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Austerity measures introduced in many European countries as a consequence of the 2008-09 economic crisis have had many adverse effects on social determinants of health. These include falling incomes, high rates of unemployment, reduced funding for education, and higher taxation. Many people (particularly young ones) are out of work-in Spain and Greece over half of under 25 year olds are unemployed. 1 The combination of long term unemployment, inappropriate skills, and high entry barriers in rigid labour markets has created fears of a "generation jobless." 2 National austerity packages that have cut health budgets and resulting health policy reforms are additional drivers for adverse health outcomes, especially where health systems were less resilient or weak.
Health effects are accumulating in countries that were severely hit by the crisis, particularly Greece, Portugal, and Spain. 3 In a linked Analysis (doi: 10.1136/bmj.f2363 ), Legido-Quigley and colleagues explore in depth the consequences of Spanish austerity on health policy. 4 They discuss lack of evidence that austerity policies work and the overall illogic of implementing serious health reforms in the current economic circumstances in Spain. Countries burdened by austerity policies have higher rates of poor health, particularly in the unemployed 5 ; increased prevalence of mental health problems (such as depression, anxiety) and suicide attempts 3 4 ; and increased incidence of infectious diseases, such as HIV. 3 Although not enough data are yet available for a comprehensive assessment of the impact of austerity, further adverse effects can be expected given the known effects of social determinants on health.
Health systems need to become more efficient and "lean," but governments must carefully consider which policies to implement lest people's health suffers. 6 7 Reforms to promote generic drug prescription and shift services from the inpatient to the outpatient setting are thought to improve efficiency and reduce costs, and many countries have made such changes. 6 7 However, at the same time, large cuts to hospital services have been made without adequate outpatient capacity in place, 7 user charges have been introduced or increased, 7 and labour costs of the health workforce have been cut. 3 7 Such measures lower the accessibility, efficiency, productivity, and quality of health systems. 6 7 8
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