Evaluation of the program “Strategic Deinstitutionalisation and Child Care Reform in Bulgaria and Moldova”

Evaluation of the program “Strategic Deinstitutionalisation and Child Care Reform in Bulgaria and Moldova”

BG1- 2014 KHC Report on HHC DI Programme – Acknowledgements

BG2 – 2014 KHC Report on HHC DI Programme – Overview

BG3 – 2014 KHC Report on HHC DI Programme – Bulgaria

BG7 – 2014 KHC Report on HHC DI Programme – Analysis of ACTIVE Family Support and financing

5 – 2014 KHC Report on HHC DI – Analysis of prevention programme data (1)

6 – 2014 KHC Report on HHC DI – Analysis of reintegration programme data (1)

7 – 2014 KHC Report on HHC DI Programme – Analysis of ACTIVE Family Support and financing (1)


Magdalena Stefanova, Natalia Mihailova,

Reni Jelezarova, Ruja Marinova,

Galina Markova, PhD,

Prof. Andy Bilson


Acronyms and Abbreviations

CM Coordination Mechanism
CPD Child Protection Department
CSRI Center for Social Rehabilitation and Integration
CSS Center for Social Support
DC Day Center
DI Deinstitutionalization
GH General Hospital
HHC Hope and Homes for Children
HRDOP Human Resources Development Operational Program
FCDPC Facility for Children Deprived of Parental Care
FCYID Facility for Children and Youths with Intellectual Disabilities
FMDCC Facility for Medical and Social Care for Children 
MBU Mother and Baby Unit
MEYS Ministry of Education, Youth, and Science
PH Protected Home
REI Regional Education Inspectorate
RDIT Regional DI Team
RHI Regional Health Inspectorate 
SAA Social Assistance Agency
SACP State Agency for Child Protection
SAD Social Assistance Directorate
SARD Social Assistance Regional Directorate
SGH Small Group Home
SI Specialized Institution
SSC /SSCCF/ Social Services Center /for Children and Families/




Table of Contents

1 Introduction

2 Methodology

2.1 Scope of the Evaluation

2.2 Sources of Information

2.3 Participants

2.4 Collection and Analysis of Information

2.5 Work Ethics

2.6 Limitations

2.7 Course of Meetings

3 Main Findings and Conclusions

3.1 Relevance

3.1.1 Description of the Situation at the Inception of the Program

3.1.2 Scope of the Program

3.1.3 Description of the Approach of and the Services Supplied under the Program

3.2 Effectiveness

3.2.1 Attitudes of the Coordination Mechanisms Members

3.2.2 Enhanced Quality of Plans for DI

3.2.3 Children Entering Pilot Institutions

3.2.4 Reintegrated Children, Sustainability of Reintegration

3.2.5 Children Prevented from Going to Institutions

3.3 Usefulness

3.4 Sustainability

4 Conclusions and Recommendations

4.1 Conclusions

4.2 Recommendations






The present report was prepared by assignment on the part of Hope and Homes for Children – Bulgaria Branch (HHC) to assess the impact and effectiveness of the deinstitutionalization (DI) program of facilities for medical and social care for children (FMSCC).  The evaluation is conducted by the Know-how Center for Alternative Care for Children with New Bulgarian University between April and June 2014.

The main objective was to carry out an external and final evaluation of the implementation and results of the program.  For this purpose, information on the impact and effectiveness of the operation of the organization over the period of the implementation of the Strategic DI and Reform for Children up to Three Years of Age in Bulgarian Project funded by the Velux and OAK foundations was collected.  On the basis of obtained data on the strengths and weaknesses of the program and the implementation thereof, conclusions by area of evaluation were drawn and recommendations towards the organization about its plans for future programs were formulated.

The major areas of evaluation are defined in accordance with the good governance principle and the guidelines of the European Commission /EC/, as well as with the need to assess the overall impact and effectiveness of the HHC program in Bulgaria.  In this sense, analyses and conclusions are drawn as to whether the program is consistent with the national and local policy in order to meet identified needs (relevance), whether ultimate results are achieved and whether enough and appropriate resources have been mobilized accordingly, and in order to evaluate the effects on target areas and groups and establish whether they are in line with the objectives (effectiveness); what the benefits are and what the impact for garget groups is (usefulness) and to what extent the elements of the program can and will continue to be implemented (sustainability).


2.1 Scope of the Evaluation

The evaluation covers the entire period of the project implementation, namely 1.06.2012 – 1.06.2014.  An assessment of the results rather than of the organization as a whole is made under the project.

