DOI: 10.17573/ipar.2015.2.04	1.04 Professional article
Unsolved Questions Regarding EU Citizens Access to Public Healthcare Services in Spain
Alejandra Boto
University of Applied Sciences Kehl, Germany botoalejandra@uniovi.es
ABSTRACT
Spain is nowadays living the echoes of economic crisis adopting measures to boost employment figures and to correct the excessive macroeconomic imbalances. This paper reviews previous research findings on how these policies affect European citizenship and the access to welfare systems, healthcare provision in particular.
Special attention is paid to the so-called "medical tourism" and to the transposition on Directive 2011/24 into national law. The challenges and transformations that the adequate provision of healthcare for EU citizens will require in the next future are also pointed out, notwithstanding some critical legal problems unsolved till the moment.
However, as the paper is aimed at underlining, the main barriers that still exist to exercise citizenship right to health protection within EU are not legal, but practical.
Keywords: medicare, public healthcare provision, medical tourism, cross-border healthcare
JEL: K 32
1 Introduction1
European citizenship is regulated in the Treaties and in the Charter of Fundamental Rights of the European Union, which can be considered as one of the main achievements of the European project. It implies, among others, the right to move freely within the territory of the Member States. While travelling or staying in another Member State, EU citizens who fall ill or suffer an injury have the right to receive the same access to healthcare as nationals of that Member State. As it will be hereby exposed, and could not be otherwise, Spanish legislation fulfils that scheme. Nevertheless, its neutral provisions, combined with inefficient and budget cutbacks policies not distinguishing between nationals and non-nationals, put nationals from other
1 This research was conceived as a part of the bEUcitizen project, which has received funding from the European Union's Seventh Framework Programme for research, technological development and demonstration under grant agreement no 320294 (http://beucitizen.eu/).
Boto, A. (2015). Unsolved Questions Regarding EU Citizens Access to 87
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EU Member States at a particular disadvantage compared with nationals of the host Member State. Validating this statement proves how far we still are from a real and effective European citizenship.
The paper begins introducing briefly Spanish social and economic background in relation to the access to an essential service: healthcare. Afterwards, some facts regarding the situation of EU citizens' towards this service are offered: firstly, it will be stated how we lack of any specific official data; secondly, a literature review on the topic will be presented. As it will thereby be explained, existing research pays special attention to the so-called "medical tourism" and Spanish Public Authorities are very concerned about the price paid for it. The next chapter of the paper gives an account of the recent legal changes put in force according to EU law in order to achieve a more effective access to cross-border healthcare, especially by providing clearer rules on reimbursements. In this new regulation, the principle of non-discrimination with regard to EU nationality is formally underlined but, as it will be finally discussed, there are still practical barriers preventing EU citizens from enjoying the benefits of national patients when needing medical assistance in Spain.
2 Spain Background
As it is widely known, Spain is currently experiencing very difficult times due to effects of the global economic crisis. Nowadays Spain still goes through a deep structural adjustment following the build-up of large external and internal imbalances during the housing and credit boom. Thus, every policy discussed in recent times has been related to boost economic growth and employment and to correct the excessive macroeconomic imbalances. Meanwhile welfare, equality and human rights remain in the background.
Since 2010, the revision of public policies has concerned mainly fiscal consolidation, recapitalization and restructuring of the banking sector. Some structural reforms have been accomplished in order to launch competitiveness and to correct external funding needs. All such reforms aim at increasing the efficiency, flexibility and competitive capacity of the Spanish economy, taking steps towards debt cuts, budgetary discipline and savings in public expenditure; goals quite contradictory and not always directly related, as proved by the evolution of Spain ranking in World Economic Forum's Global Competitiveness Index2.
The effects of these reforms are calculated in terms of impact on Gross domestic product (GDP) and impact on employment, as it can be seen in the National Reform Program, sent by Spain to European Commission by the end of 20 1 33. But the effect on immigration and access to welfare systems is not in the picture.
