Navigating and reframing tensions within equity‐centered learning health systems

Abstract

Introduction

Canada recently joined a growing list of countries that are establishing national collaboratives to exchange knowledge on and scale learning health systems (LHSs) across geographies and sectors. The first symposium of the pan‐Canadian Learning Health Hub was held in June 2024 and included a keynote presentation and breakout discussions on how to operationalize equity in LHSs.

Methods

In preparing for the keynote presentation, we examined the literature, reflected on our experiences building LHSs that have an equity focus, and on discussions we have had with other LHS practitioners on where and how equity manifests within a LHS.

Results

Through our preparation, we identified three tensions that are inherent to and result from centering equity in LHSs: (i) Divergent definitions and languages of health equity (the tension of language); (ii) rapid learning versus slow engagement (the tension of pace); and (iii) equity as a driver and an outcome (the tension of dual roles). In this analysis, we present how these tensions manifest in the practice of equity and LHSs alongside strategies for navigating and reframing these tensions to catalyze dynamic learning.

Conclusion

For individuals and organizations interested in advancing equity‐oriented LHSs, in Canada and other jurisdictions, this paper highlights how and why the goal should not be to avoid these tensions, but rather to navigate the push‐pull inherent in our contexts with intention and a commitment to transformative action.

1. INTRODUCTION

The concept of learning health systems (LHSs) as an aspirational framework for health system improvement has gained significant traction in Canada over the past decade. ¹ , ² , ³ This interest spans several levels of the healthcare ecosystem, including locally driven (community‐based) health care organizations, hospitals, regional health authorities, provincial, and federal health systems. With these diverse actors at different stages of conceptualizing and enabling their LHS goals, LHSs are predominantly being designed around specific clinical issues such as cancer, or around specific technological innovations, such as electronic medical record systems. ² Innovation and industry partners have also started to align with an LHS vision explicitly.

Using the analogy of an engine, Reid and colleagues in 2024 published an applied LHS action framework informed by the literature and expert feedback in Canada. ⁴ Comprising five main interconnected learning gears– advanced analytics and population insights; evidence synthesis; co‐design with patients, caregivers, and providers; implementation; and rapid evaluation and feedback, the framework captures the different elements that can inform if and how an LHS can be operationalized into outcomes, specifically the Quintuple Aim. These five aims are (i) achieve health equity, (ii) improve patient experience, (iii) improve provider experience, (iv) enhance population health, and (v) cost efficiency (see Figure 1). Designing, implementing, and actualizing an LHS involves multi‐disciplinary teams—patients and care partners, community organizations, researchers, practitioners, policy‐makers, system administrators, among others, partnering together. ³ , ⁴ The result of this team‐based cross‐sectoral approach is that many questions arise on the journey toward a highly functioning LHS, creating opportunities for knowledge exchange and understanding of best practices across geographies and sectors. Several groups in the United States, United Kingdom, and Australia have convened local and cross‐border learning collaboratives (sometimes called clinical learning networks) in view of their LHS interests and goals. ⁵ , ⁶

FIGURE 1.

Learning health system action framework. Reprinted from SSM—Health Systems, Vol 2, June 2024, Reid RJ, Wodchis WP, Kuluski K, Lee‐Foon NK, Lavis JN, Rosella LC, Desveaux L., Actioning the Learning Health System: An applied framework for integrating research into health systems, Copyright (2025), with permission from Elsevier.

Although LHSs are positioned to help advance the Quintuple Aim, ⁷ most of the improvements observed have been theoretical in nature, process‐oriented, or specific to a single population. ² , ⁸ For example, a 10‐year review of LHS literature reported a focus on policy and the technical tools for implementation, without much evidence on the expected outcomes. Other researchers have attempted to address this gap; two systematic reviews report that LHSs have been empirically linked to lower hospital visits, improved care coordination, and higher rates of remission for cancer patients, reductions in polypharmacy, and health system cost savings. ² , ⁵ , ⁸ Furthermore, a scoping review of LHSs in primary care showed that efforts are used differently in specific care settings or geographical networks, rather than being broadly applicable across populations. ⁹

