The role of health services focused on foreign patients is twofold. On the one hand, they can be a pole of attraction for foreign patients from other countries who are looking for a good quality and affordable medical solution in another country. In such a case, the end result of the posting is mainly valued in medical terms. This type of travel is sometimes referred to as "health tourism".  

On the other hand, health services can be seen as an infrastructure (an intermediate input) to improve the competitiveness of a country's tourism sector, or its attractiveness as a potential destination for non-permanent residence of foreign nationals. Health care is not the ultimate objective of the tourist/traveller, but, without having planned it, the tourist or non-permanent resident may require such services. These services become an indispensable input to increase tourism and the residence of foreigners in our countries. It forms part of the infrastructures of the so-called social capital (Putnam) with which societies build a friendly and safe environment in their daily relations and make themselves attractive to visitors. A factor of economic growth that many authors already detect as being of greater relevance than physical and even technological capital, as it is more idiosyncratic and less 'tradable' and importable across borders, certainly accompanying the geophysical and climatic conditions.  

The quality of health services, many authors point out, is a more important factor of economic growth than physical and even technological capital, being more idiosyncratic and less 'tradable' and importable across borders, certainly accompanying geophysical and climatic conditions.

Health services for tourists/non-permanent residents  

The range of health services can be very different depending on whether you are attracting patients from other countries (health tourism) or providing a basic service to tourists and/or non-permanent residents.  

∙ Health tourism

 Health tourism implies a certain amount of planning and, therefore, a type of pathology or non-urgent care need, related to contingencies that are not usually covered by public health insurance in Southern Europe (such as spa therapies, aesthetic treatments, wellness, sports medicine, plastic surgery, elective surgery, post-traumatic rehabilitation or assisted reproduction, for example).  

For these types of services, private sector provision is the most frequent. In 2014, an estimated 25,000 tourists travelled to Spain for hospital treatment, excluding spa treatment. They spent around 500 million euros on health care, not counting other expenses related to the stay (hotels, travel, etc.). This type of tourist spends around 8 to 10 times more than the average tourist. Recent information on Wellness tourism, with a European focus and specific information on Portugal and Spain, can be found in M. Peris-Ortiz and J. Álvarez-García (eds.) 2015. Health and Wellness Tourism Emergence of a New Market Segment. Springer. 

In 2014, an estimated 25,000 tourists travelled to Spain for hospital treatment, excluding spa treatment. They spent around €500 million on healthcare, excluding other costs related to their stay (hotels, travel, etc.).

∙ Tourists/non-permanent residents 

The health services required by tourists or residents have more to do with common contingencies (arising from new or pre-existing illnesses) and unexpected accidents. They are usually covered by specific medical insurance for displaced persons (travel insurance), or by the public insurance of the country of origin, through compliance with bilateral agreements between States, or through existing European regulations (for European originators).  

Apart from the case of patients from European countries, care for foreigners usually requires specific certification of the hospitals providing care (such as Joint Commission accreditation).

The special case of Europe  

In Europe, Directive 2011/24/EU on cross-border health care applies. According to this, any posted person has the same rights to cover (insurance) as he or she has in his or her home country. In other words, if you are German, in which case you may be covered for health care in health resorts, you will be eligible for this type of service in Spain/Portugal.  

Regardless of what cover the European has in his country of origin, the public system in Spain/Portugal does not have to vary its organisation, access filters, range of services or clinical guidelines to any foreigner. Continuing with the previous example, a German will have the spa service covered, but if the Spanish/Portuguese NHS does not provide it (does not cover it) it is not obliged to provide it to a European tourist/resident.  

The funding mechanism is that the European patient is charged for the service at the time of service, according to the provider's tariffs. The patient must arrange for reimbursement in the country of origin, where the coverage rules of the same country normally apply. In some cases, the home country may request prior authorisation for foreign coverage1. 

In summary, broadly speaking, Directive 2011/24/EU provides that, for funding (coverage) purposes, the coverage that exists in the home country of the foreigner prevails. For the purposes of provision, the provision existing in Spain and Portugal, at public and private level, prevails. 

