Paths and challenges of intersectoriality in public policies for homeless people: Brazilian perspectives in dialogue with international experiences

Abstract

Given the growing number of homeless individuals and the challenges in accessing public services, intersectorality emerges as a strategy to address this complex phenomenon. Our study systematically mapped the production of knowledge, with national and international literature, on intersectoral public policies for homeless people. A scoping review was carried out as recommended by the Joanna Briggs Institute Reviewer's Manual for Scoping Reviews and PRISMA-ScR. Thirty studies were selected. Two empirical categories were constructed, Public Policies and Intersectoral Actions. Brazilian studies emphasized actions related to care and health, while international studies focus on housing and health. Furthermore, the studies underscore weaknesses in implementation and professional practices.

Keywords:
Homeless; Intersectoral action; Public policy; Racism; Human rights

Resumo

Com o crescente número de pessoas em situação de rua e a dificuldade de acesso nos serviços públicos, a intersetorialidade se destaca como uma estratégia para abordar esse fenômeno complexo. O presente estudo mapeou sistematicamente a produção de conhecimento, com a literatura nacional e internacional, sobre as políticas públicas intersetoriais para população em situação de rua. Foi realizada uma revisão de escopo conforme recomendado pelo Joanna Briggs Institute Reviewer’s Manual for Scoping Reviews e PRISMA-ScR. Selecionaram-se 30 estudos. Construíram-se duas categorias empíricas - Políticas Públicas e Ações intersetoriais - que abordam a intersetorialidade nas políticas e as experiências intersetoriais. Estudos brasileiros enfatizam ações entre assistência e saúde, enquanto os internacionais, moradia e saúde. Os estudos destacam fragilidades na implementação de ações e práticas profissionais.

Palavras-chave:
Pessoas em situação de rua; Ações intersetoriais; Políticas públicas; Racismo; Direitos humanos

Introduction

This study aims to examine the scientific production on intersectoral public policies of care for the homeless population (HLP). For this, we performed a scope review, following a strict search protocol, contemplating Brazilian and international experiences. This research integrates the literature review stage of the first author’s doctorate.

It is estimated that more than 220,000 people are homeless in Brazil (Brazil, 2023). With a predominantly black population (68.26%), resulting from the sum of brown (50.44%) and black (17.82%), it is noted that homelessness and poverty follow historically a pattern of exclusion and marginalization of the black population. Its roots date back to the period of slavery and result in persistent damage to the present day. This marginalization manifests itself through structural racism, the silencing of black standards and the strengthening of the myth of racial democracy (Gonzalez, 1984; Nascimento, 2016). In this sense, the significant growth of the homeless population due to extreme poverty demonstrates the social relevance of the study on this reality. Despite this large number, these people remain paradoxically invisible, which has shocked the naturalization of this phenomenon. The lack of access to public services represents a challenge for the homeless population (HLP), evidenced by the low effectiveness of actions and care aimed at this group (Brazil, 2009a; b).

The National Policy for the Homeless Population (NPHLP), established by Decree n. 7.053/2009, aims to strengthen reception and ensure equity in care. In the area of health, with the creation of the Consultório na Rua (CnaR), provided for in the NPHLP, represents an advance, but its decentralized implementation and lack of prioritization hinder its impact (Brazil, 2009a; 2017; Medeiros; Cavalcante, 2018). In addition, in the area of social assistance, the Unified Social Assistance System (SUAS) and specific services such as the Specialized Reference Center for People in Street Situations (POP Center), challenge the lack of social support and prioritization on government agendas (Brazil, 2011; 1993; Vargas; Macerata, 2018).

Thus, intersectoriality emerges as a crucial strategy to deal with the complexity of the street situation, covering areas such as housing, education and work, as well as health and social assistance (Sicari; Zanella, 2018). Given the complexity, this approach offers a broad and multidimensional perspective, allowing intersectoral policies to have greater effectiveness and sustainability, promoting the link and adherence between services and this population (Nardes; Giongo, 2021).

The theoretical basis adopted follows the perspective presented by Junqueira and Inojosa (1997), which conceptualizes intersectoriality as the articulation of knowledge and experiences in every process of execution of actions in their complex situations, aiming to overcome social exclusion. As outlined by Junqueira (2004), intersectoriality not only proposes, but demands an integrated management that goes beyond the traditional boundaries of social sectors, and challenges the fragmentation and empowerment present in public policy management. It leads, therefore, the management of social policies to the intersectoral dimension.

However, intersectoral actions do not provide answers and certainties to all the complexities of social problems, since these arise from people’s interactions with the world in which they live, in its various notions and values. The solutions are also not unique. However, intersectoriality can be a means of intervening in social reality, although it requires the articulation of institutions and subjects to build networks that gradually transform the ideas and practices of social organization (Junqueira, 2004).

