Global Health Advocacy Program
Read about the Global Health Advocacy Program HERE
This Year's Theme: Access to Adequate and Affordable Housing
Housing and Health
Housing as a Social Determinant of Health
An important aspect in examining the health of both an individual and a population is an understanding of the social determinants of health (SDH). SDHs are factors that encompass the non-medical and socioeconomic aspects of health, which includes the critical factor of housing and shelter1. Housing is internationally recognized as a basic and fundamental right in order to achieve a minimum standard of living and health.
What is the State of Housing and Homelessness in Canada?
According to Homeless Hub’s report, State of Homelessness in Canada 2013, 30,000 people are homeless on any given night and 200,000 people experience homelessness in the course of a year. In addition, more than one million Canadian households are in core housing need, defined by the Canada Mortgage and Housing Corporation (CMHC) as spending more than 30% of their income on housing, with a further 380,600 households in severe housing need, spending more than 50% of their income on housing. This situation takes an enormous toll on the health of people in Canada. The cost to the Canadian economy of homelessness is an estimated $7 billion every year, largely due to the increased health care costs associated with more emergency room visits and hospital stays, as well as the higher rates of chronic disease found among those who experience homelessness2. This number, however, encompasses only the extra cost related to those experiencing homelessness. The total economic cost associated with the increased health needs of those in core and severe housing need is likely much higher.
Housing in Canada: Poor Health Outcomes Linked to Housing Insecurity
Canada faces many challenges in addressing the housing needs of vulnerable populations. A recent longitudinal study conducted by REACH assessed the self-reported health of 1200 adults across Vancouver, Toronto and Ottawa who are homeless or vulnerably housed3. There were numerous negative health outcomes reported including deficits in physical and mental health, as well as suffering from abuse and assaults. Importantly, there were also numerous reported limitations in accessing healthcare services due to homelessness or a vulnerable housing situation. Poor housing was linked to a number of chronic health conditions including but not limited to arthritis, hepatitis B, asthma, hypertension and chronic obstructive lung disorders. Further, over one quarter of the adults lived with a loss of mobility and almost forty percent had been assaulted or attacked in the past year. Food security was also poor, as many individuals reported having trouble obtaining an adequate amount of nutritious food.
Mental health is also strongly linked to housing. In the Canadian REACH report over fifty percent of adults in the study had been diagnosed at one time in their life with a severe mental disorder. There was found to be high rates of depression, anxiety, bipolar disorders, schizophrenia and post-traumatic stress disorders. Other studies have shown that homeless and vulnerably housed adults are at a greater risk for suicide, with homeless or vulnerably housed women six times more likely to commit suicide. Importantly, interactions between mental health issues and substance abuse can have a profound impact on the health of the individuals as recent studies have shown that homeless individuals are often struggling with these issues simultaneously1.
In terms of access to healthcare, the REACH report also cited poor outcomes. While the homeless or vulnerably housed in Canada’s three major cities had high rates of physical and mental health issues, almost 40 percent had unmet healthcare needs. Alarmingly, 10 percent were refused services while 20 percent were unaware of where to receive mental health support. These outcomes illustrate that the complex health needs of this vulnerable population are not being properly addressed. Hwang et al. report in their study on inadequate housing and mortality that there is a greater mortality rate among these individuals that cannot be accounted for solely based on lower incomes4. Therefore, housing plays a role in life expectancy and mortality, highlighting the need for strong housing programs worldwide.
Feb 3, 2014 the CFMS brought an ask to parliament, and medical students met with dozens of MPs to bring housing issues to the forefront. We chose to focus on social housing, and this is what we brought to parliament hill:
The Problem in Brief
Over the next 20 years Federal funding for social housing subsidies will gradually expire. Without these subsidies, the housing providers who own and operate these units may not be able to survive without raising rents to market prices or selling off some units, leading to the potential loss of over 600,000 social housing units across Canada. In the context of growing income inequality in Canada, the loss of these social housing units could lead to a great increase in the number of people experiencing housing vulnerability.
