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What is Housing for Health?
Housing for Health is a copyright methodology for improving living conditions in Aboriginal communities. It was initially developed in the late 1980s in the far north west of South Australia. The group that came to be known as Healthabitat®  set about developing a methodology that focused on environmental changes that would lead to maximum health gains, particularly for children aged 0-5 years.
 
Research has shown that improving essential health hardware (fixing a leaking toilet, electrical repairs, having sufficient hot water, having somewhere to wash a baby or child, etc.) can lead to improvements in health status and reduce the risk of disease and injury.
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Housing for Health Priorities
The Housing for Health process aims to assess, repair or replace health hardware so that houses are safe and the occupants have the ability to carry out healthy living practices (HLPs).
 
 All works carried out in the Housing for Health program are prioritised in terms of health benefit. The priorities are:
  • Safety - Immediate life threatening dangers, particularly electrical, gas, fire, sewage and structural safety issues are addressed as the highest priority.
  • Healthy Living Practices - After safety issues have been addressed, the prioritised list below of Healthy Living Practices from 1 (most important) to 9 provides a focus for prioritising repair and maintenance:
  1. Washing people - ensuring there is adequate hot and cold water and that the shower and bath work.
  2. Washing clothes and bedding - ensuring the laundry is functional with separate taps for waste for the washing machine and tub.
  3. Removing waste safely - ensuring drains aren't blocked and that the toilets are working.
  4. Improving nutrition - assessing the ability to prepare and store food, making sure the stove works and improving the functionality of the kitchen.
  5. Reducing overcrowding - ensuring health hardware (particularly hot water systems and septic systems) can cope with the actual number of people living in a house at any time.
  6. Reducing the impact of animals, vermin or insects - on the health of people, for example, ensuring adequate insect screening.
  7. Reducing dust - to reduce the risk of respiratory illness.
  8. Controlling temperature - looking at the use of insulation and passive design to reduce the health risks, particularly to small children, the sick and the elderly.
  9. Reducing trauma - being non-life threatening issues.
These principles are also adopted by the National Framework for Design, Construction and Maintenance of Indigenous Housing and the National Indigenous Housing Guide (3rd edition). More information can be found on the Healthabitat website.
 
The first four points are considered critical healthy living practices, as they are essential for people to be able to practice healthy living. Most of the works carried out as part of this program focus on safety and these top four healthy living practices. The other 5 priorities are important for healthy living, but are usually beyond the scope of the project budgets.
 
References:
Pholeros, Paul; Rianow, Stephan; Torzillo, Paul. (1993). Housing for Health: Towards a Health Living Environment for Aboriginal Australia. Healthabitat: Newport Beach, NSW.
 
Department of Family and Community Services (2003). National Indigenous Housing Guide (3rd edition) Commonwealth of Australia: Canberra.

Housing for Health Process
The Housing for Health process consists of six main stages: 
  1. Community consultation
  2. Feasibility study
  3. First survey and fix (SF1) (including training)
  4. Capital upgrade
  5. Second survey and fix (SF2)
  6. Reporting and closure
Community Consultation
The community consultation is an important part of the Housing for Health process, because the program only repairs or replaces items specifically related to safety and health, and the actual survey can be quite intrusive. It is important to clarify expectations with the community so that people are as aware of what the program doesn't deliver, as much as what it does. For example the program will cover most plumbing and electrical issues (as they relate to health and safety), but doesn't extend to painting or other aesthetic works.
 
It is at this stage that the community agrees to whether it wants a Housing for Health project or not.
 
Feasibility Study
If the community agrees to a Housing for Health project, the project manager undertakes a feasibility study with the housing provider. It is at this stage the logistics of running the project are worked out (access to the community, availability of local trades etc.) as well as the detail of the project, such as the number of houses to be included (some tenants may choose not to be involved), the general condition of the houses and plumbing, and the type of sewerage disposal.
 