Methods

The scoping review has as premises to map the main concepts of a research field, broaden the view on a topic and summarize the evidence (Peters et al., 2020). Thus, the present scope review follows the reference of Joanna Briggs for Institute for Scoping Reviews (JBI) (Peters et al., 2020), with the methodological steps of: elaboration of the research question; identification of relevant studies; selection of studies; data extraction; analysis; and synthesis of results. The review search protocol was registered in the Open Science Framework (OSF).

The search and selection process of the studies, as well as the report, followed the proposal of the checklist Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (Tricco et al., 2018), presented below:

Creation of the research question

The following guiding question was established: "What intersectoral public policies of attention to HLP have been implemented?". The strategy model Population, Concept and Context (PCC) (Peters et al., 2020) was used as a mediator in the search for literature. For this, the following criteria were imputed to be identified in the articles: Population: People on the street; Concept: Intersectionality; and Context: public policies.

Identification of relevant studies

The bibliographic survey was carried out in the bases: Latin American and Caribbean Health Sciences Literature (LILACS), National Library of Medicine (PubMed), SCOPUS; on the platform Web of Science, SciELO, OASIS, MEDLINE and SocIndex.

The search strategy was defined with the help of a librarian using the main Health Sciences Descriptors (DeCS) and Medical Subject Headings (MeSH), according to the study object and in the combination of the descriptors were used the Boolean operators AND and OR (Chart 1).

Chart 1
Description of the search strategies used in each database

Databases	Search strategy	Search Results
Lilacs (via BVS)	("Ações Integradas de Saúde" OR intersetor* OR program* OR intervention* OR service* OR treatment* OR therap* OR activit* OR outreach OR "intersectoral collaboration" OR "intersectoral action" OR "intersectoral") AND ("Políticas públicas" OR "Proteção social" OR "Política social" OR "Políticas sociais" OR "Public Policy" OR "public policies" OR "social protection" OR "social policy") AND ("falta de moradia" OR "pessoas em situação de rua" OR "População em situação de rua" OR "Morador de rua" OR "Sem teto" OR "Moradores de rua" OR "Homeless Persons" OR homeless OR "homeless people" OR homelessness OR houseless OR shelter* OR "street-involved" OR "street-connected") AND ( fulltext:("1" OR "1" OR "1" OR "1") AND db:("LILACS") AND la:("pt" OR "es" OR "en")) AND (year_cluster:[2009 TO 2024])	344
PubMed	(intersetor* OR program* OR intervention* OR service* OR treatment* OR therap* OR activit* OR outreach OR "intersectoral collaboration" OR "intersectoral action" OR "intersectoral") AND ("Políticas públicas" OR "Proteção social" OR "Política social" OR "Políticas sociais" OR "Public Policy" OR "public policies" OR "social protection" OR "social policy") AND ("Homeless Persons" OR homeless OR "homeless people" OR homelessness OR houseless OR shelter* OR "street-involved" OR "street-connected")	316
Scopus	( TITLE-ABS-KEY ( "Ações Integradas de Saúde" OR intersetor* OR program* OR intervention* OR service* OR treatment* OR therap* OR activit* OR outreach OR "intersectoral collaboration" OR "intersectoral action" OR "intersectoral" ) AND TITLE-ABS-KEY ( "Políticas públicas" OR "Proteção social" OR "Política social" OR "Políticas sociais" OR "Public Policy" OR "public policies" OR "social protection" OR "social policy" ) AND TITLE-ABS-KEY ( "falta de moradia" OR "pessoas em situação de rua" OR "População em situação de rua" OR "Morador de rua" OR "Sem teto" OR "Moradores de rua" OR "Homeless Persons" OR homeless OR "homeless people" OR homelessness OR houseless OR shelter* OR "street-involved" OR "street-connected" ) ) AND PUBYEAR > 2008 AND PUBYEAR < 2025 AND ( LIMIT-TO ( LANGUAGE , "English" ) OR LIMIT-TO ( LANGUAGE , "Portuguese" ) OR LIMIT-TO ( LANGUAGE , "Spanish" ) )	528
Web of Science (through Portal of Journals)	("Ações Integradas de Saúde" OR intersetor* OR program* OR intervention* OR service* OR treatment* OR therap* OR activit* OR outreach OR "intersectoral collaboration" OR "intersectoral action" OR "intersectoral") AND ("Políticas públicas" OR "Proteção social" OR "Política social" OR "Políticas sociais" OR "Public Policy" OR "public policies" OR "social protection" OR "social policy") AND ("falta de moradia" OR "pessoas em situação de rua" OR "População em situação de rua" OR "Morador de rua" OR "Sem teto" OR "Moradores de rua" OR "Homeless Persons" OR homeless OR "homeless people" OR homelessness OR houseless OR shelter* OR "street-involved" OR "street-connected")	761
SciELO	("Ações Integradas de Saúde" OR intersetor* OR program* OR intervention* OR service* OR treatment* OR therap* OR activit* OR outreach OR "intersectoral collaboration" OR "intersectoral action" OR "intersectoral") AND ("Políticas públicas" OR "Proteção social" OR "Política social" OR "Políticas sociais" OR "Public Policy" OR "public policies" OR "social protection" OR "social policy") AND ("falta de moradia" OR "pessoas em situação de rua" OR "População em situação de rua" OR "Morador de rua" OR "Sem teto" OR "Moradores de rua" OR "Homeless Persons" OR homeless OR "homeless people" OR homelessness OR houseless OR shelter* OR "street-involved" OR "street-connected")	89
Oasis	("Ações Integradas de Saúde" OR intersetor* OR program* OR intervention* OR service* OR treatment* OR therap* OR activit* OR outreach OR "intersectoral collaboration" OR "intersectoral action" OR "intersectoral") AND ("Políticas públicas" OR "Proteção social" OR "Política social" OR "Políticas sociais" OR "Public Policy" OR "public policies" OR "social protection" OR "social policy") AND ("falta de moradia" OR "pessoas em situação de rua" OR "População em situação de rua" OR "Morador de rua" OR "Sem teto" OR "Moradores de rua" OR "Homeless Persons" OR homeless OR "homeless people" OR homelessness OR houseless OR shelter* OR "street-involved" OR "street-connected")	157
Medline (via BVS)	Search (intersetor* OR program* OR intervention* OR service* OR treatment* OR therap* OR activit* OR outreach OR "intersectoral collaboration" OR "intersectoral action" OR "intersectoral") AND ("Políticas públicas" OR "Proteção social" OR "Política social" OR "Políticas sociais" OR "Public Policy" OR "public policies" OR "social protection" OR "social policy") AND ("Homeless Persons" OR homeless OR "homeless people" OR homelessness OR houseless OR shelter* OR "street-involved" OR "street-connected")	724
Socindex (through EBSCOhost)	("Ações Integradas de Saúde" OR intersetor* OR program* OR intervention* OR service* OR treatment* OR therap* OR activit* OR outreach OR "intersectoral collaboration" OR "intersectoral action" OR "intersectoral") AND ("Políticas públicas" OR "Proteção social" OR "Política social" OR "Políticas sociais" OR "Public Policy" OR "public policies" OR "social protection" OR "social policy") AND ("falta de moradia" OR "pessoas em situação de rua" OR "População em situação de rua" OR "Morador de rua" OR "Sem teto" OR "Moradores de rua" OR "Homeless Persons" OR homeless OR "homeless people" OR homelessness OR houseless OR shelter* OR "street-involved" OR "street-connected")	160