2.2 Sources of Information

  • Review of documents– project proposal, agreements, analyses, presentations, website
  • Interviews of focus groups with professionals and stakeholders, parents and children, conducted in four regions in Bulgaria– Montana, Pernik, Pazardjik, and Rousse

2.3 Participants

A total of 128 persons were interviewed and involved in the process of gathering of information, including:

  • National level professionals– leading team and HHC experts, representatives of the SACP, SAA, Ministry of Health (MH) – 8.
  • Regional level professionals– representatives of regional and municipal administrations, RHI, general hospitals, Regional Directorate of the Ministry of Interior, local MH and HHC coordinators in the regions of Montana, Rousse, Pazardjik, and Pernik – 30.
  • Social and health system professionals – SARD, CPD; suppliers of social services, FMSCC– 73.
  • Parents and family– biological and foster – 15.
  • Children– 10. 

2.4 Collection and Analysis of Information

The main research methods and approaches for collection and analysis of information were as follows:

  • Studying strengths through action

During the collection of qualitative information, a specific research strengths-based method was employed.  For this purpose, a manual for conducting groups and interviews, with major questions intended to identify strengths and achievements, as well as related to the values and successful DI strategies, was adapted.

  • Analysis of Stakeholders

This analysis helped identify at the beginning of the evaluation the key participants; further on it allowed for obtaining their opinion and evaluate their position in the course of the program implementation.  It allowed for identification of the characteristics of stakeholders, their interests, nature, and extent of impact and involvement.

  • Analyses of qualitative information

Qualitative analysis is a description of facts vis-à-vis their interrelation, argumentation, and evidence in support of statements.  It is based on data obtained by means of in-depth interviews and focus groups, as well as by means of reviewing documents and analysis.

  • Comparative analysis, compatibility analysis

It is focused on comparing of measures, approaches, and their compatibility for the implementation of the program.  The comparative analysis allowed for highlighting the similarities and differences between processes in the different areas, thus enabling a comparison between and among similar approaches over one and the same time period.

  • Analysis of causality

This type of analysis is based on a causality model.  This “bottom-up” effort started with identifying impacts that arose as a result of the implementation of the approach, namely the changes in the life of children and families;  subsequently, their relation with the planned program components was evaluated.

2.5 Work Ethics

The planning and carrying out of interviews and focus groups took place in accordance with ethical standards for collection and recording of information.  All participants were informed about the objectives and the tasks of the evaluation, the employed approach, the method of collecting, recording, and using information, the duration of meetings.  In addition, the anonymity of participants was guaranteed.  They were free to opt not to participate or to discontinue the meeting whenever they decided to.

2.6 Limitations

  • Professionals who had taken part during different stages and with different roles during the implementation of the project were interviewed.  This was reflected, on the one hand, by the large total number of interviewees, and on the other, influenced their perspective and judgment of achievements.
  • Key participants in the implementation of the program were not interviewed due to absence and/or change of jobs.
  • Traditionally difficult access to parents due to remoteness of their homes, inability to take up the care of children (age group in question -0-3). Whenever meetings took place at the homes of families, this too was an opportunity to observe the living environment and family interactions.
  • Due to the limited possibility of identifying parents for participation and the need to use data and contacts on the part of the HHC coordinators, some of the interviews were in the presence of the latter.  This influenced the reliability of collected data and was taken into consideration in the process of the analysis.The number of these cases was small.

2.7 Course of Meetings

All meetings were recorded, and the persons involved had no concerns or objections.  The only exception was a focus group in which the participants requested explicit permission from their leader for recording of the conversation.

The following groups can be identified in connection with the course of meetings:

  • Professionals negatively affected by the DI.  It took extra clarifications and motivation for participation to have them in groups and interviews.
  • Professionals for whom DI is part of their line of duty.For this cohort the participation in a group and in interviews was preceded by administrative procedures, and for some of them the participation was formal.
  • Parents beneficiaries of support.  With them, the participation in interviews seemed sometimes part of the interaction with the program and a chance to express gratitude and appreciation.

Main Findings and Conclusions

3.1 Relevance 

3.1.1 Description of the Situation at the Inception of the Program

  • The HHC program is relevant to the situation in the country and aims at anticipated results vis-à-vis the planned and implemented process of DI of children of 0 to

In 2009 the Government of Bulgaria set the goal of closing down all residential facilities for children in the country and replacing them with a network of community-based services for children and families.  This political process of deinstitutionalization (DI) started with the Vision for the DI of Children in Bulgaria adopted by the Council of Ministers.  This document was an expression of the political will for solving the problem of children raised in institutions.

