Health systems are a central area of national policy; even within the European Union, the primary responsibility of the EU’s member states for their own health systems is explicitly stated.1 However, one of the consequences of the current financial crisis has been that European countries are facing the kind of detailed international involvement in their health systems that has more normally been seen only in developing countries. As part of the international “bailouts” for Ireland and Greece in 2010, and for Portugal in 2011, these countries had to agree detailed economic adjustment programmes with the “troika” (the European Commission, the International Monetary Fund, and the European Central Bank). These programmes include some strikingly detailed prescriptions for change in the health systems.

It is not so much what is being done, but by whom that is important. Health is a major item of public expenditure in all European countries, and all are under pressure to ensure cost effectiveness of their health systems. Moreover, these three bailout programmes were negotiated and agreed—albeit under pressure—between the troika and the national governments concerned. But as the EU moves towards much greater supervision of national budgets, the health systems in all countries may become subject to international requirements like those set out in the bailout agreements and health ministries may need to discuss policy not only with national finance ministries but with the European Commission.