2	Available at: http://reports.weForum.org/global-competitiveness-report-2014-2015/ rankings/#indicatorId=GCI.A
3	Available at http://ec.europa.eu/europe2020/pdf/nd/nrp2013 spain en.pdf
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On top of everything, previous political debates concerning such reforms are commonly avoided due to the general use of a special executive order with the force of an Act (Royal Decree-Law) disciplined in article 86 of Spanish Constitution: in the case of extraordinary and urgent necessity, the Government may issue provisional legislative decisions which must be immediately submitted for debate and voting by the entire House of Representatives of Deputies, within a period of thirty days after their promulgation. Then, the House of Representatives must expressly declare its approval or repeal, or treat it as draft laws by emergency procedure. Governing party more than often uses then its absolute majority to validate the Royal Decree-Law without any change (Iglesia Chamorro, 2013, p. 79).
Several stakeholders have been mobilized against this situation. Some examples might be seen at the Social platform in defence of the welfare state and of the public services4 or at the so-called "white/green tides" organized as 15M spin-offs to defend public healthcare/education system^.
3 Healthcare Provision for EU Citizens: Some Data
In Spain there is not much information available to the general public related to the use of healthcare; the problems regarding the access to health services; or the healthcare insurances issues, concerning either foreign citizens or even Spanish citizens. People tend to keep themselves informed through mass media which, generally speaking, only take count of gutter cases.
There is in fact an official system of healthcare information, created by Act 14/1986, 25th April, approving the General Law of Healthcare and Act 16/2003, 28th May, regarding cohesion and quality of the National Health System. Nevertheless, the last information available dates from year 2010 and does not integrate information depending on the nationality of the users6.
Regarding EU dimension, in recent times, government representatives have increasingly condemned the so-called "medical tourism" from EU citizens from other countries7. Consequently, several pieces of regulation have been passed in order to ensure the reimbursement of the bill by the authorities of the native country and to avoid patients being encouraged to receive treatment outside their Member State of affiliation; always according to Directive 2011/24/EU of the European Parliament and the Council of 9th March 2011 on the application of patients' rights in cross-border healthcare.
4	Available at http://www.ugt.es/actualidad/2012/julio/MANIFIEST0%20PLATAF0RMA%20 REC0RTES%20Movilizaciones%2019%20de%20julio.pdP
5	Besides the commonly spread use of this expressions in media and society, see the presentations available at http://wiki.15m.cc/wiki/Marea blanca and http://wiki.15m.cc/wiki/ Marea verde.
6	See https://www.msssi.gob.es/estadEstudios/estadisticas/sisInFSanSNS/pdF/SISNS.pdF (retrieved in January 2015).
7	An official brochure published by the Ministry of health, social services and equality even talks about it; see http://www.msssi.gob.es/gabinetePrensa/reformaSanidad/docs/ cuadripticoReformaSanitaria.pdf (retrieved in January 2015).
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The most relevant of such pieces of regulation is the Royal Decree-Law 16/2012, 20th April, passing urgent measures to guarantee the sustainability of the National Health System and to improve the quality and safety of its benefits. It followed a research carried by the Spanish supreme audit institution (Tribunal de Cuentas) on the cost of management of health services derived from the application of EU regulations and international agreements on public healthcare system,
The report8, signed in March 2012 and finally approved later in October9, analyses the cost of globalizing the right to receive sanitary assistance within EU. It concludes that the Spanish National Health System more than often takes over the cost of sanitary assistance to people who have it already covered by their Member State of affiliation or by private insurances (active workers and retired people especially). Such an expenses pattern disturbance could be explained by the lack of databases and by several misfits on the monitoring processes that should be built up by the Social Security and the Autonomous Regions,
In June 2010 the same report identified more than 450,000 EU citizens from other countries and people from third countries being covered by agreements for the free healthcare assistance due to the presumed fact of not having enough economic resources. The cost of such healthcare assistance rises to more than 450,000,000€ per year and becomes unaffordable10. Thus, the government is currently working to better shape up the notion of "person without enough economic resources" in order to avoid abuses and to ensure that such people do not really have enough economic resources nor have their healthcare covered by private insurance or by their native social security system. As the first step towards that goal, the government has passed the Royal Decree 576/2013, 26th July, establishing the essential requirements to provide healthcare to people not having insured status or not being National Health System beneficiaries and modifying Royal Decree 1192/2012, 3rd August, regulating the insured and National Health System beneficiary status.
