Introduction
A substantial international body of evidence links housing to health outcomes. Housing has long been included in Social Determinants of Health (SDH) and health equity frameworks (Dahlgren & Whitehead, Reference Dahlgren and Whitehead2021; Marmot & Allen, Reference Marmot and Allen2014) and research to date has linked a wide range of health conditions to housing conditions; for example, the impact of insecure tenure on mental health (Li et al., Reference Li, Baker and Bentley2022), the presence of damp and mould with instances of respiratory and cardiovascular ill-health (Mishra et al., Reference Mishra, Wilson, Andrabi, Ouakrim, Li, Akpan, Bentley and Blakely2023), the role of overcrowding in the spread of infectious diseases (Baker et al., Reference Baker, McDonald, Zhang and Howden-Chapman2013); and the hazardous effects of toxins or air pollution in the home (Vardoulakis et al., Reference Vardoulakis, Giagloglou, Steinle, Davis, Sleeuwenhoek, Galea, Dixon and Crawford2020). An additional body of work has investigated the health impacts of housing location, looking at the ways in which neighbourhood amenity, safety and cohesion, access to green and blue space, noise levels and air pollution contribute to specific physical and mental health conditions (Browne and Lowe, Reference Browne and Lowe2021). An emerging evidence base encompasses the complex ways in which housing disadvantage compounds other kinds of socio-economic disadvantage, in a world in which both inequality and vulnerability to climate change are increasing, with significant impacts on human health.
Many existing studies focus on vulnerable population groups who are overrepresented in the health and housing service systems. However, recent events such as the Covid-19 pandemic, escalating natural disasters and extreme weather events, and housing affordability and cost of living crises have highlighted the centrality of housing to public health outcomes at a population level (Goddard, Reference Goddard2022; Li et al., Reference Li, Toll and Bentley2023). Governments globally have been slow to create and implement healthy housing policy on the scale on which it is needed, according to a 2021 report by the World Health Organisation that evaluated a selection of policies from its six geographic regions (WHO, 2021). The WHO report included eight Australian policies from thirty-two across the Western Pacific Region, but more needs to be known about how well Australia’s policy makers currently utilise the potential of housing as a means of addressing current health inequities and as a population-wide preventive health measure. As one of the world’s largest economies, one whose housing and healthcare systems have historically provided for a majority of its citizens, Australia now faces complex policy challenges in both areas, many of which are shared by other OECD countries. Housing unaffordability has led to increasing levels of homelessness, housing insecurity and housing stress (AIHW, 2023b; Pawson et al., Reference Pawson, Clarke, Parsell and Hartley2022a). Bushfires and floods, the result of climate change, have damaged tens of thousands of homes since 2020 and displaced thousands of Australians (Dept. Health and Aged Care, 2023), while contributing to worsening air quality and harmful outbreaks of household mould and damp (Graham et al., Reference Graham2021; Neumeister-Kemp et al., Reference Neumeister-Kemp, Kemp and Tijsen2023). Meanwhile, Australia’s healthcare system grapples with rising rates of chronic disease (García-Goñi et al., Reference García-Goñi, Fouda, Calder and Paolucci2018) and the looming impacts of other climate change-related health emergencies such as heatwaves (DHAC, 2023). These syndemic issues, if unaddressed, will increase the burden of public health costs well into the future.
The WHO report (2021) is critical of the way that many healthy housing measures around the world are limited to addressing single health risks when the scale and complexity of the issues call for a systemic response. To achieve safe and healthy housing for all, policy must address issues at scale – it must be coordinated, cross-jurisdictional, cross-sectoral, and appropriately funded. However, the report draws its data largely from policies that have been evaluated in the scientific literature and does not claim to be comprehensive. This paper takes a step towards addressing that by establishing an overview of healthy housing policy in Australia. In so doing, it asks: where healthy housing policy exists, what kinds of issues does it address? Where health objectives are missing from housing policy, and vice versa, what is prioritised instead?
The utility of such an overview is its capacity to inform new directions for policy change. A large body of scholarship on the social construction of ‘problems’ acknowledges that conditions do not in and of themselves demand policy intervention; rather, any focus on a given set of conditions is the end result of processes characterised by power dynamics between multiple stakeholders in particular institutional contexts (Althaus et al., Reference Althaus, Bridgman and Davis2018; Kingdon, Reference Kingdon and Wilson1993). In this ‘process of competitive claims-making’ (Jacobs et al., Reference Jacobs, Kemeny and Manzi2003, p. 430), the ‘political accomplishment’ (Kingdon, Reference Kingdon and Wilson1993, p. 42) of problem recognition is a key interpretive step in establishing a policy agenda. We can assume that the existence (or not) of healthy housing policy in Australia is the outcome of political processes that have determined policy priorities in those domains.
