Public health policies and interventions to address health inequities in high-income countries: an umbrella review.

Abstract

BACKGROUND: Health inequity: defined as systematic and avoidable difference in health outcome, remain entrenched across high-income countries, with socioeconomic gaps in life expectancy exceeding 7–10 years. Upstream interventions addressing the social determinants of health are critical. This umbrella review evaluates which macro-level policies and public health interventions most effectively reduce health inequity. METHODS: We conducted an umbrella review of systematic reviews. Four databases (Embase, Medline, Scopus, Cochrane) were searched from May 2017, the date of the last umbrella review on the subject, to September 2024. Eligible reviews reported population-level interventions in OECD countries, with outcomes stratified by socioeconomic status or related disadvantage. Included systematic reviews were appraised using AMSTAR II. We devised a conceptual Health Equity Pyramid that classified interventions by their agentic demand and population reach. RESULTS: Thirty-five systematic reviews were included. This review evaluated evidence across six policy domains. Redistributive and welfare interventions, including cash transfers, basic income and food subsidies, consistently improved food security, household financial stability and maternal–child health outcomes. Legislative and regulatory measures, such as smoke-free policies and pharmaceutical subsidy reforms, demonstrated robust population-level gains, particularly in disadvantaged groups. Community and housing interventions improved psychological health, reduced morbidity and mortality in targeted populations, and enhanced housing stability. Health system interventions, notably tailored smoking cessation and hospital discharge coordination for people experiencing homelessness, were effective in narrowing disparities. By contrast, educational and behavioural programmes and telehealth interventions often demanded high individual agency; without contextual tailoring, may exacerbate intervention-generated inequality. CONCLUSIONS: This umbrella review demonstrates that interventions characterised by low agentic demand: welfare reform, housing support, and legislative measures; yield the most consistent reductions in inequity. High agentic interventions can be effective when carefully tailored to disadvantaged populations but may otherwise exacerbate disparities. Future policy should prioritise structural, population-level strategies to achieve sustainable equity in health outcomes. TRIAL REGISTRATION: CRD42024529176.