If European tourism starts, will medical travel follow?

In the second instalment of his two-part feature on the future of European medical travel, Ian Youngman looks at the recently announced EU plan to re-boot tourism in an organised way. He predicts health and medical tourism will not re-start until 2021 when all European countries are well into phase two, with the exception of urgent treatment.

We will not see the recovery of European health and medical tourism until after the reboot of European tourism.

While European/Asian country Turkey has stolen a march on competition by opening to medical tourists, reports of other countries opening borders are confusing. The headlines of “open borders” differ from the reality that most are only open to workers and essential travel, but not tourism.

The European Commission (EC) has recently presented a detailed package of guidelines and recommendations to help member countries (but not the UK) gradually lift travel restrictions and allow tourism businesses to reopen.

As soon as the health situation allows, people should be able to catch up with friends and family, in their own EU country or across borders, with the safety and precautionary measures needed in place.

The package aims to help the EU tourism sector recover from the pandemic, by supporting businesses and ensuring that Europe continues to be the number one destination for visitors.

These are only guidelines and many countries agree with the principles, but will make their own variations.

The outlines are important as they will almost certainly be fully or partially adopted by the European countries who may not be EU members but are Schengen countries. The 26 Schengen countries are Austria, Belgium, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Italy, Latvia, Liechtenstein, Lithuania, Luxembourg, Malta, Netherlands, Norway, Poland, Portugal, Slovakia, Slovenia, Spain, Sweden, and Switzerland. Four other countries want to join Schengen (Romania, Bulgaria, Croatia, and Cyprus) and  so will probably follow the EU lead. The UK and Ireland do not want to join Schengen, and the UK has made it clear that it will continue with its go-it-alone policy on everything, including tourism.

The EU package

The Tourism and Transport package includes:

  • An overall strategy towards recovery in 2020 and beyond.
  • A common approach to restoring free movement and lifting restrictions at EU internal borders in a gradual and coordinated way.
  • A framework to support the gradual re-establishment of transport whilst ensuring the safety of passengers and personnel.
  • Criteria for restoring tourism activities safely and gradually, and for developing health protocols for hospitality establishments such as hotels.

Implications for travellers

The EC is looking to give people the ability, confidence and belief in safety to travel again by safely restoring freedom of movement and lifting internal border controls.

Free movement and cross-border travel are key to tourism in Europe. As EU countries manage to reduce the circulation of the virus, blanket restrictions to free movement should be replaced by more targeted measures. If a generalised lifting of restrictions is not justified by the health situation, there should be a phased and coordinated approach that starts by lifting restrictions between areas or countries with sufficiently similar epidemiological situations. The approach must also be flexible, including the possibility to reintroduce certain measures if the epidemiological situation requires.

Countries should act on the basis of the following three criteria:

  • Epidemiological, notably focusing on areas where the situation is improving, based on guidance by the European Centre for Disease Prevention and Control (ECDC) and using the regional map developed by the ECDC.
  • The ability to apply containment measures throughout the whole journey including at border crossings, including additional safeguards and measures where physical distancing may be difficult to ensure.
  • Economic and social considerations, initially prioritising cross-border movement in key areas of activity and including personal reasons for travel.

The principle of non-discrimination is of particular importance: when a country decides to allow travel into its territory or to specific regions and areas within its territory, it should do so in a non-discriminatory manner – allowing travel from all areas, regions or countries in the EU with similar epidemiological conditions. Any restrictions must be lifted without discrimination, to all EU citizens and to all residents of that country regardless of their nationality, and should be applied to all parts of the European Union in a similar epidemiological situation.

Several countries do not agree on this principle. Several argue that within the EU some countries have and are dealing with the crisis far better than others so they will only open borders to countries they feel happy with, and not all of the EU.


Opening borders is not effective if travellers cannot get there by air, rail or road. It is vital to restore transport services across the EU while protecting the health of transport workers and passengers.

The guidelines present general principles for the safe and gradual restoration of passenger transport by air, rail, road and waterways. They put forth a series of recommendations, such as the need to limit contact between passengers and transport workers, and passengers themselves, reducing, where feasible, the density of passengers.

The guidelines also include indications on the use of personal protective equipment such as face masks and on adequate protocols in case passengers present coronavirus symptoms. They also make recommendations for each mode of transport and call for coordination among countries in light of re-establishment of gradual connections between them.

Safely resuming tourism

The EC sets out a common framework providing criteria to restore tourism activities safely and gradually and developing health protocols for hotels and other forms of accommodation, to protect the health of guests and employees.

These criteria include epidemiological evidence; a sufficient health system capacity being in place for local people and tourists; robust surveillance, monitoring and testing capacity, and contact tracing.

These guidelines will allow people to safely stay at hotels, camping sites, bed and breakfasts or other holiday accommodation establishments, eat and drink at restaurants, bars and cafés and go to beaches and other leisure outdoor areas.

Ensuring cross-border interoperability of tracing apps 

Countries have agreed on guidelines to ensure cross-border interoperability between tracing apps so that people can also be warned of a potential infection risk when they travel in the EU.

This will guide developers working with national health authorities. Such tracing apps must be voluntary, transparent, temporary, cyber-secure, using anonymised data, should rely on Bluetooth technology and be inter-operable across borders as well as across operating systems.

Interoperability is crucial. EU citizens must be able to receive alerts of a possible infection in a secure and protected way, wherever they are in the EU, and whatever app they are using.

This is an area where some countries demand that they can make the use of apps for citizens or inbound travellers mandatory.

3-phased approach to lifting travel restrictions

Travelling abroad will depend on the evolution of the public health situation in EU countries. A staged and coordinated approach is likely to be necessary.

