Avoidable mortality is traditionally analysed at the national level. Using district-level data from 10 European countries between 2002 and 2019, Sophie Stroisch, Michael Mühlichen, Pavel Grigoriev and Tobias Vogt reveal substantial health inequalities across areas that transcend national borders.
Avoidable mortality comprises amenable deaths that should not occur with timely and effective healthcare, and preventable deaths that could be avoided through effective public health measures. It is widely used to assess health system performance and population health inequalities in Europe (Mühlichen et al., 2023; OECD & Eurostat, 2022). Over recent decades, avoidable mortality has declined substantially, reflecting advances in prevention, treatment, and living conditions. However, large disparities persist among European nations, and further gains in life expectancy could be achieved if unnecessary and untimely deaths were reduced (Hrzic & Vogt, 2024).
The limits of national narratives
Most comparative studies across Europe focus on national averages. While useful, this perspective risks obscuring important differences within countries and overlooking similarities between regions located on different sides of national borders. Health systems are organised nationally, but many determinants of health, such as labour markets, environmental exposures, infrastructure, and demographic composition, are shaped at regional level, not necessarily demarcated by national borders.
To unravel these dynamics, in a recent study (Stroisch et al. 2026) we analysed trends in avoidable mortality across 581 districts in 10 European countries, including both new and old EU member states, between 2002 and 2019. By examining districts rather than countries, we aimed to capture spatial patterns that national-level analyses cannot reveal.
Beyond national averages
While avoidable mortality has generally declined across most European regions, persistent geographic disparities remain, as shown in Figure 1. By 2017-2019, Eastern European districts continued to exhibit the highest rates of avoidable mortality for both men and women. However, these elevated mortality rates are not confined to Eastern Europe alone: regions of northeastern Germany and southern Belgium also exhibit high levels of avoidable mortality, challenging simplistic East–West dichotomies.
When hotspots for amenable and preventable mortality are examined separately, these patterns become even more evident (Figure 2). Germany is a good illustration of this complexity: despite its robust healthcare system, several regions persistently exhibit high levels of amenable mortality, placing the country in an intermediate position between Western and Eastern Europe. This aligns with previous research indicating that longevity in Germany is stagnating and lagging behind that of other high-income nations (Jasilionis et al., 2023).
Spatial patterns of avoidable mortality extend across internal EU borders, with cross-border clusters of both high and low mortality (hotspots and coldspots, respectively). A long-term hotspot of preventable mortality among women spans the French–Belgian border region, affecting districts on both sides despite differences in healthcare systems and national policies. This region’s challenges stem from shared socioeconomic issues such as deindustrialisation, demographic decline, and disparities in healthcare access (Bonnet & d’Albis, 2020; Otavova et al., 2024). In contrast, a persistent cross-border coldspot spans parts of Spain, France, Switzerland, Austria, and northern Italy, where avoidable mortality remains consistently low. This contradicts the notion that health outcomes are solely determined by national healthcare systems. These areas are united not just by geography but also by ongoing economic prosperity, robust healthcare infrastructure, and cultural practices that actively promote well-being.
These findings lead to the central conclusion that national boundaries are not always the most meaningful demarcation lines for explaining health outcomes. Local socioeconomic conditions, historical development paths, cultural and linguistic similarities, and shared regional contexts can play an important role. Regions with similar economic structures and demographic profiles often exhibit similar mortality patterns, even when located in different countries.
The need for area-specific health policies
These results have important implications for population research and health policy. First, they highlight the limits of national benchmarking. Improvements in national averages can coexist with stagnation or deterioration in specific areas. Without a regional perspective, such inequalities are liable to remain invisible. Furthermore, growing disparities in avoidable mortality within countries raise critical questions regarding the equitable and effective provision of healthcare services.
Second, the persistence of cross-border hotspots suggests that some health challenges cannot be addressed effectively within national frameworks alone. Regions facing similar structural disadvantages may benefit from coordinated transnational approaches, particularly in border areas where population dynamics, labour markets, and healthcare utilisation are closely intertwined. At the same time, cross-border coldspots offer opportunities for best-practice learning. Regions that consistently achieve low levels of avoidable mortality do so in different institutional settings, indicating that favourable outcomes are not necessarily tied to a single health system model. Identifying and transferring successful practices from these regions could support more equitable health improvements across Europe.
Finally, for European societies facing population ageing and exploding healthcare expenditures, reducing avoidable mortality is a high priority. Our findings suggest that achieving this goal requires targeted area-based interventions. Health policies should be regionally sensitive, and, where appropriate, cross-border in scope, complementing national health strategies but not replacing them.
References
Bonnet, F., & d’Albis, H. (2020). Spatial Inequality in Mortality in France over the Past Two Centuries. Population and Development Review, 46(1), 145–168. https://doi.org/10.1111/padr.12318
Hrzic, R., & Vogt, T. (2024). The contribution of avoidable mortality to life expectancy differences and lifespan disparities in the European Union: A population-based study. The Lancet Regional Health – Europe, 46, 101042. https://doi.org/10.1016/j.lanepe.2024.101042
Jasilionis, D., Van Raalte, A. A., Klüsener, S., & Grigoriev, P. (2023). The underwhelming German life expectancy. European Journal of Epidemiology, 38(8), 839–850. https://doi.org/10.1007/s10654-023-00995-5
Mühlichen, M., Lerch, M., Sauerberg, M., & Grigoriev, P. (2023). Different health systems – Different mortality outcomes? Regional disparities in avoidable mortality across German-speaking Europe, 1992–2019. Social Science & Medicine, 329, 115976. https://doi.org/10.1016/j.socscimed.2023.115976
OECD & Eurostat. (2022). Avoidable mortality: OECD/Eurostat lists of preventable and treatable causes of death (January 2022 version). https://www.oecd.org/health/health-systems/Avoidable-mortality-2019-Joint-OECD-Eurostat-List-preventable-treatable-causes-of-death.pdf
Otavova, M., Masquelier, B., Faes, C., van den Borre, L., Vandeninden, B., de Clercq, E., & Devleesschauwer, B. (2024). Trends in socioeconomic inequalities in cause-specific premature mortality in Belgium, 1998–2019. BMC Public Health, 24(1), 470. https://doi.org/10.1186/s12889-024-17933-z
Stroisch, S., Mühlichen, M., Grigoriev, P., & Vogt, T. (2026). Spatial Differences in Avoidable Mortality Across 581 European Districts, 2002–2019. European Journal of Population, 42(5), 21. https://doi.org/10.1007/s10680-025-09761-7