Environmental, Social, and Governance (ESG) frameworks have evolved as essential tools for promoting corporate sustainability and responsible business practices. The conceptual foundation of ESG integrates risk management, ethical corporate citizenship, and sustainable value creation [1]. ESG implementation involves various governance dimensions, including organizational settings, strategy, and implementation structures [2]. While developed economies demonstrate more robust ESG integration, emerging markets face challenges such as fragmented governance and limited institutional capacities [3]. ESG practices are increasingly incorporated into corporate governance frameworks, influencing board composition, executive compensation, and transparency practices [4]. The theoretical underpinnings of ESG research include sustainability of competitive advantage, compliance of social construction, and alignment of governance accountability [5]. Various ESG frameworks, such as GRI, PRI, and SASB, offer different approaches to sustainability reporting and implementation [6].

To avoid treating ESG as a generic synonym for sustainability, this review distinguishes between ESG as a corporate disclosure framework and ESG as a public governance instrument. In its original corporate use, ESG primarily organizes non-financial information on environmental risks, social responsibilities, and governance practices for investors, regulators, and stakeholders. In public health governance, ESG integration is instead understood as the deliberate incorporation of those indicators into stewardship, priority setting, planning, monitoring, reporting, and accountability processes.

This distinction guided the eligibility criteria. Studies on SDGs, CSR, sustainability metrics, and governance indicators were included only when they contributed to at least one ESG-relevant governance function: transparency, accountability, participation, equity, institutional control, risk management, or sustainability alignment. Thus, ESG-related evidence was mapped as an emerging governance architecture rather than as a single standardized measurement system.

The literature highlights significant gaps in public health governance, particularly in transparency, accountability, and strategic control mechanisms. Key challenges include weak policy implementation, limited cross-sector coordination, and inadequate understanding of accountability frameworks [7]. Corruption and lack of transparency in developing countries’ health services are major obstacles to effective service delivery [8]. The governance accountability problem (GAP) reveals a disconnect between ad hoc interventions and state responsibilities for health security [9]. Public-private partnerships in global health require improved transparency and accountability for better performance [10]. In rural settings, strong accountability towards management and partners often fails to extend to the public [11]. Enhancing citizen participation, improving human resource capacity, and adopting technology-based systems are proposed strategies to strengthen governance and accountability in public health [7, 12, 13].

The application of ESG principles to the public health sector is gaining traction as a strategic evolution of value-based healthcare [14]. ESG implementation in healthcare can contribute to sustainability goals, improve financial performance, and enhance risk management [15, 16]. While the healthcare industry has traditionally focused on social aspects, there is a growing emphasis on environmental considerations due to the sector’s significant carbon footprint [15]. ESG principles can serve as a framework for non-financial reporting in healthcare organizations, although adaptation to specific organizational missions is crucial [17]. The integration of ESG in healthcare aligns with the UN Sustainable Development Goals, particularly SDG 3 on health and wellbeing [18]. However, challenges remain in implementing ESG principles, especially in emerging markets and nonprofit organizations [16, 17].

The integration of ESG principles into public health governance and risk management is gaining strategic importance globally. ESG integration enhances governance quality, stakeholder trust, and institutional resilience [3]. It is crucial for achieving sustainability goals and offers potential economic benefits in healthcare [15]. ESG adoption improves risk management, operational efficiency, and corporate reputation [19]. Adding health considerations to ESG criteria (ESG + H) could catalyze the inclusion of health in financial decision-making [20]. An integrated population health risk management framework can facilitate evidence-based health policy development [21]. However, challenges remain, including inadequate tools and resources, particularly in emerging economies [22]. Effective ESG integration requires aligning with strategic planning, establishing robust governance frameworks, and fostering a risk-aware culture [23, 24].

The concept of good governance in health systems has evolved over time, encompassing principles such as accountability, transparency, participation, and effectiveness [25, 26]. It emerged from different disciplines, including economics, political science, and development studies [27]. Good governance is seen as crucial for improving health system performance and achieving better health outcomes [28]. Key milestones include the shift from social protection to health policy and governance paradigms [29], and the recognition of governance’s role in achieving health-related Millennium Development Goals [30]. Challenges in implementing good governance include measuring outcomes, adapting to local contexts, and bridging the gap between policy and practice [31, 32]. Various frameworks have been developed to assess health system governance, though only a few have been applied in practice [27].