The attempts at reforming institutional care in this country started far back in 2000, with the adoption of the Child Protection Act and the inception of the system for community-based services for supporting children and families at risk.  Over a period of 9 years a number of services were created, many facilities for children got reformed and restructured, the protection system got established, and targeted efforts to improve its capacity started.  Several international NGOs influenced the process and especially the closing of specialized institutions, as did the substantial public pressure for improving the quality of life of children with disabilities. (Closing down of the FCYID, village of Mogilino).

The system reported considerable drop in the number of children residing in institutions overtime.  Despite these efforts and existing schemes, the planned and absorbed funds from the World Bank (Reform for the Improvement of Welfare of Children in Bulgaria), under the PHARE program (Deinstitutionalization through the Supply of Community-based Social Services for Risk Groups – three phases), under the HRDOP (“For a Better Future” scheme), other donor programs, UNICEF, private funding, etc., the number of children going to FMSCC remained relatively constant (year 2008 – 1 993; year 2009 – 2 094; year 2010  – 2 209; year 2011 – 2 508; year 2012. – 2 485; 2013 г. – 1 190). The situation was similar with the number of FMSCC (2001-2010 – 32, 2011 – 31, 2012 – 30, 2013 – 29). The decrease of the number is due to HHC’s work in the institutions in Teteven, Shiroka Laka and Kyustendil with which they initiated the  reform for the institutions for children 0 to 3. This, in its turn, provided for “feeding” of the system of institutional care, because once children went to an institution, despite the availability of social services for support, a large part of these children, especially disabled ones, tended to remain there for a long time.

The prevailing part of children with disabilities residing in institutions comes from the FMSCC.  A considerable part of children placed in FCDPC comes from FMSCC.

In this sense it was only natural, logical, and necessary to have the process of changing the system for providing care and support start from the families of children between 0 and 3 years of age.  This would enable the other “components” of the system to get reformed in a quicker and more successful way.

  • The HHC program is relevant vis-à-vis the planned process of closing down of 8 pilot FMSCC under the Direction: Family Project

Reforming FMSCC proved to be one of the most difficult and challenging tasks for the system of care-giving.  On the one hand this is due to the health-care provider status of these institutions and the model of operation and support, and on the other hand, this is due to the serious health conditions of children residing therein and the social challenges their families face.  Nevertheless, reforms were effected in some of these facilities, and community-based services or services based in specialized institutions, mainly DC, for children between 0 and 3 or for disabled children were introduced under different projects.

Direction: Family Project BG051PO001-5.2.10-0001 under a call for direct grant aid was one of the main activities for the implementation of the Action Plan for the implementation of the Vision for DI.

The tenor of the project was 32 months – it was launched on 26.10.2011 and is due to end on 26.06.2014.  It is implemented by the Ministry of Health (MH), in partnership with the SACP and the SAA.  Measures focus on ”preparing FMSCC in 8 pilot regions for closing, the regions being: Gabrovo, Montana, Pazardjik, Pernik, Plovdiv, Sofia, Rousse, and Targovishte, through an analytical approach and synergic intervention with other relevant institutions.” (Ibid.)  This presupposes planning of relevant services in the 8 pilot FMSCC subject to restructuring; preparatory work for taking the children out of the facilities; communicating the process, and targeted motivation and awareness measures vis-à-vis stakeholders in support of the process.

The efforts of the professional community in the implementation of this process focus on the one hand on achieving “a natural stop” of the process of placing children in institutions of this type by means of support and strengthening of the capacity of existing services and measures for prevention, and, on the other, on designing of “new” services in support of the target group, namely children 0-3 and their families.  Because of this the planned activities focusing on restructuring of 8 of a total of 29 FMSCC in the country require supplementary efforts for designing and implementing the model for closing.  These efforts are identified as focusing on the process of evaluation of families, reintegration, and prevention, as well as on coordinating the process at the regional level.  The contribution of HHC in the implementation of the process of DI of care for children aged 0-3 is key in all components, especially in the work for prevention of separation of children and parents.  The involvement of the organization and its entire program provides the required inter-sectoral link for the achievement of planned results.  This is especially relevant with respect to prevention of abandonment.

If it weren’t for the efforts of HHC, there would not be work with the community for prevention.

Interview, manager, MH

HHC have the financial freedom and fill in all gaps of the MH project.

Interview, NGO coordinator

The participation of an NGO that complements the project with activities leading to and facilitating the achievement of objectives, activates all resources and, in the capacity of a provider of financial resources, demands observation of deadlines, planned actions, and responsibility for the entire process.

