OBJECTIVES: The study aims to investigate cross-country collaborations, in which governments work together in technical areas such as joint procurement and health technology assessment (HTA), by describing and assessing a few selected ones in the WHO European Region and identifying facilitating and hindering factors to progress. *** METHODS: Out of 35 cross-country collaborations identified all over the world, five collaborations were selected: Baltic Procurement initiative (Estonia, Latvia, Lithuania), Beneluxa initiative (Belgium, the Netherlands, Luxembourg, Austria, Ireland), Nordic Pharmaceutical Forum (Denmark, Norway, Sweden and Iceland), Valletta Declaration (Croatia, Cyprus, Greece, Ireland, Italy, Malta, Portugal, Romania, Slovenia, and Spain) and the Visegrad collaboration (Czech Republic, Hungary, Poland, and Slovakia). They were studied based on a review of published information and through interviews with collaboration representatives. A total of 19 interviews with 26 interviewees took place between July and October 2018. *** RESULTS: All five cross-country collaborations practice information-sharing; further key activities that are worked on jointly or are intended to be done include joint price and reimbursement negotiations (3 collaborations), joint horizon scanning (3 collaborations), joint HTA (3 collaborations) and joint procurement of medicines or vaccines (2 collaborations). The Nordic Pharmaceutical Forum was launched as a bottom-up initiative of technical experts, whereas the four other studied cross-country collaborations were established by political leaders. All collaborations established governance and working structures and defined responsibilities and principles of working together. Starting working together was usually a major challenge since differences in processes between the countries had to be addressed. Alignments of procedures, resulting in legal amendments in a few cases were needed even if joint activities were based on national legislation *** DISCUSSION: Key factors for successful cross-country collaborations include strong support and commitment of political leaders, a functioning governance and working structure and the provision of adequate resources because collaborative action is time- and resource-intensive. Differences in the national pharmaceutical systems constitute a barrier, and processes and legal provisions may need to be changed. First achievements were reported, such as the successful conclusion of joint tenders and the production of joint HTA reports. Overall, it is hard to assess the performance of the collaborations in terms of endpoints and efficiency. In any case, the value of information sharing is highly appreciated by all involved in a cross-country collaboration.