Gender equality and disease burden in 25 EU member states, 2006–2023: a fixed-effects panel analysis

Abstract

Background Gender equality is widely regarded as a social determinant of population health, but most evidence is cross-sectional or based on differences between countries. Whether within-country changes in gender equality are associated with the magnitude or composition of disease burden remains unclear, particularly in high-income settings. Objective To examine whether within-country changes in gender equality, measured by the Global Gender Gap Index (GGGI), were associated with age-standardized all-cause disease-burden magnitude and mortality–morbidity composition in 25 EU member states from 2006 to 2023. Methods This ecological longitudinal study used country-level panel data from 25 EU member states, yielding 450 country-year observations. The GGGI was linked to Global Burden of Disease Study 2023 estimates of age-standardized DALY, YLL, and YLD rates and the YLL/YLD ratio. The main models were two-way fixed-effects regressions with country and year fixed effects, country-clustered standard errors, and adjustment for log GDP per capita, log health expenditure per capita, and mean years of schooling. Robustness was assessed using wild cluster bootstrap-t inference, Mundlak within–between decomposition, restriction to the pre-pandemic period, and alternative education and macroeconomic specifications. Results Within-country changes in the GGGI were not significantly associated with the two primary summary outcomes: the age-standardized total DALY rate (β = −19.1 per 0.01 increase; p = 0.575) or the YLL/YLD ratio (β = −0.0026; p = 0.296). The same null pattern was observed for YLL, YLD, and sex-specific outcomes. The conclusions were unchanged across robustness and sensitivity analyses. A negative cross-country gradient did not persist after adjustment, and within- and between-country coefficients could not be statistically distinguished. Conclusions In high-income EU countries between 2006 and 2023, within-country changes in gender equality were not detectably associated with all-cause age-standardized disease burden or the YLL/YLD ratio. This does not imply that gender equality is unrelated to population health. Rather, broad parity indicators may be too general or slow-moving to register in all-cause burden over this time horizon. Future research should link specific gender-equality domains to disease-specific, sex-specific, health-system-sensitive, and longer-lag outcomes.