Strategies and indicators to integrate health equity in health service and delivery systems in high-income countries: a scoping review.

Health equity occurs when individuals can achieve their full health potential. 1 , 2 As early as 1974, the Lalonde Report; in Canada suggested that health systems move beyond a biomedical view of health (free of illness and disease) and toward a health promotion approach. 3 A health promotion approach recognizes and seeks to address the social and structural conditions that affect the health of communities, families, and people, which often have their origins outside of health systems. 4 These social factors are termed the social determinants of health (SDOH). 4 Income, education level, race, ethnicity, and gender, along with other SDOH, are widely accepted as having both direct and indirect implications for health system performance, and frequently intersect to affect patient experiences and outcomes. 5 As examples, the cost of transportation, poor health literacy, racial and gender discrimination, or the lack of translation services can all limit or inhibit access to health services. 6 Thus, population health, defined as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group,” 7 (p.381) is deeply connected to the social and structural conditions in which people are born, work, live, and age, as well as to health equity. 8 The pursuit of health equity has long been recognized as an important health system action, with the COVID-19 pandemic being the most recent example of the intersection of health inequities and health outcomes experienced on a global scale. 9 The 1986 Ottawa Charter for Health Promotion called for health systems to be reoriented toward a population health approach that includes SDOH, rather than a focus on individual health behaviors. 10 In 2011, the Rio Declaration on SDOH stated that the health sector should address SDOH and prioritize health equity to achieve social prosperity. 11 Most recently, the US Institute for Healthcare Improvement (IHI) noted that addressing health equity should be one of the goals of health system performance (known as the Quintuple Aim). 12 Despite persistent global health inequities and the documented importance of integrating health equity into health service and delivery systems, progress toward integration has been slow. 1 , 2 , 13 An overview of reviews on strategies to reduce health inequalities was published in 2020 and identified 4095 articles, with 97 subsequently included in the synthesis of evidence. 14 This review reported that most studies targeted health care delivery or providers within health systems, but an internationally relevant review that examines how strategies and indicators are used to integrate equity across the entire health system was still lacking. 14 Health service and delivery systems have a specific remit to promote, restore, and maintain health through delivery of services. In this review, health service and delivery system is defined as the organization of people, institutions, and resources to deliver health services to meet the health needs of a target population. 15 These systems need to consider their role beyond delivering health care to ensure that they also achieve the goal of improving population health by defining and operationalizing health equity in their practices. Health inequities that arise because of SDOH are recognized as a global threat, which can only be addressed by intersectoral, whole-of-government action. 16 Greater attention toward health equity integration is common within the public health sector in high-income countries. For example, in Canada, the National Collaborating Centre for Determinants of Health has produced guidelines and strategies describing public health roles and tools for action to address health equity since 2005. 17 Organizational frameworks to guide capacity for health equity action have also been developed for public health agencies, including the identification and development of indicators. 18 , 19 Health Quality Ontario’s Health Equity Plan embeds equity into the provincial health system based on a review of provincial plans describing health equity strategies. 19 In Australia, the Public Health Association developed a Health Equity Policy in 2001 that provided recommendations to governments at all levels, policymakers, and public health organizations to promote equity in health in Australia and globally. 20 Despite these efforts, examples of health equity integration more broadly across health service and delivery systems are hard to find. Among the few studies that exist, Shahzad et al. 21 examined cross-sectoral collaboration between public health and clinical care to integrate a population health approach within health care delivery to address inequities. Shankardass et al. 22 explored international, intersectoral, and governmental approaches to health equity action, noting a need to improve the description of these complex, multi-actor processes in the literature. The aim of this review was to identify the strategies and indicators that health service and delivery systems in high-income countries have implemented to integrate and measure health equity. We also sought to understand how health equity is defined and operationalized by examining how strategies and indicators for health equity facilitated its integration across various components of health service and delivery systems. In this review, we focused on a whole-system approach to understand how health equity is integrated across entire health service and delivery systems. A preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews, and JBI Evidence Synthesis was conducted and no current or in-progress scoping or systematic reviews on the topic were identified. Such a review is needed to guide transformation and provision of quality care by clarifying the role of health systems in addressing health inequities and advancing health system performance. Our review also extends the work of Garzón-Orjuela et al. 14 by examining strategies and indicators for health equity over a longer time period and through the inclusion of both academic and gray literature.

SFLK and SMS designed the study and obtained funding. HC, MR, SFLK, and SMS developed the search strategy. MR, HC, SMS, and PC conducted the literature search, removed duplicates, and transferred the citations to Zotero. HC, CC, ME, SFLK, SMS, LW, and JY screened the titles and abstracts. HC, CC, ME, SFLK, SMS, LW, and JY conducted the full-text screening. All authors contributed to data extraction, analysis, interpretation, and drafting of the manuscript. All authors have read, critically revised, and approved the final manuscript.

