At 65 years old, a Spaniard can expect to live another 21.9 years; a Bulgarian, only 16.9 years. These two men are citizens of the same European Union, subject to the same single market rules, theoretical beneficiaries of the same cohesion funds. The observed gap cannot be attributed or compared to the sole effect of national wealth based on this descriptive data. Eurostat measures years of healthy life and life expectancy, but does not conclude that institutional choices determine these results.
The Essential Points
- Life expectancy at 65 years varies by five years between the best and worst performers in the EU, according to 2024 Eurostat data.
- Available data does not allow us to assert that the gap follows these indicators more closely than GDP per capita.
- Several countries in the region have difficulties with access and primary care, without this sole cause explaining their longevity gaps.
- An increasing number of member states have undertaken structural reforms of primary care. Preventable mortality is a result indicator that can signal problems with care or prevention, but the effect of a reform must be established through dedicated causal evaluation.
- By 2050, sustainability depends on several demographic, economic, health, and institutional assumptions, not directly on narrowing this gap.
A Gap That Resists European Transfers
Since 2004, European structural funds have transferred hundreds of billions of euros to Central and Eastern European economies. Roads have been built, airports modernized, industrial fabric transformed. Bulgaria, Romania, and Hungary have closed part of their GDP gap. Yet in 2024, a retired Bulgarian of 65 lives on average five years less than a retired Spaniard of the same age. The money circulated.
The years of life did not.
National wealth can be associated with health outcomes, but this data is insufficient to demonstrate that it is necessary or insufficient. The organization of care and prevention are possible determinants among several social, economic, behavioral, and medical factors.
Eurostat allows these indicators to be compared separately. Some Central and Eastern European systems remain hospital-centric and experience territorial shortages, but a general and historical causality has not been demonstrated. Some Central and Eastern European systems remain hospital-centric and experience territorial shortages, but a general and historical causality has not been demonstrated.
Primary Care Medicine, A Determining Variable
Many cardiovascular, respiratory, and metabolic diseases can be prevented, detected, or better controlled in primary care before serious complications. A family doctor who regularly follows their patients, prescribes screening at the right time, and informs about risk factors avoids potentially fatal acute crises.
Spain provides the most documented demonstration. The country invested heavily in its health centers starting in the 1980s, creating a network of first-line care; according to an OCU survey from 2014, 77% of Spanish respondents said they could reach one in less than 15 minutes. The Spanish primary care system is associated with low hospitalization rates for certain chronic conditions, but this source does not demonstrate the precise causal effect on cardiovascular detection and preventive treatments. A 2025 study documents local community health initiatives in Barcelona.
Portugal followed a comparable path, lagging by a decade but with the same logic. From the 2000s onward, Lisbon launched a profound reform of its Unidades de Saúde Familiar, family medicine units working in multidisciplinary teams and partially remunerated based on their patients’ health outcomes. In 2024, life expectancy at 65 in Portugal is 21.1 years, a level close to the best in Europe for a country whose GDP per capita remains below the EU average. The Portuguese reform precedes some observed results, but its relative effect compared to wealth has not been established.
The Price Paid Today by Bulgaria and Romania
The Bulgarian case illustrates the inverse mechanism. After 1989, the Bulgarian system underwent transition and incomplete reforms rather than a partial collapse without coherent institutional replacement. Hospitals absorbed most public resources, while primary care medicine remained chronically underfunded. General practitioners experienced departures from the country or from rural areas. Result: certain rural Bulgarian areas experience difficulties with regular access to a family doctor.
Without accessible primary care, chronic conditions are detected only late. Untreated hypertension becomes a heart attack, unmonitored diabetes leads to amputation or kidney failure. These complications, beyond their human cost, drain hospital resources that the country cannot mobilize sustainably. The system is caught in a self-sustaining circle: due to lack of prevention, expensive hospitalizations increase; due to lack of resources, prevention cannot be financed.
Romania presents a similar configuration, aggravated by massive emigration of health professionals to Western Europe. The country has experienced massive departures of medical and nursing personnel over two decades. The departures generally concern the most qualified and youngest professionals. Those who remain ensure, often in difficult conditions, coverage of underserved territories.
These dynamics can contribute to health gaps without constituting a direct causal demonstration.
This phenomenon of medical desertification is not unique to Eastern Europe. As an article on working after 65 showed, territorial inequalities in healthcare access are also found in less connected metropolises of Western Europe, with direct consequences on the living conditions of seniors.
The Reforms That Work and How They Work
The five-year gap is not inevitable. An increasing number of European countries have undertaken primary care reforms. Difficulties with access to primary care can contribute to longevity gaps but cannot alone explain them.
