20943 JULY 2000 MOVING FROM RESIDENTIAL INSTITUTIONS TO COMMUNITY- BASED SOCIAL SERVICES IN CENTRAL AND EASTERN EUROPE AND THE FORMER SOVIET UNION A W O R L D F R EE OF P O V E R T Y Moving from Residential Institutions to Community-Based Social Services in Central and Eastern Europe and the Former Soviet Union David Tobis The World Bank Washington, D. C. Copyright (© 2000 The International Bank for Reconstruction and Development/THE WORLD BANK 1818 H Street, N.W. Washington, D.C. 20433, U.S.A. All rights reserved Manufactured in the United States of America First printing July 2000 1234 03020100 The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations, or to members of its Board of Executive Directors or the countries they represent. 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For permission to reprint individual articles or chapters, please fax your request with complete information to the Republication Department, Copyright Clearance Center, fax 978-750-4470. All other queries on rights and licenses should be addressed to the World Bank at the address above or faxed to 202-522-2422. Cover design by Tomioko Hirata ISBN: 0-8213-4490-0 Library of Congress Cataloging-in-Publication Data has been applied for. Contents Foreword v Abstract vii Acknowledgments viii Executive Summary 1 Chapter 1. Residential Institutions under the Command Economies of Central and Eastern Europe and the Former Soviet Union 5 History 5 Legacy 10 Chapter 2. The Transition and Residential Institutions 19 Socioeconomic Conditions 19 Increased Reliance on Residential Institutions 21 The Effects of Humanitarian Aid 25 Financing Residential Institutions 27 The Current Situation of Residential Institutions 30 The Current Situation of Community-Based Services 33 Conclusion 35 Chapter 3. The Use of Residential Institutions in Other Industrial Nations 37 Children and Residential Institutions 37 People with Disabilities and Residential Institutions 40 The Elderly and Residential Institutions 41 Chapter 4. Finding a Solution 45 Core Principles of Effective Community-Based Social Services 45 Strategies to Implement Community-Based Services 50 Increased Demand and Additional Resources 54 Chapter 5. Conclusion 57 References 59 iil iv MNfovingfrom Residential Institutions to Community-Based Social Services in Central and Eastern Europe and the Fonmer Soviet Union Boxes 2.1 Two Families Whose Children Attend a Boarding School in Yerevan, Armenia 22 2.2 Cost of Community-Based Social Service Projects: Lithuania and Romania 28 2.3 Community-Based Social Service Projects 32 4.1 Types of Community-Based Services 47 4.2 Lithuania's Community-Based Social Service Pilot Projects 48 Tables 1.1 Estimated Number of Children 0-18 in Residential Institutions in the Former Soviet Union, 1963 and 1987 7 1.2 Number of People in Residential lnstitutions for the Elderly and People with Disabilities in Republics of the Soviet Union, 1990 10 2.1 Number of Children in Residential Institutions in Central and Eastern Europe and the Former Soviet Union, 1995 24 2.2 Number of People in Residential Institutions for the Elderly and Adults with Disabilities in Countries of the Former Soviet Union, 1990-96 25 2.3 National and Local Expenditures on Residential Institutions in Lithuania, 1996 27 2.4 Recurrent Cost Analysis of Alternative Child Welfare Modalities, March 1998 30 3.1 Elderly Western Europeans Living Alone, in Institutions, or Receiving Home Care, 1990 42 3.2 Cross-National Institutional Use Rates for the Elderly, 1980 42 Foreword S ince 1989 the world has witnessed one of the these barriers are compounded by an arbitrary tragic and harmful legacies of the command placement process that does not consider emotion- economy: the institutionalization of more than al, social, and material strengths and needs. As a 1 million children, disabled and elderly people. result, a vicious cycle is created. The institutions Even worse, the number of individuals under custo- absorb much of the limited government (and often dial care in institutions has increased. As the social donor) resources that are needed to assist vulnerable and economic effects of economic decline weakened groups. The lack of alternatives for families in crisis families, the lack of community alternatives forced has pushed governments to rely increasingly on families to rely on these large institutions. Today, institutions, crowding more people into a deterio- more than 1.3 million people in the region live in rating infrastructure. 7,400 large, highly structured institutions. Few of How can the region make the transition from rely- these individuals need to be confined to institutions. ing on residential institutions to developing com- International experience shows that residential insti- munity-based social services? Based on the review of tutions are harmful. They are also expensive. successful strategies in both developed and transi- Countries spend significant resources on this care- tion countries, Movingfrom Institutions to Community as much as 2 percent of public budgets. Based Services in Central and Eastern Europe and the Moving from Institutions to Community Based Former Soviet Union proposes a strategy that Services in Central and Eastern Europe and the Former includes: Soviet Union was commissioned by the World Bank * Developing models of alternative care to demon- to understand why this problem has proved so strate that the new approach works. intractable, what are the ingredients of a successful * Changing public opinion and mobilizing com- change program to improve the lives of these vul- munity support around the new approach. nerable individuals, and what the World Bank and * Creating a national social welfare infrastructure other donor agencies can do to support this change. and training all key social service professionals in The result of a year-long examination of World Bank the new approach. and other donor experiences, it is the first compre- * Scaling up pilots by changing the legislation on hensive analysis of this complex syndrome. classification, placement, and rights while devel- The study identifies the key barriers to change in oping new funding streams and monitoring sys- Central and Eastern Europe and the Former Soviet tems and closing or converting existing Union. These include financial and organizational institutions. pressures to maintain residential institutions; public While no country in Central and Eastern Europe acceptance of this form of care as appropriate; and and the former Soviet Union has fully implement- the absence of a national social welfare infrastruc- ed this strategy, a number have implemented parts ture, of systematic monitoring and oversight, and of of the strategy with some success. Our research a legislative framework that focuses on protecting suggests that only with an understanding of the the rights of vulnerable individuals. The effects of systemic relationships is it possible to develop an v vi Movingfrom Residential Institutions to Community-Based Social Services in Central and Eastern Europe and the Former Soviet Union effective strategy that prioritizes and sequences tutions will remain, and more individuals will be key actions. The bottom line is that while strate- damaged. This is an important conclusion for all gies and timing will vary from country to country, those seeking to support the transition to a better eventually all the key barriers to change need to be life in Central and Europe and the former Soviet removed to break the cycle. If not, harmful insti- Union. Johannes Linn Vice President Europe and Central Asia Region Abstract O ne of the most harmful, costly, and these institutions-have reinforced, perhaps inadver- intractable legacies of the command tently, local reliance on residential care. economies of Central and Eastern Europe Other industrial nations have experienced similar and the former Soviet Union is the reliance on resi- periods of economic and social upheaval and also dential institutions for the care of children, the eld- relied on residential institutions to care for vulnera- erly, and people with disabilities. As a result, there ble and marginalized groups. But most of these are almost no community-based alternatives to care nations have switched from residential care for chil- for large and growing numbers of vulnerable indi- dren, people with disabilities, and the elderly viduals. At least 1.3 million children, people with (except for the severely disabled) to community- disabilities, and elderly people in the region live in based social services. some 7,400 large, highly structured institutions. How can the countries of Central and Eastern These institutions house almost 1 percent of the Europe and the former Soviet Union make the same region's children, about 4 percent of people with dis- transition? A six-step strategy for the region includes abilities, and about 1 percent of the elderly. the following: Poor, neglected, or disabled children live in insti- * Changing public opinion and mobilizing com- tutions that stunt their physical, emotional, and munity support. intellectual development. Children with disabilities * Strengthening community-oriented social welfare are segregated from society in grim facilities most of infrastructure. them will never leave. The elderly and disabled * Establishing community-based social service pilot adults are cloistered in social care homes. Few, if any, projects. of these individuals need to be confined to institu- * Using pilot projects to reduce the flow of individ- tions. This legacy has created profound barriers that uals entering residential institutions and to rein- must be overcome if reliance on residential institu- tegrate individuals into the community. tions is to be reduced. * Redesigning, converting, or closing facilities. The transition to market economies has caused eco- * Creating a national system of community-based nomic and social conditions in the region to deterio- social services. rate rapidly. As many financial and social supports Although this study reviews the use of residential have been eliminated or cut back, more vulnerable institutions throughout the region, it focuses on five individuals have been placed in residential facilities. countries-Albania, Armenia, Latvia, Lithuania, and Although the conditions have improved in some insti- Romania-where the World Bank is helping devel- tutions and staff have received some training, the over- op community-based social services to reduce the all quality of care is worse today than it was 10 years reliance on residential institutions. The study exam- ago. More children are cared for with fewer resources, ines the use of residential institutions for three and fewer options are available to them once they are groups: children, people with disabilities (mental, too old to qualify for residential care. International physical, or sensory impairment), and the frail and donors-through their work to improve conditions in isolated elderly vii Acknowledgments T his paper was written by David Tobis, Hunter Trust); Ann-Charlotte Gudmundsson (Swedish College, for the Human Development Sector Society for International Child Welfare); TureJonnson Unit of the Europe and Central Asia region (Swedish International Development Agency); John under the guidance of Louise Fox. The author would Donohue, Susi Kessler, Albert Motivans, Dita like to acknowledge the following people who pro- Reichenberg (UNICEF); Ronald Penton (University of vided data, made suggestions, or reviewed and com- Stockholm); Steven Rosenheck (Columbia mented on drafts of the report: Louise Fox, Philip University); Jerome Tobis (University of California- Goldman, Timothy Heleniak, Maureen Lewis, Irvine); Alena Halova (University of Wisconsin- Alexandre Marc, Alexandra Posarac, Dena Ringold, Madison); Robert Vitillo (Catholic Campaign for Eluned Roberts Schweitzer (World Bank); John Human Development); and Wendy Guyette, Paul Courtney, Berny Horowitz, Maria Kaloudis (Hunter Holtz, Daphne Levitas, and Marjorie Robertson College); Richard Carter (European Children's (Communications Development Incorporated). viii Executive Summary O ne of the most harmful, costly and supports have been eliminated or reduced in size or intractable legacies of the command scope, more vulnerable individuals have been placed economies of Central and Eastern Europe in residential facilities. Although the conditions in and the former Soviet Union is the reliance on resi- some institutions have improved and staff have dential institutions and the lack of community-based received some training, the overall quality of care for alternatives to care for large and growing numbers of children, people with disabilities, and the elderly in vulnerable individuals. At least 1.3 million children, residential institutions is worse today than it was 10 people with disabilities, and elderly people in the years ago. More children are cared for with fewer region live in 7,400 large, highly structured institu- resources, and fewer options are available to them tions. These institutions house almost 1 percent of once they are too old to qualify for residential care. the region's children, about 4 percent of people with International donors-through their work to disabilities, and about 1 percent of the elderly improve conditions in these institutions-have rein- Poor, neglected, or children with disabilities live forced, perhaps inadvertently, local reliance on resi- in institutions that stunt their physical, emotional, dential care. and intellectual development. Children with dis- abilities are segregated from society in grim facilities from which most will never leave. The elderly and Breaking the Vicious Cycle adults with disabilities are cloistered in social care homes. Few if any of these individuals need to be The reliance on residential institutions has created a confined to institutions. vicious cycle in the region. These institutions absorb This legacy has created profound barriers that much of the limited governmental and nongovern- must be overcome if reliance on residential institu- mental resources that are needed to assist vulnerable tions is to be reduced. These barriers include: groups. In Lithuania, for example, 1.75 percent of * Organizational pressure to maintain residential the national budget is used for institutional care of institutions. vulnerable individuals. The lack of alternatives has * Absence of a social welfare infrastructure and leg- pushed donors and governments to increase their islative framework to care for vulnerable individ- reliance on residential institutions. As a result vul- uals in the community nerable individuals will be further impaired, find it * Financing mechanisms that promote institutional harder to reintegrate into the community, and care. become a bigger burden on the public sector. This * Public opinion that views residential care as one of cycle will likely result in both multigenerational the few useful resources still provided by the state. dependency and wasted government resources. The transition to a market economy in Central How can this cycle be broken? and Eastern Europe and the former Soviet Union has In Western Europe and the United States caused economic and social conditions in the region community-based services are less expensive than to deteriorate rapidly As many financial and social residential care and far better for vulnerable indi- 1 2 Movingfrom Residential Institutions to Community-Based Social Services in Central and Eastern Europe and the For-mer Soviet Union viduals. Similar findings have emerged from new people with disabilities, and the role of residential community-based service programs developed by institutions. governments within the region in collaboration with the World Bank, European Union, United Nations Strengthening community-oriented social welfare Children's Fund, Open Society Institute, Save the infrastructure Children, Caritas, and other organizations. Although few projects have been evaluated formally, Social work schools are needed to train staff in resi- some are cost-effective alternatives to residential dential institutions, local social assistance offices, institutions, as has been found in foster care pro- new community-based social service programs, and grams in Romania and special day programs for peo- the bureaucracies that oversee all these programs. In ple with disabilities and home care for the elderly in recent years basic social work programs have been Lithuania. created in many transition economies, with some success. Many programs could benefit, however, from additional study tours, technical assistance, Finding a Solution and training in basic social work skills and specific service modalities. They could also benefit from col- How can the countries of the region make the tran- laborating to provide training or conduct research to sition from relying on residential institutions to create new social service programs, as is being done developing community-based services? Other in Lithuania. Expanding the role of nongovernmen- industrial nations have experienced similar periods tal organizations (NGOs) and their cooperation with of economic and social upheaval and also relied on the public sector are important elements of the social residential institutions to care for vulnerable and welfare infrastructure that should be strengthened. marginalized groups. Most of these nations no longer rely on residential care for children, people Establishing community-based social service pilot with disabilities, and the elderly (except for the projects severely disabled). Instead they rely primarily on community-based social services provided in a There are many advantages to using pilot projects framework of protection for the vulnerable. Six ele- to develop a network of community-based social ments are part of a comprehensive and integrated services: strategy in the region. * The flexibility to test a wide range of approaches- service modalities, organizational auspices, geo- Changing public opinion and mobilizing graphic locations. community support * Opportunities to identify and correct inappropri- ate approaches and mistakes made on a small A multipronged public information campaign could scale. be developed to change the attitudes of the public, * Time and data to gain popular support to carry policymakers, administrators, and the line staff of res- out the project on a larger scale. idential institutions. Such a campaign has begun in * Limited investment and risk by donors. Armenia and at the local level in Hungary. One impor- * The opportunity to initiate a dialogue on policy tant vehicle for such a campaign is the United Nations Each pilot project could operate as a joint effort Convention on the Rights of the Child as well as other by the government, municipalities, donors, and human rights conventions, which have been signed NGOs, with cost sharing for investment funds, train- by all countries in the region. In Romania, for exam- ing, and recurrent costs. The most effective and sus- ple, the Convention on the Rights of the Child has tainable service programs are based on citizen contributed to changing public opinion and the atti- participation, including family members, direct con- tude of policymakers on children's rights, the rights of sumers of service, and professionals. Executive Summary 3 Using pilot projects to reduce theflow of * Ensuring quality and specialized services as a individuals entering residential institutions, to human right. protect the rights of individuals in institutions, * Ensuring sustainability through long-term fund- and to reintegrate individuals into the community ing for recurrent costs. * Making evaluation a central component of a As social service projects begin to provide alterna- national social safety net to ensure quality services. tives for individuals at risk at selected residential institutions, pilot projects should be established that reduce the number of individuals entering residen- Increased Demand and Additional Resources tial facilities and increase the number returning to the community This approach was used by UNICEF The transition to a market economy has greatly and others in collaboration with local governments increased poverty within the region and decreased the in Romania. It is far more difficult, however, to resources available to help the growing number of vul- reunite a person with his or her family once those nerable individuals. New community-based social bonds have been broken and the individual has been services will increase the number of poor and vulner- placed in residential care. Reintegration programs in able people who request or demand assistance. the region have had only limited success. Residential institutions serve only a small portion of vulnerable individuals. It is often impossible to deter- Redesigning, converting, or closingfacilities mine which individuals will be placed in a residential facility and which, in a similar situation, will not. Thus Alternate uses can be found for residential institu- the target population for community-based services tions. In Hungary part of a large children's home has must be larger than those individuals who are placed been converted into apartments for young, single (or would be placed) in a residential institution. The mothers and their children. The mothers receive job increase in the number of recipients provides much- training and help finding work. In Armenia parts of needed assistance to previously unserved people but several boarding schools have been converted to will require additional resources beyond the money apartments for refugees. In Romania part of an saved by closing residential institutions. infant's home has been converted into apartments for The approaches presented in this study can be mothers and their children. part of the World Bank's poverty reduction strategy. But this strategy is not without risks. Vulnerable Creating a national system of community-based individuals could be forced out of residential insti- social services tutions before community services are available to assist them. Long-term funding may not be avail- After pilot projects have been tested and redesigned able. Governments may not request or support ade- to address community needs, programs can be imple- quate staff training, supervision, or other technical mented nationwide. A paradigm shift, however, is assistance. Nevertheless, the approaches presented needed to focus assistance on the larger group of peo- here, provided in a framework of protection for the ple in poverty and to prevent the causes of institu- vulnerable, can create cost-effective, sustainable tionalization. This paradigm shift needs to focus on alternatives to residential facilities to ease the pres- prevention and the causes of institutionalization. sures of poverty in the region. National legislation and public policy should focus on: * Restricting the use of residential institutions. Focus of the Study * Improving the care in residential facilities. * Creating alternative ways to assist vulnerable Although this study reviews the use of residential groups in the community institutions throughout the region, it focuses on five 4 Movingfrom Residential Institutions to Community-Based Social Services in Central and Eastern Europe and the Former Soviet Union countries-Albania, Armenia, Latvia, Lithuania, and groups were severely affected by conditions creat- Romania-where the World Bank is helping devel- ed in the transition to a market economy In many op community-based social services to reduce the ways the problems these individuals confront and reliance on residential institutions. the reasons they are institutionalized are applicable The study examines the use of residential insti- to other groups in residential institutions. Third, tutions for three groups in Central and Eastern remedial actions have begun in Central and Eastern Europe and the former Soviet Union: children, Europe and the former Soviet Union to prevent the people with disabilities (mental, physical, or sen- institutionalization of these individuals and to pro- sory impairment), and the frail and isolated elder- mote their reintegration into the community ly (The elderly in hospital settings are not Finally, the study uses the findings of research on included.) These groups were selected for several residential institutions, most of which examines reasons. First, they represent the majority of indi- the effects on children, both able and with disabil- viduals in residential institutions. Second, these ities, and some of which focuses on the elderly. CHAPrER 1 Residential Institutions under the Command Economies of Central and Eastern Europe and the Former Soviet Union S ocial policy throughout Central and Eastern * Educated and trained children and channeled Europe and the former Soviet Union during the them into the work force. socialist period focused on supporting labor * Trained physically and mentally individuals with productivity, creating a collectivist consciousness, disabilities who could work and created sheltered and ensuring at least a minimal standard of living for workshops in the institutions. the work force. To achieve these goals, extensive eco- * Reeducated juvenile delinquents and adult crim- nomic and social supports were provided to indi- inals. viduals and families by the state, mainly through the * Removed and isolated individuals who had severe enterprises in which they worked. mental or physical disabilities. These supports and services included social * Assisted and protected groups of vulnerable insurance (pensions, family and child allowances, individuals-orphans, dependent children, chil- health care), social assistance (for the poor and peo- dren at risk of abuse or neglect, the elderly, and ple with disabilities), free education from primary people with disabilities. school through the university level, child care, and subsidized food, housing, transportation, culture, Children and leisure activities (Madison 1968; Kuddo 1998). In the former Soviet Union family benefits and other Long before the Soviet period, Russia relied on large material supports were high. In many Central residential institutions to care for abandoned, ille- European countries, benefits as a percentage of GDP gitimate, and delinquent children. Peter the Great were more than twice the OECD average (UNICEF (1682-1725) decreed that orphanages be opened at 1995). monasteries and that the costs be covered by gov- ernment subsidies and private donations. Ivan Betsky, a researcher who had studied the care of ille- History gitimate children in Western Europe, petitioned Catherine the Great (1762-96) to create large insti- Residential institutions were a central part of social tutions for these children based on the models he policy in most of Central and Eastern Europe and the had seen. In 1763 a home for illegitimate children former Soviet Union, though the use of residential opened in Moscow and in 1771 another one opened institutions and the impact they had on their resi- in St. Petersburg. In the first four years, 82 percent dents varied. Residential institutions were more than of the children in these homes died. merely housing for marginalized populations. They No other country's metropolitan social services served a dual role of social protection and social reg- handled the volume of abandoned children that ulation. They also: Russia's did. At the height of its operations in the sec- * Socialized individuals into the collectivist culture. ond half of the 19th century, the central children's * Deculturated ethnic minorities such as Roma home in Moscow received 17,000 children a year- (gypsies). most of whom were sent to wet nurses and foster 5 6 Movingfrom Residential Institutions to Community-Based Social Services in Central and Eastern Europe and the Former Soviet Union families in the countryside. Infant mortality in With the adoption of the New Economic Policy in homes for illegitimate children and foundlings was 1921 and the strict curtailment of state spending, the frightening-three times higher than in the general Russian government reduced funding to children's population. In 1912 only 11 provincial regions institutions and transferred responsibility for them maintained orphanages; in other regions children to local governments. With few local funds available, were sent to almshouses, private orphanages, or fos- thousands of children's institutions closed. The ter homes where infant mortality was about 80 per- remaining institutions became severely overcrowd- cent (Madison 1968, ch. 1; Ransel 1988). ed and conditions deteriorated. In the late 1920s, as The use of residential institutions went through economic conditions in the country improved and three distinct periods during the command econo- the number of homeless youth diminished, the my of the former Soviet Union: the revolutionary reliance on residential institutions decreased. period, the Stalinist period, and the Khrushchev years and beyond (Harwin 1996, p. 3). STALINIST PERIOD. The death of as many as 27 million Soviet citizens in World War 11, following the col- REVOLUTIONARY PERIOD. At the beginning of its tran- lectivization of land byJoseph Stalin and the famine sition to socialism, Russia experienced a "demo- of 1933, greatly increased the number of orphans in graphic earthquake" caused by World War 1, the civil the country and in institutions. Stalin's main goals war, epidemics, and famine. Prior to the revolution after World War II were industrialization, collec- in 1917, 2 million homeless children (bespnzorniki) tivization, and rebuilding the national population. were believed to have been roaming the streets and In an attempt to rebuild the population, Stalin villages of Russia. By 1922 this number is reported created a multifaceted pro-natalist family policy that to have increased to 7 million. To respond to this cri- outlawed abortion, restricted the right to divorce, sis, the government began evacuating homeless, and made it easier for mothers to place their children famine-stricken children from cities to abandoned in state care. The child protection measures of the and confiscated estates and churches in the country's 1930s allowed for greater surveillance of the family agricultural heartland. The number of children in and easier child removal from the home. As a result state facilities increased from 30,000 in 1917 to the number of children's homes and the number of 540,000 in 1921 (Harwin 1996, pp. 3, 6). children in them increased rapidly (Harwin 1996, p. The use of institutions to care for these children 19). reflected the social philosophy on which the Soviet The conditions in many of these homes were society was initially built: collective upbringing was appalling. In 1931 the Commissar of Health more effective in raising the new Soviet citizen.1 The described the conditions in children's homes as work of Anton Makarenko in the 1920s and 1930s "completely unbearable." In 1935 legislation was formed the basis for the collective upbringing passed to allow for a differentiated system of chil- approaches used for the next 50 years in nurseries, dren's homes, separating children seven and older schools, camps, youth programs, and children's from younger children. In addition, a new law on institutions in the Soviet Union and subsequently in foster care was introduced that paid foster parents to Central and Eastern Europe (Makarenko 1976). In care for children from 5 months to 16 years. Despite the early 1920s Makarenko was made responsible the efforts to promote foster homes, the use of chil- for setting up rehabilitation programs for some of the dren's homes increased rapidly (Harwin 1996, pp. 7 million homeless children roaming the Soviet 15, 23). Union. His approach emphasized work, collective discipline, and group competitiveness. The success THE KHRUSHCHEV YEARS AND BEYOND. During the early of his approach led to its use in residential institu- years of Nikita Khrushchev's administration tions throughout much of the socialist world (1953-64) the number of orphans declined as the (Bronfenbrenner 1973, p. 41).2 population stabilized. The number of children in Residential Institutions under the Command Economies of Central and Eastern Europe and the Former Soviet Union 7 children's homes was reduced by nearly half, from dren and were used primarily to care for children 635,900 in 1950 to 375,000 in 1958, then decreased from underprivileged families (Madison 1968, p. at a slower rate into the 1960s (Harwin 1996, p. 30). 