Shifting power: co-developing a framework for equity in healthcare

Abstract

Background

Efforts to advance equity, diversity, and inclusion (EDI) in healthcare have grown quickly in recent years, spurred by the broader calls to confront systemic racism and address structural inequities exposed during the COVID-19 pandemic. While EDI initiatives have gained visibility across various healthcare domains, such as patient safety, quality improvement, and social innovation, there are questions about how deeply they engage with the systemic roots of inequity. The objective of this paper is to describe the development of a framework designed to guide healthcare organizations in advancing EDI through a process focused on disrupting systems of oppression and present the resulting framework for building EDI into health care practices, processes, and policies.

Methods

Our large team used a collaborative co-development approach involving a diverse advisory group of people with lived/living experiences of structural inequities, as well as healthcare providers, academics, and leaders. A rapid evidence scan was conducted to synthesize key definitions and existing frameworks. Through a series of virtual and in-person meetings, the advisory group refined a framework iteratively to embed an intersectional, anti-oppressive lens into healthcare improvement.

Results

The co-development process generated a health equity framework that emphasized the need to recognize systems of oppression and the creation of EDI initiatives that prioritize the disruption of these systems. The framework came about through multiple iterations based on advisory group feedback, eventually leading to a set of commitments that guide how it is used. These commitments include acknowledging intersectionality, embracing anti-oppression, fostering good relationships, building trauma literacy, and a commitment to learning and unlearning. The framework focuses on improving care for patients, caregivers, and communities, and is meant to guide work within organizations and across healthcare systems.

Conclusion

This paper highlights the importance of grounding EDI initiatives in a critical understanding of systems of power and oppression. An equity-oriented approach to healthcare improvement needs more than just inclusion efforts; it demands ongoing critical reflexivity and deliberate disruption of the structures that produce inequity. This co-developed framework provides a foundation for health organizations to advance EDI in a meaningful way, while recognizing the need for constant evaluation, learning, and adaptation over time.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12913-026-14964-7.

Background

Efforts to advance equity, diversity, and inclusion (EDI) in health care have long been grounded in efforts to address systemic racism and structural inequities. However, these efforts have proliferated substantially over the past several years, in part spurred by public outcry over the overt racism depicted in health care incidents such as Joyce Eschaquan’s death in Quebec, Canada. In addition, evidence emerging through the pandemic pointed to the disproportionate harm endured by many in equity-denied communities, including higher rates of Covid-19 and limited access to vaccines [1]. This proliferation is reflected in the growing number of contributions focused on this topic across literature on patient safety, quality improvement, implementation science, and social innovation, representing the variety of approaches that have emerged to support improvement in health equity [2–5]. Each of these domains brings along a set of specific foci, concepts, and practical tools aimed at introducing ways of delivering health care that are safer, more effective, more efficient, and, more recently, address health equity in direct ways.

However, the emergence of EDI efforts in healthcare also demands close examination. As these efforts continue to attract investment from across civil society, it is essential to ensure they align with the calls of those who have consistently emphasized the need to confront systemic inequalities, dismantle oppressive structures, and redistribute power within society for the health and wellbeing of all, especially noted by Black feminist scholars [6, 7]. In our view, this observation prompts a call for deeper critical reflection: How can the development of EDI initiatives in healthcare genuinely reflect these principles? We argue that where EDI initiatives exhibit an explicit commitment to disrupting systems of power and oppression, they are better positioned to address the root causes of the problems they intend to resolve. Doing so allows EDI initiatives and professionals to avoid “health equity tourism,” a phenomenon where public health researchers, untrained in the theories, methods, and literature on power, oppression, and health equity, shift their focus to engage in health equity research [8]. While their efforts may be well-intended, they carry the inherent risk of causing harm by inadvertently reproducing the systems of inequality in healthcare that perpetuate existing power imbalances.

Theoretical foundations

We approach the work presented in this article grounded in a set of interrelated critical theories and practices, focused especially on intersectionality. The theory of intersectionality, coined by Kimberlé Crenshaw, suggests that institutions such as education and healthcare are organized in ways that benefit those in positions of power (thereby producing “privilege”) and produce positions of marginalization that disadvantage some (thereby producing “oppression”) [6, 7, 9]. These social systems, also called systems of power, are viewed as intersecting in ways that produce compounding privileges for some communities and compounding oppressions for others [10]. For example, where a person experiences discrimination related to the colour of their skin, their first language, and their newcomer status, they experience intersecting oppressions that limit their opportunities for health and wellbeing in compounding ways. Intersecting systems of power are the root causes of health inequities, shape ideas about what is worthy of improvement in healthcare, and influence decisions about who is best positioned to make change [9, 11, 12]. Understanding and disrupting these intersecting systems of power is an essential foundation of efforts to mobilize EDI in effective ways.

