Nothing About Us Without Us: Co-Design and Integrated Care

Background: Since 2021, HENA has been analyzing the inequalities that affect the right to health and safety of people experiencing homelessness — a highly vulnerable population facing intersectional barriers that limit access to care and support services. To address this issue, a collaboration process was established with the local government of Curridabat (San José, Costa Rica) to design a comprehensive strategy adapted to the territorial context. After three years of joint work and the development of a situational diagnosis with local social actors, it was identified that public policies, reference frameworks, and local and civil society actions remain focused on assistentialist approaches reproducing structural inequalities.

 

They show limited participation or exclude this population´s voices altogether, sometimes promoting their removal from public spaces without considering them in knowledge construction processes, and lacking inclusive or integrated care perspectives. This finding motivated the development of strategies to identify conceptual foundations, experiences, and alternative narratives aimed at understanding and addressing homelessness from a more integrated and human-centered standpoint.

 

Approach: Using a qualitative research approach, data collection techniques such as documentary review were applied. A search strategy was defined to identify articles in databases such as PubMed, EBSCO, and ScienceDirect, as well as grey literature from international organizations and governmental publications from countries across the Americas. Keywords included living conditions, right to health, human security, and capacity development. Based on the results, spaces for analysis, discussion, and deliberation were held with experts to review the main findings and theoretical-methodological frameworks addressing this issue.

 

Results: Living on the streets represents a multicausal, multidimensional, and intersectional public health condition, placing individuals in heightened vulnerability. Institutional service offerings tend to render this population invisible or re-vulnerabilize them, and available information often focuses on organizations or institutions rather than on people experiencing homelessness.

In cases where public policy exists, its implementation fails to transform the situation due to inconsistencies and disparities in application, and the absence of permanent intersectoral platforms limits social dialogue to analyze and monitor persistent inequalities with community participation. As a result, civil society approaches often remain assistentialist, fragmented, and uncoordinated, creating inequities in integrated access to the right to health and security. At the theoretical-methodological level, many existing concepts and strategies remain segregating, positioning this population as inferior within their own communities.

 

Implications: This experience highlights the need to reconfigure traditional theoretical, institutional, and governance frameworks to ensure that integrated care responds to the lived realities of people experiencing homelessness. It is necessary to move toward new multidimensional and intersectional conceptual and methodological frameworks that address this issue from a systemic, complex, and integrated perspective—placing people at the center of strategies and reflecting their lived experiences.

 

Findings show that without permanent intersectoral platforms and clear mechanisms of shared responsibility, actions remain fragmented and limited in their capacity to transform structural conditions. Co-designing these frameworks with the participation of people experiencing homelessness is not only more relevant and sustainable but also redistributes power, reduces institutional stigma, and opens pathways toward more democratic models of knowledge production.