4 Actual use of public healthcare system by EU citizens
Due to the lack of official information mentioned above, scholars have studied the use of healthcare by EU citizens on their own. There are several research papers that provide information on the use of health care by foreigners but, like the few pieces of official information previously cited, they usually do not differentiate between EU citizens and citizens from third countries (García Armesto et al., 2011). Hereby, only the researches that take
8	Available at http://www.tcu.es/uploads/I937.pdF (retrieved in January 2015).
9	Available at http://www.boe.es/boe/dias/2013/03/25/pdFs/BOE-A-2013-3242.pdF
10	As an example, the Official Gazette of the Valencian Autonomous Region published last 5th February several lists with thousands of patients, the majority Foreigners, to whom the Autonomous government claims the amount of the invoices of the sanitary attention in public Valencian hospitals (see http://www.docv.gva.es/portal/).
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into account the origins of the immigrant people, or the fact of possessing European citizenship, will be considered,
Hernando Arizaleta, Palomar Rodríguez, Márquez Cid and Monteagudo Piqueras (2008) have studied acute-care hospital admissions in Murcia in 2004-2005, The groups to be compared were established on the basis of the country of birth (Spain/Europe-25/remaining countries), The paper stated that the most frequent causes of admission were related to pregnancy, childbirth and puerperium in all groups, and that hospital utilization and costs per admission and for person-year of insurance between the group "Spain" and the group "Europe-25" were very similar,
Hernández Quevedo and Jiménez Rubio (2010) have studied the existence of differences in health services use between immigrants and the native population and concluded that all immigrants, regardless their nationality or country of birth, seem to face barriers of entry to specialized care. Several papers also concluded that being a child born from immigrant parents means less access to health resources due to a poor degree of system knowledge and cultural barriers worldwide (Weinick & Krauss, 2000, p, 1771), In Spain, Rivera, Casal and Currais (2009) have found that parental origin leads to differences in the utilization of the various levels of the Spanish health system, While no widespread pattern of increased or decreased use of the whole system was identified, differences were found in the number of specialist visits and admissions, Statements of the child's perceived health status were influenced by immigrant families' socioeconomic conditions, which probably affected outcomes,
Some research has pointed that EU citizens in Spain have increasing needs on specialist consultants while non EU citizens tend to use only emergency services and general practitioners' services; Carvajal Gutiérrez and Corpas Alba (2006) explain this fact taking into account that proportionally among the EU citizens there are more elders whereas the third countries foreigners are young adults who do not need much sanitary follow-up or even they elude it due to their long workdays, This role distribution, nevertheless, is too focused, as the research paper is limited on areas around the Mediterranean Sea where there is a huge community of retired English and German people and may not be extrapolated,
The impact of medical tourism in the private sector of healthcare in Spain has been studied by the EOI (Escuela de Organización Industrial)'1'1, According to their data, EU citizens have easy access to diagnostics and check-ups, fertility treatment, cosmetic surgery, eye surgery and cancer treatment, On the other hand, they could experience severe difficulties to access to organ, cell and tissue transplantation due to the restrictions imposed by the ONT (Organización Nacional de Transplantes), Apparently, the National Transplant
11 The study is available at http://www.minetur.gob.es/turismo/es-ES/PNIT/Eje3/Documents/ turismo salud espana.pdf (retrieved in February 2015).
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Organization only gives access to transplantation to the Spanish citizens and to those foreigners who have legally established their residence in Spain12, According to that, the length of time of residence could be a barrier to accessing some health services in Spain, despite the fact that no regulation disposes such an express requirement"
According to statistics made public by the Health Department, Spain was in 2011 the second ranking country of EU-27 with a higher foreign resident population (5,7 million), only surpassed by Germany which had over 7 million", In Spain, the rights to health protection and public healthcare through the National Health System are held by people who have insured status" Not having such a status, EU citizens (Spanish nationals included), European Economic Area or Switzerland residing in Spain and foreigners holding a residence permit in Spanish territory, may be covered by NHS as long as they prove that they do not exceed the income limits of 100,000 euros, Unfortunately, as it has already been said, there is no official information available separating the use of public healthcare depending on the nationality of the insured person,
As for the access to insurance for health care, Jiménez-Martín and Jorgensen (2009) have proved that the increased percentage of immigrants has resulted in a greater demand for private health insurance. Private healthcare has then been increasingly sought to gain access to specialized and emergency services more rapidly by groups with a middle-to-high income and with children, or with a greater inclination to choose a private healthcare provider (as it happens in a paradigmatic way in the case of civil servants). According to that, the access to private insurance depends on the socio-economic level of the family and not in the origin (EU/non EU) of the citizen,
5 Recent regulatory changes to improve the situation
Just a year ago, the process of transposition on Directive 2011/24 into national law was finished, The Royal Decree 81/2014, 7th February, based on the Treaty on the Functioning of the European Union, in particular articles 114 and 168, provides rules for facilitating the access to safe and high-quality cross-border healthcare and promotes cooperation on healthcare between Member States according to the European Directive, The regulation also aims at transposing the Commission implementing Directive 2012/52/EU of 20th December, laying
12	See http://www.ont.es/inFormacion/Paginas/PreguntasFrecuentes.aspx,
13	For instance: Royal Decree 1723/2012, 28th December, which regulates the activities of obtaining, clinical utilization and territorial coordination of the human organs and establishes quality and safety requirements.