Intersectionality guided our focus on ensuring that our work accounted for interlocking systems of oppression and avoided simplistic approaches to equity. Rather than merely including diverse perspectives in our work, we sought to actively redistribute power by centering the input of people with living experiences of systemic inequity via group facilitation techniques, shared decision making, and accountability practices through the process [13, 14]. Systems of oppression such as white supremacy, settler colonialism, ableism, and structural racism were explicitly acknowledged as the root causes of healthcare inequity. We sought to focus in our work on making those systems visible and actionable within healthcare improvement efforts. Finally, we emphasized critical reflexivity. Drawing on Nixon’s coin model of critical reflexivity, we treated reflexivity as a practice of locating oneself in systems of privilege and oppression to recognize the limits of one’s own knowledge and to center other’s realities [9]. This was an expectation of participants in the co-design process described in this article.

Existing literature on equity, diversity, and inclusion in healthcare and rationale

A growing body of academic literature examines the implementation of EDI initiatives across various healthcare domains. In the field of patient safety, several initiatives have been leveraged with the intent to advance EDI [2, 15]. These include the establishment of language access services catering to diverse populations, the deliberate recruitment of a diverse workforce, and the training of healthcare workers in cultural competence [2]. Similarly, in the domain of quality improvement (QI) more generally there have been a series of initiatives described in the literature that aim to promote EDI [3, 16]. For example, organizations have worked to develop culturally sensitive QI measures, integrate health equity assessments into QI frameworks, and proactively increase diversity within quality improvement teams [3]. The domain of social innovation is pursuing pathways to advance health equity as well [5]. These strategies include advocacy and policy influence as catalysts for systemic change and the development of innovative technologies that embrace principles of accessibility and inclusivity to expand the reach of healthcare to populations marginalized by social structures.

However, although the intent of these approaches is laudable, they risk overlooking the systems of power and oppression that shape health and healthcare. For instance, initiatives that focus on enhancing cultural competence and diversity in the healthcare workforce might inadvertently neglect to confront deeper-rooted issues such as socioeconomic disparities and systemic discrimination that perpetuate unequal access to care [17]. Similarly, while health innovation strategies emphasizing accessibility and technology-driven solutions might enhance access to care for some communities, they might inadvertently overlook the socioeconomic and infrastructural barriers that hinder other communities’ abilities to take advantage of such opportunities for access. Therefore, a more holistic and multifaceted approach that crosses health and social care is imperative to address the complex web of intersecting oppressions and their impact on healthcare equity.

Although uncommon, examples of work that engages critically with intersectionality for healthcare improvement and innovation have been documented in the literature. For example, Todic et al. (2022) described an approach taken to confronting legacies of structural discrimination and oppression at University of Chicago Medicine in their work to improve a range of services across the organization [18]. The first step taken in their efforts was to deliberately ground efforts to advance EDI in critical theories that explicitly draw attention to the operations of power in producing privilege and oppression. This strong conceptual grounding guided their efforts to generate a more impactful approach to EDI, involving the effort to move beyond cultural competence/humility, strengthen relationships as change vehicles, and model the culture of equity they sought in organizational changes and dedicated implementation teams. Arising from a strong foundational understanding of the ways in which power operates, this initiative is an exemplar of EDI initiatives that aim to produce the foundational shifts necessary to observe meaningful improvements in EDI outcomes.

Aim

Our article has two objectives. First, we describe a community-engaged process of developing a framework to advance EDI in health care informed by intersectionality and anti-oppressive practice. In equity-focused work, we suggest that the quality and authenticity of engagement and co-design processes are hugely important, and we present the process followed in our work in the spirit of transparency and accountability. Second, we present the framework designed through the co-design process, describing its features and the material developed to support its implementation. Although a detailed description of strategies to apply the framework in practice is beyond the scope of this paper, we point readers to publicly available materials to support that aim.

Methods

Study design and setting

This project employed a community-engaged co-design process; a well-established methodology in which end-users (patients, community members, etc.) are meaningfully involved as equal partners throughout a design or research project [19]. Co-design for health innovation is increasingly common and is considered critical in ensuring interventions meet the real needs of those affected [20, 21]. It has been shown to benefit both researchers and participants by producing more relevant outcomes by yielding a better grasp of community needs, shaping more applicable research questions, and improving trust in innovation processes [22]. Co-design processes often vary. However, our project engaged in multiple core components of co-design described in the literature, such as early engagement of community members in shaping innovation agendas, structured collaboration in the development of the co-design process, and iterative feedback loops to refine outcomes [19].

