The right to healthcare, as a positive entitlement, is constitutionally guaranteed in all examined states [16,17,18,19,20,21,22] and finds its expression in legislations on healthcare systems in all examined states, based on insurance and providing specific measures for certain vulnerable groups, such as pregnant persons, persons with disabilities or minors. [23,24,25,26,27] However, those provisions are not derived from contemporary non-discrimination concepts but are rather related to the idea of protection of the weaker.
Our results show that the issue of equity in access to healthcare in the four countries can be analysed from two conceptually different perspectives: the perspective of the principle of equal treatment and prohibition of discrimination, that is, the perspective of human freedoms, or negative rights, and the perspective of the right to healthcare as a social entitlement, or positive right. While the former is regulated by anti-discrimination laws, the latter finds its expression in legislation on healthcare.
These aspects can intersect, which could potentially result in creating conditions of healthy functioning for all individuals, irrespective of their characteristics. With regard to the quality of healthcare, individual’s agency, and societal norms, this intersection could ensure health capabilities, as understood by Ruger [6, 7].
Implementation of anti-discriminatory regulations in healthcare is required only by the Council Directive 2000/43/EC of 29 June 2000 implementing the principle of equal treatment between persons irrespective of racial or ethnic origin.  Therefore, all examined states have relevant provisions in their anti-discriminatory regulations. Member states are obligated to implement the EU Directives in their minimum, but they can also decide if they will guarantee more comprehensive protections or not, and what specific part of their legislations will implement them. This, in turn, can translate into an impact on the legislation on a particular sector of social life. We assume that protections against discrimination in healthcare will tend to be strongest and potentially most effective when the provisions protecting equal treatment of diverse groups are included directly into the regulations on healthcare rather than merely in general anti-discrimination laws. We analysed our results from those two perspectives. Additionally, having observed the lack of provisions concerning cultural competency on the part of healthcare workers, we found out that regulations addressing religion and independent from the EU norms and guidelines are of special importance. We have also identified various legal barriers in access to healthcare as such, to specific services, or for certain groups such as migrants.
Implementation of the European anti-discrimination norms and guidelines
All constitutions of the examined states guarantee equal treatment and prohibit discrimination. However, their provisions vary with regard to the range of potential grounds of discrimination explicitly recognized. The Croatian and Slovenian basic laws provide long lists of exemplary grounds, on which discrimination is prohibited: “race, colour, gender, language, religion, political or other opinion, national or social origin, property, birth, education, social status or other status” (CoC, Art. 14) and “national origin, race, sex, language, religion, political, or other conviction, material standing, birth, education, social status, disability, or any other personal circumstance” (CoS, Art. 14). The Article 3 p. 3 of the Germany’s Basic Law prohibits discrimination on the basis of “sex, parentage, race, language, homeland and origin, faith or religious or political opinions and disability.” In Poland, “No one shall be discriminated against in political, social or economic life for any reason whatsoever” (CoP, Art. 32 p. 2). The German and Polish basic laws contain separate provisions on the equality of men and women (BLFRG, Art. 2.2, CoP Art. 33). Constitutional documents of the examined states guarantee freedom of religion. Furthermore, they specifically address equal treatment for recognized ethnic and national minorities.
Such constitutional guarantees are followed by anti-discriminatory legislations which implement the EU equal treatment directives. Regarding race and ethnicity, religion and belief, and sexual orientation and gender identity, the comparative analysis reveals deep discrepancies. Anti-discrimination legislations are not applicable by default to all areas of social and public life. These were initially introduced in the area of labour law and have been later extended to other areas. On the European level, the area of healthcare is still only partly addressed. Thus, for the purpose of our study, it was crucial to identify the potential grounds of discrimination recognized by anti-discrimination legislation, in relation to healthcare.
Chronologically first was the General Act on Equal Treatment in Germany (2006). It prohibits discrimination on “the grounds of race or ethnic origin, gender, religion or belief, disability, age or sexual orientation” (Sec. 1) and explicitly addresses the area of healthcare (Sec. 2, p. 5).  In so doing, the German Act on Equal Treatment goes beyond the minimum required by the EU. This enumerated list of grounds of discrimination does not include gender identity. However, in Germany, the concept of gender is understood broadly and includes gender identity. Therefore, although this legal act does not cover all examined grounds literally, it does so in practice.
