Healthy Life Expectancy: The Geography of Inequality in Spain

In recent decades, Spain has established itself as one of the countries with the highest life expectancy in the world, which in 2024 stood at 84.0 years (81.3 years for men and 86.5 years for women). However, speaking only about life expectancy is not enough to understand the quality of aging. It is important to know whether these additional years of life are lived in good health. To measure the years lived in good and poor health, we rely on healthy life expectancy, which has become a central aspect of demographic research and public health policy. Spain has managed to ensure that a substantial share of these gains in life expectancy is lived in good health, although this improvement has not been uniforming across the territory. The autonomous communities show significant differences both in the length of life and in the number of years lived free of limitations or disease.

Healthy life expectancy can be measured in many ways; one of them consists of observing the presence of chronic diseases or conditions, which allows us to calculate the average number of years lived with and without disease in a population. Focusing on this indicator, its evolution since the beginning of the twenty-first century reveals a complex picture. In general, both life expectancy and disease-free life expectancy have increased, although not always at the same pace. Progress was sustained throughout much of the past two decades, with a pause marked by the economic crisis that began in 2008 and reached its worst point in Spain around 2013, when improvements in healthy life expectancy slowed while overall life expectancy continued to increase at the same rate. The other major setback occurred in 2020, when life expectancy fell abruptly due to the COVID-19 pandemic. After this latest shock, recovery has been relatively rapid, confirming the robustness of the underlying trend.

Nevertheless, when examining the temporal evolution of disease-free life expectancy at age 65 at the regional level, trajectories have been uneven (Zueras and Rentería, 2021). In 2017, this indicator reached its highest values in La Rioja, Castile and León, and the Balearic Islands for men, and in the Basque Country, La Rioja, and Castile and León for women, with more than four years of disease-free life expectancy. At the same time, this indicator was at its lowest in Galicia, with barely one year for women and two years for men, followed by Valencia and Aragon (men), and Asturias and the Canary Islands (women). The temporal trend shows that between 2006 and 2012, years lived free of disease improved in most regions, for both men and women. However, this indicator worsened between 2012 and 2017, especially among men, who experienced a slight expansion in the prevalence of cardiovascular diseases and diabetes. By contrast, the upward trend in healthy life years was more stable and continuous among women, although accompanied by a persistent burden of conditions that more strongly limit mobility, such as back pain.

The reasons for these divergences are multiple and operate at different levels, demonstrating that progress in health does not depend solely on medical advances, but also on social and political conditions. At the individual level, lifestyles (diet, physical activity, smoking, and alcohol consumption), biological characteristics, and socioeconomic factors such as income or job stability play a role. In the urban context, air quality, access to health services, the availability of public transportation and green spaces, housing quality, and neighborhood social cohesion make a difference in everyday health. Finally, at the regional level, structural inequalities stand out, such as income levels, the distribution of health care resources, primary care capacity, prevention policies, and investment in social services (Rentería and Zueras, 2022). In particular, Spain is one of the European countries with the highest levels of socioeconomic inequality between regions (Díez-Minguela et al., 2018), a situation compounded by the decentralized nature of the Spanish health system, in which a large share of responsibility for managing health services and planning public health lies with the autonomous communities. The study by Rentería and Zueras (2022) showed that public health expenditure was one of the most important variables in explaining temporal changes in life expectancy with and without disease across Spain’s regions during the period from 2006 to 2019, which included the 2008 financial crisis and the subsequent cuts in health spending. Other socioeconomic variables, such as GDP per capita or the educational level of the region, were also relevant in explaining temporal trends, although they played a smaller role and were more relevant for men than for women.

In this context, the future challenge is to transform success in terms of life expectancy into an effective and equitable improvement in quality of life, ensuring that progress reaches all regions equally. It is not only about living longer but about living well. This implies reducing the years lived with disease or disability, especially among women and older adults, and reducing regional and social gaps. To achieve this, it will be necessary to strengthen prevention, invest in primary care and public health services, promote healthy lifestyles, and above all reduce the social and territorial inequalities that prevent all individuals and communities from equally benefiting from advances in health. Thus, it is important to reinforce policies that protect the financing and universality of the system, increase resources in the most disadvantaged territories, and place social equity at the center of planning and evaluating interventions. Experience in recent years has shown that adverse contexts, such as economic crises or pandemics, tend to exacerbate existing inequalities. For this reason, ensuring a longer and healthier life for all requires combining interventions from the individual to the structural level, with a shared goal: that the years gained from death also become years gained from disease.

Reference Articles

Díez-Minguela, A., Martínez-Galarraga, J., Tirado-Fabregat, D. A. (2018). Regional Inequality in Spain, 1860–2015. Palgrave Macmillan, Basingstoke. https://doi.org/10.1007/978-3-319-96110-1

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. https://doi.org/10.1016/j.ssmph.2022.101152

Zueras, P., & Rentería, E. (2021). Trends in disease-free life expectancy at age 65 in Spain: Diverging patterns by sex, region and disease. PLOS ONE, 16(3). https://doi.org/10.1371/journal.pone.0240923