The exploratory design of this study allows for identifying systematic patterns across European countries, while its grounding in social determinants of health theory supports a structured interpretation of the observed associations rather than purely data-driven inference. Our findings emphasize that factors beyond individual-level clinical care and curative medical services—such as structural, institutional, and health system characteristics—significantly influence population health outcomes. The health index shows strong inverse associations with DALYs and YLLs for chronic conditions such as cancer and cardiovascular diseases, indicating that stronger health systems correlate with lower premature mortality and disability. The inclusion of life expectancy within the health index entails an intrinsic conceptual linkage with mortality- and YLL-based outcomes. In the context of this exploratory, system-level analysis, life expectancy is not interpreted as an independent causal determinant, but rather as a synthetic proxy of accumulated population health and health system performance, reflecting long-term effects of prevention, access to care, and disease management. Similarly, the governance index reveals inverse associations with DALYs and YLLs for cancer, suggesting that effective governance reduces disease burden. By contrast, the economic index displays a mixed pattern: higher values link to increased mortality and disability in mental health disorders. The demographic index did not reach statistical significance in the multivariate model. The findings should be interpreted in light of the country selection, which was driven by data harmonization requirements rather than representativeness. Accordingly, the results reflect patterns observed among the included European countries and should not be directly generalized to the European Union as a whole. In addition, the use of 2021 data implies that mortality and YLL estimates partly reflect the impact of the COVID-19 pandemic (Brooks 2022; Pizzato et al. 2024; Barfar et al. 2025). While this limits the interpretation of findings as representative of non-pandemic conditions, it also provides insight into how underlying structural determinants and health system capacity relate to population health outcomes during a period of exceptional system stress.

European healthcare systems face unprecedented challenges, including demographic shifts, technological advancement, and climate change impacts (Seniori Costantini et al. 2015; Colombo et al. 2016; Garin et al. 2016; Emadi et al. 2021; Varbanova et al. 2023; OECD 2024; Gianfredi et al. 2024; GBD 2021 Diseases and Injuries Collaborators 2024; Santos et al. 2024; Nucci et al. 2025). NCDs, including CVDs and cancer, are consistently identified as major contributors to the burden of disease across European nations (Santos et al. 2024; Naghavi and GBD 2021 Italy Subnational Burden of Disease Collaborators 2025). Increased per capita health expenditure has been associated with a decline in DALYs, particularly in countries with higher Human Development Index (HDI) (Daroudi et al. 2021). Advances in early diagnosis, treatment, and behavioral risk-factor mitigation (e.g., smoking cessation, obesity reduction) contribute to YLL reductions (European Parliament and Scholz 2020; Jutz 2021; OECD 2024; Naghavi and GBD 2021 Italy Subnational Burden of Disease Collaborators 2025). Therefore, continuous investment in healthcare infrastructure, preventive measures, and access to quality care is paramount for public health improvement (OECD 2024; Signorelli et al. 2024; Naghavi and GBD 2021 Italy Subnational Burden of Disease Collaborators 2025). Economic development is generally associated with better health outcomes, although individual economic indicators such as GDP per capita show complex relationships with health metrics (Seniori Costantini et al. 2015; Jutz 2021; Varbanova et al. 2023). European countries are experiencing unprecedented demographic transitions, with more than 21% of the EU population now aged 65 and above, projected to reach nearly 30% by 2050 (OECD 2024).

Our findings suggest that stronger health systems, characterized by higher overall system capacity and performance as captured by the health index, are associated with lower DALYs and YLLs for CVDs, diabetes, and kidney diseases (Daroudi et al. 2021; Varbanova et al. 2023; OECD 2024; Irandoust et al. 2024). Musculoskeletal disorders show lower mortality where the health index is higher, plausibly reflecting fewer fatal complications in stronger systems (Emadi et al. 2021; GBD 2021 Diseases and Injuries Collaborators 2024; Naghavi and GBD 2021 Italy Subnational Burden of Disease Collaborators 2025).

Conversely, we observed direct associations for gynecological diseases, polycystic ovary syndrome, skin and subcutaneous tissue diseases (β = 0.62–0.84), and mental health disorders (β = 0.80–1.00). Although published sources do not explicitly report this pattern for gynecological conditions, the “pro-rich inequality” phenomenon described for mental health aligns with increased detection and reporting in higher HDI (Emadi et al. 2021; GBD 2021 Diseases and Injuries Collaborators 2024; Santos et al. 2024). Enhanced diagnostic capacity can inflate recorded prevalence and DALY estimates by uncovering previously undiagnosed cases and reflecting longer survival rather than true incidence increases (Emadi et al. 2021; OECD 2024; Pennisi et al. 2025a). The rise in DALY rates for mental disorders has been particularly noted, further aggravated by the COVID-19 pandemic (GBD 2021 Diseases and Injuries Collaborators 2024). Additionally, we found positive links between mortality and urinary diseases, male infertility, and rheumatoid arthritis, though counterintuitive in higher-index contexts, may arise from better cause-of-death ascertainment and multimorbidity (Colombo et al. 2016; Garin et al. 2016), as well as older population structures and risk profiles that heighten severe and fatal complications.

