek a quality service in her own country, putting her health and that of the fetus at high risk. For example, mothers from Barra do Quaraí (Brazil) who travel to Uruguaiana (70 km further north) to have their babies delivered within the national territory could instead go to Bella Unión (Uruguay), only 7 km away. Alternatively, if there was a bridge, they could go to Monte Caseros (Argentina), which has a more complex public health care system.⁶

2) Loss of entitlement to social assistance from one’s own country if residing on the other side of the border.

This problem has arisen, especially in the Brazilian border areas, due to the payment of the Continuous Cash Benefit (Beneficio de Pago Continuo, BPC). This is an additional social inclusion payment made by the Brazilian government to low-income people over 60 years of age. In many cases, it represents fundamental financial support for households, especially for the purchase of medicines. When residing on the other side of the border, particularly in the twin cities, the right to this benefit is lost since residency in Brazil is a requirement. For this reason, some beneficiaries do not communicate the effective transfer of their domicile to the other side of the border. This entails a situation of illegality (false declaration of residence). However, it is obvious that these people’s daily lives revolve around the border, and they continue to carry out social, economic, political (and electoral) activities in Brazilian territory. According to the documentation consulted, this is more of an administrative bottleneck; it is the responsibility of the National Social Security Institute (Instituto Nacional de Seguridad Social, INSS), which is decentralized in each federated State.

3) Reimbursement of health care expenses.

The health authorities of a border region do not always recognize access to their national health system in neighboring border countries. Although there are agreements in this respect, a serious problem is registration in the social security system and the consequent reimbursement of health expenses. Not all Mercosur countries guarantee universal access to medical care. Argentina, Uruguay, and Brazil do, while Paraguay is still moving in this direction.

The main issue is the rejection by a national health system of health care costs generated by a patient coming from the other side of the border. Often, cross-border healthcare flows are generated by the failure to find an adequate service in the municipality itself. This situation hinders the right to cross-border healthcare for both basic and more advanced and complex treatment. In some cases, there is a lack of an appropriate legal framework to recognize reimbursement; but in many other cases, the bilateral agreement exists, however, the competent administrations do not apply it due to a lack of technical standards for action, ignorance of the agreement, or lack of resources for its implementation. It is a case of an administrative/bureaucratic nature. There are many examples of this, but a complicated situation often arises along the Argentine-Paraguayan border. According to the bilateral agreement between the government of the province of Misiones, Argentina, and the government of the department of Itapúa, Paraguay, citizens of the department of Itapúa can go to specific hospitals in Posadas after a series of authorizations from Paraguayan authorities, the relevant health professional, the director of the Regional Hospital of Encarnación, the Secretary of Health of the Government and, finally, the confirmation of the availability of the Posadas hospitals, and only through the Misiones mobile unit service. However, many patients present themselves in the Posada facilities without following this procedure (the so-called self-referred) who should be charged for health expenses according to the current regulations. In many cases, they are treated in the same way as self-referred patients due to the urgency of the treatment and ethical reasons.

4) Medications are not available on one side of the border when being treated in the neighboring country.

This problem has arisen due to the closure of the Argentine-Paraguayan border in response to the spread of the COVID-19 pandemic. Due to the health agreement between the government of Misiones and the government of Itapúa, residents of the Paraguayan department─especially in the city of Encarnación and surrounding areas─received health care in the hospitals of Posadas. They were provided with oncological drugs not available in Paraguay, and the national government reimbursed the benefits. With the closure of the international bridge, patient mobility was interrupted, as were treatment cycles. Many had to be treated by a foundation in Encarnación, which does not have the medicines supplied by the Argentine hospitals, since the Paraguayan ministry does not include it in its health care system. Patients have to buy these drugs at market prices, and the health operators supply them to them. This case received significant attention in the local press. At that time, the Paraguayan consul in Posadas called on the families of cancer patients in Encarnación to deliver the drugs to the consulate to take care of the shipment across the border. The health structures in Encarnación were then concerned with providing the cure to the patients after consular management. In this case, the problem is twofold. On the one hand, the closure of the border generates unforeseen health situations in the border country, and there is no protocol to propose an alternative to the patients. On the other hand, there is no shared record of the drugs supplied to the patients and their introduction into the national health system of each country.

Patient transfer

5) Excessive bureaucracy for patient transfer.

Excessive bureaucracy is a very common situation in the study area, especially between the twin cities of Carmelo Peralta (Alto Paraguay, Paraguay) and Porto Murtinho (Mato Grosso do Sul, Brazil). Local authorities admit that bureaucracy and legal issues slow down the transfer of patients. In case of emergencies, transfers are carried out more often through personal relationships and the willingness of the health authorities than through legal channels. The bureaucratic and legal time required for medical transfers is often incompatible with emergencies. It is, therefore, a problem of administrative flexibility.

