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Recorded deaths by suicide by year Figure based on data provided by the Hellenic Statistical Authority. 

Recorded deaths by suicide by year Figure based on data provided by the Hellenic Statistical Authority. 

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Greece's economic crisis has deepened since it was bailed out by the international community in 2010. The country underwent the sixth consecutive year of economic contraction in 2013, with its economy shrinking by 20% between 2008 and 2012, and anaemic or no growth projected for 2014. Unemployment has more than tripled, from 7·7% in 2008 to 24·3% i...

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... An extensive literature has examined changes in health outcomes subsequent to the GR and cuts to healthcare spending. Some of the papers perform a systematic literature review (Suhrcke et al., 2011;Quaglio et al., 2013;Stuckler et al., 2017) or contribute to the general discussion by reviewing the background to the crisis (McKee et al., 2012;Arie, 2013b,a;Karanikolos et al., 2013;Quaglio et al., 2013;Kentikelenis et al., 2014) and assessing how austerity measures have affected population's health and access to public health services (Karanikolos et al., 2013;Quaglio et al., 2013;Kentikelenis et al., 2014) or analysing the association between austerity measures and mortality rate (Toffolutti and Suhrcke, 2019), suicides (De Vogli et al., 2013) or potential years of life lost (Almendra et al., 2019;Watkins et al., 2017). Others explicitly identify a causal framework to explore whether the GR and subsequent cuts to healthcare spending worsened health outcomes, such as general mortality rate (Franklin et al., 2017;Golinelli et al., 2017;Depalo, 2019;Lomas et al., 2019;Arcà et al., 2020;Bordignon et al., 2020;Borra et al., 2020); suicides (Branas et al., 2015;Franklin et al., 2017); road traffic injuries (Franklin et al., 2017); infant mortality rate (Franklin et al., 2017;Bordignon et al., 2020); stillbirths (Vlachadis and Kornarou, 2013); life expectancy (Franklin et al., 2017;Vallejo-Torres et al., 2018); mortality rate by specific causes, such as heart and liver diseases (Franklin et al., 2017), respiratory diseases (Franklin et al., 2017), alcohol and drug mortality due to misuse/abuse (Stuckler et al., 2009a;Franklin et al., 2017) and infectious diseases such as HIV (Franklin et al., 2017). ...
... An extensive literature has examined changes in health outcomes subsequent to the GR and cuts to healthcare spending. Some of the papers perform a systematic literature review (Suhrcke et al., 2011;Quaglio et al., 2013;Stuckler et al., 2017) or contribute to the general discussion by reviewing the background to the crisis (McKee et al., 2012;Arie, 2013b,a;Karanikolos et al., 2013;Quaglio et al., 2013;Kentikelenis et al., 2014) and assessing how austerity measures have affected population's health and access to public health services (Karanikolos et al., 2013;Quaglio et al., 2013;Kentikelenis et al., 2014) or analysing the association between austerity measures and mortality rate (Toffolutti and Suhrcke, 2019), suicides (De Vogli et al., 2013) or potential years of life lost (Almendra et al., 2019;Watkins et al., 2017). Others explicitly identify a causal framework to explore whether the GR and subsequent cuts to healthcare spending worsened health outcomes, such as general mortality rate (Franklin et al., 2017;Golinelli et al., 2017;Depalo, 2019;Lomas et al., 2019;Arcà et al., 2020;Bordignon et al., 2020;Borra et al., 2020); suicides (Branas et al., 2015;Franklin et al., 2017); road traffic injuries (Franklin et al., 2017); infant mortality rate (Franklin et al., 2017;Bordignon et al., 2020); stillbirths (Vlachadis and Kornarou, 2013); life expectancy (Franklin et al., 2017;Vallejo-Torres et al., 2018); mortality rate by specific causes, such as heart and liver diseases (Franklin et al., 2017), respiratory diseases (Franklin et al., 2017), alcohol and drug mortality due to misuse/abuse (Stuckler et al., 2009a;Franklin et al., 2017) and infectious diseases such as HIV (Franklin et al., 2017). ...