74). In 1963 about 1.8 percent of the 82 million With the population growing, the emphasis on pro- children in the Soviet Union lived in residential natalist policy was reduced and the prohibition on institutions (table 1.1). abortion was lifted. When Leonid Brezhnev came to power in 1964 he In 1956, to promote industrialization and was confronted with a falling birth rate, a high increase productivity, Khrushchev used boarding divorce rate, an increasing number of single-parent schools (internati), nurseries, and kindergartens to families, and controversy over women's roles in the educate children and free their mothers for employ- home and the workplace. In response, Brezhnev ment. The government projected that by the 1980s promoted social policies to strengthen the family all children in the Soviet Union would be educated and relieve mothers of household responsibilities so in boarding schools (Madison 1968, p. 69). that they could work. His policies led to the creation Several factors worked against the successful of family support programs in the 1970s, increased implementation of this policy. Parents strongly the number of day schools, and increased the num- opposed this approach, so educating children in ber of socially vulnerable, marginalized children boarding schools was made optional. Boarding under the state's care. schools were also very expensive-about four During glasnost official reports and articles began times the cost of regular schools (Harwin 1996, p. to appear on the abuse of children in orphanages and 29). In addition, in the early 1960s Soviet the deplorable conditions of children's homes and researchers and newspapers reported on the harm- boarding schools. In July 1987 a national decree ful effects of residential care and the importance of sought to "radically improve the care, education and family upbringing (Harwin 1996, p. 67). Soon material welfare of orphans and children left with- thereafter boarding schools were no longer consid- out parental care." Although the government also ered a solution for educating and raising most chil- encouraged the development of services to assist TABLE 1. 1 Estimated Number of Children 0-18 in Residential Institutions in the Former Soviet Union, 1963 and 1987 1963 1987 Number of Number of Number of Average number of Type of institution children children institutions children per home Boarding schools for normal children 1,047,900 Social orphans 71,000 237 300 Nonsocial orphans 94,000 - - Children's homes for normal children 246,000 Infants 35,000 422 83 Children 84,000 745 113 Schools (primarily boarding) for children with intellectual and physical defects 217,000 - Institutions for severely retarded and grossly handicapped children 3,500 Residential treatment centers for "nervous' children 1,250 - Total children in institutions 1,515,650 284,000 Total children in the Soviet Union 82,000,000 - Children in institutions (percent) 1.8 -Not available. Source: For 1963: Madison 1968, p. 175; for 1987: Waters 1992. 8 Movingfrom Residential Institutions to Community-Based Social Services in Central and Eastern Europe and the Former Soviet Union troubled families, these initiatives remained modest cared for adequately by their families-and orphans. and few (Harwin 1996, pp. 67, 84). Armenia's 1984 Decree for Secondary Boarding The social welfare infrastructure for children fur- Schools stated that children who came from "socially ther deteriorated because of fewer government vulnerable families, including parents with medical resources and competing priorities for those problems, families with many children, single par- resources. As a result fewer children entered resi- ents, and parents who do not work" were entitled to dential care. By the late 1980s there were 284,000 attend boarding schools (Soviet Socialist Republic of children in residential institutions in the former Armenia Ministry of Education 1984). Often parents Soviet Union (see table 1.1) (Harwin 1996, p. 66). petitioned the local children's commission for per- Thus, at the start of the transition to a market econ- mission to place a child in an institution (Madison omy, the number of children living in residential care 1968, p. 161). Schools and nurses in polyclinics also was relatively small compared to earlier periods in recommended the placement of children in residen- Soviet history, although the 1987 figure excludes tial institutions (Kadushin 1980, p. 662). children in boarding schools who are not in the cus- Although children in residential institutions are tody of the state. often referred to as orphans, very few do not have In the late 1980s public criticism of the care pro- living biological parents. An estimated 2-3 percent vided by residential institutions grew. The homes were of institutionalized children in Central and Eastern poorly furnished, and the children lacked proper Europe and the former Soviet Union are orphans clothing and nutrition. In one case joumalists exposed except in countries where wars or natural disasters the conditions of a boarding school where children have caused the death of both parents. According to who misbehaved were locked in a tiny, empty room one study in Romania, for example, 97 percent of the without heat, light, or adequate ventilation for up to children in residential institutions have parents and three weeks (Waters 1992). only 3 percent are orphans (World Bank 1998, p. The transition to market economies caused con- 43). Another study in Romania reported that 80 per- ditions in residential institutions to deteriorate cent of children in institutions received occasional (Harwin 1996, p. 91). In earlier periods significant visits from parents or other family members (Zamfir resources were allotted to child care institutions in and Zamfir 1998, p. 34). The confusion has devel- socialist countries to maintain good conditions. But oped in part because these children are often with the transition conditions declined, so that even- referred to as "social orphans"-children whose par- tually the consumption levels provided by many of ents are unable to care for them because of econom- these institutions were lower than those of the aver- ic or social factors. age household with children (Zamfir and Zamfir The third and largest group of children in resi- 1996, p. 29). dential institutions-those with physical and men- At the start of the transition three main groups of tal disabilities-were placed into two types of children lived in residential institutions. The first institutions-those for children who could become group-normal children-attended boarding school productive workers and those who could not. The for a variety of reasons, including: belief was that "normal" children should be separat- * Family, home, or work stresses on their parents. ed from "defective children," the physically handi- * Difficulty in another school. capped, and the retarded (Madison 1968, p. 149). * Living far from a neighborhood school. * Family difficulties in caring for the child. People with disabilities * The desire of parents and teachers for gifted stu- dents to attend specialized boarding schools. Under socialism, the approach toward people with The second group of children who lived in resi- disabilities was defined by the Soviet science of dential institutions were socially vulnerable, depend- "defectology." Developed in the Soviet Union in the ent, or neglected children-who were not able to be 1920s, defectology is both the theory and treat- Residential Institutions under the Command Economies of Central and Eastern Europe and the Forrner Soviet Union 9 ment of disability with its own methods and tech- end of the socialist period and continue to dominate niques (UNICEF 1998a, p. 50). Defectology has a the treatment of them today strong medical orientation that defines disability as a diseased state (invalid, defective, abnormal chil- The elderly dren with mental or physical disease) or a problem of the "abnormal" individual. The role of the envi- Prior to the transition, the primary assistance pro- ronment in supporting the individual is ignored; vided to the elderly was financial support in the treatment consists of a diagnosis, segregation of the form of pensions for retired persons and workers "normal" and "abnormal" individuals, and correc- who had become disabled. Pensioners benefited tion of the defect (Jonsson 1998). from heavily subsidized goods and public services Defectology and the categorization and treatment and had access to housing, summer cottages, and of people with disabilities were based on an indi- land. However, as the economic situation deterio- vidual's potential productivity Categorizations rated in the mid-1980s, the incomes and social sta- often occurred between three and four years of age tus of pensioners fell dramatically Their savings and generally became permanent labels. Mistakes became devalued and they became totally depend- were often made by the "expert" commissions that ent on heavily eroded social transfers from the pen- determined a child's level of disability. The most sion systems (Kuddo 1998, p. 153). common mistake was placing too many children in In these countries men were able to receive a the borderline category of disabled. retirement pension at the age of 60 and women at Adults with disabilities were often housed and the age of 55. Although pensions were quite low in cared for with the elderly; children with disabilities the Soviet Union, in several Central European coun- were placed in special schools, segregated from other tries, pensions were relatively high, reaching the children. Children who could be taught to work were level of 55-65 percent of the average wage in placed in institutional schools for children with less Czechoslovakia, Hungary, Poland, and Yugoslavia severe disabilities. The institutions for educable chil- (World Bank 1994, p. 366; Kuddo 1998, p. 155). dren with disabilities isolated them from their fami- Families, women, and informal community net- lies and often further disabled the children as a result works provided the elderly with long-term assistance of the custodial care they received. Staff members when they became frail, were unable to care for them- were poorly trained, and in 1960 each was responsi- selves, or were living alone. in the late 1980s, how- ble for an average of 23 children. There was also a ever, urban migration, increased employment of high staff turnover rate (Madison 1968, pp. 165-66). women, shortages of apartments, and an increased Children who were not able to learn work skills reliance on the state reduced the capacity of families were placed in other institutions. In the Soviet Union to act as caregivers to the elderly 89 percent of the "defective" group was considered Few nonmedical community-based services were educable; the rest was considered uneducable available to assist the elderly. There was no clear recog- (Madison 1968, p. 426). Children with disabilities nition that some pensioners required help in recon- who were considered uneducable were placed in structing their lives, resuming their family roles, and institutions for the "irrecuperables." The deplorable living through emotional upheavals. The few available conditions in these institutions in Romania defined social services were provided by "indigenous nonpro- the world's perception of residential institutions in fessionals" and were organized by the state or provid- Central and Eastern Europe and the former Soviet ed by trade union committees (Madison 1968, ch. Union after the fall of Nicolae Ceausescu's regime 10). Voluntary or church organizations also provided (Himes, Kessler, and Landers 1991). limited assistance to the elderly (Calasanti and Zajicek The philosophy and science of defectology and 1997, p. 457). the care provided to people with disabilities The types of in-home assistance for the elderly remained fundamentally unchanged through the available in other Western European nations-such 10 Movingfrom Residential Institutions to Community-Based Social Services in Central and Eastern Europe and the Fotmer Soviet Union as delivery of food, assistance with household chores Azerbaijan and 0.3 percent in Georgia, to 1.8 per- and personal hygiene-were largely absent. In cent in Belarus and Russia (see table 1.2). Hungary, one of the Central and Eastern European Because social care homes were often the only countries where these types of services were most resource available, there were long waiting lists to available, as much as 4 percent of the elderly had enter them (Sadowski 1997, p. 34; Madison 1968, home care in the 1980s, and only 2 percent of the p. 191). Albania was an exception-it had few resi- elderly atlended day centers (Szeman 1997, p. 28). dential institutions for the elderly and relied almost Long-term residential institutions were the main exclusively on families and communities to care for resource available to the elderly when their families the elderly. At the start of the transition no more than could not care for them and they were unable to care 300 people were living in the country's five old peo- for themselves. These institutions were generally ple's homes (Shehu 1997, p. 17). social care homes located on the outskirts of towns in pleasant natural settings, but isolated from pub- lic life. The standard of care provided in these Legacy homes was often unsatisfactory (Madison 1968, p. 194). In the former Soviet Union the average social The most visible legacy of the reliance on residential care home housed a minimum of 127 people institutions under the command economies are the (Georgia) and a maximum of 341 people (Moldova) thousands of residential institutions themselves and (table 1.2). the individuals whose lives have been stunted or In Poland about 1.5 percent of the elderly lived in shortened because of long years in residential care. social care homes in 1989 (Velkoff and Kinsella These and other elements of this legacy that are bar- 1993). In Hungary about 2.6 percent of individuals riers to change are discussed below. over 60 lived in social care homes in the mid-1980s (Szeman 1997, p. 28). In the republics of the former Thousands of large residential institutions Soviet Union 364,500 people lived in institutions for the elderly and people with disabilities in 1990. The Central and Eastern Europe and the former Soviet range was from 0.2 percent of the population in Union contain an estimated 5,500 large residential TABLE 1.2 Number of People in Residential Institutions for the Elderly and People with Disabilities in Republics of the Soviet Union, 1990 Number of Number of Number of Number of Average number of Republic institutions beds beds per 1,000 people residents beds per institution Azerbaijan 8 1,410 .20 1,190 149 Armenia 7 1,260 .37 1,030 147 Belarus 75 18,720 1.83 17,580 234 Georgia 9 1,470 .27 1,140 127 Kazakhstan 66 17,240 1.03 18,090 274 Krygyz Republic 13 3,600 .82 3,100 238 Moldova 10 3,490 .80 3,410 341 Russia 886 262,620 1.77 248,980 281 Tajikistan 7 1,140 .21 1,110 159 Turkmenistan 5 1,510 .41 980 196 Uzbekistan 32 10,050 .49 9,410 294 Ukraine 274 61,880 1.20 58,480 213 Total 1,392 384,390 .78a 364,500 262 a. Nonweighted average. Source: ISCCIS 1997. Residential Institutions under the Command Economies of Central and Eastern Europe and the Former Soviet Union 11 institutions for children with and without disabili- contact with the outside world. Still, such institutions ties.3 Each facility-ranging from small homes for are harmful to child development. Infant homes, resi- 40 infants to large residences for 400 or more school dential institutions for people with disabilities, and age children-has an average of 100-200 residents. children's homes with their own schools, however, In addition, there were 1,392 social care homes for have the characteristics of total institutions.4 adults with disabilities and the elderly in the The physical characteristics of these institutions republics of the former Soviet Union when the tran- varied greatly at the end of the 1980s. Some were ade- sition began (ISCCIS 1997). (Aggregate data for the quate though austere structures; others were dilapi- elderly in social care homes in Central and Eastern dated and rapidly deteriorating because programs Europe are unavailable.) Residential institutions are were underfunded and resources for social welfare both a vast physical resource and a costly asset for were decreasing. Some, particularly for people with the countries of the region to maintain. disabilities, were bleak, archaic, and barren struc- Many but not all of these institutions could be tures. A few facilities were comfortable, adequately referred to as total institutions (Goffman 1961). staffed facilities in pleasant settings. These tended to According to Goffman (p.5), in modern society be special programs such as Loczy (the Pikler Institute), a training center providing specialized care Individuals tend to sleep, play and work in dif- for infants in Hungary, or an orphanage run by the ferent places, with different co-participants, Catholic church in Otorovo, Poland. Nevertheless, under different authorities, and without an they suffered from being total institutions. over-all rational plan. The central feature of total institutions ... [is] a breakdown of the bar- Damaged individuals unprepared to live in a riers ordinarily separating these three spheres changed world of life. First, all aspects of life are controlled in the same place, under the same single authori- An estimated 790,000 children with and without dis- ty. Second, each phase of a member's daily abilities were living in residential institutions in activity is carried out in the immediate compa- Central and Eastern Europe and the former Soviet ny of a large batch of others, all of whom are Union at the start of the transition.5 A total of 364,500 treated alike and are required to do the same elderly and older handicapped persons resided in thing together. Third, all phases of the day's social care homes in the republics of the former Soviet activities are tightly scheduled ... Finally, the Union in 1990 (ISCCIS 1997). (Aggregate data for the various forced activities are brought together elderly in social care homes in all the countries of into a single rational plan purportedly designed Central and Eastern Europe are unavailable.) to fulfill the official aims of the institution. Many children, both with and without disabili- ties, lived in residential institutions during their Goffman describes a process of "mortification"- entire formative years; very few left before they were destruction of selfhood-upon entry into a total too old to live in a children's institution. In extreme institution. Some losses are temporary; others are cases children remained in institutions for their irrevocable and painful. He refers to this process as entire lives. In Romania, for example, in the early "civil death." years of the transition, 10-40 percent of children Not all residential institutions in Central and remained in institutional care their entire lives, mov- Eastern Europe and the former Soviet Union were or ing from a maternity hospital to an orphanage to an are total institutions in ways defined by Goffman. adult institution (Zamfir and Zamfir 1996). Some institutions-creches or boarding schools that Children's isolation was intensified because institu- allow children to return home on weekends or chil- tions were often located far from the individuals' dren's homes where children live in the institution but communities, and contact between children and go to a regular school-provide children with regular their families was often discouraged. 12 Movingfrom Residential Institutions to Community-Based Social Services in Central and Eastern Europe and the Former Soviet Union Young people received vocational training while ilies and the outside world, and ill-equipped to func- in the institutions and were placed in jobs and hous- tion independently outside the institution. Vast ing when they left. Now, during the transition, place- numbers of children who have been socialized for ment in a job and provision of housing in the one world are unable to fit into another. community have become unavailable. Although the command economies favored col- Barriers to change lectivist upbringing, research within the region doc- umented the harm caused to children by The legacy of the reliance on residential institutions institutional life and emphasized the importance of profoundly shapes and constrains the development family in raising healthy children (Bronfenbrenner of the social welfare systems that are emerging today 1973, ch. 3). The society and particularly residential Many barriers must be overcome before communi- institutions produced children who were more dis- ty-based social services can be a credible alternative ciplined, dependent, and conforming as well as less to large residential institutions. These obstacles have rebellious, delinquent, or aggressive than children in been created by the legacy of the command econo- the United States (Bronfenbrenner 1973, p. 95). my, the deteriorated socioeconomic conditions ln the 1970s Langmeier and Matejcek reviewed a resulting from the transition to a market economy, series of studies conducted in Czechoslovakia that and the loss of much of the preexisting social safety compared infants and young children raised in insti- net. This section reviews barriers that are a result of tutions with children raised at their own homes. the region's reliance on residential care. Although institutionalized children's physical devel- opment was normal, they suffered deficits in lan- ORGANIZATIONAL PRESSURE TO MAINTAIN RESIDENTIAL guage and social development (Kadushin 1978, p. INSTITUTIONS. The long history of reliance on resi- 13 1). In Russia there were reports of child beatings, dential institutions in the former Soviet Union and suicides, and the appointment of staff with criminal the more recent reliance on them in Central and records (Harwin 1996, p. 103). One Soviet Eastern Europe has created a large and influential researcher concluded that, "children brought up constituency interested in preserving these institu- without the participation of the family are at far tions. In Romania, for example, 70,000 people work greater risk of one-sided or retarded development in residential institutions that care for 100,000 chil- than those who are members of a family collective" dren (Innes 1999). (Kharchev 1963, p. 63, Cited in Bronfenbrenner Many of the people who managed residential 1973, p. 88). institutions during the socialist era continue to do so At the end of the socialist era and the beginning today They are a powerful force for the preservation of the transition to a market economy, few if any and continued reliance on residential facilities. As comparative assessments were done on the impact employment options have narrowed during the tran- of residential institutions on individual develop- sition, these groups have become increasingly ment. Nevertheless, many assessments and anecdot- dependent on residential institutions for their work, al reviews were conducted of healthy and children income, and social well-being (Herczog 1997, p. with disabilities living in residential institutions 116). soon after the transition began or who were adopt- ed from such institutions. The impression from a ABSENCE OF A SOCIAL WELFARE INFRASTRUCTURE. Four review of these studies and visits to nearly 100 insti- barriers impede the creation of a supportive social tutions in eight countries of Central and Eastern welfare structure. The first is the lack of sufficient Europe and the former Soviet Union during the early social services to help individuals with problems. years of the transition is that many children were Before the transition, policies in Central and Eastern damaged by regimented, impersonal, institutional Europe and the former Soviet Union focused on max- life and became dependent, isolated from their fam- imizing economic production. As a result the social Residential Institutions under the Command Economies of Central and Eastern Europe and the Former Soviet Union 13 welfare system promoted universal employment and A fourth barrier to the development of a social productive workers. This policy orientation, howev- welfare infrastructure is the dearth of NGOs. Few er, caused the absence of social work knowledge and operated in Central and Eastern Europe and the for- community programs to help individuals and fami- mer Soviet Union during the socialist era. Some vol- lies when difficulties arose. Nurses and teachers, untary organizations began to appear in the early community volunteers, and individuals connected 1980s, first in Poland and later in Hungary. In 1985, with trade unions provided minimal assistance with with the advent of glasnost, religious organizations, few resources to children, families, and the elderly international relief agencies, and other NGOs were (Kadushin 1980, p. 663). These individuals were finally permitted to provide some social services in largely untrained to intervene with social or person- the region (UNICEF 1997, p. 107). al problems and often played more of an investigative Many large international NGOs operating in the and monitoring role than a supportive social servic- social sector began by establishing emergency relief es role to resolve problems. programs in the region. Although some of these pro- Another barrier to the development of a support- grams evolved into longer-term development and ive social welfare infrastructure is the use of a med- technical assistance projects, most are small pro- ical model of social care. The medical model used grams that affect few people. Almost 10 years after physical health-rather than emotional or social the start of the transition, most NGOs in Central and factors-to determine the care people needed. Social Eastern Europe and the former Soviet Union are welfare personnel-physicians and civil servants- underdeveloped. generally were untrained in social work or child According to UNICEF (1997, p.107), three main development, and had difficulty seeing the social factors have contributed to the underdevelopment of causes of an individual's problems. This medical NGOs. First, legislation that clearly defines the pre- approach has limited the care provided to individu- rogatives and responsibilities of NGOs is rare. As a als and constrained the policy options that are con- result, NGOs providing residential care for children sidered immediately feasible during the transition. have often operated outside of a legal framework A third barrier is the absence of schools of social without government licensing, standards, or work. Social work training programs were disman- approval. Second, many individuals who work for tled throughout Central and Eastern Europe in the NGOs lack basic managerial skills and know little decades after World War II and never developed in about generating public awareness. Third, local and the Soviet Union. Yugoslavia retained social work national governmental subsidies-a primary source education, and Hungary reintroduced social work of revenue for NGOs-are decreasing. education in 1986 (Ruzica 1998; Herczog 1997, p. 108), but in most countries there was little knowl- ABSENCE OF A LEGISLATIVE FRAMEWORK. Legislation edge of social work practices. Although social work that affects the transition from residential institu- research and training centers, sites for practicums, tions to community-based services include laws on and adequately prepared staff were generally absent, residential institutions, social assistance (cash and social pedagogues served an educational and sup- noncash), family law (foster care and adoption), portive role. people with disabilities, and the role of NGOs. Social work departments have recently emerged Other laws that shape the social welfare context for in existing departments of sociology, psychology, or this transition include laws on social insurance pedagogy in the region. Romania has seven univer- (pensions, family benefits, unemployment insur- sities with departments of social work that graduate ance) and the decentralization of government. 