14	http://www.msssi.gob.es/organizacion/sns/docs/sns2012/SNS012 Espanol.pdf (accessed in February 2015),
15	Access to public health services is obtained through the Individual Healthcare Card issued by each Regional Health Service. This is the document which identifies every citizen as a healthcare user throughout the National Health System.
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down measures to facilitate the recognition of medical prescriptions issued in another Member State.
Thus, the Royal Decree 81/2014 establishes in article 6, regarding healthcare provided in Spain to patients whose State of affiliation is another Member state, that patients shall receive from the national contact point and healthcare providers all the relevant information and that they shall also have access to complaint procedures in order to seek remedies in accordance with Spanish legislation, if they suffer harm arising from the healthcare they receive. The very same article establishes that Spain has to ensure the patients' access to a written or electronic medical record of the treatment and the exchange of information, always according data protection legislation, to ensure the continuity of treatments. Certain healthcare (identified in annex II and related for instance to overnight hospital accommodation, radiotherapy, disabilities support and reproduction treatments) is subject to a prior authorization.
Finally, the principle of non-discrimination with regard to EU nationality is recorded in black and white in article 6.4 and so article 12 establishes that public or private healthcare providers must apply the same scale of fees for healthcare for patients from other Member States as for domestic patients. An important point to be outlined is that, due to the severe dimension of financial crisis in Spain, all the provision in the Royal Decree must be put into operation without any public cost increase.
6 Challenges for the future
Speaking about the challenges involved in a public Medicare to an increasing foreign population, there are reports stating how sanitary staff has modified the guidelines of attention to incorporate a cultural diversity dimension and to extend the knowledge of endemic pathologies of other latitudes and hemispheres through several training programs16. In some Autonomous Regions services of cultural mediation and interpretation in different languages have been put in operation but they focus mainly in non-EU citizens (Sales Salvador, 2005). For instance, in Catalonia, practical lexis and guides of conversation have been elaborate to translate, among others, Arab, Chinese, Tagalog, Ukrainian or Rumanian into Catalonian (Gracia & Bou, 2006, p. 60); in Andalusia, as reported by Mediaria, a public Foundation, cultural health mediation has been experienced, on-site, through telephone or across specific software"; in Basque Region, a project named Immigration and Transcultural Health was launched in 2003 to test immigrants' integration in socio-sanitary Basque systemi8; in Murcia Region, there are several incipient projects,
16	See the II Plan Estratégico de Ciudadanía e Integración 2011-2014 published by the Executive Management of Immigration at the Ministry of Employment and Social Security (available at http://extranjeros.empleo.gob.es/es/IntegracionRetorno/Plan estrategico20ll/, accessed in January 2015).
17	Available at http://www.fundacionmediara.es/index.php/mediacion/mediacion-sanitaria (accessed in February 2015).
18	More information at: http://www.imisate.eu/Imisate/Inicio.html (accessed in February 2015).
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still in a very early stage (Valverde Jiménez, 2013, p. 383). Several unions, charity works and NGOs also offer this kind of cultural and linguistic mediation regarding sanitary services19. Specially talking about EU citizens, there are some volunteer groups providing support in emergencies with illness and accidents when medical services are involved. They provide hospital visiting teams and an interpreting service at several hospitals around east Mediterranean villages20.