HHC, we are… a stone in the shoe of the MH …

Interview, NGO coordinator

  • The HHC program builds upon previous experience in the area of closing of institutions

The Bulgarian branch of HHC established in November 2011 “focuses its work on support of children aged 0 – 3 and their families because abandonment of infants entails trauma that stays for life and interferes with these children’s growing up for a full life.”

Our objective is to carry out a more active policy of prevention of abandonment and prevention of placement of infants in specialized institutions in Bulgaria.  A systemic approach is required with respect to family policies to ensure their sustainability.  Each kid must have a home and family of their own, in which to feel loved and protected. /Ibid./

In 2010 HHC together with the Bulgarian NGO Equilibrium closed down the first facility for children aged 0 – 3 in the town of Teteven and established the model for reforming such a kind of institutions.  The organization successfully participated in the closing down of the FMSCC in the village of Shiroka Luka and the town of Kyustendil too.

The established model for closing down of FMSCC, the main conclusions from the conducted evaluations, and the studies carried out provide a stable basis for taking further the efforts and support for closing down of this type of institutions.  In this sense the developed program for DI in support of the efforts of the government is a natural extension of the work of the organization and is consistent with its policy and objectives.

3.1.2 Scope of the Program

The Strategic DI and Reform of the System for Care-giving for Children Aged up to Three in Bulgaria Program covers and contains a set of activities and participants for the provision of secure, family-oriented care-giving for vulnerable groups of children (0-3) in 8 regions in the country.  It was planned and implemented in a systemic way, taking into consideration the need to involve all stakeholders and envisioning interventions vis-à-vis the various groups.

The key players in it are as follows:

  • Professionals in different roles

These are: the state structures in the area of social assistance locally (SARD, SAD, and CPD); the state structures in the health sector locally (RHI), as well as representatives of health care establishments, regional administration, regional directorate of the Ministry of Interior, the local government, suppliers of social services and project teams under the Action Plan for the Implementation of the Vision for DI at the local level.  The involvement of all players, their roles, responsibilities, and objectives is defined and set in memoranda of understanding signed in all 8 regions.  Such memoranda are signed also with the SACP, the MH, and the SAA.  These documents set forth the main activities and commitments of participants, requiring that the HHC program be complementary to, and not duplicating, the Direction: Family Project.

The Agreement provides for the following:  HHC does the things that are not covered by the MH, SAA, CPD.

Interview, NGO coordinator

The program is focused on improving the attitude towards and the understanding of all players in DI on regional level vis-à-vis the supply of services for children 0-3 and their families, support in the process of evaluation of the children residing in FMSCC, support to the staff of specialized institutions, direct work with families for reintegration and prevention.  A key element of the work of the organization is carrying out of cross-sectoral partnership through the involvement of all stakeholders.

  • Children placed in FMSCC and their families

At the onset of its implementation (June 2012), the program envisioned and effected participation in the process of evaluation of children residing in institutions, and subsequently, support for taking the children out of these facilities and placing them in a family environment.

FMSCC host both children aged 0-3 and children over this age who are cases of disability and serious chronic health problems. Children even over 7 have been left in the FMSCC who are extremely vulnerable to live in the disability homes. The share of children with health conditions and disabilities is high.  Their placement takes place in accordance with the Child Protection Act.  The main services they receive at the institutions are in terms of ”long-term medical observation of children with chronic conditions and medical and social problems; diagnosing, treatment, and rehabilitation of children with chronic conditions and medical and social problems; specific care of children with chronic conditions and medical and social problems: a) care-giving; b) upbringing and training; c) preparation for integration in society through attendance in regular nurseries and kindergartens, integration in the family, preparation for adoption.

The process of supporting families is carried out by the social workers assigned to the respective case in the CPD.  Through their efforts, additional services and in-kind support are provided, in order to improve living conditions and strengthen the capacity of parents.  The various social services also provide the additional services in terms of counseling and support to improve the situation in families.

A core element of the implementation of the HHC program is in terms of providing an “instrument” for carrying out of the evaluation of the needs of children and families, participation in the evaluation process, support to families for reintegration.

A form was filled in, on the basis of the evaluation, providing the team with information as to how to put together the puzzle of every child, how to have him/her reintegrated, what the resources of the family were, where support was needed.

Interview, NGO coordinator 

  • Families at risk of having their children placed in institutions

These are families with children aged 0-3 that, due to financial or other similar constraints, disrupted family relations, communication problems, health conditions etc., face difficulties raising their children.  These cases are being diagnosed in different ways and arrive in the system for assistance and support for prevention of separation of the child.  Usually the report (signal) is filed from the maternity ward/neonatal unit; subsequently the CPD steps in, suppliers of social services also get involved, as does the support on the part of HHC provided by the local coordinators of the organization.

