Summary

Homelessness is a public health challenge for modern governments. Homelessness emerged as a formal policy problem for rich nations in the mid- to late 20th century as nations developed stable economies and democracies, including housing and job markets, and social welfare mechanisms to protect citizens from disenfranchisement. In early 21st-century Organisation for Economic Co-operation and Development (OECD) nations, homelessness arises most often among at-risk or vulnerable populations, such as historically marginalized groups and/or persons with constrained access to welfare state mechanisms, such as immigrants or refugees. Thus, homelessness in OECD nations is very different from informal housing or mass poverty in poor nations and/or non-democratic regimes.

Homelessness affects individual and population health, requiring complex policy solutions across multiple domains of health, as well as intergovernmental coordination. Policy responses to homelessness vary across OECD nations in their approach and efficacy. There are four key factors influencing how OECD nations respond to homelessness: (a) the strength and inclusivity of the welfare state; (b) degrees of decentralization in homeless policy governance; (c) the strength, capacity, and inclusivity of the health and behavioral healthcare systems; and (d) the role of federated structures in health and welfare state policy. Overall, nations with weaker welfare states and health/behavioral healthcare systems face greater risks of homelessness. The inclusivity of these systems also shapes who may be eligible for protection or experience homelessness. Local governments, especially those in large metropolitan areas, are the frontline providers of homelessness services. Yet local governments are constrained at both ends: Policies designed, delivered, and funded at larger units of government—such as welfare state provisions—influence many of the determinants of homelessness, such as housing, and the resources available to subnational actors to combat homelessness. Local actors are also constrained by the degree of decentralization. Devolution of homelessness policy to smaller units of government or even solely to nongovernmental actors, through federated mechanisms or decentralization, may create barriers to locally tailored solutions by perpetuating disparities across jurisdictions and/or constraining authority and resources necessary to design or deliver homeless policy.