This work was conducted by the collaborative research team through a series of in-person and virtual meetings across Canada, with the aim of co-creating a framework to support EDI initiatives within HEC’s context and beyond. Since the inception of HEC’s inaugural organizational strategic plan, the organization has invested in a series of activities to help fulfil HEC’s commitments to culturally safe and equitable care as quality and safety perspectives to be embedded into programs, initiatives, and activities [23]. Leveraging learnings from past and current initiatives, such as the Diversity in Patient Engagement Exchange, the Promoting Life Together Collaborative and related Truth and Reconciliation work, and more recently, the Equity, Diversity, and Inclusion Virtual Learning Exchange, and programs such as the Equity in Palliative Care Collaborative, the organization sought to synthesize insights and partner with a broad group of collaborators to build an organizing framework for supporting equity-oriented healthcare [24–27].

Participants

This project was conducted by the members of the authorship team and an advisory committee as named in Table 1. The EDI advisory group was selected using purposive sampling to ensure a diverse range of perspectives across Canada. Advisory group members were selected based on their expertise or lived experience related to health EDI. Specifically, participants included those with lived and living experience of the health systems and structural and systemic inequities, academics, healthcare providers, health system leaders, and HEC staff leading quality and safety programming. All EDI Advisory Group members were invited to coauthor on this manuscript, three of whom responded to the invitation and contributed to the development and editing of the manuscript. We have listed all members of the advisory group who consented to be named in this manuscript in Table 1.

Table 1.

Names of advisory group members who consented to be named

Name
Tommy Akinnawonu
Dalyce Huot
Sutton Eaves
Jocelyn Adam
Katie Aubrecht
Myriam Fournier-Tombs
Lindsay Yarrow
Vishal Jain
Adriana Gonzalez
Corey Bernard
Matthew Murphey
Amy Ma
Cheryl Louzado
Lisa Noland
Scotty Kupsch
Kaeli O’Connor
Nandini Saxena
B Adair
Prachi Khanna
Kent Loftsgard
Ambreen Sayani
Lorraine Thomas
Maria Judd
Kortnee Tilson
Chris Cochrane
Amy Blanding
Piotr Burek
Meg Ellis
Stephanie Nixon
Raha Mahmoudi
Bruce Dumont
Meeka Kakudluk

This table names the individuals from the advisory group who provided explicit consent to have their names publicly acknowledged in publications.

Members of the authorship team began with a rapid evidence scan to understand actions and initiatives intended to support equity in healthcare and public health. The EDI Advisory Group was brought together to consider and debate what we learned through the rapid evidence scan. We then collaborated as a large team through a series of facilitated virtual discussions to co-develop a framework for equity-oriented work within HEC and to guide programs and initiatives moving forward.

Study procedures

Rapid evidence scan

We conducted a rapid evidence scan to generate definitions of key terms and to document existing frameworks on which we might wish to build. Aligned with methods of qualitative environmental scanning and rapid scholarly literature review, we conducted targeted searches guided by three questions:

1. What definitions are offered by community-based organizations, healthcare entities, and other purposefully identified institutions in the health equity domain for the concepts of “health equity,” “diversity,” and “inclusion” within healthcare quality, safety improvement, and innovation?

2. What promising frameworks exist for the integration of health equity, diversity, and inclusion into innovations concerning quality and safety improvement?

3. What synthesized definitions of health equity, diversity, and inclusion, along with corresponding frameworks, align most effectively with Healthcare Excellence Canada’s purpose, to improve the safety and quality of care with, and for, everyone in Canada?

The evidence scan was conducted using purposive snowball sampling to identify definitions and frameworks related to health equity, diversity, and inclusion within healthcare quality, safety, and innovation. To do so, three sampling approaches were used. First, Google web searches using specific keywords were conducted to extract definitions from reputable organizations’ websites. Second, Google Scholar searches were conducted to identify peer-reviewed literature pertaining to the definitions. Finally, an informal survey of the networks of those involved in the project was completed, including patient partners and researchers, to identify additional relevant sources. The results of these searches were compiled into a set of documents and a slide deck containing a table of definitions, frameworks, and brief written explanations.

Co-development process

The co-development process began with a meeting dedicated to introductions and relationship-building among the broader team, including HEC staff, collaborating researchers, and members of the EDI advisory group. The first draft framework was presented in the second meeting, representing a synthesis of the frameworks and definitions that had been found in the environmental scanning process. Over a series of 4 further meetings, the advisory group provided progressive feedback on the emerging synthesized framework. Advisory meetings consisted of a presentation of work done to incorporate past feedback, small group discussion of suggestions for improvements and iterations, followed by large group discussion to report back and bring ideas together. The advisory group meetings were hosted virtually through the Zoom platform over seven months. Materials were disseminated to the advisory group members in advance of each meeting for review and consideration. An overview of the virtual meeting structure and time commitment can be found in Table 2.

Table 2.

