A child belongs to the whole community

A child belongs to the whole community

_______________________________________________________________

A qualitative study about two support systems for Orphans and other Vulnerable Children in Burundi

SQ4562/SQ1562, Scientific Work in Social Work, 15 higher education credits Bachelor in Social work

Fall semester 2014

Authors: Lovisa Strömberg and Josefin Svensson

Supervisor: Jeanette Olsson

Abstract

Title: A child belongs to the whole community. A qualitative study about two support systems for Orphans and Other Vulnerable children in Burundi

Authors: Lovisa Strömberg and Josefin Svensson

Key words: Institutional care, family-based care, orphans and convention of the rights of the child.

This qualitative study has taken place in Burundi. Burundi suffers from years of violence and diseases like HIV/AIDS. Many parents have passed away or are not capable to take care of their children, which are leading to a lot of Orphans and other Vulnerable Children (OVC). The study describes and compares two kinds of support systems, which are taking care of OVC in Burundi, one institution, named Emmanuel, with one family-based organization, named FVS-AMADE.

The aim in this study was to analyse which model that is in the best interest of the child according to the OVC and the staff members from the studied organizations.

Our definition of the best interest of the child is based on the criteria from our 33 selected articles in The Convention of the Rights of the Child (CRC), The African Charter on the Rights and Welfare of the Child (ACRWC) and The Guidelines for The Alternative Care of Children. Three research questions have been created to get an understanding about the aim. The research questions focus on; what views the staff members, youths and children from FVS-AMADE and Emmanuel have about the advantages and disadvantages with the two studied support systems, what they think about the various forms of support within these systems and what the OVC’s overall impression are about them. The questions were answered by;

analysing literature reviews, participant-observations and collecting interview data. The data was collected through 13 semi-structured interviews and the re- spondents to these were found by using the network model. The collected data has been analysed with the theory of empowerment and the theory of social support.

The result of this study show that in general, a family-based model is in the best

interest of the child compared to an institutional solution. The conclusion of the

result is also that it is important to see the context within the family and that the

OVC sometimes can receive more adequate care by living in an institution. If the

family for instance is suffering from poverty and do not have the resources to take

care of the child, an institution could be a better solution for the OVC but this

should always be seen as an exception.

Acknowledgements

First of all we want to recognize Conny Rudin who inspired us to travel to Bu- rundi and who supported us with information and ideas for this study, thank you.

We would also like to thank Barnabé Karareo who was our guide in Burundi and who always was there for us when we were in need of help.

Thank you to our respondents who were willing to participate in the interviews.

Without you we would never manage to conduct this study.

We would also like to say thank you to our friends and family who have listened to our thoughts and ideas and who have supported us when we were frustrated.

Especially Johan Beigart and Mikael Zellén, you have both been wonderful.

Last but definitely not least; we would like to say thank you to our supervisor

Jeanette Olsson. You have truly encouraged us and always given great ideas in the

process of writing this study. Thank you to everyone involved making this study

possible!

Table of Contents

1 Introduction...1

1.1 Introduction to the problem...1

1.2 Aim...2

1.3 Research questions...2

1.4 Relation to social work...2

1.5 Delimitation of the research area...2

1.6 Declarations for children’s rights...3

1.6.1 The Convention on the rights of the child 3 1.6.2 The African Charter on the Rights and Welfare of the Child 3 1.6.3 The Guidelines for the Alternative Care of Children 3 2 The Burundi context...4

2.1 Geography and short facts...4

2.2 Socio-economic situation...4

2.3 History...4

2.4 Children’s situation in Burundi...5

2.5 Institutions for Children in Burundi...5

2.6 Presentation about the studied support systems...6

2.6.1 The institution Emmanuel 6 2.6.2 FVS-AMADE Burundi 7 3 Literature review...9

3.1 Family-based care...9

3.2 Institutional care...10

3.2.1 Physical and psychological harm caused to children in institutional care 11 3.2.2 Long-term effects of institutional care 11 3.3 Recommended models for care...12

4 Theoretical framework...14

4.1 Empowerment...14

4.1.1 Community Empowerment 14 4.1.2 Individual Empowerment 15 4.2 Social support...15

4.2.1 An ecological approach of Social support 15 4.2.2 Different types of social support behaviours 16 5 Method...18

5.1 Preconceptions...18

5.2 Choice of method...18

5.3 Interviews...19

5.3.1 Semi-structured interview guide 19 5.3.2 Themes of the interview guide 20 5.3.3 Sample 20 5.3.4 Respondents 21 5.3.5 Data collections 21 5.4 Observations...22

5.5 Analysing method...23

5.6 Ethical considerations...24

5.7 Language and the use of an interpreter...25

5.8 Validity, reliability and generalization...25

5.9 Literature search...26

5.10 Division of labour...26

5.11 Discussion of method...26

6 Result and analysis...28

6.1 Introduction...28

6.2 Best interest of the child...28

6.3 Adequate standard of living...32

6.4 Parental Care and Protection...33

6.5 Health and Health Services...36

6.6 Freedom of expressions...39

6.7 Leisure, Relax, play and Cultural Activities...40

6.8 Protection of Privacy...42

7 Discussion and Conclusions...44

7.1 Study limitations...44

7.2 What are the respondents´ views of the advantages and disadvantages with Emmanuel and FVS-AMADE?...45

7.3 What do our respondents think about the various forms of support that exist within FVS-AMADE and Emmanuel?...45

7.4 What are the OVC´s overall impression about FVS-AMADE and Emmanuel?...46

7.5 Suggestions for further research...47

8 References...48

9 Appendix...53

Interview Guides...53

Consent Forms...56

Our selected articles from the declarations for the children’s rights...59

1 Introduction

1.1 Introduction to the problem

Years of war and armed conflict continue to have a negative impact on the situa- tion for children in Burundi (UN 2010). It is not easy for a child to live in a post- war environment with really hard living conditions (UNICEF 2014a). The United Nation (UN 2010) expresses its concerns about a large proportion of families and children in Burundi continue to live in extreme poverty. The fact that Burundi is one of the poorest countries in the world has terrible consequences for the chil- dren. The huge lack of medical hygiene, infrastructure, and materials produce a variety of diseases and viruses and this seriously affect the health of the children.