Overall, equity is an oft‐cited goal for LHSs, and explicit commitments to health equity in LHS varies significantly by jurisdiction and political and societal priorities. ¹⁰ , ¹¹ , ¹² A recent systematic review found that health equity definitions, strategies and outcomes varied significantly across clinics, locations, and sectors, making it challenging to accomplish the desired “system‐level” learning or improvements. ¹³ Drawing from the National Institute on Minority Health and Health Disparities, health equity can be viewed as “…the principle underlying the continual process of ensuring that all individuals or populations have optimal opportunities to attain the best health possible. Applying the principle of health equity requires dismantling barriers to promoting good health and allocating resources proportional to the need(s) of populations and/or communities.” ¹⁴ [Emphasis ours]. In line with efforts to achieve and sustain improvements in the Quintuple Aim, LHSs must strategize and execute at a system‐level, beyond traditional health care organizations (i.e., hospitals), and integrate a whole‐of‐system approach that embeds accountability mechanisms inward (e.g., funder) and outward (e.g., social systems).

In Canada, a national initiative—the Learning Health Hub—was launched in 2024 to transform the Canadian health system by fostering connections, knowledge exchange, and collaboration between various actors with interests and expertise in LHSs (www.learninghealthhub.ca/). The first virtual meeting of the Hub was held in June 2024 to formally launch the initiative and convene people across Canada with various roles, perspectives, and expertise who are already actively engaged in an LHS initiative or are curious to learn more. In addition to enabling collaboration and networking, the two‐day event, which was attended by over 130 healthcare leaders, researchers, clinical practitioners, and patients, was a discussion forum on existing barriers to the implementation of LHSs.

The goal of LHSs has always been to improve health and health care outcomes using rapid cycles of learning (data collection and analytics), system improvement (co‐design and implementation) and monitoring what works or does not, to inform further action (evaluation and adaptation). ⁴ , ⁸ As knowledge on how different LHSs are established and implemented grows, there have been several calls for equity‐centered LHSs to address concerns regarding how and to what extent health equity aligns with LHS models and more specifically, how equity is being operationalized. This was one of several core topics addressed in the June 2024 Learning Health Hub virtual symposium (hereinafter simply referred to as the Symposium). In this policy analysis, we identify and examine three tensions inherent to and as a result of centering equity in Canadian LHSs, elaborating on summary points presented by IA and BW as a joint keynote presentation at the Symposium, which was titled: “Growing Pains: Navigating tensions in Building Equity‐centered Learning Health Systems”. The analysis presented here draws from our knowledge of the literature, our experiences of contributing to LHS‐oriented projects with an equity focus, and from several in‐depth discussions the authors had before and during (with symposium attendees) the keynote.

By using the word “tensions”, we are referring to seemingly contradictory recommendations or practices associated with the LHS paradigm that generate new or different challenges than anticipated. These tensions might arise from difficulties translating theory into practice or with adaptation and transferability of what has worked well in one context to a new setting. Additionally, tensions with centering equity in (learning) health systems might emerge because the term “equity” has become more mainstream in usage, although those who are invested in the LHS may not have the capacities, capabilities, or commitment (so‐called “political will”) to health equity that is needed to effect change. ¹⁵ , ¹⁶ Drawing on the literature, evolving discussions with subject matter experts on LHSs, and from our experience involved in LHS initiatives, we provide an in‐depth analysis of three tensions: (i) Divergent definitions and languages of health equity (the tension of lexicon); (ii) rapid learning versus slow engagement (the tension of pace); and (iii) equity as a driver and an outcome (the tension of dual roles). To facilitate the conversion of these three tensions to learning, we offer recommendations on how to navigate or harness them.

2. TENSION 1: DIVERGENT DEFINITIONS OF HEALTH EQUITY—THE TENSION OF LEXICON

There have been varied efforts to advance a common definition for health equity. ¹⁵ , ¹⁶ On one hand, there is recognition that doing this would foster a shared language and dialogs that emerge from similar starting points. However, the multiplicity and often varied values and paradigms that various LHS actors bring to the conversation have made this goal hard to attain. ¹⁵ This pursuit of consensus has also further complicated advancement in operationalizing and measuring progress. ¹⁷