However, such processes are not the only factor determining policy measures. Bacchi’s (Reference Bacchi2009) What is the Problem Represented to Be? (WPR) approach challenges the idea that ‘problems’ are exogenous to policy making. Instead, argues Bacchi, ‘problems’ are discursively produced by policy makers in an act of ‘problematisation’ underpinned by their own knowledge and assumptions. Critical scrutiny of policy documents can reveal these problematisations, which are implicit in the measures they contain and an expression of paradigms dominant in the policy space. As such, they can also point to paradigm shifts necessary for policy reform. This paper takes the novel step of applying Bacchi’s WPR approach to a wide-ranging thematic analysis of over 300 federal, state, and territory policies across the domains of health and housing and related policy areas. In so doing, it illuminates – as a starting point for the interrogation of problematisations in Australian policy – the conceptual understandings and priorities of policy makers. It raises urgent questions about the limits of policy domains, the need for cross-sectoral vision, and even contradictions in how we define terms like ‘health’ and ‘prevention’ in a health policy context.
The paper prepares for this analysis by first providing an overview of healthy housing definitions and applying these to the Australian context. It then considers the institutional frameworks within which Australian health and housing policy are made. Following Bacchi (Reference Bacchi2009), it lays out a theoretical approach to analysing the selected policy documents. The methods of the study are then followed by an overview of Australian healthy housing policy and a discussion of the implications of the findings, with a focus on challenges and opportunities for healthy housing policy in Australia.
Unhealthy housing – an Australian condition
Housing has been linked to some of Australia’s most pressing health concerns, including three of the top five diseases in its disease burden: coronory heart disease, anxiety disorders, and chronic obstructive pulmonary disease (COPD) (AIHW, 2023a). There is strong evidence of a relationship between cold housing and cardiovascular disease, and linking unaffordable and insecure housing to mental health conditions such as anxiety and depression (Mishra et al., Reference Mishra, Wilson, Andrabi, Ouakrim, Li, Akpan, Bentley and Blakely2023). While this draws a line between housing conditions and clinical health, in both policy and practice ‘health’ is a multi-faceted domain that includes the protective and preventive functions of public health and the broad concept of ‘wellbeing’, which overlaps with physical health but also encompasses psycho-social factors, not all of them health-related. The conceptual breadth of the terms ‘health’ and ‘wellbeing’ is critical to understanding the multi-directional and, at times, compounding impact of housing conditions. If we understand health to be the result of both individual characteristics and structures, and to have physical, psychological, and social dimensions, then it is apparent how both housing systems and housing as place of physical and psychological safety can interact powerfully with health.
Indeed, the WHO’s Housing and Health Guidelines (WHO, 2018) define healthy housing as ‘shelter that supports a state of complete physical, mental, and social wellbeing’ (p. 2), and identify numerous health risks associated with poor housing that encompass the condition of the housing itself as well as its geographical location and community context. Risks to health include injury from hazards associated with poorly constructed or maintained housing; respiratory and cardiovascular illness from housing that is not thermally controlled or from indoor air pollution; spread of infectious diseases due to overcrowding; and hygiene risks from inadequate sanitation or water supply. In emphasising that the environment beyond the home contributes to health, the guidelines point to access – specifically to services, opportunities to be active outdoors, and transport options – as well as community safety and cohesion, which enables social participation that is vital for mental health. The Guidelines reference the association between housing and mental health, for example as a result of overcrowding (pp. 27-28) or high and low indoor temperatures (p. 37, p. 49).
While there is ample evidence of the negative health impacts of each of these housing elements, Baker et al. (Reference Baker, Beer, Lester, Pevalin, Whitehead and Bentley2017a) have argued housing has such profound and complex effects on our health that it is not only challenging but misleading to separate out its impacts from the broader complexities of our lives, or to quantify only the impacts of individual determinants. Baker et al. (Reference Baker, Beer, Lester, Pevalin, Whitehead and Bentley2017a) align themselves with a recent body of scholarship that has emphasised a more ‘holistic conceptualisation’ (p. 3) of how housing conditions interact with other health determinants, particularly in relation to compounding disadvantage. Using a model underpinned by this conceptualisation, Baker et al.’s (Reference Baker, Lester, Beer and Bentley2019a) geographical analysis of unhealthy housing in Australia found only 1.8m of Australia’s 14m adult population were living in healthy housing, versus 2.5m in unhealthy housing and an ‘overwhelming majority’ of just under 9m in moderately unhealthy housing (p. 48).