In Poland the so-called Equality Act (2010) lists “sex, race, ethnic origin, nationality, religion, denomination, beliefs, disability, age or sexual orientation” (Art. 1).  However, Article 7 specifies grounds of protection in the area of healthcare as “race, ethnic origin or nationality”, thereby adding nationality to the required minimum. Therefore, in case of discrimination in healthcare on the basis of religion or belief or sexual orientation or gender identity the Equality Act cannot be cited as the legal basis of complaint. In such cases one can only seek appropriate legal remedy for infringement of their personal rights.
The Croatian Anti-Discrimination Act (2008, amended 2012) provides an enumerated list of protected grounds: “race or ethnic affiliation or colour, gender, language, religion, political or other belief, national or social origin, property, trade union membership, education, social status, marital or family status, age, health condition, disability, genetic heritage, gender identity, expression or sexual orientation” (Art. 1) and addresses the health insurance and healthcare (Art. 8 p. 3 and 4).  Thus, complaints regarding discrimination in healthcare can be made according to dedicated procedures.
The Slovenian Protection Against Discrimination Act (2016, amended 2018) provides an exemplary list of grounds: “gender, nationality, racial or ethnic origin, language, religion or belief, disability, age, sexual orientation, gender identity or gender expression, social status, property status, education, or any other personal circumstance” (Art. 1).  This act also addresses healthcare explicitly (Art. 2 p. 1). Since this catalogue is accompanied by the phrase “or any other personal circumstance”, which is open to interpretation, the act can cover much broader scope of discrimination cases than the Croatian law.
Thus, protections against discrimination in healthcare are most comprehensive in Slovenia and Croatia. The German General Act on Equal Treatment does not explicitly recognize gender identity but it does apply to it. The so-called Equality Act in Poland lags behind all of them, by leaving out discrimination in healthcare on the basis of religion and belief, or sexual orientation and gender identity.
The EU does not require member states to legally recognize non-heteronormative partnerships. Accordingly, the situation of non-heteronormative couples with regard to access to healthcare differs among the examined countries. While legislations on same-sex partnership in Croatia and Slovenia, and marriage equality in Germany guarantee access to healthcare for non-heteronormative partners on the basis of a partner’s health insurance, in Poland, whose law does not recognize non-heteronormative couples, there is no such explicit entitlement. [33, 34]
National legislation on healthcare
Legislations on healthcare can protect patients’ rights, provide institutional solutions or establish legal apparatus. However, with the exception of Slovenia, the states under consideration are reluctant to incorporate into their healthcare legislations explicit anti-discrimination regulations regarding the grounds under investigation.
Patients’ rights acts
Patients’ rights acts have been adopted by all examined states. They cannot be easily classified as protecting individual rights and freedoms or guaranteeing social rights, as they combine both aspects. They can play the role of a legal instrument, which transposes protection against discrimination into the sphere of healthcare. These acts establish patients’ rights offices (such as ombudsperson office), in order to facilitate claims in case of discrimination in healthcare.
Legislations on patients’ rights protect freedoms of patients, such as the right to privacy, confidentiality, intimacy, consent and information, and address the issue of equality in healthcare to various extent. The Act Improving the Rights of Patients in Germany (2013) does not refer directly to non-discrimination and equal access.  In Croatia the Act on the Protection of Patients’ Rights (2004, with amendments) , in Poland the Act on Patient’s Rights and Patient’s Rights Ombudsman (2008, with amendments)  and in Slovenia Patients’ Rights Act (2008, amended 2017) , guarantee the right to proper and equally accessible medical treatment. Only the Slovenian act contains a provision prohibiting discrimination on exemplary grounds: “sex, nationality, racial or ethnic origin, religion or belief, disability, sexual orientation or any other personal circumstance” (Art. 7). However, Croatian and Polish acts address specifically patients’ religious freedoms. In Croatia, Poland and Slovenia patients whose rights have been violated can complain to ombudspersons or to patients’ rights offices, such as the Regional Commissions for Patient’s Rights Protection and Ministerial Commission for Patient’s Rights Protection in Croatia, Patient’s Rights Ombudsman in Poland, and Patients’ Rights Advocates in Slovenia, or to general ombudspersons.
Acts on patients’ rights often refer to the ethical principles, which are prescribed by the respective professional legal acts and codes of ethics. Such documents prohibit discrimination and require medical staff members to provide care regardless of personal circumstances. [39,40,41] However, ethics codes do not have the same status as legislative acts and therefore cannot be the basis for legal action. They can, however, play a supplementary role. Discrimination claims can be filed to professional responsibility bodies, if not guaranteed by other legislative acts.