We posit that while an understanding of health equity is crucial for policymakers, healthcare providers, and other actors aiming to address health disparities effectively, the definition is not as important as the principles and paradigms underpinning it. For example, when health equity is viewed through the lens of economic efficiency and optimal resource allocation, its definition emphasizes maximizing health outcomes relative to the resources invested. This lens comes into play, for example, in public health vaccination campaigns where policies on access and coverage are guided by return‐on‐investment calculations that lead to costs saved. Hence, groups in which the prevention of illness relative to the cost of treatment is significantly lower are prioritized. However, this lens ignores the need for targeted approaches for marginalized groups which may not necessarily be cost efficient, leading to a choice between initiatives that are cheaper for the majority over those that might be exponentially beneficial to a minority but are relatively more expensive. This seeming juxtaposition of choices puts health care and social care at odds, yet they should be taken together even if it requires complex implementation strategies. Similarly, approaches to health equity from a social justice perspective depart from an understanding of the social determinants of health alongside historical and structural conditions that perpetuate disparities in the experiences and outcomes of health care. Definitions that align with a social justice approach to health equity will therefore inspire investments in programs such as housing subsidies, employment, universal health coverage, and advocacy for systemic reform. In this paradigm, an intersectional approach that frames equity as a fundamental human right is prioritized— embracing a multi‐faceted understanding of health equity beyond narrow biomedical or economic viewpoints. The manifestation of health equity in the actions (policies, practices, ideas) attributed to it is therefore not merely in its face‐value definition, but more importantly in the paradigms that underlie how it is defined.

2.1. Normalization of a reductionist approach

Focusing on definitions and categories can normalize a reductionist view of health equity. ¹⁸ This happens because defining complex concepts is often motivated by a desire to develop checklists for measuring them. When we use such checklists to track health equity initiatives, they can misrepresent or blur the hard work needed to make progress. For example, gathering disaggregated data alone does not prove that an LHS is improving health equity. Also, there are no checklists that push practitioners to think about how they use this data to dismantle oppressive systems that keep certain groups marginalized.

One source of the tension of lexicon is that we operate within cultures that rely on and prioritize quantitative measures. Leaders and researchers in the LHS field often understand the world through data points and numbers. Much of health system learning focuses on “closing the gaps” in disparities between populations. This approach centers on whiteness (i.e., where privilege and power held by White and Westernized societies is considered the norm) and “privileges an external gaze to inequity” such that non‐white groups are considered the problem to be fixed. ¹⁹ Therefore, fixating on definitions and the language we use can normalize metrics that lack narratives and strong qualitative data. Evidence has shown that storytelling and narratives are powerful sources of information that contextualize and humanize data. ²⁰ , ²¹ Qualitative data can be used to validate how and why equity is advanced or achieved, complementing quantitative insights that reveal the what and where of unequal health experiences or outcomes. If the only way health disparities are understood and acted upon is from a quantitative lens, there is a risk that we ignore the fundamental changes needed for social justice. ²² For example, in a study of primary health care indicators, ²³ authors found that core equity indicators (e.g., number of outreach programs for specific populations) failed to capture what and how equity‐centered care changes outcomes for patients and communities. Consequently, without additional narrative information, LHS will not be held to account for a (lack of) shift in equity outcomes, nor will LHS practitioners understand ways to optimally deliver care. We must shift from a reductionist approach to a multimodal approach‐ valuing different forms of evidence and data sources and embracing their complementary function to address the complex problems we aim to solve. ²⁴ , ²⁵ , ²⁶

The tension in language and lexicon in LHSs which skews how equity is addressed also arises from our preference for simple mental models. Health system researchers deal with complex interconnected and hard‐to‐solve issues, also known as wicked problems. To make sense of these complexities, we often reduce or eliminate complexity in our framing (i.e., minimize it). The goal being to avoid the discomfort that comes with challenging dominant power structures which have been accepted as the norm. This tension leads us to question how we can emphasize and advance health equity within LHSs without downplaying the challenges involved. Definitions might serve as a coping mechanism, allowing us to focus on easy, tangible issues while ignoring deeper systemic problems and the structures that uphold these inequities. These underlying power structures have been fueled by (neo)colonialism, slavery, racism, and discrimination affecting Indigenous peoples, ethnic minorities, and other marginalized groups. These forces are crucial factors that influence how effectively an LHS operates and progresses ⁴ and serves as moderators and brakes but often go unnoticed in standard LHS frameworks. Following Carol Bacchi's critical policy analysis framework, LHS practitioners should start asking: “What is being silenced by this representation (or definition) of the problem?”. ²⁷ In our case, the problem is equity within LHSs.

