10 elements of Deinsitutionalisation

Georgette Mulheir: For more than 20 years now I have worked in many countries across 4 continents and I have led programmes that have helped more than 27,000 children to come out of institutions and have prevented tens of thousands of other children from entering.

They’ve also helped to save the lives of more than 6000 children who were either dying from malnutrition or because of lack of access to basic medical care.

Now across all of those countries and programmes and working with babies and older teenagers, children with disabilities, children without disabilities, what I’ve found is the challenges are very similar across geographical boundaries or cultural boundaries.

When a government or community first decides to end institutionalisation, they usually do so because they’re aware of the harm institutions cause to children. 

So they start out with good intentions. But once you start talking about the change process itself and how we move from a system that relies heavily on orphanages to a system that provides community based services, so how we get from where we are now to where we want to be, what we find is a lot of the adults involved in the process become very fearful about the change and very resistant to the change, and so we find for example that the staff in the institutions will worry about what will happen if they lose their jobs and whether they’ll be able to feed their own children. 

And we see that directors of institutions, they worry about their position and their status and they worry about their personnel and what will happen to them. And frequently they worry about the kids and they think well what on earth are all these children going to go if we close the institution. And then there are politicians, so local and national politicians know that programmes of change like this which perhaps might make some personnel redundant will actually be unpopular and might have an effect on the outcome of the next elections, so they can be very resistant. And we find finance managers say no this is not possible because we cant afford to make this change happen. And everybody that we ask and everybody that we see and talk to about ending institutionalisation will say what on earth are we going to do with the building and how will we reuse it? And what we find is that the individual, vulnerable children involved actually go down to the bottom of the list of everyone’s priorities, and the needs of those individual children can get lost in this process.

So because of that, over the last 20 years and working with man differently colleagues, I’ve developed a model, an approach to ending institutionalisation, which addresses all of those needs of the adults who are concerned so that everybody can focus on the individual child and make sure that all of the decision making for children is about individual children and their needs rather than being about the individual needs of adults.

Now this method is not the only way to approach the problem and we’re not suggesting that everybody has to do it in this way, but what we have found is that this is a way that works. It has been tried and tested in many countries and so we hope that it can be helpful to governments, communities, organisations to anybody who is grappling with this same problem of where do we start? How do we move from where we are now to where we want to be and how do we genuinely end the institutionalisation of children?

And so this model has ten key elements, all of which need to be in place if we want to make sure that deinstitutionalisation happens properly for children, but we must also understand that we are never talking about a blank sheet of paper. No country has not done something, every country is already somewhere in the process of deinstitutionalisation. And the ten elements are not a linear process, it’s not a step by step process. In fact some of these elements need to run throughout the entire course of the deinstitutionalisation programme and other elements need to take place at specific times during the programme.

But I hope that this introduction to the ten elements of deinstitutionalisation will be helpful for those who are trying to get started.

So these elements are not in order of importance. But the first one in our diagram of the ten elements of deinstitutionalisation, is actually about communications and awareness raising. And the reason that we start with this is because this needs to start at the very beginning of the process and needs to run all the way through. Because there is so much resistance to change and that resistance is about fear and it’s about myths and it’s about misunderstandings, we need a really good communications strategy that is aimed at a wide range of stakeholders and is sending them the right messages that they need at the time that they need it, so that we can reduce the resistance to change.

And what we find is that this particular element is often either completely ignored or significantly underestimated. And anyone who is planning a deinstitutionalisation process needs to make sure that they put in sufficient resources and get good expertise to help them to develop and implement the right communications strategy. If you do this I can guarantee that you will really minimise the harm to children and maximise the efficiency of your resources.

The second element in our DI process is equally important and that is putting in the right structures to manage the process of reform, because one of the things that can be forgotten is that shifting from a system that relies on institutions to a system of community based services is actually a major exercise in change management and very often from my experience, the resources and the skillset and the tools and the people needed to make this happen properly are considerably underestimated by those planning the reform.

So it’s really important to put in place the right structures to manage reform at every level. So that’s the people at policy level who are having to make changes on legislation and regulation and it’s the people at the ground level who are working with individual children and families but across the entire structure we need to make sure there is really good project management.

Element number three is carrying out a strategic review of the system at national level. It’s almost impossible for anyone to think about planning a review and reform process unless we understand the scope and the scale and the nature of the problem itself. Now, often estimates of children in institutions are either wildly over-exaggerated or more frequently considerably underestimated and unless we know how many children we are dealing with, why they are in institutions, what are the barriers to them going back to families, we will not know what resources we are going to need and we will not be able to put the right plans to put in place.

So our strategic review looks at regulation, legislation, practise, numbers of children in care, reasons for children in care as well as looking more broadly at health education and social service systems to see what needs to change at a national level to make change happen on the ground.

Our fourth element is to carry out a strategic review in much more depth, either at a regional or local level and we do this for two different reasons. The first is that it’s usually the case that the best way to start a DI process is to pilot it in one or more regions or counties rather than thinking that we can make massive change happen across the whole country all at one time and so we need more information about what’s happening at county level in order to plan. But even if we’re planning for the entire country, looking in depth at one or two counties or regions will give us enough information to help us know exactly how we plan the change. Now this looks in more detail at each of the institutions in that region. It looks at how many children come in, how many leave, how long they stay, why they are coming in to institutions, where they go when they leave, what the reasons are they are coming in to institutions in the first place. And this helps us to be able to plan exactly the services that we are going to need to help all of those children move out of institutions as well as to prevent other children from entering.