What health equity strategies and indicators are used by health service and delivery systems in high-income countries to address health equity? The review subquestions are as follows: How is health equity defined and operationalized within health service and delivery systems in high-income countries? What frameworks are commonly used to guide the integration of health equity indicators within health service and delivery systems in high-income countries? How do health service and delivery systems measure health equity integration (eg, indicators, accountability frameworks) in high-income countries? What strategies to address health equity have been implemented in the health service and delivery system, and for what populations (eg, patients, families, communities, health care workers) in high-income countries? What are the levels of integration of health equity indicators within health service and delivery systems (eg, delivery arrangements, financial arrangements, governance arrangements, and implementation strategies) in high-income countries? How is health equity defined and operationalized within health service and delivery systems in high-income countries? What frameworks are commonly used to guide the integration of health equity indicators within health service and delivery systems in high-income countries? How do health service and delivery systems measure health equity integration (eg, indicators, accountability frameworks) in high-income countries? What strategies to address health equity have been implemented in the health service and delivery system, and for what populations (eg, patients, families, communities, health care workers) in high-income countries? What are the levels of integration of health equity indicators within health service and delivery systems (eg, delivery arrangements, financial arrangements, governance arrangements, and implementation strategies) in high-income countries? The review subquestion “What strategies to address health equity have been implemented in the health service and delivery system, and for what populations (eg, patients, families, communities, health care workers) in high-income countries?” was modified from our initial protocol 23 to better capture that our review included sources that described the implementation of health equity strategies and not the description or proposal of them. Our 5 review subquestions were also modified from the initial protocol to include the mention of high-income countries and improve clarity for readers. The review title was also modified to include the term integrate rather than address to reflect our review’s focus on implementation and integration.

Funding for this review was provided by the Canadian Institutes of Health Research Catalyst Grant (FRN 170322). This funding provided salary support for HC, CC, PC, JY, and LW. The funder was not involved in the content development of the review. SMS and ME each held a Health System Impact Fellowship that was jointly funded by the Canadian Institutes of Health Research and Nova Scotia Health.

This scoping review was conducted in accordance with JBI methodology for scoping reviews, 26 and in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). 27 An a priori protocol guided the conduct of this scoping review. 23 The search strategy aimed to locate 2 types of evidence sources: scholarly, peer-reviewed publications and gray literature. 28 , 29 The search strategy was developed and underwent a Peer Review of Electronic Search Strategy (PRESS) by a qualified health sciences librarian (MR). Following an initial limited search of MEDLINE (Ovid) and CINAHL (EBSCOhost) articles on health equity, the text words contained in the titles and abstracts of relevant articles and the index terms were used to develop a full search strategy (see Appendix I ). This search strategy, including all identified keywords and index terms, was adapted for each included information source. Searches were undertaken initially in January 2021 and again in January and May 2022. Additionally, reference lists of included sources were also screened to identify other relevant evidence. 26 The databases searched were MEDLINE (Ovid), CINAHL (EBSCOhost), Embase, Scopus, Academic Search Premier (EBSCOhost), TRIP Database (basic version), ProQuest Dissertations and Theses Global, and PAIS (ProQuest). Unpublished gray literature was searched with the terms health equity , equity , and equity indicators using databases such as ProQuest Dissertations and Theses; internet search engines such as Google (first 10 pages); websites of relevant organizations specified in the Canadian Agency for Drugs and Technologies in Health Grey Matters tool; and websites of relevant organizations and government agencies suggested by the authors (eg, Institute of Health Equity, Institute for Healthcare Improvement, the National Collaborating Centre for Determinants of Health, and Health Quality Ontario; see Appendix I for full details). The gray literature search followed the processes and procedures described in the template, “How to Find and Document Grey Literature.” 