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Home truths: The phenomenon of residential care for children in a time of AIDS

Helen Meintjes, Sue Moses, Lizette Berry & Ruth Mampane

Children's Institute, University of Cape Town & Centre for the Study of AIDS, University of Pretoria

June 2007

SARPN acknowledges the Children's Institute as a source of this document:
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Executive summary

In the face of the burgeoning AIDS epidemic in sub-Saharan Africa, there is widespread concern that responses to increasing numbers of orphans are resulting in a proliferation of orphanages across the region. This unease emanates from the view that care for children – orphaned or otherwise – in a ‘home’ and ‘community’ environment is ideal. Institutions, on the other hand, are noted to impact negatively on children, to operate as ‘magnets’ for children growing up in poverty-stricken environments, and to be disproportionately costly. Arguing that residential care violates the principles of the UN Convention on the Rights of the Child, the international child welfare sector is united in advocating its use as only a temporary ‘last resort’ for children. The position is shared by the South African government and other key players in the local child welfare sector.

Two important policy processes that are underway aim (in part) to limit, transform and regulate residential care for children. Globally, a range of international agencies are spearheading a campaign for international standards for ‘children without parental care’. In South Africa, the primary piece of children’s legislation – which includes all provisions for residential care – is under review, and soon to be replaced by a new Children’s Act.

However these policy processes are occurring amidst a dearth of systematic empirical evidence about the phenomenon of residential care in sub-Saharan Africa in general, and in South Africa more specifically. We have little more than an anecdotal picture of how the sector manifests in practice on the ground. In particular, little is known about less formal residential care provisioning, about residential care settings that do not conform neatly in their origins, form or function to conventional institutions and which tend not to be registered with the State as required by law.

It is within this context of inadequate description and analysis of the phenomenon of residential care – particularly in the context of HIV/AIDS – that this study aims to contribute to policy. It sets out to advance understanding of the complex patterning of residential care in South Africa, as well as how it relates to national policy and law and to international child welfare policy on the issue.

Following a careful examination of international and local policy directives regarding residential care, primary research was conducted in four diverse study sites in four South African provinces: Gauteng, KwaZulu-Natal, Limpopo, and the Western Cape. This included a scoping exercise to identify a broad range of residential care arrangements, interviews in residential care settings and with the providers of social services, as well as an audit of children resident in participating homes. Only those facilities concerned with children ‘in need of care’ – those which would be technically defined as Children’s homes in terms of South African law – were included in the study.

Subsequent to an overview of the study methods (sections 2.1-2.6), the report commences with a description of how the international child welfare sector and the South African government define and conceptualise the role of residential care in the context of the HIV epidemic (section 3). It then provides an analysis of basic characteristics of children found to be resident in the range of settings identified (section 5). The remainder of the report is dedicated to detailed exploration of different aspects of residential care settings in the study sites. Particular attention is paid to examining the complexity that exists in practice regarding the legal status of homes, their models of care, staffing, programme provision, relationships to ‘community’, and funding (section 6). In addition, the critical issues of children’s referral to, and admission into, residential care, and the factors affecting their subsequent exit or otherwise from homes, are examined (section 7). The interface between children’s homes and government social services is documented throughout the discussions, with focussed consideration occurring primarily in sections regarding legal status, funding, referrals, leaving care and – of key importance – registration (sections 6.1, 6.9, 7.3 and 8). A stand-alone section (9) provides a brief analysis of knowledge and practice regarding HIV/AIDS in the homes.

The primary conclusions emerging from the study findings can be grouped into six key areas:

Children in residential care

Contrary to popular perception, the child population in the children’s homes in the study was neither disproportionately skewed towards large proportions of very young children, nor predominantly constituted by children who had been orphaned. However homes were providing care to an exceptionally high ratio of HIV-positive children. This feature of the child population in the homes raises important considerations for the provision of adequate and appropriate care, including in relation to caregiver skills, training and continuity; and children’s access to health services.

While it is tempting to become pre-occupied with ‘categories’ of children in homes however, it is important not to conflate these with the reasons for children’s admission into them. In this regard, the study suggests widespread abuse, neglect and abandonment of children to be the major reasons for their entry into the residential care settings, and that HIV/AIDS and poverty are part of a complex causal pathway rather than the dominant reasons for admission in and of themselves. If this is indeed the case, the distinction has important implications for the design and delivery of ‘prevention’ services.

Knowledge and practice regarding HIV/AIDS

Despite the high proportion of HIV-positive children resident in homes, knowledge about HIV and AIDS in the residential care settings was uneven and far from comprehensive. In addition, homes’ practices regarding HIV tended to be unsystematic, and to address only limited components of the necessary spectrum of HIV interventions. A number of homes nonetheless demonstrated that administration and management of paediatric antiretroviral therapy is possible in group-care settings, as long as systems for doing so are in place.