500 social workers a year. On the other hand, the Legislative reform has occurred in several relevant first qualified social workers trained in Albania will areas, including social insurance (creating self-sup- not begin working until the year 2000 (UNICEF porting systems) and social assistance (consolidating 1997, p. 109). multiple cash benefits, decentralizing the provision 14 Movingfrom Resideritial Institutions to Community-Based Social Services in Central and Eastern Europe and the Former Soviet Union of cash benefits, and targeting limited financial assis- Legislation on foster care and adoption in the tance). But few countries have significantly changed region is outdated. Legislation that allows short- laws to reduce reliance on residential institutions or term foster family care with nonrelatives is absent in to create community-based social services. many countries in the region, though countries such Residential institutions in many countries follow as Hungary and Romania had such legislation prior laws from the Soviet era that are no longer in force to the transition (Herczog 1997, p. 113; UNICEF but continue to guide practice. In Armenia, for 1997, p. 73). In Hungary professional foster families example, the 1984 Soviet Law on Boarding Schools account for about a quarter of the children in foster defines practice within boarding schools for vulner- care (Herczog 1997, p. 114). able children though the law is no longer operative. Legislation for people with disabilities has changed The United Nations Convention on the Rights of in two significant ways. First, categories of eligibility the Child, adopted by the U.N. General Assembly in have changed thereby increasing the number of ben- 1989, discourages the use of residential institutions eficiaries. The largest increases have occurred in for children. The convention has been ratified by all Estonia, Lithuania, and Russia. Second, legislation has but two countries. So far, however, this convention been passed in several countries, including Armenia appears to have had a limited effect on changing the and Lithuania, that allows children with disabilities to conditions in or reliance on residential institutions go to mainstream schools. Implementation, however, in most countries of Central andEastern Europe and lags far behind the legislation. the former Soviet Union-with some exceptions. In Romania, for example, the convention played a role FINANCIAL INCENTIVES TO PLACE INDIVIDUALS IN RESIDEN- in improving conditions in the worst facilities. But TIAL INSTITUTIONS. During the transition responsibility there has been no sustained reduction in the num- for administering social assistance services has been ber of children in residential care. transferred to municipalities in most countries while Although adequate legislation for community- responsibility for residential institutions generally has based social services is lacking in most countries in been transferred to regions or remained with the state. the region, several countries have passed relevant This disparity has created a financial incentive for legislation, including Poland (1990), Latvia (1995), municipalities to reduce their expenses by placing Romania (1997), and Lithuania (1998). In Lithuania vulnerable individuals in residential facilities financed the Law on Development of Social Service Infra- by other levels of government. In some countries, structure authorizes the Ministry of Social Security however, some social care homes for the elderly have and Labor to assist municipalities in developing been transferred to or developed by municipalities. social services pilot projects for vulnerable groups. This new financial responsibility of municipalities will Funding has been made available by the government likely promote the development of alternative, less and, through a tender offer, municipalities and NGOs expensive community-based care by municipalities. have developed proposals to provide social services. A new funding approach for social services may In Romania legislation for the Organization of the be tried in Latvia. Under one proposal, municipali- Activity of the Local Public Administration ties would receive a lump sum payment from the Authorities in the Field of the Protection of national budget for each at-risk individual. The Children's Rights created a national system of child funds could be used to pay for community-based protection under each county council. The new sys- services or for an individual to live in a residential tem allows the creation of family-type alternatives to institution. This approach may create a financial institutions and the provision of social services for incentive to use community services because they vulnerable children in each county. Adequate fund- are less expensive than residential care. ing has not yet been provided, however, to create an effective system of community-based social services PUBLIC OPINION. Although residential facilities throughout the country. increasingly are seen as a last resort, many people of Residential Institutions under the Command Economies of Central and Eastern Europe and the Former Soviet Union 15 Central and Eastern Europe and the former Soviet The thousands of residential institutions for chil- Union believe that residential institutions are a valu- dren, people with disabilities, and the elderly were able resource provided by the state to assist vulner- subordinated to one of four national ministries in each able individuals. In Armenia, for example, while country or republic: health, education, social welfare, very poor or overwhelmed parents (often single or interior. Throughout the region, children under 3 mothers) of children who reside in boarding schools years of age were generally the responsibility of the generally prefer to care for their children themselves, ministry of health. At age 3 they were placed in pre- they believe that their children are better off living in school institutions under the auspices of the ministry an institution with adequate food, shelter, and of education. When they reached school age, they heat-regardless of how inadequate the institution remained the responsibility of the ministry of educa- might be (Gomart 1998; Bertmar 1999). The insti- tion but were transferred to boarding schools. tutional and civil service staff that manage residen- Children with disabilities who could be educated tial institutions express a similar belief. remained the responsibility of the ministry of educa- Social fears also affect a family's decision to use tion. Adults with disabilities and those who could not residential care-particularly for people with dis- be educated or trained and the elderly were the abilities. In Albania and Armenia, for example, par- responsibility of the ministry of social welfare. ents believe that their other children would not be Juvenile delinquents were the responsibility of the able to find spouses if the existence of a sibling with ministry of interior. These national ministries set stan- disabilities became known. Residential institutions dards and loosely monitored the performance of each are a way to solve some of the problems associated institution. Regional and local offices (inspectorates) with having a family member with disabilities. ensured that national policy was carried out. The sentiment in favor of residential institutions Monitoring the performance of residential institutions is widespread, but not universal. In Albania, for was minimal, particularly for program activities, and example, residential institutions were not provided was divided among several national ministries and by the government or desired by the community; their regional offices (Madison 1968, ch. 9). as in many other countries in the region, the The Soviet welfare system was characterized by extended family or neighbors helped individuals centralized policymaking in Moscow and financial when they had problems. Families in Albania today planning and decentralized administration in the do not consider residential institutions to be a solu- Soviet republics (Madison 1968, p. 88). This model tion to their economic or social problems or a way stands in contrast to that used in Central and Eastern to care for children, people with disabilities, or the Europe, where national ministries played a central elderly. role in developing policy CENTRALIZED FRAGMENTED BUREAUCRACIES. A central- THE PLACEMENT PROCESS. The criteria for placement ized, fragmented national bureaucracy with little and the role of directors of residential institutions accountability for the care provided within residen- contribute to the excessive number of children, peo- tial institutions was a defining result of social welfare ple with disabilities, and elderly placed under resi- policies in Central and Eastern Europe and the for- dential care. The criteria for placing an individual in mer Soviet Union. As might be expected in bureau- a residential institution are often vague, inappropri- cratic systems of the size and complexity used for ate, outdated, and arbitrarily applied. In most cases residential institutions, there were many areas of more attention is paid to compiling case documen- confusion, fragmentation of authority, and unclear tation (such as birth certificates or medical certifi- delegation of responsibility The diminished sense of cates) than to assessing individual or family managerial accountability that arises under such problems and strengths. conditions contributes to the discontinuities in care Individuals with disabilities are categorized based (Tobis, Krantz, and Meltzer 1993). on poorly defined medical conditions rather than on 16 Movingfrom Residential Institutions to Community-Based Social Services in Central and Eastern1 Europe and the Former Soviet Union functional abilities. In most countries, for example, Social Services in Tirana. The extremely low a medical panel determines a person's level of dis- placement rate in Albania, conditioned by a ability, whether residential placement is needed, and national culture of community and family the type of institution into which the individual responsibility, has enabled this centralized deci- should be placed. The person's social, emotional, sionmaking process. The directors of residential material, and often intellectual strengths and needs institutions have relatively little influence in are rarely taken into consideration. Minor medical determining how many or which individuals conditions such as epilepsy, harelip, crossed-eyes, enter their institutions, particularly when beds cleft palate, and scoliosis are sufficient reasons for are filled to capacity placement in a long-term residential facility One * Decentralized. Romania-which has the highest study in Russia reported that "between one-third placement rate of children in residential and two-thirds of the children living in orphanages institutions-has had a decentralized decision- for mentally handicapped children were of average, making process since the Ceausescu period. or above average intellectual ability" (Cox 1991, p. Each county (judet), sector of Bucharest, and 4. cited in Harwin 1996, p. 104). This approach several large cities has an intergovernmental increases the number of residential placements dra- commission for the protection of minors. The matically by including cases where minimal inter- commissions make all decisions to place chil- vention would be sufficient. Other individuals dren in residential institutions, including chil- whose material, social, and health situations are con- dren with disabilities. siderably worse reside in the community-at con- Each commission, subordinated to the County siderable risk but with minimal assistance. Council, has a representative from the local The directors of residential institutions face sub- inspectorates of the Ministries of Health, Social stantial organizational pressure to keep their beds Protection, and Education, the police, and the filled to preserve their budgets, which are largely local residential children's institutions. The direc- determined by the number of residents in their care. tors of residential institutions have significanL Directors exercise excessive influence in determin- influence to decide which children are placed in ing which individuals are placed in their institutions their institutions and which are sent to other and how many are placed. They may also selective- institutions in other judets. ly choose which children are admitted to their insti- * At the residential institution. In several former tutions, taking the most desirable and easily Soviet republics the decisionmaking process for manageable children. placement in a residential institution has broken The influence of the directors of residential institu- down. No formalized, consistent process has tions varies depending on the formal placement replaced it. The directors of residential institu- process. Placement decisions are made at three lev- tions fill this void. They have broad discretion els-centralized, decentralized, and at the residential (constrained only by their budget and bed capac- institution. The more decentralized the decisionmak- ity) in deciding who and how many individuals ing process, the greater the influence of institution are placed in Lheir institution. In Armenia, for directors. example, a parent seeking to place a child in a Centralized. Albania-with the lowest placement boarding school or infant home goes directly to rate in residential institutions of any Central and the institution. If the director approves, the child Eastern European country or former Soviet is placed. If the child is not accepted, the parent Union republic-has a centralized decisionmak- has the right to petition the regional or relevant ing process. Any child, person with disabilities, national ministry (education, health, or social or elderly person placed in residential care must welfare) to place the child. Most children are be approved, generally in person, by the director placed directly into institutions with the approval of social care in the General Administration of of the institution's director. Residential Institutions under the Command Economies of Central and Eastern Europe and the Former Soviet Union 17 Notes important difference that the Russian volume is concerned not with physical health but with the development of char- 1. A. Goikhbarg, responsible for the committee that acter" (Makarenko 1967, ix). drafted the first Soviet Code in 1918 on Marriage, the Family 3. Based on an estimate of 820,000 children in residen- and Guardianship, summarized this position: "Our [state tial institutions in Central and Eastern Europe and the for- institutions of guardianship] ... must show parents that mer Soviet Union and an average of 150 children per social care of children gives far better results than the pri- institution. vate, individual, inexpert and irrational care by individual 4. According to Kadushin (1978, p. 143), in the United parents who are 'loving,' but in the matter of bringing up States "most children's institutions are not 'total' institutions children, ignorant" (Madison 1968, p. 36). in that they do not carry out all life-supporting functions in 2. Despite the recognition he received for institutional isolation from the outside world. Most are mediatory insti- upbringing, Anton Makarenko never regarded residential tutions oriented to and interacting with the surrounding upbringing as ideal for the child. In fact, his work was also community" the primary guide for raising children within families dur- 5. The estimated number of children in residential insti- ing the same period (Bronfenbrenner 1973, p. 41). Uri tutions between 1989 and 1995 based on the data gathered Bronfenbrenner, the child psychologist, in his introduction by UNICEF Data for 13 countries were available for 1989 or to Makarenko's Book for Parents (called in English The 1990 and 1994 or 1995. The countries had about 4 percent Collective Family) wrote that "its closest counterpart in the fewer children in infant or children's homes at the start of the West is Benjamin Spock's Baby and Child Care, with the transition than in 1994-95. CHAPTER 2 The Transition and Residential Institutions T he transition from reliance on residential Economic conditions institutions to community-based services has created opportunities as well as problems for The region's economic conditions deteriorated dramat- the region. Rapidly deteriorating socioeconomic ically during the early years of the transition. In the conditions and limited government resources have mid-1990s the general decline in economic output increased the use of residential institutions. At the began to abate, but in 1997 real GDP in many coun- same time, a slow but growing interest in communi- tries was still about 40 percent below the level in 1989. ty-based alternatives by people in the region and Transition in the countries of the former Soviet Union international organizations has laid the groundwork has generally been much more difficult than in the for change. countries of Central and Southeastern Europe (UNICEF 1998a, p. 2). Unemployment, almost nonexistent in the com- Socioeconomic Conditions mand economies of the region, rose rapidly Employment rates in the 18 countries for which data The transition from a command economy to a mar- are available were almost 15 percent lower in 1995 ket economy in Central and Eastern Europe and the than in 1989 (UNICEF 1997, p. 6); moreover, real former Soviet Union caused rapid deterioration in wages were more than 45 percent lower. The per- economic and social conditions throughout the centage of the population living in poverty rose dra- region. Between 1990 and 1994 countries in the matically throughout the region, affecting families region fell an average of 32 positions in their rank- (particularly single mothers with children) and the ing on the Human Development Index (UNDP var- rural, isolated elderly most acutely According to a ious years). At the same time, many of the financial World Bank study of 18 countries of the region the and social supports that had been available during estimated number of poor people increased twelve the socialist period were eliminated, reduced in fold from 1987 to 1988 and 1993 to 1995, with sub- size or scope, or deteriorated in quality Limited stantial variations among countries (Milanovic means-tested financial assistance and few commu- 1998, p. 67). nity-based services have developed to replace the supports that were eliminated. The overall result Social supports has been a significant increase in the number of people who are poor, vulnerable, demoralized, and The movement to a market economy encouraged the who are forced to cope with profound and rapid privatization of services that had previously been free changes with very little assistance. Residential or heavily subsidized. Millions of children, families, institutions increasingly have become a primary and the elderly, lost the benefits they had received as resource for a small percentage of children, the eld- entitlements. For example, thousands of nurseries, erly, and people with disabilities to survive the day care centers, and kindergartens closed-between socioeconomic crisis. 1991 and 1995 more than 30,000 preschools were 19 20 Movingj-om Residential Institutions to Community-Based Social Services in Central and Easter-n Europe and the Former Soviet Union closed in the countries of the Commonwealth of (-28.0 percent).2 Latvia was one of the few countries Independent States. Access to health care become in the region that showed any increase during this more restricted. In Georgia 670,000 primary school time period (+0.6 percent) (UNICEF 1997, p. 134). children received a health checkup in 1989; only Recently, however, there have been modest improve- 250,000 had one in 1996 (UNICEF 1998a, p. ix). ments in public finances. Subsidies for food, housing, and transportation were dramatically reduced or eliminated. Childcare leaves, Social consequences after-school programs, and free or subsidized vaca- tions were also eliminated. The unprecedented peacetime deterioration in the Many of the cash benefits that had been provided standard of living, coupled with the loss or reduc- during the socialist period were either eliminated, tion of social supports and financial assistance, dramatically reduced in value (due to high inflation), resulted in profound consequences-particularly or provided to smaller segments of the population. for children, people with disabilities, and the rural Family and child allowances were phased out and elderly living alone. Most of the demographic, eco- replaced with cash assistance targeted on the most nomic, and social changes in the region have needy In many poorer countries, such as Albania increased the health, psychosocial, and develop- and Armenia, means-tested financial assistance to mental risks for children. Life expectancy has fallen families approximately equals the cost of a loaf of dramatically, leaving more children vulnerable to the bread a day premature death of parents from such factors as poor The number of pensioners increased in many nutrition, alcoholism, smoking, stress, and deterio- countries, even as the real value of pensions rated living conditions (UNICEF 1997, pp. 37, 39). decreased (Bezrukov 1997). During the first five In Poland, for example, 100 people froze to death in years of reforms the number of pensioners increased the first month of the 1998-99 winter season, almost by almost 3 percentage points in Kazakhstan, Latvia, twice as many as in the entire winter of 1997-98. Russia, and Ukraine. Between 1991 and 1995 the Most of the victims were men aged 40 to 60 who had number of pensioners grew by 20 percent in been drinking and fell asleep in the cold (New York Armenia, and by 17 percent in Kazakhstan (Kuddo Times 1998). 1998, p. 153). Poverty among the elderly has grown With the decrease in marriages, more children are though there is considerable debate about its extent being born out of wedlock. The number of single and depth. In all eight countries in the region report- mothers has increased and represents an increasing ed on by Milanovic, poverty rates decline with age portion of the poor. In Poland 11.7 percent of chil- (Milanvoic 1998, p.102). Other studies report high dren live in single-parent families. Births to teenage poverty rates for the elderly in countries such as mothers have also increased in most countries, Albania, Russia, and Ukraine (Bezrukow 1997; reaching a high of 22.6 percent in Bulgaria (UNICEF Simonova 1997; Shehu 1997). 