Questionnaire for the FEANTSA Annual Theme
The Right to Health is a Human Right:
Ensuring Access to Health for Homeless People
AC members are asked to draft a national report for their country, based on responses to the questions outlined in this questionnaire. The reports should be 10 – 15 pages in length, written in
either English or French and they should be submitted to the office by June 15th 2006. AC members are asked to consult with all FEANTSA member organisations in their country in the preparation of the reports; a copy of the questionnaire will be circulated to all FEANTSA members. The European report on Delivering Healthcare to Homeless People will be prepared over the course of the summer, on the basis of the responses received, and will be presented at FEANTSA’s
thannual conference in Wroclaw on the 13 of October 2006.
For all questions, please contact Dearbhal Murphy
Tel: 0032 (0)2 534 49 30
Preamble: health and homelessness:
When considering homelessness and the best ways to tackle it, one cannot fail to be aware of the close links between health and homelessness. Looking at health and how it relates to homelessness offers a view of homelessness in health terms that is very useful. A definition of health is set out in the preamble to the World Health Organisation Constitution: “Health is a state of complete
physical, mental and social well-being and not merely the absence of disease or infirmity.” Given
that being homeless will certainly affect at least one of these spheres of health, homelessness may, by its very nature, be considered as a state of ill-health.
There is a range of factors, which may lead to a person eventually becoming homeless and often health issues are among them. Health and homelessness have a relationship of both cause and effect: illness (such as mental illness, substance-abuse or illness leading to loss of employment) may be among the trigger factors that lead to homelessness. Once in a situation of homelessness, a variety of health problems may result, such as exposure to infectious illness, mental health problems, development or aggravation of substance-abuse and addiction, or health problems resulting from an unsanitary or overcrowded environment. These health problems may make it harder to break out of a cycle of homelessness. What is more, accessing healthcare is often very problematic for homeless people.
This health perspective offers many people a better grasp of homelessness and can serve to counteract stereotyped visions. Health is one of the elements that has been used to define homelessness in Australia for example: in Australian legislation, homelessness is defined in the Supported Accommodation Assistance Program Act 1994. This act defines a 'homeless' person as
“For the purposes of this Act, a person is homeless if, and only if, he or she has inadequate access
to safe and secure housing. “(Section 4) The Act goes on to define 'inadequate access to safe and secure housing' and the very first criteria that is used is that of health: “For the purposes of this Act, a person is taken to have inadequate access to safe and secure housing if the only housing to which the person has access: damages, or is likely to damage, the person's health; or threatens the person's safety…” This offers a concrete understanding of homelessness in terms of a threat to health and well-being that policy-makers are likely to be able to identify with and which is concrete enough to mobilise political will.
Health is a vital factor for social inclusion. Good health is a prerequisite to reintegration and is a vital factor in being able to access and maintain employment and housing. Conversely, having a home and a job are important to good state of mental and physical well-being. Thus the right to health underpins and reinforces the right to employment and to housing. What is more, the right of a person to enjoy the highest attainable standard of health has a strong place in international human rights law and is enshrined in international conventions and charters such as the International Convenant on Economic, Social and Cultural Rights and the European Social Charter. This right has been clarified in the General Comments of the UN Committee on Economic, Social and Cultural rights, where it is set down that “the right to health is closely related to and dependent upon the realisation of other human rights, including the right to food, housing, work, education, participation…” So it is clear that health is a good way of framing and approaching these other needs, which are particularly acute in the case of homeless people.
Thus it is clear that health has a role to play in understanding homelessness and in communicating about homelessness. It is also true that health policy is a useful avenue for tackling homelessness in a preventative and also a holistic manner. Health services have a vital role in the fight against homelessness, as meeting health needs is an important step towards
tackling homelessness and health services should be a gateway to other services. It is for all of these reasons that FEANTSA has dedicated 2006 to exploring the theme of health and homelessness. This questionnaire will try to establish a broad overview of the issues relating to health and homelessness across Europe. It will look at health profiles of homeless people, access to healthcare, training of health professionals, inter-agency working, data collection on health and the right to health.
Q1: Health profiles of homeless people:
This section aims to establish an overview of the main mental and physical health needs of homeless people in Europe; the public health issues that arise from them; as well as common treatment problems. When answering the questionnaire, it may be useful to refer to the ETHOS (European Typology of homelessness and housing exclusion) categories in order to ensure clarity and comprehensiveness. You will find the ETHOS typology in Annexe 1. It is also useful to bear in mind that many homeless people will present with more than one health problem and that these multiple problems across a range of areas may interact with each other and add up to a high aggregate of vulnerability. Please take multiple needs into account when answering these questions.
For reference, here is a definition of multiple needs:
“A typical homeless or ex homeless person with multiple needs will often present with three or
more of the following, and will not be in effective contact with services:
• mental health problems • misuses various substances
• personality disorders • offending behaviour
• borderline learning difficulties • disability
• physical health problems • challenging behaviours
• vulnerability because of age.