Overview of virtual meeting structure and time commitment

Meeting	Description	Date	Duration
Advisory Group #1: Introduction Meeting & Overview of Work	In the first meeting, we got to know each other, as well as provide an overview of the work, presentation about HEC, and collectively discuss and finalize the Terms of Reference for this group.	September 29, 2022, from 3:30 to 5:00 pm (ET)	Prep: 30 min Virtual meeting: 1.5 hour
Advisory Group #2: Rapid Environment Scan & Synthesized Framework	In the second meeting, we focused on the literature gathered and definitions of equity, diversity, and inclusion, and other concepts. The purpose was to discuss the key components for HEC to consider in its definitions and frameworks related to Equity, Diversity, and Inclusion.	October 20, 2022, from 3:00–4:30 pm (ET)	Prep: 1 Hour Virtual meeting: 1.5 hours
Advisory Group #3: Synthesized Framework – continued	In the third advisory group, the revised ‘synthesized framework’ was presented. The framework has been updated to reflect what we have heard from the previous advisory group meeting. Moving into smaller groups, we discussed the revised framework in more detail, specifically, what might be missing and where we may need to do a deeper dive. The discussion from the meeting helped to give final direction and input to the framework.	December 16, 2022, from 12:00 pm to 1:30 pm (ET)	Prep: 1 hour Virtual meeting: 1.5 hours
Advisory Group #4: Wrapping up	In the fourth advisory group meeting, we provided an update on the revised ‘synthesized framework’, including an overview of our anticipated next steps. We then presented the common elements of ‘equity-informed’ innovations uncovered in the rapid review of the evidence. Moving into smaller groups, we discussed equity-informed innovations with consideration of if the examples provided resonate as strong equity-informed practices and how HEC may support any of these activities.	March 3, 2023, from 2:00 pm to 3:30 pm (ET)	Prep: 1 hour Virtual meeting: 2 hours
Additional meetings (optional, voluntary, non-compulsory)	Members of the advisory group came together and expanded on the discussions of the topics above, including: (a) Opportunity to use definitions, ideas and emerging, EDI concepts in consideration to current program work at HEC (b) Final review of materials (c) Debrief meeting to provide closure to work	As needed and discussed in advance * Optional 60-minute meeting to discuss next steps in May 2023 * Optional Opportunity to provide input on the final layout of the synthesized Framework

This table outlines the sequence of meetings held with the EDI advisory group throughout the co-development process of the health equity framework

Subsequently, a large in-person meeting was held to bring together members of the EDI advisory group with additional participants with broad expertise and experience related to EDI, to test and further refine the framework (a total of 26 participants). Over 2 days, participants engaged in a series of small-group and large-group dialogue to critique and strengthen the framework, modifying language and providing new, more practical examples to guide its implementation. The activities were designed to prioritize relationality and justice, giving each contributor time and attention to contribute to the dialogue. Each iteration of the framework, reviewed by additional HEC staff, is presented in the Results section.

During smaller-group breakout discussions, members were asked to focus on the following questions:

1. What do you like about the framework presented?

2. What is missing in the framework?

3. What areas do we need to explore in more detail?

4. What is the most important message you would like to share with the team for further exploration?

Data collection and analysis

Several note-takers took detailed written notes of both large-group and small-group discussions, which were used to generate thematic understandings of important insights to be built into future iterations of the framework. A smaller team consisting of the advisory group co-chairs, HEC staff leading the work, and a small research team supporting research-related aspects worked on generating iterations of the framework between meetings. Themes from co-design discussions, personal narratives from advisory group members, and concepts from the literature were shared during these discussions to propose specific changes to the framework. Where disagreements existed, the team sought out additional input from the literature and individual members of the advisory committee until consensus was reached prior to presenting subsequent iterations of the framework to the advisory group. The advisory group approved the final conceptual iteration of the framework through consensus, at which time a visual design professional was engaged to promote understandability of the visual version of the framework.

We adopted an explicitly anti-oppressive and anti-colonial approach to advisory group meetings, including practices such as taking turns doing a personal land acknowledgement that may have included art/poetry, checking in as a group to bring minds and hearts together each meeting, sharing roles to flatten hierarchy, ensuring time for smaller breakout discussion to promote space for all voices to contribute, encouraging multiple modes of input/feedback, and actively welcoming a diversity of critical views.

Author reflexivity

Our authorship team represents a diverse group of researchers, leaders, educators, and change-makers, bringing together lived and living experiences of identities shaped by systems of white supremacy, racism, ableism, sexism, heterosexism, and other systems of oppression. We built strong relationships grounded in respect and shared commitment to this work and brought this energy to our collaborative effort to engage in the work described in this manuscript. Throughout this project, we engaged in reflexive dialogue about how our backgrounds and biases could impact the codesign process. This foundation of trust and reflexivity enabled us to collaborate authentically and navigate difficult conversations with openness. By locating ourselves as author-participants in the research, we hope to reinforce the values of co-design and show how our collective experiences have shaped the framework we developed.