1997, pp. 37, 38, 129). The dramatic decrease in government revenues, The deterioration in the quality of people's lives especially among countries of the former Soviet may also have heightened both the incidence of Union, has been a driving force in the reduction of child abuse and wife battering within the marriages social supports and resistance to reducing the that remain (UNICEF 1997, p. 13). In Lithuania, for reliance on residential institutions. Public revenues example, one survey of 1,000 married women decreased as a percentage of GDP throughout the reported that 18 percent were severely beaten by region, at the same time that GDP decreased. their husbands (Lietuvos Aidas 1998). Data, howev- Between 1990 and 1995 public revenue as a per- er, are unavailable to compare with the incidence of centage of GDP decreased in Lithuania (-5.4 per- domestic violence before the transition. cent), Romania (-6.1 percent), Poland (-6.7 A growing share of children do not attend schools percent),' Albania (-20.1 percent), and Armenia because of truancy, work, or family problems. In The Transition and Residential Institutions 21 Romania secondary school enrollment rates in 1995 healthy children whose families seek residential care were 14 percent lower than in 1989. In Poland has increased. Being labeled as disabled is necessary nearly 1 in 10 7-to-9-year-olds were left without for placement in a specialized boarding school. In adult supervision for more than two hours a day in addition, adoption legislation in several countries the mid-1990s, a large increase over the beginning permits international adoptions only for children of the decade (UNICEF 1997, pp. ix, viii). with disabilities. And the lack of proper supervision The number of children involved in juvenile and monitoring of the adoption process facilitates crime, child prostitution, and drug abuse has also international adoption of healthy children who are increased throughout the region. The number of classified as disabled. children living on the street, many of whom are The number of children who have become homeless, has increased as well. Between 1992 and refugees because of war or natural disasters has 1995 the number of street children held in detention increased. In Armenia the earthquake in 1988 and centers grew 300 percent in Bishkek, Kyrgyz the war with Azerbaijan in 1992 created 1.28 mil- Republic (Goldman 1998b). lion refugees and displaced persons (380,000 in These growing social problems have increased the Armenia, 900,000 in Azerbaijan). The 1991-92 civil percentage of children who are placed in residential war in Georgia created 280,0000 refugees and dis- care by a court order. In Russia court-ordered place- placed persons, including roughly 90,000 children ments accounted for 20 percent of children left with- under the age of 16-of whom 1,700 had disabili- out parental care in 1991. By 1994, 33 percent of ties and 8,000 were orphans. In 1995 more than 1 children were entering the care system by court million refugees resulted from the conflict in order (Harwin 1996, p. 137). Chechnya, Russia. In Tajikistan the number of dis- Deep historical prejudice toward and discrimina- placed persons peaked at 660,000 in 1993. The tion against ethnic minorities have also been 1991-95 conflict in the former Yugoslavia created unleashed. These attitudes have led to armed con- about 4.2 million refugees and displaced persons; flict in many parts of the region and to pogroms of about 1.4 million were children. Most recently, in Roma in Romania, Hungary, the Czech and Slovak Kosovo there are roughly 1 million displaced per- Republics, and other countries. Historical prejudices sons; about one-third are children (UNICEF 1997, have contributed to extreme disproportionate repre- pp. viii, 29). sentation of Roma in many residential institutions in The social, economic, and health effects of the several countries of the region. The number of chil- transition on the elderly have also been severe, dren registered with disabilities has grown sharply though there is still a lack of adequate knowledge because of broadening categories and levels of dis- about the full impact (Calasanti and Zajicek 1997, p. ability. In addition, deteriorating maternal and child 452). In Albania homelessness among the elderly is health during the transition may indicate that part of increasing. In Hungary an estimated 32 percent of the registered increase in some of these countries is the elderly require home help. In Ukraine 10 percent due to a rise in the number of new cases of children of the elderly and 23-30 percent of the very old need with disabilities. In addition, there are indications periodic or constant help and care (United Nations that only a portion of individuals with disabilities are 1997, pp. 56, 119). actually registered as disabled. In Russia, for exam- ple, the number of children with recognized disabil- ities is almost 400,000, though one estimate places Increased Reliance on Residential the actual figure at no less than 1 million (UNICEF Institutions 1997, p. 47). There are strong incentives to classify healthy chil- Although residential institutions have always cared dren as disabled and place them in residential insti- for a small percentage of vulnerable individuals, tutions. As poverty has increased, the number of more children and people with disabilities are resid- 22 Movingfrom Residential Institutions to Community-Based Social Services in Central and Eastern Europe and the Former Soviet Union Box 2.1 Two Families Whose Children Attend a Boarding School in Yerevan, Armenia The long-term placement of poor children in residen- home. In addition, the child was teased at the regular tial institutions is often the result of chance, as well as school because of her disfigurement. The mother would arbitrary or inappropriately applied placement criteria. like to take her daughter home every night but she In Armenia there is often very little difference between works until 11:00 p.m. and there is no one to take care the family living situation of children who live in a of the child. The mother does not have enough money boarding school and those children who attend a to pay for the bus twice a day for herself and her daugh- school during the day and go home to their families ter and to buy food for her daughter. In addition, she each night. has a two-month debt for electricity The following are profiles of two families, both of The mother was affectionate and caring during her which are very poor. A child in the first family lives in a interaction with the child. The mother expressed a boarding school in Yerevan. In the other family, equally desire for the child to live with her but felt financially poor and vulnerable, the child attends the boarding unable to do so. school during the day but goes home to her family every Family 2: The child resides at home. The family consists night because she lives within walking distance of the of a single mother and two children. The younger sclhool. daughter has epilepsy and attends a boarding school Family 1: Child resides in the boarding school. The fam- during the day and comes home at night. She is the only ily consists of a single mother, her two children, the child in the boarding school who goes home every mother's sister, and the sister's child. The 12-year-old night. The family members are refugees from daughter lives in a boarding school. Her sibling is 9 and Azerbaijan. her cousin is 14. The mother and her two daughters live in a one-room The girl lived at home when she was younger. One apartment, about 8 feet by 15 feet plus a small alcove for day she was severely burned by the heater in her kinder- cooking. The three share one bed. The apartment is in a garten. Her face is severely disfigured as a result of the building within a few hundred yards of the school, allow- burn. ing the child to walk to and from school by herself every The mother buys and roasts sunflower seeds and sells day them in Republic Square. Her husband has died, which The mother works as a cleaning woman in a local entitles her to a pension of 7,500 drams a month ($15). hospital and earns 4,000 drams a month ($8). The She receives a children's allowance of 6,000 drams a mother was affectionate during her interaction with the month ($12). She earns about 600 drams ($1.20) a day child. selling seeds. Summary. The income and housing of the two fami- Her flat consists of two sparsely furnished, cold lies are similar. A primary difference between the child rooms with a cement floor. One room has only a couch; who lives at home and attends the boarding school dur- the other has a cabinet, table, and chairs. One room has ing the day and many other children in the school does a light bulb. The only heating element is a hotplate that not involve poverty, housing conditions or parental is used for heat and cooking. The apartment is about a availability or involvement, but the family's proximity to 40-minute car ride from the boarding school. the school. The simple lack of money or transportation The mother placed the child in the boarding school has contributed to many children residing in boarding because she cannot work and also care for the child at schools in Armenia. Source: World Bank mission to Armenia, November 1997. ing in long-term facilities throughout Central and pitals to long-term residences for the elderly In Eastern Europe and the former Soviet Union today Central Asia the number of institutionalized elderly than 10 years ago (UNICEF 1997, p. 66). As for the has decreased because of lack of resources to care for elderly, roughly the same number are residing in res- additional people. idential institutions as 10 years ago, though the sit- At least 820,000 poor, vulnerable, or children uation varies by country. In Lithuania that number with disabilities in the 27 countries of Central and has increased substantially with the creation of new, Eastern Europe and the former Soviet Union live smaller facilities and the conversion of former hos- the early years of their lives isolated in 5,500 large, The Transition and Residential Institutions 23 regimented residential institutions. Excluded from 1998, p. 110). Hungary is the only country in the these figures are many children who live in board- region where the drop in the number of children in ing schools or sanatoria, but are in the custody of public care is an unequivocally positive sign their parents. Included in this number of institu- (UNICEF 1997, p. 66). tionalized children are about 495,000 children In 10 of the 14 countries of Central and Eastern with disabilities or labeled with disabilities (table Europe surveyed by UNICEF, the rates of infants and 2.1). Roughly 365,000 elderly and elderly with dis- toddlers living in institutional care have risen since abilities lived in social care homes in the former 1989. In Latvia, Romania, and Russia the number of Soviet Union in 1990 (see table 1.2); no aggregate children under 3 placed in infant homes has risen data are available for the institutionalized elderly 35-45 percent (UNICEF 1997, p. viii). The number today in the former Soviet Union or in Central and of children abandoned in maternity wards and the Eastern Europe. number of parents seeking placement for their chil- At least 0.7 percent of the region's children, 4 per- dren in infant and children's homes also increased. cent of people with disabilities, and 0.8 percent of The number of children in homes for people with the elderly live in residential institutions. The high- disabilities has increased in countries such as Poland est percentage of institutionalized children in the and Romania but decreased in Bulgaria, Moldova, region is in Romania (1.8 percent); the lowest is in and Russia. But in poor countries such as Armenia, Albania (0.05 percent). Nearly one-third of all chil- poverty leads many parents to place their healthy dren in residential institutions are in Russia. children in special boarding schools for people with Although it is difficult to compare rates of institu- disabilities (UNICEF 1997, p. 67). tional placement among countries in different Children generally remain in residential institu- regions, some broad comparisons are possible. In the tions from the time of placement until they reach the United States, for example, 0.7 percent of children institution's age limit of 14 to 18, although some are in out-of-home care (500,000 of 69,000,000 chil- return home or are adopted. Lithuania has one of the dren under age 18)-roughly the same percentage highest return rates-40 percent of the children who are in residential institutions in Central and placed in infant homes return to their families Eastern Europe and the former Soviet Union (Casey (Karcauskiene 1994). 1998). But, only 4 percent of the U.S. children are in Many factors contribute to the excessive and institutions, 13 percent are in group homes, and 81 harmfully long lengths of residential care for chil- percent are in foster care (USDHHS 1997).3 dren. First, staff believe that vulnerable children, Roughly 10 years after the fall of the Berlin Wall, people with disabilities, and the elderly are better off in most countries throughout Central and Eastern in residential institutions than in the community, Europe and the former Soviet Union more children especially because community-based social services and people with disabilities live in residential insti- are rarely available. tutions than before the transition. In several coun- Second, many institutions-particularly those for tries children in institutions are disproportionately children with disabilities, children with medical from ethnic minorities, particularly Roma. In conditions, some boarding schools, and children's Lithuania the number of residents in infant and chil- homes-accept children country- and regionwide, dren's homes increased 32 percent between 1990 increasing the distance between them and their fam- and 1995. In Armenia the number of children in ilies. In addition, staff in institutions discourage con- boarding schools rose 20 percent between 1995 and tact between children and their families because 1997. In the Kyrgyz Republic the number of young such contacts disrupt the daily routine. Moreover, children under residential care jumped 69 percent many staff believe that families have a harmful influ- between 1991 and 1994 (Armenia Ministry of ence on children in residential care. Education and Science 1998a; Lithuania Ministry of A third factor that contributes to the excessive Social Security and Labor 1996; Bauer and others length of care is the lack of responsibility and over- 24 Movingfrom Residential Institutions to Community-Based Social Services in Central and Eastern Europe and the Former Soviet Union TABLE 2.1 Number of Children in Residential Institutions in Central and Eastern Europe and the Former Soviet Union, 1995 Total number Children in residential institutions Share of total Share of children of children Without With children in with disabilities in Country under 18 disabilities disabilities Totala institutions (percent) institutions (ercent)b Albania 1,246,000 - _ 585c 0.05 Armenia 1,213,000 - - 10,131 0.80 Azerbaijan 2,828,000 1,148c 695 1,843 0.20 0.07 Belarus 2,655,000 5,587 1,841 7,428 0.30 0.70 Bosnia and Herzegovina 933,000 - - - - - Bulgaria 1,903,000 12,718 8,246 20,964 1.10 4.0 Croatia 1,034,000 - - - - Czech Republic 2,400,000 8,684d 11,583 20,267 0.80 5.0 Estonia 358,000 1,470 404 1,874 .50 1.0 Georgia 1,529,000 723 1,634 2,357 0.20 1.0 Hungary 2,250,000 9,708 738 10,446 0.50 0.3 Kazakhstan 5,890,000 - - - - Kyrgyz Republic 1,904,000 - - - Latvia 609,000 1,751e 420 2,171 0.40 0.7 Lithuania 957,000 5,037 1,790 6,827 0.70 0.2 Macedonia, FYR 636,000 - - - - Moldova 1,382,000 1,084 600 1,684 0.10 0.4 Poland 10,589,000 30,265d 37,700 67,965 0.60 4.0 Romania 5,646,000 39,622d 62,230 101,852 1.80 11.0 Russia 37,115,000 106,094 231,433 337,527 0.90 6.0 Slovak Republic 1,468,000 6,815 4,386 11,201 0.80 3.0 Slovenia 426,000 - - - - Tajikistan 2,842,000 Turkmenistan 1,887,000 - - - - Ukraine 12,377,000 16,433 8,525 24,958 0.20 0.7 Uzbekistan 10,614,000 - Yugoslavia 2,678,000 - - - - Total for countries with data available 115,369,000 247,139 372,225 630,080 0.70 4.0 Total estimate for countries with no data available 28,844,000 79,188f 122,720 201,908 0.70 4.0 Total 115,369,000 326,327 494,945 821,272 0.70 4.0 - Not available. Note: This table understates the total number of children who reside in residential institutions. It is based primarily on data gathered by UNICEF on children in public care. According to UNICEF (1997) children in residential institutions include "children in permanent and temporary residential care (various types of infant and children's homes, including boarding schools for children without a parental guardian); [and] children with severe disabilities in health facilities, although in some countries this includes children with less severe disabilities in full or part-time care ... Children in punitive institutions are excluded in most instances." These data also generally exclude children who attend boarding schools or sanatoria and are in the custody of their parents. a. It is difficult to determine a precise total because no database covers all countries of the region, there is no standard methodology for counting institutions and children, country classifications of children by level of disability are increasingly arbitrary, and some residen- tial institutions have inflated the number of children on their rosters to increase government funding for those institutions. b. According to WHO (1978), about tO percent of the population in each country has disabilities. c. Data are for 1998. d. Data are for 1994. e. Data are for 1992. f The aggregate number of institutionalized people with disabilities in countries for which data are unavailable was estimated using the same percentage (60.8 percent) of people with disabilities among all institutionalized children in countries for which data are available. Source: UNICEF 1997, 1998b; Albania General Administration of Social Services 1998; Armenia Ministry of Education and Science 1998b. The Transition and Residential Institutions 25 sight outside the institution for a child. In Romania, mer Soviet Union for which 1996 data are for example, any movement of a child from an available-Azerbaijan, Belarus, Kazakhstan, the institution-whether to another institution or back Kyrgyz Republic (1995 data), Moldova, Tajikistan, to the community-must be approved by the com- and Uzbekistan-the number of elderly in residen- mission for the protection of minors that placed the tial institutions dropped by 16 percent between child. The commission, however, has no ongoing 1990 and 1996 (table 2.2), though the number of responsibility for the child, and rarely receives infor- institutions for the elderly increased by 4 percent. mation about any child it has placed. These countries, however, account for only 16 per- A fourth factor is that a disproportionately large per- cent of all the institutions for the elderly in the for- centage of children placed into residential facilities are mer Soviet Union and may not reflect the overall ethnic minorities, particularly children of Roma. In situation in the region. Romania as many as 40 percent of institutionalized children are Roma, though less than 10 percent of the population is Roma. In Bulgaria the disproportion is The Effects of Humanitarian Aid reported to be more extreme. Prejudice toward ethnic minorities has led staff in residential institutions to dis- As the international community became aware of the courage contact between parents and their institution- conditions of children in residential institutions, alized children and has reduced the options for foster emergency assistance and humanitarian aid poured care and adoptive placements in community-based in to assist specific institutions. International service programs. donors, NGOs, and religious organizations provid- Finally, housing and employment are scarce for ed assistance by training staff, renovating the appear- children who leave residential care. Children are ance of institutions, and providing fuel, food, books, now unofficially allowed to remain in many institu- toys, clothes, and recreational opportunities. This tions beyond the institution's age limit to avoid the assistance reached a large number of institutions homelessness, unemployment, and social isolation throughout the region. that afflicts many deinstitutionalized children. Organizations also redesigned a few large institu- In the 12 republics of the former Soviet Union the tions to make them more homelike. Large dormito- number of elderly and adults with disabilities in ries were divided into smaller units. Children reside institutions increased by almost 8 percent between in multiage groups, with each group having its own 1980 and 1990, rising from 338,940 to 364,500 eating and, on occasion, its own cooking facilities. (ISCCIS 1997). Among seven countries of the for- Although these residences are intended to be more TABLE 2.2 Number of People in Residential Institutions for the Elderly and Adults with Disabilities in Countries of the Former Soviet Union, 1990-96 Change in number of Percentage change, Country 1990 1995 1996 people, 1990-96 1990-96 Azerbaijan 1,190 980 900 -290 -24 Belarus 17,580 15,340 14,900 -2,680 -15 Kazakhstan 18,090 15,970 16,000 -2,090 -12 Kyrgyz Republic 3,100 2,780 - -320a loa Moldova 3,410 2,200 2,200 -1,210 -35 Tajikistan 1,110 760 1,100 0 0 Uzbekistan 9,410 - 7,200 -2,210 -23 Total 53,890 38,030 42,300 -8,800 -16 Note: These figures exclude individuals in sanatoriums, rest homes, and boarding houses with medical facilities. a. 1990-95 difference. Source: ISCCIS 1997. 26 Movingfrom Residential lnshtutions to Community-Based Social Services in Central and Eastern Europe and the Former Soviet Union supportive of children, no formal research has contributed to the development of national plans to demonstrated that they mitigate the harm caused by reduce the reliance on residential care in Armenia, long-term residential living. Bulgaria, and Romania. But the reduced humanitar- International donors, NGOs, and religious organ- ian aid has also resulted in renewed deterioration of izations have also built smaller group homes for vul- conditions in these institutions. nerable individuals. In Romania, for example, homes In Romania, for example, international public range in size from an agency-operated boarding reaction to the terrible conditions in institutions for home for 6 children in Cluj (funded by a European people with disabilities led to additional government foundation) to group residences for 25 children with funding and international emergency assistance to disabilities in Cluj (run by nuns and funded by improve the conditions in many of them. But as pub- Caritas) to several cottages for 100 children in Bacau lic attention decreased, international humanitarian (funded by the Romanian Orphanage Trust and run assistance and real government expenditures on by Pentru Copii Nostri). Some international donors children's institutions also began to decrease. A sur- have built cottages on large campuses that are often vey in late 1993 showed that central government isolated from the community, as SOS Kinderdorf has expenditures on children's homes had not kept pace done in Romania and other countries. with inflation, causing large reductions in staff. Since This type of humanitarian aid has been a double- then the conditions in the worst institutions have edged sword. On the one hand, the aid has improved improved from the deplorable pretransition condi- conditions in many institutions, primarily through tions, but the level of care provided in most resi- staff training, capital renovations, and the provision of dential institutions continues to be far below books, toys, food, and supplies.4 On the other hand, acceptable standards. As the director of one home for these changes created the false impression among pol- children under 3 in Romania said in 1995, "we do icymakers, donors, and the public that large residen- not have enough staff to care for the children. The tial institutions were not so harmful to children and infants arrive healthy and leave disabled" (Tobis people with disabilities. In the worst facilities, such as 1994). After several years of improvement, the con- institutions for the severely disabled in Romania, basic ditions in residential institutions again deteriorated survival needs were met, but other problems of living in 1999 after the institutions were decentralized in an institution continued. The changes at most of without transferring adequate funding from the the residential institutions, however, were minor rel- national budget to the localities. International ative to the magnitude of the harm caused by life in humanitarian assistance is again being sought to these institutions. Humanitarian aid reinforced the alleviate the recurring crisis. belief in and reliance on the use of residential institu- As another example, the earthquake in 1988 and tions, and it also strengthened the influence of indi- the war with Azerbaijan in 1992 brought interna- viduals who promote and run the facilities. tional attention and resources to Armenia. The large A second negative consequence of humanitarian and wealthy Armenian diaspora contributed to indi- aid to residential institutions has been that it has vidual boarding schools. This aid perversely allowed reduced the financial strain on the public sector from the national government to abrogate its responsibili- operating these facilities. Whereas the high cost of res- ty to provide adequate resources for children in pub- idential institutions has been a primary reason for lic residential institutions. Government funding for Western countries to phase out such facilities, human- food in boarding schools in Armenia fell to roughly itarian aid has allowed countries of Central and one-third of the standard set during the Soviet peri- Eastern Europe and the former Soviet Union to avoid od. As humanitarian assistance began to decrease or delay reducing their reliance on these institutions. toward the end of the 1990s, the govemment of Finally, humanitarian assistance has been provid- Armenia has not proportionately increased its fund- ed only briefly and is now decreasing throughout the ing to replace the lost assistance. As a result the con- region. This reduction in financial assistance has ditions in boarding schools continue to deteriorate. The Transition and Residential Institutions 27 Financing Residential Institutions are financed by transfers from national budgets to regional budgets. Although the localities generally The financing of residential institutions promotes have the legal authority to raise taxes, the local tax reliance on them but increasingly will contribute to base is limited. As a result local governments gener- a reduction in their use. Residential institutions are ally contribute little to the cost of financing residen- a very expensive way to assist individuals who are tial institutions in their jurisdictions. experiencing difficulties and the pressure to reduce In Lithuania 25 percent of the budgets of residen- government expenditures during the transition has tial institutions are financed by municipalities, rang- led to reductions in expenditures for residential ing from 45 percent for institutions for children to 4 institutions. These reductions may lead to the clos- percent for institutions for people with disabilities ing or conversion to day programs of some residen- (table 2.3). It seems likely that the municipal contri- tial facilities. In 1998, for example, the Armenian butions are primarily transfers from the national Parliament cut funding for boarding schools by 30 budget and that the differences primarily reflect the percent. The Ministry of Education and Science is degree to which different types of institutions have trying to use the reduction as an opportunity to con- been decentralized. vert 20 percent of boarding schools into general Many residential institutions receive marginal, schools and to close some facilities. supplemental financial assistance from foreign donors, NGOs, and individuals over several years. In Source of fundingfor residential institutions Armenia, for example, 46 of 48 residential institu- tions received support from foreign donors for food During the socialist era all residential institutions in in 1997. The average amount received by each insti- Central and Eastern Europe and the former Soviet tution is about 10 percent of its annual budget Union were financed exclusively by the state budg- (Armenia Ministry of Education and Science 1998a). et.5 Funding for these institutions was channeled through the ministry responsible for each type of Public expenditures for residential institutions institution. Each institution received an annual budget allocation from the ministry of finance based Reliable information on total public expenditures on a projection from the previous year's actual on children's institutions is limited. UNICEF esti- expenditures and a projection of the number of chil- mates that between 0.1 and 0.3 percent of all pub- dren to be served. lic expenditures in Central and Eastern Europe and Today residential institutions that remain subor- the former Soviet Union go for children in institu- dinated to national ministries continue to be tional care. But this estimate may be low. In financed in the same way Residential institutions Lithuania, for example, 1.75 percent of national that have been decentralized to regional or local gov- public expenditures in 1996 was for residential ernments are funded differently These institutions institutions for children, people with disabilities, TABLE 2.3 National and Local Expenditures on Residential Institutions in Lithuania, 1996 (thousands of litas; 4 litas=$1) Type of State share Municipal share residential institution National State (percent) Municipal (percent) Totala 131,749 98,336 75 33,413 25 Institutions for children 27,785 15,312 55 12,473 45 Institutions for the elderly 31,337 21,558 69 9,779 31 Institutions for people with disabilities 61,510 59,008 96 2,502 4 a. Also includes other institutions and institutions for home visiting and housekeeping. Source: Larsson 1998, table I 1. 