Importantly, many of those found to be living in unhealthy housing belonged to vulnerable population groups, increasing the likelihood of multiple adverse impacts linked to their housing situation. Mansour et al.’s (Reference Mansour, Bentley, Baker, Li, Martino, Clair, Daniel, Mishra, Howard, Phibbs, Jacobs, Beer, Blakely and Howden-Chapman2022) recently updated glossary of healthy housing terms helps us to understand these cascading impacts, due to its organisation of healthy housing concepts according to three housing ‘elements’ of affordability, security, and suitability. In so doing, it emphasises the overlap between many of the concepts, as well as highlighting the interplay of low socio-economic status with many aspects of unhealthy housing.
These ‘elements’ have been under increasing scrutiny in Australia, which is experiencing a widely reported housing affordability crisis for both homeowners and renters. After a long period outstripping wages growth, rising house prices and rents have left a growing number of low-to-moderate-income earners in housing stress, further exacerbated by mounting fuel and living costs (AIHW, 2023b). Closely related to affordability, housing insecurity is growing in Australia and two issues have dominated debates about this dimension of the housing crisis. The first is the lightly regulated rental sector, in which short leases, no fault evictions and uncapped rents can result in mental distress and/or unwanted mobility for tenants (Morris et al., Reference Morris, Hulse, Pawson and Morris2021). The second is growing homelessness, across previous vulnerable cohorts as well as a newer cohort of ‘working homeless’ as housing unaffordability increasingly becomes a driver of homelessness nation-wide (Pawson et al., Reference Pawson, Clarke, Parsell and Hartley2022a).
The suitability of housing is determined by many elements related to its physical condition, configuration, accessibility, and sustainability. Australia has a relatively young housing stock, but evidence is emerging to challenge commonly held beliefs about how much Australian housing is of good quality, able to meet diverse needs, and climate-change ready. For example, around a quarter of renters report problems with cold, mould, and damp (Baker, Reference Baker, Daniels, Pawson, Baddeley, Vij, Stephens, Phibbs, Clair, Beer, Power, Bentley, Kulik, Sinha, Stone, Dignam, London, Rowley, Hulse, Nygaard, Holst, Leishman, Rogers, Jacobs, Beer and Bentley2020), while severe overcrowding continues to be the most common form of youth homelessness (AIHW, 2021).
Unhealthy housing as an Australian policy ‘problem’
The quality of Australia’s housing stock today, as well as its housing affordability crisis, can be understood as a product of historical policy environments and traditional housing pathways. Australia achieved high rates of home ownership earlier than most other developed countries, and renting has remained a transitional tenure in the predominant housing pathway. Since the turn of the century, however, more Australians are renting for longer due to increasing housing unaffordability. Building regulations ensuring housing quality have weakened (Shergold & Weir, Reference Shergold and Weir2018); housing has become increasingly financialised (Jacobs, Reference Jacobs2015); and investment in social housing has receded considerably (Troy et al., Reference Troy, van den Nouwelant and Randolph2019). Rental reforms have not kept pace and despite some recent gains, policy settings that ensure the profits of landlord-investors over the wellbeing of tenants persist, with significant impacts on rental housing quality and tenure security. Mechanisms designed to address housing affordability have prioritised homeownership, although strong arguments exist that these do not adequately target the most disadvantaged and may even inflate house prices (Pawson et al., Reference Pawson, Martin, Lawson, Whelan and Aminpour2022b).
As a federation, Australia has a high degree of centralisation of power, with relatively weak local government. It has seen a growing concentration of resources collected by its federal government, even as the states and territories retain responsibility for the most important areas of social policy. These are enabled through a complex array of agreements and funding arrangements, in which states and territories authorise activity but the primary funding for those activities comes from the federal government. Major funding for affordable housing initiatives and related infrastructure is available to state/territory governments and community housing providers from the National Housing Finance and Investment Corporation (NHFIC), a corporate Commonwealth entity set up in 2018 and reporting to both Treasury and Housing. In July 2024, the National Agreement on Social Housing and Homelessness (NASHH) became the latest deal between federal and state/territory governments to support the funding of homelessness services and access to housing. Broadly speaking, Australia’s health system mirrors this structure. Federal government has oversight of national benefits schemes and subsidies and regulatory functions, with the states and territories responsible for the delivery of clinical, emergency, and public health services, with the help of federal funding. In policy terms, then, Australia’s two highest tiers of government are where major funding is committed and decisions about long-term, wide-ranging strategic priorities are made.