Governance in public sector health systems involves multiple dimensions, with transparency and accountability emerging as key principles [10, 27]. These concepts are often interconnected and contribute to improved organizational performance and public trust [33]. Various frameworks have been developed to assess health system governance, drawing from disciplines such as economics, political science, and public management [27]. The TAPIC framework, for instance, identifies five domains: Transparency, Accountability, Participation, Integrity, and Capacity [34]. Challenges in implementing effective governance include weak policy execution, limited cross-sector coordination, and inadequate understanding of accountability frameworks [7, 35]. Strategies for improvement include digitalization of processes, enhancing community participation, and adopting complementary accountability approaches [7, 11]. Research in this field has increased, particularly since the rise of public sector governance as a focal point [36].

Recent research on ESG indicators in healthcare highlights their growing importance for sustainability and financial performance. Studies show that ESG implementation in healthcare management is crucial for achieving Sustainable Development Goals [15]. However, there’s a lack of consensus on defining sustainability and its impact on organizational performance across the three ESG pillars [37]. The relationship between ESG activities and firm performance varies between developed and developing economies [38]. Research gaps exist, particularly in social and governance measures [39]. The healthcare sector’s significant environmental impact necessitates urgent research to inform policy and practice [40]. Future research should focus on developing standardized sustainability metrics, revising infection control standards, and increasing federal funding for sustainability research in healthcare [18, 41].

International governance frameworks for transparency, accountability, and sustainability in health systems and public institutions include the World Health Organization (WHO), Global Reporting Initiative (GRI), and frameworks developed by the World Bank and United Nations Development Programme (UNDP) [42–44]. These frameworks emphasize principles such as strategic vision, participation, rule of law, transparency, responsiveness, equity, effectiveness, accountability, and ethics [42]. The GRI framework has been applied to assess sustainability in healthcare organizations globally [45]. Governance in global health operates across three spaces: global health governance, global governance for health, and governance for global health [12]. Transparency and accountability are crucial for assessing and designing governance in global health partnerships [10]. Anti-corruption measures, including community monitoring and fraud control, are essential for strengthening health systems and achieving universal health coverage [46].

Recent studies highlight the growing adoption of ESG principles in public governance domains outside healthcare. In education, universities are implementing ESG practices to promote sustainability and social inclusion [47, 48]. The integration of ESG principles into environmental education is being explored in the MENA region to address pressing environmental challenges [49]. In public administration, ESG considerations are enhancing government transparency, reducing debt, and attracting foreign investment [50]. The interplay between public and corporate governance in driving ESG engagement has been examined across multiple countries [51]. Some researchers argue for applying ESG principles to both public and corporate governance. In Brazil, the potential application of ESG principles in public administration is being analyzed [52]. These studies demonstrate the increasing relevance of ESG principles in various public governance domains.

This scoping review aims to explore the extent and nature of evidence on the integration of ESG indicators into public health governance, as a policy innovation for institutional accountability and control. Following the methodological framework proposed by Arksey and O’Malley [53] and refined by Levac et al. [54], and reported according to PRISMA-ScR guidelines [55].

A scoping review was selected because the evidence base is still emerging, conceptually heterogeneous, and composed of policy documents, conceptual papers, reporting studies, and empirical evaluations. The objective was therefore to map the range of frameworks, definitions, governance applications, implementation conditions, and knowledge gaps, rather than to estimate a pooled effect or determine intervention effectiveness. Consistent with scoping review methodology, a formal risk-of-bias assessment was not conducted; instead, the synthesis explicitly distinguishes conceptual claims, implementation experiences, reporting practices, and empirical outcome evidence.

In order to ensure methodological transparency and to precisely delineate the scope of the review, the inclusion and exclusion criteria were structured according to the PCC framework (Population, Concept, Context) recommended by the Joanna Briggs Institute for scoping reviews [56, 57]. This approach allowed us to systematically define the relevant population (e.g., public health institutions, health systems, and regulatory bodies), the core concept under investigation (i.e., the integration of ESG indicators, sustainability metrics, SDGs, or corporate social responsibility frameworks), and the context (e.g., public health governance, institutional accountability, and national or international policy settings) (Table 1).

Operationally, ESG integration was defined as the use of environmental, social, and governance indicators or ESG-related reporting logics within public health decision-making, monitoring, accountability, or institutional control. Broader SDG, CSR, or sustainability studies were included only when they addressed these functions in public health institutions, health systems, or policy settings.