Federal leadership is crucial to coordinating efforts to ensure access to adequate and affordable housing to everyone in Canada, and the maintenance of hundreds of thousands of social housing units is essential to provide the infrastructure necessary to achieve this goal. We therefore propose that:
In each budgetary year, beginning with 2014, the federal government reinvest the savings gained from the end of social housing agreements to enable social housing providers to maintain the same number of units with the same affordability, as well as make the necessary retrofits and upgrades to keep the buildings efficient and safe. Any remaining funds should support new affordable housing.
More information about social housing HERE
We're currently in the process of developing a clinical tool for frontline practitioners that will help in caring for those in precarious and vulnerable housing situations
Our team is putting together a policy statement for the CFMS that would specifically lay out our positions and objectives with respect to Housing and Health
Canadian Housing and Renewal Association: http://www.chra-achru.ca/
Wellesley Institute: http://www.wellesleyinstitute.com/
- Wellesley Institute. (2010) Precarious housing in Canada
- Stephen Gaetz, Canadian Homelessness Research Network. ( The real cost of homelessness: Can we save money by doing the right thing?
- REACH (2010). Housing vulnerability and health: Canada’s hidden emergency: A report on the REACH health and housing in transition study.
- Hwang SW, Wilkins R, Tjepkema M, O’Campo PJ, Dunn JR. Mortality among residents of shelters, rooming houses and hotels in Canada: An 11 year follow-up study. BMJ. 2009 Oct 26; 339: b4036.
About the Global Health Advocacy Program
The GHAP strives to create a culture of advocacy and awareness of global health issues
among medical students as a means of embracing the CanMeds role of health
advocate, with the goal of creating physician advocates engaged with their patient
populations, locally and globally.
To help Canadian medical students become physician advocates through:
Representation: Uniting students around a specific global health theme, relevant nationwide,
in order to advocate on behalf of underserved populations.
Communication: Disseminating information on this global theme to students, in order to
raise awareness of needs among underserved populations.
Service: Providing advocacy training to Canadian medical students, using this unifying
theme, to help them bring about lasting change in their respective communities.
The National Officer for Human Rights and Peace (NORP) provides a formal training workshop for a Global Health Advocates (GHAs), who are representatives from each CFMS medical school. This training workshop helps GHAs to develop advocacy skills and network with people working within the field of advocacy, social justice, and human rights. The NORP provides resources and support to GHAs to complete three objectives:
1. Conduct a local advocacy training event at their medical school
2. Organize a local campaign based on the national theme
3.Participate in the national campaign.
The NORP also works to advocate at the national level on the global health theme and other advocacy topics chosen by CFMS.
List of Global Health Advocates Contacts, By Medical School
What is Social Housing?
Quick answer: A social housing unit is any home that receives funding or subsidy from the government in order to allow it to be rented at below the market rate for its value. Social Housing in Canada can either be 1) Public Housing, where units are owned and operated by governments, or 2) Non-Profit, Co-op, and Urban Native housing. From 1973-1993 the federal government, through the CMHC, entered agreements with Provincial/Territorial and Municipal governments (1), as well as independent housing providers (2), to purchase or construct social housing, with mortgage payments and operating costs subsidized by the federal government.
The basic structure of Canada’s housing economy is that of the market, where housing units are constructed, sold, and rented without government regulation of prices. This leads to adequate housing outcomes for many people in Canada, but for a significant segment of the population, support is needed to ensure they are adequately housed. Since the 1930s the Canadian government has engaged in many forms of intervention to enable access to affordable housing for those who cannot afford it on the open market:
Before 1949: Social housing before 1949 generally consisted of large one-off projects purchased or constructed by federal or provincial governments, often to help people in wartime or returning veterans.
1949-1964: The federal and provincial governments jointly purchase or construct public housing, usually designed by the federal government and administrated by the provinces.
1964-1983: The federal government develops a program in which the CMHC makes a loan to the provinces or territories to purchase or build public housing. The loan would be repaid over 50 years, and during this time the CMHC would cover 50% of the operating losses associated with operating the projects at rent-geared-to-income (RGI), where tenants pay rent as a fixed proportion of their income, often 20-30%.
