review of the policies and outcomes in other countries, but we believe that such an exercise would be worthwhile to identify useful lessons (see Chapter 9). Reports like the Transportation Research Board study (see Box 8-1) would be valuable for each of the leading causes of the U.S. health disadvantage. However, there are valid questions about the generalizability of “imported” models from overseas, and comparisons with other countries—even other high-income countries—may be seen as less applicable if the comparison countries are much smaller, have a more homogenous population, or have very different social or political systems.

The Measurement and Evidence Knowledge Network (Kelly et al., 2007, pp. 31-32) examined these issues in its final report to the World Health Organization Commission on the Social Determinants of Health. Its conclusions included the following challenges to implementation of such policies:

•   [Social factors and other nonmedical determinants of health (SDH)] are multifaceted phenomena with multiple causes. [Although] conceptual models of SDH are useful, they do not necessarily provide policy makers with a clear pathway towards policy development and implementation. As specific policy initiatives tend to be targeted to a specific (population) group in certain circumstances and for prescribed time-periods, they can neglect the wider context within which the social and other determinants are generated and re-generated.

•   … [R]ecent studies of SDH have emphasized the significance of the life-course perspective (Blane, 1999). Such a perspective poses serious challenges to policy-making processes whose time-scales are rarely measured over such long periods. The tenure of elected or appointed officials is measured in months and years rather than decades. Moreover, coalitions of interests in support of [these policies] may be unsustainable over the time periods necessary to [achieve] significant change. There have been some exceptions to this [general finding], especially in the field of public pension policies, but the general problem of time-scales remains important.

•   … SDH necessarily imply policy action across a range of different sectors. It is increasingly recognized that action beyond health-care is essential and, as such, intersectoral partnerships are critical to formulating and implementing effective … [policies]. However, there is a significant body of evidence which shows that partnerships are hampered by cultural, organizational, and financial issues (Sullivan and Skelcher, 2002).

•   Traditionally, government agencies have been organized vertically according to service delivery (Bogdanor, 2005; Ling, 2002) and



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