Results

The definitions synthesized through the rapid evidence scan are available in the supplementary files (Supplementary Table 1). Although the definitions generated substantial discussion among the EDI advisory group, no specific suggestions were put forward for changes to the definitions. They were accepted by the group and referred to when needed in the remainder of the project discussions.

The initial version of the framework was intended to be a representation of the literature (Fig. 1), outlining the series of considerations for healthcare organizations as they develop EDI initiatives. The literature included a diversity of initiatives, but did not present a comprehensive framework that brought potential initiatives together. The EDI advisory group outlined two points of feedback in particular that shaped the development of the second iteration. First, they emphasized that the framework was confusing with respect to potential actions to take, such that the actions appeared ambiguous and lacking appropriate direction. Second, they emphasized that the framework did not state clearly enough the role and importance of systems of power and oppression.

Fig. 1.

Framework version 1. First version of the framework synthesizing literature on EDI efforts

Building on the feedback from the EDI advisory group, the research team developed a second iteration employing a different visual metaphor altogether. The second version was based on a metaphor of gears interacting, with a first large gear representing intersecting systems of oppression and a second gear representing more clearly stated potential actions that could be taken by healthcare organizations (Fig. 2). Although the stated actions were articulated more clearly and viewed as an improvement, the gears metaphor was seen as inappropriately separating the systems of oppression from the realities of healthcare delivery and improvement. Furthermore, some members of the EDI advisory group identified that white supremacy should be identified as an overarching system of oppression, given its framing effects in making other kinds of oppression possible.

Fig. 2.

Framework version 2 second version of the framework using a gears metaphor to represent actions and systems of oppression

The research team then produced a third iteration (Fig. 3), aiming to maintain the visual separation of intersecting systems of oppression from the actions of healthcare organizations while doing more to emphasize their interactions and interconnectedness. The team also emphasized white supremacy among the intersecting systems of oppression and laid the potential actions along the bottom with directional arrows indicating that these actions aim to “act upon” systems of oppression. A crucial addition to this iteration was the notion of disruption; the idea that actions of healthcare organizations must disrupt systems of oppression to meaningfully advance EDI became a central feature of the framework. The EDI advisory group approved of this general direction, however wanted to see a clearer recognition of the comprehensive impacts of systems of oppression. Ultimately, they decided to de-emphasize white supremacy to give appropriate recognition to each intersecting system of oppression.

Fig. 3.

Framework version 3. Third version of the framework highlighting the interaction between systems of oppression and healthcare actions

The fourth version of the framework involved two distinct visuals. The first visual intended to orient viewers to the operations of oppression at multiple levels. This language was used by the EDI advisory group to refer to the internalized dimensions of oppression (individual level), the ways oppressive systems shape social interactions (interpersonal level), and the oppressive nature of institutional structures themselves (institutional level). This was identified by the EDI advisory group as requiring additional education and context for people to properly interpret the framework (See Fig. 4).

Fig. 4.

Framework version 4. Fourth version showing oppression operating at internalized, interpersonal, and institutional levels

In addition to the visual about the intersecting systems of oppression, the fourth version of the framework included the systems of oppression wrapped around the actions that can be taken by healthcare organizations and individuals to disrupt systems of oppression (Fig. 5). Improved care for patients, caregivers, and communities was placed at the center of concentric circles to represent the centrality of this aim. The fourth figure was accompanied by text explaining the importance of the notion of intersecting systems of oppression, their disruption through EDI initiatives, and the centrality of patients, caregivers, and communities.

Fig. 5.

Framework version 4. Fourth version of the framework shows intersecting systems of oppression surrounding actions to disrupt them

In an effort to test the existing framework with a new set of participants and generate further refinements, the team held an in-person meeting to facilitate deeper engagement. Over the course of the two-day in-person meeting, participants converged on a set of critiques related to the language of certain aspects of the framework, and most especially “share power with community”. Based on this feedback, the language describing this action was changed to “Shift power and create space for communities to lead.” A series of additional changes to language in the framework were also made. Furthermore, participants emphasized the importance of a clearer introduction and overview of the framework, including the development of a set of principles or commitments that give context for the way the framework should be understood. The final framework is depicted in Fig. 6, and the set of commitments accompanying the framework is available in Table 3.

Fig. 6.

Final HEC health equity framework. Final version of the framework integrating systems of oppression with equity actions

Table 3.