At this stage each house to be included in the project is given a Housing for Health number that is different to the street address to ensure confidentiality.
 
Survey Fix 1
If, after stages 1 and 2, the community agrees to receive the program then a first survey/fix (SF1) is scheduled. This consists of a comprehensive survey of around 240 items in all houses in the community. The surveys are carried out by teams of around four people (usually three community people and a technical support person), and the first day is designated to training the teams in the testing, recording and if possible, repair of those items. There is a standardised test for each item and the information is recorded on survey sheets. Survey teams also have a toolbox with them and any minor repairs not requiring a licensed trade are done on the spot. On average it takes around 45 minutes to an hour to complete one house.
 
The completed surveys are then taken back to a central point in the community where the information from the surveys is then entered into a database, which takes about 5-10 minutes. Once entered into the database a list of prioritised works required for each house is printed out for each trade (plumber, electrician etc). The trades usually start about half a day behind the teams so they have enough work when they begin. The community are involved in the selection of trades and where possible, local and/or Aboriginal trades are used.
 
The trades report back to the project manager on the work carried out, and also the reason for the problem (i.e. routine maintenance, faulty or damaged). This information is noted in the database. The database becomes the tool for managing the project.
 
Capital Upgrade
There are often works identified at Survey Fix 1 that are too big to fix on the spot (such as rewiring a house), or require the replacement of particular items in a number of houses (such as stoves or hot water systems) and may need to be put out to tender.
 
These larger and more time-consuming works form the basis for a scope of works for the capital upgrade component. From this information, the design, specification and schedule of works are developed. Work included in the capital upgrade component is completed between the first and second survey/fix. This can take around six to nine months depending on community size.
 
As with the survey fix stages, all works are prioritised in accordance with the Housing for Health Priorities.
 
Survey Fix 2
A second survey/fix (SF2) is carried out following the capital upgrade. This uses the same process as the first survey fix, and addresses any works that may have either been missed at the first survey and upgrade or arisen since. The second survey also provides a comparison of house function at the first survey.
 
Reporting and Closure
Once any work identified at the second survey/fix is completed a report of the work done to each house by each trade is provided to the community housing provider. In some cases it is also possible to provide a list of works that the project was unable to cover within the budget, but would recommend for inclusion in any future programs the community may run. Again these are prioritised in terms of safety and the nine healthy living practices.

Housing for Health Projects in NSW
In 1997, a trial of Housing for Health was undertaken in Muli Muli in the far north of NSW. This was funded by an interagency forum, the Aboriginal Environmental Health Infrastructure Forum.
 
Since 1997, NSW Health has delivered 78 Housing for Health projects with communities. To date (August 2013) over 86,702 items have been fixed in 2,995 homes, benefiting over 12,700 people.
 
The map here shows the locations of completed, current and proposed Housing for Health projects around NSW.

Housing for Health Results
Outcomes of the Housing for Health Program can be measured in terms of health and house function.

House Function Outcomes


The results of each Survey-Fix are recorded as part of every project, and the two surveys provide a before and after assessment of house function.
 
The graph in this link shows the overall improvements made by Housing for Health in NSW as at 2009.  The graph shows the difference in the function of the houses at Survey-Fix 1 (red) and Survey-Fix 2 (blue).  It gives an overall picture of the improvements in the houses in this project.
 
 It should be noted that for each of the critical healthy living practices (listed along the bottom of the graph), there are a number of criteria that must be working.  For example Washing People: Shower working, there are seven criteria that must be working.  If there are 6 out of 7 criteria working, it is not considered OK.  This graph shows only the percentage of houses where ALL of the criteria are met.
 