• Source: Created by the authors.

Selection of the studies

The inclusion criteria were: articles that reported experiences, actions and/or intersectoral public policies of attention to HLP; published from January 2009 to April 2024; complete studies in Portuguese, English or Spanish. The beginning of the selection period is justified by the year of implementation of the NPHLP, provided for in Decree n. 7,053 of December 23, 2009. The studies were organized through the Zotero Reference Manager to optimize the verification of duplicates and selection of articles.

Data extraction, analysis and synthesis of the results

A matrix was created for the extraction of descriptive results of the included studies, considering characteristics such as title, authors, year, place of study, language and area of knowledge. The conceptual model of the scope review, focused on the description and evaluation of intersectoral actions for equity in health, provided the basis for the elaboration of qualitative data categories (Shankardass et al., 2012). The data were grouped by categories, and the analysis was based on the characteristics of the studies and the intersectoral policies found. Thematic categories were developed through the analysis of content and meanings (Bardin, 2011).¹

Results and Discussion

The selection process identified 3,079 articles, of which 691 duplicates were excluded. After the analysis of abstracts, 198 articles were discarded, and another 31 were eliminated after the full reading, because they did not address the theme in a specific way. At the end, 30 articles on public policies and intersectoral actions for HLP attention were selected (Figure 1).

Figure 1
Description of the study selection process

Most studies, 17 (56.6%), were in English, while the rest were in Portuguese. As for the location, 14 (46%) studies were conducted in Brazil, listing national policies and experiences in large centers such as Rio de Janeiro, São Paulo, Florianópolis, Distrito Federal, Belo Horizonte and Teresina. A study addressed Brazil, Portugal and the United States of America (USA), performing a comparative analysis.

At the international level, studies were developed on policies for HLP in Norway, England, Scotland, Spain, France, Ireland, Italy, Poland, Switzerland and the Netherlands; in addition, studies conducted in the United States, South Korea, as Argentina, Brazil, Chile, Colombia and Cuba (Chart 2).

