The crisis has given substance to an old and often hypothetical debate about the financial sustainability of health systems in Europe. For years it was the spectre of ageing populations, cost-increasing developments in technology and changing public expectations that haunted European policy-makers troubled by growth in health sector spending levels. The real threat, however, came in the shape of a different triumvirate: financial crisis, sovereign debt crisis and economic crisis. After 2008 the focus of concern turned from the future to the present, from worrying about how to pay for health care in thirty years’ time to how to pay for it in the next three months. Not all European countries were affected by the crisis. Among those that were, the degree to which the health budget suffered varied. Some countries experienced substantial and sustained falls in public spending on health; others did not. These changes and comparative differences provide a unique opportunity to observe how policy-makers respond to the challenge of meeting health care needs when money is even tighter than usual. The magnitude of the crisis – its size, duration and geographical spread – makes the endeavour all the more relevant. We know from the experience of previous crises that economic shocks pose a threat to health and health system performance. They increase people’s need for health care and make it more difficult for them to access the care they need. They affect health systems by heightening fiscal pressure, stretching government resources at the same time as people rely more heavily on publicly financed health services. We also know that negative effects on health tend to be concentrated among specific groups of people – especially those who experience unemployment – and that they can be mitigated by public policy action. While many important policy levers lie outside the health sector, in the hands of those responsible for fiscal policy and social protection, the health system response is nonetheless critical.