30 Following the search, all identified sources were uploaded into Covidence (Veritas Health Innovation, Melbourne, Australia) and duplicates were removed. After a pilot test of our inclusion/exclusion criteria and data extraction tool with 3 sources by 6 members of our research team, all citations and abstracts were screened by 2 independent reviewers (HATC, JY, CC, ME, SFLK, SMS, LW) for assessment against the inclusion criteria, in accordance with the JBI Manual for Evidence Synthesis . 26 Any disagreements that arose between the reviewers were resolved through discussion or with a third reviewer (HATC, JY, CC, ME, SFLK, SMS, LW). The full study team met weekly to discuss inclusion and exclusion criteria to ensure all team members were following the same protocol. The full texts of included studies were retrieved and imported into Covidence. Full-text studies that did not meet the inclusion criteria were excluded, and reasons for their exclusion are provided in Supplemental Digital Content 1: http://links.lww.com/SRX/A44 . Included sources were also imported into Zotero (Corporation for Digital Scholarship and Roy Rosensweig Center for History and New Media, VA, USA) for the purpose of reference management. Data were extracted from included evidence sources by 2 independent reviewers (HATC, JY, CC, ME, SFLK, SMS, LW) using an extraction tool developed by the authors and published in the review protocol (see Appendix II ). 23 Any disagreements were resolved through consultation with a third reviewer (HATC, JY, CC, ME, SFLK, SMS, LW). Following a post-publication testing of this tool by the authors, the instrument was modified and 2 categories were added: how the authors determined success of the health equity strategies implemented and which, if any, outcomes were mentioned. 26 The outcomes category provides a summary of the outcomes measured and/or reported in the included sources that were not captured in the extraction of health equity indicators. The extracted data from the full-text sources are presented in Appendix III . No translated sources were included in data extraction. This table of included studies presents the following extracted findings: author/year and title, study design, and key findings related to our 5 review subquestions (ie, definitions, frameworks, level of integration, strategies, and indicators). Due to the variation in the types of outcomes reported in the included sources, it was not possible to collectively analyze these data, and only a summary of outcomes is reported in Appendix III . This review used different methods to summarize (eg, tables) and visualize (eg, graphics and charts) findings to best reflect the objectives of the scoping review. To complete the narrative summary of results, we used various qualitative methods. To define the health service and delivery system settings, we used the following established definitions. Primary health care was defined as “an approach elaborated in the 1978 Declaration of Alma-Ata based on the principles of equity, participation, intersectoral action, appropriate technology and a central role played by the health system for the delivery of services that are made universally accessible to individuals and families.” 31 (p.20) Health service and delivery systems were defined as delivery arrangements that organize different providers and services to ensure timely and efficient delivery of health care 25 ; for example, provision of disease-specific care for diabetes or dementia; organized networks of similar providers, such as public health or US/federally qualified health centers; or collaborations and partnerships between hospitals and community health or primary care providers. Physician/general medical practitioner offices were defined as “establishments of health practitioners who hold the degree of a doctor of medicine or a corresponding qualification and are primarily engaged in the independent practice of general medicine.” 32 (p.136) Results for subquestion 1 (how health equity was defined in our included sources) were analyzed with a qualitative content analysis. 33 Two reviewers (JY, PC) independently considered the health equity definitions and coded them for central characteristics using NVivo Release 1.0 (QSR International, United Kingdom). The University of Maryland’s e-resources was used as a guide for coding central characteristics of extracted health equity definitions. 34 The 2 reviewers used an open coding approach, noting key characteristics of definitions followed by an iterative process of refining before meeting to discuss coding. A third reviewer (CC) checked the coding and resolved any discrepancies between reviewers. Results for subquestion 2 (frameworks to guide integration of health equity) were described narratively. To analyze responses to subquestion 3 (measurement of health equity integration), a content analysis was completed based on a framework used in British Columbia to create a 3-tier classification of the health equity indicators. 35 Results for subquestion 4 (strategies to address health equity) were analyzed with a content analysis. 33 Responses for subquestion 5 (level of integration of health equity strategies and indicators) were summarized based on the EPOC taxonomy, and results were displayed graphically. Results of the settings for health equity work and populations involved were summarized in charts but were not described in Appendix III , to avoid duplication.