European regulations establish that, for the purposes of financing (coverage), that which exists in the foreigner's country of origin prevails. For the purposes of provision, the provision existing in Spain and Portugal, at public and private level, prevails.

This directive entered into force on 24 April 2013 and was due to be transposed by Member States on 25 October 2013, and provided for a report (in its article 20) published on 4 September 2015, including the state of transposition, patient mobility, reimbursement practices, information to patients and cooperation under the Directive.  

In relation to the transposition of the Directive, the report highlights the high number of incidents and implementation difficulties. Patient flows of patients being treated abroad under the Directive are low, according to the report. The report only contains reports of prior authorisation requests from 17 of the 21 Member States, with a total of 560 authorisation requests (360 of which were granted). In addition, France reported having granted 57,000 authorisations (including authorisations relating to Social Security Regulations). 

Concerning treatments without authorisation, Finland reimbursed 17,142, France notified 422,680 and Luxembourg 117,962 (including authorisations relating to Social Security Regulations). 

One of the difficulties of effective enforcement of the provision, which is aggravated for the elderly, relates to the principle of mutual recognition of prescriptions between Member States. Implementing Directive 2012/52/EU sets out the list of elements that must be included in cross-border prescriptions, such as the requirement to use the "common name" of the product (which corresponds, in practice, to the international non-proprietary name for the vast majority of products). 

In conclusion, the level of mobility of patients travelling abroad for planned care (both under the Directive and under the Social Security Regulations), remains low (except in France, where it is subject to planning constraints where it involves at least one overnight stay in hospital or requires the use of specialised and costly medical infrastructure or equipment). Article 8(2)(b) and (c) also allows them to require prior authorisation for treatments that expose the patient or the public to a particular risk, or for care provided by a healthcare provider that raises serious doubts related to the quality and safety of the healthcare. However, in practice, prior authorisation systems rely almost entirely on Article 8(2)(a).

The level of mobility of patients travelling abroad for planned care remains low (except in France, Luxembourg, Finland and Denmark). However, it appears to be much higher for unscheduled healthcare. According to the Commission's report, part of these low figures could be explained by delays in implementing the Directive, or a lack of information for patients on reimbursement capacity. It may also be that the natural demand for cross-border healthcare is relatively low for several reasons: patients are reluctant to travel (e.g. to avoid being away from families for care), language barriers; price differences between Member States (lower reimbursement rates than those applied in the home state), cumbersome administrative requirements and authorisation processes, and waiting times in destination countries. 

The level of mobility of patients travelling abroad for planned care remains low (except in France, Luxembourg, Finland and Denmark).

Challenges to be taken into account in promoting health services for older people 

- Older people have a more chronic and multi-pathological type of pathology. This implies a greater relevance, for effective care, of the transversality of services: good coordination between specialities and levels of care, and between social and health services. It is important to implement these characteristics in Spain and Portugal in order to be competitive in attracting this type of population, as it is not a reorganisation that can be implemented on an ad-hoc basis for foreign patients.; 

It is important to implement in Spain and Portugal, in order to be competitive and to promote health services for foreign elderly people, a good coordination between specialities and levels of care, and between social and health services.

- The physical dependence of this population group to carry out part of their daily activities and to move around must be taken into account (e.g. inability to drive). It requires an organised extra-health network. 

- Advances in technology can provide for further implementation of telemedicine (including online pharmacies) and integration of (electronic) medical records. There is no legislation on this exchange of information and it is therefore a pending issue. However, if properly legislated, it can provide an opportunity for travel by making care much more efficient. 

- Hospitals and other providers must pass the known accreditations and quality controls (such as the Joint Commission). It is equally important that protocols for prosthetics and other devices are standardised. 

- Devices need to be more flexible in response to seasonal demands, if necessary by contravening the conventional holiday periods of their professionals.

- It is important to solve problems of language barriers, especially among an older population with less language skills than the younger generation. 

- The hotel quality of some hospitals in Southern Europe needs to be improved to be competitive. 

- Providers must ensure billing capacity, or support from the health administration, so that care for foreigners does not cost the hospital anything. 

- The adaptation of service portfolios in Spain and Portugal must be competitive with those of other countries seeking to attract foreign patients.