Guiding commitments for engaging with the health equity framework

1. Reflect deeply. We invite those who engage with this framework to think deeper, more reflectively, and with a greater openness to questioning one’s assumptions than is typically possible in everyday work. We use the word “critical” here to refer to a commitment to understanding our own social locations, how we are situated in systems of oppression, and how we might disrupt those systems in the effort to enhance equity. Critical reflection in this sense is a challenging skill that requires practice, patience, dialogue, and an openness to unlearning. 2. Recognize intersectionality. Acknowledge that systems of oppression intersect in their impacts on the experiences of people and communities. Where people are impacted by multiple systems of oppression simultaneously, such as racism, ableism, and sexism, their experiences in health care are different from others in important ways. The unique impacts of intersecting systems of oppression for each unique person must inform how the framework is understood and applied. 3. Adopt an anti-racism and anti-oppression approach. An anti-oppression orientation is one that seeks to understand and address how intersecting systems of oppression operate. This means first seeing how they show up in everyday life, even in seemingly mundane realities like the questions asked on an intake form, and then collaborating to build approaches to address them. The framework presented in this document insists on an anti-oppressive approach. 4. Develop trauma awareness. Understanding how systems of oppression have an impact on peoples’ lives, including the ways that trauma can be shared across generations, is an important foundation for equity work. Living in circumstances of structural marginalization relates to experiences of trauma in many ways. Although the notion of trauma-informed care is an important part of service delivery from an equity perspective, here we emphasize the concept of trauma literacy as a commitment to more deeply understanding the dimensions of trauma, its impacts on health, and the implications for health equity work. 5. Build relationships based on trust and accountability. Relationships are a vehicle of change [6]. Relationships foster the sharing of knowledge and the mobilization of action. Where we approach equity work focused on building good relationships and being accountable to those around us, we produce a platform for meaningful change. 6. Commit to learning and unlearning. The ideas and practices that inform health equity work are not timeless. Communities change, and people do too. As efforts to adopt and apply the framework presented here evolve, it will be essential to revisit and revise the content of the framework and the approaches to applying it in health equity initiatives. Revising our ongoing work is a sign that we are responsive to what we are learning along the way, an important element of collaboration to achieve shared goals.

This table summarizes six guiding commitments developed to inform and support the application of the HEC Health Equity Framework. Each commitment reflects a foundational principle for advancing equity, diversity and inclusion by addressing intersecting systems of oppression

The final version of the framework includes “improved care for patients, caregivers, and communities” at the centre, surrounded by the actions that health care actors and organizations can take to advance EDI for health. The actions constitute an explicit focus on the practical dimensions of implementing EDI in health care and public health, emphasizing that organizations must see the actions as complementary, as opposed to being isolated activities that should be done independently. Rather, the actions represent the practical core of the framework, with accompanying descriptions of the framework encouraging multiple actions connected over time to support the achievement of health equity. Importantly, the final framework was explicitly focused on implementation. These actions are then further surrounded by the recognition that such actions are framed by institutional, interpersonal, and internalized oppressions, around which are the intersecting systems of oppression that constitute the ultimate targets of anti-oppressive activity.

Discussion

The aims of this project were two-fold. First, we sought to describe the process by which an EDI framework was co-developed to guide efforts at disrupting systems of power and oppression to enhance EDI in healthcare improvements. Second, we sought to describe the resulting framework and highlight the action domains that constitute its practical focus. The EDI framework presented here is publicly available via the HEC website, alongside a series of supports for its implementation in health care (https://www.healthcareexcellence.ca/resources/health-equity-framework/). By describing the process through which the framework was developed in this article, we intended to uphold the importance of transparency and accountability to community-engaged practices in EDI work. In this discussion section, we comment on existing literature and two central aspects of the HEC framework: power and critical reflexivity.

Numerous established frameworks have shaped equity work in healthcare, offering important guidance on identifying disparities and improving outcomes. For example, NHS England’s Patient Safety Healthcare Inequalities Reduction Framework 2025 outlined five key principles to reduce inequities in patient safety outcomes: ensuring accessible communication for patients (language support), staff training in safety inequities, collecting/using data to spot disparities, involving communities in co-design of safety improvements, and prioritizing research on inequality-related patient safety issues [28]. While this model is useful for guiding system improvements and better monitoring, it treats equity as a distributive issue, targeting “who” is affected and “what” to improve, with little attention to “how” inequity is produced.

In contrast, a smaller subset of frameworks explicitly calls out structural oppression and intersectionality as core determinants of health inequities. Two prominent examples are the Intersectionality-Based Policy Analysis (IBPA) framework and the Addressing Racism, Inequity, and Exclusion (ARIE) framework. The IBPA offers a policy analysis tool for policy analysis through an intersectional lens, encouraging users to examine how systems of oppression shape problems and solutions [29]. The ARIE explicitly names racism and ageism as targets for reform [30].

A growing body of work also emphasizes the need to embed equity into quality improvement projects. The “Equity in Action” meta-framework, developed through a scoping review of 40 sources, provides practical guidance to QI teams on where and how to incorporate equity at each step of improvement work [31]. It identifies what needs to happen (engage communities, broaden perspectives, challenge organizational culture, etc.). Yet even this framework, despite its practical orientation, does not address the messy relational work of how to truly share power, or how to overcome resistance in healthcare organizations. The authors themselves note that more research is needed to determine how to implement the framework.