The Housing for Health program has been able to demonstrate clear improvement in house function such as:

  • 9 fold improvements in electrical safety;
  • 4 fold improvement in fire safety;
  • Over 2 fold improvement in structural safety and access in houses;
  • Over 2 fold improvement in occupants' ability to wash themselves and to wash clothes and bedding;
  • 2 fold improvement in removing waste safety from homes;
  • Over 3,5 fold improvement in the ability to prepare, store and cook food in home
An evaluation of the NSW Housing for Health Program was completed in 2010. The evaluation report "Closing the Gap: 10 Years of Housing for Health in NSW" includes the finding that “Those who received the Housing for Health intervention had a significantly reduced rate of hospital separations for infectious diseases – 40% less than the hospital separation rate for the rest of the rural NSW Aboriginal population who did not receive the Housing for Health intervention.” This finding demonstrates that Housing for Health has a significant impact on improving the health of Aboriginal people in NSW.
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Housing for Health Funding Sources
Housing for Health Projects in NSW have been funded from a number of state and national funding programs, including:
  • NSW Aboriginal Communities Development Program (ACDP)
  • NSW Two Ways Together (TWT)
  • Australian Government Fixing Houses for Better Health Program
  • National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes

NSW Health has managed the delivery of Housing for Health under these programs.
These programs all use the same methodology; only the funding sources differs.  Projects are delivered with the Public Health Units in regional Local Health Districts.  To date, projects have only been delivered in housing owned by Aboriginal community housing providers.
 
Aboriginal Communities Development Program (ACDP)
Between 1998 and 2008, NSW Health had a Partnership Agreement with the NSW Department of Aboriginal Affairs (DAA) to deliver the Housing for Health © program as part of the Aboriginal Communities Development Program (ACDP).
The ACDP is a works program to upgrade living conditions in Aboriginal communities. The Program invested $240 million over ten years (1998 - 2008) to raise the health and living standards of selected, priority Aboriginal communities where major environmental health needs were identified. $10M was allocated to Housing for Health over the life of the ACDP.
 
Thirty eight communities (1,171 houses) participated in the ACDP Housing for Health program.
 
Two Ways Together Housing Initiative (TWT)
In 2004, NSW Cabinet granted additional funding to expand the Housing for Health program under its Two Ways Together initiative over four years. NSW Health delivered this under the Housing for Health Partnership Agreement with the NSW Department of Aboriginal Affairs (DAA).
 
Nineteen communities (666 houses) participated in the Housing for Health program under the Two Ways Together initiative.
 
Fixing Houses for Better Health (FHBH)
Between 2001 and 2003, the former Aboriginal and Torres Strait Islander Commission (ATSIC), the NSW Aboriginal Housing Office (AHO) and NSW Health funded the Fixing Houses for Better Health project (FHBH) in 191 houses in eight communities being Goulbourn, Queanbeyan, Yass, Moruya, Narooma, Bodalla, Bega and Eden.  The projects used the same Housing for Health process to address health issues associated with poor housing conditions.
 
The Australian Government's Department of Families, Housing, Community Services and Indigenous Affairs (FaCHSIA) has continued to administer the Fixing Houses for Better Health program nationally.  NSW Health participated in this program again in 2005 working in partnership with FaCHSIA and DAA to enhance projects in Malabugilmah, Baryugil, Purfleet (Taree), and Cabarita (Forster) and in 2007 in Condobolin and Wellington and in 2009 in Bourke, Enngonia and Wilcannia.
 
National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes 2009-2013
In July 2009 $2.66M, to be spent over 4 years, was provided to NSW Health through a Coalition of Australian Governments agreement to fund an expansion of the Housing for Health Program to include projects in urban areas and integrated/inter-agency projects.
 
Currently the Aboriginal Environmental Health Unit is working with the Aboriginal Housing Office (AHO) on  integrated Housing for Health projects.  The collaborative partnership ensures that tenants receive the benefits of combining the surveys undertaken by Housing for Health with the extensive repairs and maintenance works carried out by the AHO with a focus on addressing key problems that lead to health issues. Integrated projects were recently completed at Coffs Harbour and on kitchen upgrades in community houses at Wilcannia. The AHO and NSW Health are currently working (2013) on an integrated project in Toomelah and Boggabilla, Balranald, Murrin Bridge, Cudjallagong, Armidale and Batemans Bay.
 