This scoping review synthesized evidence from 25 studies examining how ESG indicators and related frameworks are being integrated into public health governance. The results show that ESG frameworks are increasingly viewed as mechanisms for strengthening institutional accountability, promoting transparency, and aligning public health systems with global sustainability goals. However, the findings also highlight significant heterogeneity in approaches, levels of implementation, and reported outcomes.

These findings should therefore be read as evidence of the potential governance functions of ESG-related frameworks, not as proof of causal effectiveness. In particular, the review supports the proposition that ESG can structure accountability and reporting processes, but it does not demonstrate that ESG adoption alone improves population health outcomes or eliminates governance deficits.

Our findings align with prior analyses of governance frameworks in public health, which emphasize the need for standardized indicators and cross-sectoral collaboration. Several studies in this review [60, 63, 75] confirm that standardized frameworks such as the WHO Europe SDG Roadmap can help governments systematically monitor progress and reinforce accountability. These results mirror the conclusions of broader governance reviews [85, 88] which showed that structured evaluation frameworks support more transparent decision-making and better alignment of health system priorities with the SDGs.

At the organizational level, ESG tools such as disclosure indexes and processing maps [65, 66, 78] were associated with improvements in sustainability reporting and stakeholder engagement. These findings complement earlier corporate responsibility analyses [73, 90] which found that ESG and CSR approaches can create reputational and operational benefits for healthcare organizations. Nevertheless, the variability in adoption and reporting practices across contexts underscores the lack of harmonized standards [69, 82, 91].

Recent studies have examined the impact of ESG frameworks on healthcare organizations’ performance and accountability. Evidence suggests that ESG performance can positively influence financial performance, particularly in developed economies [38, 92]. The environmental pillar shows a concave impact on return on assets, while governance consistently predicts positive financial outcomes [92, 93]. ESG implementation in healthcare can contribute to sustainability goals and offer economic benefits [15, 94]. Local institutional ownership has been found to reduce toxic chemical releases and enhance firm performance through pollution abatement policies [95]. However, the relationship between ESG and performance varies across different contexts and measures [17, 18]. Overall, ESG frameworks appear to have a growing influence on healthcare organizations’ practices and outcomes.

Governance mechanisms in health systems have been shown to influence health outcomes in low- and middle-income countries through decentralization, stakeholder alignment, community engagement, and social capital strengthening [86, 96]. Key governance areas impacting healthcare quality include leadership, system design, accountability, financing, private partnerships, information systems, community participation, and regulation [97, 98]. Good governance enhances the efficacy of health expenditure and service delivery [99]. ESG frameworks can guide sustainable development in healthcare organizations [94], while the SDGs complement ESG standards by focusing on externalities [18]. Effective governance is crucial for translating resources into quality care [100]. In developing countries, non-governmental and international actors play vital roles in connecting global and local health governance [101]. A comprehensive framework for assessing health system governance includes principles such as strategic vision, participation, transparency, and accountability [42].

The evidence reviewed suggests that effective ESG integration depends on multiple enabling conditions. First, strong institutional leadership and political commitment are critical. Bickler et al. [63] and Martins and Paes-Sousa [75] illustrate how leadership can drive alignment between ESG metrics and national reporting obligations, such as Voluntary National Reviews. Second, legal and regulatory frameworks that mandate disclosure, such as the European Corporate Sustainability Reporting Directive (CSRD) analyzed by Zariņš and Siders [83] and Capobianco et al. [68], increase compliance and improve the quality of reporting in public health institutions.

Another implication for practice is the need to strengthen technical capacity for data collection, analysis, and reporting. Several studies [61, 74, 82] emphasized that data gaps and inconsistencies undermine the ability of ESG frameworks to generate actionable insights. Capacity-building efforts must therefore be prioritized, particularly in low-resource settings, as highlighted by Hone et al. [72] and Ahen [90]. Finally, a culture of stakeholder engagement and participatory governance, documented in studies such as Mesa-Vieira et al. [89] and Brizolla et al. [67], is essential to ensure that ESG initiatives are responsive to community needs and foster shared accountability.

A recurring concern across the literature is the risk that ESG remains a reporting exercise rather than a mechanism for substantive institutional change. In public health, this distinction is particularly important because improved disclosure does not necessarily translate into better service quality, equity, or community accountability. Measurement inconsistency, lack of comparable indicators, weak data infrastructures, and fragmented regulatory requirements can generate symbolic compliance or selective reporting, especially when ESG adoption is voluntary or weakly linked to public oversight.

