Exploring the role of health in policy responses to homelessness: an in-depth explanatory case study of policy action on the social determinants of health equity

Abstract

Homelessness is associated with high levels of unmet healthcare need in Australia. A critical realist, explanatory case study was undertaken of the role of health in homelessness policy in Sydney, Australia between 1995 and 2015, using data comprised of key informant interviews, policy documents, evaluations of homelessness programs, and newspaper media. This was analytically resolved using a new institutionalist framework of actors, ideas, and institutions to produce fifteen mechanisms by which health intersected with homelessness policy: homelessness can be described as an issue of environmental health and assertive health outreach; a biomedical epidemiology risks reinforcing individual causal models of homelessness; biomedical modes of intervention emphasise individual treatment over structural change; policy discourse can emphasise access to healthcare or housing as a determinant of health; evidence-based policy discourses align with biomedical discourses; costings studies are a key strategy in presenting homelessness as an economic issue; health research can explore the structural drivers of homelessness; people with lived experience of homelessness participate in health policymaking; service integration within healthcare and with social care systems is required, and integrated intersectoral governance; a medicalised welfare system; legislation can support rights-based approaches to housing and intersectoral working. People experiencing homelessness would be better served with a more person-centred model of healthcare and a rights-based approach to housing provision. Future health research should include structural competency and policy advocacy skills, the evaluation of models of homelessness care and the design of models of governance that support intersectoral working.