The search of databases and the gray literature yielded 26,109 records. After removing duplicates, 16,297 titles and abstracts were screened, and 824 went forward to full-text screening. From this process, 18 sources were not retrieved because the full text was not available through our institutional library, internet search, or by contacting the relevant authors. As a result, 806 full-text sources were assessed for eligibility. Of these, 684 were excluded, as they did not meet our inclusion criteria. A list of excluded sources and an accompanying rationale for exclusion is presented as supplemental digital content http://links.lww.com/SRX/A44 . Subsequently, 122 sources were included in this review. 21 , 35 – 155 A description of the included sources is available in Appendix III . The PRISMA flowchart (see Figure 1 ) shows the study selection process. Search results, study selection, and inclusion process 27 Of the 122 sources of evidence included, the year of publication ranged from 1996 to 2022. The number of records published from 2019 onwards was 61, reflecting an increase in attention to health equity in recent years. The year with the largest number of records (n = 27) published was 2021, likely reflecting an increase in attention to health equity because of the COVID-19 pandemic. 9 We classified our evidence sources in accordance with our search strategy. Of the 122 included sources, 108 sources were from scholarly publications. 21 , 36 – 131 , 144 – 154 More than half (n=70) of these sources were primary research, 36 – 104 , 154 24 review papers (eg, literature, scoping, systematic), 21 , 109 – 131 12 reports, 35 , 36 , 38 , 52 , 55 , 61 , 72 , 83 , 104 , 110 , 130 , 155 10 commentary/opinion, 60 , 82 , 86 , 102 , 107 , 108 , 126 , 140 , 142 , 147 and 6 other sources. 39 , 44 , 81 , 103 , 106 , 150 The gray literature sources included user guides for implementing health equity tools, organizational reports describing frameworks and indicators recommended for implementation, and organizational evaluations. All included a description of implementation in the health service and delivery system. Based on our methodological approach and protocol, 23 we did not initially exclude primary sources that were also in review papers included in our scoping review. Due to the objectives of this paper being exploratory, we interpreted the results of systematic reviews as part of a narrative analysis. After completion of screening and data extraction, we observed minimal overlap between primary sources and sources included in review papers in outcomes and indicators, and thus we did not further exclude those sources affected by overlap (see Appendix IV ). We observed different study objectives, populations, contexts, health equity strategies, and outcomes among the review papers and included primary sources. There is no single standardized approach or formal guidance on how to quantify and resolve overlap for scoping reviews. 156 , 157 Of the 24 review papers included in our scoping review, 8 reviews included sources that were also included in our scoping review. 112 , 113 , 121 , 123 , 124 , 129 , 131 , 148 Five reviews included between 1 and 3 other studies from our review, 113 , 121 , 123 , 124 , 148 2 included 4 other sources, 112 , 131 and 1 included 8 other sources. 129 Garg et al. 65 was cited in 7 of the 8 reviews, and the 12 other sources were referenced 1, 2, or 3 times ( Appendix IV ). In addition, Andermann et al. 113 and Gottlieb et al. 121 were included both as reviews and as citations in reviews. This review was limited to sources from high-income countries with developed economies: 56 from the United States, 41 , 43 – 46 , 52 , 54 , 56 , 59 , 64 – 68 , 71 , 73 , 74 , 78 , 80 , 83 , 84 , 89 , 92 , 95 – 97 , 99 – 101 , 103 , 105 – 107 , 115 , 119 – 121 , 124 , 125 , 128 , 134 – 139 , 142 – 147 , 149 – 151 , 153 20 from Canada, 35 , 37 , 39 , 40 , 42 , 48 – 50 , 63 , 86 , 88 , 90 , 91 , 98 , 104 , 108 , 113 , 141 , 152 , 155 16 from the United Kingdom, 38 , 53 , 55 , 61 , 62 , 69 , 70 , 81 , 85 , 87 , 112 , 114 , 130 , 132 , 140 , 154 8 from Australia and New Zealand, 51 , 58 , 72 , 79 , 94 , 102 , 122 , 133 and 22 from other countries. 21 , 36 , 47 , 57 , 60 , 75 – 77 , 82 , 93 , 109 – 111 , 116 – 118 , 123 , 126 , 127 , 129 , 131 , 148 The “other” designation includes both single and multicountry sources; for example, Kaper et al. 76 focused their study on Ireland and the Netherlands, whereas Daban et al. 57 examined community-based interventions in Barcelona, Spain. Two sources within the “other” category identified as high-income countries only and no further geographical information was provided. 