The review also highlights the need to examine ESG integration through the lens of structural inequalities. Low-resource governance environments may lack reliable data systems, technical staff, legal mandates, or financial capacity to implement sophisticated ESG reporting architectures. In these contexts, ESG tools should be adapted to avoid increasing administrative burden or widening inequities between well-resourced institutions and under-resourced public health systems. Practical implementation should prioritize a limited set of feasible, equity-sensitive, and locally validated indicators.

Recent research highlights the growing importance of ESG and sustainability reporting in corporate governance, particularly within the European Union. The Corporate Sustainability Reporting Directive (CSRD) and European Sustainability Reporting Standards (ESRS) are driving significant changes in non-financial disclosure practices [102, 103]. These frameworks aim to enhance transparency, stakeholder trust, and corporate accountability [83, 104]. While implementation challenges persist, including regulatory fragmentation and data reliability concerns [76, 105, 106], studies indicate that effective ESG reporting can improve financial performance and investor confidence [107]. The EU’s proactive approach in mandating sustainability reporting is setting global standards [108], with some countries adopting strict penalties for non-compliance [83]. Future research should focus on refining sector-specific impacts and standardizing reporting practices to ensure comparability and credibility across industries [106].

Successful implementation of ESG indicators in public health institutions requires multifaceted strategies. Key approaches include stakeholder engagement through participatory planning and adaptive program models [109], formation of technical coordination units [110], and clear communication channels [111]. Effective data systems for real-time monitoring and impact assessment are crucial [109], as is aligning efforts with organizational objectives [111]. Multi-sectoral collaboration is essential, involving diverse stakeholders and sectors to leverage combined strengths [112]. This approach can promote transformative change [113] and address complex health challenges [114–116]. Ethical considerations in stakeholder engagement should be guided by a unifying framework integrating core research principles [70]. Successful implementation can lead to improved health outcomes and recognition, as demonstrated by Assuta Medical Centers’ ESG initiatives [94].

This review revealed several strengths in the emerging literature. Many studies used mixed methods allowing for triangulation of findings across qualitative and quantitative data sources. There was also evidence of innovative applications of ESG indicators to public health contexts, including the integration of environmental criteria in health technology assessments and the use of community engagement frameworks in urban governance [111, 112].

However, important limitations persist. ESG integration remains inconsistent across settings, with many studies documenting fragmented adoption and reporting practices. Few studies rigorously evaluated the direct impact of ESG frameworks on health outcomes such as mortality or service quality. The majority of evidence came from high-income or European settings, with fewer contributions from low- and middle-income countries, limiting generalizability.

An additional limitation is that no formal critical appraisal was undertaken, consistent with the scoping review design. Consequently, conclusions about effectiveness are intentionally cautious and framed as hypotheses for future evaluation rather than definitive evidence.

Future research should focus on developing and validating standardized ESG indicators tailored for public health governance. Comparative analyses across different contexts could help identify best practices and contextual factors that facilitate successful implementation. There is also a need for longitudinal studies that measure the impact of ESG frameworks on institutional performance and health outcomes over time.

Moreover, deeper exploration of the social dimensions of ESG is warranted. While several studies addressed equity and participation, these aspects are often underrepresented compared to environmental and governance indicators. Strengthening the evidence base in this area will be critical for ensuring that ESG integration not only improves transparency but also contributes to more inclusive and equitable health systems.

This scoping review highlights the growing relevance of ESG frameworks as instruments for enhancing institutional accountability and sustainability within public health governance. The integration of ESG indicators, when supported by strong leadership, standardized reporting mechanisms, and multisectoral collaboration, can promote transparency, stakeholder engagement, and more effective alignment of health systems with global sustainability goals. However, the evidence reveals significant heterogeneity in implementation, persistent data and reporting gaps, and regulatory inconsistencies that limit the scalability and impact of these approaches across contexts. To address these challenges, efforts should focus on developing and validating sector-specific ESG indicators, harmonizing reporting standards, and strengthening technical and institutional capacity, particularly in low-resource settings. In addition, further research is needed to evaluate the long-term effects of ESG integration on health outcomes and system performance and to better capture the social and equity dimensions of sustainability. Strengthening these foundations will be essential to ensuring that ESG frameworks evolve from voluntary initiatives into effective tools for advancing transparency, accountability, and equitable health governance worldwide.

Overall, the contribution of this review is conceptual and policy-oriented: it clarifies how ESG can be reframed from a corporate disclosure logic into a public governance tool, while showing that this transition requires theoretical precision, validated indicators, and evidence on implementation and impact.