Some local authorities also point out that the free circulation of emergency vehicles in the linked border localities of Brazil is not fully operational. Despite the existence of bilateral agreements (Montevideo Agreement of 2013) and Mercosur (Agreement on Linked Border Localities of 2019), it seems that the technical implementation of the agreement is at a standstill in the Brazilian capital. The above is, therefore, both an administrative and, hypothetically, a political problem. According to these agreements, vehicles used for emergencies (accidents, natural disasters, among others) such as ambulances and fire trucks can provide assistance services in urban, suburban, and rural areas of the border localities linked to the country’s border areas. These will be coordinated by the focal points and must comply with the technical regulations of both parties.

6) Patient transfers are limited to emergency cases and do not include situations of greater complexity.

The above bottleneck shows how informal cross-border relationships can be used to operate in emergencies, despite regional, State, or federal legal and administrative difficulties. An even more difficult issue is the transfer of patients for more complex situations, such as surgery and specific treatments (oncology, contagious and transmissible respiratory diseases, among others). Bilateral agreements and technical protocols shared by both countries, such as the agreement between the provincial government of Misiones and the departmental government of Itapúa, are often used for this purpose. Even so, the closure of the international bridge between Posadas and Encarnación as a COVID-19 containment measure has shown the fragility of these agreements. Highly complex health transfers lack a common legislative and operational framework based on multilevel governance to integrate border needs with national policies.

Health professionals

7) Invalidity of prescriptions issued by a physician or hospital on one side of the border because pharmacies or physicians do not recognize them on the other side of the border.

The lack of collaboration between border health authorities leads to difficulties in obtaining some medicines. It is a bottleneck that mainly affects twin cities. In particular, a medicine prescribed by a doctor in a neighboring country is not always valid on the other side of the border. For the above reason, pharmacies do not recognize the validity of the document issued, especially if it concerns specific and expensive drugs not subsidized by the national health system. In addition to this problem, it is important to mention that the high cost of drugs in a country limits access to cures. The difficulty in cross-border territories is twofold: expensive drugs in the country and prescriptions that pharmacies do not recognize in twin cities where the cost could be more affordable. The situation is even more complicated in Paraguay, where universal health care has not been implemented for all its citizens, although there have been many advances in recent years.

8) Partial right to practice of physicians practicing on the other side of the border. The recognition of degrees and the legal practice of medicine on the other side of the border is still a pending issue.

Health professionals (doctors and nurses, among others) who have studied in their country of origin cannot perform their functions in the neighboring country due to a lack of validation of their degrees. Between Uruguaiana and Paso de los Libres and between Bella Unión and Barra do Quaraí, professionals working in hospitals in the neighboring country are not authorized to issue medical prescriptions because they are not registered in the national professional registries. For example, in the case of Brazil, this situation generates great inefficiency since Brazilian physicians must reissue the certificate issued by their counterparts in Argentina or Uruguay. Although there is an agreement with Argentina that attempts to solve this problem, the mutual validation of qualifications is still pending. Similarly, when studying at a university in another country, nationals who return to their country of origin without a validation process do not have their studies recognized. The above is the case for future Argentine and Uruguayan doctors studying at the Universidade Federal do Pampa (Unipampa) in Uruguaiana or those Brazilians studying medicine at universities in Paraguay and Argentina. This issue continues to be a long and costly process managed by the central authorities of the border countries, which hinders the labor mobility of health professionals in the border areas and negatively affects patient mobility and the organization of the health services network.

Accessibility and healthcare facilities

9) Lack of health care equipment, especially highly complex equipment.

There is a lack of healthcare facilities at different border points, particularly highly complex ones such as oncology, radiology, and hemodialysis centers. Among the areas that stand out is the lack of neonatal care centers between Nueva Palmira-Carmelo-Colonia de Sacramento-Juan Lacaze-Rosario and Pedro Juan Caballero and Ponta Porã, or of mobile units in more rural areas. To avoid legal and administrative obstacles, many patients turn to the closest healthcare facilities in their own country, even if they are far away. Therefore, a comprehensive approach is needed, one that corresponds to the geographical, demographic, and socioeconomic reality of the border areas, where health facilities consider the population of their own country and the population living on the other side of the border, i.e., a functional cross-border health area. There are no mobile river units in a border territory dominated by rivers, whether owned by one country or bi- or tri-national. These structures would increase healthcare access in the most rural and underpopulated border areas according to river conditions. Likewise, the use of border telemedicine seems to be not very widespread. However, digital access to health is one of the main challenges of the post-covid era that will have to be considered for future cross-border health policies in Mercosur.

10) Lack of road infrastructure and regular public transport services.