While both levels of government assume some responsibility for preventive health, initiatives are usually the responsibility of specialised health agencies. This structure and policy siloing more generally create barriers to addressing SDH, which reach into policy domains outside of health, including housing. Partly this is process-related – Baker et al. (Reference Baker, Friel, Kay, Baum, Strazdins and Mackean2017b) underline the influence on health inequities of governmental distribution of resources and power, noting a ‘mismatch’ between the complexity of socially determined health and health equity issues and ‘political preferences for simple policy problems that are solvable using existing policy instruments’, or the lack of ownership conferred by policy silos (p. 102). It also reflects the way that ‘preventive approaches to health cross-cut the biomedical and social paradigms’ (Bacchi, Reference Bacchi2009, p. 130). While a biomedical paradigm focuses on treatment of disease, a social paradigm emphasises non-biological factors in determining health, with the dominance of the former meaning there is little remit or funding for preventive action beyond existing instruments of the health system. Even within SDH policy, a ‘know-do’ gap points to the limitations of evidence-based policy driven by the results of Randomised Controlled Trials (RCTs). While its original promise was to counter the political nature of many policy decisions, the efficiency and narrowness of RCT-driven data does not match well with issues requiring holistic approaches and makes them vulnerable to selectivity (Bacchi, Reference Bacchi, Beasley and Bletsas2012). Even when SDH are included in health policy, ‘evidence in support of different causal theories (e.g., lifestyle-behavioural, psychosocial, and material-structural interpretations) may be selectively “filtered” to align with the ideological preferences of government’ (Baker et al., Reference Baker, Friel, Kay, Baum, Strazdins and Mackean2017b, p. 108). Interpretations that emphasise the role of individual behaviours in relation to health risks confine ‘preventive’ action to early detection measures or to public education, rather than ‘upstream’ structural determinants like housing disadvantage, and remove the impetus for policy that crosses departmental boundaries. The result is that issues such as health equity can be difficult to get onto government policy agendas, but at the same time, the act of reframing ‘problems’ can be powerful in influencing political will and challenging policy norms (Baum et al., Reference Baum, Townsend, Fisher, Browne-Yung, Freeman, Ziersch, Harris and Friel2020).
It is in policy documents, according to Bacchi (Reference Bacchi2009), that we find evidence of these norms and interpretations, articulated in the measures they contain. For Bacchi, policy makers do not simply recognise or prioritise problems that are constructed externally to policy processes; rather, policy processes are another means by which problems are discursively produced. In other words, policy documents are the site of the production of problems, articulated primarily through their proposed ‘solutions’. It is therefore more accurate, she suggests, to look at policy documents not as representations of problems but of problematisations. Such problematisations have ‘programmatic outcomes’ – that is to say, they result in government action or inaction that affects people’s lives (Bacchi, Reference Bacchi, Beasley and Bletsas2012). That is not to say policy rhetoric is always reflective of action taken, or indeed much more than ‘symbolic reassurance’ that issues are being addressed (Jacobs et al., Reference Jacobs, Kemeny and Manzi2003). However, implicit in them as problematisations are ‘unexamined assumptions and deep-seated conceptual logics’ as well as ‘forms of knowledge’ (Bacchi, Reference Bacchi, Beasley and Bletsas2012). Crucially, the process of deconstructing these interpretations tells us as much about what is considered unproblematic – how the representation of issues on the policy agenda ‘limits what is talked about as possible or desirable, or as impossible or undesirable’ (p. 3).
Bacchi offers policy analysts a series of six questions to prompt this mode of enquiry. These are intended for application to single policies or comparative analysis. In order to widen the scope of our analysis, we take the step of applying Bacchi’s concepts and approach not to policy documents in turn but to a thematic analysis of a wide range of Australian policy related to healthy housing. This approach has limitations: it does not allow in-depth analysis of policy language or nuanced comparison. However, it does achieve the aims of the paper, namely to provide a broad overview of healthy housing policy in Australia, and to uncover the conceptual thinking that informs policy at a systems level. We therefore let two of Bacchi’s questions guide our analysis of Australia’s healthy housing policies:
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1. What is the problem represented to be in a policy or policy proposal?
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2. What is left unproblematic in this problem representation?
The following section outlines how policies were selected for inclusion and the steps of the thematic analysis.
