Building the future of European health and care with regional and local health authorities at the centre


The last few years have proved crucial for rethinking health as an essential element for the social and economic well-being of citizens, their communities, and the whole European continent. In an era marked by major global trends and challenges already underway for our healthcare systems, such as the digital and green transformation, demographic and climate change, and healthcare workforce shortages – to mention a few –, the need to have resilient and sustainable health systems has been highlighted even more by the COVID-19 pandemic and other devastating humanitarian and geopolitical crisis linked to the recent conflicts on Europe’s doorstep. However, in parallel, innovation and research are making great strides with the deployment of breakthrough technologies and innovative approaches in supporting health promotion, meeting citizens’ needs and implementing high-quality, accessible, and person-centered care.

Although health remains a national competence, the European Union plays a critical role in improving public health policies and citizens’ health and well-being by providing frameworks for design, cooperation, research, and policy intervention and acting as a booster of best practices and knowledge exchange. The building of the European Health Union (EHU) represents an ambitious but crucial step to give a further boost to the EU integration process by implementing strengthened, more resilient, and future-proof health and care systems and, consequently, creating better health for current and future generations. With this ambition in mind, the upcoming EU elections and the appointment of the new European Commission team is a unique opportunity to keep health high on the political agenda and reinforce coordinated and synergistic endeavour towards the Health Union project, which needs the involvement of all the actors across all the levels of design and action – local, regional, national and European.





“Regions play a most important role in delivering healthcare services which are central elements of a strong European Health Union. I look forward to continuing working with EUs regions and cities to deliver resilient, accessible, affordable, and effective health systems across the EU.”

Stella Kyriakides, European Commissioner for Health and Food Safety, at the European Committee of the Regions plenary session on 10 October 2023.

In about two-thirds of EU Member States, local and regional authorities bear the responsibility or an important degree of competence for the planning, organizing, and delivering healthcare services to citizens. Their proximity to communities’ places regions in a unique and fundamental position to detect populations’ health needs and local challenges while, at the same time, supporting research and innovation and implementing actions that can positively address other determinants of health, such as social, economic, and environmental factors. Given their role as frontline implementers of health policies, regional and local ecosystems have often been configured as living laboratories in which to put into practice innovative approaches and interventions in healthcare and have proven to be fertile ground for European cooperation and integration, especially in multi-regional settings like border areas.

Also, acting as a bridge between people, institutions and all other relevant actors, local and regional authorities are key in fostering participatory co-creation models and mechanisms for health policies and implementation, from the local to European level.

For all these reasons, recognising the importance of the regional and local dimension is key to advancing the shared Health Union project, ensuring that policies and programmes are shaped and resourced reflecting actual health systems and population needs. Within this context, the recommendations included in this manifesto offer a range of solutions and opportunities to improve health and care systems in Europe, towards more efficient and impactful care, higher attention on prevention, with a focus on the regional and local dimension, to engage, connect, and grant them the right resources and opportunities to play a central role in the positive transformation, digital, green and organizational, of health and care delivery and policy, for healthier Europeans.



While the road taken by the European Health Union ‘framework’ is surely positive and helped to launch new fundamental initiatives on health at the EU level, it is now necessary to go beyond this and set a path towards a true vision and long-term ambition for health at European level, with regional and local health authorities playing a more central role.

While the European Treaty boundaries remain known and clear, through commitment to advancing, sustaining and implementing existing actions such as the European Health Data Space or the Beating Cancer Plan, adding new flagship initiatives and ‘ EHU pillars’ (e.g., on health and care workforce) and making the most of instruments as the European Semester, it will be possible to further foster health and care in Europe, improving coordination and moving towards more equitable access for all Europeans.

Such an approach should be underlined by a stronger health governance at the European level that allows to set, pursue, and remain accountable for driving an ambitious European vision for health supported by evidence-based policies and programmes. The appointment of a dedicated high-level European Commission representative as a Vice-president for health in all policies and wellbeing, as already advocated by several other European health stakeholders would represent an essential starting point. This appointment should be coupled with parallel similar endeavours in the other institutions, for instance through a stronger and more independent SANT committee in the European Parliament and a reinforced NAT Commission and Interregional Group on Health and Wellbeing in the European Committee of the Regions. By doing so, it will be possible to advance crossinstitutional accountability and give healthcare a stronger position and coordination-driving capacity with other policy areas, fostering a connection with sectors such as education, environment, energy and more, for true health in all policies and one health based approach.