1983-present: In 1983 the federal government discontinued public housing programs.
Non-Public Social Housing20
In 1973, the federal government amended the national housing act to allow the CMHC to make loans to Non-Profit and Co-op housing providers, covering up to 100% of the start-up costs. Like the Public Housing agreements, these loans would be repaid over 50 years, with operating costs subsidized by the CMHC during that time. The major difference was that these operations were non-governmental, and often mixed-income, where some, but not all rental units were rented at subsidized rates. In 1986 the program was amended such that loans and subsidies for Non-Profit housing would be over 35 years, rather than 50.
Non-Public Social Housing also includes housing specifically geared towards Aboriginal groups, including both on and off reserve housing initiatives. The Urban Native Housing Program was begun in 1982 and incorporated into the Non-Profit housing program in 1986. It consisted of aboriginal community groups entering into similar agreements with the CMHC as non-Aboriginal Non-Profit housing providers.
All programs for Co-op and Non-Profit housing agreements ended in 1993, and programs for Public Housing development ended in 1983, meaning that contracts signed between 1973-1993 will continue for their 35-50 year term, but no new contracts were signed after that.
What Does the End of Federal Subsidy Agreements Mean for Social Housing?
Quick Answer: Because the situation of each public and non-profit housing provider is different with respect to its size and mix of rent supplement, RGI, and market rental units, the end of subsidies will affect each one differently. There is currently no central information about the post End-of-Agreement (EoA) viability of social housing providers, but recent research has suggested that as many as 25-50% of social housing providers are at risk of being unable to maintain their current level of social housing. Focusing on higher risk projects such as Urban Aboriginal projects, this number is as high as 80%. This would mean more people at risk of being vulnerably housed or homeless.
Nearly all of the federal agreements made between the CMHC and Public, Non-Profit, Co-op, and Urban Native housing providers were signed between 1964 and 1993 for a period of either 35 or 50 years. That means that the period of 2008-2034 will gradually bring the end of subsidies to the existing social housing stock. This phenomenon can be visualized below.
EoA will mean different things to different housing providers, given that each one will have a different number of units, serve different populations, have different operating expenses, and have a different mix of social and market units. One aspect of EoA that will help providers remain viable is that they will have paid off their mortgages. However, operating social housing without subsidy still often means operating at a loss, and since many of the buildings are 25-50 years old or older, necessary new capital expenses may be out of reach for providers21.As can be seen, we are currently entering into the time period of the peak rate of agreement expiry, with around 150,000 agreements expiring between 2014-2020.
In private correspondence with the Canadian Housing and Renewal Association, they suggested that “operating costs will not, in fact, be the most significant issue for social housing providers, particularly over the medium to long term (although in the case of some, the short term). Rather, capital needs will be the biggest issue. That said, we have estimated about 1/3 of the social housing stock (200,000 units) will need some operating support after agreements end.”
If housing providers can no longer support their social housing units without federal subsidy, there is a risk that to make ends meet they will need to either raise rents, therefore putting the units out of reach of those who need them, or sell off some units into the private market so that they have the capital to maintain a smaller number of social units.
What We Recommend
While some organizations have suggested that the federal government simply renew its agreements with housing providers, we feel that this is too much of a one-size-fits-all tool, given the diversity of projects and their financial situations. We instead recommend that in each budgetary year, beginning with 2014, the federal government reinvest the savings gained from the end of subsidies into programs that will enable social housing providers to continue to provide housing to those in need at below-market rent. Since the agreements are currently administered by provinces and territories, the federal government should work with these bodies to develop a system to evaluate the need of social housing providers with regard to capital and operating costs. Federal funding will then be used towards programs that will allow social housing to remain social, either through the existing funding stream of Investment in Affordable Housing, or through a new funding stream specifically for social housing built under federal agreements. If there is money remaining after the needs of existing social housing have been met, this money should be put into streams to support expanding affordable housing.