3. TENSION 2: RAPID LEARNING VERSUS SLOW ENGAGEMENT: THE TENSION OF PACE

Within systems of change that strive for rapid results and quick wins, most of the discourse in the LHS literature is about efficiency and speed as reflected in references to “rapid learning”. ¹ , ²⁸ , ²⁹ The emphasis on speed suggests that legitimate learning only happens when those with power determine it. This may have impeded the adoption of the LHS model arising from tensions between LHS actors with different priorities, who characterize LHS initiatives mainly based on the speed of learning. ²⁹ Other researchers have noted barriers to advancing LHSs due to misaligned priorities of healthcare and research funders. ³⁰ The tension between LHS adoption and speed of learning cycles can be credited to misaligned priorities among system actors and organizations, a lack of capacity and expertise in leading system learning, and resistance to changing existing processes and infrastructure or trying out something different, yet potentially transformative.

The goal to “speed up” test and change cycles in LHSs is quite antithetical to the timelines and processes that are inherent to patient‐ and community‐engaged research and health systems operations. Research efforts driven by social justice principles, including equity‐centered health services research, demand careful and intentional steps such as engagement of several interest holders, establishment of trust and ownership, co‐design, and priority setting, to name a few. In essence, engagement across all stages —occurring with (i) patients, care partners, and communities throughout the LHS lifecycle; (ii) engagement within academia such as research collaborations and interdisciplinarity, and clinical networks, and (iii) self‐engagement with one's own ideas and assumptions (i.e., reflexivity). This has been characterized as “slow” “engagement”. ³¹ The LHS concept and lexicon inadvertently complicate temporal perceptions and goals by attempting to create a “cross‐sectoral fusion” of different interest holders (i.e., research/academia, health system operations, communities and patients) that have distinct paradigms, value systems, and ultimately distinct objectives. ⁴ Conceptually, this seems harmless, and perhaps necessary, in fact. In practice, however, the reality of the different perspectives and ways of working that each actor brings to the learning cycle is amplified in a way that distorts a learning opportunity as a tension. Consequently, the LHS approach represents a net new paradigm and value system that is not simply an amalgamation of each of the different ways of thinking and doing but introduces a unique set of value propositions and goals, and notably, timelines.

By assuming that a linear, predictable sequence of actions will advance the goals of equity‐centered LHSs, interest holders could face disappointment, or worse, feel disempowered if the collective (i.e., the system) caused them to sacrifice their individual values and goals without achieving meaningful outcomes, where the definition of “meaningful” varies across perspectives. One common manifestation of this assumption is the so‐called “equity‐efficiency trade‐off” which implies that centering equity requires health systems to sacrifice efficiency or productivity. ³² To overcome the misconceptions that equity‐centered learning is not conducive to rapid learning, we must acknowledge that the equity‐efficiency tradeoff is a fallacy. To find the right and desired pace of learning in equity‐centered health systems means that we tune into recommendations from the LHS body of literature and our LHS interest holders, focus on processes and principles, allocate resources, and commit to full and multiple learning cycles‐ the long road. Timely learning will have LHS actors and interest holders wanting and feeling empowered to move learning forward and being prepared to collectively tackle obstacles as they arise so that they see the work through to completion. This might involve contributing additional resources or shifting implementation strategies. In so doing, LHS actors will feel accountable to themselves, to each other, as well as to others within the health system who are motivated to participate in learning cycles. Theoretically, once health systems have learning infrastructure in place, and teams committed to equity principles with co‐defined outcomes, equity‐centered learning will accelerate ⁴ as well as close the feedback loop, ensuring that the learning can translate into improvements to achieve the quintuple aims. ³³ , ³⁴

4. TENSION 3: EQUITY AS A DRIVER AND AN OUTCOME: THE TENSION OF DUAL ROLES

In the LHS Action framework, equity is both a driver and an outcome of the LHS. ⁴ Other frameworks conceptualize equity as an outcome (e.g., something that can be achieved, often measurable), ³⁵ , ³⁶ , ³⁷ a “lens” (e.g., an analytic perspective to understand and interpret observations), ¹⁵ a “competency” (e.g., a collection of skills), ³⁸ , ³⁹ among several different intersections and applications of these concepts. Within the context of performance‐driven approaches, there is a tendency to pursue checklist outcomes at the expense of the process—the deep work of understanding, unearthing uncomfortable histories, building trust, and showing up consistently that the doing of equity work requires. Because health systems incentivize outcomes but not processes, we need to think of new ways to celebrate progress. This will require participatory and co‐designed learning approaches that embrace the complexity of equity‐centered work and recognize that equity‐centered learning can lead to outcomes outside of the Quintuple Aim. This multiplicity of equity manifestation in learning thus requires practice, patience, and acknowledging trade‐offs in being equity‐centered, doing equity‐centered work, and achieving equity‐centered outcomes. ⁴⁰ This interrelatedness of learning is central also to Indigenous pedagogies, which have long been ignored and often considered inferior to western approaches. ⁴¹ While we have identified that appreciating multiple ways of knowing is an important principle for equity‐centered LHS (Tension 1), acknowledging that there are multiple ways of learning requires us to prioritize research paradigms outside traditional westernized methods.