129 , 131 Figure 2 includes the context or setting for the included sources. Primary health care (n=58) was the setting for almost half of the included sources, 21 , 37 , 39 – 42 , 44 , 45 , 47 – 51 , 54 , 56 , 57 , 62 , 63 , 65 , 67 , 72 , 73 , 75 , 77 , 79 , 81 – 84 , 87 , 88 , 91 , 94 – 96 , 98 – 100 , 104 , 106 , 108 – 110 , 112 , 114 – 116 , 122 , 123 , 125 , 128 , 129 , 140 , 142 , 143 , 146 , 152 , 153 followed by health service/delivery system (n=31), 35 , 36 , 38 , 43 , 71 , 92 , 93 , 97 , 102 , 103 , 105 , 107 , 111 , 117 – 121 , 124 , 126 , 130 , 132 , 133 , 135 , 136 , 141 , 144 , 145 , 150 , 154 , 155 hospital (n=19), 55 , 57 , 61 , 72 , 75 , 76 , 87 , 89 , 102 , 109 , 112 , 123 , 124 , 129 , 131 , 132 , 140 , 148 , 151 and general medical practitioner offices (n=14). 36 , 53 , 66 , 68 , 71 , 77 , 78 , 92 , 94 , 96 , 107 , 108 , 114 , 116 Setting of health service and delivery systems in included sources (n=122) The aim of this scoping review was to identify strategies and indicators implemented by health service and delivery systems in high-income countries to promote and measure population-level health equity to improve health outcomes. Sixteen included sources provided 18 definitions for health equity or related terminology (ie, equity, health care equity). 35 , 36 , 50 , 88 , 93 , 104 , 116 , 127 , 132 , 133 , 135 , 136 , 141 , 143 , 150 , 155 Six of these 18 definitions used some or all components of the World Health Organization (WHO) definition of health equity (ie, “health equity is achieved when everyone can attain their full potential for health and well-being”). 1 (para.1) , 93 , 104 , 116 , 127 , 141 , 155 Table 1 presents the content analysis conducted by 2 reviewers to deconstruct these definitions into 5 core elements, which we classified as: i) optimal health, ii) absence of differences, iii) fairness in distribution of resources, iv) population groups, and v) needs-based resource allocation. Of the remaining included sources, almost half (n=56) did not define health equity or related concepts. 38 , 41 – 46 , 48 , 51 , 54 – 56 , 58 , 60 – 62 , 64 , 66 , 67 , 69 , 70 , 72 , 75 , 76 , 78 – 80 , 83 , 84 , 87 , 89 , 92 , 94 , 96 , 99 , 100 , 103 , 105 , 108 , 110 , 112 , 114 , 115 , 120 , 122 – 125 , 128 , 134 , 137 , 139 , 140 , 142 , 147 , 154 Fifty sources did not define health equity, but did include definitions of related concepts of interest (eg, health inequity/inequality, SDOH). 21 , 37 , 39 , 40 , 47 , 49 , 52 , 53 , 57 , 59 , 63 , 65 , 71 , 73 , 74 , 77 , 81 , 82 , 85 , 86 , 90 , 91 , 95 , 97 , 98 , 101 , 102 , 106 , 107 , 109 , 111 , 113 , 117 – 121 , 126 , 129 – 131 , 138 , 144 – 146 , 148 , 149 , 151 – 153 Central characteristics of health equity definitions Of the included studies only 55% (n=67) were identified as using a framework or model to guide the research. 21 , 35 , 37 – 41 , 44 , 47 , 48 , 50 , 52 , 54 – 56 , 61 – 63 , 66 , 71 , 73 – 78 , 83 – 85 , 88 , 92 – 94 , 96 , 98 , 101 – 107 , 109 – 112 , 116 – 118 , 123 , 127 , 130 , 131 , 133 , 135 – 138 , 140 , 141 , 143 – 145 , 149 , 151 – 153 The most reported framework was Health Equity Impact Assessment (n=4), 37 , 98 , 133 , 135 followed by the Quality and Outcomes Framework (n=2), 61 , 112 and the Dismantling Racism framework (n=2). 71 , 73 All the remaining sources (n=59) used unique frameworks to operationalize their health equity work within a specific organizational or system context. 21 , 35 , 38 – 41 , 44 , 47 , 48 , 50 , 52 , 54 – 56 , 62 , 63 , 66 , 74 – 78 , 83 – 85 , 88 , 92 – 94 , 96 , 101 – 107 , 109 – 111 , 116 – 118 , 123 , 127 , 130 , 131 , 136 – 138 , 140 , 141 , 143 – 145 , 149 , 151 – 153 The health equity work described in our included sources took place in multiple settings that ranged from a whole health system to clinical and community health service providers, meaning there was substantial variation in the frameworks that were used. This made it challenging to assess their utility. Examples of the distinctive frameworks found within our sources include disease-specific results, such as the Community Cancer Care model 75 ; improvement and change management approaches, such as Plan-Do-Study-Act 138 ; and shared decision-making models 118 or community navigation models. 140 Additional information is captured in Appendix III . Within our included studies, we looked for whether, or how, health service and delivery systems were measuring health equity (eg, using indicators or accountability mechanisms that assessed health equity actions). Overall, we found that indicators for measuring health equity in our included sources were not well described or, in some cases, not reported (n=68). 21 , 36 , 37 , 40 , 47 , 50 , 51 , 53 – 55 , 57 , 59 , 60 , 66 , 68 , 69 , 71 , 74 , 76 , 78 , 79 , 81 , 82 , 88 , 90 – 92 , 94 , 95 , 98 , 100 , 102 , 103 , 106 – 108 , 110 , 111 , 113 – 116 , 118 – 121 , 123 – 126 , 129 – 135 , 139 , 143 – 146 , 148 , 149 , 151 , 153 , 154 When indicators were included (n=54), sources revealed a considerable array of indicators that were employed to measure health equity integration. 35 , 38 , 39 , 41 – 46 , 48 , 49 , 52 , 56 , 58 , 61 – 65 , 67 , 70 , 72 , 73 , 75 , 77 , 80 , 83 – 87 , 89 , 93 , 97 , 99 , 101 , 104 , 105 , 109 , 112 , 117 , 122 , 127 , 128 , 136 – 138 , 140 – 142 , 147 , 150 , 152 , 155 There was also overlap in the types of indicators used (ie, race, income, language, sex, housing); but specific information was not provided about how indicators were developed or used to assess or understand health equity integration. Table 2 provides examples of how we grouped the variety of indicators from our sources. 