For a family it is important to have the shoulder of institutions to lean on, to have their support… what is enduring over time… is the sense of being supported and the sense that support is available if needed, but this also means that people must chip in too…  the perceptions of social work have been reversed – people, relying on the support, give more of themselves.

Interview, CPD

A leading element in prevention is to provide in-kind support and counseling.

  • Foster parents

Support of foster parents in the context of increasing the quality of care-giving and making available services as an alternative to institutional care-giving is within the scope of the program.  The support is in-kind in the first month of placement of children in foster families, and in terms of counseling, when needed.

  • FMSCC teams

The teams and the management of specialized institutions are partially included within the scope of the program.  The objective is to improve the quality of life of children, carry out evaluation and preparation for exiting the institution.  The main interventions are in terms of support to evaluation teams that include representatives of the FMSCC too and training of teams of institutions for preparing children for relocation.

3.1.3 Description of the Approach of and the Services Supplied under the Program 

  • The HHC program covers the two main components of the DI process – reintegration and prevention

The HHC program focusing on developing of capacity and providing services for support and family-oriented care for children of 0-3 at the local level is planned and implemented through its two main components – prevention of separation of children and their families and reintegration of children placed at FMSCC.  Over a period of two years (June 2012 – June 2014), the program provided in-kind support and counseling to families at risk, including families with newborn infants with health problems, families of immediate and extended family members, foster families.

The main component of the program for prevention is in-kind support which often is a “response at a moment of crisis” /Interview, NGO manager/.  It is in terms of providing a “baby bed,” “nappies,” “formula,” “babyhaler,” “payment of electricity bills” etc., depending on identified needs.  An additional component of the program is the communication with various institutions, issuance of personal ID cards, birth certificates, registration with the Employment Offices, support for obtaining housing, home refurbishment, payment of medical examinations, placement of contraceptive coils for women, fuel and all transport costs for visits to families, etc.  Counseling and formation of skills for raising children is a supplementary element.

Situation with reintegration is a bit different – again there is in-kind support, but in some cases the organization takes on the role of a “guardian of families.”

A specific part of the program is the support to foster families.  This support is in-kind in the first month of placement of children.

The section on Effectiveness contains more analytical information about the programs.

  • The HHC approach is defined as a model of effective support to the family or “active prevention”

In the memorandum of understanding with the SACP, the program and the approach of HHC are defined as ”complementary, building-upon, and supportive activities”.  This approach is effected through in-kind support, counseling, and other necessary activities depending on the judgment and workplan made.  The organization is not a supplier of social services, it does not supplement the capacity of given structures or suppliers;  what it does instead is only to support local professional communities and institutions for the effective implementation of their responsibilities.  An especially clear demonstration of this is the work of the CPD social workers.  They said that they felt more relaxed and secure, enjoying the confidence and resources to meet the needs of families.  The approach also rests on the assumption of joint efforts – “we” (HHC, author’s note) step in where you (the CPD, author’s note) step out.” /Interview, SARD manager/.

“Arms” the social workers, provides them with security, self-confidence, and reassurance.  We approach clients holding our head high – I have resources.

Focus group, CPD

By involving various participants in their various roles and by making efforts to make them work together for a common cause, HHC become a key player in the local DI.  “The Sofia organization that closes facilities… ” / Interview, SARD manager/.

A catalyst of the process on the local level.

Interview, NGO expert

HHC define their approach as ACTIVE which stands for: Appropriate (taking into account the local cultural context and socio-political climate); Community (working with formal and non-formal actors);  Targeted (tailored to each family’s specific needs); Independence (working towards families becoming self-sufficient); Value (offers better value for money than interventions such as the institutionalization of children); Effective (keeps children who would otherwise have been institutionalized with their families, while improving their wellbeingfamily support) .

According to stakeholders, the organization is primarily recognizable through the support provided to families at risk.  It is defined as “active prevention.”  Less and less often is “reintegration” talked about as a result of the support provided.  Moreover, the borders between the two components seem to blur, as in one and the same case, subsequently or not, children get reintegrated and then become beneficiaries of support for the purpose of prevention.

The trademark of HHC is active prevention – when we take up a child, we do everything possible to keep the child in the family, we assess the needs focusing on the strengths.  We ask the question what needs to be done to keep the child in the family.  This makes the family think proactively.

Interview, NGO manager

The cornerstone of the approach is the in-kind support to families.  It is not monetary support, but instead a support specifically targeted at improving the elements of the physical environment or the needs of children.   Characteristic features are the attempts to negotiate each instance of support individually, to require participation on the part of parents, and to set a time period accordingly.