The tension of using equity in multiple ways for learning is not something that can be mitigated. Instead, LHS actors must recognize this tension and reflect on how it is impacting their equity work, hindering opportunities to tap into the different types of learning as a means of engaging the “equity gear” in the LHS engine. Finally, we must also be mindful that equitable processes do not always lead to equitable outcomes. Embracing these “tensions” will feel often uncomfortable for leaders who must cede individual control over how knowledge is generated and translated in their contexts, so that they can nurture relationships and participate in collective learning. As we heard during the Symposium, LHS leaders often face institutional pressure or incentives that celebrate learning that is easy, quick, uses few resources, and looks good (e.g., checkboxes). Navigating this tension requires that we avoid focusing narrowly on data infrastructure, analytic methods, and only partnering with researchers and clinicians to advance learning in value‐based health care. ² , ⁸ Balancing the being, doing, and knowing ⁴¹ in equity‐centered learning means integrating recommendations from person‐centered LHS, ⁴² community‐led transformation, ⁴³ and social justice‐oriented knowledge translation, while trusting that the patients, community leaders, clinicians, researchers, decision‐makers, and others with whom you have built a relational network will collectively guide the way.

5. WAY FORWARD: MAXIMIZING LEARNING THROUGH TENSIONS

Uncomfortable and challenging as they might be, tensions are not inherently things to be avoided or eliminated. There is a body of research backed by theories that suggest learning and innovation can be enhanced when individuals or organizations confront challenges, tension, or resistance. Examples include Manu Kapur's Productive Failure framework, which encourages designing failure into learning approaches, making room for rapid and early disappointments that could eventually foster deep understanding of concepts and retention of new habits. ⁴⁴ The Yerkes–Dodson law ⁴⁵ can also be applied here. Established by two psychologists in 1908, it describes the relationship between pressure and performance, stating that a right level of stimulation by way of moderate level pressure is required for humans to thrive. Modeling an inverted U‐shaped curve, the law states that in low pressure states, performance is sub‐optimal, but high‐pressure conditions are counterproductive, resulting in diminishing returns. Similarly, we accept that a right amount of tension or stress within LHSs could lead to optimal performance and desired outcomes. In the following subsections, we share some approaches for maximizing (as opposed to avoiding) tensions that may arise within equity‐centered LHSs.

5.1. A Principles‐oriented approach

Common languages and mental models are crucial for teamwork, performance tracking, and accountability. To navigate the tension of lexicon around equity, our call to action is for all LHS practitioners and enthusiasts to focus less on the “best” definition for equity and invest more resources and reflection on how their values, organizational priorities, and capabilities inform how equity work is being done, how progress is measured, and which principles foreground their approach as they move from no proficiency to competent in the equity domain of their LHS. ³⁶ This mandates a departure from checklist‐type approaches to an understanding of the principles underpinning how health equity is operationalized within an LHS, which may aid a transition from equity as a noun to equity as a verb. Essentially, health equity as social justice.

This conceptualization of equity evokes perhaps more readily than others, the uncomfortable deep work that advancing health equity entails while still acknowledging that how equity is defined at a granular level will inevitably vary from one context to the other because “different people may have very different ideas of what is avoidable, unnecessary, and unjust”. ²²

Anchored in this viewpoint and knowledge of the health equity literature, we present six guiding principles that could ground health equity approaches within an LHS framework even when LHS practitioners use different definitions. These principles represent anchor elements that should be central to an equity‐oriented LHS. We describe each briefly, acknowledging that they require further detailed elaboration beyond the scope of this article. Figure 2 captures the principles that lay the foundation for approaches to equity‐centered learning.