On the other hand, some private medical centers have a specific "welfare" department to handle tourist healthcare2\ Finally, some universities offer PhD programs on intercultural communication and public service interpreting to train students into the theoretical knowledge and the skills, abilities, and tools they need to act as linguistic, communicative, and cultural liaisons between institutional, medical, judicial, educational staff and the users of these public services who do not speak fluent Spanish^. All these programs pay particular attention to healthcare settings and provide stages at hospitals and healthcare centers despite the fact that no juridical framework is fairly established in the matter and some relevant problems remain unresolved regarding, for example patients' rights, privacy and nondisclosure agreements,
Respective the need of cultural mediation, there are studies that have concluded that foreign population access to public healthcare in Spain depends more on the language skills and on the cultural proximity than on the fact of being EU or non EU citizen (Baigorri Jalón et al., 2006, p. 175). Certainly, the biggest difficulties in accessing to public National Health System in Spain are referred to the bureaucracy, especially in terms of severity, dehumanization and coldness in the manners, the rigid system of appointments and the undue administrative filters (Raga Gimeno, 2006, p. 217).
7 Discussion
The above summarized findings point out relevant problems regarding access of European citizens to Spanish healthcare services. That is not surprising taking into account that healthcare system in Spain is characterized by a territorially complex and diverse provision, because it falls under Autonomous Regions jurisdiction (according to the constitutional rule provided in article 148.1.21 of the Spanish Constitution of 1978). Misinformation, cost inefficiency and challenges regarding interoperability systems are a direct consequence.
19	See for instance, in Navarre: http://www.saludaria.org/programa-de-mediacion-linguistica-e-intercultural-en-navarra/; in Catalonia: http://obrasocial.lacaixa.es/ambitos/inmigracion/ mediadoressanitarios es.html (both last accessed in February 2015).
20	More information at http://www.helpofdenia.com/pages/denia/index.php
21	See, for example, information regarding Quiron Palmaplanas Hospital in Balearic Islands: http://www.quiron.es/es/mallorca palmaplanas/informaci%C3%B3n util (accessed in February 2015).
22	See, in particular, FITISPos Group's initiatives at University of Alcala (Madrid): http://www2. uah.es/traduccion/inicio.html (accessed in February 2015). The Master program provides training on Arabic-Spanish, Bulgarian-Spanish, Chinese-Spanish, English-Spanish, French-Spanish, German-Spanish, Polish-Spanish, Portuguese-Spanish, Romanian-Spanish and Russian-Spanish.
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There is no legal barrier in form of direct discrimination that European citizens can find when they access public healthcare services in Spain. On the contrary, the principle of equal treatment is word-for-word outlined in regulation. As mentioned in previous sections, it is only a question of practical barriers, which means that, despite there is no direct discrimination for European citizens with a non-Spanish nationality, they can find difficulties on effectively exercising their rights (e.g. those due to the language in which the service is provided).
It is vital to overcome those barriers, because in the current situation the notion of European citizenship is not complete. In order to achieve this goal, a more extensive provision of resources is vital, for example regarding foreign language skills of sanitary staff, but a definition of clearer legal frameworks, for instance aimed at marking out the role and duties of mediators and interpreters, is also needed.
Alejandra Boto holds a European PhD in Administrative Law and currently works as a lecturer and researcher in Public Law at the University of Oviedo in Spain. Her research interests cover administrative organization, public services provision and users' rights. She is the author of "La pervivencia de la potestad gubernativa de derribo" (Oviedo: University of Oviedo, 2006), "La Administración instrumental en el proceso" (Madrid: Reus, 2011), "El enigma de la descentralización funcional" (Barcelona: Erasmus, 2013) and several parts of books published in Canada, Germany and Spain. Recent work also includes a wide range of articles in journals published in The United States, France, Italy and Colombia, focusing on Comparative Public Law.
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Campos López, J. G. (2004). Mediación intercultural y traducción/interpretación en los servicios públicos: el caso de la atención sanitaria a población inmigrante de origen magrebí. Jornades de Foment de la Investigació, Jaume I University. Retrieved 02.03.2015 from http://www.uii.es/bin/pubi/edicions/ jFH0/trad/12.pdF
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Gracia, L., & Bou, C. (2006). Lenguas, inmigración y comunicación en los centros de salud. In B. Gallardo, C. Hernández & V. Moreno (Eds.), Lingüística clínica y neuropsicología cognitiva. Actas del Primer Congreso Nacional de Lingüística Clínica (pp. 60-82).Valencia: Universitat.