This would start by lifting restrictions and controls between regions and countries with sufficiently similar epidemiological situations. The approach must also be flexible, including the possibility to reintroduce certain measures if the health situation requires.

The European Commission is proposing a gradual approach to lifting travel restrictions, comprised of three phases.

  • Phase 0, the current situation, where several travel restrictions are in place for non-essential travel.
  • Phase 1, travel restrictions and border controls should be gradually lifted throughout the EU starting between regions, areas and EU countries with a positively evolving and sufficiently similar epidemiological situation. During this phase, smooth transit should be allowed for professional and for personal reasons as well as for tourism. IMTJ does not currently know if personal reasons would include essential medical tourism.
  • Phase 2, all coronavirus related restrictions and controls at the internal borders should be lifted, while keeping the necessary health measures in place. Travel for all purposes should be permitted throughout the region. So arguably in this phase, medical and health tourism would be allowed.

Understanding where restrictions apply

At present, other than the IMTJ log of travel restrictions, interpreting and getting updated information is difficult for travel professionals. The detail of what is not allowed usually varies from the headlines in the media and changes frequently.

EU countries and other neighbours are encouraged to regularly communicate on the state of play of restrictions. This is necessary to ensure that people wanting to cross borders can plan and act on the basis of transparent information and full awareness of the situation, allowing them to follow the relevant health recommendations when travelling.

The EC has a website with the list of internal border controls in place at any given time, as well as links to other relevant information for travellers (on local health situation, health services, applicable health protocols, etc.) but when IMTJ checked, information for many countries has not been kept up to date.

What safe travel might mean

As long as there is a risk of infection, travelling entails some risks. To protect the health of passengers as well as workers, it is essential to follow infection prevention measures, such as physical distancing and hygiene, respiratory etiquette and use of facemasks as well as cleaning and disinfection.

The EC guidance states that the health of people remains the number one priority. To ensure the protection of both employees working in transport and passengers, the guidelines on the progressive restoration of transport services and connectivity recommend several measures:

  • To minimise contact at departure, passengers will be encouraged to buy tickets and check-in online. Physical distancing should be ensured at security checks and luggage drop-off and collection.
  • Fewer passengers may be allowed on board, for example buses, trains or ferries, to allow physical distancing, and passengers who are not from the same household may be seated apart.
  • Where physical distancing is more difficult to ensure, additional safeguards and measures should be put in place, such as the wearing of face masks.
  • Transport staff should be provided with adequate protective equipment.
  • Transport operators may install protective barriers, e.g. between passengers and the driver, and travellers may be asked to board through a rear door.
  • Doors should be opened automatically or remotely by the driver at every stop – so travellers do not need to touch buttons or door handles.
  • Sanitising/disinfecting gel should be available in vehicles and in transport hubs.
  • Vehicles should be cleaned and disinfected regularly.
  • Food, drinks and other goods may no longer be on sale on board, to minimise contact.
  • Ventilation should be strengthened, for example by using appropriate air filters, and natural ventilation should be prioritised where possible.
  • Transport operators are advised to develop strategies in case a passenger falls ill or shows symptoms of coronavirus during the journey.

Passengers should wear facemasks in transport hubs and vehicles used for collective transport, especially where physical distancing measures cannot be fully observed at all times. These do not need to be medical masks.

National health/safety authorities will specify the exact requirements per transport mode, based on the epidemiological risk in that country, the availability of masks, and other considerations. Many countries require that masks be worn in public – some just in shops but others at all times.

Air travel specifics

The EC states that the priority is to protect passengers, crew and transport workers when air transport restarts.

The guidelines recommend a number of preventive measures such as personal protective equipment (facemasks), hygiene and cleaning measures, reduced interaction on board, plus strengthened filtering and airflow systems used in aircraft cabins, which mitigate the risk of transmission.

The forthcoming health and safety protocol that is being developed by the European Union Aviation Safety Agency (EASA) and European Centre for Disease Prevention and Control (ECDC) will specify additional risk mitigation measures to address physical distancing on board. Accessible information on airport processes and airline policies should be provided to passengers in advance of travel.

This is a problem area, as airlines argue that some ideas such as social distancing or limiting passenger numbers are only feasible in the very short term. In the longer term, high numbers are essential to stop airlines going out of business, unless they are given state support or even nationalised. Another problem is that extra cleaning leads to long turn-round times that are not economic.

Hotel safety

The EC has also issued guidance for the safe and gradual restoration of tourism activities and for health protocols in hospitality businesses such as hotels and other types of accommodation, including indoor and outdoor areas, restaurants and cafés.

This guidance provides considerations, from a public health perspective, on the prevention and control of coronavirus for the tourism sector, while acknowledging the specificities across the EU/EEA. This includes considerations for staff as well as clients before, during and after their stay in a hotel and during visits to restaurants, coffee shops, or bars.

Support for tourism businesses

The EC recommends ensuring liquidity for tourism businesses, in particular SMEs, through flexibility under state aid rules.  These allow countries to introduce schemes, such as guarantee schemes for vouchers and liquidity schemes, to support companies in the transport and travel sectors.   It also encourages countries to  work on connecting citizens to the local tourism offer, promoting local attractions and tourism, and communicating that Europe is a safe tourist destination.

Medical tourism and the future

Medical travel in and around Europe will not recover until all European countries are well into phase two of this tourism plan, with the exception of urgent treatment. This will not be until 2021.

What can be done in theory and what will happen in practice for medical travel may differ greatly and may vary considerably for “who went where for what” in previous years.

What European countries are doing and negotiating with each other is changing daily.  Much of the world (with the exception, perhaps, of the USA) is watching Europe for how it turns tourism and medical tourism back on to see what works and what needs to be altered. Expect many changes from the above by 2021.