Sex disparities in health of older adults in India: assessing the morbidity-mortality paradox through disability-free life expectancy.

Background: Older adults face substantial sex gaps in health. In many contexts, females live longer than males, but their time spent with disability is also higher. Our study assesses (i) the sex gap (female-male) in health through life expectancy and healthy life expectancy and (ii) the morbidity-mortality paradox among older adults aged 60 and above in India and its states. Methods: We utilized data on age-specific death rates obtained from the Sample Registration System and age-specific disability prevalence from the Longitudinal Ageing Survey (LASI) in India. We estimated abridged life tables between age groups 60-64 to 85 + using Greville's method. We then combined the disability data obtained from LASI with the constructed life tables using Sullivan's method to estimate disability-free life expectancy (DFLE) and life expectancy with disability (DLE). Finally, we decomposed the sex gap in DFLE and DLE into mortality and disability components using a stepwise replacement decomposition method. Results: At the national level, life expectancy at age 60 for males were 17.4 years and for females 19.2 years, indicating a female mortality advantage of 1.8 years. At the state level, the sex gap ranged between 5.1 years in Jammu & Kashmir and -1.1 years in Jharkhand. The disability prevalence was higher among females compared to males at the national level and in all states. The decomposition result indicates that 98% of the mortality advantage of females at the national level was spent in disability. The disability disadvantage of females over their mortality advantage was highest in Uttar Pradesh; 93% of additional years of life were spent with disability. The disability disadvantage of females over their mortality advantage was lowest in Rajasthan where only 9% of additional years were spent in disability. Stepwise replacement decomposition of the sex gap in DFLE by age groups shows that as age increases, the contribution of mortality effects decreases, whereas disability effects increase. Conclusions: We find evidence of a morbidity-mortality paradox in India nationally and sub-nationally. As the sex gap in health and its implications vary across the states of India, policies to address these inequities must also vary across the states. Supplementary Information: The online version contains supplementary material available at 10.1186/s41118-025-00247-2.