Chart 2
Characteristics of the studies included in the scoping review

Authors	Year	Journal	Knowledge area*	Language	Study site
Adorno	2011	Etnográfica	Anthropology/Archaeology	Portuguese	São Paulo, Brazil
Anderson; Ytrehus	2012	Journal of Social Policy	Interdisciplinary	English	Norway, Scotland
Batchelor; Kingsland	2020	International Journal of Environmental Research and Public Health	Public Health	English	England
Borysow; Conill; Furtado	2017	Ciência e Saúde Coletiva	Public Health	English	Brazil, Portugal, and the USA
Cabral Junior; Costa	2016	Revista Brasileira Políticas Públicas (Online)	Law	Portuguese	Brazil
Cameron et al.	2009	Health and Social Care in the Community	Medicine I	English	England
Canato; Bichir	2021	Revista de Administração Pública	Public and Business Administration, Accounting, and Tourism	Portuguese	São Paulo, Brazil
Che et al.	2020	Health & Social Care in the Community	Medicine I	English	South Korea
Gomes; Elias	2016	Revista Comunicação em Ciências da Saúde	Nursing	Portuguese	Brazil
Greenwood et al.	2021	Journal of Community & Applied Social Psychology	Psychology	English	France, Ireland, Italy, Poland, Spain, Switzerland, and the Netherlands
Greenwood et al.	2013	Journal of Social Issues	Social Sciences	English	United States
Hamada et al.	2018	Revista De APS - Atenção Primária À Saúde	Public Health	Portuguese	Brazil
Hwang; Burns	2014	Lancet	Public Health	English	United States
Kertesz et al.	2009	Milbank Quartely	Medicine	English	United States
Kriel	2017	Development Southern Africa	Social Sciences	English	Tshwane, South Africa
Macedo et al.	2020	Revista Psicologia e Saúde	Psychology	Portuguese	Teresina, Brazil
Martinelli et al.	2020	Textos & Contextos	Social Work	Portuguese	Brazil
Martins et al.	2023	Ciência e Saúde Coletiva	Public Health	Portuguese	Brazil
Martins et al.	2024	Frontiers in Public Health	Public Health	English	Belo Horizonte, Brazil
Mattos	2019	NOMOS: Revista do Programa de Pós-Graduação em Direito da UFC	Law	Portuguese	Brazil
Medeiros et al.	2020	Psicologia em estudo	Psychology	Portuguese	Argentina, Brazil, Chile, Colombia, and Cuba
Moledina et al.	2022	Campbell Systematic Reviews	Social Sciences	English	Canada
Naidoo	2010	Development Southern Africa	Social Sciences	English	South Africa
O'Carroll et al.	2021	International Journal of Drug Policy	Public Health	English	Dublin, Irlanda
Oliveira; Guizardi	2020	Saúde e Sociedade	Public Health	Portuguese	Distrito Federal, Brazil
Oliveira et al.	2015	Argumentum	Social Work	Portuguese	Florianópolis, Brazil
Parsell et al.	2013	International Journal Of Social Welfare	Social Sciences	English	Australia
Rubio-Martin	2018	Cuadernos De Trabajo Social	Social Work	English	Spain
Serafino; Luz	2015	Revista Katálysis	Public Health	Portuguese	Rio de Janeiro, Brazil
Wijk;. Mângia	2017	Saúde em Debate	Anthropology/Archaeology	English	São Paulo, Brazil

• * Area of knowledge, according to the Sucupira Platform (2024), except articles 11, 14, 15, 22, 23 and 27, with the source Scimago Journal & Country Rank (2024).
• Source: Created by the authors.

The distribution of studies by area was not homogeneous. Public Health had the largest number, with nine articles between 2014-2024, followed by Social Sciences and Anthropology, with six studies in the years 2010-2022, and by Social Service, with four studies in the years 2015-2020 (Figure 2).

Figure 2
Number of articles by area of knowledge/year

With a variety of methodologies, contexts and objectives, the studies presented a focus on intersectoral policies and actions for HLP, which support the development of public policies for this population group. After reading the articles, two empirical categories were created: public policies and intersectoral actions. The literature synthesis identified intersectoriality as a transversal axis in the discussion of these categories.

Although intersectoral actions are a means of implementing public policies, they appear differently in the literature. Public policies refer to the set of formal guidelines that guide the actions of the State, while intersectoral actions concern concrete practices and local articulations between different sectors. This distinction allows us to understand what is provided for in the regulations, and how policies are effective in practice. Thus, in this work, we chose to explore the local actions and experiences of workers separately, dedicating a specific space to analyze what occurs in the daily implementation and territorial dynamics. This approach is fundamental to identify the challenges and opportunities that arise in the operationalization process, especially in contexts marked by inequalities and territorial diversity (Lotta; Pavez, 2010).

In the studies included in the review, arguments were presented that discuss the fragilities of intersectionality. This approach was described as a strategy that aims to integrate and complement a local action network (Oliveira; Alison; Guizardi, 2020). It was considered, by other studies, an important form for the care of HLP (Borysow; Conill; Furtado, 2017; Macedo; Sousa; Carvalho, 2020; Mattos, 2019; Serafino; Luz, 2015; Wijk; Mângia, 2017).