35 Three-tier categorization of health equity indicators Adapted from Rasali et al. , (2014). Development of priority health equity indicators for British Columbia: Process & Outcome Report. 35 Indicators in the health status and outcomes grouping are commonly used by health systems and provider organizations, and include incidence of diseases or health status. Interestingly, the health service and delivery systems performance cluster was the only one that encompassed summary scores for health equity, such as those developed by Ontario’s public health system. 155 The SDOH grouping included many familiar examples that are used by health service and delivery systems concerned with measuring inequities in care and program provision, such as gender, race/ethnicity, and age. As outlined in our protocol, the EPOC taxonomy and its 4 domains were used to classify the mechanisms that facilitated health equity strategy implementation within and across health service and delivery systems. 23 Unique strategies within each domain were employed to address health equity (see Table 3 for examples and Appendix III for full details). For example, staff and leadership training, alongside partnerships and teamwork, were used within the delivery arrangements domain. Furthermore, we found some health services embedded dedicated staff, such as community health workers or patient navigators, to make connections across and within providers to address inequities associated with the SDOH. However, despite progress by sector-specific providers in using data collection tools and indicators, there is a dearth of evidence in the governance arrangement domain to support a whole-system approach or accountability framework to improve health equity across systems. Strategies to address health equity, arranged according to Effective Practice and Organisation of Care taxonomy 25 Multiple strategies were used across papers, so the numbers exceed the number of included studies (n=122). Figure 3 illustrates the populations represented throughout our sources, of which the majority (n=90) identified strategies that targeted patient populations, such as Indigenous populations, older adults, or populations with disease-specific conditions. 37 – 41 , 43 – 45 , 47 – 56 , 59 – 63 , 65 – 72 , 74 – 77 , 79 , 82 – 87 , 90 , 92 – 97 , 99 , 101 – 103 , 107 – 121 , 123 – 127 , 129 – 132 , 134 , 138 , 140 , 143 , 146 – 149 , 151 – 155 The health system workforce was another common target (n=19) and included physicians, nurses, and others, such as rehabilitation and public health staff. 35 , 36 , 42 , 51 , 58 , 61 , 73 , 80 , 81 , 88 , 91 , 100 , 104 , 133 , 136 , 137 , 139 , 141 , 144 Community/organizational partners (n=13) represented standalone services or sectors and were also a common target of the sources that sought to address health equity. 21 , 57 , 64 , 78 , 89 , 98 , 105 , 106 , 122 , 127 , 128 , 142 , 145 One source focused on staff within a government health department. While the numbers in Figure 3 add up to 122, some sources featured more than one population while others did not provide this information. Populations represented in included sources (n=122) To understand the levels of integration of the strategies that addressed health equity within health service and delivery systems, we again applied the EPOC taxonomy. Figure 4 illustrates both the independent and blended use of the 4 domains. More than three-fourths of the strategies identified in the sources (n=88) could be categorized using 2 or more EPOC domains, 21 , 35 , 36 , 37 , 39 – 41 , 49 , 50 , 52 , 53 , 55 – 57 , 59 – 67 , 69 – 75 , 77 – 84 , 88 – 97 , 99 , 101 – 103 , 106 – 111 , 113 – 126 , 128 , 131 , 132 , 134 , 136 , 137 , 139 , 140 , 142 , 143 , 146 , 148 – 150 , 152 , 153 and 13 sources were classified with all 4 domains. 21 , 36 , 57 , 61 , 78 , 95 , 107 , 110 , 121 , 122 , 124 , 143 , 150 A combination of delivery arrangements (ie, changes in how and who delivers care) with implementation strategies was the most common combination (n=45). 35 , 39 – 41 , 52 , 53 , 55 , 62 – 67 , 69 , 70 , 74 , 77 , 80 – 84 , 89 , 91 , 94 , 96 , 99 , 101 , 106 , 109 , 111 , 113 – 116 , 119 , 123 , 125 , 128 , 131 , 137 , 139 , 140 , 148 , 149 Strategies categorized solely as delivery arrangements (n=13) 38 , 45 , 47 , 51 , 54 , 58 , 68 , 86 , 87 , 104 , 105 , 129 , 154 or solely as implementation strategies interventions (n=11) 42 – 44 , 46 , 76 , 98 , 100 , 127 , 133 , 138 , 151 were also found. The “other” category consisted of 4 sources that we were unable to classify due to insufficient information provided. 48 , 85 , 135 , 141 Studies including strategies categorized by their level of integration within the health system (EPOC taxonomy). The colors indicate 1 or a combination of up to 4 EPOC (Effective Practice and Organisation of Care) domains: DA (blue), delivery arrangements; IS (red), implementation strategies; GA (green), governance arrangements; and FA (yellow), financial arrangements. “Other” (orange) indicates sources unable to be classified due to insufficient information.