Methods
For this study, we looked to the policies of the Australian Government and of its six states and two territories to gain our overview of the Australian healthy housing policy landscape.
The WHO’s (2021) evaluation showed that healthy housing policy often has a narrow focus, limiting the scope of its interventions, or is a co-benefit of policies formulated in domains outside of health or housing and with other primary intentions. The search strategy was therefore based on the assumption that a search for ‘healthy housing’ policy was unlikely to yield a great number of results, show policy with healthy housing co-benefits, or, importantly, identify relevant policy that is silent on the matter of healthy housing. Instead, a wide net was cast to capture the reach of housing as an SDH into other policy domains and provide a comprehensive overview of the kinds of healthy housing issues that Australian policy currently addresses – and those that it ignores.
The healthy housing evidence base correlates a range of housing conditions with health risks and harms and so policy domains relevant to those conditions and risks were included. This allowed cross-referencing of policy objectives: for example, whether mental health policy recognised the role of housing in mental health outcomes; or conversely, whether housing policy recognised potential impacts on mental health. It also captured policy at the intersection of multiple health risks associated with multiple housing conditions. For example, unaffordable housing is often also cold housing, leading to respiratory conditions and mental ill-health as well as a range of other health impacts related to poverty and other kinds of social disadvantage. Major housing and public health policies (see Table 1) were included to show where healthy housing was integral to, or absent from, big-picture conceptions that might address this complexity or aim for population-level impacts.
Major health and housing strategies and plans for general population
The WHO’s (2021) evaluation showed that policies relevant to healthy housing aims and co-benefits ‘take a wide range of forms: [t]hey include those based on compulsory and voluntary mechanisms’ (p. ix) and exist at both local and national levels. As such, and since these can all be understood as problematisations, our search sought to capture the widest possible range of relevant policy mechanisms. Broadly, these could be categorised as strategies and plans, schemes and programs, and legislation, regulations, and guidelines. The policies captured were also categorised under broad policy areas. Table 2 shows the number of strategies and plans captured that were targeted to specific health conditions and/or at-risk populations, where the evidence base suggests that housing as an SDH may impact health outcomes.
Strategies and plans targeted to specific health risks or at-risk populations
The remainder of the policies analysed were schemes, programs, regulations, legislation, and guidelines, from both federal and state/territory governments.
The search was conducted between July and October 2022. Policies with an end date were automatically included if the end date was 2022 or later. Policies with no end date were included if the government department website listed the policy as current. The earliest of these was published in 2008, although this in itself points to the way some policy areas can lie untouched through successive governments with shifting agendas, with implications for policy efficacy. The majority were published between 2017 and 2022, and one included NSW program has been running since 1997.
Relevant departmental and agency websites were searched for policy documents. These were identified according to the domains listed above, using online government directories. Google searches for ‘healthy housing’, ‘housing policy’, and ‘health policy’ by jurisdiction were also conducted as a cross-check, as well as similar searches for some sub-categories of policy, such as ‘mental health policy’, ‘wellbeing policy’, and ‘energy assistance’. The website Analysis and Policy Observatory (APO) was monitored for policy releases during the data collection period. The search protocol resulted in n > 300 separate policies for analysis. Policy documents were exported into NVivo and labelled to enable comparative searches across policy types and jurisdictions. Following Herzog et al.’s (Reference Herzog, Handke, Hitters and Bulck2019) steps of thematic analysis, familiarity with the data, coding and identification of themes was achieved through the following steps. First, the aims, objectives and measures of all policies were read. Where these aligned with healthy housing, the policy was read and noted in more detail. Word frequency searches then identified further instances where housing appeared in health policy and vice versa, or where a health-housing link appeared in policies from other domains, and those policies were also read in more detail.
Second, several codes were created to capture different aspects of policy content. These included key priorities in health and housing policies; references to housing as an SDH; and healthy housing co-benefits found in policies with other primary intentions. Third, themes were identified, reviewed through a process of re-reading and refinement of coding, and finalised.
The following section provides the overview yielded by this process: a brief description of policies with healthy housing aims or co-benefits.
Where healthy housing policy exists in Australia, what kinds of issues does it address?