Nevertheless, as noted by some authors (Adorno, 2011; Anderson; Ytrehus, 2012; Macedo; Sousa; Carvalho, 2020; Mattos, 2019; Serafino; Luz, 2015; Wijk; Mângia, 2017), although there is a cross-sectional and intersectoral proposal, there is recurrent emphasis on one specific sector, more involved than another, mainly at the local level, as it occurs in municipalities. This characteristic of intersectoriality acts contrary to the expected, considering the need for actions that integrate other areas to ensure better living conditions for this population (Cabral Júnior; Costa, 2016; Gomes, 2016; Hamada et al., 2018; Mattos, 2019). In this sense, intersectoriality is more challenging when it comes to ensuring attention to HLP. The stigma and prejudice, also experienced in institutional racism, suggest a lack of preparation of network workers (Macedo; Sousa; Carvalho, 2020).

Public policies

Concerning public policies, the first question that arises is about the service intended for HLP. In Brazil, the service is mainly related to policies inserted into the Unified Health System (SUS) and Unified Social Assistance System (SUAS) (Medeiros et al., 2020).

From the re-democratization and health reform, social protection and health care began to have social demands incorporated into public health policies (Adorno, 2011; Hamada et al., 2018; Martinelli; Nunes; Machado, 2020; Mattos, 2019). However, even with the Federal Constitution of 1988, rights are still fragmented and sectorized. The search for universal health promotion has limits even by the construction of the state, balance of social inequality and the continental dimension of the country (Adorno, 2011; Martinelli; Nunes; Machado, 2020).

In health, the UHS, as established by Law n. 8080/90, with the principles of equity, universality, comprehensiveness, proposes to care for and focus on the most vulnerable groups. However, the reality of health care was not aligned with the challenges faced by HLP. These individuals were denied access to services due to the prejudice that permeates their lives. The lack of documentation, the use of drugs, dirty clothes and unpleasant odor are cited as justifications for the exclusion of these people from health units, impacting on the low effectiveness of actions and care aimed at this population (Brazil, 2009a, b; Brito; Silva, 2022). And thus, a discourse is perpetuated that affirms the street situation as a problem of Social Assistance.

Social assistance has a history linked to welfare, a concept rooted in the popular imagination as synonymous with charity. Historically, in Latin America, HLP was served by philanthropic and charitable institutions related to the Catholic Church (Adorno, 2011; Cabral Júnior; Costa, 2016; Medeiros et al., 2020). This association influences a discourse that suggests that the HLP needs exclusively care, positioning them between guardianship and effective citizenship (Benelli; Costa-Rosa, 2012). Thus, although there are advances in guaranteeing rights and an effort to build a care network for this population, the service still maintains welfare practices (Adorno, 2011; Cabral Júnior; Costa, 2016; Medeiros, Cavalcanti de et al., 2020).

From the Organic Law of Social Assistance (LOAS) instituted in 1993, together with the National Policy of Social Assistance (PNAS) of 2004, the SUAS was consolidated in the following year. Given the guidelines of SUAS, Law no 11.258/2005, there were extensions to the care network to the HLP, which normatizes the mandatory creation of programs directed to the HLP, in the organization of social assistance services, adopting an intersectoral action perspective.

In 2006, there was the construction of the Interministerial Working Group, coordinated by the Ministry of Social Development and Fight against Hunger (MDS) and composed by the National Movement for People on the Street (MNPR), interested institutions and members of other ministries were included in the group. The group built intersectoral public policy proposals for HLP, linking areas of health, education, work, justice and social assistance. These proposals culminated in the construction of NPHLP (Cortizo; Santo, 2019).

The NPHLP, decreed in 2009, presents objectives of articulation between different sectors, promoting a network of protection, promotion and assistance (Adorno, 2011; Cabral Júnior; Costa, 2016; Gomes; Elias, 2016; Mattos, 2019). It is portrayed as a recent political milestone. However, there is a gap between the creation of the policy and effective implementation (Martins et al., 2023), such as the late implementation of CnaR teams that occurred only from 2011 (Brazil, 2017).

Although it seeks to act and incorporate all spheres of public power, the NPHLP does not guarantee the rights of the HLP in full (Mattos, 2019). An example of this, a study developed in Rio de Janeiro highlights its application at the municipal and state level, responding to the street situation through hygiene policies (Mattos, 2019; Serafino; Luz, 2015).

The relations between state and society can sometimes hinder the realization of rights, especially due to the lack of articulation between sectors. The little integration between SUS and SUAS compromises integral care, as well as the disconnection between food security and nutritional policies limits its effectiveness. In addition, state action can aggravate social vulnerability, either by the violence of public security agents (Macedo; Sousa; Carvalho, 2020; Martinelli; Nunes; Machado, 2020) or by the precariousness of outsourced services, resulting in disassistance.

