Deinstitutionalisation (orphanages and children's institutions)

Deinstitutionalisation largely occurred in the US between 1941 and 1980.[1][2] In the US it was a consequence of the Social Security Act of 1935 (SSA), which allowed Aid to Dependent Children (ADC) to be passed, and meant that children could no longer be removed from their families due to poverty alone.[3] Deinstitutionalisation occurred over a similar period in some Western European countries, although rates varied between countries. In 2009, the European Union began to prioritise deinstitutionalisation among member-states.[4] The European Commission changed its funding regulations to promote deinstitutionalisation and discourage investment of EU funds on residential institutions. This resulted, in particular, from an understanding of the legal framework, including the UN Convention on the Rights of Persons with Disabilities, the UN Convention on the Rights of the Child and the European Convention on Human Rights.[5] Deinstitutionalisation also progressed in some South American countries.[6] The current alternative in the US is known as the Foster Care system.

Deinstitutionalisation is currently most common in the former Soviet Bloc.[7] Increasingly the institutions that remain in Eastern Europe are occupied by disabled children who can be harder to place in the community.[8] Completing their closure and supporting the development of places they can be cared for in the community is seen as a priority by the EU and that has encouraged many countries wishing to accede to it including the Czech Republic,[9] Romania, whose orphanages are the most infamous in the world,[10][11][12] and Bulgaria.[13][14][15][16] It is also happening in Hungary where no new children can be placed in orphanages.[17] Moldova[18] has made considerable progress, where investment in inclusive education means many children with disabilities can live at home with their families, reducing the need for institutional placements.[19] Ukraine, Belarus and Bosnia. Azerbaijan has established a Department for De-institutionalisation and Child Protection.[20][21]

The majority of orphanages in Africa are funded by private donors and are often not part of a larger coherent child protection system. In Africa deinstitutionalisation has support from the Governments of Rwanda[22] and Ghana[23][24][25][26] and Ethiopia however as the governments do not run the institutions the process can be more complex.[27] Sudan is also making moves towards deinstitutionalisation with the partial closure of Mygoma Orphanage and the setting up of foster placements for babies abandoned there consistent with the principle of Kafala.[28]

More recently many countries in Sub-Saharan Africa have begun to work on the transition from institutional to community-based care for children.[29]

As a whole there is estimated to be about 52 million orphans in Africa, largely due to high mortality rates from various diseases within the continent (HIV/AIDS, malaria, tuberculosis), but also due to natural disasters, conflicts or other pregnancy and birth related reasons. In Malawi, some are simply abandoned due to financial of family reasons in orphanages. In 1997 the Chikondri Centre opened, and the founder, Mussa, found that many ended up in "special need’s schools, vocational training, starting small businesses, getting jobs and living independently." In 2014, UNICEF started aiding the Malawi government to support the change from institutionalized care to a more family-centered care, following the global trend to do this across the world. As of 2018, 300 children had been transitioned through this standard.[30]

There are some small scale moves to increase the number of family based placements in China but this is not yet a large scale movement.[31] It is now a priority of NGO's in Nepal[32] and the government in Cambodia. In Malaysia, the government is piloting deinstitutionalisation detailed analysis in Negeri Sembilan State as a pilot project, with the aim of scaling up to the entire country.[33]

This Randomised Controlled Trial is a scientific study that compares the development of children raised in institutions with children raised in birth families and foster care. It is the first study to assess brain functioning among children who have experienced institutionalisation.[41] The study took random samples of 208 children and followed their physical growth, cognitive, emotional and behavioral development over a number of years. The study found that the institutionalised children were severely impaired in IQ and manifested a variety of social and emotional disorders, as well as changes in brain development.[41]

• For every 2.6 months spent in a Romanian institution a child falls behind one month of normal growth
• Institutionalised children had significantly lower IQs and levels of brain activity than the other children, especially those who were institutionalised at a young age
• Children in institutions were far more likely to have social and behavioural abnormalities, including aggressive behaviour problems, attention problems and hyperactivity and a syndrome that mimics autism.
• This syndrome and the behaviours reduce when the child is placed in a family.[42] However, the earlier an institutionalised child was placed into foster care, the better the recovery.[41]

In 2020, the Lancet Journal published the findings of the Lancet Group Commission on institutionalisation and deinstitutionalisation of children, including a systematic and integrative review of evidence regarding effects on development.[43] This meta-analysis of 308 studies found strong negative associations between institutional care and children's development, especially in relation to physical growth, cognition and attention. Significant but smaller associations were found between institutionalisation and socioemotional development and mental health. Leaving institutions for foster or family care is associated with significant recovery from some developmental outcomes (e.g. growth and cognition) but not for others (e.g. attention). The length of time in institutions was associated with increased risk of adverse sequalae and diminished chance of recovery. The Commission concluded that reducing the number of children entering institutions and increasing the number leaving institutions is urgently needed.[44]

Universal Health Coverage 2030 has an aim for these to include "advocacy, accountability, knowledge exchange and learning, and civil society engagement" supported multilaterally by UNESCO, the World Bank, and UNICEF under the Global Partnership for Education to focus on accomplishing this by strengthening the education systems in low-income countries. The focus and guidelines for international policies is to transform care systems based on the idea that children thrive and are supported the best in a family-based environment.

Some examples of this in action include the UK Aid Direct funding guidance from the UK Government's Department for International Development, which prevents private rather than governmental funding proposals from trying to form child institutions. Similarly, the US has the Advancing Protection and Care for Children in Adversity under its government strategy from 2019 to 2023, which states its intentions to fund family-first in international development and funding. Additionally, part of the problem has also included volunteerism, and in response, foreign policy has been created to limit and properly address this. Of all the foreign legislation, Australia has the most comprehensive model on developing specific legislation on what volunteering in children's institutions looks likes. Faith-based organisations, which often lead these efforts, engage in discussions of voluntourism and the negative consequences of supporting institutions.[45]

When possible, children are reunited with their birth or extended family. This may require short term psychosocial or financial support but is generally seen as the ideal.[49]

Children transitioning out of care and into the community may need significant support as their life skills may be limited. Failure to prepare them can cause a significant number of them to return to institutions in later life or end up in crime or prostitution.[50]

Domestic adoption is adoption within the home country. Until a country's child protection system is well developed the adoption of children internationally is at risk of corruption.[51][52]

Long term fostering, defined as fostering for over a year, can often bridge the time between the closure of an institution and independent life.[53]

Small group homes or family type homes - ideally with 8 or fewer children - can provide life-time care for the most disabled children or act as a half way house where children leaving an institution can learn to live in a family.[54][55]