In advancing the European Health Union, it is also necessary to enhance the recognition of regional and local health authorities as key actors in shaping and implementing current and future initiatives. As health competencies are held at the regional/local level in several countries in Europe, their role is essential to ground programmes and policies to existing experiences, close connection with the population’s needs and local knowledge institutions supporting evidence development. This recognition can be achieved, for instance, by clearer mention of the regional and local level in policy documents and programmes, and sustainable involvement of regional authorities’ networks in consultation opportunities.


The health and care workforce is at the heart of health and care delivery, and it thus deserves continuous focus to ensure that has the right tools, working conditions and resources to thrive in and enable the continuous rapid transformation of health and care, while safeguarding its mental and physical wellbeing. While several initiatives and projects at European, national, and regional levels have been deployed over the years, much remains to be done.

To put further emphasis on this theme and ensure long-term actions and sustainability and going beyond ad-hoc initiatives such as the European Year of Skills, health and care workforce improvement through tackling skills, shortages and better working conditions, should be set as a true pillar of the European Health Union going forward, as a whole European commitment to jointly work on this topic through dedicated initiatives, collaboration and building on existing actions and practices.

As part of this effort, Europe must look at current regional experiences of working within and across borders (e.g., also through initiatives such as the Technical Support Instrument or INTERREG) as an example of European collaboration on building a more resilient health workforce together, and to avoid duplication of efforts. EUREGHA will keep playing an important role in this through its participation in the BeWell project and co-leadership of the Pact for Skills Partnership for the Health Ecosystem, an initiative targeted at involving stakeholders towards a joint strategy for green and digital skilled health workforce.


Health and care systems are in constant transformation, and regional and local health authorities play a central role in driving such change on all fronts, digital, green, and organisational.


The digital transformation has been at the centre of debates and initiatives since years, but much more remains to be done and potential to be exploited, also in light of the digital health potential to deliver healthcare to underserved areas. Indeed, all stakeholders must now take a new step ahead to truly harness it in a joint effort covering all its elements, from health data to telemedicine to digital skills. Initiatives such as the European Health Data Space are going in the right direction, promoting harmonisation and interconnection across Europe. However, implementation will be key and will rely, as discussed in the 2023 EUREGHA statement on the EHDS, on tackling existing challenges – such as the General Data Protection Regulation implementation, limitations for sharing health data in crossborder regions, consent and use of data –, a secondary use that supports research, innovation and policy making while protecting people’s rights, boosting trust, improving skills and literacy at all level, increasing resources and funding dedicated to its deployment, integrating regional and local health authorities views into its development, and finally learning on existing initiatives. On this last point, EUREGHA will publish a dedicated Booklet of practices developed with its members, to showcase some important examples of initiatives and approaches at regional and local level, on which other regions, countries and European-level actors should build.


Addressing green transition and the broader environmental impact of health and care is becoming more and more of great urgency. While initiatives in this field are already ongoing, it remains a topic on which further research and attention is still needed, calling for additional targeted studies, conceptualisation and definition efforts, awareness raising and skills development for all healthcare actors.

Indeed, the green transition is such a multifaceted concept that encompasses a wide range of actions to be implemented through planning and adequate resourcing: greener hospitals, waste management, energy efficiency, responsible water use, prevention of environmental health risks from chemicals used in healthcare, urban planning and more. Once again, regional and local health authorities are and will play a key role in this transition and will represent a reference point for practices and examples of working with a one-health approach within their ecosystems.


Transformation, of course, is not just about innovative digital or greener solutions, but also about continuing to study and implement improvements in the way that health and care are organised, and services delivered.

This implies further research and investments in the integration of care (horizontal – social and health – and vertical – connecting the entire care pathway for patients), revision and exchange of knowledge on primary care, and a greater effort in engaging in mutual learning activities between regions and local authorities. This is particularly important in the context of the transition to a more community-based approach across Europe, a topic of central importance for EUREGHA and for its network of regional and local health authorities, as mentioned in our recent 10th Anniversary Statement. Working on such approach also features a better understanding of the peculiarity of the local level, enables further engagement with the population and ultimately allows more tailored solutions and ability to coherently tackle specific issues such as medical deserts. Initiatives such as the Horizon Europe Transforming Health and Care Systems Partnership, where several regions are already actively involved, have the potential to play a central role in this transformation through research and innovation support.


Improving health does not only go through better treatments. It is equally important to take decisive steps in the field of health prevention and promotion, with more resources and a lifelong and community-based approach considering the entire population and its different needs. As we are moving towards a new phase in European health, this should be taken into primary consideration in policy development and programming. Investing in prevention, promotion and public health leads to a strong return on investments and positive impact on the population and can be done in collaboration with other non-health sectors such as education to pool resources.

As concerns prevention, it is necessary to strengthen it at all levels – primary to tertiary -, to thus prevent the onset of diseases, identify them through adequate and timely screening, and limit the impact of the disease in patients.