People in Burundi are also fighting a hard battle against AIDS, 1.3 percent of the population, approximately 90,000 people, are carriers of the HIV virus. This also affects young children; 17,000 children in Burundi between the age of 0 and 14 are estimated to be infected with HIV (ibid.; UNAIDS 2013). The committee is also concerned about the Orphans and other Vulnerable Children (OVC) in the country and the fact that the numbers are increasing rapidly. UNICEF (2008) de- fines an orphan as a child of 0-17 years old whose mother, father, or both are dead. The definition of a vulnerable child is a child under the age of 18 years old who currently is in high risk of lacking adequate care and protection. Of course every child is vulnerable comparing to adults, but some children are more criti- cally vulnerable than others. For example children who are orphans, abandoned by parents, living in extreme poverty, HIV-positive or living with a disability (ibid.).

United Nations Children’s Fund (UNICEF 2014a) estimates that 680,000 children in Burundi are orphans and that the civil war, AIDS and other common diseases such as malaria have orphaned most of them. The orphans are suffering from the poverty and are also facing problem with access to education. Many primary schools were destroyed in the war and many teachers have been killed. Among the orphans only 82 percent of all the 68,0000 attended school from 2008 until 2012 (ibid.).

Different organizations in Burundi are trying to help the OVC by building more institutions to give these OVC a home (UNICEF 2010). Institutional care is aim- ing on providing housing support, personal and social care to an individual. Insti- tutional care could support different kinds of social groups, in this study institu- tional care refers to provision of home for OVC who's family are not alive or do not have the resources to take care of their own children (Harris & White 2013).

The opinion of the United Nations Committees is that institutional care should be the last solution for children (UNICEF n.d.). Instead The UN Committee on the Rights of the Child (2010) has identified the family-based model as the most ap- propriate model. Family-based care refers to supporting OVC to live in a family environment, which could be the biological family, extended family or other fami- lies in the community. In this study this model of support is aiming to organize communities to create resources to care for OVC in the family (Greenberg &

Williamson 2010). If this model fails, adoption is seen as preferable alternative

before institutional care (UNICEF n.d.).

What we wanted to examine through this study was how two support systems, one institution and one family-based organization, for OVC work in Burundi and we also wanted to compare these organizations with each other. The studied institu- tional organization is named Emmanuel and is located in Kiremba and the family- based organization is named FVS-AMADE and is located in Bujumbura. We got in contact with these organizations through a friend who inspired us to create this study. Our friend had contact with both FVS-AMADE and Emmanuel and since both of the organizations are working to support OVC´s in Burundi were the orga- nizations suitable for the aim of this study.

1.2 Aim

The aim of this study was to describe two support systems for Orphans and Vul- nerable Children (OVC) in Burundi. The study compares one institution with one family-based organization to analyse which model that is in the best interest of the child according to the OVC and the staff members from the studied organizations.

Our definition of the best interest of the child is based on the criteria from our 33 selected articles in The Convention of the Rights of the Child (CRC), The African Charter on the Rights and Welfare of the Child (ACRWC) and The Guidelines for the Alternative Care of Children

1.3 Research questions

1. What are the OVC´s and staff members at FVS-AMADE and Emmanuel’s views of the advantages and disadvantages with the organizations?

2. What do the OVC and the staff members at FVS-AMADE and Emmanuel think about the various forms of support that exist within the organiza- tions?

3. What are the OVC´s overall impression about FVS-AMADE and Emmanuel?

1.4 Relation to social work

This study is highly relevant to social work since it studies the social work carried out by two organisations to assist OVC, and how they work in relation to the best interest of the child. This is relevant to social work because the OVC are in a vul- nerable position. Vulnerable children are a major target group for social work and the best interest of the child is often forgotten when dealing with issues related to children.

1.5 Delimitation of the research area

What we wanted to examine through this study was how two support systems for OVC work in Burundi and compare these with each other. We decided to evaluate where it is best for these children to live according to the best interest of the child.

We think that the most important thing is that a child has a safe and loving envi-

ronment to live in. Therefore, we decided to not focus on the fact that OVC also are victims of violence, sexual abuse, drugs, alcohol, because if the child has a safe and loving home it is more possible for the child to have a good life without these problems.

1.6 Declarations for children’s rights

Our definition of the best interest of the child is based on the criteria from our 33 selected articles (appendix 6) in the declarations below. The best interest of the child is to have a life with a standard that is good enough to meet the child´s men- tal and physical needs and to have the right to live in a supportive, protective and caring environment. In each and every decision affecting the child the primary concern must be what is best for the child and the child should be entitled to ex- press his/her feelings and opinions in all matters affecting him/her. The best inter- est of the child also includes the child´s right to play, leisure, relax, participate in cultural activities and the right to have privacy in his/her life.

1.6.1 The Convention on the rights of the child

UNICEF is the driving force of CRC and works to ensure that the rights of chil- dren are realized. The convention consists of 54 articles and is divided into four categories of rights and a set of guiding principles. Each article has focus on dif- ferent aims to strengthen the children’s rights. Almost every country in the world has adopted CRC. Burundi ratified CRC in 1990 (UNICEF 2014b; UN 1989).

1.6.2 The African Charter on the Rights and Welfare of the Child

ACRWC is based on CRC. These conventions strengthen each other, but the ACRWC is adjusted to the society of Africa and was founded to more look into the children’s of Africa’s needs and lifestyles. Burundi ratified the ACRWC in 2004 (ACRW 2014; AU 1999).

1.6.3 The Guidelines for the Alternative Care of Children

The Guidelines for the Alternative Care of Children were formally confirmed by

the United Nations General Assembly in 2009. The guidelines were founded to

support the CRC with focus on children’s right to live with their parents. These

guidelines show how to help children to live with families and how to avoid being

placed in institutions (UN 2009; Cantwell et al. 2012).

2 The Burundi context

To be able to understand the context of this study a short review of Burundi’s po- litical history, current social situation and the children’s situation will here be given, along with short facts about the country. To help the reader to further un- derstand the result and analysis, a description of the two studied organizations will also be given.

2.1 Geography and short facts

Burundi is a country in east-central Africa, south of the equator. The country is landlocked and boarded by Rwanda in the north, Tanzania in the east and south, and the Democratic Republic of the Congo in the west (Utrikespolitiska institutet 2013). In 2013, Burundi's population was estimated to be ten million inhabitants and a population density with more than 300 inhabitants per square kilometre (ibid.). The capital and the biggest city in Burundi is Bujumbura, the official lan- guages are Kirundi and French (Globalis 2013).