Governance quality emerges as a key driver of population health. Studies on European antimicrobial resistance have demonstrated that stronger governance correlates with lower resistance, after controlling for antibiotic use, implying roles for infection control, regulatory oversight, and public health infrastructure (Maugeri et al. 2023). The governance index negatively correlates with health outcomes, particularly DALYs and YLLs for cancer, suggesting that stronger governance reduces NCD burden (Marmot and Bell 2019; OECD 2024; Santos et al. 2024). Effective governance (transparency, rule of law, control of corruption) enables efficient systems and evidence-based public health policies (Emadi et al. 2021; GBD 2021 Diseases and Injuries Collaborators 2024; Santos et al. 2024; Naghavi and GBD 2021 Italy Subnational Burden of Disease Collaborators 2025), while corruption undermines health system effectiveness (Varbanova et al. 2023). Positive associations for conditions like urinary diseases may reflect improved detection and reporting in stronger institutional contexts rather than true deterioration. Mechanistically, governance improves resource allocation, policy implementation, prevention environments, and intersectoral coordination to address complex health challenges (European Parliament and Scholz 2020; OECD 2024).

The economic index shows limited and sometimes counterintuitive links, indicating a complex Europe-specific relationship between development and health. Economic strength is directly associated with mental health burden (the “mental health paradox”), where higher incomes coincide with more anxiety and depression, likely reflecting both greater detection/diagnosis and genuinely higher rates (Garin et al. 2016; Emadi et al. 2021; OECD 2024). As wealth rises, marginal health gains diminish while challenges tied to affluence, aging, urbanization, and lifestyles increase (Garin et al. 2016; Marmot and Bell 2019; Daroudi et al. 2021; Varbanova et al. 2023). In high-income settings, further growth yields smaller overall health gains yet a higher NCD burden, including mental disorders (Daroudi et al. 2021; Emadi et al. 2021; GBD 2021 Diseases and Injuries Collaborators 2024; Santos et al. 2024). By contrast, we find a negative association between the economic index and YLDs for digestive diseases, consistent with higher digestive DALYs in Central and Eastern Europe, which suggests benefits from improved sanitation, access, treatment, and prevention (Seniori Costantini et al. 2015; Santos et al. 2024). At the indicator level, GDP per capita is a recognized determinant that typically relates inversely to DALYs and directly to life expectancy (Seniori Costantini et al. 2015; European Parliament and Scholz 2020; Jutz 2021; Daroudi et al. 2021; Varbanova et al. 2023; OECD 2024; Irandoust et al. 2024), even as development can generate new challenges and widen inequalities; persistent poverty maintains unmet needs and poorer outcomes for vulnerable groups. Overall, economic growth improves health but entails trade-offs, requiring policies that maximize benefits while mitigating unintended consequences.

Despite Europe’s well-documented aging (Colombo et al. 2016; Garin et al. 2016; Varbanova et al. 2023; OECD 2024; Naghavi and GBD 2021 Italy Subnational Burden of Disease Collaborators 2025), the lack of significant associations with the demographic index indicates that population structure is less predictive of health outcomes than health system and governance quality. Evidence from frailty research shows wide cross-country variation among older adults not explained by demography alone, underscoring the role of system responses and social support (O’Caoimh et al. 2018; Jutz 2021; Varbanova et al. 2023). A healthy aging approach should prioritize functional ability and quality of life across the life course (Gianfredi et al. 2025), supported by enabling environments, accessible care, and robust social policies (Rudnicka et al. 2020). Accordingly, focus should shift from aging per se to societal preparedness to sustain health, independence, and well-being in older populations.

Health system and governance factors significantly impact health outcomes, suggesting that policy interventions should extend beyond healthcare spending or economic development. Strategies aimed at improving institutional quality and governance are likely to provide better returns on population health. This aligns with the European Health Union and WHO’s focus on resilient health systems and effective governance to address NCDs and promote health equity (WHO Regional Office for Europe 2020). Strengthening health systems and ensuring universal health coverage is essential for improving population health.

Research shows that interventions addressing governance quality, such as transparency, accountability, and regulatory effectiveness, can positively impact health (Varbanova et al. 2023; Irandoust et al. 2024; Santos et al. 2024). Priority investments should focus on healthcare access, institutional capacity, and health inequity monitoring. Europe’s minimum income schemes exemplify successful inequality reduction through enhanced healthcare access and stress reduction (Jutz 2021).

Integrated health system-governance approaches are evidence-based. Strong systems improve chronic disease and emergency outcomes, as COVID-19 demonstrated (Pennisi et al. 2024). Better governance enhances expenditure efficiency (Daroudi et al. 2021; Vigezzi et al.