... Specifically, among the causes of amenable mortality (similarly to Arcà et al. (2020)), we account for disaggregated disease-specific mortality rates, such as cancer mortality rates, respiratory or heart disease mortality rates, as during recessions adverse effects on vulnerable groups in the population (e.g., people affected by heart diseases) might be masked by improvements in another group (e.g., people affected by cancer) (Karanikolos et al., 2013). Among the causes of preventable mortality, analysed for the first time for Italy to the best of our knowledge, we account for suicide rates, murder rates and road traffic injuries, linked to psychotic behaviours and depressive conditions peculiar to economic recessions (Karanikolos et al., 2013;Kentikelenis et al., 2014). In addition, we complete our analysis with mortality rates by age groups (partly, similarly to Bordignon et al. (2020) who analyse infant mortality rates), such as potential years of life lost (PYLL, as far as we know, never used before in this literature for Italy), an explicit measure of premature death that assigns more weight to injuries and infectious diseases; on morbidity, measured as the incidence of the infectious disease; and on the use of health services, measured as HIV discharge rates and discharge rates for psychological diseases, both used to gauge psychological fragility and social distress. ...
Article
Since 2007 financial recovery plans have been adopted by some Italian regions to contain the costs of the healthcare sector. It is legitimate to ask whether spending cuts associated with the austerity policy have had any effect on the health of the citizens. We examine the indirect impact of financial recovery plans on a broad set of health indicators, accounting for several dimensions of both physical and psychological diseases. We use an instrumental variable fixed-effects model to control for time-varying heterogeneity and to deal with the potential endogeneity of the enrolment in the austerity programme. We find that the Italian austerity policy Piano di Rientro resulted in unintended negative effects on several dimensions of health, hurting and potentially jeopardising the health of citizens.
... Let's compare, for instance, Italy to Greece and Spain. Even though Greece and Spain went through a phase of stagnation/contraction in per capita health expenditure, as Italy did, they did not see a deceleration in life expectancy at birth (Filippidis et al., 2017;Kentikelenis et al., 2014;Regidor et al., 2013Regidor et al., , 2016. It must be remembered, however, that in these countries the crisis also produced a huge rise in unemployment: levels reached well over 25% of the working population (see Fig. 1). ...
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The 2008 economic crisis, also called the Great Recession, produced only a moderate rise in unemployment in Italy, but the consequences for public debt management were far more serious. Italy makes for a good case study for evaluating the effect on life expectancy at birth of the cost containment program in the health care system, implemented after the crisis began. To this end we employed the Artificial Control method using the data from the Human Mortality Database to assess the causal effect of the 2008 economic crisis on the subsequent evolution of life expectancy at birth (until 2019, before the onset of the COVID-19 pandemic). Our analysis identifies a significant deceleration in the progression of Italian life expectancy. Ten years after the onset of the crisis, Italy appears to have lost almost 1 year of life expectancy with respect to what would have been expected had the crisis never happened.
... The austerity era following the 2008 financial crisis set a context where health systems decisionmaking was highly influenced by outside agents (e.g. Troika) [75][76][77][78][79] . The lack of transparency* about these outside influences, compounded by poor communication from policy-makers / management and lack of co-production with frontline staff [80][81][82] , led to a lack of ownership and buy-in from those delivering care and a distrust of the decision-making agenda 80,83,84 . ...
... spending76, 82,[84][85][86][87] . Health professionals perceived a loss of autonomy*77, 85,[87][88][89][90] and decision-making power*77, 84 , leading to a sense of powerlessness 86, 91 and detachment and ultimately a resistance to change and conflict between front line workers and policy decision makers / management76, 81, 84 .CMOC 3 -Perceived Value ShiftIn context of restrictive fiscal policies (staffing, consumables, treatment options,available time with patient), a perceived value shift* is evident for health professionals, INTERNATIONAL JOURNAL OF HEALTH POLICY AND MANAGEMENT (IJHPM) ONLINE ISSN: 2322-5939 JOURNAL HOMEPAGE: HTTPS://WWW.IJHPM. ...
... spending76, 82,[84][85][86][87] . Health professionals perceived a loss of autonomy*77, 85,[87][88][89][90] and decision-making power*77, 84 , leading to a sense of powerlessness 86, 91 and detachment and ultimately a resistance to change and conflict between front line workers and policy decision makers / management76, 81, 84 .CMOC 3 -Perceived Value ShiftIn context of restrictive fiscal policies (staffing, consumables, treatment options,available time with patient), a perceived value shift* is evident for health professionals, INTERNATIONAL JOURNAL OF HEALTH POLICY AND MANAGEMENT (IJHPM) ONLINE ISSN: 2322-5939 JOURNAL HOMEPAGE: HTTPS://WWW.IJHPM. ...