2.2 Socio-economic situation

Burundi is one of the world's poorest countries; it is ranked 225 out of 228 coun- tries in terms of per capita income 2013 (UN 2013). The country is also ranked 185 out of 187 countries in the United Nations Human Development Index, which ranks countries according to factors including health, education, and income. The country has suffered from warfare, corruption and poor access to education and 81 percent of the population live below the international poverty line of $US1.25 per day (UNICEF 2014a).

2.3 History

Since the 1800s, Burundi was part of the German colony in Africa, which in-

cluded Burundi, Rwanda and Tanzania. The colony was shattered when Germany

lost the First World War and the colony was divided between Belgium and Eng-

land. Burundi and Rwanda were merged into one country as Ruanda-Urundi and

became a Belgian colony. In 1962 Rwanda and Burundi became independent

countries. It took about two years for Rwanda and Burundi to form their own sep-

arate governments. In 1966 Burundi became a republic instead of a monarchy

(Worldatlas 2014). In Burundi 85 percent of the population are Hutus and approx-

imately 14 percent are Tutsi. From the day of independence until the present con-

stitution was adopted in 2005 Burundi was marked by disagreements, rebellion,

coups and civil war between these ethnic groups. The Hutu leader Melchior Nda-

daye became president in the country 1993 and later that year; Tutsi soldiers as-

sassinated him. As a result, the country ended up in a civil war that lasted for

twelve years. During the war, hundreds of thousands of humans were killed in Bu-

rundi and tens of thousands of children were exposed to extraordinary high levels

of violence. Although Burundi’s twelve-year civil war ended in 2005 and the

country is now returning to a peaceful state, the war is still affecting the country

(Worldatlas 2014; Globalis 2013). Some social problems are very serious in the country, including one great part of the country’s future, the children’ situation.

2.4 Children’s situation in Burundi

Many children in Burundi have seen their rights violated due to the war and dif- ferent diseases but the last decade has included some improvements (UNICEF 2014a). The net enrolment rate in primary school in Burundi was 96 percent in 2010. This is an improvement since the percentage was down to 36 percent during the war before gradually rising up again in 2009 after the peace was restored. It has also been an improvement regarding the literacy rate among men and women in the ages 15 to 24 years old (UN & the Government of Burundi 2012).

According to the UN and the Government of Burundi (2012) the infant and child mortality rate in Burundi was 183 deaths per 1000 births in 1990, and in 2010 the rate was down to 142. While the number of infant and child mortality has been re- duced the neonatal mortality, which is the statistic rate of infant death during the first 28 days after birth, remains unchanged. The main reason for this is the low quality of new-born and maternal care.

Access to vaccinations has also been improved in Burundi, for example measles vaccination. This had a positive impact on infant mortality rates. Unfortunately, this improvement was affected by the negative changes in household living condi- tions related to a long period of socio-political crisis. This mortality rate also re- mains high due to the poverty, diseases and malnutrition (ibid.).

2.5 Institutions for Children in Burundi

UNICEF (2010) has done a study regarding children in institutions in Burundi and there are 98 institutions for children in the country. Around 50 of these 98 institu- tions opened during the civil war and at least 15 out of these 98 have been open during the last five years (ibid.).

In order to measure the quality of care UNICEF adapted the Standards for the Quality of Care: East and Central Africa, published by Save the Children in 2005.

These 85 standards were used to collect information for each institution and to an- alyse the situation of the children living there. The institution has to meet at least the standards for personal care of children or 60 percent of the standard to pass. In cases where the institution does not pass the Technical Committee must find an appropriate and permanent family alternative based on the best interest of the child. The study shows that the majority of the institutions were not able to achieve even half of the 85 standards. The situation is worrying in a lot of institu- tions; basic needs are not being met, such as health, education, hygiene and nutri- tion. The research also made it clear that the majority of the children in institu- tions may not need to be in institutional care at all, because they have continuous contact with a parent or the extended family, and the family could perhaps take care of the children by themselves (UNICEF 2010).

2.6 Presentation about the studied support sys-

tems

The information in this section is based on written information, oral communica- tion and information through interviews with staff members and own observa- tions.

2.6.1 The institution Emmanuel

We visited an institution named Emmanuel during our time in Burundi and this institution became the support system we analysed to get an understanding of an institutional care model. Emmanuel is located two hours north of Bujumbura in a village called Kiremba. The institution started in 1962 by two missionaries from Sweden, Inger-Britt Ahlström and Anne-May Eriksson (Örebro pingstförsamling 2014). The director of Emmanuel told us that in a Burundi context, the father do not know how to take care of a new-born child by himself. Therefore, if the mother passes away during birth, the children often move to an institution. In this case they are moving to Emmanuel where currently 71 children are living.

When Emmanuel first started to support OVC, children could sometimes live there until they were about nine years old. Nowadays the goal is that children will move back to their family again when they are three or four years old (Örebro pingstförsamling 2014). The staff members at Emmanuel are trying to get the fa- ther to visit his child at the institution once a month to make the children's transi- tion to the family less dramatic. The director told us that unfortunately this is hard because the father often gets a new wife and children which are often more impor- tant than the child he has with his previous wife who passed away.

There are 25 caregivers who currently are employed by the institution, and twelve of them are working at the same time. Since there are 71 children living at the in- stitution one caregiver is in charge of at least five children. The children that the caregiver is in charge for are all in the same age, for example between two and five months old. There are five different houses at the institution and the children are divided according to age in these houses. In every house there are different rooms where five to seven children sleeping together in separate cribs. The care- giver who is in charge of the children has a separate bed to sleep in during the night. The tasks assigned for the caregivers are to take care of the children, pro- vide food, take care of their hygiene, give them clean clothes, protect them and play with them. In addition to the caregivers there are four men who are in charge of the security of the institution, five women who take care of the garden, one psychologist who teaches the caregivers how to take care of the children and one director who is in charge of the institution. One of the 25 caregivers is the head caregiver and is in charge of welcoming and registering the new children who are coming to the institution.