Principle #1: System Disruption. An LHS that seeks to be driven by and to achieve equity in action throughout its ecosystem, demands that we cannot maintain the status quo. We need to disrupt existing structures and traditional ways of knowing and doing which are not inclusive or equitable. The challenge inherent in this principle is that LHS are established and operationalized within the very systems that we aim to reform. So, how do we “rock the boat and stay in it”? ⁴⁶ One example is from the Canadian context where strategies that authors described as tension‐surfacing were implemented in primary care clinics that served populations experiencing structural marginalization. The intervention involved the delivery of culturally safe, trauma‐ and violence‐informed care, enhanced by staff training. ⁴⁷ Moving toward community designed and delivered models of care as against institutionalized care has also been proposed as a way to inform equitable models of care that center the experiences and realities of those who are disadvantaged from accessing quality and timely care. ⁴⁸

Principle #2: Privilege and Power. Stephanie Nixon's coin model of privilege and critical allyship uses the coin as a metaphor to illustrate how systems of inequality operate. ⁴⁹ Like the two sides of a coin, Nixon shows that while one side of a coin represents unearned disadvantage (i.e., oppression), the other side of the coin simultaneously represents the unearned advantage (i.e., privilege) experienced by different groups. Because both sides are the result of the same social structures, the coin model captures the realities and implications of focusing narratives about health equity only on the groups or communities at the bottom of the coin, i.e., those who are systematically disadvantaged. This results in saliently or intentionally losing sight of the top of the coin issues—that is, the people, structures, and processes that reinforce and benefit from the existence of a coin, even if that privilege is unearned and often invisible. Recognizing where, how, and under what circumstances privilege and power drive health access and outcomes challenges teams to think first about the top‐of‐the‐coin factors that are resistant to system disruption and that need to be negotiated or shifted for the equity gear to turn.

Principle #3: Upstream Determinants. Because differential access to care and outcomes of care between populations are all too often presented as morbidity, mortality, incidence, and prevalence measures, which are standard for public health, health inequities run the risk of taking a biomedical and clinical approach, ignoring the broader social and structural determinants of health that address the why of population differences and take a root cause approach. Without an appreciation of the complex systems that influence health of individuals, communities, and populations (e.g., by assuming that health outcomes, such as an obesity diagnosis, is primarily determined by individual, lifestyle choices), health systems will continue to develop and implement ineffective and unjust models of care. ⁵⁰

Principle #4: Proportionate Universalism. Health system solutions should be widely accessible but implemented at a scale and intensity that is proportionate to the level of disadvantage. This requires tailoring health interventions to meet the specific needs of different population groups without having to compromise or eliminate solutions that are available for everyone else. This principle debunks an often‐cited argument against equity (and diversity and inclusion) that presumes that health equity can only be achieved if one group of people benefits at the expense of others—a line of thinking that further highlights the harm of systems that are based on an us‐them dichotomy. See earlier example on public vaccination campaigns (Tension 1). From a governance and system administration perspective, Carey, Crammond, and De Leeuw have developed a policy framework to guide practical application of this principle, ⁵¹ demonstrating that universalism and health equity are complementary. Without an equity‐oriented (i.e., proportionality lens), universalism presumes that everyone in society faces the same barriers and starts from the same baseline, thus inadvertently widening inequalities.

Principle #5: Epistemic Recognition. LHSs must develop a culture of knowledge diversity, similar to how epidemiology has embraced qualitative perspectives. ⁵² Equity needs a multilingual approach, and epistemic recognition is an invitation to recognize and value that different individuals, irrespective of their social position and professional backgrounds, can contribute to and respond to knowledge. Thus, we should not only rely on quantitative (i.e., positivist) data and performance metrics, especially when these do not capture the measures that matter most for equity‐denied groups. Practitioners must equally prioritize narratives and storytelling, with an understanding that people describe their experiences in various ways. Instead of dismissing alternative learning “languages” (i.e., forms of knowledge) as low‐quality data, data and analytics systems should invest in capturing non‐positivist data to support LHS the learning and feedback cycles. Epistemic injustice occurs when certain knowledge systems, like Western biomedical knowledge, are favored over Indigenous or lived experiences. ⁵³ This creates tensions and disparities within learning systems by neglecting the forms of knowledge that can fully inform LHS cycles. The 6 R's of Indigenous Research, while designed for academic work with Indigenous communities, provide a holistic approach to this principle. ⁵⁴ It emphasizes respect, relationship, representation, relevance, responsibility, and reciprocity to value diverse forms of knowledge.