Despite the presence of important border crossings (bridges, fords, or urban crossings) and attempts to continuously improve accessibility, especially between Argentina and Paraguay (inauguration of the Ituzaingó-Ayolas International Crossing in 2019 and the future bridge between Puerto Iguazú and Presidente Franco), connectivity between many linked border towns remains precarious. However, patient mobility depends not only on the presence of physical infrastructure but also on transportation services. Excluding specific agreements for patient transfer, there is a lack of regular river crossings and cross-border buses in terms of the number of routes and timetables. Moreover, the supply of integrated cross-border transportation, whether public or private, is conditioned by the different sector regulations in each country. For these reasons, flows go through social and family relationships that can offer an emergency transfer to the jetty in the neighboring city or a car ride to the necessary health structure, free of charge or at an affordable price. Likewise, displacement impacts health care, since in many cases, low-income people have greater mobility difficulties.

11) The repatriation of corpses does not have a streamlined system for border citizens.

Bureaucratic problems hinder the quick and easy repatriation of the deceased across the border, respecting the family’s wishes. The cases in which this situation occurs are very diverse: an accident, a death following hospital treatment, whether due to an emergency or of high complexity, elderly people admitted to nursing homes on the other side of the border, or simply residents in the neighboring country who have not communicated their change of residence to their State (see point 2). For bureaucratic reasons, the repatriation of corpses in cross-border areas is considered international repatriation. It entails a too slow and costly process because it is only a few kilometers from the border, requiring protocols from consular bodies or embassies. In addition, the coffin must arrive in the country already sealed. For these reasons, in cases of the imminent death of a border resident, and thanks to the good informal relations between local authorities, the person is transferred to the competent structures on the other side of the border. This is a situation at the limit of legality that needs a response through a bilateral agreement and for all Mercosur countries.

Information exchange, monitoring, and communication

12) Discontinuity in the surveillance and control of communicable diseases.

Over the past decades, Mercosur countries have reached important agreements on epidemiological surveillance and control of communicable diseases. Bilateral agreements have been signed, especially with the Brazilian authorities. These agreements generally include implementing specific actions such as joint vaccination campaigns, coordination, exchanging information, and joint sanitary controls. Some examples are the cooperation for the control of influenza between Chuy (Rocha, Uruguay) and Chui (Rio Grande do Sul, Brazil), of dengue, yellow fever, and HIV-AIDS between Paraguay and Argentina, or for the creation of a Binational Emergency Operations Center (Centro Binacional de Operaciones de Emergencia, COE) to face the current COVID-19 pandemic between Santana do Livramento (Rio Grande do Sul, Brazil) and Rivera (Rivera, Uruguay). However, many initiatives lack appropriate resources and an integrated vision between territories and the different communicable diseases. In the Bella União-Barra do Quaraí-Monte Caseros triple border, local authorities have called for joint action against leishmaniasis for years, and a cooperation agreement is still lacking. The agreement between Brazil and Uruguay on joint control of COVID-19 in the transboundary strip seems to be moving in this direction. However, the major difficulty is to transfer the results of the pilot projects within regional policies to truly address surveillance and sanitary control. The above is a crucial point for the internal borders of Mercosur exposed to multiple communicable diseases that can combine with each other. In the north of the province of Salta in Argentina, cases of corona-dengue and corona-salmonella have recently been detected, i.e., patients affected by COVID-19 and dengue or salmonella (^{Programación Canal 9 Televida, 2021}). Coordinated initiatives are therefore needed to provide diagnostic tools and adequate treatment.

13) Lack of a shared cross-border sanitary monitoring system among Mercosur countries.

The monitoring of cross-border health flows is a fundamental element to understand the communities’ needs and plan joint actions between the competent authorities. Although pilot projects for the integration and exchange of health data have been carried out at some local or regional levels, a permanent network for monitoring health mobility is still lacking. Accordingly, big data studies would be very useful to detect the concentration and evolution of cross-border flows. To this end, it is essential to establish stable collaboration between public and private institutions. Through this collaboration, it will be possible to establish shared definitions, methodologies, and indicators supported by the Mercosur Observatory of Health Systems (Observatorio Mercosur de Sistemas de Salud, OMSS) or the Pan American Health Organization (PAHO).

14) Lack of disaggregated, updated and shared statistical data among the competent authorities.

The lack of updated socioeconomic, demographic, and health statistics remains a challenge. Methodological differences in data collection remain between statistical institutes in each country and at the provincial/departmental/state level. It is therefore difficult to gather evidence to identify the needs of border communities for proper planning.

15) Lack of integration of technology in the provision of services.

