Abstract: Identifying the space-time variability of regional ecosystem health along with the influencing pathways of its driving factors is significant for ecosystem management and restoration. The ecosystem health level of the Beijing-Tianjin-Hebei (BTH) region from 2000 to 2022 was assessed using the Vigor-Organization-Resilience-Services (VORS) model, and its dynamic evolution characteristics were analyzed from overall and sub-regional perspectives ( mountains and plains). The influencing pathways of human activity and natural factors on ecosystem health were analyzed by Partial Least Squares-Structural Equation Modeling (PLS-SEM), and the major driving factors of ecosystem health were identified by the optimal parametric geographical detector model. The results indicated that from 2000 to 2022, the ecosystem health showed a positive trend in the BTH region. In mountainous areas, it increased continuously, and in plains, it first decreased and then increased. The spatial distribution showed higher health in mountainous areas compared to plains, with significant improvements in the northern and western parts of the mountainous areas. The negative impacts of human activities on ecosystem health exceeded the positive impacts of natural factors. In overall and mountainous areas, topography and vegetation cover had high positive impacts, landscape composition had significant direct negative impacts, and socio-economic factors had indirect negative impacts. In plain areas, the landscape composition, topography, and vegetation cover had high direct positive impacts, and socio-economic factors caused significant negative impacts. The single factor analysis showed that the percentage of forested and constructed land, slope, and elevation were the main driving factors of overall ecosystem health. The percentage of forest land, cropland, and constructed land, and normalized difference vegetation index (NDVI) were dominant factors in mountains, while the percentage of constructed land, NDVI, and nighttime lighting were the main driving factors in plains. In the future, based on the driving factors of ecosystem health in mountains and plains, regional policies should be adopted to strengthen the implementation of ecological protection policies in mountains, and optimize land use and vegetation cover in plains, thus achieving ecologically sustainable development in the region.