prove that external urban development interventions such as transportation improvements or improved walkability of neighborhoods (which is highly effective in developed countries) can have health benefits. affordable housing options (including public housing) can make large contributions to both social determinants of health, as well as the local economy, and access to public natural areas -including green and blue spaces- is also associated with improved health benefits. the commission on social determinants of health made recommendations in 2005 for action to promote health equity based on three principles: "improve the circumstances in which people are born, grow, live, work, and age; tackle the inequitable distribution of power, money, and resources, the structural drivers of conditions of daily life, globally, nationally, and locally; and measure the problem, evaluate action, and expand the knowledge base." these recommendations would involve providing resources such as quality education, decent housing, access to affordable health care, access to healthy food, and safe places to exercise for everyone despite gaps in affluence. expansion of knowledge of the social determinants of health, including among healthcare workers, can improve the quality and standard of care for people who are marginalized, poor or living in developing nations by preventing early death and disability while working to improve quality of life. challenges of measuring value of interventions many economic studies have been conducted to measure the effectiveness and value of social determinant interventions but are unable to accurately reflect effects on public health due to the multi-faceted nature of the topic. while neither cost-effectiveness nor cost-utility analysis is able to be used on social determinant interventions, cost-benefit analysis is able to better capture the effects of an intervention on multiple sectors of the economy. for example, tobacco interventions have shown to decrease tobacco use, but also prolong lifespans, increasing lifetime healthcare costs and is therefore marked as a failed intervention by cost-effectiveness, but not cost-benefit. another issue with research in this area is that most of the current scientific papers focus on rich, developed countries, and there is a lack of research in developing countries. policy changes that affect children also present the challenge that it takes a significant amount of time to gather this type of data. in addition, policies to reduce child poverty are particularly important, as elevated stress hormones in children interfere with the development of brain circuitry and connections, causing long term chemical damage. in most wealthy countries, the relative child poverty rate is 10 percent or less; in the united states, it is 21.9 percent. the lowest poverty rates are more common in smaller well-developed and high-spending welfare states like sweden and finland, with about 5 or 6 percent. middle-level rates are found in major european countries where unemployment compensation is more generous and social policies provide more generous support to single mothers and working women (through paid family leave, for example), and where social assistance minimums are high. for instance, the netherlands, austria, belgium and germany have poverty rates that are in the 7 to 8 percent range. within clinical settings connecting patients with the necessary social services during their visits to hospitals or medical clinics is an important factor in preventing patients from experiencing decreased health outcomes as a result of social or environmental factors. a clinical study done by researchers at the university of california san francisco, indicated that connecting patients with the resources to utilize and contact social services during clinical visits, significantly decreased families social needs and significantly improved children's overall health. in addition, within the clinical setting, it was noted that in order to better health outcomes for the patients in any clinical setting, a collection of shd data should be documented. this helps maintain the connection between healthcare systems and organizations that address these needs that were documented. public policy the rio political declaration on social determinants of health embraces a transparent, participatory model of policy development that, among other things, addresses the social determinants of health leading to persistent health inequalities for indigenous peoples. in 2017, citing the need for accountability for the pledges made by countries in the rio political declaration on social determinants of health, the world health organization and united nations children's fund called for the monitoring of intersectoral interventions on the social determinants of health that improve health equity. the united states department of health and human services includes social determinants in its model of population health, and one of its missions is to strengthen policies which are backed by the best available evidence and knowledge in the field social determinants of health do not exist in a vacuum. their quality and availability to the population are usually a result of public policy decisions made by governing authorities. for example, early life is shaped by availability of sufficient material resources that assure adequate educational opportunities, food, and housing among others. much of this has to do with the employment security and the quality of working conditions and wages. the availability of quality, regulated childcare is an especially important policy option in support of early life. these are not issues that usually come under individual control but rather they are socially constructed conditions which require institutional responses. a policy-oriented approach places such findings within a broader policy context. in this context, health in all policies has seen as a response to incorporate health and health equity into all public policies as means to foster synergy between sectors and ultimately promote health. yet it is not uncommon to see governmental and other authorities individualize these issues. governments may view early life as being primarily about parental behaviors towards their children. they then focus upon promoting better parenting, assist in having parents read to their children, or urge schools to foster exercise among children rather than raising the amount of financial or housing resources available to families. indeed, for every social determinant of health, an individualized manifestation of each is available. there is little evidence to suggest the efficacy of such approaches in improving the health status of those most vulnerable to illness in the absence of efforts to modify their adverse living conditions. a team of the cochrane collaboration conducted the first comprehensive systematic review of the health impact of unconditional cash transfers, as an increasingly common up-stream, structural social determinant of health. the review of 21 studies, including 16 randomized controlled trials, found that unconditional cash transfers may not improve health services use. however, they lead to a large, clinically meaningful reduction in the likelihood of being sick by an estimated 27%. unconditional cash transfers may also improve food security and dietary diversity. children in recipient families are more likely to attend school, and the cash transfers may increase money spent on health care. one of the recommendations by the commission on the social determinants of health is expanding knowledge – particularly to health care workers. although not addressed by the who commission on social determinants of health, sexual orientation and gender identity are increasingly recognized as social determinants of health. with all the different health inequities and differences in quality of care addressed in social determinants of health, the american hospital association created the value initiative project which helps make healthcare more affordable to people of all types. it does this four different ways: it frames issues regarding the healthcare system and its pricing and affordability. it provides knowledge, resources, and tools for hospitals to supply affordable healthcare and increase value the initiative collects data of hospital experiences to develop new federal policy solutions builds a platform for the american hospital association to discuss with policymakers to find solutions to the lack of affordable care. this initiative educates the public and makes sure there is transparency in pricing of hospital bills, making sure patients are not billed more than they should be. it also addresses the cost drivers in the healthcare system, and urges for legislators to take action to make healthcare affordable and to prioritize health over profit. this organization asks congress to control the rising costs of pharmaceuticals by encouraging competition between manufacturers, and improving transparency in drug pricing. in this value initiative, they have started the affordability advocacy agenda (aaa) which improves the ongoing policy and advocacy activities. with the covid-19 pandemic health care spending increased and there was a rise in hospitalizations and therefore a rise in demand for health care providers. the price for care has increased and there aren't enough workers to meet the demand for care. the aaa and congress are working together to provide relief from the pandemic in order to make healthcare more affordable to all. as of january 1, 2022 there are regulations placed for healthcare providers about no surprise billing. this is the "no surprises act" of division bb of the consolidated appropriations act, 2021 and this rule was made by the biden-harris administration. patients should not be billed more than they expected to pay, it is often noticed with emergency services and this rule will stop patients from getting worried about any bills out of their budget, and they will be able to get the proper care they need for their health with peace of mind. the act was passed by congress at the end of 2020 and offers protection against insured americans getting surprise bills from out-of-network providers they struggled to find an amount that an insurer should pay to the out-of-network provider, but eventually found an amount and the law is now in effect as of january 2022. when it comes to out-of-network providers, patients often rely on these services in an emergency and then get stuck with the bill afterwards. air ambulance bills are a big problem for consumers, not just because they are out of network and cost a lot, but also for their lack of billing transparency. since the airline deregulation act, which allows air ambulance to make their own prices, federal solutions to this increasing cost of emergency care is needed. a possible solution is to allow air ambulance services to be administered and financed in a way that combines competitive bidding and public utility regulation.