Legislation addressing access to healthcare in specific areas
Access to healthcare for persons of diverse race or ethnicity, religion or belief, or sexual orientation or gender identity is also affected by legislation that addresses provision of specific healthcare goods and services with the notable example of sexual and reproductive health goods and services. For example, in all four countries under investigation, non-heteronormative persons are denied access to medically assisted procreation, which is available only to persons in heteronormative relationships [27, 33, 34, 42,43,44]. States also vary with regard to the accessibility of gender confirmation services in relation to both payment and administrative barriers.
Specific provisions of other legislative acts also affect access to healthcare for various groups. Regulations on the relations between the state and religious communities (such as concordats), specifically address access to pastoral/spiritual care and freedom of religious practices in medical facilities. Legislations on national and ethnic minorities aim to meet their special needs, including in the area of healthcare [45, 46]. Those legislations are followed by further regulations or programs, e.g. National Roma Inclusion Strategy from 2013 to 2020 in Croatia, the Multiannual Programme for the Integration of the Roma Community for 2014–2020 in Poland, or National Program of Measures of the Government of the Republic of Slovenia for Roma for the Period 2017–2021 [47,48,49]. Such regulations are of particular nature. They concern members of specific, historically present communities, and so they can produce inequalities between “old” and “new” (i.e. migrant) minorities.
Access to healthcare for migrants and persons without entitlements
Access to healthcare for EU-citizens in each of the examined states is guaranteed on the basis of social security coordination and the legislation implementing the Directive 2011/24/EU.  Access to healthcare for non-EU citizens is regulated by respective legislation on foreigners. In principle, in all examined states, persons who are legally employed or have refugee status or international protection, are provided with access to healthcare according to the same rules as citizens.
For asylum-seekers, access to healthcare is regulated separately. Croatia, Germany and Slovenia have lists of services guaranteed to asylum-seekers. However, they include only a small portion of the services guaranteed to people with health insurance. In Croatia asylum-seekers have guaranteed access to emergency care, treatment of urgent cases, and serious mental disorders; additional care is provided to persons who have experienced severe forms of violence.  In Germany, asylum-seekers are entitled to treatment in case of acute illness or pain, vaccination, medically indicated preventive check-up, obstetrics, child-delivery and post-partum care, and urgent dental services in individual cases. Those who remain in the country longer than 18 months during their application process, are provided with the same scope of services as insured citizens . In Slovenia, the free care package for asylum-seekers includes emergency medical and dental care, sexual and reproductive health services together with contraception and abortion; minors enrolled in the school system and students under 26 are granted the same entitlements as citizens. Additional care is provided to vulnerable persons . In Poland, the package of medical services provided to the applicants for the refugee status or protection is formally the same as for persons holding public health insurance, with the exception of spa treatment and spa rehabilitation. Given this, in practice, the implementation of this formal entitlement could be limited by the fact that healthcare for asylum seekers is provided on the basis of agreements between the Head of the Office for Foreigners and healthcare providers rather than within the general healthcare system. 
Undocumented migrants in Croatia, Poland and Slovenia are seen by the systems as persons without entitlements to public healthcare system. Therefore, they can obtain the minimum of services that is provided to everyone without payment regardless of their legal status, insurance or other formal claims. This minimum can be different in different countries. In Croatia there are no unpaid services for undocumented migrants. In Poland they have free access to some services, including emergency care in outpatient settings, treatment of infectious diseases, or HIV testing and counselling. [55,56,57] In both countries they can purchase healthcare services for market prices, if they can afford them. In Slovenia undocumented migrants have access to primary healthcare in pro bono clinics. In Germany the situation of undocumented migrants differs from other uninsured persons. Formally, undocumented migrants are entitled to the same healthcare package as asylum-seekers. In practice, however, seeking this help is burdened with a substantial risk of deportation, because healthcare facilities belong to the entities which are required to notify the police if they have information about undocumented migrants.
Healthcare legislation – in general
Diversity as an integral element of the healthcare system has been explicitly identified only in Slovenia. Such integration is a condition of access to healthcare as understood by the capability theory. In this way it is responsive to the diverse needs of patients, and such responsiveness is often conceptualized as cultural competency. However, with the exception of some elements addressing religious freedoms or minority rights of historically rooted communities, we have not identified in the analysed documents provisions which would specifically address cultural competences.