3.1. Strengths and limitations

The policy options outlined in this review were derived from recommendations made by several intergovernmental and international organizations. They indicate potential mechanisms for improving child development, fair employment and decent work, social protection and the living environment. Official publications of international and intergovernmental organizations were considered reliable sources of policy options because they are generally based on detailed evidence reviews and/or expert panel methods, with clear referencing of the underlying evidence. However, the strength of the evidence underlying the recommendations was not assessed in this review, and this is likely to vary for each policy option. As all of the outlined policy options are complex social interventions, and therefore difficult to evaluate, there may be limited high-quality evidence of their impact. Where evidence is available, it is likely to be highly context dependent, thus limiting generalizability. The intergovernmental organizations making these recommendations include WHO European Member States and these organizations have extensive experience of policy implementation in these countries; consequently, their recommendations are likely to be appropriate and feasible. This report is not a systematic review of all the research evidence, and national policy documents or documents not in English were not reviewed. It is likely, therefore, that other evidence-informed policy options (as well as other policy options for which there is currently insufficient evidence) were not included in the reviewed documents. The focus was on policy options with a direct impact on social determinants of daily living conditions in the short to medium term. Other, broader national and international policy actions that influence structural inequities over the longer term, such as free trade agreements, progressive taxation and political participation, were not included in this review. However, these will be important for sustained improvements in the social determinants of health and health inequalities.

3.2. Policy considerations

This review brings together and discusses policy options from a wide range of intergovernmental policy frameworks and recommendations relevant to action on the social determinants of health. The Review of social determinants and the health divide in the WHO European Region, the review by the Commission on the Social Determinants of Health and other reviews (10,13,19) highlight the evidence for action for improvements in four key policy areas:

• early child development;
• access to fair employment and decent work;
• social protection through social cash transfers; and
• the living environment.

Improvements in these areas are most likely to contribute to the Health 2020 strategic objective of improving health for all and reducing health inequities through action on the social determinants of health (7). But what are the specific policy options for acting in these four areas? That is the question this review seeks to answer.

3.3. Multisectoral action

There are multiple interactions and intersections between the four policy themes:

• actions to improve child development rely on effective social protection measures;
• actions to promote child development and improve social protection include investment in human capital to promote educational attainment, economic growth and employment;
• actions to promote employment and decent work can reduce demand for social cash transfers; and
• investment in housing and other infrastructure can have benefits for economic growth and decent work.

Inappropriate economic developments could, however, have negative impacts on climate change and the environment, while green development can lead to environmental improvements. Gender equality has an important impact across the social determinants of health and is the key to improving child development and employment and working conditions.

Implementing the policy options described in this review will support Member States of the WHO European Region to achieve the Health 2020 strategic objective of improving health for all, will reduce health inequities and will contribute to SDG 3 (healthy lives and well-being); it will also contribute to many other SDGs and their specific targets. Actions across the four policy themes in this review are fundamental to social investment, directly contributing to SDG 1 (no poverty), SDG 2 (zero hunger), SDG 4 (quality education), SDG 5 (gender equality), SDG 8 (decent work and economic growth), SDG 9 (industry, innovation and infrastructure), SDG 10 (reduced inequalities) and SDG 11 (sustainable cities and communities). Table 1 outlines the specific SDG targets likely to be addressed through the policy options across the four identified themes of this review.

Table 1.

SDG indicators addressed by each of the four policy option themes.

The identified policy options can be implemented in isolation but integrating support across sectors will have the most impact on health and across SDGs. Effective and integrated delivery of the outlined policy options across sectors will depend on achieving the second Health 2020 strategic objective: improving leadership and participatory governance for health (7). To improve governance and delivery of multisectoral action for health (see Annex 4), governments are recommended to:

• promote inclusion and transparency in decision-making for health and health equity);
• develop a comprehensive strategy to tackle the social determinants of health and health inequities across the whole of government and whole of society;
• develop equity-focused approaches to planning, budgeting and resource allocation;
• strengthen health information systems (measure and monitor the social determinants of health and health equity, and assess the impacts of policy actions); and
• ensure policies are evidence informed and that systems are put in place to evaluate the implementation and outcomes of policy options so that they can be refined.

Multisectoral action can be enabled by establishing common goals and mechanisms for coordination across government departments and levels of government (e.g. central, regional, municipal). Knowledge translation platforms, such as EVIPNet (Evidence-informed Policy Network), and strong health information systems supported through the WHO Health Information Inititative can help in adapting policy options to local circumstances (138–140). Defining the roles of organizations (e.g. ministries, specialized public agencies, nongovernmental organizations) and levels of government can enable integration and coordination of actions across sectors (90). Health and environmental, or integrated, impact assessments are also key tools for promoting multisectoral action (141).

3.4. Different country contexts

Although the policy options described are applicable to all Member States of the WHO European Region, the policy frameworks included in this review highlighted several dimensions that need to be considered in different country contexts. For example, the mixture of private and public sector organizations delivering ECEC services varies among countries. Evidence from the United Nations Children's Fund comparing direct public funding of ECEC with models in which parents purchase subsidized care indicate that publicly funded models demonstrate a better ability of governments to manage ECEC services nationally, better national quality, higher quality of training for workers and more equitable outcomes (25). In more mixed systems, the quality and provision of ECEC vary more widely.

When dividing the responsibility for ECEC between national and local levels of government, experience from the OECD suggests that devolving responsibility for ECEC provision to local government may widen inequities in access and quality between regions and perpetuate health inequities (25). Therefore, countries with mixed provision and devolved responsibilities have a greater need than their counterparts for robust national goal setting, regulations, programme standards, legislation and staffing criteria.

Suitable approaches for improving employment are likely to differ according to country context. Job search assistance may, for example, have limited impact where structural unemployment is high, there is a lack of demand for labour or there are high numbers of people working in the informal economy (63). Countries with high levels of unemployment and participation in informal work need to combine ALMPs with interventions to create new employment and increase regulation of the informal economy.

The ILO recommends careful consideration when setting a minimum wage, especially in low- and middle-income countries. It should be based on local evidence and take into account concerns that introducing a statutory minimum wage may reduce employment opportunities. Evidence suggests that the negative effects on employment are small for high-income countries but is less clear for lower income countries. This highlights the importance of monitoring the effects of new policies when they are introduced (88).

Although narrow targeting of social cash transfers can be ineffective in reducing poverty, there is often a trade-off between the amount of money that people receive and the number of people receiving transfers (90). Policy-makers may need to narrow eligibility criteria to ensure that those receiving the benefit receive a sufficient amount to lift them out of poverty. Although it is possible to increase the resources allocated to social transfer schemes, even in low-income countries, this may not always be politically feasible. The evidence reviewed here indicates that the additional costs of targeting (administrative, financial, psychosocial, behavioural, political) should be carefully appraised before deciding on alternative options for targeting (67).