Policy in Australia that recognises a health-housing link is most prominent in certain policy areas. The most notable of these is Aboriginal and Torres Strait Islander health and housing; it is in this area that the most cross-sectoral and cross-jurisdictional policy is found (see Tables 1 and 2). Health strategies and plans include aims related to improving housing, for example:
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Korin Korin Balit-Djak: Aboriginal health, wellbeing and safety strategic plan 2017–2027 (VIC) aims to ‘[a]dvance self-determination in Aboriginal housing and homelessness’ and ‘[i]mprove access to suitable, stable and supported housing’ (DHHS, 2017, p. 58)
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the National Aboriginal and Torres Strait Islander Health Plan 2021–2031 includes the objective ‘[s]upport community driven housing and infrastructure solutions’ (DHAC, 2021, p. 48), and emphasises a range of linked health and housing issues
Three states/territories (NSW, NT, and WA) have Aboriginal environmental health programs that address health concerns by assessing and maintaining home health hardware. Two of these use guidelines devised by non-profit Healthabitat. These are the NSW ‘Housing for Health’ program and the NT ‘Healthy Homes’ program (NSW Health, 2010; DTFHC, 2020).
A few programs and guidelines address healthier housing for this target group: NT’s ‘Room to Breathe’ program funds the addition of living space to existing homes, with the aim of addressing overcrowding, better functionality, and reduced wear and tear (DLGHCD, 2019); while similar issues are addressed for new builds in design guidelines issued by NSW’s Aboriginal Housing Office (AHO, 2020).
The second policy area in which healthy housing measures or co-benefits are reasonably prominent is energy and climate. Most of these are schemes and programs with sustainability objectives, such as increasing uptake of renewable energy or making households more energy efficient. However, some aim to alleviate hardship. In both cases, the policies create healthy housing co-benefits at the intersection of housing affordability and thermal comfort. A third category of policies – strategies for climate change adaptation and mitigation – recognise the role of the built environment in climate change and link it to health risks. The types of healthy housing-relevant measures suggested by these categories of policy are laid out in Table 3.
Energy and climate policy
The majority of Australia’s remaining healthy housing measures and co-benefits are found in its building and environmental health standards, regulations, and guidelines. Table 4 shows the types of policy mechanisms and the level of government responsible for them.
Building and environmental health standards, regulations, and guidelines
A scattering of policy in other areas recognises the health-housing link. In summary:
Domestic and Family Violence (DFV) strategies and schemes. While provision of crisis accommodation is a core element of DFV responses across jurisdictions, some states and territories also address the availability of stable, long-term housing for victim-survivors and even link DFV strategies to affordable housing strategies (see, for example, Victorian Government, 2020).
Supported and/or accessible accommodation. Programs vary between state and territories but address the housing needs of specific high-needs groups, who either need support to sustain tenancies due to existing health issues (e.g. mental ill health) or who face safety hazards and other health risks without specialised accommodation (e.g. modified housing for people with disability or older people) (see, for example, SA Housing Authority, 2020 and DHAC, 2020).
Housing affordability measures. Housing affordability is a busy policy area in Australia as well as complex and highly contested. Broadly speaking, any measure to increase housing affordability may offer health co-benefits because unaffordability, housing stress, housing insecurity, and poor housing condition are strongly correlated with poor health in the evidence base. For the same reasons, interventions to decrease homelessness or achieve rental reform may also offer health co-benefits. However, on the whole, the potential health impacts are too weakly defined in such policies for them to be included in this overview.
Discussion – problematisations in Australian healthy housing policy
We now turn to Bacchi’s (Reference Bacchi, Beasley and Bletsas2012) first question for analysts, ‘What is the problem represented to be in a specific policy or policy proposal?’ As previously discussed, the aim of this paper is to discover what policy documents reveal about how policy makers understand housing-related health issues. While it is beyond its scope to pose Bacchi’s questions for each individual policy in the analysis, we can gain useful insights from considering these policies collectively.
Policy areas offer the first clue in our analysis. Some housing-related health problems are addressed where they disproportionately affect specific target populations, most prominently Aboriginal and Torres Strait Islander people. Creators of these policies are aware that Aboriginal people experience higher rates of housing insecurity and homelessness than non-Aboriginal Australians and are more likely to be living in poor housing; and that they experience a range of serious health disadvantages, including higher incidence of child mortality, lower life expectancy, and one of the highest rates of rheumatic heart disease in the world (Lowitja Institute, 2022). Major strategies problematise systemic disadvantage (including housing disadvantage) causing poor life outcomes (including health); schemes and programs are discussed below.