The director told us that the institutions biggest finance support comes from Öre-

bro Pentecostal church in Sweden (60 percent). Except from this income, the insti-

tution gets money from the local church (15 percent), selling their own eggs (14

percent), volunteers (ten percent), and one percent of the money comes from the

state. The total cost for one child per month is 300,000 Burundi francs, which are

approximately 1,500 Swedish crowns and 200 USD. This money is divided to

give the children food, milk, clothes and salary to the caregivers.

We observed that the children at the institution had difficulties with their develop- ment. When we played with the children we noticed that the oldest children could just speak baby talk, some of them had problems with walking, and we also no- ticed that most of the children were under-stimulated. Sometimes when we walked into the children´s room one of the children could be in there all by itself, lying on the floor and just staring into the wall. Accordingly, it was clear through our observations that the caregivers truly loved the children at Emmanuel. They gave them the best possible care, love and attention as they could from their con- ditions. Being this few caregivers to so many children is difficult, if not impossi- ble, and we were very impressed with their efforts.

We also observed that the children had big areas to play in and the institution had, for example, a seesaw, climbing frame and swings. The children had access to various footballs, stuffed animals and other toys. Contrarily, we observed that the children often argued about the toys because they did not have one toy to every child and it was sometimes hard for the children to share toys and play together and this lead to the fact that the caregivers had problems with stimulating all 71 children at the same time.

2.6.2 FVS-AMADE Burundi

FVS-AMADE has been working in Burundi since 1992 to support OVC. The union of two non-profit organizations; FVS, Family to Vanquish AIDS and AMADE Burundi, the Burundian Chapter of Global Association of Friends of Children created the organization. The organization is a non-governmental, non- profit organization and its mission is to protect OVC and promote the economic autonomy of vulnerable households for the ultimate wellbeing of the children (FVS-AMADE 2014a). FVS-AMADE´s (ibid.) vision is to build, through the in- tegral development of families, a united Burundian community that supports all vulnerable individuals and children. Therefore they decided to involve the com- munities in caring for OVC and to work with empowerment by strengthen the community to find permanent homes to all the OVC in the community. The orga- nization mainly works with three different programs within the framework of their organization to give the community capacity and strength to solve their own prob- lems:

Solidarity groups

FVS-AMADE has 1,200 solidarity groups and these groups taking care of over 45,000 OVC (FVS-AMADE 2014a). The members, who are the foster parents to the OVC, collect savings each week in three different boxes that each has a differ- ent purpose. One fund from which they are able to take out loans, one with sav- ings to buy school supplies for the OVC, and the last fund is for emergency needs within the solidarity groups. This system leads to sustainability; if the organiza- tion would close, the communities can still be able to continue with this system to improve their quality of life (FVS-AMADE 2014b; FVS-AMADE 2014c).

Community health insurance

The member’s families, including the OVC in their care, have access to healthcare

and support for the battle against HIV/AIDS (FVS-AMADE 2014b).

Children's Protection Committees (CPC)

CPC is committed to protect the rights of the children. The members of these committees are known in the community as friends of the child, the children know who they are and feel comfortable talking to them about their problems. The CPC members visit the OVC in their guardian households each week, talk to the chil- dren and the guardians, to make sure that everything is okay and to give them ad- vice (FVS-AMADE 2014c).

The first thing we observed during our visit at FVS-AMADE was that the organi-

zation definitely is working with empowerment. They want to help the community

to help the OVC, so they have created these different programs for the community

to start taking care of themselves. Everything about their approaches and different

programs sounded really good during our visit at FVS-AMADE, but it was hard to

see how all this worked in practice. We only got one opportunity to follow the

staff members to the community, and during that time we only had time to focus

on our interviews.

3 Literature review

In this chapter studies about family-based care and institutional care for OVC are introduced to show the current global knowledge about these support systems.

The discussion about the impact of placing an OVC in institutional care, com- pared to a more family-based solution, is a major discussion around the world. We are going to discuss this debate and we will also highlight instances where it is better with the institutional placement for the child and discuss recommended models for care. We have chosen to describe the literature review in three differ- ent sections; Family-based care, Institutional care and Recommended models for care, which have focus on different aspect within the subject. We think it is im- portant to show both sides of the debate, which is why we are discussing Family- based care and are continuing with Institutional care.

We are aware of that this chapter involves less literature about the positive effects in institutional care compared to studies about positive effects in family-based care. Very little was found in the literature about advantages to place OVC in in- stitutions and the negative aspects with family-based care, but we still chose to de- scribe what we found about the institution, as it is relevant for the aim of this study. We are aware that there is an uneven balance between the different sides in the debate and that this could affect our preconceptions about what is best for the child.

3.1 Family-based care

Sanou et al. (2008) have written an article about how to care for OVC. The article focuses on a foster home program in Burkina Faso, Africa and analyses the chil- dren’s development when they are living in a foster home. The findings from this article are that OVC who lived in family environments were treated in a way that gave them stable vital needs. The article also mentions that these children devel- oped strong ties between the members of their foster family. The conclusions were that family-based care provided a stable family environment within the fos- ter family, which was important for the preparation for the children’s social life.

The authors suggest that other organizations for OVC in Africa should consider using a more family-based model, instead of caring for these children in institu- tional care, where the strong ties and family bonds were not possible to develop.

Killén (1994) states that it is not always in the best interest of the child to have the child placed in a family environment. There are always going to be families where the care for the child will not be good enough for the child’s development. For ex- ample families without enough resources to be able to take care of the child. Kil- lén (ibid.) explains that in these cases can it be better of to place the child in an in- stitution than keeping it in the family.

Cantwell et al. (2012) state that if a child suffers from trauma in its family or if the

child has another negative family experience it may find it impossible to settle im-

mediately into a new family-based solution and this can leadto that the placement

does not work and the child has to move again. In such circumstances, it is not the

best option to place a child in a family-based environment, because this can lead to highly damaging serial family placements.

3.2 Institutional care

Several studies have shown that institutional care is increasing in countries where there have been changes in families and communities because of the economic transition (Brown 2009; Carter 2005; Tinova, Browne & Pritchard 2007). The changes have increased migration, family breakdown, single parenthood and un- employment. The authors state that the main underlying factor for placing a child in an institution in these countries seems to be poverty (ibid.).

If we look at the economically developed countries instead, Browne et al. (2005) have made a study in European countries and found different reasons for young children to live in institutions. Most of the children (69 percent) were placed in in- stitutional care because of abuse and neglect, 23 percent for social reasons such as family ill health or parents in prison, 4 percent due to abandonment and 4 percent because of disability. Browne et al. (ibid.) also state that no children without par- ents were placed in institutions; these children were placed by different family so- lutions instead.