Principle #6: Participatory Governance and Accountability. Governance and accountability structures within all systems are implicit in shaping the extent to which services, processes, and outcomes are inclusive of the most marginalized. Inclusive governance models establish mechanisms that ensure diverse system partners—including patients, communities, frontline workers, non‐health actors, and policymakers—work in concert to shape decision‐making in health systems through continuous cycles of learning and improvement. Although social accountability is central to how LHSs are conceptualized, this is not always translated into practice, ⁵⁵ leaving the opportunity to address health system inequities up to chance or choice. By redistributing power through co‐creation and shared accountability at all levels (individual, community/family, institution, population, and system), learning cycles are better optimized for equity. Furthermore, jointly established measures and indicators for performance and progress assessment embedded in a data collection infrastructure (and associated data sovereignty needs) can inform if and when expectations are being met and assist all actors to hold themselves accountable.

FIGURE 2.

Six principles of an equity‐centered LHS.

Central to how these principles are enacted is the important role that patient (or people with lived experiences) engagement and participation plays in informing equity‐centered LHSs. The patient engagement and co‐production movement has been documented as transformational in improving patient‐centered outcomes, as well as an imperative from a democratic and value‐based perspectives. ⁵⁶ , ⁵⁷ However, LHS practitioners must be mindful not to assume or conclude that by working closely with persons with lived experience (e.g., patients), that their initiatives are inherently “equity advancing”. Snow and Plamondon highlight that patient engagement and co‐production approaches often ignore inequitable power dynamics in learning environments, which risks perpetuating tokenism and systemic passive violence. Lee‐Foon et al. ⁵⁸ have discussed the missed opportunities for involving people with lived experience in LHS, such as a lack of tools or common language to support (equitable) engagement, inadequate training, or fragmented involvement, which often serves to further amplify those at the “top of the coin”. These authors highlight how suboptimal patient engagement will impede the ability to realize or strengthen an LHS. Conversely, an LHS grounded in equity principles will improve equitable engagement of patients and people with lived experience.

Heterogeneity around which populations are Underrepresented, Underserved, and Underreported (U3) and the paradigms that each institution or LHS team will draw from requires a way forward that harnesses our collective vision for a socially just health system. This can be anchored in a common set of principles‐driven questions that challenge us to think more critically about health equity within an LHS. Quasi‐standards in the form of an LHS equity guideline can draw from existing work that is geared toward promoting reflection, strategies, and actions on health equity. The conversation guide on health equity ⁵⁹ by Reos Partners, and the critically informed question‐based framework for health data equity, ⁶⁰ are a few examples that could serve as starting points. Because such questions will more likely move LHS practitioners from a prescriptive approach (à la checklists) to a critical and more informed approach, they can foster shared reflections on equitable health systems, even if the resulting initiatives and projects have different foci. Using these six principles of an equity‐oriented LHS (Figure 2) with the LHS equity question guide can direct how teams co‐develop a learning (action) plan to address health inequities and injustice, working closely with LHS partners.

6. DISCUSSION

Within organizational networks and systems thinking paradigms, tensions and paradoxes should be viewed as necessary ingredients for “generative learning” creating opportunities to understand and work through seemingly intractable problems in health care. ²⁶ , ⁶¹ Our intention, therefore, is not a call to eliminate the tensions we have presented, but to rather acknowledge, reflect on, and open discourse on how advancements in health equity within LHS can still be worked towards amidst these tensions. In the Canadian health research landscape, for example, there are competing discourses around how to generate and translate knowledge of health (in)equity and health care transformation. ⁶² As identified in our paper, the increasing demand to prioritize equity in healthcare and health systems research is paralleled in the LHS literature. Sorting through the different equity‐centered frameworks, ways of thinking, and then applying learnings into local practice is challenging and uncomfortable for many LHS practitioners and scientists.