Systematic reviews of existing equity frameworks further highlight these limitations. The National Collaborating Center for Determinants of Health (NCCDH) in Canada conducted a rapid review in 2023, identifying 47 health equity frameworks applicable to public health systems [32]. One finding was that many frameworks, even those acknowledging structural drivers, lacked detailed guidance on implementation. Frameworks frequently present important principles/domains and recognize the need to disrupt power imbalances at organizational, system, and clinical levels but say little about the practical “how-to” of organizational change, ongoing learning, and relationship building needed to make those principles come alive. These insights resonate strongly with the motivation behind our project.

The unique contribution of the HEC framework described in our paper lies in its explicit focus on addressing the underlying power dynamics that shape health disparities. Our process was inclusive and intentionally designed to resist and disrupt entrenched systems of power and oppression that contribute to health inequities. Throughout this collaborative effort, we emphasized the importance of centering the voices of those with lived and living experiences of systemic inequity in collaboration with leaders and providers across health systems. This focus was integral to ensuring that our framework does not merely add diversity and inclusion as an afterthought, but actively challenges the power dynamics that perpetuate disparities.

Addressing power for health equity

Literature that seeks to foreground the operations of intersecting systems of power and oppression in work on equity, diversity, and inclusion in health care is well established [33–35]. However, the way that power is understood and operationalized in these works demands close attention [35]. When viewed as a finite concept, power can be embedded in thought and practice for health equity in ways that imply that power must be “given” or “shared”, transferring from people who hold power to people who do not in simplistic, transactional ways [36]. Such an approach is characteristic of a deficits-based orientation to health equity action, as opposed to a strengths-based orientation that seeks to build on the existing gifts and strengths of communities.

Our experiences of co-developing the framework presented in our paper, and engaging with literature on this topic, have clarified the importance of understanding power in different ways. First, we found that it was important to conceptualize power as having dimensions that are more diffuse and structural than interpersonal and transactional [37]. The dialogue informing refinements to the framework consistently drew attention to the intersecting structures that shape who has unearned privilege and disadvantage/barriers, thereby directing action for equity toward inequitable structures of society and social institutions that create inequities in health and health care in the first place. Second, we found it was important to understand power as the capacity of people to act in the world even in a context of social and structural constraints [35]. The capacity to act is something shared by all, but influenced by social structures and institutions that represent intersecting inequities in power and oppression.

By deepening our understanding of power in these ways, the framework directs attention to more explicitly engaging with structural and institutional changes in a variety of ways, some of which are short-term and immediately practical, others of which are longer-term and requiring complex efforts of coordination. However, putting these actions into practice requires a clear understanding of how we as actors are implicated in such structures and institutions, and which specific strategies and relationships are necessary to produce change – the framework is intended to support such efforts. This observation also highlights the tension between seeking to meet people and organizations where they happen to be in their understanding of equity and related topics, while also seeking to push the field forward in its commitments to social justice. This recognition points toward the central importance of critical reflexivity as a complement to efforts to use the framework to develop specific initiatives that advance health equity.

Critical reflexivity for health equity

Critical reflexivity is a practice designed to locate oneself and others in the systems of power and oppression that must be well understood to devise actions that disrupt such systems. In this way, critical reflexivity is a fundamental skill in the effort to apply any framework informing equity, diversity, and inclusion in health care. Nixon and colleagues defined critical reflexivity as “A process of recognizing one’s own position in the world in order both to better understand the limitations of one’s own knowing and to better appreciate the social realities of others” [9]. Processes of critical reflexivity are at the root of the efforts described by Todic and colleagues to implement widespread efforts to enhance the structures and practices of health equity at University of Chicago Medicine, as summarized in our introduction section. In that work, the authors outlined how specific training in critical reflexivity and the effort to nurture relationships as vehicles of change led to the large scale uptake of equity-focused initiatives across the organization [18]. We suggest that making investments in education for critical reflexivity must take place alongside efforts to apply this framework for health equity in health care improvement and innovation.

Critical reflexivity has many dimensions, and drawing on Nixon’s coin model of privilege and oppression and the history of important work on intersectionality, we suggest two elements are especially important [6, 7, 9]. First, learners must understand that privilege and oppression exist, and that where oppression is understood as unearned, structural disadvantage, privilege should be understood as unearned, structural advantage [9]. This starting point illustrates the structural and institutional realities that produce inequities and that must be changed to meaningfully enhance equity in health. Second, learners must understand that such structural and institutional realities are multiple and intersecting [7, 37], representing social systems of oppression such as racism, ableism, ageism, sexism, and many others. These two insights, as central elements of the practice of critical reflexivity, provide a foundation for understanding and applying any framework for efforts to enhance equity in health and health care.

