National budget cuts of 13.65% (€365m) and regional budget cuts of up to 10% to health and social care services in 2012 have coincided with increased demands on the health system, particularly affecting the elderly, disabled and those with poor mental health. The authors, led by the London School of Hygiene & Tropical Medicine, also highlight the increase in depression, alcohol related disorders and suicides in Spain since the financial crisis hit and unemployment increased.

Spain already has one of the lowest public expenditures on healthcare for its GDP in the European Union. Further cuts of €1108m will be made to the dependency fund for elderly and disabled people in 2013, putting these vulnerable people even more at risk.

Key changes made by the Spanish government include excluding undocumented immigrants from accessing free healthcare services and increasing co-payments that patients must make for extra treatments such as drugs, prosthetics, and some ambulance trips. Authorities with devolved powers in 17 regions across Spain have also been required to make further cuts. In Madrid and Catalonia this has led to a move towards privatisation of hospitals, increases in waiting times, cutbacks in emergency services and fewer surgical procedures.

Lead author Dr Helena Legido-Quigley, Lecturer in Global Health at the London School of Hygiene & Tropical Medicine, said: "Our analysis is the first to look at the overall impact of austerity measures in Spain on the healthcare system and the findings are of great concern. Many of the measures taken to save money do not have a strong evidence-base. We are seeing detrimental effects on the health of the Spanish people and, if no corrective measures are implemented, this could worsen with the risk of increases in HIV and tuberculosis -- as we have seen in Greece where healthcare services have had severe cuts­ -- as well as the risk of a rise in drug resistance and spread of disease."

As part of the analysis, researchers conducted interviews with 34 doctors and nurses across Catalonia. Many reported feeling 'shocked', 'numbed' and 'disillusioned' about the cuts and expressed fears that 'the cuts are going to kill people'. Some also raised concerns around the 'clear intention to privatise and... make money on health and social services' and made allegations of corruption and conflicts of interest.

Co-author Martin McKee, Professor of European Public Health at the London School of Hygiene & Tropical Medicine, said: "For five years, policies to address the financial crisis have focussed almost entirely on economic indicators. Our paper sheds light on the burden of human suffering that has followed from these policies."

Co-author Jose Martin-Moreno, Professor of Medicine and Public Health at the University of Valencia, added: "I believe that this article sheds some much-needed light on the details of the cuts we are seeing in the Spanish health system. In fact, the cuts in public health expenditure, which are being implemented in response to a general economic crisis, are coming at a moment when health systems need more -- not fewer -- resources, among other reasons, to deal with the adverse health effects associated with unemployment. Cuts to essential health services, when insufficiently assessed or supported by evidence, can destabilise the health system, threatening not only equal access to healthcare, but also health care quality, which can even generate increases in other costs in the long term."

The analysis was led by the London School of Hygiene & Tropical Medicine with the University of Alicante, the University of Lleida and the University of Valencia. The authors note that their analysis was limited by gaps in key Spanish government data.