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Background  Health system policies and programs that reduce health inequities and improve health outcomes are essential to address unjust social gradients in health. Prioritization of health equity is fundamental to addressing health inequities but challenging to enact in health systems. Strategies are needed to support effective prioritization of health equity.    Methods  Following provincial policy recommendations to apply a health equity lens in all public health programs, we examined health equity prioritization within British Columbia health authorities during early implementation. We conducted semi-structured qualitative interviews and focus groups with 55 senior executives, public health directors, regional directors, and medical health officers from six health authorities and the Ministry of Health. We used an inductive constant comparative approach to analysis guided by complexity theory to determine critical elements for prioritization.    Results  We identified seven critical elements necessary for two fundamental shifts within health systems. 1) Prioritization through informal organization includes creating a systems value for health equity and engaging health equity champions. 2) Prioritization through formal organization requires explicit naming of health equity as a priority, designating resources for health equity, requiring health equity in decision making, building capacity and competency, and coordinating a comprehensive approach across levels of the health system and government.    Conclusions  Although creating a shared value for health equity is essential, health equity - underpinned by social justice - needs to be embedded at the structural level to support effective prioritization. Prioritization within government and ministries is necessary to facilitate prioritization at other levels. All levels within health systems should be accountable for explicitly including health equity in strategic plans and goals. Dedicated resources are needed for health equity initiatives including adequate resourcing of public health infrastructure, training, and hiring of staff with equity expertise to develop competencies and system capacity.

Values are not enough: qualitative study identifying critical elements for prioritization of health equity in health systems