Commentary on Housing,Health,and Well-Being in Aotearoa/New Zealand

Housing is a critical social and environmental determinant of health and well-being. We spend most of our time in our homes—around 90% for preschool children and retired people (Baker et al., 2007). Yet even in affluent Organisation for Economic and Cultural Development (OECD) countries, like Aotearoa/New Zealand and the United States, housing-related poor health is a major social and environmental problem, contributing to significant health inequalities (Jacobs et al., 2014; Johnson et al., 2018). Poor-quality housing drives housing-sensitive morbidity; preventable ill health, which includes increased rates of respiratory, cardiovascular, and close-contact communicable diseases (Baker et al., 2012; Oliver et al., 2018); as well as neighborhood effects (Mackenbach & Howden-Chapman, 2002).

In New Zealand, British colonial settlement, formalized in the 1840 Treaty of Waitangi between the British Crown and Māori tribal chiefs, largely shaped the way in which early housing development took place. Major earthquakes forced a realization that building in stone was unwise, so most New Zealand houses are wooden. Reflecting the British colonial housing legacy of nations like Scotland and Ireland (Healy, 2004), housing is poorly constructed for the climate, and the price of residential electricity has been increasing, resulting in high levels of fuel poverty and high levels of excess winter mortality, particularly in the elderly (Davie et al., 2007; Grimes et al., 2016). New Zealand has a population of 5 million and a high level of public infrastructure, such as schools, hospitals, and roads, yet many houses are cold, damp, and moldy. Building codes are minimal (Bierre et al., 2015) and until 2018 have only really applied to new residential buildings. A public debate about reforming quality standards is currently underway.

Private rental houses are generally poorer quality than public housing and owner-occupied homes (Johnson et al., 2018). Most of the worst quality housing is in the lower, older end of the private rental market, so that ethnic inequalities in income and wealth are exacerbated by housing and socioeconomic conditions. While adequate housing is a recognized human right, New Zealanders face significant challenges with declines in the building of affordable housing, particularly in rental housing, which has contributed to a housing crisis and an increase in homelessness (Amore et al., 2013; Howden-Chapman, 2015). There is growing awareness that government investment in ameliorating the socioeconomic determinants of health, such as housing quality, could alleviate demand on the health care system (Chapman et al., 2009)—particularly because New Zealand has a universal publicly funded health care system, as well as a no-fault accident compensation corporation scheme, which would benefit from a systems approach to improving population health (Skegg, 2019).

The poor quality of the housing stock has led to a major research program focused on the link among remedial interventions, such as retrofitted insulation/weatherization (Howden-Chapman et al., 2007), heating (Howden-Chapman et al., 2008), reduction of injury hazards (Keall et al., 2014), and fuel poverty policies (Viggers et al., 2013), which can help reduce inequalities in housing, health, and well-being. These studies have influenced the International Energy Agency (Ryan & Campbell, 2012) and the World Health Organization (2011, 2018). In this collection of articles on New Zealand housing and health, we profile four articles from multidisciplinary researchers at He Kainga Oranga/Housing and Health Research Programme, funded for over two decades by the Health Research Council of New Zealand. These studies have provided a strong evidence base for government policies.

The first article, “Structural Adjustment and Community Resilience: The Case of Postdisaster Housing Recovery After the Canterbury Earthquakes of 2010 and 2011,” by Rivera-Muñoz and Howden-Chapman considered the effects on the population after the 2010 and 2011 Canterbury earthquakes damaged an estimated 90% of housing in the city. This was the first major natural disaster to hit a large urban center in a developed country since Hurricane Katrina in 2005. Qualitative interviews with community members and public officials explored the role of power and partnerships in postdisaster housing recovery, within the context of the statutory framework imposed by the central government. This approach aimed to restore confidence in the business sector and relied on the insurance and financial markets to stimulate economic recovery and growth. The authors conclude that this centralization of government authority over housing recovery in the city resulted in an erosion of democracy and representative government at a local level.

The second article by Telfar-Barnard et al., “Renting Poorer Housing: Ecological Relationships Between Tenure, Dwelling Condition, and Income and Housing-Sensitive Hospitalizations in a Developed Country,” analyzes the effects of poor housing quality in the rental sector, which has grown rapidly to a third of the New Zealand housing stock. In the United States, federal inspection requirements ensure that rental private apartments funded under Section 8 meet certain standards. There is no such oversight in New Zealand for the Accommodation Supplement, which was modelled on Section 8 and provides welfare housing assistance for people on low incomes (Kuila, 1993). However, minimum legislative requirements (Ministry of Social Development, 2017) were recently updated to incorporate the World Health Organization Housing and Health Guidelines for insulation and heating (Parliamentary Counsel Office, New Zealand Government, n.d.).

Telfar Barnard and colleagues unpicked the relative contributions of tenure and housing quality to hospitalization of those in rental housing. They matched available administrative rental data with hospitalization data and controlled for confounders. They found that while both high rental tenure and poor housing conditions were associated with the risk of housing-sensitive hospitalizations, the association for housing condition disappeared after controlling for income. This suggests that those on higher incomes are better able to offset poor housing quality and rental tenure–related health risks. Based on these results, they concluded that interventions to improve housing condition and tenure security should be targeted both at households and place—that is, low-income areas.

In the third article, “Public Housing and Well-Being: Evaluation Frameworks to Influence Policy,” Rangiwhetu and colleagues looked at the history and role of public housing in New Zealand, which is now explicitly to house people in warm, dry, and safe housing to promote health and increase tenants’ health and well-being. The majority of public housing is directly owned by the central government through a Crown Agency, Housing NZ (since late 2019 Kāinga Ora—Homes and Communities), with only a small local government and community sector (OECD, 2017). In the United States, the Department of Housing and Urban Development administers federal funding to local housing agencies and private entities, both for profit and nonprofit, that manage supportive housing (OECD, 2016). Potentially these state organizations, informed by a reliable evidence base, have the potential for quick implementation of good, well-reasoned policy changes (Mazzucato, 2018).

Using a systems approach and theory of change models, which acknowledged and engaged with stakeholders, they developed a mixed-methods quasi-experimental before-and-after outcomes evaluation framework, with control groups, for three public housing sites of increasing size and complexity. In this article, they reported the results of the apartment-level evaluation, which generally confirmed the proof of concept and viability of this approach and showed specifically that minor draught stopping measures had a relatively big impact on indoor temperature and thermal comfort. This has subsequently informed healthy housing standards. Such systematic evaluations are important to develop an evidence base to inform decision making in both the public and private sectors.

In the fourth article, “Well Homes Initiative: A Home-Based Intervention to Address Housing-Related Ill Health,” Pierse and colleagues analyzed an ambitious, secondary prevention intervention. The intervention was designed to mitigate the high rate of rehospitalization for children for housing-sensitive conditions. Well Homes is funded by the central government, with additional money coming from a local charity, but is implemented at a local level through a community-based partnership between primary and secondary health care providers and researchers. Well Homes provides a mixture of immediate and practical interventions, education, connection with social agencies, and advocacy for more substantial structural home improvements to help families keep their home warmer, drier, and healthier. Each child referred to the program is linked to a national health index, which enables the researchers to undertake a process evaluation, reported here, which will be followed later by an outcome evaluation.