If one were to be resolved, the others would still give cause for concern.”
(Definition from Homeless Link Good Practice Briefing “Multiple Needs” August 2002)
It should be noted that these multiple needs may also be complicated by previous bad experience of health or social services and a mistrust of health and social workers.
1.1: Please outline the common mental, physical and substance abuse related health problems of the homeless people bearing in mind the conceptual ETHOS categories. Some of the health problems will reoccur in several categories.
1.2: Certain diseases, which are widespread among the homeless population, carry a clear public health risk. This is the case, for example, with tuberculosis. Tuberculosis incidence is much higher among homeless people than among the general population and there is a risk of the spread of this infectious disease and the development of multi-drug resistant strains. For this reason, some countries have put in place specific programmes or strategies to combat tuberculosis among homeless people. Please outline any public health risks associated with the health of homeless people and actions taken to alleviate these risks.
1.3: Certain health conditions experienced by homeless people pose significant problems of treatment. (For example: tuberculosis treatment can be rendered difficult by a mobile and chaotic lifestyle and overcrowded conditions; there may be availability problems for mental health treatment and drug and alcohol treatment etc…) Treatment of mental health problems is evolving and deinstitutionalisation has taken/ is taking place in many countries, but this too has given rise to new challenges and problems. Multiple needs are another factor that can make treatment problematic. Please outline treatment problems encountered when trying to ensure access to health for homeless people.
Q2: Social Protection: Healthcare entitlements of Homeless People
The healthcare entitlements of homeless people vary from country to country according to the social protection system in place. It may also relate to their administrative status (whether they have registered). It may also vary according to whether the homeless people are nationals or non-nationals. This question seeks to examine the impact on access to healthcare and quality of care available to homeless people.
2.1: What are the healthcare entitlements of homeless people in your country (for nationals; for non-nationals, including asylum seekers and undocumented migrants)? What are the registration requirements etc.?
2.2: Has the health system evolved in such away that it is getting harder for homeless people to access their entitlements?
2.3: What do you consider to be the main barriers facing homeless people in your country when they try to access healthcare (stigma, financial barriers, administrative barriers, etc.)?
2.4: Have attempts been made to overcome these barriers? Have they been successful?
Q3: Ensuring Access to quality healthcare
This question will explore why homeless people across Europe have difficulty accessing the good quality healthcare that they need. There is a range of services that homeless people should access in order to enjoy good health: these include medical treatment; but also preventative services (screening, check-ups etc.); specialised services such as dental services; and health promotion services.
3.1: Are you aware of specialist and/or outreach healthcare centres that have been put in place specifically for homeless people? Do you consider that this is a good way to meet the health needs of homeless people? What are the costs and benefits of targeting homeless people in healthcare provision?
3.2: Are you aware of any health promotion/ preventative health initiatives that are accessible to homeless people? Do you think that these impact positively on access to employment?
3.2: How do homeless people in rural areas access health care?
3.3: Do you consider the healthcare received by homeless people in your country to be comparable, in terms of quality of care, to that received by the general public? In what health areas is there the greatest lack of access to care and why?
3.4: In some countries, a specific policy framework and action plan around health and homelessness has been put in place in order to ensure that homeless people can get full access to quality care. Has such an approach been tried in your country?
Q4: Training of health professionals
Homeless people sometimes encounter a lack of understanding and reluctance to engage with them from healthcare professionals that might be overcome through training for health workers on how to work with homeless people, as well as on their specific health issues. The problem of homeless people presenting with multiple needs can also be professionally challenging for healthcare workers. This is another area where training would be useful.
4.1: Do you know of any such training courses (in all areas of healthcare – nurses and doctors, but
also mental health workers, dentists, podiatrists etc.) or plans to put them in place, as part of medical training or as follow-up training?
Q5: Interagency working
Ideally, accessing healthcare should provide a route into other care and integration services, through referral and transfer practices between homeless services, social services and health services.
5.1 Are you aware of instances of this kind of networking in your country?
5.2: Are health and social services supportive of this type of working? Have administrative procedures or agreements been put in place to facilitate transfer and sharing of information and cooperation between different services? What are the discharge practices from hospitals in your country?
5.3: Have you encountered instances where there is an obvious breakdown in this kind of networking? (eg: homeless people being retained in hospital because no other option has been found for them to move on to other services).
Q6: Health indicators, data collection and research
It is not always easy to access information on the health situation of homeless people. Yet such information can be crucial to making the case for political investment in healthcare for homeless people. This question seeks to establish possible effective ways of accessing reliable data on the health situation of homeless people.
6.1: Is data collected on any area related to the health of homeless people in your country? (such as the different illnesses suffered by homeless people, number of homeless people using specialist health services, number of people using general services, causes of death, life expectancy, etc.) If so, who collects it? (hospitals, homeless service providers, Accident & Emergency, youth care centres, psychiatric services, etc).