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1.04 Strokovni članek
Nerešena vprašanja glede dostopa državljanov do storitev javnega zdravstva v Španiji
Evropsko državljanstvo med drugim pomeni pravico do prostega gibanja na ozemlju držav članic. Državljani EU, ki zbolijo ali se poškodujejo med potovanjem ali bivanjem v drugi državi članici, imajo pravico do enakega dostopa do zdravstvenega varstva kot državljani te države članice. Španska zakonodaja to shemo ustrezno izpolnjuje. Kljub temu njene nevtralne določbe, skupajz neučinkovitimi politikami proračunskih znižanj, ki ne razlikujejo med državljani in nedržavljani Španije, postavljajo državljane druge države članice EU v posebej neugoden položaj v primerjavi z državljani države članice gostiteljice. Kar dokazuje, da smo še vedno daleč od resničnega in učinkovitega evropskega državljanstva.
Članek uvodoma na kratko predstavi špansko socialno in ekonomsko zaledje v zvezi z dostopom do temeljne storitve: zdravstvenega varstva. Kot je znano, se danes Španija sooča s posledicami gospodarske krize, zaradi katere sprejema ukrepe, ki spodbujajo stopnjo zaposlenosti in odpravljajo prekomerna makroekonomska neravnovesja. Cilj vseh takšnih reform je povečati učinkovitost, prilagodljivost in konkurenčno sposobnost španskega gospodarstva, kar naj bi vodilo v smeri odpravljanja dolga, proračunske discipline in prihrankov pri javnih izdatkih; kar precej nasprotujoči si cilji, ki niso vedno neposredno povezani, kot dokazuje razvoj uvrstitve Španije na lestvici globalnega indeksa konkurenčnosti Svetovnega ekonomskega foruma. Učinki teh reform so izračunani glede na vpliv na bruto domači proizvod (BDP) in vpliv na zaposlovanje, kot je razvidno iz nacionalnega programa reform, ki jih je do konca leta 2013 Španiji poslala Evropska komisija; vendar pa njihov učinek na priseljevanje in dostop do sistemov socialnega varstva nista poznana. Potemtakem ni presenetljivo, da so se v tej situaciji aktivirale številne zainteresirane skupine, ki zahtevajo varstvo socialne države in javnih storitev, ohranitev javnega zdravstva in izobraževalnega sistema.
V nadaljevanju članek analizira posebnosti položaja državljanov EU v javnem sistemu zdravstvenega varstva v Španiji. Predstavljen je pregled literature na to temo. Uradni podatki o tem položaju so pomanjkljivi. Uradna statistična baza podatkov je neuporabna, saj ni bila posodobljena od leta 2010 in v nobenem primeru ne vključuje informacij o državljanstvu uporabnikov. Po drugi strani pa je odkrito izražena zaskrbljenost o tako imenovanem zdravstvenem turizmu državljanov EU iz drugih držav. Vlada, več upravnih organov in ne nazadnje zakonodajalci so obravnavali ta pojav in posledično je bilo odobrenih več različnih uredb, na podlagi katerih so organi v domovini bolnika dolžni zagotoviti povračilo stroškov zdravstvenih storitev bolnikom, ki bi želeli
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Alejandro Boto
prejemati zdravstveno oskrbo izven njihove države, članice zdravstvenega zavarovanja,
Glavna takšna uredba je Kraljeva uredba 81/2014, zlasti člena 114. in 168., z dne 7 februarja 2014, ki temelji na Pogodbi o delovanju Evropske unije, in določa pravila, ki zagotavljajo lažji dostop do varnega in visokokakovostnega čezmejnega zdravstvenega varstva v Uniji, ter spodbuja sodelovanje med državami članicami na področju zdravstvenega varstva v skladu z Evropsko direktivo 2011/24/EU Evropskega parlamenta in Sveta z dne 9. marca 2011 o uveljavljanju pravic pacientov na področju čezmejnega zdravstvenega varstva,
V	tej novi uredbi je načelo prepovedi diskriminacije glede na državljanstvo EU sicer formalno zapisano, vendar še vedno obstajajo praktične ovire, ki preprečujejo državljanom EU, ki potrebujejo zdravniško pomoč v Španiji, da bi izkoristili prednosti, ki jih imajo domači bolniki. Kot je poudarjeno v pregledani literaturi, so take praktične težave v glavnem povezane z nizko stopnjo sistemskega znanja, s kulturnimi ovirami, z znanjem jezika in s socialnoekonomskim statusom. Tudi časovno obdobje prebivanja je lahko ovira pri dostopu do presaditve organov, celic in tkiv v skladu z omejitvami, ki jih določa španska nacionalna organizacija za presaditve (ONT).