Children are very often placed in institutional care throughout the world. This take place regardless of the wide recognition that institutional care isrelated to negative consequences for children’s development (Carter 2005; Johnson, Browne &

Hamilton-Giachritsis 2006; Höjer 2001; Wiener 1998). Institutions often have too few caregivers and are therefore limited in their capacity to give children the at- tention, personal identity, affection, and social connections that communities and families can offer (UNAIDS, UNICEF & USAID 2004). Young children in insti- tutional care are more likely to suffer from poor health, physical underdevelop- ment, emotional attachment disorders, different cognitive functions and lack of identity formation. Consequently, these children have reduced intellectual, social and behavioural abilities compared with those growing up in a family home (ibid.). Children who have grown up in institutions have also developed trust is- sues and stress factors caused by psychological problems (Wiener 1998; Sanoue et al. 2008). Despite this, there are several reasons that can make institutions the best option for a small minority of children at a given point in their lives. Sanou et al. (2008) emphasise the danger of generalizing that institutional care always is negative for the OVC. They mean that it is important to see the context of the country and what kind of socio-cultural history the country has. In an African con- text it is the high rate of adult mortality, poverty and cultural difficulties that lead to the challenges of the family care model in the communities. Furthermore, some adolescents express a preference for living in a small institution with friends, for example, if they feel it hard to cope with the expectations and intimacy of life in a family environment. One other example is children who need specialised treat- ment and assistance, this can usually be hard to provide in a family-based model, because of poverty (Cantwell et al. 2012). Wiener (1998) also mentions that these institutions can sometimes be a safe environment for the child due to the fact that the children have access to adequate nurturing care and a safe environment.

Wiener (ibid.) points out that sometimes it is important to explore institutions as

an alternative care.

3.2.1 Physical and psychological harm caused to children in insti- tutional care

Nelson et al. (2007) state that institutions are typically overcrowded around the world. They also state that institutions are most often in clinical environments and the caregivers are often more related to nursing and physical care than to psycho- logical care. Maclean (2003) states that it is very common that the children spend most of the days in their crib without any stimulation. The children often spend very little time outside the institution; it only happens on rare occasions under strict supervision and limited play. This complicates the children’s opportunity to play and have contact with dirt, which challenges and helps develop a child’s im- mune system. Play is also a process at the root of all learning and it influences our capacity to survive and develop. The word play describes a range of behaviours, which are expressions of the child’s desire to know and understand the surround- ing world. Without play there is little understanding (Hughes 1990). Most people would agree that all children have a fundamental right to receive a level of health care, education, nutrition and good housing sufficient to ensure a reasonable qual- ity of life and life expectancy. What about children’s right to play? CRC (UN 1989) states that the child shall have full opportunity to play and this should be di- rected to the same purpose as education. CRC also states that the public authori- ties and the society shall endeavour to promote the aim of this right (ibid.).

Several studies state that institutions have a number of other physical and psycho- logical harmful effects, for example weight and height below the norm, poor diet, under-stimulation, delay of the motor skills, missed developmental milestones and in difficult conditions stereotypical behaviours, such as head banging and body rocking (Carter 2005; Mulheir & Browne 2007). Children are also often isolated from staff members and other children when they are sick and this is a time when they need comforting and sensitive care the most (ibid.).

Brown (2009) highlights that children living in institutions are reported to be slow learners with specific difficulties in language and social development and perform poorly on intelligence tests in comparison to children in family-based care. Other studies are showing that children who have lived in institutions also have higher risk of developing psychological behaviour, emotional problems (Sanou et al.

2008) and complications with building relationships with adults compared to chil- dren who have grown up in a family-based environment (Tizard 1977 1978 re- ferred in Bilson 2009:1386).

3.2.2 Long-term effects of institutional care

Bilson (2009) states that children who live in institutions have a higher risk of get- ting long-term effects on their development. The risk is lower for those children who stayed in an institution for shorter periods, compared to the children who ba- sically had their whole childhood in an institution. Killén (1994) emphasises the importance of searching for a suitable family while the children are staying in an institution, in order to move them to a family-based environment as quickly as possible.

Freidus and Ferguson (2013) discuss the possible impact for children who live in

institutions. Children living in institutions may receive food, clothes and other in-

strumental support, but the fact that they are being separated from their families and community has a huge impact on their future. This can lead to difficulties to gain employment since they do not have any bonds to their family or society, which lead to difficulties to create a stable future. The potentially damaging and long-term impact on children placed in institutions are due to many factors. For example the lack of a primary caregiver with whom to bond, poor access to stimu- lation and constructive activity, an absence of basic services, violence, and isola- tion from the family and the world outside the institution (Cantwell et al. 2012). If the staff members do not prepare the children for a life after leaving the institution the children will face difficulties with the reintegration to the community. Besides this the children will face even more problems due to the institutional care if the staff members do not do follow-ups when the children are leaving them and if the institution does not achieve family reintegration at all (ibid.).

3.3 Recommended models for care

UNICEF (n.d.) has identified the model when OVC are living with extended fam- ily or other people close to the family as the most appropriate support model for OVC according to the best interest of the child. If this model fails, adoption or placement in foster care is a preferable alternative. Institutional care should al- ways be the last solutions regarding to UNICEF (ibid.). The Joint United Na- tions Programme on HIV and AIDS and UNICEF (2004) agree with this. They state that children should be placed in institutional care only when no better place- ment options are possible. They are also saying that if a child in some circum- stances needs to be placed in an institution it should be preferably only on a tem- porary basis until a family or community placement can be made.

Article 20 (appendix 6) in CRC (UN 1989) states that every child that cannot be taken care of by their own family has the right for special care from the commu- nity. Since the family is the fundamental unit of the community and the natural environment for children, the last option to solve the problem should be to move a child from his/her family. In situation when the child has to be moved, due to dif- ferent reasons, efforts should primarily aim to maintain or return the child to his/her parents or, where applicable, other members of his/her immediate family.

All children should live in a supportive environment with protection, which en- courages the development of their potential (UNICEF n.d.).