At the same time we look at any social services system if there is one of that kind at the community level, because quite often we find that there’s a real under investment in social workers and they don’t have the tools and skills that they need to be able to support families and prevent children from entering institutions. So the data from the strategic review is the information that we need to be able to plan the services that will be necessary to replace institutions.

Element five is the process of designing the services needed to replace institutions and this is based on the information that we have gathered through our strategic review at elements three and four. And what we do is we work with local authorities, with institution providers, with various different government departments, with NGOs and we come together using the data, to make a plan that says well we need foster care and family support but says exactly how much foster care and family support services, what type and how many Small Group Homes we might need and how much inclusive education we need in order to end institutionalisation in our region. And that design of services provides us with all the information we need to be able to convince the authorities, both state, national and local level that change is possible. Because what we do is we take the information about the services that we need to replace institutions and we cost it out and we show how much it would cost to run those institutions for the future and we compare that with the amount that the government is currently spending on running the institutions.

Our experience is that it is always cheaper to run the community based services than it is to run the institutions and once we are able to show governments that this is affordable then this becomes the catalyst to getting the deinstitutionalisation process started.

So the service design at element five helps us convince government, but it also gives us the blueprint for the implementation of DI.

Now the sixth element is about planning the transferring the resources and this is key because this is actually about convincing everybody that the DI process is not nearly as scary as it seems in the first place. All those people who have been worried about people working in institutions losing their jobs, or directors of institutions losing their status and jobs, will find that for the most part they can find employment in the new services that are designed to replace institutions. This is one of the few situations in life where it really is win-win because in order to run the community based services we need personnel. 

And so from our experience, usually about 80% of the personnel from institutions can be retrained and redeployed and become great community social workers, or family support workers or teachers in inclusive schools or even foster parents and do a fantastic job in the community services and once people become aware that we aren’t talking mass redundancy for employees then their resistance and the fear start to reduce. 

So planning that transfer is really important in terms of again convincing everybody that this is possible, but secondly it’s important because then we know we have to put in structures that will retrain personnel, that will assess them, that will help them develop the skills they need to move into these services but it’s also an opportunity to make sure the budgets and the institutions, and the equipment and the cars and the vehicles can also be transferred across and that those great material resources that are useful to us don’t just somehow disappear out of the system, so once we have all the of the plans in place and we have the agreements of the governments and of the local authority and we’ve gone out and we’ve found the funding and we know that it is possible to start the deinstitutionalisation, the next and most important step is to ensure that we start with an individual assessment of every single child and that child assessment needs to be complex and it needs to be multidisciplinary. 

It needs to look at the child’s health, educational outcomes, development behaviours, any specific challenges they’re facing and then the planning for where they will go needs to be based on that assessment, but also the assessment of their family and so even children who have been away from their families and haven’t been contacted by them for a very long time, we have been surprised by how often it is possible to reunite those children if we do a careful assessment of the family and see what’s possible at the same time as that it’s really important that we prepare the children carefully to move from the institution and to their next family based placement because particularly if children have been in institutions for a long time and their family is unfamiliar to them this can be a very scary process. Moves of any kind are scary for children, but if you’ve been in an institution for a long time it can be absolutely terrifying. But our experience is that with really good preparation children can’t wait to leave the institution and are ready and thrive and do very well in their new placements.

Element number eight is about the development and redeployment of the workforce needed to run the community based services. And as we’ve said before this is in the most part people who were working in institutions who are retrained and redeployed to work in community services. But sometimes there are new kinds of services that being set up that we don’t have the right specialists working in the institutions and sometimes we have to go out and employ the right kind of specialists such as physiotherapists or occupational therapists or child psychiatrists. It’s important not to underestimate the resources needed to train and train some more the workforce who are going to be providing services to families and children in the community. So we need to make sure we invest the right kind of resources in this but also put in place a good supervision system so that personnel who are now working in different kinds of services and doing something very different from what they have done for decades have someone to turn to, they can ask questions, they can take advice when they’re dealing with some of the challenges of children.

So again element eight must not be underestimated, we need to make sure if we’re moving children from institutions to other services, that the key element of service provision – and that is the employees - are of quality that is good enough to make sure that all children are cared for well.

Now element number nine is the most boring of the ten elements and I beg you not to fall asleep when I talk about this, but it is crucial and this is about logistical and administrative planning. We have to make sure because we are going to be moving lots of different children at different times, we’re training personnel, we’re employing new personnel, we’re getting buildings open, we’re closing other buildings, we’re transferring one budget from one system to another system and we have to make sure that all of this happens in the right order because if we don’t children can get hurt, and unfortunately I have seen instances where because not enough trained personnel were in place in a new service, children were harmed. And so this is why it’s really important that we plan our logistics and our administration and our project management in such a way that it focuses on the best interests of every individual child.

Last but not least, element number ten is monitoring and evaluation. And the reason I say not least is because it needs to be built in from the beginning of the process and we need to monitor a number of different things because we need to be certain that we’re doing the right thing for children and that we are making the best use of resources and of the finances available to us. The most important thing that we need to monitor is the health and the development and the wellbeing and the quality of life of the individual children involved. And the easiest way to do that is to make sure that the assessment of each child becomes a baseline, provides baseline data that we can then compare against once we have moved children out of the institution and into community based services.

At the same time, we need to check that our plan is going according to a timetable but we mustn’t hurry things up if hurrying that up might harm a child. So we need to be flexible with our plan, we need to try to stick to deadlines but we need to be flexible. And finally we need to be monitoring how much money we are using and whether we are using it in the best way we possibly can in order to learn lessons and to improve the process for the future.