Denmark is the textbook case most often cited by public health researchers. The country has maintained since the 1970s a family medicine system where each inhabitant is attached to a referring practitioner responsible for coordinating all their care. This practitioner is remunerated according to a mixed model: a fixed amount per registered patient, a variable amount linked to prevention activities performed. This mechanism actively incentivizes early detection rather than accumulation of curative acts. Danish life expectancy at 65 reached 20.1 years in 2024, for a country that does not rank among Europe’s economic leaders.
Finland pursued a different but convergent path, focusing on the integration of social and health services at the municipal level. Finnish local health centers combine general medicine, chronic disease management, psychological support, and social assistance under one roof. This integration reduces coordination costs and facilitates detection of social vulnerabilities that worsen morbidity. The result on preventable mortality, that which could be prevented through adequate care, is documented and significant.
These models are not beyond the reach of Central and Eastern European countries. Poland has pursued a gradual reform of its family medicine network since 2016, with modest but measurable results in areas where practitioner density has increased. The Czech Republic in 2024 has life expectancy at 65 of 18.9 years, lower than Spain and 2.0 years higher than Bulgaria, with steady progression. Trajectory matters as much as level.
Which Health Systems Will Be Sustainable by 2050
The longevity challenge is not just humanitarian. It is directly fiscal. Effects on pensions and health spending also depend on pension rules, morbidity, prices, and care organization. A country whose residents age in better health spreads expenditures over a longer period, but with lower intensity at each stage.
Systems that invest in prevention and primary care pay less, in the long term, for the consequences of untreated chronic diseases. Certain prevention and primary care interventions can be efficient or produce savings, depending on their design and context. The mechanism is known. But it assumes a capacity to defer spending over time, invest today to save in ten years, which governments under budget pressure find difficult to maintain.
By 2050, two trajectories emerge for the European Union. In the first, several countries experience stagnation or deterioration of their primary care indicators. Preventable mortality remains high in Eastern Europe, pension regimes there are relatively less strained in duration, but health insurance systems absorb growing hospital costs related to complications from chronic diseases. Emigration of health professionals could worsen shortages in certain Eastern European countries and might complicate the reduction of health inequalities. European cohesion funds continue to finance physical infrastructure without leverage on care infrastructure.
In the second trajectory, the Union conditions part of its transfers on measurable health indicators: density of family doctors per territory, diabetes and cardiovascular disease screening rates, share of health budget devoted to outpatient care. Several member states would benefit from such conditionality, as it would provide them political leverage to promote reforms that internal resistance makes difficult. This logic extends that of structural funds oriented toward competitiveness: health as investment, not as burden.
A third variable is added to this picture: demographics. As illustrated by this article on the American senior housing market, countries that age rapidly without anticipating needs in care and suitable housing accumulate costs that their fiscal structure would struggle to absorb. Eastern Europe is aging rapidly, with capacity challenges in primary care, geriatric infrastructure, and prevention.
The most relevant signal to monitor in the coming years will be the evolution of preventable mortality by country. Preventable mortality groups premature deaths that could have been avoided either through effective prevention and public health, or through prompt and effective care. A decrease in this indicator can be compatible with advances in primary care, but it is insufficient to demonstrate them causally.
Available Levers for European Policymakers
Nothing forces the EU to passively accept divergence in life expectancy between its members. Several levers are available, some already active on a small scale.
The first is health conditionality in structural funds. Linking part of financing to measurable objectives of medical density, screening rates, or preventable mortality would create a direct incentive to reform primary care systems. The EU already has the technical expertise to define these indicators: Eurostat publishes them annually, and comparisons are robust.
The second is reverse professional mobility. If Western Europe attracts doctors from the East, it could help finance their training and retention in their countries of origin, through exchange programs with return obligations. Several member states have experimented with similar mechanisms without lasting success, but European scale would provide resources that national budgets cannot mobilize alone.
The third lever is model sharing. Spanish, Danish, and Portuguese primary care reforms have produced documented results. Transferring them, not mechanically, but by adapting incentive mechanisms to local contexts, is a feasible task. Several EU-funded projects have attempted this dissemination with mixed results. The key seems to be local ownership of change rather than importing a turnkey model.
The next EU multiannual financial framework will raise the question of conditioning transfers on health indicators as much as on economic indicators. Five years of life expectancy difference between two citizens of the same political space constitute a cohesion deficit as serious as a five percentage point GDP gap. Integrating this reality into transfer criteria represents a change in doctrine, not simply procedure. Available data in 2024 make this change of doctrine increasingly difficult to defer.
Sources
- Eurostat, Mortality and life expectancy statistics, 2024
- Frontiers in Public Health, analysis of prevention configurations in Europe (EU), 2025, no link (URL verification not possible)
- European Federation of Salaried Doctors, data on medical emigration in Central and Eastern Europe