Moreover, it is important to understand the materiality of NPHLP, underfunding, threats to social security policies and the importance of social participation of HLP in the construction of public policies (Martinelli; Nunes; Machado, 2020). An analysis of experience in the Federal District presents the existence of intersectoral committees, such as the Intersectorial Committee for Monitoring and Follow-up of NPHLP (CIAMP Rua), which function as a space for social participation and monitoring of NPHLP. However, civil society has little resolution in the public agenda, being necessary new spaces for dialogue with the state and have as a proposal the revision of its own policy (Oliveira; Guizardi, 2020).

MNPR has a key role in the creation of national public policies (Medeiros et al., 2020). Another study, carried out in England, also defends the social participation and listening of this population segment, strengthening the importance of popular pressure on social control to guarantee minimum rights, which do not represent the search for advantages, but for historically denied rights (Batchelor; Kingsland, 2020; Medeiros et al., 2020).

Even in the face of public policies for HLP, implementation faces obstacles such as the limited vision of the street situation as a state rather than a process, the difficulty of mapping the individuals that compose it and the lack of knowledge of this population in relation to their rights.

Intersectoral actions

In the context of intersectoral actions, health, social assistance and housing are highlighted. In the area of health, CnaR faces dilemmas in the intra and intersectoral network, although it is a device of Primary Health Care, its implementation and integration to Basic Health Units do not always occur in a fluid way, requiring strategies to strengthen this bond and ensure continuity of care (Borysow; Conill; Furtado, 2017; Oliveira; Guizardi, 2020).

The work of CnaR teams has a fundamental role for the health network through the articulation of different actors and services of mental health, urgency and basic care (Brazil, 2017). The lack of societal support and prioritization in government agendas hinders access, adherence and longitudinal care, leading to a marginalization of CnaR teams in the Health Care Network and hindering the development of their actions (Valle; Farah, 2020; Vargas; Macerata, 2018), as well as recognition by other health professionals due to the specificities of working with this population (Wijk; Mângia, 2017). CnaR allows access to health for HLP, leading the care and fight for the inclusion of this population in the health network, since barriers persist in this network (Andrade et al., 2022).

In the work between Health and Social Assistance, a Brazilian study with workers from CnaR and the POP Center in Teresina, Piauí (Macedo; Sousa; Carvalho, 2020), reported intersectionality as a challenge. The difficulty of working in network intensifies when dealing with vulnerable populations. The lack of integration is attributed to the absence of common objectives and objects in a restricted intersectoral network, which also excludes people (Hamada et al., 2018; Macedo; Sousa; Carvalho, 2020). However, the Pop Center and CnaR have a common assisted population, which allows for closer dialogues and discussions.

In an international study conducted in England, it was possible to see improvements in the health of HLP due to the articulation between sectors such as health and social assistance. For the work in partnership to develop, in fact, intersectoral action, it is necessary training and education of professionals from various sectors. Thus, professionals must cross organizational boundaries to achieve the objectives of attention to the population (Batchelor; Kingsland, 2020). It is important to highlight the need to qualify professionals from the entire network on the flows of service and the rights of vulnerable populations, which minimizes stigma and access barriers, enabling equitable care (Hallais; Barros, 2015).

In the case of intersectoral actions related to HLP mental health care, active search and harm reduction strategies were identified as important resources for teams to promote access (Borysow; Conill; Furtado, 2017; Oliveira; Sampaio; Saldanha, 2015).

Some services relate mental health strategies to housing to control the use of psychoactive substances (Anderson; Ytrehus, 2012). An example of this were the actions developed in the Open Arms program, which sought to promote the psychosocial rehabilitation of people in social vulnerability and use of psychoactive substances, offering housing, social rent and work (Canato; Bichir, 2021). The use of psychoactive substances leads the population to become even more distant from health and social services. The active search plans to reach those who need care most, offering assistance and social reintegration projects.

The Street Teams in Portugal, directed to HLP that use psychoactive substances, highlight the importance of network care through a harm reduction program funded by the federal government and provides for coordination with the health sector (Borysow; Conill; Furtado, 2017).

Unlike Portugal, Norway includes the HLP in existing services and does not aim to create new health services. Other strategies include the prevention of the street situation, with the distribution of financial resources for housing in residences or social assistance service, articulating the work of municipal entities and volunteer organizations. Thus, the Norwegian study showed that social welfare service was more involved and health service less (Anderson; Ytrehus, 2012).

In the US context, the Patient Protection and Affordable Care Act represents a breakthrough in the care of people who consume high-risk psychoactive substances, directing to primary care, as does CnaR (Borysow; Conill; Furtado, 2017). In addition, they presented the training of social assistance professionals to care for this population. There was, however, the same training to health professionals, which demonstrated a disparity in actions in each sector (Anderson; Ytrehus, 2012; Borysow; Conill; Furtado, 2017).