Health cooperation in the technological field between Mercosur countries includes some experiences. The current pandemic has marked a turning point in applying information and communication technologies (ICT), especially in the health sector. The use of technologies between the healthcare structures of the linked border localities does not seem to be widespread. Sharing and exchanging the clinical history of patients treated between healthcare structures in the cross-border area, activating telemedicine to provide quality service and proximity to patients (virtual accessibility), and harmonizing customer care methods are some of the challenges that should be prioritized to ensure quality healthcare along the internal borders of Mercosur.

16) Need for a joint and integrated approach to healthcare in the cross-border territory, sharing procurement and contracting systems and financing procedures.

Many of the bottlenecks identified, such as the lack of health equipment, health professionals, or the partial right to practice of doctors in the neighboring country, have a common origin. It is, therefore, appropriate to move toward a more “holistic” approach to cross-border cooperation in health matters, promoting virtuous and efficient investments. Concrete aspects could be, for example, a single system for the purchase of health material and the recruitment of health professionals for the border localities linked to each other.

17) Communication and information to the population on the agreements and procedures.

It is very common for patients to go to the other side of the border searching for health care without knowing the cooperation agreements and conventions in force. This is due, in part, to the lack of an effective communication plan by the institutions and health structures on the procedures to be followed. The phenomenon of Paraguayan self-referrals in the hospitals of Posadas (see point 2) at times generates some difficulties (refusal of free care, complaints, tension between health personnel and patients, among others), which in some circumstances have required the intervention of diplomatic bodies to resolve the situation.

Support for cross-border cooperation

18) Lack of support to local administrations to undertake and maintain cross-border cooperation measures in the health field.

Along the Mercosur borders, there are highly innovative cross-border cooperation structures that have emerged from the local level, such as the border integration consortium (Consorcios de Integración Fronteriza, CIF), binational working groups, and the Permanent Municipal Interparliamentary Forum between the cities of Posadas and Encarnación, among others. The local administrations involved in health cooperation experiences share the same concern of not having sufficient financial and human resources to maintain the measures undertaken in health matters. For a cooperation structure to work effectively and efficiently, it is necessary to have adequate human (technical and administrative personnel), technological, and financial resources.

19) Cooperation programs with topics specifically aimed at cross-border health promoted by Mercosur or other international organizations.

Local institutions have shown their willingness, proactivity, and creativity to face the daily challenges of healthcare in cross-border areas. They have developed relevant cross-border institutional capital⁷ and territorial know-how embodied in agreements, partnerships, projects, and informal relationships. In this context, the studies carried out by the Mercosur Social Institute (Instituto Social del Mercosur, ISM) represent a fundamental contribution to the design of new cross-border health cooperation projects and policies. Among the most relevant studies, the following stand out:

Beyond these studies, a financial cooperation mechanism to support direct actions in border territories with a regional approach at the Mercosur level still needs to be defined.

Gender approach

20) Little attention to the gender approach in health cooperation. While every administration develops some kind of initiative focused on improving access to healthcare for women, in general, many cross-border cooperation projects and initiatives lack a gender perspective. Health is perhaps the sector where this approach should be adopted in all aspects. The approach to cross-border health cooperation based on gender covers several dimensions, from representing women in cross-border organizations (mostly led by and composed of men) to promoting cross-border policies and actions aimed at specific issues. Some of these issues are the right to assistance in childbirth and abortion, protection and shelter for victims of domestic violence, abuse, prostitution, and human trafficking. It is also important to promote and guarantee access to health care for women belonging to ethnic-linguistic minorities and socially vulnerable groups.

Positive impacts

1) Memorandum of understanding on sanitary cooperation between Uruguay and Brazil:

2) Barra do Quaraí-Bella Unión and Quaraí-Artigas coordination committees to create a single epidemiological unit.

3) CIF of Barracão-Bom Jesus do Sul-Dionísio Cerqueira-Bernardo de Irigoyen:

4) Promotion of the project for a new international bridge between Puerto Iguazú and Presidente Franco.

5) Implementation of facial recognition technology at the Friendship Bridge border crossing between Ciudad del Este (Paraguay) and Foz do Iguaçú (Brazil), to increase controls and streamline cross-border flows.

6) Inauguration of a new pediatric hospital in Eldorado, which increases the availability of healthcare facilities at this border crossing point.

7) Reopening of the border between Brazil and Paraguay in October 2020 through a protocol for the coordination of sanitary controls (^{Paraguay y Brasil reabrieron sus tres fronteras terrestres tras siete meses de cierre por el coronavirus, 2021}).

8) Increase in health infrastructure in the border department of Ñeembucú (Paraguay), supported by the Yacyretá Binational Entity, including the new hemodialysis service in Pilar (^{Ñeembucú ya cuenta con su propio servicio de hemodiálisis, mediante inversión del Gobierno nacional y departamental, 2021}).

Negative impacts