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Table 3 Example recommendations and coding

From: Systems change for the social determinants of health

Leverage point   Marmot review [2] WHO review [23] EU Marmot review [24] Acheson report [22] Black report [21] Implications
ILF [20] Meadows       
Paradigm 1,2 Develop and implement standards for a minimum income for healthy living Improve the level and distribution of social protection according to needs to improve health and address health inequities. None stated None stated None stated Explicitly stated or inferred (i.e., paradigm change would be required for recommended change to occur)
Goals 3 Extending the role of schools in supporting families and communities and taking a ‘whole child’ approach to education Provide universal high-quality and affordable early years, education and child care system. Ensure actions to reduce health inequalities are included in the mainstream of all policies. High priority is given to policies aimed at improving health and reducing health inequalities in women of childbearing age, expectant mothers and young children. National health goals should be established and stated by government after wide consultation and debate. Measures that might encourage the desirable changes in people’s diet, exercise and smoking and drinking behaviour should be agreed among relevant agencies. Changes to the goals of the system to make them more equitable
Providing equitable access to effective care in relation to need should be a governing principle of all policies in the NHS
System structure 4,5,6 Increase the proportion of overall expenditure allocated to the early years and ensure expenditure on early years development is focused progressively across the social gradient Undertake regular reporting and public scrutiny of inequities in health and its social determinants at all governance levels, including transnational, country and local. Consider additional actions that engage with a wider variety of sectors, such as on public safety, energy, sustainable development, agriculture, tourism, consumer protection, justice, immigration and finance. A review of data needs to improve the capacity to monitor inequalities in health and their determinants at a national and local level. General Household Survey steps should be taken to develop a more comprehensive measure of income. Recommendations here reflected ‘joined-up’ action across sectors through information sharing, greater monitoring and data collection.
Feedback & delays 7,8,9 Providing work-based learning for young people and those changing jobs/ careers, including apprenticeships Take action to develop systems and processes within societies that are more sustainable, cohesive and inclusive, focusing particularly on groups most severely affected by exclusionary processes. Explicitly link health inequality objectives to existing cross-cutting strategies Establishing mechanisms to monitor inequalities in health and to evaluate the effectiveness of measures taken to reduce them. Boost evaluation research and statistical and information units Closely linked to system goals. Included evaluation efforts, scaling up of programs and reorientation of funding.
We recommend assessing the impact of employment policies on health and inequalities in health
Providing easily accessible support and advice for 16–25 year olds on life skills, training and employment opportunities
Structural elements 10a,10b,11,12 Review and implement systems of taxation, benefits, pensions and tax credits to provide a minimum income for healthy living standards and facilitate upwards pathways Ensure concerted efforts are made to reduce inequities in the local determinants of health through co-creation and partnership with those affected, civil society and a range of civic partners Foster ‘health-in-all-policy’ and ‘whole-of-government’ Further investment in high quality training for young and long-term unemployed people Resources to be allocated should be based upon the future planned share for different services including a higher share for community health. Physical changes to subsystems, including the introduction of programs (e.g., seeking to change social network structures or the build environment)
Ensure that coordinated actions are taken, across policy domains and for all social groups, which improve health across the causal pathways that affect health. The provision of additional resources for schools serving children from less well off groups to enhance their educational achievement.
System parameters, such as income taxation
A non-means-tested scheme for free milk should now be introduced beginning with couples with their first infant child and infant children in large families.