The action framework for health system equity: a review of Australian health equity frameworks and their operational implementation of the Ottawa Charter

1️⃣ ANALYTICAL SUMMARY

Four decades after Ottawa, equity still to be operationalised Health inequalities remain massive in Australia: up to 7 years difference in life expectancy between the poorest and richest areas, and about 8 years difference between Aboriginal and non-Aboriginal populations (p. 2). The Ottawa Charter (1986) set out five action strategies for equity but never specified the institutional mechanisms for implementation. Health equity frameworks have become the public policy tool intended to bridge this gap between intention and administrative practice, at all levels of the Australian health system (federal, states, Local Health Districts, Hospital and Health Services, Primary Health Networks, health organisations controlled by Aboriginal communities) (p. 2-3). The review analyses 45 frameworks published between 2000 and 2025, including 18 in depth (p. 3-4).

A new framework to transform principles into organisational actions The authors propose the Health System Equity Action Framework, which intersects four modes of action of health systems (respond, prevent, promote, integrate equity) and six organisational areas (governance and accountability; engagement and partnership; human resources development; service design and delivery; action on determinants; data and knowledge) (p. 8-9). This model is aligned with the five strategies of the Ottawa Charter (Table 1, p. 11). The review also identifies concrete tools already used in the field — equity impact assessment, audits, check-lists — but emphasises that accountability (who is responsible, to whom, how) remains the main missing link, except in frameworks led by Aboriginal and Torres Strait Islander peoples (p. 9-10).

2️⃣ KEY POINTS OF THE DOCUMENT

1️⃣ 45 equity frameworks identified in Australia (2000-2025), 18 analysed in detail; the vast majority (32/45) come from local levels (Local Health Districts, Hospital and Health Services) rather than national or state levels (p. 4).

2️⃣ Health equity is consensually defined as a "fair and equitable opportunity to reach one's full health potential," based on the social determinants of health (cited in 16/18 frameworks) and proportional universalism (8/18) (p. 5).

3️⃣ Accountability is identified as the main blind spot of the frameworks: few specify who is responsible for equity outcomes, to whom, and according to what monitoring mechanism — with the notable exception of frameworks led by Aboriginal and Torres Strait Islander peoples (p. 9-10).

4️⃣ These frameworks led by Aboriginal communities are distinguished by self-determination, community and cultural governance, and formalised accountability mechanisms; emblematic example: the Queensland law that requires 16 Hospital and Health Services to co-design and co-monitor their equity strategies with the communities (p. 6, p. 10).

5️⃣ The new Health System Equity Action Framework proposes an operational framework crossing 4 modes of action and 6 organisational areas, aligned with the 5 strategies of the Ottawa Charter (Figure 2 p. 5, Table 1 p. 11).

3️⃣ ACTION PATHWAYS FOR LOCAL ACTORS

1️⃣ Use the 4 modes x 6 areas grid (Figure 2, p. 5) as a self-diagnostic tool to position its structure between reactive posture and fully integrated equity in governance.

2️⃣ Adopt an equity impact assessment tool (such as Equity Impact Assessment or Rapid EFHIA) systematically before the adoption of new projects or plans, as done by the South Eastern Sydney LHD (p. 9).

3️⃣ Formalise explicit indicators and accountability mechanisms (who responds, to whom, how monitoring is communicated) rather than sticking to declarative principles — a gap identified in the majority of frameworks (p. 9-10).

4️⃣ Draw inspiration from Aboriginal co-governance models to integrate community representatives into decision-making bodies, and not just consultative ones (example Making Tracks Together, p. 7 and p. 38 of the cited source framework p. 6-7).

5️⃣ Integrate an intersectional reading of the public (intersection of discriminations: gender, disability, origin, precariousness) rather than a siloed approach by "priority groups", still rare in the frameworks analysed (p. 10).

6️⃣ Broaden the scope of action to contemporary determinants underutilised by current frameworks — commercial, digital and cultural determinants of health — almost absent from the studied corpus (p. 11).

4️⃣ ADDITIONAL REFERENCES

•  🔍➕ For more information, see the articles referenced by "Health Practices" on the theme History of Health Promotion  ➡️🔗 https://pratiquesensante.odoo.com/1-5-hisoire-promotion-sante

• IHI — New Framework to Standardize Health Equity Measurement (Institute for Healthcare Improvement, October 2025). Practical framework in four steps to measure health equity gaps; directly complements the finding of the document on the lack of standardised indicators. https://www.ihi.org/about/news/ihi-releases-new-framework-standardize-health-equity-measurement
• WHO — World Report on Social Determinants of Health Equity (World Health Organization, May 2025). Global reference report on social determinants of equity, extends the theoretical grounding (SDH, proportionate universalism) mobilised by the review. https://www.who.int/teams/social-determinants-of-health/equity-and-health/world-report-on-social-determinants-of-health-equity
• Los Angeles County Department of Public Health — Public Health Equity Framework Overview (November 2025). Framework integrating Results-Based Accountability (measures of volume, quality and impact), a concrete response to the lack of accountability highlighted by the Australian review. http://publichealth.lacounty.gov/centerforhealthequity/PDF/PublicHealthEquityFramework_Overview2025.pdf

5️⃣ FREQUENTLY ASKED QUESTIONS (FAQ)

1️⃣ What is a "health equity framework" in the sense of this review? A public policy tool of primarily procedural nature: it defines concepts, sets principles, and guides planning processes, without necessarily directly affecting resources or services (p. 2).