As per our protocol, participant details were not used for selection of studies. 23 This scoping review’s main concept was the definition and operationalizing of health equity strategies and related indicators in the health service and delivery system in high-income countries (Q1). Definitions explain or describe the meaning of health equity, while operationalizing refers to putting healthy equity into action. Frameworks were considered to be formal guides or documents to support health equity (Q2). Strategies were defined as any efforts or actions put in place with the purpose of enhancing health equity for patients or broader populations served by such systems, and indicators were defined as ways to measure health equity integration within the health service and delivery system (Q3 and Q4). 23 Integration was considered to be the degree to which health equity was embedded within and across health service and delivery systems (Q5). The context was health service and delivery systems in high-income countries, including health care sector–specific settings. Only sources from high-income, developed economies (eg, Canada, Australia, the United States), as defined by the World Bank, 24 and those sources where health equity work was implemented within health service and delivery systems, were included. The World Bank defines high-income economies as those that have a gross national income per capita of US $13,846 or more. 24 Health equity is defined and operationalized differently in different countries. Our decision to limit to high-income countries was made in recognition of the similarities of these systems and the actions that have been taken within them to address health equity since the publication of the Ottawa Charter. We defined health service and delivery system as the organization of people, institutions, and resources to deliver health care services to meet the health needs of a target population, whether a single-provider practice or a large health care system. 15 If a strategy was implemented by a health service or delivery system in a community organization, it was included, but if the community organization was the implementer, it was excluded. As per our protocol, 23 we used the Cochrane Effective Practice and Organization of Care (EPOC) taxonomy of health system interventions to identify the levels of integration of health equity strategies and related indicators within health service and delivery systems. 25 This taxonomy was also used in the review of reviews by Garzón-Orjuela et al. 14 and includes 4 main domains: delivery arrangements: changes in how, when and where health care is organized and delivered, and who delivers health care financial arrangements: changes in how funds are collected, insurance schemes, how services are purchased, and the use of targeted financial incentives or disincentives governance arrangements: rules or processes that affect the way in which powers are exercised, particularly regarding authority, accountability, openness, participation, and coherence implementation strategies: interventions designed to bring about changes in health care organizations, the behavior of health care professionals, or the use of health services by health care recipients. delivery arrangements: changes in how, when and where health care is organized and delivered, and who delivers health care financial arrangements: changes in how funds are collected, insurance schemes, how services are purchased, and the use of targeted financial incentives or disincentives governance arrangements: rules or processes that affect the way in which powers are exercised, particularly regarding authority, accountability, openness, participation, and coherence implementation strategies: interventions designed to bring about changes in health care organizations, the behavior of health care professionals, or the use of health services by health care recipients. We considered scholarly, peer-reviewed, published primary sources that used quantitative, qualitative, and mixed methods approaches, in addition to reviews (ie, literature, scoping, systematic), and text and opinion papers. Unpublished or gray literature sources (eg, dissertations, government white papers or policy reports, quality reports) were also reviewed for inclusion. To capture evidence globally, sources published (or available) in all languages were included in the search, provided that an English abstract was available; however, data extraction only occurred if an English translation of the full text was available. Sources published from 1986 to May 2022 were included to align with the release of the Ottawa Charter for Health Promotion that recommended health systems reorient to focus on population health approaches. 10

Health equity has long been identified as an important component of delivering effective health care to populations, as is demonstrated in various approaches by the WHO, IHI and the Quadruple Aim. 13 , 37 , 158 This scoping review identified strategies and indicators that health service and delivery systems used to integrate health equity within their organizations and across systems. Our search initially identified a high number of records relating to strategies and indicators to improve health equity in health services and delivery systems, suggesting that the issue of health equity is receiving greater attention within health services research, policy, and practice. A limitation of this review is that the number of included sources was much lower after our exclusion criteria were applied, suggesting that there are gaps in evidence from within health service and delivery systems, despite the degree of attention paid to the issue throughout the COVID-19 pandemic. Furthermore, our sources provided limited or no descriptions of the implementation of health equity actions, making it challenging to summarize the results. We also found that many of our sources did not define health equity, and when sources did define it, multiple definitions were used, leading us to conclude that there are discrepancies in how health equity is being interpreted. Health equity was also inconsistently defined and operationalized in the sources we identified for inclusion. For example, we uncovered various indicators, many of which were lacking in adequate descriptions. Additionally, the use of equity frameworks was limited and, where present, there was little agreement about the elements or domains. Furthermore, strategies were often integrated within specific programs, services, or clinics rather than being more broadly applied across health systems, which suggests that current health equity work is siloed. Most health equity strategies and indicators could be integrated into the EPOC domains of delivery arrangements and implementation strategies, with fewer being implemented within or across governance or financial arrangements (see Appendix III ). However, some were found to address multiple types of arrangements; for example, implementation strategies, either alone or combined with delivery arrangements, were a common structure in the sources we identified. A strength of this review is the broad and inclusive search that was conducted to provide a comprehensive assessment of health equity definitions, strategies, and indicators. While this generated a large volume of sources for review, it gives us confidence that our review was thorough and extensive, including both primary research