Health integration across international borders : an integrative review

Universidade do Estado do Amazonas, Manaus, AM, Brazil. Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil. Confl icts of interest: none to declare. Abstract Objective: Evidence the types and goal of the healthcare integration agreements in international border regions. Methods: Integrative literature review, in which studies published between 2006 and 2015 were selected that were indexed in the electronic databases CINAHL, Clinics Collection, LILACS, MEDLINE, PubMed, Scopus and SocINDEX. Thirteen studies were included. Results: The results demonstrate that formal and informal integration agreements exist in border regions, formalized by federal governments or international laws. The prevalent goals of these agreements are monitoring, disease detection and control in border regions. Conclusion: The agreements studied aim for cooperation to cope with regional diffi culties. The integration actions tend to minimize the health asymmetries of border populations.


Introduction
Th e integration of health between countries is a recurring theme, discussed by border region managers, whose manifestations on cross-border health situations take positive and negative forms. (1)ost of the border regions are distant from the large urban centers, a fact that can negatively aff ect the health conditions of the population living there.Th e formulation of integration policies in these scenarios can minimize the economic and social impacts of these regions. (1)ntegration processes between countries, including those accomplished in border regions, are motivated by economic and geopolitical issues regulated by the World Trade Organization. (2)Th e created policies result in the abolition of legal and institutional tariff barriers that facilitate the access to shared institutions and rules for the consumption of social services between countries. (3)nternational health integrations turned into a social fi nancing power as from the 1990s, when the fi nancial capacity of development banks led to the creation of a new design of government policy decisions, which gradually established itself as the dominant technique. (4)In this context, integration has played a key role in achieving the global health objectives, refl ecting its importance for trade, population mobility, public fi nances and other international issues. (5)nternational cooperation, and its eff ects in health, have been instrumental in achieving the goals globally agreed upon, which reinforces the relevance of recognizing the types and purpose of health care integration agreements in border areas.In addition, the common interests of the states facilitate the consolidation of regional integration spaces, in which joint actions ensure projects to guarantee the right to health, (6) especially the right of access to services. (7)Considering the geopolitical dimensions of the Brazilian state, member of the Mercosur and a signatory of the United Nations, with an extensive territorial interface with other countries; and its model of comprehensive care and universal access to health, this study aimed to highlight the types and purpose of the health care integration agreements that occur in international border regions.

Methods
Integrative literature review, whose method permits the systemization of empirical and theoretical knowledge about a topic of interest, as well as to synthesize diff erent perspectives on a phenomenon. (8)Th e study was designed through the recommendations of the Statement for Reporting Systematic Reviews and Meta-Analyses of Studies (PRISMA) checklist and the elaboration of a protocol, validated by an expert reviewer, consisting of fi ve sequential steps: problem identifi cation, data collection, data evaluation, analysis and interpretation, and presentation of results. (8,9)n the fi rst stage, the problem was identifi ed and the review question was defi ned: What are the types and purpose of the healthcare integration actions that take place in international borders regions?For the data collection, the fi lters included the Portuguese, English and Spanish languages, in the time frame from 2006 to 2015, which considered, as a milestone, the implementation of the Integrated Border Health System in Brazil in 2005.Th is system aimed to promote the integration of health actions and services in border regions of Brazil. (10)riginal articles fully available online were included.Experience reports, refl ections, literature reviews, editorial management reports, letters, opinion articles, comments, congress abstracts, essays, repeated articles, dossiers, offi cial documents, theses, dissertations, books and articles that did not meet the scope of this review were excluded.
In the literature review, electronic bibliographic databases were consulted in June and July 2016: CINAHL, Clinics Collection, LILACS, MEDLINE, PubMed, Scopus and SocINDEX.To compose the search strategy, we used the Boolean operators "OR" and "AND" and keywords and descriptors combined with their respective terms in English and Spanish: Health management, Systems integration, Health Care, Border Health, Border Health integration across international borders: an integrative review Figure 1.Flowchart of search and selection of studies on healthcare integration agreements in international border regions, adapted from PRISMA Health and Border.Based on this strategy, 742 articles were identified, 125 of which were excluded due to repetition, totaling 617 studies.
In the third stage, the 617 studies were pre-selected by reading the title, abstract, keywords or descriptors, excluding those that did not meet the inclusion criteria, so that 106 studies remained.These were read in full, excluding articles that did not meet the scope.In this review, 13 studies were considered.
The selected studies were categorized in a table in Microsoft Excel®, which included the following items: article and journal title; year and language of the publication; authors (name, degree and institution); method, research question and objective; research scenario (border countries, states and cities); existence of health integration actions between the countries studies; and existence of integration between border countries.The search and selection method of the studies is displayed in figure 1.In the fourth stage, the data were analyzed and interpreted and, in the fifth phase of the review, the research report was elaborated.