HHC have the financial resources, and this is a great benefit.

Focus group, CPD

The strengths of the approach are in terms of complementing a substantial and necessary element of support, and this is done according to specific needs, not as a general principle.

Prior to the work of HHC, I personally had reported conclusions that children were prevented from being reintegrated due to lack of financial resources.  The financial factor was a very big risk factor.

Focus group, social workers, SSC

One area for improvement and debate is related to the issue of whether this is required in all cases and what the benefits of the formation of skills and strengthening of the capacity of families are, together with the issue of preventing beneficiaries from becoming “but consumers who expect to get something every time you go visit.” /Interview, NGO coordinator/.  A key aspect here is the ”stepping down of support, involvement of the client, and transfer of responsibilities.” /Interview, SARD manager/.  Another important element of in-kind support is the example demonstrated to the CPD to use or not to use available statutory instruments to provide support.  Two options came up from interviews:  the first is the motivation, something like ”we managed to make departments stop sitting on their money” /Interview, SARD manager/ or ”because of HHC, they became totally reluctant to provide money, they avoid doing this” /Focus group, social workers, SSC/. 

In cases of coupling of in-kind support with counseling and formation of skills the approach is comprehensive and results are evident.  Still, this is a long-term process which is not a mandate for a single HHC coordinator covering the whole district. Rather, HHC invested in  facilitating the work done by multidisciplinary teams of services providers like the Centres for Social Support and the Family Consultative Centres. It was essential to involve them in the case management and longer term work on good parenting. AFS could not replace service provision, it is rather a new element to the service provision which can be adopted by the providers if they develop: 1/ attitudes to value parents, 2/ commitment and creativity in generating resources, 3/professional judgment on the content and the duration of th support.

Two issues remain open for debate – whenever the support is primarily in-kind, there is this “rumor of gold around the Roma neighborhood” /Focus group, social workers, SSC/ and about the parameters of the formation of parenting and social skills and sustainability of results.

The sections on Effectiveness and Usefulness contain more details on achievements, benefits, and issues.

  • The approach of HHC is described by the other players as being a different one, “fast, flexible, and timely,” consistent with the needs of families

What is characteristic of the approach and what sets it apart from the measures employed by the other players in the process is in terms of the fast, direct interface among people at all levels and in terms of overcoming red-tape mechanisms for support.

We value our time …

Focus group, CPD

Especially important is the fast delivery of support, at the moment a report comes in and when parents need help “right there and then,” “like a special operations squad.”  This brings about meaning to social work as a field effort, in direct interaction with families.

Thanks to them, we visited every single family …

Focus group, CPD

The support goes to the right families, at the right time, and at the right place.  Oftentimes these are families that can make it on their own, that have the skills but need an extra helping hand.  This is especially true for support for reintegration where typically the relations between parents and children are intact.

There is a risk of having a child placed in a facility… until the machine starts moving, until the procedure gets going – things tend to happen slowly at our end (state structures, author’s note); while, in contrast, they are much more flexible, they are able to respond on the spur of the moment and help.

Interview, MH manager

This is especially valid for the in-kind support that with NGOs is agreed very quickly, while in contrast the one-off aid from the CPD often can take more than a month.

The support provided by HHC is described as one that could be available ”at any time, on weekends too,” “very quickly,” “when needed,” “by a single phone call,” “through a direct contact with the family.”  This support is key for all regions, in order to stop placing children at FMSCC.  On the one hand the employed approach complements the work of social services – “the right hand of the CPD” – on the other hand it is different from the one employed by the CPD and sometimes by the suppliers of services.  The latter approach is defined as ”slow,” “ridden with red-tape,” “administrative,” “institutional.”  The short response time and the flexibility of support promote an individualized approach to cases while taking account of specific needs.  This in turn brings about results because “risk factors get quickly out of the way.” /Focus group, social workers, SSC/.  Subsequently this entails role-changing.  Quite often the first “institution” referred to for support is the HHC coordinator, not the CPD.  Changing roles is also due to the supportive function of the organization which is the exact opposite of the sanctions-prone and controlling role of social services.  “The only person I could turn to is her (HHC coordinator, author’s note) because the FMSCC is neither closed nor functioning, and I do not know where to send the children to.” /Interview, manager, general hospital/.  The fact that the organization operates at a higher level via the CM is an additional factor of support and motivation for the various players in the DI to look for the figure that would be quick to respond and able to provide effective help.

The direct call to the HHC coordinator takes place almost immediately after a risk and problem gets identified at the maternity ward.

