Knowing equity, doing equity: healthcare cultures and why reforms stall in everyday care

Health systems have multiplied equity-oriented frameworks over recent decades, yet inequities remain embedded in routine care. We argue that this persistent gap reflects a structural blind spot: culture is typically treated as an external attribute of patients or communities rather than as a constitutive dimension of healthcare itself. Reframing healthcare as culturally organised reveals how classification, knowledge validation, and criteria of efficiency shape what problems become visible, whose accounts are legitimised, and which responses are deemed appropriate. We introduce an analytical framework and typology of non-reflexive, adaptive, and transformative healthcare cultures to clarify why equity reforms often underperform and how institutional reflexivity can become operational. The framework includes a set of operational indicators, organised by mechanism and level of analysis, that can be used to evaluate healthcare cultures empirically and support institutional reform across settings. For public health, the implication is direct: evaluation and governance must move upstream, beyond downstream outcomes, to examine the cultural infrastructures that organise routine decision making. Equity becomes not an added objective, but a property of how care is structured, enacted, and assessed.