Results
The 13 articles analyzed revealed that health actions exist that provided for integration among countries, which took form in the model of international agreements.(22)(23) In these scenarios, the types and goals of the integration agreements could be identified.
In the analysis, ten articles were published in English, two in Portuguese and one in Spanish, between 2007 and 2015.In the scope under analysis, no studies were published in 2006, 2008, 2009 and 2010.3) Four studies used quantitative methods (17)(18)(19)21) and two followed the mixed method. (22,23)A synthesis of the themes addressed is displayed in chart 1.
(13)(14)(15) In Asia, agreements are closed across borders close to regions of conflict, (17,19) involving political (18) or religious conflicts. (16)In South America, differences between health systems in countries make it difficult to close agreements.22)(23) Health integration agreements are formal and informal.The formal ones are legitimized by federal governments (13,(17)(18)(19)(20) or supported by international legislations. (11,12,14,15)Informal agreements, on the other hand, can be closed between non-gov-ernmental organizations, for example, Middle East Association for Managing Hearing Loss (16) or between subnational governments, such as the Charter of Posadas (22) between the State of Santa Catarina in Brazil and the Province of Misiones in Argentina.
There are also agreements that cooperation takes place on the basis of informal requests between local health authorities (23) or through exchange of favors among health professionals in the countries concerned. (21)art 1. Synthesis of types and goals of the healthcare integration agreements according to the international border scenarios Health integration across international borders: an integrative review Most health integration agreements aim to monitor, (17,21,23) detect and control diseases of epidemiological importance for border regions. (18,19)he agreements between European Union countries aim to facilitate patient mobility, (11)(12)(13) mainly in emergency situations (14) and hospital care of medium and high complexity at the borders of member countries. (15)ther agreements seek to promote equity in the care for border populations, (20) train health professionals working in border regions (22) and treat newborns with congenital disabilities. (16)

Discussion
This literature review contributes to the recognition and understanding of the types of actions and their goals for health integration agreements across international borders, and can help managers in decision making, planning and implementation of public health policies in favor of the border populations.This review is limited by the non-inclusion of other review studies, experience reports and official documents that discuss this subject, in accordance with a previously approved protocol.
Border regions can be complex, as frontier cities naturally integrate culturally, socially and economically.They create a kind of third space, forming a new society, with its own culture and values, which grants them an identity different from the remaining contingent of the countries they belong to. (24)n the health area, the international agreements in these regions tend to guarantee the right to health of the local population as, in addition to their own characteristics, the borders are distant from the political and governmental centers of their countries, in mountainous or geographically isolated regions and generally with limited health infrastructure. (5,12)n this condition, the health resources result from their own country's complementary system or from services across the border (20,21) because, when ill, people choose the paths that are most meaningful to them, based on the possibilities they envisage. (25)he demand for health care in neighboring countries may also be related to the differences between national health systems, which is the main factor for the success of integration agreements in international border regions. (20)Due to the unique characteristics of national systems, there are operational difficulties in integration processes, making border health management more complex. (26)or the success of health integration agreements between governments of the border countries, managers and health professionals need to understand foreigners' rights to health.The results of a study carried out on the borders between Brazil, Argentina, Paraguay and Uruguay showed that these issues reveal the lack of common ethical and political principles and the institutional fragility of existing agreements. (22)hen they occur, such agreements offer benefits to the populations living in those regions. (11,15)ontextual factors exert a strong influence on their implementation and maintenance though.Even when agreements are carried out in conflicting or isolated border regions, their success depends more on the sensitivity and performance of the stakeholders in the process than on the policies that created them. (12,16)An example of this can be observed in the results of the hearing loss project in Arab and Israeli infants. (16)

Conclusion
Health integration agreements in border regions are a possible initiative and can effectively minimize the existing asymmetries between urban centers and these regions.The results of this review have shown that the existing agreements are formal and informal in nature and aim to co-operate to address regional difficulties due to disparities in the access to health for border populations.Health integration agreements gain consistency when their foundation is based on analyses about which management strategies are necessary for a specific reality.These strategies relate to infrastructure and government policies, as well as to the engagement of actors in the integration process, including the populations in the region.