Health promotion and an overall stronger focus on public health are equally fundamental. Creating an environment that supports the population in making better choices for their health, increases their health literacy and helps them better interact with the health and care system and supporting healthy choices and a healthy living environment is essential.

Regional and local health authorities are already playing a central role in this, and much more can be done and supported, especially thanks to their capacity and proximity to their communities, thus making prevention, health promotion and public health policies more targeted to people’s needs.

In this framework, it will be particularly important to dedicate strong attention to mental health. EUREGHA supported the development of the European Comprehensive Approach on Mental Health in 2023, by endorsing a joint stakeholders declaration and promoting the work of the BOOST project, dedicated to improving mental health promotion in schools. The Approach should become a cornerstone of the European Health Union and must be transformed into implementation action starting from the regional and local levels.


In recent years, also due to the COVID-19 crisis, European funding directed to health has greatly increased, with programmes such as EU4Health experiencing a ten-fold increase for their overall budget and a stronger focus on health in other horizontal programmes such as Horizon Europe, the Recovery and Resilience Facility Funds, Cohesion Funds, INTERREG and more.

Going forward, in view of future Work Programmes discussions and debates of budget allocation and financial frameworks, it is imperative to build on this increased level of resources and focus on health, to further improve it and to ensure adequate support to the implementation of existing and newer policies and frameworks, from the Beating Cancer Plan and the European Health Data Space to mental health, from health workforce to health preparedness and health systems resilience.

In ensuring strengthened resources, it will be equally fundamental to shape work programmes and related calls to better reflect the essential role that regions and local authorities have in many countries in implementing health policies and initiatives and engaging in research and data-focused actions. This is particularly important for horizontal funding programmes, such as Horizon Europe (e.g., on Cancer Mission calls), where better targeting of regional and local health authorities can support better and clearer engagement, improving the bridge between research and policymaking and implementation. In addition, further addressing administrative and other (e.g., application timeframes) barriers in applying and managing EU funds could facilitate engagement from a higher number regional and local health authorities, in particular those with less resources and capacity. This could have a positive impact on a more equitable and diffused access to important EU resources, supporting a more even transformation of health and care across Europe.

Finally, networks such as EUREGHA, acting as a bridge between regional and local health authorities, between them and with other key stakeholders, can help and support regions to find the right opportunities and collaborations, and help EU institutions to better engage the sub-national level. These networks should thus equally be supported in their sustainability, as other non-governmental and civil society organisations. This can be done through more streamlined opportunities in terms of operational grants for NGOs, enhanced options for direct participation in Joint Actions, and other strategic consortia where the role of regions is key.


Since its launch, the Directive 2011/24/EU on the application of patients’ rights in cross-border healthcare, promised a comprehensive and consistent framework supporting cross-border movement across Europe. As confirmed by the recent evaluation study in 2022, it is equally clear that much more remains to be done, as defined in the set of follow-up actions to enhance its implementation. These should be taken forward in close collaboration with regional and local health authorities, exploring their existing activities, taking advantage of active cross-border networks, collaborations, and their learnings to transform current barriers into solutions to grant patients their rights together with information and structures to fully exploit them. To overcome the obstacles posed by structural differences of the healthcare systems across EU, investing in cross-border public health policies and programs aimed at evaluating systems’ performance and identifying best practices represents an important step in this direction.

Furthermore, to put cross-border healthcare back at the centre of the agenda, it is also essential to explore its newer application and perspectives, going beyond the provision of care between two neighbouring countries. Among the most important issues to start further supporting and exploring with cross-border regions there is cross-border public health and linking environment to health impacts, joint preparedness and response to health crisis or cross-border citizens engagement and health prevention and promotion activities.


With healthcare expenditure constantly increasing, EUREGHA highlights once again the importance of investing resources and attention to study, discuss and implement the transition to value-based healthcare. Focusing on the delivery of the maximum possible value in care is essential to make the most of the limited resources available, to both boost the impact of health and care investments and to deliver the best care possible to every European, based on their true needs. To achieve this objective, it will be necessary to go beyond the current discussion on the topic, focusing on collecting the right data to measure outcomes and value and engaging in a comprehensive transformation where all healthcare actors, from authorities to patients, from industry to healthcare professionals, will all move in the same direction, supported by the right research, education, and training.

Several regions are already playing a central role in this transition, increasingly becoming reference centres at European level, with numerous initiatives, dedicated strategies, educational activities, dedicated procurement projects and actions that can inspire other actors across Europe. EUREGHA is also directly committed to supporting this transition, for instance by engaging in the activities of the European Alliance for Value in Health.