The academic literature offers helpful insights and examples for applying an equity lens to LHSs, ³⁷ , ⁶³ though the questions and discussions from the Canada‐wide LHS event highlighted that though LHS practitioners know where they need to go, it is hard to understand how to operationalize equity within their unique contexts. In this paper, we present an analysis showing that tensions in equity‐centered learning can be experienced intra‐personally, interpersonally, and institutionally, and we offer a principles‐oriented approach (Figure 2) to foreground thinking. Our discussions with Symposium attendees on their questions and experiences with health equity further affirmed this; while there is general agreement that equity is a priority, there is a desire for a networked community in emerging contexts like Canada similar to what has been achieved in the United States. This will enable cross‐pollination of best practices and experiences across varying contexts. LHS scientists and practitioners in general may struggle to navigate the balance between context‐dependent and overly reductionist recommendations on how to operationalize equity. Of note, many of the foundational publications on equity and LHSs are published as commentaries or brief reports. Additionally, most of the literature speaks to researchers (i.e., LHS scientists) or a broad audience (either a collective or non‐specific group) which inadvertently creates an escape clause—making it convenient for many others responsible for operationalizing an LHS to think “not me” and distance themselves from being responsible for equity‐oriented shifts. The notion that inequities are a result of individual adoption resistance minimizes the nature of the problem, where it is often seen as a zero‐sum game—a competitive view. ⁶⁴

Although equity is one of the dominant wheels in an LHS, serving a dual role of process and outcome, the mechanisms by which it stays aligned and sustainably in motion to “activate” other gears within the system have not received the required attention. Tension is critical to how any gear system functions; however, a balancing act is necessary to eliminate over‐ or under‐tensioning of the system. As shown in the LHS Action framework, ⁴ the five learning gears are necessary but not sufficient to power the equity wheel nor achieve equitable outcomes—there are moderators, brakes, and accelerants that shape the ecosystem of LHS practice. Paradox science further offers a way by which tensions can be reframed to help LHS practitioners get past the friction that might be created from having to choose one of seemingly opposing goals. ⁶⁵ Importantly, beyond only applying a “both/and” framing (as paradox science encourages us to), we must lean towards system disruption (Principle 1) that challenges and seeks to address the unjust systems currently at play. There is a need to expertly steer through our equity‐centered work while pushing and pulling away from the dominant, inequitable LHS structures.

An equity‐centered LHS will threaten power structures as the move towards a principles‐oriented approach which we propose is a threat to existing power dynamics in organizations, systems, and even communities. Nevertheless, these can be acknowledged and reframed as opportunities to not only acknowledge these tensions but importantly embed dynamic learning cycles into our LHS initiatives. Beyond the expansion of knowledge, evidence must also inform a commitment to action and dismantling of the systems that impede progress in health equity.

Our article calls for health system attention to the transformations necessary to correct for tension dissonance despite increasing demands on healthcare, multifaceted priorities, and resource scarcity. It is a call to depart from silencing narratives and to make health equity loud, visible, and tangible, beyond measuring and tracking differences (e.g., statistics on health disparities). There are unique implications of this analysis for different roles that individuals and organizations play within LHS:

Learning health system leaders bear the responsibility for ensuring that the health equity gear is functioning according to the equity principles, for actively seeking additional “fuel” and for preventing or responding to the brakes as they arise. A “tight‐loose‐tight” approach ⁶⁶ could be used by LHS leaders, funders, and practitioners to strategically commit to addressing locally determined equity goals that are built upon equity principles (“tight”), while permitting contextually and collectively determined ways to implement the principles and evaluate progress (“loose”). These must be backed by transparent accountabilities and expectations informed by continued health equity assessments. Learning health system funders must challenge how research and health care are currently funded and be prepared to incentivize the disruption of existing power structures and resource flows. Learning health system scientists must embrace participatory and flexible methodologies in their research activities, adapting to emerging circumstances that are determined by the diverse perspectives of LHS interest holders. Notably, there might be divergent preferences and priorities within the collective, and rather than shying away from addressing the plurality, LHS scientists and practitioners must transparently capture and illustrate the differences in each of the learning gears. Other Learning health system interest holders, including patients, families, caregivers, and community members, must be empowered to hold LHS leaders, funders, and scientists accountable to equity‐centered learning and outcomes. The Learning Health Hub has started playing a key role in enabling and amplifying these interest holders through their patient, caregiver and community partnership working group. Finally, as each LHS identifies how it will center equity in its work, we need to think about what we are not defining and how certain groups of peoples, societal ills, community priorities, and indigenous ways of knowing may be erased in the choices made defining, operationalizing, and measuring health equity within an LHS.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Abejirinde I‐OO, Wood B. Navigating and reframing tensions within equity‐centered learning health systems. Learn Health Sys. 2026;10(2):e70040. doi: 10.1002/lrh2.70040

DATA AVAILABILITY STATEMENT

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.