Focus group, social workers, SSC

In this sense, one of the key issues is how to preserve the roles of different institutions.  “To have the CPD keep its child protection prerogatives, to have the SSC deliver the services, while we do the supportive role…” /Interview, NGO coordinator/.

  • The HHC approach is effected through a change of attitudes and motivation

Prevention and reintegration of children of 0-3 happen through a planned and implemented process of motivating and changing attitudes of all players and through efforts focusing on the understanding of the DI process.  The chief measures effected in this direction are primarily training and public events.  Training events are intended to strengthen competence and motivation, while public events aim at raising the awareness and changing attitudes.

The change that happens for social workers and the professionals directly involved in the support to families is two-fold:  in personal terms results are related to getting confidence in the possibility to provide support that brings about definite results, that makes available resources and mechanisms making work easier, that promotes professional support and competence.

HHC brought me back to where I belonged.

Interview, SARD manager

At the institutional/group level, the change is associated with social work as a whole, and in particular with the opportunity to communicate at different levels.  This is achieved through changing/ascertaining the understanding of the meaning and benefits of DI locally.

Doors wide open for social work for each institution.  As a whole people are aware what DI is about, how harmful for kids institutions are.

Interview, MH coordinator

The approach of the organization, described as proactive, fast, and timely, enables social work to ”inspire enthusiasm,” to nurture “confidence,” and to “support.”

We acquired confidence that no case was impossible to solve.  Not only financial resources, but lots of fresh ideas how to resolve cases.

Focus group, social workers, SSC

  • The role of HHC coordinators at the local level is key

At the local level the organization implements its program solely through coordinators (one for each region) who directly liaise with the managers of the organization in Sofia.  Their task is to work with all institutions and to provide support to families, to do field work.  Effectively they account for the image of the program locally and implement all of its components.  They have the authority, freedom, and responsibility for all decisions, although they coordinate them with the manager of the organization if necessary.  Usually coordinators are locally recognized professionals, active participants in the DI, having the skills for and knowledge of the process.  They have a mission which encompasses a broad range of activities.

“Terrorists” in the social assistance system.

Interview, manager, SARD

The key role of coordinators is largely defined by the need of the entire DI process to have leaders for others to follow, to make decisions, to set and achieve goals.  This is dictated by the very specifics of the process – multiple aspects and sectors, multitude of participants, need for clear setting of objectives, understanding and frequent change of institutional attitudes.  By virtue of being the only representatives of the organization on the ground, the coordinators run, communicate, and facilitate the entire program of HHC.

Coordinators assume a leadership role that is specific.  They are leaders who are always available, equally responsive both to the needs of families and institutions, ready to get into versatile roles in order to achieve the objectives, to work incessantly, with no days off, providing support and possessing the required knowledge and skills; they are proactive in communication and are able to “bring down walls.”

Coordinators are people who love their job, we are very pragmatic, we do not need lengthy explanations, we get everything from a single word.

Interview, NGO expert

They have the specific task of working with the attitudes of stakeholders, to initiate meetings and debate, as proactively as they might do field work, to work as a team with other professionals from other organizations and projects.

The greatest achievement in the joint work with the HHC is the good teamwork.  The colleagues on the ground managed to build excellent teamwork.  They share one cause.

Interview, MH manager

Their authority is extremely broad – from work related to the functioning of the CM, through communication with different, often closed institutions, institutions perceived as “difficult and resistant” (FMSCC, RHI, Ministry of Interior, general hospitals), through the judgment related to providing financial resources and in-kind support, to direct work with parents of children at risk.

By and large, we are everywhere where we could help families.

Interview, NGO coordinator

This makes the task related to their recruitment an extremely interesting one in view of required knowledge, skills, and position.  Major attention is focused on the understanding, motives, and attitude, on the use of “people’s strengths.” /Interview, NGO expert/.  The persons selected are persons who take DI as a personal and professional mission and cause, ”who have negotiating skills, who are “out of the box”. Interview, NGO expert /

I got an opportunity to fight for every single child, I got the freedom which otherwise is restricted in an administrative setting.  The opportunity to work in a team and take decisions.  To make a change towards an attitude that DI is a mission that is possible.  We struggled and fought as if scrambling up a rock.

Interview, SARD manager

One factor is of great importance for the program:  despite the fact that it was planned in an identical way for all towns and villages subject to intervention, it turned out to be specific just because of the different position, experience, and capacity of coordinators.  This demonstrates that it is very difficult to plan and implement DI centrally, the latter being essentially a local process, and that analyzing local needs, although non-conducted, must be taken into account.