UNICEF and UNAIDS (2004) also state that care provided in institutions often fails to meet the long-term need for the children and their development often take damage by staying there. Children do not just need good physical care; they also need attention, security, social connections and affection that families and com- munities can provide. Other African countries, like for example Burundi’s neigh- bour Rwanda has seen children that have grown up in institutional care become young adults with problems and difficulties to reintegrate into the community.

This has led the government in Rwanda to adopt policies of de-institutionalization and support for family-based care (ibid.).

UNICEFs minimum standards for institutional care were developed based on the

provisions of CRC and the Guidelines for the Alternative Care of Children. They

represent an adaptation to the standards for the quality of care for children in East Africa and Central Africa, published in 2005 by Save the Children. The minimum standards are important to keep good quality of the services for children deprived of a family environment (UNICEF n.d.).

A lot of studies that are mentioned in this chapter make it clear that the best solu-

tion for an OVC is to stay in a family-based environment. Despite from these

studies it is also more expensive to maintain institutions than providing direct as-

sistance to existing family and community structures. Institutional care would be

too expensive for the vast majority of countries around the world. An example for

this is a research made by the World Bank in the United Republic of Tanzania,

showing that institutional care was about six times more expensive than foster

care (UNICEF & UNAIDS 2004).

4 Theoretical framework

In this chapter we are going to introduce the theoretical perspectives that we have chosen to use when we are analysing our collected data in order to get answers to our aim and research questions. As described earlier in the section, Presentation about the studied support systems, FVS-AMADE is working to empower the community to start helping themselves. To get a deeper understanding of this way of supporting OVC and to be able to get answers to our research questions we have chosen to adapt the theory of Empowerment. To analyse the two studied sup- port systems and to reach the aim of this study we also adapted Vaux’s (1990) definition of social support. This theoretical framework gives an understanding of various approaches of how to achieve children’s rights to a protecting and caring environment.

4.1 Empowerment

Payne (2008) explains that empowerment as a wide concept used both as a theory and a method aiming to free groups and individuals from oppression and to obtain control over their lives. The method Payne (ibid.) is talking about is the same method FVS-AMADE is working with to strengthen the community in order to find a home to all the OVC in the community (FVS-AMADE 2014a).

Empowerment is related to the word power. The concept leans on its original meaning of investment with legal power, which means permission to act for some specific purpose or goal (Askheim & Starrin 2007). FVS-AMADE (2014a) wants to give the community support so they are able to create power to act towards their goal, which is to build a united Burundian community that supports all OVC through the integral development of families. With this power people are manag- ing to gain more control over their lives, either by themselves or with the help of others (Payne 2008). Empowerment is based on an approach where the most im- portant is that all people have the resources and capacity to define their own prob- lems and develop action strategies for solving them (Askheim 2007). FVS- AMADE (2014a) has given the community resources in forms of different pro- grams, Solidarity groups, Community health insurance and Children's Protection Committees to give the community capacity and strength to solve their own prob- lems. Askheim (2007) states that the importance of empowerment is for people in a powerless position to find this strength to create a driving force to leave a pow- erless position. Through this the individual is capable to work against the forces that are keeping him/her in this powerless position and create a life where one has more influence of one’s life (ibid.).

Empowerment is a wide theory with many different definitions and explanations.

We choose to focus on community empowerment and individual empowerment because this was tangible in our collected data.

4.1.1 Community Empowerment

Community Empowerment focuses on changing the social and political environ-

ment by working on critical consciousness and shared control (Wallerstein 2002).

This change of the social and political environment and the shared control is something that FVS-AMADE is working with when they give the community power within the different programs. Community empowerment includes good re- lationships, which lead to strength and empower the people to act together in the community to solve the problem. This also creates strength to the individual and a sense of pride rather than shame or powerlessness (Westerlund 2007). The indi- vidual becomes part of a collaborative learning to create a context that everyone can participate in (Starrin 2007). Relationships create a kind of group member- ship, which strengthens the individual sphere but also personal and collective re- sources (Payne 2008). To work together like this, with others who are in the same vulnerable social situation, or to show solidarity with the vulnerable people, is one of several expressions of community empowerment (Starrin 2007). Groups with people who are vulnerable and people who want to show solidarity with the vul- nerable people will strive towards the same goal, that all people should feel in- cluded in the community, even the OVC (ibid.; Askheim 2007).

4.1.2 Individual Empowerment

Westerlund (2007) describes individual empowerment as the individual's ability to use power and influence in relation to important areas in their own lives. The indi- vidual can use the support that FVS-AMADE is giving them through the different programs to create power to solve their personal problems in their lives (FVS- AMADE 2014a). Another important concept regarding individual empowerment is mastery. Askheim (2007) describes mastery as individuals having to learn to live with their situation and overcome everyday challenges to have control over their lives. Askheim (ibid.) and Wallerstein (2002) also state that when you are working with empowerment the individual should be the main focus and it is where the change will take place. The individual should be asked to take care of herself/himself using empowerment strategies (ibid.).

4.2 Social support

Social support is a broad theory with different definitions and explanations. We have chosen to explain our understanding of the theory, which is based on Vaux ecological approach of the theory. We are also going to introduce different types of the supportive behaviours.

4.2.1 An ecological approach of Social support

Social support is a complex system according to Vaux (1990). In his article; An ecological approach to understanding and facilitating social support he adapts an ecological understanding of social support to describe this complex system. Vaux

´s definition is that social support is best demonstrated in an ecological context,

including supporting networks in a person's life, supportive behaviour and subjec-

tive evaluations of support. This ecological context of social support contains

transactions and recourses in an individual’s social network, for example different

supportive behaviours. Nordin (2010) explains that social network is the structure

of social support and that the supportive behaviours that come from the social net-

work are the function of social support. The structure of social support can for ex-

ample be friends, biological family, extended family and persons at work (Vaux

1990; Nordin 2010). To give a subjective evaluation of the social support Vaux ecological context also involves an understanding of how to support someone and what kind of supportive behaviour that is suitable for an individual (Vaux 1990).

4.2.2 Different types of social support behaviours

Different types of supportive behaviours are vital to understand the theory of so- cial support. People can be in need of different kinds of supportive behaviours in life and this can be given in different ways. We have therefore chosen to adapt Langford et al. (1997) categories of different kinds of supportive behaviours in the process of analysing since these categories are our respondents most frequently described way of support. The chosen categories are introduced below.