6.2: Do you know of any research undertaken on the health of homeless people by academic or other bodies? (eg: Government reports, NGO reports, scientific reports, etc.)
6.3: Do you know of data collection in the following areas that might be relevant in relation to the health of homeless people?
- Health determinants including lifestyle factors, drug and alcohol abuse and smoking - Environment and health
- Access to health
- Mental Health
6.4: Do you know of any indicators used to measure the effectiveness policies/services in the following areas that might be used to get information on the health and well being of homeless people?
- Health determinants including lifestyle factors, drug and alcohol abuse and smoking - Environment and health
- Access to health
- Mental Health
Sometimes "self-perceived health status" is used as an indicator to collect health data - do you think this is useful in relation to homeless people?
6.5: In relation to housing, are you aware of any comparisons undertaken between the health of the well and poorly housed populations? In relation to employment, do you know if comparisons between the health and well being of homeless or formerly homeless people who have access too employment and those who don’t?
Q7: The Right to Health
The right to health is enshrined in several international human rights texts. You can find the articles on health brought together in FEANTSA’s brief on the right to health. It is further strengthened by the right to non-discrimination in the area of access to health. Tackling health inequalities is an ongoing priority at European level. For this reason, expressing homelessness in terms of health has the potential to be a powerful political tool. The right to housing, the right to employment and to access to the services you need are all underpinned by the right to be healthy and to enjoy a state of well-being.
7.1: Do you know of any examples where a rights-based approach has been adopted in relation to health for homeless people or other vulnerable groups, whether in the form of court cases or campaigns?
7.2: Is the health of homeless people a political issue in your country? Could it be a useful campaigning point? Why? Why not?
thPlease return your completed questionnaires to dearbhal.Murphy@feantsa.org before June 15 2006.
Annexe 1: ETHOS TYPOLOGY
European Typology of Homelessness and housing exclusion
Homelessness is one of the main societal problems dealt with under the EU Social Inclusion Strategy. The prevention of homelessness or the re-housing of homeless people requires an understanding of the pathways and processes that lead there and hence a broad perception of the meaning of homelessness.
FEANTSA (European Federation of organisations working with the people who are homeless) has developed a typology of homelessness called ETHOS.
The ETHOS typology begins with the conceptual understanding that there are three domains which constitute a “home”, the absence of which can be taken to delineate homelessness. Having a home can be understood as: having an adequate dwelling (or space) over which a person and his/her family can exercise exclusive possession (physical domain); being able to maintain privacy and enjoy relations (social
domain) and having a legal title to occupation (legal domain). This leads to the 4 main concepts of
Rooflessness, Houselessness, Insecure Housing and Inadequate Housing all of which can be taken to indicate the absence of a home. ETHOS therefore classifies people who are homeless according to their living or “home” situation. These conceptual categories are divided into 13 operational categories that can be used for different
policy purposes such as mapping of the problem of homelessness, developing, monitoring and evaluating policies.
ETHOS European Typology on Homelessness and Housing Exclusion
Conceptual Operational Category Generic Definition
ROOFLESS 1 People Living Rough 1.1 Rough Sleeping (no access to 24-
hour accommodation) / No abode
2 People staying in a night 2.1 Overnight shelter
HOUSELESS 3 People in accommodation 3.1 Homeless hostel
for the homeless 3.2 Temporary Accommodation
4 People in Women’s 4.1 Women’s shelter accommodation
5 People in accommodation 5.1 Temporary accommodation /
for immigrants reception centres (asylum)
5.2 Migrant workers accommodation
6 People due to be released 6.1 Penal institutions
from institutions 6.2 Medical institutions
7 People receiving support 7.1 Residential care for homeless
(due to homelessness) people
7.2 Supported accommodation
7.3 Transitional accommodation with
7.4 Accommodation with support
INSECURE 8 People living in insecure 8.1 Temporarily with family/friends
accommodation 8.2 No legal (sub)tenancy
8.3 Illegal occupation of building
8.4 Illegal occupation of land
9 People living under threat 9.1 Legal orders enforced (rented)
of eviction 9.2 Re-possession orders (owned)
10 People living under threat 10.1 Police recorded incidents of
of violence domestic violence
INADEQUATE 11 People living in 11.1 Mobile home / caravan
temporary / non-11.2 Non-standard building
standard structures 11.3 Temporary structure
12 People living in unfit 12.1 Unfit for habitation (under national
housing legislation; occupied)
13 People living in extreme 13.1 Highest national norm of
For more information please see FEANTSA’s 2005 Review of Homeless Statistics in Europe (Edgar et al.) at www.feantsa.org
FEANTSA is supported financially by the European Commission. The views expressed
herein are those of the author(s) and the Commission is not responsible for any use that
may be made of the information contained herein.