Addressing health equity during design and implementation of health system reform initiatives: a scoping review and framework
Bibliographic record
Abstract
BACKGROUND: 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. METHOD: 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. RESULTS: 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. CONCLUSION: 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.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.142 | 0.233 |
| Meta-epidemiology (narrow) | 0.003 | 0.002 |
| Meta-epidemiology (broad) | 0.005 | 0.006 |
| Bibliometrics | 0.044 | 0.040 |
| Science and technology studies | 0.005 | 0.008 |
| Scholarly communication | 0.016 | 0.017 |
| Open science | 0.005 | 0.011 |
| Research integrity | 0.008 | 0.005 |
| Insufficient payload (model declined to judge) | 0.003 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".