Emotional support

Langford et al. (1997) are saying that emotional support is one of the most com- mon ways of describing social support. The authors mean that emotional support includes caring, empathy, love and trust. The emotional support is crucial to be open to receive other types of support. The authors mean that if a person receives care, empathy, love and trust, the person will probably feel like he/she belongs somewhere and feel accepted, loved and needed. Ewelöf and Sverne (1999) put emphasis on that emotional support can provide a positive development and that love is essential for the children to be seen as individuals on their own terms.

The caregivers at Emmanuel tried to achieve this by giving the children the best possible care, love and attention as they could from their conditions

In addition to these aspects of emotional support, Hedin (1994) describes emo- tional support as a way of feeling engaged and encouraged. For example, if an in- dividual is feeling encouraged this kind of emotional support can lead to the indi- vidual starting to handle his/her problems in life in a better way. Just because the person gets a little encourage and emotional support from the social network around him/her. This could be translated to FVS-AMADES work. They help the community so they are able to encourage and give the OVC emotional support to empower him/her to handle his/her own problems (FVS-AMADE 2014a).

Instrumental support

Instrumental support is referring to economic, material and practical help (Me- lander 2009; Nordin 2010). This kind of instrumental support is very distinct at Emmanuel. Some of the caregivers’ main tasks are to take care of the children’s hygiene and to provide them with food and clean clothes

. Langford et al. (1997) also point out that instrumental support is different forms of services to help an in- dividual, for example providing a place in a treatment centre or giving food to someone (Hedin 1994). This kind of instrumental support could be translated to FVS-AMADES program Community health insurance, where the health insurance gives the members families, including the OVC in their care, access to healthcare and support the battle against HIV/AIDS (FVS-AMADE 2014b).

1 Oral communication with the director of Emmanuel 2014-10-21.

2 Oral communication with the director of Emmanuel 2014-10-21.

Informational support

The informational support is aiming at information or guidance about how to act

in different situations (Hedin 1994). Langford et al. (1997) emphasises the impor-

tance of giving an individual this kind of support since this is useful in times dur-

ing stress, when need of guidance is crucial to make appropriate decisions. This is

something that FVS-AMADE is working with in their program Children's Protec-

tion Committees. The members of these committees should be friends of the child

and talk to them about their problems and give advice (FVS-AMADE 2014c).

5 Method

5.1 Preconceptions

Before our trip to Burundi we got information about the country from a friend who had been there several times. This led to that the two of us, who had never visited the country before, arrived with basic information about the culture and the history of the country. Although, we still found it hard to understand the culture of Burundi since it is very different from the one we have in Sweden. We think this may have affected us in a positive way since we did this study with different glasses than someone who knows the culture would have done.

According to Thurén (2007) researchers are constantly affected by their feelings, impressions and preconception when they conduct their studies. He states that it is important to be aware of your preconception to reduce the risk of letting your view of the aim influence the study.

Our preconception about the two support systems for OVC in Burundi was that we thought that the family-based model seemed to be the best solutions for the child in line with our definition of the best interest of the child. The two of us have grown-up in family environments and we believe that the love you get from your family is hard to get in an institution. We also had some preconceptions from our studies in social work, for example the value of emotional support and we thought that this also was something that you easier get in a family-based model then in an institution. We are aware of that these preconceptions influenced our opinions when we analysed the collected data. Our values and feelings about plac- ing OVC in an institution have most likely affected the interviews and the process of analysing the collected data. Therefore, we found it important to try to be criti- cal about our preconceptions in order to do a better study with a wider perspec- tive.

5.2 Choice of method

The aim of this study was to describe two support systems for OVC in Burundi and to compare one institution with one family-based organization to analyse which model that is in the best interest of the child according to the OVC and the staff members from the studied organizations.

According to Kvale, Brinkmann (2009) and Bryman (2011) this study was suit-

able for a qualitative method since the research questions were based on the re-

spondents´ own opinions, descriptions and feelings about the subject. A quantita-

tive method was not chosen in this study because that method is useful in studies

when you are interested about generalize an aim within a bigger population

(ibid.). The ambition of this study was to analyse what a chosen group thought

about the aim and not to generalize the conclusions to a bigger population.

Observations and interviews with staff members, youth and children from the studied support systems have been performed to enable answers to the aim of this study. A key informant interview with a staff member from UNICEF was also conducted to receive fundamental knowledge about the situation for the OVC in Burundi. These methods are introduced in detail below.

5.3 Interviews

This study has been conducted with qualitative interviews to collect the data.

Kvale and Brinkmann (2009) emphasise that the respondents´ practical skills and personal opinions are in focus when you are using qualitative interviews as a method. This method was suitable since the ambition of the study was to examine the respondents’ individual descriptions and feelings about the aim. Kvale and Brinkmann (ibid.) are saying that the purpose of using qualitative interviews is to understand the world from the respondent’s point of view and then use these un- derstandings in the process of analysing when you are explaining their words with a theoretical view. This can be translated to the hermeneutic research tradition, which states that it is important to create a contextual knowledge about a subject.

Through a perspective mixed with preconception, along with the respondents’

opinions and a theoretical view, you achieve a wide perspective within the aim (Thurén 2007).

5.3.1 Semi-structured interview guide

A qualitative interview can be conducted in different ways. This study has adopted Kvale and Brinkman (2009) method of semi-structured interview guide (appendix 1 -3). By using a semi-structured interview guide the respondent get an opportunity to differ from the interview guide and talk about subjects outside the guide. This was important in order to let the respondent freely talk about the sub- ject and not be affected by the interview questions (Bryman 2011).

Kvale and Brinkmann (2009) mention the importance of having a theoretical background about the research that is being studied, in order to have an interview guide with relevant questions. With this in mind, the first step in the process of making a suitable interview guide was to read, get knowledge and compare the ar- ticles in CRC, ACRWC and alternative care guidelines. The ambition of the inter- view guide was to ask questions regarding different themes of the best interest of the child. The next step was to choose which articles that seemed most appropriate to use in the guide towards the aim of the study. Eventually 33 articles were cho- sen from CRC, ACRWC and alternative care guidelines and these articles were used to create seven new themes with different interview questions (appendix 6).

Kvale and Brinkmann (2009) emphasise the importance of having knowledge about the study setting and the culture of the respondents’ life. Therefore was the interview guide in this study changed after having awareness about Burundi, the organizations and the population. The seven different themes still remained, but dependent on the direction of the interview, some of the themes were more in fo- cus then others.

