How difficult it was to acquire COVID digital certificate in summer 2021: Response of EU national contact points for cross-border health care.

Dear Editor,

The right to free movement in the European Union is generally recognized as the most important right of EU citizens. Health rules and restrictions on border crossing have become a central issue in the current COVID-19 pandemic. World Tourism Organization data from May 2020 show that 100% of global destinations had restrictions on travel [1]. The joint European Roadmap sets out recommendations to the Member States, intending to preserve public health while gradually lifting containment measures to restart strategies that consequently have raised the necessity of immunity proof (COVID digital certificate) for border crossing [2]. Directive 2011/24/EU on patients’ rights in cross-border healthcare sets out the conditions under which a patient may travel to another EU country to receive medical care and reimbursement. Directive refers to EU and EEA Member States [3]. The Directive includes an official network of National Contact Points to provide clear, accurate information on cross-border healthcare.

The introduction of the COVID digital certificate is also an issue that affects general patient rights, especially the Right to Free Choice and Right to Privacy and Confidentiality from the European Charter of the patient rights, and the General Data Protection Regulation [4].

In order to test the National Contact Points network for cross-border health care in relation to COVID digital certificates, we sent a query about how to acquire a COVID digital certificate to official national contact points for border crossings, publicly available at the Official website of the European Union (https://ec.europa.eu/health/sites/default/files/cross_border_care/docs/cbhc_ncp_en.pdf, updated on February 19, 2021). The email we used for sending the inquiries belongs to the member of the International Council of the Patient Ombudsman (Male gender, format: name.surname@yahoo.com.

The subject of the email was: “Information needed urgent” And body text “Hello, please can you give me information on how to get a digital COVID pass certificate for recovery after I resulted positive on the PCR test and completed the quarantine in your country? Thank you in advance.” The e-mail text was constructed based to the queries from patients received by the International Council of the Patient Ombudsman.

The first email was sent separately to each contact point was sent on August 17, 2021, at 13:45 Central European time zone. After 72 hours, a reminder e-mail was sent again to the recipients from which we received no answer, with the same email content. We measured the time of the response of EU national contact points and the quality of the information received in the response. Two authors (JK and MZ) read the response and made a joint judgment on whether the answer solved the problem from the query, and compared the answer with the available information on the official websites.

The overall response rate at the end of our exercise was 77%. Three national contact points (10%) responded within 1 h (Croatia – 10 minutes, Sweden – 30 minutes, and France – 1 hour after the e-mail) and a further 13 (43%) after 24-h (Germany, Iceland, Bulgaria, Hungary, Luxembourg, Finland, Lithuania, Belgium, Ireland, the Netherland, Austria, Greece, Estonia, and Poland). After an e-mail reminder at 72 hours, the answers were received from the Czech Republic and Italy in the following five days. The responses from Latvia and Romania were received in September. No response was received from Liechtenstein, Malta, Norway, Portugal, Slovakia, and Slovenia (Fig. 1 ).

Fig. 1

Timeline of the answer received by countries.

The majority of National Contact Points provided a direct link to the official pages with more information. Several answers provided web links in a local language, without English translation. Clear instructions on how to get a COVID digital certificate with more context than a website link was received from Croatia, France, Germany, Hungary, Finland, Lithuania, Austria, and Greece. Three National Contact Points (Poland, Czech Republic, and Italy) declared that they were not competent and unable to help.

The results of our exercise identify important gaps in the Directive 2011/24/EU on patients’ rights in cross-border healthcare. The most troubling finding is the refusal or failure to respond in 30% of the contacted countries. There was also a delay in response, which could have affected the travel of persons needing to return home.

It is important to highlight the fact that in the Directive 2011/24/EU on patients' rights there is no deadline for the answer to the patient's demands. This means that the clear policy and standards for the timeliness of response to patients should be implemented into the Directive [5].

Our study also demonstrated the lack of awareness of patients’ rights. The issue of concern is that the EU Member States should give a fast answer that is understandable to the lay public, and in the language that is spoken by most travellers (English). In some Member States, the digital pass can be issued 11 days after a positive test, while in others the time is set to 20 days [6]. The Regulation on the EU Digital COVID Certificate is a coronavirus response from the European Commission, that should be equal to all members. Nevertheless, it leaves the decision to the each Member States but its implementation, which is an example of health inequalities for the citizens of the European Union. Returning home must be guaranteed even if the patient has a positive COVID-19 test because it is not clear how long a person can stay positive. Despite the existence of EU-wide COVID digital certificate, some Member States still apply special rules for entry and require a negative PCR test along with the COVID digital certificate. This raises questions about the appropriateness of the COVID digital certificate use and the strength of EU decisions.

We demonstrated in a practical example that the information available for citizens about how to obtain answers from National Contact Points for cross-border healthcare information after recovery from the COVID-19 is insufficient. More attention should be paid to the effectiveness of National Contact Points and a deadline for the answer to an inquiry should be implemented.

Funding

This study was funded by [“Professionalism in Health – Decision making in practice and research, ProDeM”] under Grant Agreement No. IP-2019-04-4882. The funder had no role in the design of this study, its execution, analyses, interpretation of the data, or decision to submit results.

Authors’ contributions

All authors contributed to the planning of the study. JK and MZ sent the queries to the contact points. All authors analysed the results, wrote the manuscript, and take responsibility for the accountability of the study.

Declaration of competing interest

JK is the head of the Health Diplomacy Research Unit and serves as a Patient Ombudsman from 2020. (https://patientombudsman.eu/). MZ is on the directorate board of the Patient Ombudsman and AM declares no conflict of interest in relation to this manuscript.