Strategies and indicators to integrate health equity in health service and delivery systems in high-income countries: a scoping review
Authors: Caldwell Hilary A.T. , Yusuf Joshua , Carrea Cecilia , Conrad Patricia , Embrett Mark , Fierlbeck Katherine , Hajizadeh Mohammad , Kirk Sara F.L. , Rothfus Melissa , Sampalli Tara , Sim Sarah Meaghan , Tomblin Murphy Gail , Williams Lane 
Published: April 2024

Objective:
The objective of this review was to describe how health service and delivery systems in high-income countries define and operationalize health equity. A secondary objective is to identify implementation strategies and indicators being used to integrate and measure health equity.

Introduction:
To improve the health of populations, a population health and health equity approach is needed. To date, most work on health equity integration has focused on reducing health inequities within public health, health care delivery, or providers within a health system, but less is known about integration across the health service and delivery system.

Inclusion criteria:
This review included academic and gray literature sources that described the definitions, frameworks, level of integration, strategies, and indicators that health service and delivery systems in high-income countries have used to describe, integrate, and/or measure health equity. Sources were excluded if they were not available in English (or a translation was not available), were published before 1986, focused on strategies that were not implemented, did not provide health equity indicators, or featured strategies that were implemented outside the health service or delivery systems (eg, community-based strategies).

Methods:
This review was conducted in accordance with the JBI methodology for scoping reviews. Titles and abstracts were assessed followed by a full-text review. The information extracted consisted of study design and key findings, such as health equity definitions, strategies, frameworks, level of integration, and indicators. Most data have been quantitatively tabulated and presented according to 5 review questions. Some findings (eg, definitions and indicators) were summarized using qualitative methods. Most findings are visually presented in charts and diagrams or presented in tabular format.

Results:
Following review of 16,297 titles and abstracts and 824 full-text sources, we included 122 sources (113 peer-reviewed, 9 gray literature) in this scoping review. We found that health equity was inconsistently defined and operationalized. Only 17 sources included definitions of health equity and we found that both indicators and strategies were lacking adequate descriptions. The use of health equity frameworks was limited and, where present, there was little consistency or agreement in their use. We found that strategies were often specific to programs, services, or clinics, rather than broadly applied across health service and delivery systems.

Conclusions:
Our findings suggest that strategies to advance health equity work are siloed within health service and delivery systems and are not currently being implemented system-wide (ie, across all health settings). Healthy equity definitions and frameworks are varied in the included sources, and indicators for health equity are variable and inconsistently measured. Health equity integration needs to be prioritized within and across health service and delivery systems. There is also a need for system-wide strategies to promote health equity, alongside robust accountability mechanisms for measuring health equity. This is necessary to ensure that an integrated, whole-system approach can be consistently applied in health service and delivery systems internationally.

Review registration:
Dal Space dalspace.library.dal.ca/handle/10222/80835

Supplemental digital content is available for this review:

http://links.lww.com/SRX/A45