Unequal burdens: a subnational analysis of disease burden in Estonia using 2023 DALY estimates

Abstract While national-level estimates of disease burden are widely used for health planning, they can obscure important subnational disparities. Estonia regularly publishes national Burden of Disease data, but limited attention has been given to spatial health inequities. This study provides a novel subnational analysis of the 2023 Estonian Burden of Disease data to identify regional variations and their potential policy implications. This is a secondary analysis of the 2023 Estonian Burden of Disease data, based on the Global Burden of Disease (GBD) framework. Disability-Adjusted Life Years (DALYs), comprising Years of Life Lost (YLL) and Years Lived with Disability (YLD), were analyzed by sex, age group, and county. We calculated DALY rates per 1,000 population for each of Estonia's 15 counties. We then assessed disparities by comparing high- and low-burden regions and explored possible associations with socioeconomic indicators such as employment, income and education. Estonia experienced a total of 424,044 DALYs in 2023. Cardiovascular diseases (35%) and malignant neoplasms (17%) remained the top contributors to total burden. The analysis revealed marked regional disparities. Counties with higher unemployment and lower educational attainment tended to experience greater health losses. Mental health-related YLDs, particularly from self-harm, showed an upward trend among young people in urban areas. These regional patterns were not emphasized in the national report and reveal critical gaps in health equity. Subnational analysis of Estonia's disease burden highlights pronounced regional inequalities, likely driven by socioeconomic factors. This research demonstrates the added value of disaggregating national DALY estimates and supports the integration of regional burden data into public health planning. Addressing these disparities requires geographically targeted and socially sensitive health interventions. Key messages • Subnational Burden of Disease analysis reveals regional disparities in Estonia, informing more equitable public health policies. • The burden of noncommunicable diseases, particularly cardiovascular diseases and cancers, is disproportionately high in regions with lower socioeconomic status, necessitating targeted interventions.