HEC understands that providing care that is culturally safe and equitable is key to delivering safer high-quality healthcare. As outlined in this paper, the HEC Health Equity Framework has been co-developed through an iterative and collaborative process. The framework will help advance equity by offering practical approaches to guide healthcare improvements; it is intended to provide a foundation for equity-oriented work in the planning, delivery and evaluation of HEC’s programs and initiatives. HEC is also committed to supporting health system partners in applying equity principles through learning opportunities on anti-oppressive practices (as described earlier in this paper), an implementation guide and other learning pathways linked to this framework. Additionally, the framework will inform HEC’s internal efforts to foster a diverse workforce within an inclusive equity-oriented organization.

Acknowledging these points of departure, the framework is intentionally designed to evolve as lessons are learned from its use and implementation. A core commitment is to continue learning, unlearning and relearning, as we did throughout the process of co-development. Ongoing reflection and refinement will ensure that its language, principles and recommended actions remain relevant and meaningful over time. While developed to guide equity-oriented healthcare improvement, its foundational principles may also offer insights applicable to other sectors. In the near term, we suggest that the co-development process, framework and similar initiatives provide a valuable foundation for advancing equity in healthcare improvement and innovation across a variety of health-related contexts.

This work has several limitations. First, despite efforts to prioritize diverse perspectives, the advisory group composition and facilitation process may have introduced biases and shaped the final framework. While the group brought together people with a wide range of lived experiences, certain voices – especially those facing compounded systemic barriers – may not have been fully represented. Second, while the iterative development of the framework allowed for deep reflection and refinement, the framework has not yet been implemented, and its effectiveness remains to be evaluated in a real-world setting. Application of the framework in diverse organizational and geographic contexts will be required to assess its practical utility and adaptability. Future work should focus on engaging a broad range of community and health system stakeholders and testing the framework in a variety of healthcare settings.

Conclusion

Through a collaborative, community-partnered process, we co-developed a framework to advance EDI in healthcare with a particular focus on disrupting systems of power and oppression. The framework builds on existing equity literature by centering critical reflexivity and structural change as a core piece of action. By embedding lived/living experiences into the co-development process, we aimed to challenge conventional approaches to EDI that risk reproducing inequities. This work contributes an important tool to guide equity-oriented healthcare improvements. Ongoing learning and evolution of the framework will be critical to its success as health systems continue to strive for greater social justice and equity.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

S.M contributed to conceptualization, analysis of insights, writing of the manuscript, and approval of the final paper. B.C contributed to conceptualization, analysis of insights, writing of the manuscript, and approval of the final paper. S.C contributed to conceptualization, analysis of insights, writing of the manuscript, and approval of the final paper. C.F contributed to conceptualization, analysis of insights, writing of the manuscript, and approval of the final paper. D.G contributed to conceptualization, analysis of insights, writing of the manuscript, and approval of the final paper. K.L contributed to conceptualization, analysis of insights, writing of the manuscript, and approval of the final paper. C.L contributed to conceptualization, analysis of insights, writing of the manuscript, and approval of the final paper. S.N contributed to conceptualization, analysis of insights, writing of the manuscript, and approval of the final paper. S.S contributed to conceptualization, analysis of insights, writing of the manuscript, and approval of the final paper. K.T contributed to conceptualization, analysis of insights, writing of the manuscript, and approval of the final paper. C.W contributed to conceptualization, analysis of insights, writing of the manuscript, and approval of the final paper. J.S contributed to the project conceptualization; project design and methodology; funding acquisition; project administration; supervision; data curation; formal analysis and interpretation of participant data; and writing, reviewing, and editing the manuscript drafts and final version. All authors have read and approved the final version of the manuscript.

Funding

This project was funded by Healthcare Excellence Canada.

Data availability

The data generated or analysed during this study consist of co-design notes recorded during co-design sessions in the online platform Miro, which were not retained for data sharing. Any additional information is available from the corresponding author on reasonable request: Sumaya Mehelay, Women’s College Hospital Institute for Health System Solutions and Virtual Care, 76 Grenville Street, Toronto, Ontario, Canada M5S 1B3; 19sm156@queensu.ca.

Declarations

Ethics approval and consent to participate

This project involved engagement with advisory group members in the co-development of a healthcare framework and did not involve the collection of identifiable personal health information or interventional research. According to the Women’s College Hospital Research Ethics Board, this work was exempt from formal ethics review. All participants provided informed consent to participate in meetings and to be named in publications, in accordance with the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (TCPS2, 2018) and the Declaration of Helsinki.

Consent for publication

All advisory group members listed in Table 1. provided consent to be named in this manuscript.

Competing interests

Two coauthors are employed by Healthcare Excellence Canada, a non-profit organization focused on supporting the spread and scale of innovations in primary and community health care in Canada. Healthcare Excellence Canada funded the project reported in this manuscript, which included commissioning the authors affiliated with Women’s College Hospital to support research activities described in the article.