Bouckley Tristan, Peiris David, Nambiar Devaki, Mishra Shraddha, Sood Tushar, Purwar Parnika, Elshaug Adam G, Landon Bruce E, Pearson Sallie-Anne, Huckel Schneider Carmen, Schierhout Gill
The George Institute for Global Health, University of New South Wales, Sydney, Australia.
The George Institute for Global Health, Delhi, India.
Int J Equity Health. 2025 Mar 11;24(1):68. doi: 10.1186/s12939-025-02436-z.
Health equity is a commonly asserted goal of health systems. However, there is a limited understanding on how best to promote equity as a part of health system reform initiatives. We conducted a scoping review to (1) identify and characterise strategies that promote health equity during the design and implementation of health system reform initiatives; and (2) determine opportunities to strengthen health equity informed policy design and implementation processes and outcomes.
We systematically searched peer-reviewed literature from 2013 to 2022 focussing on four search domains: (1) health equity; (2) implementation; (3) health system; and (4) reform, policy, or theories, and only included papers that represented a population health or system-wide intention. Health equity promoting strategies were categorised into those occurring at national, regional, state, or local levels. Themes common across system levels were mapped, which alongside theory, informed the development of a health equity promoting framework for reform initiatives.
The search returned 10,999 articles after duplicates were removed. 384 articles underwent full text review and 68 met the inclusion criteria. Thematic analysis of results identified health equity promoting themes derived from numerous strategies, with a median of 10 strategies (interquartile range 7,15) per article. Accountability, commitment, shared power, and adaptability emerged as some of the most prominent equity promoting themes applicable at all system levels. Across strategies, two cardinal conditions were identified: (1) the need for health equity implementation strategies to be made explicit, and (2) the need for alignment and complementarity of strategies. The framework developed demonstrates equity-oriented reform implementation, which embeds broader equity change throughout the system through inclusive and reflexive governance.
This review synthesises diverse literature about how health equity has been considered across levels of the health system during reform design and implementation, providing to our knowledge, the first comprehensive multi-level approach to this issue. Our resulting framework presents policymakers, implementers, and researchers a novel cross-scholarship perspective and process to support the implementation of health equity within system reform initiatives. Throughout design and implementation, consistent vision and a coordinated approach for equity across system levels, underpinned by reflexive governance, will be vital to ensuring that those most in need of healthcare benefit equitably.
健康公平是卫生系统普遍宣称的目标。然而，对于如何作为卫生系统改革举措的一部分来最好地促进公平，人们的理解有限。我们进行了一项范围综述，以（1）识别和描述在卫生系统改革举措的设计和实施过程中促进健康公平的策略；以及（2）确定加强基于健康公平的政策设计、实施过程和结果的机会。
我们系统地检索了2013年至2022年的同行评审文献，重点关注四个检索领域：（1）健康公平；（2）实施；（3）卫生系统；以及（4）改革、政策或理论，并且只纳入那些代表人群健康或全系统意图的论文。促进健康公平的策略被分类为在国家、区域、州或地方层面出现的策略。绘制了各系统层面共有的主题，这些主题与理论一起为改革举措的健康公平促进框架的制定提供了信息。
去除重复项后，检索返回10999篇文章。384篇文章进行了全文评审，68篇符合纳入标准。对结果的主题分析确定了源自众多策略的促进健康公平主题，每篇文章的策略中位数为10个（四分位间距7,15）。问责制、承诺、共享权力和适应性成为在所有系统层面适用的一些最突出的促进公平主题。在各种策略中，确定了两个基本条件：（1）需要明确健康公平实施策略；以及（2）需要策略的一致性和互补性。所制定的框架展示了以公平为导向的改革实施，通过包容性和反思性治理在整个系统中嵌入更广泛的公平变革。
本综述综合了关于在改革设计和实施过程中如何在卫生系统各层面考虑健康公平的不同文献，据我们所知，这是针对该问题的首个全面的多层次方法。我们得出的框架为政策制定者、实施者和研究人员提供了一种新颖的跨学科视角和过程，以支持在系统改革举措中实施健康公平。在整个设计和实施过程中，以反思性治理为支撑的全系统层面一致的公平愿景和协调方法，对于确保最需要医疗保健的人群公平受益至关重要。