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Background The Great Recession, following the 2008 financial crisis, led many governments to adopt programmes of austerity. This had a lasting impact on health system functionality, resources, staff (numbers, motivation and morale) and patient outcomes. This study aimed to understand how health system resilience was impacted and how this affects readiness for subsequent shocks.Methods A realist review identified legacies associated with austerity (proximal outcomes) and how these impact the distal outcome of health system resilience. EMBASE, CINAHL, MEDLINE, EconLit and Web of Science were searched (2007– May’21), resulting in 1,081 articles. Further theory-driven searches resulted in an additional 60 studies. Descriptive,inductive, deductive and retroductive realist analysis (utilising excel and Nvivo) aided the development of Context, Mechanism, Outcomes Configurations (CMOCs), alongside stakeholder engagement to confirm or refute emerging results. Causal pathways, and the interplay between context and mechanisms that led to proximal and distal outcomes, were revealed. The refined CMOCs and policy recommendations focused primarily on workforce resilience.Results Five CMOCs demonstrated how austerity-driven policy decisions can impact health systems when driven by the priorities of external agents. This created a real or perceived shift away from the values and interests of health professionals, a distrust in decision-making processes and resistance to change. Their values were at odds with the realities of implementing such policy decisions within sustained restrictive working conditions (rationing of staff, consumables, treatment options). A diminished view of the profession and an inability to provide high-quality, equitable, and needs-led care, alongside stagnant or degraded working conditions, led to moral distress. This can forge legacies that may adversely impact resilience when faced with future shocks.Conclusion This review reveals the importance of transparent, open communication, in addition to co-produced policies in order to avoid scenarios that can be detrimental to workforce and health system resilience.
... In fact, there was a 37% increase between 2015 and 2019, after a reduction of almost 60% between 2002 and 2014 36 . Other studies [37][38][39][40][41][42][43] , focused on European countries, have already identified the relationship between a financial crisis, fiscal austerity, and the impact on the health situation of the population. ...
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This paper describes the structure and results of Primary Health Care (PHC) in Brazil between 2008 and 2019. The medians of the following variables were calculated: PHC spending per inhabitant covered, PHC coverage, and rates of mortality and hospitalizations due to primary care sensitive conditions (PCSC), in 5,565 Brazilian municipalities stratified according to population size and quintile of the Brazilian Deprivation Index (IBP), and the median trend in the period was analyzed. There was a 12% increase in median PHC spending. PHC coverage expanded, with 3,168 municipalities presenting 100% coverage in 2019, compared to 2,632 in 2008. The median rates of PCSC mortality and hospitalizations increased 0.2% and decreased 44.9%, respectively. PHC spending was lower in municipalities with greater socioeconomic deprivation. The bigger the population and the better the socioeconomic conditions were in the municipalities, the lower the PHC coverage. The greater the socioeconomic deprivation was in the municipalities, the higher the median PCSC mortality rates. This study showed that the evolution of PHC was heterogeneous and is associated both with the population size and with the socioeconomic conditions of the municipalities.
... For example, European countries with large fiscal adjustments exhibit a rise in suicide rates Karanikolos et al., 2013;Antonakakis & Collins, 2014). Studies for Greece also suggest that the reduction in government health expenditure is correlated with a rise in infant mortalities, stillbirths, and the number of low-birth-weight infants (Ifanti et al., 2013;Kentikelenis et al., 2014). By contrast, countries that failed to consolidate their public finances in the aftermath of the financial crisis had higher debt-to-GDP ratios and lower fiscal leeway to support the health system, the economy, and the most vulnerable members of the population during the pandemic crisis. ...
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Decisions on public health measures to contain a pandemic are often based on parameters such as expected disease burden and additional mortality due to the pandemic. Both pandemics and non-pharmaceutical interventions to fight pandemics, however, produce economic, social, and medical costs. The costs are, for example, caused by changes in access to healthcare, social distancing, and restrictions on economic activity. These factors indirectly influence health outcomes in the short- and long-term perspective. In a narrative review based on targeted literature searches, we develop a comprehensive perspective on the concepts available as well as the challenges of estimating the overall disease burden and the direct and indirect effects of COVID-19 interventions from both epidemiological and economic perspectives, particularly during the early part of a pandemic. We review the literature and discuss relevant components that need to be included when estimating the direct and indirect effects of the COVID-19 pandemic. The review presents data sources and different forms of death counts, and discusses empirical findings on direct and indirect effects of the pandemic and interventions on disease burden as well as the distribution of health risks.
... Studies sometimes examined additional investments made during a shock and where these were targeted, for example additional investment in mental health or telehealth (during COVID-19) [36,62]. Finally, finance measures of resilience also examined the impact of the shock, often focusing on service users, for example out-of-pocket payments [57,[63][64][65], loss or limitation of health coverage or entitlements [64,66,67], access, unmet need and waiting lists [31,43,66,67], stakeholder perceptions of the impact of austerity on the health system and health outcomes [29][30][31], as well as protective measures put in place for disadvantaged groups [68]. ...
