Abstract: Accurately assessing ecosystem health and its driving mechanisms is important for regional ecological security. Based on the "risk-process-value" evaluation framework, this study constructed a multi-dimensional ecosystem health assessment system. Using the geographical detector and structural equation modeling (SEM), this research explored the health status and driving mechanisms of ecosystems in Shanxi Province from 2000 to 2020. The results show that: (1) From 2000 to 2020, the ecosystem health index in Shanxi Province exhibited a stable upward trend, with the average value increasing from 0.16 to 0.20. Areas with excellent and good grades increased notably. (2) Regions with excellent and good health grades were mainly distributed in mountainous areas, whereas poor and relatively poor grades were primarily located in plains and basins. Transitional zones between these areas mostly exhibited moderate health grades. Improvement in health grades occurred progressively year by year, predominantly in adjacent regions. (3) Analyses using the geographical detector and SEM revealed that ecological stability and soil erosion were significantly influenced by natural factors such as topography and climate, whereas ecological risk and ecosystem service value were markedly affected by human activities. This study offers new insights into understanding ecosystem health and provides scientific references for ecological restoration and sustainable management.