The Map of Longevity and Healthy Life Expectancy in Spain, a Challenge of Inequalities

Spain today stands as one of the world’s leading references in longevity, consolidating a trend of sustained growth only temporarily interrupted by the impact of the COVID-19 pandemic. Over the past two decades, life expectancy at birth has increased significantly: by around 2.5 years for women and 4.5 years for men compared with the 84.2 and 77.7 years, respectively, recorded in 2006. However, this progress has not been homogeneous across the territory, as there are relevant differences among autonomous communities both in life expectancy and in healthy life expectancy. This demographic success thus poses a double challenge: ensuring that the years gained are lived in good health and reducing territorial inequalities.

The increase in longevity in Spain coexists with important territorial differences in the quantity and quality of life during those additional years. Data from the Spanish Health Survey (ESdE) allow us to go beyond the total number of years lived and analyze whether we live longer and in better health, as well as the evolution of these dimensions between 2006 and 2023. By also incorporating information from the 2012 and 2017 health surveys, we have a solid historical series to examine the evolution of healthy life expectancy in Spain and its autonomous communities. The temporal and territorial analysis draws a geography of health marked by important regional contrasts.
We have analyzed healthy life expectancy at age 45 for men and women based on two health indicators: the presence of chronic diseases and limitation in performing daily activities. This approach reflects the disablement process (Verbrugge and Jette 1994), in which health does not deteriorate suddenly, but is the result of a process that begins with the onset of disease, passes through functional limitation, and ends in disability.

First, if we were to draw a map of Spain based on life expectancy at age 45 in 2023, the result would be a mosaic with very marked contrasts, since the difference between the autonomous community with the highest life expectancy and the one with the lowest is up to 3 years. The areas of greatest longevity are concentrated in the center and north of the Peninsula, with Madrid being the autonomous community where people live the longest after age 45: 42.6 years for men and 47.7 years for women. It is closely followed by Navarre, the Basque Country, and Castile and León. In the south are the regions with the most modest survival figures: Andalusia, Murcia, and the Canary Islands. In all cases, women live more years than men, with the gender gap standing at around 5 years.
Regarding regional differences in healthy life expectancy, these vary depending on the indicator considered. In 2023, more than half of the expected years of life after age 45 were lived with chronic diseases. The best results for women were obtained in Catalonia and Cantabria, with 43% and 41% of expected years of life without chronic disease, respectively, while in Murcia this percentage was barely 30%. Men spent up to 52% of their expected years of life without chronic diseases in Catalonia and 47% in Navarre, in contrast with men in Murcia or the Canary Islands, with only 36% and 39%. Functional limitation appears at more advanced ages, so the proportion of life without activity limitation at age 45 is higher, especially among men. This proportion without limitations is highest in the Balearic Islands (71%), Castile and León, the Basque Country, and Navarre — above 66% — but falls below 60% in Murcia, Extremadura, Galicia, and Asturias. Women show significantly lower proportions. Only in Madrid, Castile and León, the Basque Country, Navarre, and Cantabria did this exceed 56%. At the opposite extreme, women in Extremadura and Galicia are expected to live less than 40% of their remaining time free of limitations. Therefore, women currently live more years than men, but they also live more years in poor health, according to either of the two indicators and in all autonomous communities. In general terms, we see that, similarly to longevity, the best results in healthy life expectancy are observed in the communities of the northwest, together with Madrid and Castile and León, and the worst in the southern Peninsula and the Canary Islands.

When analyzing the evolution of these health indicators since 2006, a contradictory picture emerges, since there have been increases in life expectancy free of chronic diseases, but these have not always translated into a decrease in activity limitation. On the one hand, Spain has demonstrated a remarkable capacity to contain the advance of chronicity. The expected years of life with chronic diseases have decreased in Andalusia, Cantabria, Catalonia, and Madrid, while most of the remaining communities have maintained stability. However, this success contrasts with the trends observed in life expectancy with activity limitation. In this area, the results are worse: no autonomous community registers a clear improvement and, in fact, a large group of communities — including Aragon, Asturias, Extremadura and, in the case of women, also the Canary Islands, Galicia, and Murcia; and Castile and León and the Basque Country in the case of men — experience how the increase in longevity translates into a parallel increase in the years lived with limitations. Only communities such as Catalonia, the Valencian Community, or Navarre remain stable, which shows that the true current challenge is not only to survive disease, but to prevent it from leading to a loss of autonomy in daily life.

In short, the map of expectancies in good and poor health in Spain shows a success that is still incomplete. Although we have conquered time, personal autonomy remains a pending challenge that depends on place of residence and sex. The data confirm that it is not enough to add years to life if these years pass under the weight of functional limitation, which is why the challenge for public policies in the coming decades must focus on regional equity and on strengthening primary care and prevention (Rentería and Zueras, 2022). The aim is to ensure that longevity ceases to be a simple figure and becomes healthy life, and that living longer also means living better in a homogeneous way throughout the country.

References

Rentería, E., & Zueras, P. (2022). Macro-level factors explaining inequalities in expected years lived free of and with chronic conditions across Spanish regions and over time (2006–2019). SSM-Population Health, 19, 101152.

Verbrugge, L. M., & Jette, A. M. (1994). The disablement process. Social Science & Medicine, 38(1), 1-14.

Acknowledgments

Pilar Zueras — RYC2023-042942-I grant funded by MICIU/AEI /10.13039/501100011033 and by the ESF+.

Elisenda Rentería — Ramón y Cajal 2017 grants from the State Program for the Promotion of Talent and its Employability (RYC-2017-22586), and the project from the Knowledge Generation program of the State Research Agency WELLHEALTHFAM (Ref. PID2023-152779OB-I00).