Riverside greenways are complex artificial–natural composite ecosystems that occupy significant linear open spaces in urban areas. Healthy riverside greenways promote public health and improve urban environmental quality. This study developed an evaluation system with four criteria layers and 31 indicators, using a comprehensive method that combines the analytical hierarchy process (AHP), entropy weight method (EWM), and technique for order preference by similarity to ideal solution (TOPSIS) to assess the ecological health of the Shangtang River greenway in Hangzhou, China.Additionally, structural equation modeling analyzed key factors influencing riverside greenway health and their pathways. Redundancy analysis (RDA) was used to explore how design and non-design factors affect the ecological health of riverside greenways. The results showed health values for different sections of the riverside greenway ranging from 0.16 to 0.69. The use of ecological design techniques was the main factor causing significant variations in health values across sampling plots. Specifically, ecological revetments, the slope of terrain at water entry, and ecological conservation measures positively impacted the ecological health of the riverside greenway, while non-native invasive plants and building density had negative effects. Non-design factors, such as physical states, also play an equally important role in the ecological health of urban riverside greenways. Effectively assessing the ecological health of these greenways is essential for developing management strategies. This study presents a novel framework for evaluating the ecological health of urban riverside greenways by quantifying indicators related to the regional environment, physical conditions, management practices, and design techniques. It quantitatively analyzes how landscape design techniques contribute to ecological health and serves as an empirical tool for improving urban waterfront environments and advancing riverside greenway construction and management.