... Studies sometimes examined additional investments made during a shock and where these were targeted, for example additional investment in mental health or telehealth (during COVID-19) [36,62]. Finally, finance measures of resilience also examined the impact of the shock, often focusing on service users, for example out-of-pocket payments [57,[63][64][65], loss or limitation of health coverage or entitlements [64,66,67], access, unmet need and waiting lists [31,43,66,67], stakeholder perceptions of the impact of austerity on the health system and health outcomes [29][30][31], as well as protective measures put in place for disadvantaged groups [68]. ...
... In terms of economic crises, the metrics related to governance during management stage reveal key shortcomings, such as corruption, lack of accountability, planning, transparency and stakeholder buy-in to decision making [29,56,57,66], although there was also evidence of opportunities for reform [57,66,68]. In terms of measuring impact, metrics related to staff not only measured the number of staff [30,66,84,85] but crucially the adverse impact of the economic shock on staff motivation, workload, burnout, emigration, turnover [28,29,[86][87][88], supplemented by metrics that allude to adverse effects, such as restrictive policies in the delivery of care, rationing, quality of care, reduced infrastructure and patient outcomes [28,29,43,57,67,68,85]. ...
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Health system resilience has never been more important than with the COVID-19 pandemic. There is need to identify feasible measures of resilience, potential strategies to build resilience and weaknesses of health systems experiencing shocks. The purpose of this systematic review is to examine how the resilience of health systems has been measured across various health system shocks. Following PRISMA guidelines, with double screening at each stage, the review identified 3175 studies of which 68 studies were finally included for analysis. Almost half (46%) were focused on COVID-19, followed by the economic crises, disasters and previous pandemics. Over 80% of studies included quantitative metrics. The most common WHO health system functions studied were resources and service delivery. In relation to the shock cycle, most studies reported metrics related to the management stage (79%) with the fewest addressing recovery and learning (22%). Common metrics related to staff headcount, staff wellbeing, bed number and type, impact on utilisation and quality, public and private health spending, access and coverage, and information systems. Limited progress has been made with developing standardised qualitative metrics particularly around governance. Quantitative metrics need to be analysed in relation to change and the impact of the shock. The review notes problems with measuring preparedness and the fact that few studies have really assessed the legacy or enduring impact of shocks.
... The health budgets reacted to these new economic conditions dissimilarly. Some countries implemented significant restrictions [10][11][12][13], which, according to Bosch and colleagues, was not the best strategy [14]. In some states, the funds were frozen, usually since there were earmarked for health care (as in compulsory health insurance). ...
... A lower level of public financing also forced cost-sharing-generally in the form of higher deductibles or copayment [7], [10][11][12], [21][22][23][24][25]. It changed the structure of healthcare financing by increasing the percentage of private funds [12,26] and the situation of most vulnerable groups [23], especially the elderly [24,27]. ...
... Lags in explanatory variables in models[8][9][10][11][12][13][14][15][16] ...
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Background The economic slowdown affects the population's health. Based on a social gradient concept, we usually assume that this detrimental impact results from a lower social status, joblessness, or other related factors. Although many researchers dealt with the relationship between economy and health, the findings are still inconsistent, primarily related to unemployment. This study reinvestigates a relationship between the economy's condition and health by decomposing it into macroeconomic indicators. Methods We use data for 21 European countries to estimate the panel models, covering the years 1995–2019. Dependent variables describe population health (objective measures – life expectancy for a newborn and 65 years old, healthy life expectancy, separately for male and female). The explanatory variables primarily represent GDP and other variables describing the public finance and health sectors. Results (1) the level of economic activity affects the population’s health – GDP stimulates the life expectancies positively; this finding is strongly statistically significant; (2) the unemployment rate also positively affects health; hence, increasing the unemployment rate is linked to better health – this effect is relatively short-term. Conclusions Social benefits or budgetary imbalance may play a protective role during an economic downturn.
... More generally, IMF-mandated policy reformsknown as 'conditionalities'-have been associated with reduced state capacities and declining population health [4][5][6]. The availability of doctors, nurses, community healthcare workers, and associated laboratory and hospital infrastructure are known to be affected by IMF interventions, especially when it comes to tuberculosis and broader communicable disease control [7,8]. Infectious disease burdens are known to depend on health infrastructures but also on broader social and institutional determinants of health, all of which are impacted by the Fund's wide-ranging policy reform packages [1]. ...