28 Movingfrom Residential Institutions to Community-Based Social Services in Central and Eastern Europe and the Former Soviet Union and the elderly (Larsson 1998). The data seem to lower government budgets for residential institu- show, according to UNICEF, that the level of fund- tions and decreases in government consumer subsi- ing for residential care is associated more with dies that increase the cost of operating institutions. changes in GDP than with changes in the assess- As a result the living standards of children in long- ment of children's needs (UNICEF 1997, p. 85). term residential institutions in most countries have In real terms fewer government resources are worsened. Available data show that per child expen- devoted to residential institutions for children now ditures are often lowest or have declined the most in than when the transition began. This drop is due to special institutions for children with disabilities. As Box 2.2 Cost of Community-Based Social Service Projects: Lithuania and Romania How much does it cost to create community-based National child welfare reform in Romania. This three social services? The experience of Lithuania in creating and a half year project, begun in 1998, was developed pilot projects and of Romania in creating the foundation by the Romanian government through the Department for a national community-based social welfare system for Child Protection to reform the child care and child for children and families can provide some guidance on protection system by reducing the flow of children into the order of magnitude of investment and recurrent institutions, improving the quality of care for institu- costs. tionalized children, developing alternative care systems, Pilot projects in Lithuania. The government of and assisting older institutionalized children to adapt to Lithuania approached the World Bank to develop a life in the community The project will build on small- project to support the introduction of community- scale initiatives of other donors and NGOs and imple- based social services. The project included 14 service mentation structures within each county (judet). programs located in six municipalities. These pro- The goals of the project are to: grams include a social service reception center, home * Use 40 percent of the national budget allocated for care for the elderly, a day center for the elderly and child welfare ser-vices for communiity-based services. people with disabilities, a training center for youths * Decrease by 35 percent the number of children enter- with disabilities, four day centers for children with ing large, state-run institutions. severe disabilities, a temporary children's home, a tem- * Increase by 35 percent the number of children who porary shelter for battered women, and a short-term leave state-run institutions. reintegration residence for former prisoners. The proj- * Ensure that the cost per child served in community- ect provided investment funds (for renovation of based care is not more than half the cost of care in buildings, equipment, and vehicles), technical assis- state-run institutions. tance (to design and evaluate the program and to train * Increase by 60 percent the number of street children and supervise staff), and recurrent costs. About 1,000 who secure shelter. people are served by the projects (box table 1); 1,500 - Encourage the government and NGOs to incorporate people will be served in a year, when the projects are lessons from the sub-projects into future community- fully operational. based child welfare services. Box TABLE 1 Actual Costs of Selected Pilot Projects in Lithuania (U.S. dollars) Education centerfor Shelterfor Programrforformer Home carefor Reception children with disabilities battered women prisoners the elderly center Expenditure category (Anyksciai) (Vilnius) (Svencionys) (Svencionys) (Svencionys) Number of clients served 30 44 8 365 400 Physical expendituresa 118,358 371,219 43,835 97,667 25,177 Technical assistance and training 160,833 92,000 64,290 64,290 64,290 Annual recurrent expenditures 54,966 121,475 18,250 93,225 21,325 a. Civil works, equipment, furniture, and vehicles. Source: World Bank 1999. The Transition and Residential Institutions 29 Box 2.2 CONTINUED Cost of Community-Based Social Service Projects: Lithuania and Romania Box TABLE 2 Projected Costs of the Child Welfare Reform Project in Romania (millions of U.S. dollars) Project component Local Foreign Total Community-based child welfare services 21.9 5.1 27.0 Street children initiative 0.6 0.1 0.7 Institution building, monitoring, and evaluation 1.2 0.6 1.8 Total project cost 23.7 5.8 29.5 Note: Actual costs for all project components are not yet available because the project has only recently begun. Funding for the $29.5 million program (box table 2) is coming from the government of Romania ($3.3 million), Council of Europe Social Development Fund ($10.9 million), government of Japan ($0.5 million), U.S. Agency of International Development ($5.5 million), European Childrens Trust ($2.7 million), PHARE ($0.5 million), Spain ($0.2 million), Switzerland ($0.1 million), SERA ($0.8 mil- lion), and World Bank ($5.0 million). Source: World Bank 1998. UNICEF concludes, "consequently, many of those In Romania a study conducted by UNICEF and the who are especially dependent upon the state receive National Committee for Child Protection (1996) less financial support today than they did under showed that the cost for foster care in a program run socialism" (UNICEF 1997, p. 85). by an NGO was no more expensive than the cost of In Poland, for example, total public expenditures institutional care and was far better for the children. In for children under 17 living in long-term care cen- Lithuania community services to provide home visits, ters, smaller family homes, children's villages, and meals, medical care, and other assistance to the elder- temporary centers had dropped by 20-39 percent in ly are projected to be only 25 percent of the cost of res- real terms by 1992 and remained at that level until idential care. The same analysis found that it is no more 1995. In poorer countries of the region the deterio- expensive to serve children with disabilities in an ration in funding of residential institutions has been enriched day school program that provides education, more severe. In Bulgaria expenditures on homes for two meals a day, job training, and transportation, than infants and children and homes for children with in long-term residential care (World Bank 1995). disabilities have fallen relentlessly In 1995 the real In the early 1990s the monthly cost per child under expenditure level per child reached only one-third residential care ranged between roughly one to three of the 1989 level (UNICEF 1997, pp. 85, 86). times the average wage in the region. The Czech Republic spent about 3.5 times the average monthly Relative cost of residential care wage per institutionalized child, Poland spent almost 2.0 times the average wage, and Bulgaria spent the aver- Residential care is far more expensive than alternate age wage per institutionalized child. Romania spends forms of care such as foster family homes for chil- about 90 percent, and Moldova allocates only 70 per- dren or community-based services for children, peo- cent of the average wage (UNICEF 1997, pp. 84, 87). ple with disabilities, or the elderly Armenia's According to UNICEF, the per bed expenditure is Ministry of Education and Science reports that it is highest in infant homes. Estonia allocates 1.9 times 10 times more expensive to educate a child in resi- the average wage per child in infant homes, but only dential boarding school than in a regular school. 1.3 times the average wage per child in homes for Under the command economy residential education people with disabilities. In Romania in 1995 per in Russia was reported to cost four times the cost of child expenditures in infant homes (leagan) equaled regular schools (Harwin 1996, p. 29). the average wage and per child expenditures in 30 Movingfrom Residential Institutions to Community-Based Social Services in Central and Eastern Europe and the Former Soviet Union homes for people with disabilities equaled 74 per- the most important social unit for raising children cent of the average wage. In Lithuania in 1995 1.8 and fostering social values. The family is becoming times the average wage was spent per child with dis- a primary focus of social welfare policy reflecting a abilities in residential care. (UNICEF 1997, p. 88). return to the more traditional role of the family that On the other hand, the operating costs per child for was deemphasized during the command economy many of the newv, small group homes being built by At the same time, attitudes toward residential insti- NGOs throughout the region may be more expensive tutions are also changing, albeit slowly Senior poli- than the cost per child in residential institutions. This cymakers, newly trained social workers, some social is because of higher salaries and better supervision, welfare administrators, and staff in some residential food allotments, and programming in group homes. institutions are beginning to recognize the limita- The World Bank's Romania country team com- tions and harm of residential care and the high cost pared the costs of various types of care for children to government. They increasingly see residential in Romania. Table 2.4 shows that state institutions care as a last resort, an orientation that began to are far more costly than community residential care, develop before the end of the socialist era (UNICEF foster care, or family reintegration. 1997, p. 64). The concerns raised by senior policy- makers, however, often focus on the high cost of res- idential care. The importance of quality care, high The Current Situation of Residential standards, and the harm to clients caused by resi- Institutions dential care are still secondary concerns. The use of residential institutions in Central and Few residential institutions have closed Eastern Europe and the former Soviet Union has shifted since the transition began almost a decade Changes in attitudes have had little impact on the ago. Some changes-in attitudes and oversight- region's reliance on residential institutions. Few resi- may have improved conditions of children in institu- dential institutions have been closed throughout the tions. Other changes-such as deteriorating care and region. Even in a country like Romania, which has reduced funding-have had detrimental effects. An hundreds of residential institutions for children and examination of these changes can inform the debate people with disabilities and new legislation to create on social welfare policy in the region. a national system of social services, only a very few residential institutions have closed. War-torn Georgia Attitudes have changed and Moldova are two notable exceptions-severe government deficits drastically reduced the funding Throughout Central and Eastern Europe and the for- to institutions and caused their closings. But even in mer Soviet Union the family is increasingly seen as those two countries the numbers of closed institu- TABLE 2.4 Recurrent Cost Analysis of Alternative Child Welfare Modalities, March 1998 (millions of lei per child per month) Community Professional Voluntary Adoption or Cost category State institutions residential care foster care foster care family reintegration Operational costs per child 1. 7 to 2.4 0.8 to 1.1 0 0 0 Foster parent salary 0 0 0.40 0 0 Foster allowance 0 0 0.15 0.15 0 Child allowance 0.07 0.07 0.07 0.07 0.07 Supervision costs 0 0 0.18 0.18 0.10 Total 1.77 to 2.47 0.87 to 1.17 0.80 0.40 0.17 Source: World Bank 1998. The Transition and Residential Institutions 31 tions are small. In Georgia between 1992 and 1996 in administrative responsibility Lhat has caused little the number of children's homes dropped from 12 to change in authority or financial control. These 9; the number of boarding schools for children with changes appear to have had little effect on clients in disabilities was also reduced (UNICEF 1997, p. 86). the institutions. The clients of decentralized institutions came from Some residential institutions have been redesigned the regions where the institutions were located. for other purposes Residential institutions that serve an entire country gen- erally remained under the national government's In Yerevan, Armenia, a wing of a boarding school is authority. Armenia's boarding school for hearing- being used to house refugees of the war with impaired children, for example, remains under the Azerbaijan. In Budapest, Hungary, part of a long-term national government's control; boarding schools that children's institution was converted to temporarily serve socially vulnerable children from a particular house and train teenage mothers and their children. In region are transferred to the respective regional gov- Bucharest, Romania, part of an infant home was con- emient's control. Since March 1998, 30 of 49 board- verted into short-term apartments for mothers and ing schools, children's homes, and sanatoriums for their children. In Utena, Lithuania, plans are being children have been transferred to regional governments developed to convert part of a temporary children's (Armenia Ministry of Education and Science 1998b). home into apartments for mothers and their children. Most decentralized institutions serve children, fol- lowed by social care homes for the elderly. Institutions Some children with disabilities have been for people with disabilities have rarely been trans- reintegrated into general schools from special ferred from state to local authority, primarily because schools they serve people who come from areas throughout each nation. These children represent only a small fraction of the children living in residential facilities and are prima- Conditions in institutions have deteriorated rily well-functioning individuals. In the Czech Republic, where integration has been strongly pro- Although the conditions in some of the worst insti- moted and national laws have been changed, the care tutions have improved and staff in many have and education of the majority of children with dis- received some training, the overall picture for resi- abilities is still provided in special institutions, but the dential care is worse today than it was 10 years ago. process of integration has begun. Between 1989 and More people are cared for with fewer government 1995 about 25,000 children with disabilities were resources. Although private donors have supple- integrated into regular schools. Of this number, 9,000 mented government revenues to the institutions, students attended regular classes and 15,000 went to these funds have generally not fully compensated for special classes in regular schools. However, about the loss of public funding. 70,000 students still attend one of the 1,370 special In addition to the general harn caused by residen- schools. Nevertheless, the Czech Republic, as well as tial care, research has begun to document abuse of chil- other economically more developed countries of the dren in facilities. In Armenia, for example, children region, are considering allocating funds to construct report being exposed to frightening incidents, includ- new residential institutions (Halova and Bottge 1999). ing harsh punishment by staff and attacks by other children at or outside the institutions (Bertmar 1999). Administrative responsibility for some institutions Abuse of people with disabilities is especially has been decentralized acute, particularly in southeastern Europe and the countries of the former Soviet Union. According to Some residential institutions have been decentral- UNICEF, in Moldova 73 of 493 mentally disabled ized, primarily to the regional level, through the shift children in state residential facilities died in 1995. In 32 Movingfrom Residential Institutions to Community-Based Social Services in Central and Eastern Europe and the Former Soviet Union Box 2.3 Community-Based Social Service Projects Many community-based social service projects have Support for Families in Especially Difficult been established in Central and Eastern Europe and the Circumstances, Romania. The Commissions for the former Soviet Union by local governments and NGOs. Protection of Minors in two counties in Romania (Cluj, Few of these projects have been formally assessed, fewer Iasi) and three sectors of Bucharest set up programs still have had outcome evaluations, and none has been with assistance from UNICEF to help families whose evaluated with a comparison group to assess its impact. children were at risk of being placed in residential insti- Nevertheless, site visits to these programs, interviews tutions. At each site, two to four government social with staff and clients, and reviews of program materials assistants who investigate whether a child should be and limited assessments suggest that some of these pro- placed in an institution were trained to counsel fami- grams provide important help to vulnerable individuals. lies, conduct social work home visits, and place chil- The brief descriptions below reflect the range of new pro- dren who could not remain safely with their families in grams that have begun operating in the region, includ- foster homes. Although the projects kept many chil- ing social services, foster care, and small group homes. dren from entering residential institutions, some work- Family Support Center Albania (Shkodra). The center ers found that families needed more material assistance opened in 1996 to help needy families with children at than was provided. risk of institutionalization. It was established by Save Temporary Families for Children, Romania (Constansa the Children (Denmark), which provided training, tech- and Bucharest). The program was created by Holt nical assistance, and funding until 1998, when the International in the mid-1990s to place children in tem- General Administration of Social Services began paying porary foster care until a permanent placement can be the program's recurrent costs. The center has two social found, either by retuming them to their families or by workers who assists 10 families with children living at having them adopted. Social assistants received special home, providing food, education, home visits, parent training to recruit temporary foster homes, assess and training, and help with school work for the children. train foster families, and place and supervise children in The program also identifies children in local infant and the foster homes. In 1995 the average placement lasted children homes who could return to their families. In 4.5 months for the 32 children who were placed in tem- the first year and a half, four children returned home porary foster homes. Of these children, 21 were adopt- safely and six others were close to doing so. ed (20 within Romania, 1 internationally), 5 were Bridge of Hope, Armenia (Yerevan). The program was reintegrated with their birth families, 1 died of Sudden set up by Oxfam for children with severe disabilities who Infant Death Syndrome and 5 were awaiting a perma- were not permitted to attend regular schools. About a nent placement. dozen children attend daily classes provided by the pro- Group Home For Mentally Disabled Young Adults, gram, including some on academic subjects such as lit- Lithuania (Vilnius). Twelve severely disabled adults live in erature, history, and English as a foreign language and a large house on the outskirts of Vilnius. During the day some on developing skills for independent living. The the young people go into Vilnius to an employment train- program also created a theater company in which chil- ing center for people with disabilities. When they return dren with disabilities perform with children who do not to the center, they participate in regular household chores have disabilities. A parent of one of the children in the and other social activities. The program is funded by the school said, "I used to be afraid about my daughter's municipality and administered jointly with Viltis, an future. I'm not afraid now. NGO of parents of children with disabilities. Ukraine about 30 percent of severely disabled chil- financial collapse" (UNICEF 1997, p. 86). In Armenia dren living in specialized homes die before they reach there has been a general deterioration in institutional the age of 18 (UNICEF 1997, pp. 88, 89). conditions. More than 10 years after an earthquake The worst conditions in the region exist in coun- struck northern Armenia, children still attend board- tries that have experienced war, natural disasters, or ing schools in temporary trailers with minimal heat. have severe poverty, such as Georgia and Moldova. Directors of residential institutions report that condi- According to UNICEF, children in those two countries tions are worse and resources are more scarce now "are now living in institutions beyond the point of than before the transition. The Transition and Residential Institutions 33 Life after dischargefrom an institution is more isolated programs have been established by multi- difficult national organizations, international donors, NGOs, and religious organizations. These projects often col- Many children who grow up in residential institutions laborate with national or local governments, operate find it difficult to reintegrate into mainstream society mainly in large cities, and serve relatively small com- and have fewer options available to them than before munities. Romania is one of the few countries that the transition. According to survey data from the has passed legislation creating a national social serv- Procuracy General of Russia, 1 in 3 children who leave ice system for children and families, though imple- residential care becomes homeless, 1 in 5 ends up with mentation of the legislation has only recently begun. a criminal record, and as many as 1 in 10 commits sui- Lithuania has also passed national legislation cide. In Romania many homeless street children fled authorizing localities to deliver community-based residential institutions. One study reported that 1 of social services to vulnerable groups but has provid- 10 young offenders in Russia was raised in public care ed funding to cover only a limited number of pro- (Harwin 1996, p. 147). In one case 25 young people grams in specific municipalities. In Hungary, one of who aged out of the children's home in Tirana, Albania, the few countries with an extensive family support have been living as squatters in an abandoned voca- network, there are 150 family help centers and 20 tional training center. After living most of their lives in advisory centers for parents, all funded by munici- institutions, these children received no assistance in palities (Herczog 1997). finding a job or a home. In contrast, many countries are developing indi- Few studies have been conducted on the effects of vidual programs. In Shkodra, Albania, a family sup- residential care on children who left institutions dur- port center provides counseling, parent training, ing the transition (except for children who were adopt- home visits, and referrals. In Vilnius, Lithuania, ed), and no study with a control group has been youths with disabilities are taught work skills. undertaken. Without such studies it is difficult to dif- Yerevan, Armenia, now has a theater company and a ferentiate the effects of poverty from the effects of res- special education program for children with severe idential care. In Albania, for example, the director of a disabilities. In several cities in Armenia, as well as in children's home reported that in 1998 all the children many countries in the region, Special Olympics and who left the institution are now unemployed except sports and recreation programs for people with dis- those who pursued additional education. Their life in abilities have been established. the institution as well as the current conditions in Fewer programs have been set up for the elderly Albania could have contributed to this result. than for children or people with disabilities. Still, programs include home delivery of food, household chores, and senior citizen centers. In Svencionys, The Current Situation of Community-Based Lithuania, home care for the elderly provides assis- Services tance with meals, heating, household chores, and planting. Many community-based service modalities are being tried in various parts of the region, most k-oster care notably in three areas-social services, foster care, and adoption. Another community resource used in the region to care for vulnerable children is foster parents. Most Social services children in foster placements in the region reside in the homes of relatives, primarily grandparents or Over the past 10 years community-based social serv- aunts. Relatives, for example, account for about 80 ices have developed very slowly in Central and percent of foster parents in Poland, Romania, and Eastern Europe and the former Soviet Union. Small, Russia (UNICEF 1997, p. 90). 