In the Brazilian experiences, the alignment between primary care and mental health services seek to occur from access to psychosocial care centers and basic health units (Wijk; Mângia, 2017). The link of users with multiprofessional teams can be used as a strategy for working with HLP. Despite the efforts, the teams present difficulties, such as lack of care for mental health for the population, deficiencies in training and scarcity of resources, highlighting the need for a more effective intersectoral network, even given the existing guidelines (Cameron et al., 2009; Macedo; Sousa; Carvalho, 2020; Oliveira; Sampaio; Saldanha, 2015; Wijk; Mângia, 2017).

Furthermore, by using the Harm Reduction strategy for the individualized care of users in the POP Center, it was possible to change the work dynamics and the relationship between the subject and the service. Users who make use of psychoactive substances were not judged and, thus, could develop strategies in the service itself to improve their life dynamics (Oliveira; Sampaio; Saldanha, 2015). It is observed, however, an increase in the lack of protection by the health network even when attention is being built with HLP, evidencing a lack of responsibility that ends up directing this population to specialized services, while they seek their insertion in the network. The existence of specialized services does not intend to exclude users from other services; on the contrary, it seeks to ensure intersectoral articulation for continuity of access and care (Macedo; Sousa; Carvalho, 2020).

Therefore, it is necessary to recognize the difficulties for intersectoriality to be effective, considering the tensions between knowledge, practices and hierarchies, which reflect power disputes. In daily life, we try to ensure the reception through personal contacts and friendships, generating "exclusionary inclusions". In other words, a network that depends on contacts, calls or specific people in each service, and not the service itself, is not a network. Informality and the absence of processes disrupt the network or facilitate only some articulations, creating barriers for others. Thus, it is necessary to question whether the articulated network really exists (Macedo; Sousa; Carvalho, 2020; Martinelli; Nunes; Machado, 2020).

A study conducted in South Africa revealed that prevention actions prioritized the reduction of the risks of vulnerability of the street situation. The study highlighted the need for policies to share objectives in order to effectively address HLP, especially in the housing and social security sectors, combining resources from different areas with an integrated approach (Naidoo, 2010). However, in this country, the absence of a national plan to coordinate policies for HLP hinders the success of actions (Kriel, 2017).

Regarding housing issues, the study conducted in South Korea evaluated the lack of access to dental services among HLP, highlighting the importance of integrated services for this population. The study found that individuals who received housing assistance had a higher frequency of visits. On the other hand, those who slept on the streets were more likely to have their needs unmet, compared with institutionalized people or those living in one-room occupations (Che et al., 2021).

An analysis of the Supporting People Programme in England, which plans to provide housing, health and social inclusion support for HLP with human immunodeficiency virus (HIV), revealed positive results due to coordination between different sectors. The follow-up of health professionals and harm reducers in health consultations supported people to overcome access barriers, avoiding duplication of efforts. In addition, having someone who acts as an advocate during health consultations can amplify the bond and be a valuable resource for meetings with HLP in services (Cameron et al., 2009).

The housing program Housing First, originated in the USA, is directed to HLP with mental health issues, and has been implemented in several countries, such as France, Ireland, Italy, Netherlands, Poland, Portugal, Spain, Sweden, Japan and Australia. This program offers institutional reception and community support to expand access to services and strengthen the autonomy of individuals based on the principles of harm reduction, since it recognizes housing as a fundamental right, and not as a conditional reward at the end of a care.

The strategies of this program are used for people with severe mental disorders. Combined health and housing interventions are effective, reflecting a two-way approach that encompasses both health awareness and social policies. These aspects are considered structural factors and highlight the importance of not limiting the focus only to housing or recovery (Greenwood et al., 2021; Greenwood; Stefancic; Tsemberis, 2013; Hwang; Burns, 2014; Kertesz et al., 2009; Moledina et al., 2022). Therefore, Housing First is recognized as an innovative approach due to its emphasis on autonomy, differentiating itself from traditional methods and interventions for HLP, promoting an expanded perspective on housing and its relationship with other sectors (Greenwood et al., 2021; Stefancic; Tsemberis, 2013).

In the 2000s, Norway, which has a decentralized health system and provides health services run by municipalities, established a national program to address homelessness, entitled På vei til egen bolig (A Path to a Permanent Home). This program aims at an interministerial approach, addressing the issue in all sectors and policy areas and with strategies implemented at the local level, valuing the reduction of evictions and the number of HLP (Anderson; Ytrehus, 2012).

Scotland included HLP care in its 2004 national health service reform through community health services, aiming to reduce social inequalities. As in Scotland, projects for a multi-ministerial strategy have been implemented in Norway; however, there are still authorities concerned with the fight against homelessness in Scotland. There is a substantial difference between the structures of the experiences in these countries: while the approach in Scotland is more focused on housing, in Norway the positive results are given in the longer time of implementation of its actions (Anderson; Ytrehus, 2012).