The issue of thermally inefficient housing is problematised as a sustainability issue first and a cost-of-living problem second; any health benefits associated with measures to address these are not the central concern of the policies’ creators. Nearly all measures designed to make homes more thermally efficient problematise inefficiencies at the individual level: people are in fuel hardship because they are ‘low-income’ or have a medical condition, as revealed by ‘solutions’ that offer concessions to eligible consumers rather than structural approaches that might address poverty, fuel prices, or poor-quality housing. Schemes to improve energy efficiency rely heavily on voluntary uptake by households-as-consumers willing to audit their homes, search for better energy deals and install solar panels. This contrasts with the slow rate of change on building standards relating to thermal efficiency and poor rates of compliance in the construction industry.
These problematisations exist in climate change policies alongside measures to prepare for the health impacts of climate change, but are not, for the most part, integrated with them. Health objectives in climate change strategies are focused on healthcare delivery, in particular reducing emissions within the system and building capacity to respond to health risks associated with a changing climate. This includes disaster preparedness. The area where these segmented policy measures overlap are in the mitigation of, and adaptation to, heatwaves and their effects on human health. However, the policies do not acknowledge the preventive potential of housing in mitigating other climate-changed related health risks, although strategies from the ACT and VIC do contain measures aligned with the concept of ‘just transition’. These recognise the intersection of health, housing, and disadvantage for groups deemed to be more vulnerable to climate change impacts as well as the impacts of adaptation measures (EPSDD, 2019; DELWP, 2021).
The regulatory category of healthy housing policy reflects an assumption that healthy living environments are created by adherence to identified standards relating to separate elements of those environments. It also sees adherence as a governance problem. Such standards can be effective if compliance can be and is enforced, and if they are designed to be effective when enforced; but when we apply Bacchi’s second question ‘What is left unproblematic in this problem representation?’, we might consider their limitations in light of the dynamic, social aspects of healthy housing. A program such as Housing for Health (NSW) illustrates this: it does not enforce compliance with health housing hardware standards; rather it addresses the capacity to comply. In so doing it problematises housing with inadequate plumbing and hygiene provision differently to the way a regulation does, providing knowledge and resources as the solution rather than the threat of sanctions.
On the other hand, while major strategies have the scope to consider housing as part of a structural context of disadvantage in which poor health outcomes occur, smaller programs are limited to more ‘downstream’ concerns. In the Housing for Health program, the ‘solution’ to widespread inadequate housing is to provide maintenance to households, in so doing problematising poor housing at the level of the household. While this has positive localised impacts, it does not address why the housing was inadequately built or has fallen into disrepair in the first place, nor why its residents have no capacity to arrange repairs without government support. The answer to Bacchi’s second question, in this instance, is that the policy conceptually separates the conditions from the larger contexts in which they occur, such as income inequality, the housing crisis or other systemic forms of disadvantage, such as racism.
Any intervention targeted to vulnerable populations reveals a paradigm in which housing is understood to be an SDH, but at the same time, not one that impacts on the broader population in a way significant enough to warrant government intervention at a systems level. This understanding is not necessarily based on ‘evidence’, but is a convenient position to take for those seeking to manage political risk and navigate institutional dynamics (Baum et al., Reference Baum, Laris, Fisher, Newman and MacDougall2013). We therefore see major housing strategies attempt to address a range of issues across the housing system, from supply to affordability to services, without recognising the potential for health intervention, even as their priorities overlap with a health equity agenda. Meanwhile, across a wide range of health policies at both a federal and state/territory level, among the most common strategic priorities are: prevention, including early intervention; increased equity of access to healthcare and health outcomes; and more research, innovation, and evidence-based policy. There is a disconnect, however, between the context statements provided in many policy documents and the measures they contain – so, between the background to the problem and the problem as it is represented in its ‘solution’. Health policy overwhelmingly recognises SDH, including housing, but contains measures to influence individual outcomes and behaviours through healthcare and health promotion activities. In this paradigm, the strategic goal of ‘prevention’ becomes fairly toothless as it can only practically extend to early detection, education, or community support measures that seek to mitigate the harm done by unhealthy housing and inequality. This is acknowledged in Queensland’s Human Health and Wellbeing Climate Adaptation Plan (H-CAP):
The determinants of health and wellbeing (and illness) arise largely outside the healthcare system (e.g. economic, social, environmental, cultural and technological factors). However, the health sector and those focused on community health and wellbeing are in the frontline in responding to the health impacts of climate change. Thus the H-CAP and its strategies are largely focused on the factors that services involved in delivering healthcare, aged care, and child care can influence. (Queensland Government, 2018, p. 5)
This observation aligns with those of other policy researchers, as laid out in Baum et al. (Reference Baum, Townsend, Fisher, Browne-Yung, Freeman, Ziersch, Harris and Friel2020), who assert that ‘governments have rarely turned the rhetoric of “prevention is better than cure” into a set of detailed, consistent, and defendable policies’ (p. 949). Meanwhile, persistently inadequate funding for social housing and an emphasis on interventions designed to boost home ownership reflects what Jacobs (Reference Jacobs2015) sees as a deliberate prioritisation of household wealth creation and investor profit over the housing needs of low-income Australians and conditions for renters; one which decouples the government from responsibility for rental housing quality and tenure security, and their attendant health impacts.