5.3.2 Themes of the interview guide

Best interest of the child

This theme focuses on that in each and every decision affecting the OVC the pri- mary concern must be what is best for the OVC. This includes decisions regarding their future and where the OVC should live.

Adequate standard of living

The focus of this theme is every OVC´s right to a life with a standard that is good enough to meet their mental and physical needs. OVC have the right to live in a supportive, protective and caring environment.

Parental care and protection

This theme highlights the importance of parental care and focuses on OVC who are separated from their parents and how they can be protected. Additionally this theme focuses on what a family is for an OVC.

Health and health services

The aim of this theme is to urge that every OVC has the right to an adequate health care, in order to have a stable physical and psychological health. This also includes OVC’s right to provision of nutritious food and safe drinking water.

Freedom of expression

This theme affirms that OVC, in accordance with the OVC’s age and majority, are entitled to express their feelings and opinions in all matters affecting them.

Leisure, relax, play and cultural activities

The aim of this theme is to highlight the importance of OVC’s right to play, leisure, relax and participate in cultural activities.

Protection of privacy

This theme emphasises the importance of an OVC’s right to privacy in their life.

5.3.3 Sample

Since the aim of this study was dependent on the respondents’ personal opinions, feelings and thoughts we found it important to build trust and show respect to the respondents. With this in mind we wanted to have one separate meeting with FVS-AMADE and one with Emmanuel, with the purpose of introducing the aim of the study and ourselves. The staff members that were participating in the meet- ings asked questions about our personal background, what we thought about their country and what kind of respondents that was needed for the aim with the study.

Additionally we informed them that we wanted to interview staff members, youth

and children from each organization to get a varied data material. Since we did

not know how the possibilities were to find suitable respondents we asked one of

the staff members from each organization that participated in the meeting if he/she wanted to be our first respondent. It also seemed convenient to ask if he/she wanted to participate since we had started to build trust with these staff members.

The first respondents from the organizations introduced the remaining participants to the interviews. This method of choosing respondents can be translated to a net- work model where the researcher finds suitable participants introduced by the first respondent (Bryman 2011). One issue with this model was that we did not have influence over which respondents that were asked to participate. The respondents were often introduced just a few minutes before the interview took place and this lead to situations where it was important to be flexible and to have an interview guide to lean on. If we had more influence over which respondents that were asked to participate, the interview may have been different. Another aspect within the network model was that staff members from the organizations chose the re- spondents. There is a risk that the staff members chose respondents that were in the organizations advantage. If we had used another model of choosing respon- dents the empirical findings and the result of this study may have been different.

Totally we had six respondents from FVS and six respondents from Emmanuel, with different ages, sex and positions in the organization. We also decided that we wanted to interview someone from UNICEF to get a larger perspective and over- view towards our aim. We got in contact with a person at UNICEF in Bujumbura by e-mail and got an appointment for a meeting.

5.3.4 Respondents

Seven different respondent groups were made to get a variety of opinions about the aim. The respondent groups and number of participant in each group are presented below.

 Three staff members from FVS in the age of 25 – 50 years old.

 Three staff members from Emmanuel in the age of 25 – 50 years old.

 One staff member from UNICEF in the age of 25-50 years old.

 One youth who has had support from FVS who was in the early twenties.

 One youth who has been living at Emmanuel who was in the early twenties.

 Two children in the age of three years old, which are currently living at Emmanuel.

 Two children in the age of three years old, which are currently receiving support from FVS.

5.3.5 Data collections

All of the staff members from FVS and Emmanuel chose to have the interview in their office, because it was the most comfortable and convenient place. The interview time varied from 45 to 90 minutes. An interpreter was used in three out of these six interviews.

The interview with the staff member from UNICEF was used as a key informant

for this study. The purpose of the key informant was to collect data from a profes-

sional who had a great knowledge about the country, the situation for OVC and

how UNICEF is supporting them (Marshall 1996). The interview was held at UN

in Bujumbura where UNICEF had their office. The interview time was about 40 minutes and since the staff member from UNICEF could speak English an inter- preter was not needed.

The interview with the youth who has had support from FVS-AMADE and the youth who has been living at Emmanuel took place at the organization where they had received support. In one of these two interviews an interpreter was needed to translate the conversation. The staff members had contacted the youths before the interview and had asked them if they wanted to participate in the study. The inter- view time was about one hour in both cases.

The interview with the children currently living at Emmanuel took place at the in- stitution. A staff member chose which children that seemed most appropriate to interview. Both of the children were in the age of two-three years old. Kvale and Brinkmann (2009) point out the value of asking questions that are adapted to the age of the child. To make the interview more child-adapted we had prepared a pa- per with three smileys; one happy, one neutral and one sad. These smileys were going to help the child to point out the feelings about the question (appendix 3).

Kvale and Brinkmann (ibid.) write about interviewing children and point out the importance of keeping the interview simple. The interview time ended up to last for ten minutes, which seemed suitable for children at that low age.

The interview with the children who currently have support from FVS took place in a small village named Kanyosh where the children lived. Staff members from FVS had prepared the children for the interview and had informed the children that we, with their approval, were going to interview them. The children who participated were 15 and three years old. The interview with the 15 years old child took about 30 minutes, compared to the interview time with the three years old child that took about ten minutes. Since the children who participated in the interview were introduced to us when the interview started, we did not know that one of the children were only three years old and we did not get the chance to prepare our child adapted interview with the smileys. We solved this by selecting and asking the three most adequate questions from the interview guide we used with the older boy (appendix 1 & 2). Due to the young age of the three years old child it was considered suitable to have an interview, which only contained three questions. An interpreter helped out with translation in both of the interviews since the children did not speak English.

5.4 Observations

During our time at FVS-AMADE and Emmanuel we got the opportunity to get a

valuable insight of the two different models. When we visited FVS-AMADE we

got the opportunity to see how the staff members worked at their office but unfor-

tunately we did not get the chance to be in the community more than one time and

this was when we held our interviews with the children in the community who get

support from FVS-AMADE. Of course we could observe a lot of things during

this visit, for example the standard of the houses, the appearance of the children

and their reactions when they met us, but it would have been good for the study to

get more opportunities to just go out in the community to observe.