34 Movingfrom Residential Institutions to Community-Based Social Services in Central and Eastern Europe and the Former Soviet Union Across the region there are marked differences in sidelined (Harwin 1996, p. 142). Several factors the use of foster care. Foster care was most common account for the difficulty of using foster care in the in the western former Soviet Union and Central region. First, the financial and housing difficulties of Europe but is still rarely used in southeastern many families make it hard to care for an additional Europe. Despite the rise in children in public care, person, particularly with the limited financial assis- Bulgaria still has no formal foster care program. An tance provided by government. In Lithuania, for attempt to introduce foster care there in 1993 was example, reimbursement to foster parents in 1994 largely unsuccessful (UNICEF 1997, pp. 65, 73). was less than 20 percent of the average wage, and in With few exceptions, the number and rates of Romania it was less than 10 percent (UNICEF 1997, children in foster care have increased across the p. 91). region-reflecting both an increased use of foster Countries like Lithuania that have recently rather than residential care and a larger number of increased financial support to foster families have children residing outside their homes. In Poland, for been able to increase the number of foster families. example, the number of children in foster homes The rise in fostering rates in Poland has been influ- increased from 38,000 in 1989 to more than 46,000 enced by the doubling of allowances to relatives in 1997. Poland has the highest rate of foster chil- since 1991-from 20 to 40 percent of the average dren in Central Europe-433 per 10,000 people. wage for children over 2. Families that care for chil- Throughout the region, however, relatively few chil- dren younger than 2 or who have special needs dren in public care (less than 40 percent) are in fos- receive 100 percent of the average wage (Stelmaszuk ter homes (UNICEF 1997, pp. 72, 73). and Klominek 1997; UNICEF 1997, p. 90). Other Nonrelative foster homes are used infrequently factors also limit the use of foster care, including cul- throughout Central and Eastern Europe and the for- tural prejudices toward children who have lived in mer Soviet Union. And when they are, few countries residential institutions, limited public awareness have programs to recruit, train, monitor, and assist about foster care, and the absence of a legal frame- foster families. When nonrelative foster care is used, work or cultural tradition to use nonrelative foster it is often as a pre-adoptive placement or in place of care. adoption rather than as a short-term placement (as is the case in Western Europe). Few children from Adoption infant or children's homes are returned to the com- munity through placement in a foster home, and Adoption is still an underdeveloped resource in almost no children with disabilities are placed in fos- Central and Eastern Europe and the former Soviet ter families. Union. Only a small percentage of children living in Professional foster parents-though rare in the infant homes are adopted each year. Some countries, region-have been used in Hungary since 1986. however, have relatively high adoption rates from Some 30 percent of the 8,500 children in foster care infant homes-such as Hungary (21.8 percent) and in Hungary live with professional foster families. Russia (36.5 percent) (Harwin 1996; UNICEF 1997, These families are trained as educators and have p. 74). raised children of their own. They receive 60 percent Since 1990 the number of children adopted each of the average national salary in addition to a foster- year has decreased in all parts of the region except child allowance, and care for at least five children in Bulgaria, Slovak Republic, and the western CIS addition to their own (UNICEF 1997, p. 90). (UNICEF 1997, p. 74). This decrease partly reflects In the past few years NGOs, international schools disruptions in old administrative systems for adop- of social work, and multinational agencies have pro- tion without adequate replacements. In Armenia, for moted foster care as an alternative to the residential example, adoptions had been the responsibility of placement of children, with limited success. In district committees on guardianship, foster care, and Russia, for example, foster care is increasingly being adoption. These committees no longer function but The Transition and Residential Institutions 35 have been replaced by municipal committees that do rules must be developed to make possible the adop- not yet operate. As a result adoption lacks formal cri- tion of a child by the most suitable person or per- teria, referral, or decisionmaking procedures sons. Currently, most adoptions are geared toward (Duncan and Vitillo 1998). Another factor con- the needs of the adopting family rather than the tributing to the reduction in adoptions has been the needs of the child first. decrease in the age cohort of children under 3, the main age group of adopted children. International adoption has been a significant fac- Conclusion tor in the increasing adoption rates of southeastern Europe and the Baltics. Most countries of the region, The continued reliance on residential institutions with the exception of Poland and Hungary, had no has created a vicious cycle in the region. The insti- experience with international adoption during the tutions absorb much of the limited governmental socialist period. As a result these adoptions initially and nongovernmental resources that are desperate- were poorly controlled and monitored, resulting in ly needed to assist vulnerable groups. The lack of many violations of the 1986 United Nations alternatives has pushed donors and governments to Declaration on Adoption. Albania, Georgia, increase the regions reliance on residential institu- Romania, Russia, and Ukraine imposed temporary tions. More vulnerable individuals are being placed moratoriums on intercountry adoptions until more into deteriorating residential institutions. As a result appropriate standards and procedures could be they experience more hardship and find it difficult established. Still, violations continue to be prevalent to reintegrate into the community, further burden- throughout the region, even with the adoption of ing the public sector. standards. Nonetheless, international adoptions The transition to a market economy has created continue to account for a small percentage of adop- opportunities as well as problems for people of the tions in the region, though reaching relatively high region. Political openness and democratization have percentages in Romania (42.8 percent), Lithuania given rise to new governmental and nongovemmen- (36.5 percent), and Latvia (45 percent) (UNICEF tal solutions for vulnerable groups. Decentralization 1997, pp. 75-79). and community participation have laid the ground- The 1986 United Nations Declaration on work for consumers to influence the types and qual- Adoption and the 1993 Hague Convention on ity of services that they receive. And the transition has Intercountry Adoption view intercountry adoption created the opportunity for new community-based as a last resort because of the problems it can cause. social service systems to reduce the region's reliance Although interests in intercountry adoption are on residential institutions. often purely humanitarian, many complications can develop, including international child trafficking and unforeseen problems with the child leading to Notes disrupted adoptions. As a result the Hague Convention specifies that intercountry adoption 1. Poland 1991-94. should be used only when appropriate care, includ- 2. Armenia 1990-93. ing adoption, cannot be provided in the child's coun- 3. Amount does not total 100% due to rounding. try of origin (UNICEF 1994). 4. Not all of this humanitarian assistance was helpful. Major work is needed to improve adoption prac- For example, a large shipment of wood chips to heat board- tices throughout the region. Most countries lack a ing schools after the Armenian earthquake was unusable. central adoption authority to provide high-level As a result enormous boxes of wood chips litter the play- oversight of adoptions. Countries lack simple, clear, ground in front of Boarding School #5 in Gumri, Armenia and transparent procedures for adoptions that are (World Bank Mission to Armenia in November 1997). In communicated to the general population. Eligibility addition, not all of the humanitarian assistance actually 36 Movingfrom Residential Institutions to Community-Based Social Services in Central and Eastern Europe and the Former Soviet Union reached the children for whom it was intended (Hunt Poland during the command economy nuns were permitted to 1998). administer a few residential institutions for children and peo- 5. In rare instances NGOs or religious organizations pro- ple with disabilities. The state provided the operating budgets vided funding for residential institutions. For example, in and staff salaries; the church provided supplemental funding. CHAPIER 3 The Use of Residential Institutions in Other Industrial Nations R eliance on residential institutions to care for tutions, (which also increased costs; Jones 1993). about 1.3 million vulnerable individuals in More recently, the United Nations Convention on Central and Eastern Europe and the former the Rights of the Child, which deemphasizes the use Soviet Union has created powerful barriers to of residential institutions, has become a standard in change. In industrial nations similar barriers caused Western European countries that has contributed to a slow transition from residential care to communi- the move away from residential care (Madge and ty-based services. Nevertheless, efforts to overcome Attridge 1996, p. 145). these barriers were successful and offer valuable les- sons for Central and Eastern Europe and the former Impact of residential institutions on children Soviet Union. One factor that contributed to the decline of residential institutions was the harm they caused to Children and Residential Institutions children. However, in the 19th century, criticism of orphanages-and their detrimental effects on In the past the countries of Western Europe and the children-did not limit the growth of residential United States relied on residential institutions to care institutions. The number of residential institutions, for vulnerable individuals. Until the mid-20th cen- and the number of children residing in them, tury dependent, neglected, abused, and orphaned increased well into the 20th century. children were one of the primary groups to receive More recent formal studies have documented the residential care. The recent trend in the industrial- harm caused by residential institutions. Research ized world, however, has been away from institu- conducted by John Bowlby in 1951 for the World tional care. Institutions have been replaced with the Health Organization began the recent attack on res- increased use of community-based social services for idential institutions. Bowlby reviewed the literature families, kinship foster family homes, and nonkin- on children deprived of maternal care who were sep- ship foster family homes for children who cannot arated from their families-whether in institutions, remain safely with their own families, and small group homes, or foster homes. He concluded that group homes for the most severely troubled children "when deprived of maternal care, the child's devel- (Tolfree 1995, p. 11). opment is almost always retarded-physically, intel- Many factors, primarily related to cost, con- lectually, and socially" (Bowlby, p. 15). "Neither tributed to the demise of large residential institutions foster homes nor institutions," he wrote, "can pro- as a primary resource for the care of children in the vide children with the security and affection which United States and Western Europe. Factors includ- they need" (p. 112). He argued in favor of child care ed the high cost of institutions relative to foster fam- for brief periods by foster parents in the child's ily homes, the professionalization of institutional neighborhood (p. 111). "Small group homes should staff (which further increased costs), and the increas- always be avoided for children under six years, ing needs of the children who were placed in insti- though it is a suitable alternative under special cir- 37 38 Movingfrom Residential Institutions to Community-Based Social Services in Central and Eastern Europe and the Former Soviet Union cumstances for older children, including the seri- for Children International concludes that "the use of ously maladjusted child and adolescents who do not institutional placements is in itself a form of violence readily accept strangers in a parenting role" (p. 137). on the child." Save the Children, on the other hand, Bowlby concluded that as of the 1950s, "even in believes that "institutions are not intrinsically dam- so-called advanced countries there is a tolerance for aging to children, but the evidence suggests that cer- conditions of bad mental hygiene in nurseries, insti- tain features of institutional care are likely to have a tutions, and hospitals to a degree which, if paralleled detrimental effect on children's development" (cited in the field of physical hygiene, would long since in Tolfree 1995, p. 29). have led to public outcry" (p. 157). Kadushin (1980), author of an encyclopedic Since then much research has documented the study of child welfare services, concludes that "for difficulties for children living in residential institu- infants and young children, there is really no con- tions. These difficulties include the inability to bond troversy There is a general consensus that institu- with a primary caregiver (close and continuous rela- tions are undesirable for infants and young children" tionships with trusted adults), the lack of individu- (p. 133). But "it is difficult to find empirical support alized attention, the regimentation of daily activities, for the contention that alternative facilities are more the isolation from normal life, and the stigma of liv- advantageous for the development of children than ing in a facility for marginalized individuals. As a well-run small institutions"(p. 136, emphasis result institutional care has been found to limit chil- added). dren's ability to bond and form lasting relationships, to delay or stunt their cognitive development, and to Residential institutions for children in the United prepare them inadequately to live in the broader States society (Rutter 1981; UNICEF 1997, p. 64; Tolfree 1995, p. 16; Kadushin 1980). Most studies of the The movement in the United States away from effects of institutions on children indicate that the reliance on residential institutions for children is longer they stay in an institution, the greater is the illustrative of the international trend. Residential likelihood of emotional or behavioral disturbance institutions for children in the United States devel- and cognitive impairment (Tolfree 1995, p. 23). oped as a social phenomenon in the latter half of the Some research, however, has found that institu- 19th century, when the social turmoil and poverty tions are not harmful to older children; the harm caused by the industrial revolution, the Civil War, results from the conditions in the institutions. immigration, epidemics, and the diminishing role of Tizard, Sinclair, and Clarke (1975) identified "child- the family as a unit of production created large num- oriented" and "institution-oriented" residential units bers of homeless, vagrant, delinquent, orphaned, that have very different effects on children with and neglected children. Residential institutions learning disabilities. The child-oriented units had developed to care for these children at the same time more flexible systems of staff deployment, which that specialized institutions developed for other allowed more continuous relationships for the chil- populations-the mentally ill, the blind and deaf, dren (Tolfree 1995, p. 64). Tizard and Rees (1975, and criminals. In 1851 there were only 77 residen- p. 98) concluded that "as far as cognitive develop- tial institutions for children in the United States. By ment is concerned, institutional life is clearly not 1910 there were 1,151, peaking at 1,613 in 1933 inevitably depriving." Thomas (1975, p. 206) stud- (Smith 1995, p. 118). ied 36 institutions for dependent and neglected chil- Residential institutions for children served sever- dren and found that competency levels of al functions. First, they removed potentially disrup- institutionalized children do not differ radically from tive children from the streets. Second, they educated those of noninstitutionalized children. and socialized immigrants or the children of immi- Among child advocate organizations there is also grants into the mainstream values of the dominant disagreement on the effects of institutions. Defense culture. Finally, the institutions provided care and The Use of Residential Institutions in Other Industrial Nations 39 assistance to vulnerable youngsters. Children's insti- Community alternatives to residential institutions tutions were often run by private religious organiza- for children tions that were established to care for children of their own denominations. Local, state, and, later, the The Convention on the Rights of the Child, adopted national government provided an increasing share of by the United Nations General Assembly in 1989 the funding for residential institutions. and ratified by almost all nations, established the As the use of institutions spreads, criticism of international standard for the rights of children. them increased. Reformers reported widespread Among other provisions, the convention states that abuse of children and other harmful consequences families should be the primary caretakers of children of institutional life (Leiby 1978). Representatives of and that the best interests of the child should be the government and the philanthropic community primary consideration. The state is obliged to help found these large institutions to be far more costly families care for their children, but when a child than the foster homes. The 1909 White House must be temporarily or permanently deprived of his Conference on the Care of Dependent Children or her family environment, alternative forms of marked a national consensus against residential care care-including foster placement and adoption- for children, concluding that children should be should be tried. Residential institutions should only helped in their families before being placed in a fos- be used, however, "if necessary ... for the care of ter family, and only in the most extreme situation children" (UNICEF 1991, p. 54, Article 19.3). The should a child be placed in a large orphanage-type Convention on the Rights of the Child has been used institution (Bremner 1971, p. 365). by UNICEF, NGOs, and other development agencies Despite this consensus, after the White House as a guiding principle to encourage countries to conference the number of children in large resi- reduce their reliance on large residential institutions. dential institutions increased for the next quarter of Large residential institutions in the United States a century, rising from 115,000 in 1910 to 144,000 and in most industrial countries were replaced with in 1933. Subsequently the number of children in four primary modalities of care. The first, and by far institutions slowly decreased, falling to 95,000 in the largest in terms of expenditures and children 1951, 79,000 in 1962, and 20,000 in 1996. These served, particularlyin the United States, is foster fam- 20,000 children in residential institutions repre- ily care. In the United States in 1933, 58 percent of sent about 4 percent of the 500,000 children in children in out-of-home care resided in institutions out-of-home placement (Wolins and Piliavin 1964, and 42 percent were in foster homes. In 1996, 4 per- p. 37; U.S. Department of Health and Human cent were in institutions, 13 percent were in group Services 1997). homes, and 81 percent were in foster families (U.S. The decrease in the number of children in large Department of Health and Human Services 1997).1 residential institutions occurred on a large scale after Although foster care is an improvement over large the passage of the Social Security Act in 1937, which residential institutions for abused and neglected chil- provided financial assistance to poor families with dren, foster care can also be harmful to children. The dependent children (Lerman 1982). Over more than placements are temporary, and children are often 60 years the number of institutionalized children moved from one home to another, increasing the decreased at an average rate of only 1-2 percent a impermanence experienced by children. Potential fos- year. There was substantial institutional and politi- ter parents too often are inadequately assessed and at cal pressure to maintain these residences. times provide inadequate care or abuse their charges. Institutions serving as a source of employment, Finally, children often spend an excessive number of income, and patronage were most salient and great- years in these temporary placements. Optimally, chil- ly prolonged the reliance on residential institutions dren should remain in foster care for no more than a for the care of vulnerable children (Wolins and year; in New York City the average placement is for Piliavin 1964, p. 17). more than four years (Child Welfare Watch 1998, p.15). 40 Movingfrom Residential Institutions to Community-Based Social Services in Central and Eastern Europe and the Former Soviet Union The second and preferred approach to creating a ties. These schools were created for the blind, the deaf, permanent home for children is to provide assistance and the mentally disabled. This approach was then to families so that children can remain safely in their typically adopted and extended as part of national homes. Types of assistance include so-called soft education arrangements. Although many of these seg- services such as parent training, counseling (family, regated facilities provided humane care for people individual, and group), respite care, drug and alco- with disabilities, some had subhuman conditions, as hol treatment, and in-home assistance. They also in the notorious case of the Willowbrook Center for include so-called hard services that help with a fam- people with disabilities in New York City in the mid- ily's material needs-housing, cash assistance, 1960s. In recent years, however, the idea of having a health maintenance, job training, or job placement. separate system for children with disabilities has been The use of a third approach, group homes that challenged-both from a human rights perspective house as many as 25 children, expanded greatly dur- and an effectiveness perspective-and given rise to ing the 1960s. Ideally, these facilities should be locat- the notion of "integration for people with disabilities." ed in community settings and used as short-term The term integration is sometimes used for all placements for children with special needs-such as attempts to avoid a segregated and isolated education older children with behavior problems or physical or for children with disabilities. Integration is location- mental disabilities. Too often, however, younger al (being present), social (mixing with other pupils), children or children who do not have severe prob- and curricular (learning together with other pupils) lems are housed in such institutions. (UNICEF 1998a, p. 51). The scope of integration can Adoption is the final approach used to provide a range from the actual integration of regular and spe- permanent placement for children who cannot be cial schools or classes to measures for reducing the cared for in their own homes. About 1 in every 100 outflow from general education to special education. children born in the European Union will be adopt- The principle of integration is contained in the ed (Madge and Attridge 1996, p. 148). Adoptive par- Framework for Action on Special Needs Education, ents may be related to the child, or they may be adopted by the World Conference on Special Needs people who were total strangers to the child. Education and jointly arranged by the United Nonrelative adoptions make up about half of all Nations Educational, Scientific, and Cultural adoptions and are generally by individuals who were Organization and the Ministry of Education in foster parents of the child. Kadushin's (1980, pp. Salamanca, Spain (1994) states: 565, 566) review of the literature on completed adoptions in the United States and other countries Integrated education and community based through the 1970s concludes that about 65 percent rehabilitation represent complementary and are unequivocally successful and that an additional mutually supportive approaches to serving 18 percent achieve some intermediate level of suc- those with special needs. Both are based upon cess; 17 percent are deemed unsuccessful. the principles of inclusion, integration and par- ticipation and represent well tested and cost- effective approaches to promoting equality of People with Disabilities and Residential access for those with special educational needs Institutions as part of a nationwide strategy aimed at achieving education for all. The World Health Organization estimates that the world prevalence rate for all levels of disabilities- In some industrial countries integration is still an mental, physical, or sensory impairments-is 10 per- unrealized goal. In Germany, for example, many chil- cent (WHO 1978). In many industrial countries dren who are declared eligible for special education religious and philanthropic organizations originally are placed in special schools. In the Netherlands established separate schools for people with disabili- almost 4 percent of students aged 4 to 18 attend full- The Use of Residential Institutions in Other Industrial Nations 41 time, special schools, though recent policy is small, specialized units, well integrated into the attempting to change this emphasis. Canada, standard school environment, are a better alternative Denmark, Italy, Norway, Spain, and parts of Australia to give the knowledge, equipment, and support to have made considerable progress in implementing students for which mainstream classrooms and the integration principle. teachers can never be a full substitute. The culmination of this line of thinking is the con- Regardless of which approach is used, the trend is cept of inclusive education. Instead of emphasizing toward educating children with disabilities within the integration of exceptional children within a sys- the mainstream educational environment. In the tem that remains largely unchanged, inclusive edu- short run substantial costs may be incurred in mov- cation seeks to restructure schools and classrooms to ing from a system of separate schools to integrated respond to the needs of all children. Indeed, children schools because of the requirements for new facili- with special needs are the stimulus for a richer envi- ties and teaching and support staff (UNICEF 1998a, ronment for learning (UNICEF 1998, pp. 51, 52). A p. 51). In the longer term, however, this approach primary component of this approach is community- may lead to lower costs, the improved well-being of based education, sometimes referred to as community- children with special needs, and more productive based social services or community-based rehabilitation. members of society (Simms 1986). According to a joint position paper by the Evaluation is needed to document that the pro- International Labour Organization (ILO), UNESCO, jected cost savings and desired changes in the school and WHO (1994), community-based rehabilitation: system have occurred-including in curriculums, teacher training, examinations, and child-centered Is a strategy within community development for methodologies. Unless these elements have changed, the rehabilitation, equalization of opportunities the reforms may only result in mainstream dumping. and social integration of all people with disabil- ities. It is implemented through the combined and coordinated efforts of people with disabili- The Elderly and Residential Institutions ties themselves, their families and communities, and the appropriate health, education, voca- The elderly are the largest group of people receiving tional and social services. Its goals are to bring social care in Western Europe (table 3.1). Western about a change; to educate and involve govern- European policy responses to the growing need for ments and the public; to develop a system capa- long-term care among the elderly have taken two ble of reaching all people with disabilities in main forms, according to a report prepared for the need; to empower people with disabilities and United Nations on lessons from the European Union promote their human rights; and to build that for Central and Eastern Europe (Walker 1997). The system with resources that are both realistic and first response has been an increased emphasis on sustainable in the national context. community care that maximizes the use of both for- mal and informal resources as a cost-effective alterna- Through this approach it is estimated that up to tive to long-term institutions. This policy has support 70 percent of people with disabilities can receive from the elderly and the general public in the coun- meaningful rehabilitation in their own communities. tries of the European Union. However, recent limita- Conventional, institution-based rehabilitation serv- tions in the growth of long-stay facilities have not been ices would still play an important role in assessing matched by a comparable expansion in home care or and referring severely disabled persons for assistance other social services for the elderly. Similarly, social (Jonsson 1998). services for the elderly are failing to keep pace with Advances in the implementation of this new ori- the needs created by aging populations. As a result entation is difficult, and evidence of progress is lim- smaller families are expected to do more at a time ited in most countries. In addition, some argue that when they are less able to care for the elderly 42 Movingfrom Residential Institutions to Community-Based Social Services in Central and Eastern Eur-ope and the Former Soviet Union TABLE 3.1 The HCFA survey reported that the most fre- Elderly Western Europeans Living Alone, in quently cited long-term policy concern of govern- Institutions, or Receiving Home Care, 1990 ments was the high cost of institutional services. (percent) Most of the industrial countries surveyed considered Living In Receiving their institutional long-term care use rates for the Country alone institutions home care elderly to be higher than necessary. Most also report- Austria 36.0 - 1.0 ed pursuing policies to expand home- and commu- Belgium 38.0 6.6 6.0 nity-based long-term care services as a means of Denmark 53.0 5.3 20.0 reducing institutional use (Doty 1988). France 28.0 4.5 8.0 The