2️⃣ How many frameworks have been identified and how were they selected? 45 frameworks, strategies, and implementation plans published between 2000 and 2025 have been identified, of which 18 were analysed in depth, through a Google search, a Scopus search, and an existing Zotero database, following the Joanna Briggs Institute's scoping review methodology (p. 3-4).

3️⃣ What definition of health equity dominates in the analysed frameworks? A "fair and just opportunity to achieve full health potential," based on the social determinants of health and the removal of systemic barriers (p. 5).

4️⃣ What is the main issue identified by the review? A persistent gap between stated principles (justice, cultural safety, participation) and concrete mechanisms for implementation and accountability — the so-called "accountability gap" (p. 9-10).

5️⃣ How do frameworks led by Aboriginal and Torres Strait Islander peoples differ from others? They explicitly integrate self-determination, community and cultural governance, and co-constructed accountability mechanisms, particularly anchored in the United Nations Declaration on the Rights of Indigenous Peoples (p. 6, p. 8).

6️⃣ What is the Health System Equity Action Framework proposed by the authors? A model crossing four modes of action of health systems (respond, prevent, promote, integrate) and six organisational areas (governance, partnership, human resources, service delivery, determinants, data) (p. 8-9, Figure 2).

7️⃣ What limitations do the authors acknowledge themselves? The analysis focuses solely on the content of published documents, without assessing their actual implementation or impact; the corpus is exclusively Australian and internal or non-public frameworks could not be captured (p. 8).

6️⃣ REWRITING IN PLAIN LANGUAGE

What does this document say?

In Australia, some people live shorter lives than others. The difference can be up to 7 years depending on income level. Aboriginal peoples live about 8 years less than other Australians.

Since 1986, a text called the Ottawa Charter has called for health systems to act for greater equity. But this text does not specify how to do so concretely.

To address this gap, 'health equity frameworks' have been created. These are documents that explain how to act for greater equity.

Researchers studied 45 of these documents in Australia. 18 documents were studied in detail.

What the researchers found

Most documents explain well what equity is. But few explain how to put it into practice.

Few documents state who is responsible for the outcomes. Few documents explain how to check if it works.

Documents created by Aboriginal peoples are different. They give more decision-making power to communities. They specify who is responsible for what.

What researchers propose

A new model to help health systems take action. This model has two parts.

The first part: 4 ways to act.

• Address existing inequalities.
• Prevent future inequalities.
• Promote equity in other sectors.
• Integrate equity throughout the organisation.

The second part: 6 areas of action.

• Governance and accountability.
• Partnership with communities.
• Staff training.
• Service design.
• Action on the causes of inequalities.
• The use of data and knowledge.

7️⃣ CROSS-CUTTING ANALYSIS — VALUES OF HEALTH PRACTICES

Literacy : The document does not propose specific tools tailored to varying health literacy levels; this theme is not treated as a standalone area of action in the frameworks analysed.

Empowerment : Models that truly transfer decision-making power to communities appear in only 6 of the 18 frameworks analysed in depth, primarily driven by indigenous frameworks (p. 6).

Participation : Three models of participation are identified — co-design (10/18), intersectoral collaboration (12/18), general consultation (13/18) — participation often remaining a declarative principle rather than an operationalised mechanism (p. 6-7).

Community health : The collective dimension is integrated through action on social determinants and the strengthening of community action, in line with the Ottawa Charter, but engagement with living environments (schools, workplaces, neighbourhoods) remains limited (p. 10-11).

Ethics : Structural biases — institutional racism, colonisation — are explicitly named and addressed in Aboriginal frameworks, but rarely in general frameworks, which adopt more ahistorical framings (p. 8).

Human rights : Human rights and the United Nations Declaration on the Rights of Indigenous Peoples explicitly underpin the legitimacy of Aboriginal frameworks; general frameworks refer to them in a more marginal way (p. 6).

Intersectorality : Intersectoral collaboration (housing, education, employment) is identified as a key area of action, but with limited attention paid to the commercial and environmental determinants of health (p. 7-8, p. 11).

Partnership : Partnership models remain poorly formalised; the actual degree of shared decision-making power with communities varies greatly from one framework to another and is rarely detailed (p. 7).

Combating discrimination : Institutional racism and the need for anti-racist mechanisms are explicitly mentioned, but the intersectional approach (intersection of discriminations: gender, disability, origin, precariousness) remains largely absent from the frameworks studied (p. 10).

8️⃣ EVALUATION OF RESOURCE RELIABILITY

Scientific relevance : scoping review conducted according to the methodology of the Joanna Briggs Institute, thematic analysis via NVivo, corpus of 45 documents (18 analysed in depth), published in a peer-reviewed journal (Health Promotion International, Oxford University Press). Funded by the Ian Potter Foundation and the NSW Ministry of Health (Prevention Research Support Program), no declared conflicts of interest. Limitation acknowledged by the authors: the analysis focuses on the published content of the frameworks, without assessment of their actual implementation or their effective impact.

Operational relevance : directly usable as a self-diagnostic grid (Figure 2 and Table 1) to situate a field structure on equity. However, the document remains analytical and conceptual: it provides few ready-made operational “recipes” beyond the cited examples, and requires adaptation to the local context for direct use.

9️⃣ STRATEGIC HASHTAGS

#healthpractices #HealthEquity #SocialDeterminants #IndigenousHealth #HealthGovernance #OttawaCharter #HealthAccountability #CoDesign #healthpromotion