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Abstract Background Inequalities in the distribution of the social determinants of health are now a widely recognised problem, seen as requiring immediate and significant action (CSDH. Closing the Gap in a Generation. Geneva: WHO; 2008; Marmot M. Fair Society, Healthy Lives: The Marmot Review. Strategic Review of Health Inequalitites inEngland Post-2010. London; 2010). Despite recommendations for action on the social determinants of health dating back to the 1980s, inequalities in many countries continue to grow. In this paper we provide an analysis of recommendations from major social determinants of health reports using the concept of 'system leverage points'. Increasingly, powerful and effective action on the social determinants of health is conceptualised as that which targets government action on the non-health issues which drive health outcomes. Methods Recommendations for action from 6 major national reports on the social determinants of health were sourced. Recommendations from each report were coded against two frameworks: Johnston et al's recently developed Intervention Level Framework (ILF) and Meadow's seminal '12 places to intervene in a system' (Johnston LM, Matteson CL, Finegood DT. Systems Science and Obesity Policy: A Novel Framework forAnalyzing and Rethinking Population-Level Planning. American journal of public health. 2014;(0):e1-e9; Meadows D. Thinking in Systems. USA: Sustainability Institute; 1999) ( N = 166). Results Our analysis found several major changes over time to the types of recommendations being made, including a shift towards paradigmatic change and away from individual interventions. Results from Meadow's framework revealed a number of potentially powerful system intervention points that are currently underutilised in public health thinking regarding action on the social determinants of health. Conclusion When viewed through a systems lens, it is evident that the power of an intervention comes not from where it is targeted, but rather how it works to create change within the system. This means that efforts targeted at government policy can have only limited effectiveness if they are aimed at changing relatively weak leverage points. Our analysis raises further (and more nuanced) questions about what effective action on the social determinants of health looks like.

Background: Inequalities in the distribution of the social determinants of health are now a widely recognised problem, seen as requiring immediate and significant action (CSDH. Closing the Gap in a Generation. Geneva: WHO; 2008; Marmot M. Fair Society, Healthy Lives: The Marmot Review. Strategic Review of Health Inequalitites inEngland Post-2010. London; 2010). Despite recommendations for action on the social determinants of health dating back to the 1980s, inequalities in many countries continue to grow. In this paper we provide an analysis of recommendations from major social determinants of health reports using the concept of 'system leverage points'. Increasingly, powerful and effective action on the social determinants of health is conceptualised as that which targets government action on the non-health issues which drive health outcomes. Methods: Recommendations for action from 6 major national reports on the social determinants of health were sourced. Recommendations from each report were coded against two frameworks: Johnston et al's recently developed Intervention Level Framework (ILF) and Meadow's seminal '12 places to intervene in a system' (Johnston LM, Matteson CL, Finegood DT. Systems Science and Obesity Policy: A Novel Framework forAnalyzing and Rethinking Population-Level Planning. American journal of public health. 2014;(0):e1-e9; Meadows D. Thinking in Systems. USA: Sustainability Institute; 1999) (N = 166). Results: Our analysis found several major changes over time to the types of recommendations being made, including a shift towards paradigmatic change and away from individual interventions. Results from Meadow's framework revealed a number of potentially powerful system intervention points that are currently underutilised in public health thinking regarding action on the social determinants of health. Conclusion: When viewed through a systems lens, it is evident that the power of an intervention comes not from where it is targeted, but rather how it works to create change within the system. ...

In recent years, public health research has become increasingly focused on issues of social inequality and social disadvantage. This is because social issues, such as poor housing and unemployment, have been found to impact health significantly, and are now referred to as 'the social determinants of health'. As a result of this shift, public health is now principally concerned with what are historically considered to be social policy issues. This paper discusses the confluence of public health and social policy; it examines the opportunities and risks posed by this convergence for those working in social policy seeking to reduce poverty and inequality. We argue that, while much can be gained in the two fields by working more closely together, there remain fundamental differences in perspectives and approaches. In order to maximise benefits, these points of difference need to be thought through sooner rather than later.

'Joined‐up government' (JUG) approaches have emerged in many industrialized countries as a means to tackle persistent 'wicked' public and social policy problems (Pollit ). Despite this, limited evidence exists concerning their implementation or effectiveness. 'JUG' was popularized by the Blair Government (UK) with its focus on addressing social exclusion. Following in these footsteps, in 2007 the Australian Government launched the Social Inclusion Agenda: a joined‐up approach to improving the wellbeing of all Australians and addressing disadvantage. This paper focuses on findings from a study that examined the SIA as a natural experiment in JUG. Drawing on the implementation experiences of federal policy makers, our findings lend weight to emerging research into JUG that suggests that compatibility and consistency between goals, instruments, and processes is critical to success. We argue that closer attention needs to be given to developing 'supportive architecture' around joined‐up initiatives to facilitate implementation.

Background: The evidence base for the impact of social determinants of health has been strengthened considerably in the last decade. Increasingly, the public health field is using this as a foundation for arguments and actions to change government policies. The Health in All Policies (HiAP) approach, alongside recommendations from the 2010 Marmot Review into health inequalities in the UK (which we refer to as the 'Fairness Agenda'), go beyond advocating for the redesign of individual policies, to shaping the government structures and processes that facilitate the implementation of these policies. In doing so, public health is drawing on recent trends in public policy towards 'joined up government', where greater integration is sought between government departments, agencies and actors outside of government. Methods: In this paper we provide a meta-synthesis of the empirical public policy research into joined up government, drawing out characteristics associated with successful joined up initiatives. We use this thematic synthesis as a basis for comparing and contrasting emerging public health interventions concerned with joined-up action across government. Results: We find that HiAP and the Fairness Agenda exhibit some of the characteristics associated with successful joined up initiatives, however they also utilise 'change instruments' that have been found to be ineffective. Moreover, we find that - like many joined up initiatives - there is room for improvement in the alignment between the goals of the interventions and their design. Conclusion: Drawing on public policy studies, we recommend a number of strategies to increase the efficacy of current interventions. More broadly, we argue that up-stream interventions need to be 'fit-for-purpose', and cannot be easily replicated from one context to the next.