reported institutional rates in industrial coun- Germany 41.0 5.9 4.0 Greece 14.0 0.6 1.0 tres varied considerably for elderly individuals- Italv 31.0 2.3 1.0 from a low of 3.6 to 4.5 percent in the Federal Ireland 20.0 5.0 3.0 Republic of Germany to more than twice that rate in Netherlands 31.0 9.7 12.0 Sweden and the Netherlands (see table 3.2).2 Portugal 18.0 2.0 1.0 Institutional rates tend to be lower in countries with Spain 19.0 2.0 1.0 less generous (that is, means-tested) government Sweden 41.0 10.0 16.0 United Kingdom 26 0 5.0 9.0 financing, representing about half of the countries SoUrce: Kiadok and0Ely 1996. surveyed. Medical facilities tend to house a larger per- Source: Baldock and Ely 1996. centage of the elderly than nonmedical facilities.3 The second policy response in Western Europe TABLE 3.2 has been the encouragement of pluralism in the sup- Cross-National Institutional Use Rates for the ply of care services for the elderly This involves Elderly, 1980 assistance from various sources, including the pub- (percent) lic sector (national and local), NGOs, informal and Medical Nonmedical volunteer support, and church groups. But there are Country Total facility facility risks associated with this approach. First, increasing Argentina <0.1 - - welfare pluralism in social care may threaten the cur- Australia 6.4 4.9 1.5 rent universalism of service provision in some coun- Belgium 6.3 2.6 3.7 tries. This "piecemeal pluralism" may result in Canada 8.7 2.6 3.7 inconsistent care for the elderly based on different Costa Rica 1.5-2.0 n.a. 1.5-2.0 assumptions, providers, and eligibility require- Denmark 7.0 n.a. n.a. ' . . ' . . ~~~~France 6.3 5.3 1.0 ments. Second, increasing pluralism could result in Grany, Federal 7 U ~~~~~~~~~Germany, Federal the replacement of rights with discretion-leaving Republic of 3.6-4.5 1.2-3.6 0.9-2.4 the elderly with no voice in a pluralistic system with- Greece 0.5 n.a. n.a. out intervention by the state. Israel 4.0 1.4 2.6 Japan 3.9 3.1 0.8 Netherlands 10.9 2.9 8.0 Institutional care or community services? Netherlands 10.9 2.8 3.9 Newr Zealand 6.3-6.7 2,4-2.8 3.9 Spain 2.0 n.a. 2.0 A cross-national survey conducted by the U.S. Sweden 8.7-10.5 4.6 4.1-5.9 Health Care Financing Administration (HCFA) Switzerland 7.8-9.0 2.8 5.0-7.2 reviewed long-term care policies for the elderly in 18 Turkey <0.2 n.a. n.a. industrial countries (as well as some middle-income United States 5.7 4.5 1.2 countries; table 3.2). The findings of this study are - Not available. relevant for the transition economies of Central and na. Not applicable. Note: Data vary between 1980 and 1984. Eastern Europe and the former Soviet Union. Source: Doty 1988. The Use of Residential Institutions in Other Industrial Nations 43 The use of alternatives to institutional care for the lower cross-national use rates of institutional care. elderly varies greatly among the countries surveyed. Indeed, use rates of these noninstitutional servic- The use rates of home nursing services ranged from es tend to be especially high in those countries 30-40 home nursing service users per 1,000 elderly that also have above-average institutional use people in Israel, Sweden, and the United States to 164 rates (e.g. Sweden and The Netherlands). It is users per 1,000 elderly in the Netherlands. Home- therefore inferred that the populations typically delivered nursing is a more recent phenomenon in served by home-care programs tend to be more France-included in national health insurance cover- moderately disabled than those in institutions, age only since 1981. Professional home nursing care and most such clients are probably not at immi- in most European countries and the United States is nent risk of institutionalization. primarily a short-term service for individuals recover- ing from an acute illness that required hospitalization. Two factors contribute to the limited success of In most European countries nonmedical home home and community-based care as a successful and community-based long-term care services are alternative to institutionalization for the elderly One generally characterized as social services. They are is the insufficiency of the services offered. The kind administered locally and are likely to be paid for by of intensive (20 hours or more a week, including a combination of central and local government nights if needed), nonprofessional nursing or per- financing. Although eligibility for these services is not sonal care required by persons with severe impair- means-tested in Scandinavia, income-related co-pay- ments in their ability to perform activities of daily ments are required. Sliding-scale cost sharing is also living-bathing, dressing, eating-are typically not required from home-help clients in France, where widely available in any of the countries surveyed. close to 5 percent of elderly people living in the com- The second factor is the lack of coordination among munity received such care (Dotty 1988, p. 152). providers and payers of medical services and social According to the HCFA survey, policy initiatives services. Fragmentation of long-term care services to promote noninstitutional alternatives to institu- organization and financing is a perceived problem in tional long-term care have had limited success. nearly all countries (Dotty 1988, p. 153). There is evidence from Sweden and other The lesson for the countries of Central and Scandinavian countries that home-delivered servic- Eastern Europe and the former Soviet Union, there- es, especially those provided in sheltered housing fore, is that it is not sufficient to create community- environments (such as service flats) can reduce use based alternatives to institutional care for the elderly rates of nonmedical homes for the elderly. In Britain To reduce the number of elderly residing in long- there has been an historic association between fund- term institutions, it is necessary to provide intensive ing home help and low institutionalization rates community-based support and to limit the number (4-5 percent). However, political decisions that of institutional beds. limit the availability of beds seem to keep institu- tional use rates low more than the availability of home and community-based alternatives. As the Notes author of the HCFA survey concluded (Dotty 1988, p. 153): 1. Amount does not total 100% due to rounding. 2. When age and sex differences between countries were The data suggest-albeit in most cases more by held constant, the institutional placement rates among inference than by direct measures-that commu- countries were found to be less extreme. nity-based services complement, rather than sub- 3. The data on residential care for the elderly presented stitute for, institutional-level care. Thus, greater for Central and Eastem Europe and the former Soviet Union availability of public funding for noninstitutional elsewhere in this study correspond to placements in non- services is not systematically associated with medical facilities. CHAPTR 4 Finding a Solution A s this study has documented, the countries of assistance would be provided at one location in a ,A,of Central and Eastern Europe and the for- community. mer Soviet Union increasingly rely on resi- Community-based services provide individuals dential institutions as the primary form of care for with assistance in a comfortable, familiar environ- a growing number of vulnerable children, people ment. The people who assist them know the neigh- with disabilities, and the elderly. This approach is borhood, the needs of the community, the services harmful for the individuals who reside in the insti- that are available, and how to get them for their tutions, undermines family bonds, and is financial- clients. Individuals who are assisted in their neigh- ly costly for government. borhoods maintain close bonds with their friends The experience in other industrial nations and and families, which is important for normal child increasingly in Central and Eastern Europe and the development and maintenance of healthy adults. former Soviet Union is that community-based social One goal of community-based social services in services are a preferred way to care for and ensure the region should be to assist individuals and fam- the social protection of these vulnerable groups. ilies in periods of difficulty and ensure their safe- Community services are better for the individuals ty. These services should also be used to promote who are served and in many situations may be less independence, not merely to care for those who expensive for government. are temporarily dependent. In the longer term * How can the countries of Central and Eastern however, when additional resources are available Europe and the former Soviet Union make a tran- within the region, community-based social servic- sition from relying on residential institutions to es should try to maximize an individual's chances developing community-based social services? of reaching his or her full potential and be avail- Three interrelated parts are essential to a solution: able before an individual's problems become * Principles of community-based social services severe. appropriate for Central and Eastern Europe and The principles on which community-based social the former Soviet Union. services are based are key to their effectiveness in * Service modalities in a continuum of community- achieving these goals. One widely accepted set of based care. principles for highly effective social services was * Strategies to implement community-based social identified by Lizbeth Schorr in the book, Within Our services. Reach (1988). The following attributes of outstand- ing community-based social service programs are based on her review of exemplary programs for fam- Core Principles of Effective Community- ilies in the United States: Based Social Services * Programs that are successful in helping the most disadvantaged children and families typically Community-based services are provided where peo- offer a broad spectrum of services. They recognize ple live, close to friends and relatives. Ideally, a range that social, emotional, and material support may 45 46 Movingfrom Residential Institutions to Community-Based Social Services in Central and Eastern Europe and the Former Soviet Union have to be provided before a family can make use Service modalities in a continuum of community- of other interventions such as antibiotics or par- based services enting advice. * Successful programs provide services that are People experiencing difficulties such as unemploy- coherent and easy to use. Relying on too many ment, poverty, and hardships created by the transi- referrals to other agencies interferes with the tion to a market economy, require material development of a good working relationship help-such as cash assistance, food, wood, or with the client and impedes the delivery of need- clothes. Financial assistance, however, is often nec- ed services to the individual or family essary but insufficient to meet the wide range of * Successful agencies provide a continuum of servic- needs that people have. Problems such as alco- es to meet a range of needs to individuals andfami- holism, child or wife abuse, teenage pregnancy, or lies. A continuum of care enables some kind of juvenile delinquency cannot be solved by financial help to be provided no matter how severe the assistance alone. Other kinds of support are needed. problem or what type of problem the child or Poverty is often the context in which these prob- family confronts. lems surface-and once they appear, poverty makes * Interventions cannot be routinized or applied coping with them much more difficult. Financial uniformly, staff members and program structures assistance to meet the minimum subsistence level of must be flexible, able to exercise discretion about an individual or family is the prerequisite to address- meeting individual needs allowing families to ing all other problems (Maslow 1970). Both cash choose the services they use and how they want assistance and noncash assistance must be provided to participate. to avoid the placement of vulnerable individuals in - The child should be seen in the context of thefamily residential institutions. and the family in the context of its surroundings. Preferably, these services are provided free of Successful programs mobilize parents in a collab- charge, because services exclusively for the poor orative effort to help the child, to strengthen the tend to be poor services, and the absence of these family, and to build the community These pro- services could lead to residential care and much grams offer services and support to parents who greater expenses for government. For some need help with their lives so that they can make nonessential services, a sliding-fee scale can be used. good use of services for their children. The list of service modalities presented below is • Successful programs have skilled and highly com- not meant to be comprehensive or prescriptive. mitted staff. Staff have the training, support, and Rather, it is meant to illustrate the range of commu- time to establish trust and personal relationships nity-based social services that could eventually be with clients. available as part of a continuum of care to individu- * Successful programs also adapt or circumvent tra- als and families and to prevent institutionalization of ditional professional and bureaucratic limitations as vulnerable groups. These services can provide some necessary to meet the needs of clients. Professionals help regardless of the severity of the problems. sometimes provide services in nontraditional set- Social services can be provided before problems tings, including homes, and often at nontradi- develop, when problems begin to surface or become tional hours. severe, when problems are overwhelming and one or * Programs should be inclusive for individuals with more individuals must be removed from the home, disabilities.1 Instead of emphasizing integration, and as reintegration services to reunite individuals inclusive programming should seek to restructure with their families or communities after they have schools, work settings, and other environments to been removed from their homes. Countries of respond to the needs of all individuals. Central and Eastern Europe and the former Soviet Individuals with special needs should be regard- Union will likely focus on service modalities for indi- ed as the stimulus of a much richer environment. viduals and families after problems begin to surface. Finding a Solution 47 Services when problems begin to develop or become severe ~~~~~~~Box 4.1 become severe Types of Community-Based Services Social service programs should provide services that General (for all individuals) are tailored to individual needs rather than based on * Assessment (of an individual's or family's social, an arirrctgrztinolr t. Teconomic, physical, and psychological situation) an arbitrary categorization of all recipients. They * Service plan should provide a wide range of assistance-ideally, * Case management a continuum of care-to help individuals regardless * Advocacy of how severe their problems are. All individuals * Hot lines, early warning systems need to have their physical, emotional, and financial * Transportation situation assessed and served by a case manager to Family support ensure proper assistance. * Respite care Children and families may need several types of * Child care services, including housing, counseling, child care, * Parent training respite care, health care, family planning, material * Counseling assistance, parent training, crisis intervention, alco- * Peer support groups hol treatment and prevention job training and job * Homemaker services holatreatment. andprevention, , * Home visiting (crisis intervention, risk manage- placement. ment) Assistance for people with disabilities includes * Domestic violence counseling trained teachers, vocational training centers, special * Alcohol treatment and rehabilitation equipment, day treatment centers and community * Family planning schools for children with disabilities, visiting nurs- * Day treatment for troubled children and youth es to provide home care, and specially designed, People with disabilities small, and semi-independent living facilities in the * Inclusive education community * Special education classes The elderly can receive assistance at senior citizen * Sheltered workshops, job training and placement centers where they eat, socialize, receive medical or * Special day schools for children with disabilities other help, and work or volunteer. For the frail or * Rehabilitation (to promote self-care and self- homebound elderly, visiting nurses, social workers, relcance) and volunteers can help with household chores, - Techncal aids cooking, medical visits, and errands. Elderly * Senior citizens centers (meals, social activity) Services when problems are overwhelming and an * Home visiting (food, health, household chores) individual must be removedfrom the home * Respite care (for caregivers) * Small-scale enterprises and cooperatives Some community-based services are designed to Out-of-home placement provide help when problems have become so * Kinship foster care severe that an individual must be removed from his * Nonkinship foster care or her home. Ideally, all of the relevant services * Temporary shelter (for battered women and their above have been offered and tried before an indi- children) vidual is removed from the home. It is hbviously * Supportive apartments (semi-independent living ovfrbeteoeh or h iosyi for children and the elderly) preferable to remove the source of the risk in a * Small group homes family-such as a physically abusive father or a * Relocation homes for a family (with supervised, dangerous apartment-than to remove a child. therapeutic treatment) Removal of a child or a person with disabilities or * Adoption elderly person should be the last option considered 48 Movingfrom Residential Institutions to Comminity-Based Social Services in Central and Eastern Europe and the Former Soviet Union or tried. Even then, it should be used for a brief tive state), the very frail elderly, or adolescents with period, until the individual can be reunited with extreme behavior disorders. his or her family If reunification is not possible, a pertnanent solution, such as adoption for children, Reintegration services should be found. Out-of-home services for children include It is much harder to reintegrate a child with his or neighborhood foster care (preferably with rela- her family or community than to prevent the child's tives), adoption, temporary shelters for battered removal from the family in the first place. The soon- women and their children, and small group homes er the child can be reunited with the family, the in the community For people with disabilities, greater is the likelihood that a permanent, safe, and semi-independent living programs or small group nurturing environment can be established. homes may be helpful. Assisted-living programs or As soon as a child has been removed from his other community-based social care facilities, or her home, efforts should be made to ensure reg- including skilled nursing care, for the elderly are ular and frequent contact between the child and also options. the child's family in a safe setting. A range of serv- There are, of course, limited circumstances in ices should be available after a child is removed which residential care is the appropriate service and reintegrated into his or her family to assist modality. Such circumstances include placement for with the difficult task of reintegrating a child into the severely disabled (such as a person in a vegeta- the family. Box 4.2 Lithuania's Community-Based Social Service Pilot Projects During the Soviet period the Lithuanian Republic relied viding a small cash allotment to poor families, cash on an extensive network of residential institutions- alone could not meet many of the social, emotional, or infant homes, boarding schools for vulnerable and gift- other service needs of at-risk individuals or families. ed children, institutions for mildly and severely disabled The government approached the World Bank to children, and residences for adults who were incapable develop a project to support the introduction of com- of caring for themselves. Almost 8,000 children, people munity-based social services to meet the needs of vari- with disabilities, and elderly lived in such institutions in ous groups at risk of placement in long-term residential 1995. institutions. A four-part partnership was created to As the transition progressed, new ideas for the care develop and implement the project: the Ministry of of children with disabilities, as well as neglected chil- Social Security and Labor, the University of Stockholm dren and the elderly, began to appear in cities through- School of Social Work (supported by the Swedish gov- out Lithuania. These new ideas were nurtured by ernment), six Lithuanian municipalities, and the World contact with state of the art social work practice and Bank. training from Sweden and other countries. Several The Ministry of Social Security and Labor, through fledgling nongovernmental organizations, particularly its Department of Social Care, oversees institutions for Viltis, an organization of parents of children with dis- the elderly and people with disabilities and social serv- abilities, championed these reforms and lobbied for leg- ices. The ministry was the primary counterpart for the islation granting equal rights to people with disabilities. project. The University of Stockholm's School of Social The Ministry of Social Securitv and Labor, which set Work (funded by a grant from Sida, the Swedish policy for residential institutions that housed people International Development Agency) organized study with disabilities and the elderly began to implement tours to Sweden, worked with social welfare staff in the these reforms. municipalities to design each pilot project, and worked Even as the new ideas were taking root, the country's with the Department of Psychology at Vilnius University GDP dropped by 55 percent between 1990 and 1993, to train staff for the new programs, to conduct a base- drastically reducing the country's ability to support the line study, and eventually to evaluate the project. growing number of individuals placed in large residen- Each municipality where a pilot project was located tial institutions. Although the government began pro- agreed to provide a building for its project and to cover Finding a Solution 49 Box 4.2 CONTINUED Lithuania's Community-Based Social Service Pilot Projects all recurrent costs (including staff salaries, building porary residence for 50 mothers and their children. All maintenance, heat, and transportation) throughout the the mothers have been physically abused, some are five years of the project. teenagers and others have grown up in a children's home The World Bank developed the plan and provided and have children of their own. The project provides funding to renovate all buildings in the project and to social services and helps these mothers find permanent purchase furniture, vans, office equipment, and spe- and safe living accommodations and employment. In cialized equipment for people with disabilities. The the first six months of the program, seven mothers and project cost $8.5 million-$3.75 million from the their children found work and a safe living situation. World Bank (loan), up to $3.2 million from Sida (grant), Without such a program, mothers might become home- and $2.5 million from the municipalities. A $400,000 less and their children might have to be placed in a long- grant from the Japanese government funded project term institution. development. Programrforformerprisoners (Svencionys). Individuals During project preparation a competitive tendering who have returned from prison have caused serious process for the community pilots was developed and problems in Svencionys. This program provides a short- implemented with foreign technical assistance. Among term residence, services, and assistance to find work to Lithuania's 56 municipalities, 6 were selected from 16 eight former prisoners. Without this assistance, former responses to the tender offer. This was the first tender prisoners returning to Svencionys would be more like- offer ever conducted for social services in Lithuania. ly to commit new crimes and return to prison. The selected municipalities submitted 14 pilot proj- Home carefor the elderly (Svencionys). Many elderly in ects that became the community-based social services this rural community are frail or homebound. The pilot initiative. Each project was designed to be a feasible, project provides daily and weekly in-home services for cost-effective approach to social service delivery that is 365 elderly, including counseling, food delivery, home community-based and responsive to local needs. Each chores, wood cutting, and transportation to medical project was designed to result in fewer individuals care. Several years ago the municipality converted a hos- placed in institutional care, and thus lower the cost per pital to a long-term residence to care for the rapidly client served. growing number of frail elderly There was a 35-person The following illustrate some of the 11 pilot projects waiting list for the residence until the home care pro- operating at the beginning of 1999. gram began. Now there is no longer a waiting list. Education centers for children with disabilities in four The different groups served by these programs-the municipalities (Anylzsciai, Moletai, Svencionys, and Utena). parents of people with disabilities children, the home- Before these projects began, many of the severely dis- bound elderly, former prisoners, abused and neglected abled children in the region resided in their own homes, children, and battered women-have been enthusiastic received no education or training, and had very little about the care they have received. The Ministry of Social social contact. They were at risk of being placed in long- Security and Labor has been so encouraged by the proj- term institutions because of the strain on their parents. ects that in 1998, even before the mid-term evaluation These four schools now provide daily, individualized began, the government passed legislation providing education classes to almost 100 children. Vans pick up $1.25 million for the creation of additional community- the children from their homes, take them to school, and based social service projects. Municipalities submitted return them home at the end of the day. Seven of the 143 project proposals; 40 were selected for funding. The children in these centers had been living in large, long- government and the European Social Development term residential institutions for the severely disabled but Fund made additional funding available in 1999. More are now living at home. Children from the schools in than 230 proposals have been submitted by municipal- Anyksciai and Svencionys attend classes and share ities and NGOs to establish additional pilot projects. meals and special events with children in the neighbor- The Ministry of Social Security and Labor has begun dis- ing regular schools. The Utena school has plans for sim- cussions to pursue a follow-on project with the World ilar integration. Bank that would focus on creating elements of a nation- Shelter for battered ,women (Vilnius). A former chil- al system of community-based social services to reduce drens nursery in Vilnius has been converted into a tem- the country's reliance on residential institutions. Source: World Bank 1997. 