In 2011, an urban project was completed in La Perouse.  A further urban project in Sydney West is currently being negotiated with a number of agencies and Aboriginal people living in social housing.
 
Under the Indigenous Health National Partnership Agreement (IHNPA) funding,  projects are currently (2013) underway in Muli Muli, Cabbage Tree Island, Menindee, Cummeragunja, Bellbrook.
 
AHO Murdi Paaki Trial
In 1999/00 and 2000/01 the NSW Aboriginal Housing Office funded a trial in six communities in the Murdi Paaki ATSIC region in the far west of NSW.  The communities were Enngonia, Weilmoringle, Ivanhoe, Dareton, Gulargambone and Coonamble.  This project used the same Housing for Health methodology and was managed by Far West Area Health Service.
 
Other Projects
NSW Health also received some special project funding to carry out a Housing for Health project in Karuah in 1999/00. 

Future Housing for Health Projects
The selection of future Housing for Health projects is co-ordinated with other housing programs undertaken in relevant agencies including NSW Aboriginal Land Council and the NSW Aboriginal Housing Office . Following consultation, the relevant agency approves the list of communities to be included in the program.
 
Selection of future communities takes into account a number of criteria including (but not limited to): need (condition of housing); availability of project management resources; ability to cluster projects in similar locations; other housing works undertaken by other programs, and the ability of Housing for Health to support or compliment other work being undertaken in the community.
 
Communities interested in participating in the Housing for Health program should contact NSW Health Aboriginal Environmental Health Unit in the first instance.
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Adding Value to Housing for Health
Over the life of each community project (around 12-18 months), Housing for Health (HfH) works with community housing providers to ensure priority works and capital upgrades are carried out within reasonable timeframes.  While the program has clear parameters, it has potential to also engage communities around other issues that impact on the life of the housing hardware and possibly achieve additional health outcomes.
 
NSW Health's commitment to the program is a platform from which Public Health Units (PHU) can continue to expand their work with Aboriginal communities, identifying and implementing other programs to address a broad range of health related issues.
 
An 'Adding Value' project aims to -
  • Build on and expand the involvement of Environmental Health Officers (EHOs) in more aspects of Housing for Health within communities;
  • Work with EHOs to explore and develop environmental health focussed projects in partnership with the communities;
  • Identify, with other sections of the PHU their capacity to work alongside Housing for Health in delivering complementary public health programs;
  • To assist in creating more robust pathways for continued involvement of PHU in Aboriginal communities;
  • Identify whether HfH could form gateways for other service providers (e.g. local government, fire service, RSPCA, Landcare) to work in partnership with communities on other health related issues.
This work: 
  • Does not alter the Housing for Health methodology, but works alongside its implementation;
  • Is only explored if the community considers it worthwhile;
  • Can only be developed if there is goodwill expressed by the PHU and other related service providers to work in partnership;
  • Recognises the unique nature of each community and builds services/projects identified according to need, and agreed upon by the community and partner services;
  • Focuses on the active delivery of services/projects identified through the community consultation and health research
The following are some examples and ideas.  It is imperative that they are based on health related identified needs and community priorities: 
  • Improving nutrition and nutrition related hardware within the house
  • Further examining the house fabric to help reduce incidence of asthma
  • Reducing internal house temperature through installation of awnings, insulation and shading through a tree planting program
  • Improving community responses to emergencies, working with the local fire service and SES
  • Well person health checks
  • Animal health programs
  • Pest management and control
  • Lung friendly house - reducing respiratory problems through reducing smoking inside house
  • Mr Germ -  improving hygiene through washing hands
  • Mould project -  Reducing respiratory problems
Page Updated: Friday 30 August 2013