The Health System Equity Action Framework: a review of Australian health equity frameworks and their operationalization of the Ottawa Charter.

Four decades after the Ottawa Charter called on health systems to advance equity, health equity frameworks are increasingly used across Australian health systems. However, little is known about how these frameworks conceptualize or operationalize equity within health systems. This scoping review identified 45 national, state, regional, and local health equity frameworks, with 18 analyzed in depth. Documents from health departments, Local Health Districts, Hospital and Health Services, Primary Health Networks, and Aboriginal Community Controlled Health Organisations were examined using structured data extraction and thematic analysis. We found frameworks consistently articulated equity as a fair and just opportunity for health and drew on concepts, such as the social determinants of health and proportionate universalism. Aboriginal and Torres Strait Islander-led frameworks emphasized self-determination, community governance, cultural governance, and accountability mechanisms. While most frameworks established strong principles and policy commitments, they provided limited guidance on implementation and accountability. Frameworks broadly aligned with the Charter's five strategic action areas but engaged less fully with healthy settings, developing personal skills, and contemporary determinants of health. Synthesizing findings across frameworks, we propose the Health System Equity Action Framework, which identifies four modes of health system action and six organizational domains through which equity commitments are operationalized. Equity frameworks play an important role in institutionalizing equity within health systems but often lack mechanisms linking principles to action. The Health System Equity Action Framework provides a conceptual model for translating the Ottawa Charter's commitments into organizational practice four decades after its call to reorient health services towards health equity.