Homelessness, health and the policy process: A literature review

Homelessness has serious consequences for the health of people experiencing homelessness, and presents a challenge to the provision of quality care by health services. Policymaking to address homelessness, as with other social determinants of health (SDH), is complicated by issues of complex causation, intersectoral working and the dominance of biomedicine within health policy. This paper investigates how policies addressing homelessness have been explored using formal policy process theories (PPT). It also examines how health (as an actor and an idea) has intersected with the issue of homelessness reaching policy agendas and in policy implementation. A systematised search of academic databases for peer-reviewed literature from 1986 to 2018 identified six studies of homelessness policy change from Australia, Canada, France and the United States. PPT were able to articulate the interplay of actors, ideas and structures in homelessness policymaking. When the health sector was involved, it tended to be in terms of healthcare service utilisation rather than a broader public health framework emphasising structural social determinants of homelessness. Tensions between differing the priorities of local homelessness actors and a biomedical evidence-based policy paradigm were noted. Future policy action on homelessness requires new models of intersectoral governance that account for the complexity of health determinants, a health workforce enabled to engage with the SDH, and meaningful inclusion of those with lived and living experience of homelessness in policy formulation.