50 Movingfrom Residential Institutions to Community-Based Social Services in Central and Eastern Europe and the Forner Soviet Union Strategies to Implement Community-Based that formal changes in legislation rarely lead to Services meaningful change in practice, unless there is broad preexisting administrative support and funding for Many approaches for making the transition from res- reform. Those two conditions are rarely met without idential institutions to community-based social serv- considerable education of policymakers and admin- ices have been developed and tried in Central and istrators, pilot testing of service models, formal and Eastern Europe and the former Soviet Union. These informal evaluation, and changes in public opinion. approaches and others used in other Western nations Although countries may be at different stages in could be used effectively on a far broader scale their willingness to support and fund large-scale throughout the region. national reform, the development of community- The transition from residential care to community- based social services should proceed in roughly the based services is a long and complex process. It following order. requires careful planning, adequate resources, and an involved constituency The lives and well-being of Changing public opinion and mobilizing many individuals-children, people with disabili- community support ties, the elderly and their families, as well as the staff of residential institutions and of the new service A multipronged public information campaign programs-are at stake. should be developed to change the attitudes of the Six elements are part of a strategy to reduce the public, policymakers, administrators, and line staff region's dependence on residential institutions. They toward residential institutions. The campaign could are not separate strategies but are part of an inte- build and nurture the region's reliance on families grated, comprehensive approach to restructure the and local communities-an approach that was noncash social assistance systems of transition deemphasized under command economies. economies: Such a campaign might begin with a national or * Changing public opinion and mobilizing com- local survey to assess the reasons people support the munity support. use of boarding schools, infant and children's homes, * Strengthening or creating a social welfare infra- social care homes for the elderly, and institutions for structure. people with disabilities. A series of messages for the * Establishing community-based social service pilot campaign might emphasize that: projects. * Children, people with disabilities, and the elder- * Creating pilot projects to reduce the flow of indi- ly can thrive and grow with the support of family viduals entering residential institutions and rein- and the community. tegrate individuals into the community * Children, people with disabilities, and the elder- * Redesigning, converting, or closing individual ly are often harmed by living in residential insti- facilities. tutions. * Creating a national system of community-based * Most children in such institutions are not orphans social services. but have families who would care for them if assis- The sequence in which these activities occur is tance were available. Many of the elderly could important. Should reform begin with pilot projects also remain in their homes with assistance. that test various approaches, demonstrate their effi- * Alternative ways to help children, families, peo- cacy, and provide the rationale for national legisla- ple with disabilities, and the elderly are available tive reform? Or should legislative reform be and may soon be created within the country implemented first to create the conditions for revis- A public opinion campaign could be conducted as ing entire systems? Although no one rule applies in a collaboration among national and local govern- all situations, the experience in Central and Eastern ments, NGOs in the field, and donors. Ideally a grass- Europe and the former Soviet Union appears to be roots effort in Central and Eastern Europe and the Finding a Solution 51 former Soviet Union would rely on local constituen- orating to provide training or research to create new cies such as women's organizations, organizations of social service programs, as is being done in parents of children with disabilities, and NGOs Lithuania. Personnel from local universities could involved in community development. Such a cam- work in collaboration with advisers from external paign will not only begin to change attitudes but will schools of social work, child development, special mobilize these groups as allies in efforts to develop education, or other disciplines. The participation of community-based social services for vulnerable these nascent departments of social work could both groups. strengthen their capacities as well as enhance the In Armenia, for example, a public information quality of social work in the community. Some coun- campaign has begun on a national level that describes tries, however, still require initial investments and the harm of residential care and the benefits of com- local capacity building in social work education. munity services. In Hungary a public awareness cam- NGOs, working in close cooperation with the pub- paign was developed in Debrecen and Pecs at the lic sector, should also be a vital component in a new, community level that emphasizes the value of com- effective social welfare infrastructure. The develop- munity integration for children with disabilities. One ment of these organizations needs to be nurtured, important vehicle for such a campaign is the United and their cooperation with and support by govern- Nations Convention on the Rights of the Child as well ment need to be encouraged. as other human rights conventions, which have been signed by all countries of the region. In Romania, for Establishing community-based social service pilot example, the Convention on the Rights of the Child projects has contributed to changing public opinion and the attitude of policymakers on children's rights, the There are many advantages to using pilot projects rights of people with disabilities, and the role of res- to develop a network of community-based social idential institutions. Advocacy and promotion of services: human rights, including children's rights and the * The flexibility to test a wide range of approaches- rights of people with disabilities, will help move the service modalities, organizational auspices, geo- social consensus toward more effective ways to help graphic locations). vulnerable groups. * Opportunities to identify and correct inappropri- ate approaches and mistakes made on a small Strengthening or creating a social welfare scale. infrastructure * Time and data to gain popular support to carry out the project on a larger scale. Social work schools are needed to train staff in resi- * Limited investment and risk by donors. dential institutions, local social assistance offices, * The opportunity to initiate a policy dialogue. new community-based social service programs, and Pilot testing can lead to the development of the the bureaucracies that oversee all these programs. In most cost-effective service models for a country The recent years basic social work programs have been main disadvantages to pilot projects are that they created in several transition economies, with some reach only a small portion of the population in need success. These programs are often in departments of of assistance, and the policy environment is not nec- psychology, sociology, or social pedagogy, while staff essarily changed as a result of the projects. training centers continue to be located in depart- A community-based pilot project can be created ments of defectology within schools of pedagogy. that provides a specific service to a specific group of Many programs could benefit, however, from clients (such as home delivery of food to the elderly) additional study tours, technical assistance, and or that provides a range of services to different groups training in basic social work skills and specific serv- of clients (such as a multiservice center). Programs ice modalities. They could also benefit from collab- that provide a range of assistance are preferable 52 Moving from Residential Institutions to Commnunity-Based Social Services inCenitral and Easte-n Europe and the Formner Soviet Union because they serve many individual needs and can be areas of focus of a reintegration program. One of the located in a variety of settings-in a free-standing rights ensured by international human rights taw is a service center (such as a multi-service center or a right to community integration for children with and family ser-vice center) or in a larger organization (such without disabilities. As social service projects begin as a government social assistance office, a general to provide alternatives for individuals at risk, pilot school, or a polyclinic). Community-based social projects should be established that reduce the num- service programs should be operated by municipal or bet of individuals entering residential facilities and regional government agencies or NGOs, preferably increase the number returning to the community close to the point of service delivery. The most effec- This approach was used by UNICEF and others in tive and sustainable service programs are based on collaboration with local governments in Romania. citizen participation, including family members, This can be done by developing new standards for direct consumers of service, and professionals. placement and working with the local referral agency Many strategies could be used to identify the to use those standards as prerequisites to placement. municipalities or regions where community-based Additional approaches include developing a system social service pilot projects should be located. One to assess individuals' strengths and needs, using indi- approach is a national tender offer, as in Lithuania, vidualized service plans, and retraining staff to work for which a ministry might establish broad guide- on reintegrating children or people with disabilities lines for municipalities to develop service programs. into the community As noted however, it is far more Each project could operate as a collaborative, cost- difficult to reunite a person with his or her family sharing effort by the government, municipalities, once those bonds have been broken and the individ- donors, and NGOs. ual has been placed in residential care. For this rea- A second approach is to establish pilot projects in son the reintegration programs in the region have had municipalities where residential institutions are only limited success. located. This approach may increase the likelihood that a social service program will be targeted to indi- Redesigning, converting, or closing individual viduals who are more at risk of institutionalization facilities or who are already living in a residential institution. Pilot projects should also be developed in munici- Most staff in residential institutions are untrained in palities without residential institutions, because social work, child development, child psychology, or these municipalities place residents into institutions special education. Staff and oversight personnel in in other localities, residential institutions should be trained in the value An essential element to creating successful proj- of family upbringing and the limitations of residen- ects is frequent, ongoing training and supervision. In tial care. Such staff are often eager to receive training Lithuania, for example, in addition to study tours that may both improve the way they care for chil- and formal classroom training, a team of social work dren and give them additional marketable skills. A experts visited the project sites every two to three local university can provide training with consulta- weeks during the two years the pilot projects were tion from external advisers who have experience in being established, social work and in reducing reliance on residential institutions in their own countries. Creating pilot projects to reduce the flow of Alternative employment can be found for staff in individuals entering residential institutions, residential institutions. One option is to redeploy protect the rights of individuals in institutions, educators and child care personnel who work in and reintegrate individuals into the community boarding schools. As community services are creat- ed and the population of residential institutions The protection of the rights of individuals who are decreases, staff could be reassigned (on a voluntary already institutionalized should be one of the first basis) to work in a community service program that Finding a Solution 53 reintegrates children from boarding schools into the who, with assistance, could be reunited with their community families. In addition, residential institutions can be * Improving the care in residentialfacilities. The quality redesigned to allow staff to focus on reintegrating of care in residential institutions could be improved children into the community. Sites can be redesigned by developing individual service and treatment to create smaller, semi-independent units housing for plans, focusing on reintegrating individuals into no more than 15-25 children. These group homes their families and communities, and creating small- should be used only for children over 6 and only in er residential units. International human rights laws cases of severe disability or behavioral problems. provide a primary framework for these changes. Finally, alternate uses for institutions can be * Creating alternative ways to assist vulnerable groups found. In Hungary part of a children's home has been in the community. Legislation should authorize and converted to apartments for young mothers and fund localities to provide the range of essential their infants. In Armenia part of a boarding school services-including social work, material assis- has been converted to apartments for refugees. In tance, special education, home care, foster care, Romania part of an infant's home was converted into and adoption. In most cases a national ministry apartments for mothers and their children. In will need to initiate efforts to create community- Lithuania plans are being developed to convert part based social services, such as a ministry of social of a children's home to rooms for mothers and their security that establishes national policies and children to stay during a family crisis. Many groups guidelines for social services. Ideally, an inter- of vulnerable individuals-single mothers and their ministerial working group, including NGOs and infants, battered women and their children, advocates of children, people with disabilities, refugees, former prisoners-in the region could ben- and the elderly, should lead the effort to create efit from short-term stays in redesigned residential community-based social services. The reform institutions. The risk, however, is that short-term efforts should also be integrated and coordinated facilities have a tendency to become long-term resi- across sectors, including education, health, dences if people are not reintegrated into their employment, and social services sectors. homes and communities. * Ensuring quality and specialized services. A broad continuum of high quality services should be Creating a national system of community-based available as a human right, Specialized, qualified social services human resources at all levels need to be developed to staff and sustain these programs. Such services After pilot projects have been tested and redesigned would include, for example, staff in schools or to best address community needs, programs can be assessment centers that make the decisions to implemented nationwide. National legislation and refer children or others to community services or public policy should focus on: residential care. Restricting the use of residential institutions. In few * Ensuring sustainability through long-termrfundingfor situations some individuals-disturbed older chil- recurrent costs. Donors generally provide invest- dren, severely disabled children, or frail elderly ment funds for civil works, equipment, furniture, persons-will require placement in residential technical assistance, training, and perhaps short- care. Prerequisites and standards should be creat- term salaries for specific projects. Recurrent costs ed to ensure that only severely and permanently for salaries, utilities, supplies, and other ongoing vulnerable individuals are placed in residential expenses must be provided locally-generally by institutions-and only after community-based a level of government. Without a secure source of alternative services are offered, provided, and funds for recurrent costs, projects will end when unable to remedy the individual's risk of harm. donor participation ends. In Central and Eastern These criteria should also be used to determine Europe and the former Soviet Union many excel- 54 Moving-from Residential lnstitutions to Community-Based Social Services in Central and Eastern Europe and the Former Soviet Union lent community-based social service projects have Project evaluation should begin with a baseline been suspended because long-term funding was study to examine the composition and needs of vul- not secured. nerable groups and assist policymakers. A baseline Recurrent costs can be provided in a variety of study can also use socioeconomic and social service ways. A municipal government may agree to fund conditions as a basis for comparison with other eval- recurrent costs (either initially or after the cost- uations at important stages of intervention. Multiple effectiveness of the pilot project has been demon- pilot projects in Lithuania are being assessed in this strated) in exchange for the creation of a pilot way project in its city The national government may There are, however, many ways in which a pro- agree to allocate additional resources so that a gram may achieve positive results that are not easily series of pilot projects can be created. Staff lines measured through program evaluation. For exam- and other expenses might be reallocated from res- ple, the quality of life of a person with a disability idential facilities (as the number of staff needed may improve through increased social contact, but decreases). Armenia is considering such an this subtle improvement is difficult to measure. Case approach. In some situations a sliding-fee scale for studies that illustrate such changes should be gath- services may provide a portion of the funds need- ered in areas that are not easily quantifiable. ed for recurrent costs. • Eliminating the financial incentive to use residential institutions. Current funding streams create a Increased Demand and Additional Resources financial incentive for local governments to reduce their expenses by placing vulnerable indi- One key element that should be evaluated is the viduals in residential institutions that are funded cost-effectiveness of community-based social serv- by a higher level of government. Shifting the ices relative to residential care. Community servic- financial incentive from residential institutions to es are likely to be less expensive on a per client basis community-based social services can be achieved than residential care. A simple cost-benefit analysis by having "money follow the client." In this to compare the recurrent cost of residential care approach, which may be tried in Latvia, localities with the recurrent cost of community social servic- receive one allocation from the national budget to es can demonstrate the relative cost of the two be used for social services or residential care on a approaches. per client basis. Localities must pay all or part of Several factors, however, limit the actual savings the cost for each individual placed in a residential that government will accrue by using community institution or receiving social services. Because social services. First, creating alternative social serv- community-based social services are less expen- ices requires an initial investment in capital, staffing, sive than residential care, this approach creates an training, and other resources. Second, government incentive for community care. savings from the use of community-based social * Making evaluation a central component of a national services are likely to accrue only after the number of social safety net. Pilot projects and systemwide individuals in a residential institution decreases. reforms must be evaluated to identify strengths Savings may not be substantial until a residential and weaknesses, improve program designs, and facility is closed or an alternative use is found. provide documentation to assess whether a pro- Finally, and most important, new services gram should be expanded, replicated, or estab- generally increase the number of individuals who lished systemwide. Project evaluation is also a receive assistance. Residential institutions serve necessary component to ensure that the service only a small portion of vulnerable individuals. system is accountable to the people who are Community social service would assist not only served, the public and donors who fund it, and current recipients (the institutionalized) but also the staff who work in it. many others who previously received no assistance. Finding a Solution 55 Thus the target population for community-based A second risk is creating inadequate community services would be significantly larger than those services. Staff may not be well trained, and services individuals who receive residential care. The may not fully address an individual's problems or increase in the number of recipients provides much- material needs. This risk can surface when success- needed assistance to previously unserved people ful, carefully nurtured, small-scale pilot projects are but will require additional resources beyond the replicated or expanded. money saved by closing residential institutions. A third risk is that projects may not be sustain- Ultimately the focus of assistance should be to pre- able. Governments change, priorities shift, resources vent the underlying causes of institutionalization- decrease, or a different level of government becomes unemployment, poverty, and social exclusion of responsible for the project and may not treat it as a ethnic minorities, people with disabilities, the eld- priority. These changes can profoundly affect finan- erly, and other vulnerable groups. cial sustainability, programmatic integrity, and staff continuity. Risks Risks can be mitigated with careful, continuous planning, adequate funding, and, most important, There are three salient risks to reducing the region's with an active constituency that is involved in the reliance on residential institutions. The first is that decisionmaking for these services. vulnerable individuals could be forced out of resi- dential institutions before community services are available to assist them. The United States failed to Note provide alternate housing when the mentally ill were deinstitutionalized in the third quarter of the 20th 1. This principle is not included in the list developed by century, contributing substantially to the homeless- Schorr (1988) but reflects views in ILO, UNESCO, and ness of the mentally ill. WHO (1994). CHAPIER 5 Conclusion en years have passed since the Berlin Wall fell A few seeds for such a change have been planted. T and the conditions in residential institutions Multinational donors (the World Bank, the in Central and Eastern Europe and the former European Union, UNICEF), and individual nations Soviet Union became known to the world. The most (Sweden, Denmark, the United States), and NGOs vivid images from this period were the shocking pic- (Save the Children, Caritas, International Social tures of children with disabilities in residential insti- Service) have worked with the governments of the tutions in Romania. The worst of these institutions region to create community-based social service were improved to provide for basic material needs, programs. These efforts build on global best prac- yet roughly 100,000 children still live in residential tices to prevent institutionalization and to reinte- facilities in that country-similar to the number grate individuals into the community The soon after the transition began. preliminary results of these programs are During the transition a more extensive and encouraging-people are able to remain safely with intractable problem of residential care has appeared. their families at a cost similar to or less than that for Residential institutions are the main type of assis- institutional care. tance for vulnerable children, people with disabili- These programs, however, operate on a small ties, and the elderly who experience severe scale, generally covering only parts of a few large difficulties. Many of these children remain in insti- cities. Hungary, Lithuania, Poland, and Romania are tutions throughout their childhood, people with dis- among the few countries in the region that are devel- abilities remain throughout their lives, and the oping or planning for national systems of communi- elderly remain until they die. Residential institutions ty-based services as a primary way to prevent are costly for governments and destructive to the institutional placement. Existing pilot programs individuals who live in them. As the director of one need to become the first steps of a longer process of infant home said, "The infants arrive healthy and creating national systems of high quality communi- leave disabled." ty care for vulnerable individuals. As the economic and social conditions in Central Donors, governments, and NGOs should further and Eastern Europe and the former Soviet Union reduce the region's reliance on residential institu- deteriorated, more people were placed in these insti- tions and increase the use of community-based tutions. Today at least 1.3 million people live in 7,400 services. This study presents a six-part strategy to institutions in Central and Eastern Europe and the make that transition. The strategy begins with pub- former Soviet Union. The conditions in most of these lic information and pilot projects and concludes facilities are worse today than they were 10 years ago. with the transformation of national laws, funding, Unfortunately, the well-intentioned work of donors and uses of institutions. In the short term it is a to improve conditions in residential institutions rein- costly strategy. Although on a per client basis com- forced the reliance on them. Community-based munity services are far less expensive than residen- social services that are cost-effective in industrial tial care, such services should be provided to the nations are still uncommon in the region. much larger group of vulnerable people who have 57 58 Movirgfrom Residential Institutions to Community-Based Social Services in Central and Eastern Europe and the Former Soviet Union the same problems as those living in institutions assistance to individuals and families before prob- but who receive little or no help. Whereas just 1-4 lems develop or become overwhelming. percent of vulnerable children, people with dis- The strategy also carries the risk that deinstitution- abilities, and elderly individuals in the region live alization will occur without preestablished communi- in residential institutions, far more live in poverty, ty-based services or long-term support. 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Child Development Centre, Florence, Italy T H E W O " L D B A N K en years after the fall of the Berlin Wall, the countries in Central and Eastern Europe 1818 H Street, N.W and the Commonwealth of Independent Washington, D.C. 20433 USA States still face major challenges: although Telephoie: 202-477-1234 much has been achieved in the transition to Facsimile: 202-477-6391 market-based democracies, much remains to Telex: MCI 64145 WOPLWDBANK be done. The World Bank has been an active partner in helping countries design and im- plement their reforms. Internet: www.worldbank.org E-mtiail: books@worldbank.org The region has witnessed many successes, as well as setbacks, in the transition process. This series of publications is part of the Bank's con- tribution to the debate about the unfinished agenda and possible approaches to future chal- lenges. The 14 titles in the series cover the issues of resurgent poverty and inequality, the importance of sound corporate citizenship, strategies for better education systems, social and environmental protection, institution building, investments, and livable cities. The series was prepared to facilitate the discus- sions during the thematic seminars at the 2000 Annual Meetings of the World Bank and the International Monetary Fund in Prague, and the broad-based dialogue to follow. *n al Documents Unit C3-129 p - ~~~3 copiesI 9 780821 344903 0-8213-4490-0