Abstract: Identifying the spatiotemporal dynamics of ecosystem health and its driving mechanisms is important for regional ecological management and restoration. Based on the Risk-Process-Value assessment framework, this study integrated landscape ecological risk, ecosystem stability, soil erosion, and ecosystem service value to evaluate the spatiotemporal evolution of ecosystem health in Shanxi Province from 2000 to 2020. Geographic detectors and structural equation modeling were further employed to identify the dominant driving factors and their influence pathways. The results indicated that ecosystem health in Shanxi Province showed a continuous improvement trend during the study period. Areas with good ecosystem health were mainly distributed in mountainous regions such as the Taihang and Lüliang Mountains and expanded outward from core areas, whereas areas with poor ecosystem health were concentrated in basins and plains characterized by intensive urbanization and agricultural activities. The spatiotemporal variation patterns and driving mechanisms of key indicators differed significantly: ecosystem stability and soil erosion were primarily controlled by natural factors such as topography and climate, while ecological risk and ecosystem service value were mainly influenced by human activities. Analysis of driving mechanisms further revealed that building density, slope, and annual potential evapotranspiration were the dominant drivers affecting ecosystem health. Natural factors posed an overall positive influence on ecosystem health by reducing landscape ecological risk and enhancing ecosystem services and stability, whereas human activities mainly exerted negative effects by weakening ecosystem service functions, reducing ecosystem stability, and intensifying landscape fragmentation. Accordingly, this study recommends the implementation of spatially differentiated management strategies, emphasizing ecological process restoration and soil and water conservation in mountainous areas, as well as optimizing development intensity and spatial patterns in plain areas, to enhance regional ecological security and promote sustainable development.