In Brazil, hostels managed by social organizations, financed by public resources from the federal, state or municipal levels, and operating under a shared or outsourced management regime, establish several requirements for the admission of individuals. Still, the number of available vacancies is proportionally lower than the number of HLP, as occurs in the city of São Paulo (Adorno, 2011; Macedo; Sousa; Carvalho, 2020; Mattos, 2019). However, the specialized assistance and introduction of Social Service professionals in shelter teams has been positive (Mattos, 2019; Serafino; Luz, 2015).

The integrated construction of social policies requires more than "political will" and resources, as demonstrated in Australian and Spanish studies (Parsell; Jones; Head, 2013; Rubio-Martin, 2018). In the Spanish public social system, there is still a poor development in social policy for HLP (Rubio-Martin, 2018). In addition, the realization of articulated projects of social policies demands changes in organizational culture, since each sector policy has its own interests and practices (Junqueira, 2004). A study on the analysis of social policies and Brazilian health recommends that sectoral programs should not deal in isolation with the multiple dimensions of social problems (Martins et al., 2023). They also describe the difficulties of such projects, corroborating with the results of this review.

It should also be considered that, in the context of crises, the situation of the HLP is aggravated. Studies conducted during the COVID-19 pandemic in Belo Horizonte and Dublin, Ireland, demonstrate the importance of a rapid and coordinated response with existing services, directing resources and assistance and housing interventions to this population during crises (Martins et al., 2024; O'Carroll; Duffin; Collins, 2021).

In summary, all projects in different contexts and countries share similarities and present differences throughout the intersectoral experiences. It is essential to consider the points of contact in the panorama of different projects and value them, given the diversity and complexity, combined with the dynamics of power and social relations within and between sectors (Magalhães; Bodstein, 2009).

Conclusion

In studies on the attention to HLP, intersectoriality is seen as a potential to be effective, but faces weaknesses in practices, management and implementation. Despite these difficulties, articulation is essential to deal with the complexity of the street situation. In successful cases, strategies aimed at various objectives, such as harm reduction in substance use, access to housing and specialized services.

In summary, the different reflections presented in the studies on the policies and practices of professionals in specialized services present difficulties in articulation with the network. The preparation of professionals was also identified as an emerging point and, therefore, stands out the need to think the training of public sector professionals for the care of people in vulnerability and defense of their rights. Therefore, the work, by being performed in a humanized way and by sensitized professionals, can contribute to the recognition of citizenship and rights of HLP.

For this, it is assumed that the intersectoral work makes attention to HLP more tangible and possible. However, in everyday life there are many difficulties for its execution in the work processes, such as the overload of professionals, difficulties of contacts in the network and in the service itself from the demands of the population, requiring the expansion of resources and services. In addition, national articles report more experiences on the articulation between social assistance and health, while international studies demonstrate positive relationships between housing and health. Thus, there is a gap in Brazilian studies that address aspects beyond the health and social assistance sectors, this gap being more evident when it comes to the area of mental health, housing, health and work.

It should be noted that the street situation is not a phenomenon restricted to the countries of the Global South, being present also in countries such as Canada and England. However, it assumes specific characteristics in each context, which makes it essential to understand the uniqueness of what it means to be a homeless population in Brazil, without losing sight of its global dimension.

The review has broadened the understanding of intersectoral actions in recent decades. In Public Health, there are various challenges, it is necessary to expand the discussions on intersectoral practice beyond the gaps and difficulties presented, suggesting new paths and perspectives for Brazilian policies.

Despite the rigor in the search and deliberation of articles, this study has some limitations. The selection was conducted by a single reviewer, which may induce biased interpretations. The racial debate was not initially contemplated in the scope of the article, and we recognize that this theme is fundamental to understand the historical legacy of slavery and its consequences in the formation and dynamics of the population on the street in Brazil. Authors such as Santos, Sarreta and Guilherme (2023) have deepened this discussion, which is deeply intertwined in the Brazilian history. Thus, we highlight the need for future studies that explore this relationship in greater depth. In addition, only complete texts signed by the CAPES Journal Portal or in open access were included, excluding paid studies not available on this portal.²

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• All research data are available in this text
• 1
  The protocol for this scoping review is registered with the Open Science Framework (OSF), according to the Joanna Briggs Institute methodology, under DOI: 10.17605/OSF.IO/4H2XA.
• 2
  C. dos S. Pereira: study conception and planning, data collection, analysis, and interpretation, review and approval of the final version of the manuscript. W. B. Marcondes and K. Njaine: study conception and planning, data analysis, review and approval of the final version of the manuscript. This work was supported by the Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES) - Funding Code 001, Doctoral scholarship.
• This work was supported by the Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES) - Funding Code 001, Doctoral scholarship.

• Editor:
  Jane Russo

Data availability

All research data are available in this text

Publication Dates

• Publication in this collection
  08 Dec 2025
• Date of issue
  2025

History

• Received
  16 Aug 2024
• Reviewed
  10 Apr 2025
• Accepted
  29 July 2025