Key areas requiring strengthening relate to staff and caregiver HIV literacy, including awareness of the prevention of mother to child transmission, post-exposure prophylaxis, HIV testing and disclosure, and antiretroviral therapy; and relationships between HIV health services and homes. In addition, widespread perceptions that HIV-positive children are not suitable for foster care or adoption are of concern.

Policy discourse

Despite the international drive to limit residential care facilities to small, local homes that minimise the physical and social separation of children, the discourse surrounding residential care throughout both international and South African policy and legislation is anchored in a perception of residential care as that provided by ‘conventional’ institutions. This institutional discourse represents the practice of residential care as a professionalised, highly structured, service-oriented, formalised intervention. Recommendations and provisions clearly envisage professional interventions designed to provide temporary therapeutic care to children in order to ‘return’ them to family or community settings.

A clear distinction between residential care and family- or community-based care is inherent throughout policy discourse. At the core of this distinction is a series of overlapping dichotomies: A ‘first resort’ model of care for children juxtaposed with an explicit ‘last resort’ model; a context of care in which children’s rights are protected juxtaposed with one in which rights are violated; and an existence embedded in everyday community juxtaposed with an existence ‘inside’ an institution, separate from community.

The complexity of residential care provision ‘on the ground’

The situation of residential care ‘on the ground’ in South Africa is demonstrated to be much more complex than is acknowledged in policy discourse and debate both locally and internationally. Data from the study documents how residential care settings for children vary substantially across multiple axes, and how in many instances negative features associated with residential care settings do not apply. These include concerns about children’s routine dislocation from family, community, and cultural background; their marginalisation from everyday society; and the absence of opportunities to develop secure, long-lasting attachments.

Furthermore, given the extent of heterogeneity in the sector, the inherent focus in policy on conventional institutional forms seems misplaced in the South African context. The study findings clearly illustrate the blurring of boundaries between family-based, community-based and residential care, and raise questions about the usefulness of the categorical distinction between the ‘first’ and ‘last resorts’.


Much of the attention directed at residential care by both the State and non-governmental children’s sector in South Africa is preoccupied with the legal status of existing and new residential care settings, with the tendency to characterise unregistered homes in entirely negative terms. However, the study indicates that the legal categorisation of residential care settings reveals little about homes themselves, or more broadly about the nature of residential care. Rather it masks the phenomenal diversity that exists across the sector, both within and across legal categories of homes.

Furthermore, the study findings raise concerns about current and pending registration requirements and practices. Not only does the law and its implementation work against the registration of many community-based residential settings that are providing important (if imperfect) support to children, but it is also more facilitative of the establishment of more conventional institutions. The nature of the legal requirements for registration propels creative, responsive community-based residential initiatives pursuing registration towards care of a more stereotypically institutional nature, resulting in the loss of some of their more positive qualities in the process. They can also introduce practices that jar with the essence of the care environments, and are somewhat incoherent in the context.

The interface between legislation, government practice and residential care provision

In practice, all too often government’s interactions with residential care settings are fraught with confusion and frustration. Mixed messages are communic ated to unregistered homes: Contradictory funding mechanisms operate within and between departments and tiers of government. Social workers place children in care at unregistered homes while concomitantly homes’ official registration is rejected. The dr ive to place children in family-based settings is not matched by the capacity of the Social Services to process, monitor or support placements adequately. Services aimed at ‘prevention’ and ‘early intervention’ – critical components of the Department of Social Development’s vision for the provision of a developmental continuum of care for children – remain insufficiently resourced, and limited in reach. Homes are refused registration and are shut down on the grounds that residential care is unsuitable for children, while current circumstances render overburdened and under-funded state Social Services unable to support children in families adequately.

Paradoxically, at the core of the Developmental Social Welfare mode l that underpins all post-1994 social development policy in South Africa is a recognition of the value inherent in ‘indigenous’ responses. The model sets out to resource and empower local level insights and responses to social circumstances and to place emphasis on the provision of a wide range of interventions that together support a broad ‘continuum of care’ for children as part of wider social development goals. It is precisely the creativity and sensitivity of local responses that the model aims to build upon in strengthening social service delivery.

However, it is also the complexity and the ambiguity that is described in the course of this report that makes the broad arena of residential care for children a difficult one for the State to systematise, support, monitor and regulate. The danger is that at this time of much policy and legislative review in South Africa we – as both government and the children’s sector – promote unhelpful, inappropriate, unfacilitative policy and legislation based on conventional and simplistic notions of what residential care is and should be. It would be preferable to seize the opportunity to ensure flexibility in our policy and law that recognises the need to resource as well as regulate the wide variety of informal social care responses that exist.

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