Ko govorimo o izzivih, ki zadevajo naraščajočo populacijo tujcev, vključeno v javni sistem zdravstva, obstajajo poročila, ki potrjujejo, da so zdravstveni delavci spremenili smernice o zdravstveni oskrbi z namenom vključitve razsežnosti kulturne raznolikosti. V nekaterih avtonomnih pokrajinah so vzpostavili storitve kulturne mediacije in tolmačenja v različnih jezikih, vendar kljub temu še vedno obstajajo velike regionalne razlike. To pravzaprav ni presenetljivo ob upoštevanju, da je za španski zdravstveni sistem značilna ozemeljsko kompleksna in raznolika določba, ki sodi pod pristojnost avtonomnih pokrajin (v skladu z ustavno ureditvijo, določeno v 148.1.21 členu španske ustave iz leta 1978). Povrhu vsega so zaradi finančne krize javne spodbude majhne. V velikih mestih se v glavnem osredotočajo na neevropske državljane, medtem ko v nekaterih bolnišnicah v vzhodnih mediteranskih vaseh nudijo tolmačenje prostovoljne medicinske ekipe na terenu. Nekateri zdravstveni centri imajo celo t. i. posebne oddelke za dobro počutje, ki skrbijo za zdravstveno nego turistov. Ne nazadnje, univerze ponujajo doktorske študijske programe o medkulturni komunikaciji in tolmačenju v javnih službah, s katerimi študenti pridobivajo teoretično znanje, veščine, sposobnosti in orodja, ki jih potrebujejo, da delujejo kot jezikovni, komunikacijski in kulturni posredniki med institucionalnim, zdravstvenim, sodnim, izobraževalnim, itd. osebjem in uporabniki teh javnih storitev, ki španskega jezika ne govorijo tekoče. Vsi ti programi posvečajo posebno pozornost izvajalcem zdravstvene oskrbe in v bolnišnicah ter zdravstvenih centrih omogočajo pripravništvo, kljub dejstvu, da v zvezi s tem pravni okvir dejansko ni oblikovan in je še vedno treba razrešiti nekaj zadevnih težav, na primer, v zvezi z bolnikovimi pravicami, zasebnostjo in sporazumi o varovanju informacij.
V	Španiji obstajajo težave v zvezi z dostopom državljanov EU do zdravstvenih storitev v javnem zdravstvu. Ni nikakršnih pravnih ovir v obliki neposredne
88 International Public Administration Review, Vol. 13, No. 2/2015
Unsolved Questions Regarding EU Citizens Access to Public Healthcare Services in Spain
diskriminacije, s katerimi bi se državljani EU lahko srečevali, ko dostopajo do zdravstvenih storitev v španskem javnem zdravstvu. Nasprotno, princip enake obravnave je v uredbi dobesedno izpostavljen. Gre torej zgolj za vprašanje praktičnih ovir, kar pomeni, da čeprav ne gre za neposredno diskriminacijo državljanov EU, ki nimajo španskega državljanstva, se le-ti lahko srečujejo s težavami pri učinkovitem uveljavljanju pravic.
Da bi premagali te ovire, si je treba prizadevati, da se koncept evropskega državljanstva izvaja, saj v trenutni situaciji ni popoln. Da bi dosegli ta cilj, je bistvenega pomena bolj obsežno zagotavljanje sredstev, na primer v zvezi z znanjem tujih jezikov zdravstvenih delavcev. Vendar je kljub temu potrebna tudi opredelitev bolj jasnih pravnih okvirov, ki bi določala vlogo in dolžnosti mediatorjev in tolmačev.
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