Background This systematic review investigates the relationship between macroeconomic austerity policies and mortality trends in high-income countries, addressing whether austerity measures have contributed to observed changes in mortality rates, life expectancy, and lifespan variation.

Methods The review used a systematic search across nine databases and grey literature, adhering to PROSPERO registration CRD42020226609 guidelines. Studies were selected based on their quantitative assessment of austerity’s impact on mortality, employing ROBINS-I for risk of bias assessment and GRADE framework for evidence certainty. Due to heterogeneity among studies, a synthesis without meta-analysis was conducted.

Results Out of 5720 screened studies, seven met the inclusion criteria, with six showing harmful effects of austerity on mortality outcomes and one indicating no effect. Consistent harmful impacts of austerity were demonstrated for all-cause mortality, life expectancy and cause-specific mortality across studies and different austerity measures. Excess mortality was higher in countries with greater exposure to austerity. Certainty of evidence (assessed using the GRADE framework) was ‘low’. Risk of bias (assessed using ROBINS-I) was ‘moderate’ to ‘critical’. A ‘typical’ austerity dose was associated with 74,090[-40,632, 188,792] and 115,385 [26,324, 204,446] additional deaths per year. The evidence suggested that countries with greater austerity exposure experienced higher excess mortality.

Conclusion The review consistently links austerity policies with negative mortality outcomes, highlighting the variability in effect magnitude depending on austerity implementation methods. While the results suggest a clear association between austerity and adverse health outcomes, the exact impact magnitude remains uncertain. Policymakers should consider the potential health implications of austerity measures, focusing on balanced approaches to public spending and taxation to mitigate harm.