Although a residually active policy area at the time of data collection – and as such, not included in the overview of current healthy housing policy – interventions related to the Covid-19 pandemic showed that Australian governments can make a direct connection between housing provision and public health outcomes and respond in a coordinated way. The pandemic demanded an urgent response that saw more collaboration and data sharing across jurisdictions, mobilisation of relationships in the health and housing sectors, and innovative interventions. However, the rapid nature of many of these created patchy successes and some unintended consequences. Notably, because the impacts of the pandemic were all problematised as part a health emergency, initiatives were short-term on the whole and had little long-term impact on issues caused or exacerbated by systemic health and housing inequalities (Leishman et al., Reference Leishman, Aminpour, Baker, Beer, Crowe, Goodall, Horton, Jacobs, Lester, Torchia, Maclennan, Martin, Nash, Pawson, Rowley, Stone and Ong ViforJ2022). At the same time, these interventions came at a high cost and the expense of focus on other policy areas.
A final observation relates to two new federal government strategies. Since the data for this study was collected, the Australian Government has released its National Health and Climate Strategy (DHAC, 2023) and an Issues Paper towards development of a new, ten-year National Housing and Homelessness Plan (DSS, 2023). What is striking about these two strategies is how visibly they are a product of the policy paradigms revealed by our analysis: the former is a whole-of-government plan containing a Health in All Policies objective, but it devotes little space to the built environment, defers a number of measures to forthcoming urban and housing policies, and lacks innovation on household energy policy; and the latter has been vigorously criticised for an absence of housing systems analysis, a convincing grasp of the most recent evidence, or a vision for reform (Pawson, Reference Pawson2024).
Conclusion
The goal of this paper was to determine the extent to which policy in Australia reflects the findings of the WHO’s (2021) report on healthy housing policy globally. It also sought to provide a starting point for healthy housing policy critique, by shedding light on how Australia’s policy makers understand and prioritise the link between health and housing.
The WHO’s findings, despite only considering eight Australian policies, were reflective of Australian healthy housing policy as a whole: largely focused on single health risks or specific populations; localised, and fragmented; and deployed at different levels of government and through a wide range of policy instruments. This reflects the differing needs of populations across a country as geographically large and varied as Australia, but also reflects the fragmented nature of government oversight and funding and a tension between federal and state/territory governments. Given that the WHO’s (2021) analysis evaluated policies across its geographic regions, this study arguably supports the WHO’s overall findings, pointing to a generalisability in other countries. Even so, given the geographic and cultural specificity of many of Australia’s policy concerns – for example, the issues facing Aboriginal and Torres Strait Islander peoples, localised climate change challenges and Australia’s orientation towards home ownership – similar policy surveys in other settings would offer the benefit of uncovering local policy priorities.
The analysis also revealed several factors at work in the problematisation of housing-related health issues among policy makers. The application of Bacchi’s analytical questions has illuminated a preoccupation with the social and economic determinants of health and health equity, but also a tendency to problematise conditions in ways that enable policy makers to apply straightforward solutions that address symptomatic effects rather than root causes. This includes preventive health policy, which sees health promotion, education, and early detection as the limits of its purview.
In housing policy, poor investment in social housing, a predominance of measures designed to encourage home ownership and property investment, coupled with a recalcitrance on rental reform, prompt us to question whether policy makers’ objectives are in fact aligned with the economic, social, and health benefits offered by housing for all. A wide range of policy ‘solutions’ to housing unaffordability exist, but few of these problematise factors that would disturb the interests of homeowners or investor-landlords. The issue of affordability overlaps with that of housing quality; however, ‘solutions’ to the latter as it impacts on health are mostly emerging from climate change policy, where the scale and urgency of the climate crisis is galvanising cross-sectoral collaboration and suggests what is currently the most promising avenue for healthy housing policy development, albeit one that is yet to be fully realised.
Acknowledgements
This study was undertaken as part of the Healthy Housing Centre for Research Excellence, funded by the Australian National Health and Medical Research Council (NHMRC).
Competing interests
The authors declare none.
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