and gray literature. In addition, the scope and time frame of our review was larger than the review conducted by Garzón-Orjuela et al. 14 because we included both academic and gray literature over a 38-year time period following the release of the Ottawa Charter. Another strength was the application of JBI methodology, which provided a structure for the systematic handling of data identified. The findings of our paper may be limited by the overlap between included review papers and primary sources; however, we determined the overlap was minimal and did not change the overall findings of this scoping review. Our updated search was conducted in May 2022, and more research may have been published since this date. Despite limitations, the findings of our review have implications for health systems policies and processes for collecting, measuring, and reporting health equity data. For instance, provider organizations and health systems appear to be at different stages in their work on health equity. Our review has uncovered sources where organizations, and to a lesser extent health systems, are at the initial stage of their health equity work, whereby they are collecting and analyzing data to identify groups of patients at risk of poor outcomes relative to the rest of their populations. By contrast, we also found sources that were more advanced in that these organizations and, in some cases, systems have used indicators to identify populations for whom they are designing and testing strategies and initiatives that address their specific needs. However, from this review, it appears that there is more health equity activity being carried out at the patient or individual and organizational or delivery levels, rather than at the system level. These results together suggest that most strategies appear to be integrated within specific programs or clinics and that whole system integration of health equity is not yet happening. Results may help guide organizations in the early stages of developing equity measures to identify appropriate methods of collecting, measuring, and reporting equity outcomes. Our findings indicate that health equity is not routinely considered as a system-wide, collective issue to be addressed. Progress could be advanced if or when accountability requirements are implemented by accreditors, such as Accreditation Canada, or government funders of health care. While there are efforts to better integrate health equity into health service and delivery systems, such as through the fifth IHI aim of health equity and mandatory annual reporting about health equity, as recently implemented by the Ontario and Nova Scotia governments, there is still a long way to go for health equity to be considered a system-wide priority in health care and delivery systems. 159 , 160 Indeed, it has been suggested that current attention to health equity, without attending to the discourses of power, hierarchy, and control that operate within public policy, will not translate into the explicit outcomes necessary to truly embed equitable outcomes. 161 This point is illustrated in our review by the lack of attention to governance structures across the strategies we identified. We recognize that our review was conducted during the COVID-19 pandemic, a situation that has reinforced attention to long-standing health inequities. 162 This can be seen through the increasing number of sources we identified in this review over the latter few years (2020–2022). Many of these sources were ineligible for inclusion in our review as they did not evaluate the frameworks, strategies, or indicators they were proposing. It is encouraging that there is an increase in attention being paid by all levels of governments, providers, advocacy organizations, and health service and delivery systems on how to improve health equity, both within clinical, preventive, and primary care services and programs as well as across systems. Our scoping review provides a foundation upon which to build more consistent ways to define and operationalize health equity to address the deficiencies we have noted and to establish an integrated, whole-system approach towards health equity.

There is variation across health service and delivery systems regarding the type of work being done related to health equity. This includes differences in how health equity is defined and operationalized, the types of indicators used, and the strategies employed. Some variation is to be expected, largely because of the unique organizational and structural factors underlying health service and delivery systems; in particular, the populations they serve, coupled with the lack of accountability mechanisms that explicitly address health equity. Furthermore, the frameworks used by our sources to guide their health equity work were inconsistently applied and most did not build on international work published by the WHO. It is evident that health equity is a complex concept with no clear consensus about how it should be defined or applied within health service and delivery systems. Therefore, it is not surprising that there are inconsistencies in how it is considered across different systems and settings. These inconsistencies, coupled with our finding that most of the work was happening at a clinical or provider level, mean that we cannot expect health service and delivery systems to have elevated this work within an integrated, whole-system approach without strategic direction, adequate governance structures, or dedicated resources to do so. 96 There is a need to eliminate siloed health equity work, but not at the expense of progress to date. Policymakers and senior leaders who are charged with system oversight should consider adapting their efforts along the lines of the WHO definition, 1 as demonstrated by some of our sources. This scoping review has taken place alongside the COVID-19 pandemic wherein inequities among vulnerable populations were revealed. 162 We suggest that our scoping review be considered as a first step through which other efforts could build on to analyze system-wide efforts that integrate health equity work within and across health service and delivery systems. We conclude that health equity work will continue to be siloed until it is considered a collective issue that can be mitigated through system-wide measurement and identification of vulnerable populations; implementation of remediation strategies; and application of accountability mechanisms that employ integrated approaches across the care continuum with the aim of preventing, restoring, and maintaining health. Among the vast health equity literature we identified, there is a need to clearly articulate the essence of the health equity concept. We recommend that future authors be intentional about their focus on a whole-system approach. There is a need to uncover and better understand the barriers to and enablers of the strategies used by health service and delivery systems for each of the EPOC domains and how SDOH influence the integration of health equity across different health sectors and settings where programs and clinics are delivered.

Sara Brushett, Emma Stirling Cameron, and Emily Haley for contributions to the protocol development, title and abstract screening, and full-text review.

Information about this scoping review, including the data extraction, can be found in the accompanying appendices or in the original protocol publication. 23