Understanding the implementation and impact of health equity frameworks in health systems: a mixed methods systematic review

Health inequities are systematic, avoidable, and unjust differences in health arising from unequal social, economic, and environmental conditions, as well as inequitable access to and experiences of healthcare. Despite sustained policy commitment, inequities persist, indicating that fragmented or program-specific approaches are insufficient. Health equity frameworks have emerged to embed equity within health system governance, planning, and service delivery; however, evidence regarding their implementation and impact is limited. This systematic review examined the implementation and impact of health equity frameworks within health systems and identifies factors that influence their successful implementation and sustainability. This mixed-methods systematic review, conducted in accordance with PRISMA guidelines, searched PubMed and Embase (2015–2025) for studies evaluating the implementation and/or impact of health equity frameworks in high-income country health systems. Screening, data extraction, and quality appraisal were completed in Covidence, with methodological quality assessed using Critical Appraisal Skills Programme tools and findings synthesised thematically. Of 3,552 records identified, 11 studies met the inclusion criteria. Frameworks were applied across primary care, public health, and specialty services in Australia, New Zealand, the United States, and international initiatives. Most were grounded in social determinants of health and health system strengthening approaches, with several incorporating proportionate universalism and intersectionality. Reported impacts spanned system, organisational, local, and individual levels. These included institutionalisation of equity within policy, strengthened data and accountability systems, workforce capacity building, community engagement, and in some cases, service-level and health improvements. Key facilitators included Indigenous leadership, aligned leadership, cross-sector partnerships, robust data infrastructure, and secure funding, while barriers included policy instability, fragmented governance, resource constraints, and challenges in measuring long-term effects. Health equity frameworks show promise but require sustained organisational and system level commitment, culturally legitimate governance, organisational capability, and rigorous evaluation to achieve durable and equitable impact.