“You don’t do it for them, you do it with them” Policymaker Perspectives on Implementing Health Equity Frameworks across the European Union and United Kingdom

Abstract Background Despite growing policy commitments to health equity across the European Union (EU) and United Kingdom (UK), the implementation of Health Equity Frameworks (HEFs) remains inconsistent and fragmented. This study investigates how policymakers understand and apply HEFs in practice and identifies the barriers and facilitators shaping their implementation within multi-level health governance systems. Methods Eighteen semi-structured interviews were conducted with high-level stakeholders from EU institutions, national public health agencies, and Non-governmental organizations (NGOs) engaged in health equity work. Using a directed content analysis informed by the Health Equity Implementation Framework, data were coded across seven domains: innovation characteristics, clinical encounters, patient and community factors, inner context, outer context, societal context, and culturally relevant factors of recipients. Results The participants consistently reported gaps between equity goals and reality. HEFs were often perceived as overly theoretical, Western-centric, and disconnected from the lived realities of marginalized communities, including migrants, LGBTQI + populations, and racialized groups. Barriers included institutional inertia, fragmented governance, lack of equity training across all levels, lack of trans-disciplinarity, inadequate data, and minimal community engagement. Facilitators included co-design with communities, plain-language frameworks, mandatory cross-sector training, integration of lived experience, inclusion of administration staff in health equity training, and stronger funding and accountability mechanisms. Participants emphasized the importance of political will, culturally competent care, and intersectionality in addressing intersecting forms of exclusion. Conclusion Findings highlight that for HEFs to be effective, they must be adaptable, inclusive, and operationalized across all system levels. Recommendations include embedding lived experience in framework design, simplifying language, investing in equity-driven data systems, and mandating cross-sectoral collaboration. A shift towards participatory, rights-based implementation, grounded in structural awareness and long-term political commitment, is essential to translate health equity frameworks into impactful outcomes.