The millions of children separated from their families around the world would do best in a family environment, not institutional care, and leaders should prioritize a collaborative, well-managed shift toward family-centered care, according a report from a commission based in the Lancet Group of medical journals.

"The global intent to provide optimal care for separated children has never been greater. Momentum to move children from institutions and into families is building, led by welcomed evidence and practical leadership from many sectors within child health, child protection, and social welfare," said the report's executive summary, authored by The Lancet Psychiatry editor-in-chief Niall Boyce; Jane Godsland, editor-in-chief of The Lancet Child & Adolescent Health; and King's College London professor Edmund Sonuga-Barke.
"It is essential that governments, voluntary organizations, and health and social care professionals work together so that action is not taken precipitately, with potentially unintended adverse consequences, but is instead timely, sustainable, and child-centered," they said.
The last century in North America and most of Europe has seen a major shift toward family-based care.
"The same shift elsewhere in the world is urgently needed," said the commission report's executive summary.
As of 2015, 5-6 million children were estimated to live in institutions such as orphanages and residential homes in some 137 countries, most of which are low or middle income. In some countries this number has decreased, but in others the numbers have increased due to HIV. The commission said factors driving institutionalization include poverty, social deprivation, poor parenting skills, illness and disability of the child or the carer, natural and manmade disasters, and child abuse and neglect.
Institutional care is usually inconsistent, with poorly paid and poorly trained staff. High staff turnover hurts the possibility of building relationships and providing basic standards of care. Children might suffer mistreatment from both staff and their peers.
"Institutional care denies children and adolescents access to kinship networks that have a major role in many societies," the commission report said.
"Institutionalization often has a profound effect on a child's physical and psychological development and can be associated with long-term mental health problems," the report continued. At least 80% of institutionalized children were below average in physical growth and cognitive development, and they face greater risk of attachment problems. There are "strong negative associations between institutional care and children's development, especially in relation to physical growth, cognition and attention."
The effects could be especially harmful to babies and young children aged six to 24 months. Longer stays in institutions are associated with larger delays in development. These effects can be "rapidly reversed, especially in physical growth and brain growth, but the children most affected can face longer-term effects." However, the situation of these children "rapidly improves" when they leave institutions for family-based care in adoption, kinship, or foster care.
"Moving children from institutions to families requires the coordination of an integrated set of global, national, and local initiatives," the commission said. "Only a combined effort that links national and international policies and resources with local knowledge and practices can create meaningful, sustainable change. Global development, governmental, donor, faith-based, and volunteer agencies need to work together to transform care systems, address the drivers of institutionalization, support child protection, and end child trafficking."
The commission encouraged policy makers to reconsider incentives that support children's institutions, including tax breaks for donations, financial transfers and volunteer tourism "voluntourism" to visit children's institutions. Rather, policymakers should incentivize the promotion of family-based care.
National frameworks must be established to eliminate institutions and to reform care for children in need, with good data collection and monitoring of care. Workforce development is needed for new professions that support family-based care, and funding should be redirected from institutions to family-based care in "a deliberate, phased and safe manner." The ultimate goal should be "safe, sustainable, and nurturing family-based care for every child."
The means to this goal should include strengthening family-based alternatives, a broader child protection system, and the progressive elimination of institutions.
The report pointed to the Rwanda program Let's Raise Children in Families as an example. That program has the support of the government, the Catholic Church, and many other non-profit groups.
Sonuga-Barke, the King's College London professor, chaired the Lancet group commission on the subject of institutionalization and deinstitutionalization of children. The commission's leaders are 22 experts on reforming care for children. Its report includes a review and a meta-analysis of the effects of institutionalization and de-institutionalization, plus 14 policy recommendations.
The first part of the commission's work was published in The Lancet Psychiatry journal, while the second part was published in The Lancet Child & Adolescent Health journal. Sonuga-Barke said this work is both "a call to action to end the scourge of institutionalization" and "a carefully considered and practical plan of action for agencies working at all levels across the international community."
"Building on the very welcome growing momentum for a shift from institutional to family-based care, this commission calls for a step change in the rate of de-institutionalization and the promotion and delivery of high-quality family-based care alternatives," he said.
Religious organizations have a role in this work.
"Faith-based organizations and leaders should work with other stakeholders and use their voices to change knowledge, attitudes, and practices in their communities to promote the protection of children in family-based care, and to strengthen families," the Lancet group journals said June 23.
The commission was supported by the Lumos Foundation and led by Lumos, King's College London, and the global child welfare advocacy group Maestral International.
Catholic Relief Services, the U.S. bishops' international aid agency, has been active in working to move children from institutions to family-based care. In October 2018, the agency launched its "Changing the Way We Care" program. As of February 2020, CRS-backed programs to change care systems have begun in Guatemala, Kenya, and Moldova. It hopes to expand these programs to Haiti, India, Indonesia, and Lebanon.
The initiative is joined by the Lumos Foundation and Maestral International, the same groups that supported the Lancet group's commission. CRS partners include national governments, the Better Care Network, and the Faith to Action Initiative.  The program itself is backed by the U.S. Agency for International Development, the MacArthur Foundation, and the GHR Foundation.
"With COVID-19, we have been working on being agile so we can continue our work supporting governments and local actors in these countries to continue to support children and families," Megan Gilbert, a CRS spokesperson, told CNA June 23. "In other words, we are continuing with the work despite the coronavirus, and we are considering the impact the virus has on families and children."