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International financial organisations like the International Monetary Fund (IMF) play a central role in shaping the developmental trajectories of fiscally distressed countries through their conditional lending schemes, known as ‘structural adjustment programmes’. These programmes entail wide-ranging domestic policy reforms that influence local health and welfare systems. Using novel panel data from 187 countries between 1990 and 2017 and an instrumental variable technique, we find that IMF programmes lead to over 70 excess deaths from respiratory diseases and tuberculosis per 100,000 population and that IMF-mandated privatisation reforms lead to over 90 excess deaths per 100,000 population. Thus structural adjustment programmes, as currently designed and implemented, are harmful to population health and increase global infectious disease burdens.
... Όντας στην εκπνοή του χρονικού περιθωρίου, γίνεται μια προσπάθεια παρουσίασης των διακυμάνσεων ανάμεσα στις ευρωπαϊκές χώρες, ενώ απορρέουν ενδιαφέροντα συμπεράσματα για την Ελλάδα, ώστε να θεμελιωθούν κατάλληλα συστήματα που αποσκοπούν στην πρόληψη, προαγωγή και αγωγή της υγείας. 3 Πρόκληση των στρατηγικών παρεμβάσεων που αναπτύσσουν τα έθνη αποτελεί η επιδημία του καπνίσματος, το οποίο θεωρείται μείζων παράγοντας κινδύνου νοσηρότητας και θνησιμότητας. 4 Στο επίκεντρο της πολιτικής του ΠΟΎ βρίσκεται στόχος για τη σχετική μείωση κατά 30% της τρέχουσας χρήσης καπνού σε άτομα ηλικίας 15 ετών και άνω. 5 Ο στόχος αυτός έδωσε κίνητρο για ανάπτυξη πολιτικών προγραμμάτων δράσης, σύμφωνα με τα οποία θεσπίστηκε πρόσφατα ο νέος αντικαπνιστικός νόμος πλαίσιο από την ελληνική κυβέρνηση. ...
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(Iatriki 2020, 109(2):113—122) There is no doubt that the improvement of public health is to be given a higher place on the political agenda of European countries. The World Health Organization (WHO) aimed to achieve six basic targets for health promotion in Europe until 2020. WHO notes that the level of health of the population is significantly affected and measured by some indicators. These indicators are described in this review and a picture of the last ten years in Greece compared to the rest of Europe is also presented. Emphasizing on smoking as a factor of bad health, an extensive reference to its prevalence in Greece and its harmful effects is made. Finally, prevention measures are proposed and how they can help improve the health of the Greek population. We conclude that socio-economic, political, environmental and in particular behavioral factors affect the quality of health. As health should be considered an inalienable human right, it is necessary to properly inform and educate the public about the dangers that threaten it and also provide targeted policies. WHO has set the next target in 2030. His emphasis should be placed on all levels of prevention; otherwise, the full impact on both the health and the economy will be visible.
... Falls from height have substantial fatal rates due to the multiplicity and the severity of the injuries sustained by their victims [1,2]. According to the WHO, falls from height or ground level, are the second cause of accidental deaths worldwide, counting approximately 646,000 deaths annually [3]. ...
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Falls are the second cause of accidental deaths worldwide. Falls from height are also a common method of suicide. The aim of this study is to compare the characteristics of the victims, the circumstances of the fall and the severity and distribution of the injuries reported in an autopsy case series of falls from height. This study is a retrospective analysis of consecutive autopsy cases of suicidal and accidental falls from height which were investigated in the Department of Forensic Medicine and Toxicology of the National and Kapodistrian University of Athens during the period 2011–2019. The recorded variables included demographic data of the victim, height of fall, length of hospital stay, toxicological results, the existence and location of injuries and Injury Severity Score (ISS). Victims of suicidal falls were younger (55.53 vs. 62.98, p = 0.001), they fell from higher heights (12.35 vs. 5.18 m, p < 0.001), and they sustained more severe injuries compared with victims of accidental falls (ISS 51.01 vs. 40.88, p < 0.001). Injuries in the thorax, abdomen, pelvis, upper and lower extremities were more frequently observed after a suicidal fall (93.6% vs. 67.3%, 72.1% vs. 21.4%, 72.1% vs. 27.6%, 42.9% vs. 15.3%, 45.7% vs. 13.3%, respectively-p < 0.001), probably due to the higher height of fall. Our study outlines the differences in the profile of the victims and in the severity of injuries caused by falls from height depending on the intention of the victim to fall. However, a distinctive injury pattern in victims of suicidal falls was not demonstrated.