Several types of coordinators can be defined depending on the position they hold and on their previous experience and qualities.  The attempt at classification is solely for the purpose of understanding the specifics of the program, of the approach and its implementation in relations with clients;  no presentation of specific persons is intended.

The ”manager-type” coordinator – rests upon the managerial experience and role.  In the course of the implementation of the program he/she inevitably intertwines these two capacities.  He/she is able to fully use his/her capacity for working with institutions, has knowledge of all services and uses them successfully, manages to provide additional sources of in-kind support.  The program seems to provide first training to teams, in-kind support to families, and communication with institutions, “mediation and advocacy being very important” /Interview, NGO coordinator/.  Sometimes, when working with clients, power/authority mechanisms may come into play, as well as posing of requirements and demanding reporting to the “social workers” /Interview, parent/ in connection with implementation of tasks.  Dialog-based interactions and reaching of agreements are achieved less easily because the active role is assigned to the manager-coordinator, while the passive one – to the client.

The “psychologist-type” coordinator – once again rests on his/her professional experience, inevitably intertwining both roles.  He/she works with institutions and organizations, with the social services and the protection system because these are stipulated duties.  The program may seem predominantly a consultative and supporting one.  Towards clients the employed approach is psychological, providing ”opportunity for development” /Interview, NGO coordinator/, supporting and responding to their different needs, ”engaging in an in-depth analysis” /Interview, foster parent/, immersing in the details of each case, “fighting for” parents.

The ““non”-social worker-type” coordinator – has a clearly defined role, provides counseling and support upon filing of a signal and evaluation.  The program seems effected in its various components, but through the effort of teaching parents to cope by themselves, ”to mobilize their own resources” /Interview, NGO coordinator/ and to regard the support as part of this learning.  The support to families is viewed as a whole, for strengthening the family and achieving sustainability and stability, for ”having an effect,” “for having their priorities right” /Interview, NGO coordinator/.  The work with institutions and organizations is supplementary, “we are to show the way to institutions” /Interview, NGO coordinator/.

The “expert-type” coordinator – has different roles and a very broad range of competencies. He/she works equally actively both with institutions, and is recognized by them too, and with clients along all lines.  The program seems effected through its counseling, social, and in-kind component.  A distinctive feature is the extremely fast response and competences in all the areas of DI, including the area of “combating staff of institutions /Interview, MH coordinator/, including through ”resourceful forms of communication” when necessary /Interview, NGO coordinator/.  He/she can be relied upon “any time,” “for being there for us” (the parents, author’s note) /Interview, parents/.  Support is primarily provided in expert terms, in the role of the ”beam of light”, exploring different options and “non-traditional” solutions in tough cases /Interview, manager, general hospital/.

3.2 Effectiveness

As to the evaluation of the effectiveness of the program and the achievement of anticipated results, the team employs the major indicators set by the organization, namely:

3.2.1 Attitudes of the Coordination Mechanisms Members

  • Coordination Mechanisms of DI as “focal points of power”

The Coordination Mechanisms for DI were established in all the regions in which the organization complements the activities under the Direction: Family Project.  They are “institutionalized” by means of decrees of regional governors.  The permanent membership of these CM includes managers of SARD, RHI, Regional Directorates of the Ministry of Interior, mayors of municipalities, DI projects coordinators.  Associated members include other stakeholders.  CM are established in regions designated as pilot regions under the implementation of the Direction: Family Project.  These regions or big municipalities are associated with substantial previous record of piloting of DI practices and models which has an impact on the sustainability of the mechanism and the attitudes of players because of the effective process of building upon experience.

This organization (HHC – author’s note), through its proactiveness, built upon previous achievements.

Focus group, Regional administration

Different regional and/or municipal structures operate on the ground, their tasks being in terms of coordination and communication in the area of DI as a whole or in terms of individual elements of the protection of children, Roma integration, in view of the vast multitude of measures and projects – RDIT, Monitoring and Evaluation Unit, CM for interaction for responding to cases of violence against children or children at risk of violence and for joint actions for intervention in crisis; Regional Council for Cooperation on Ethnic and Integration Issues etc.

The specifics of CM for DI, initiated by HHC, are in terms of the established ”system for interinstitutional referral of specific cases”, meaning that the process of coordination goes not through the process of planning and monitoring, but through the stories and needs of families and children instead.

According to the documents, CM shall be convened by the Regional Governor upon a report on specific cases (within 14 days from filing the report) prepared by HHC and MH.  Reports are discussed at the sessions, and the heads of relevant agencies and institutions take on specific commitments for support of cases; minutes are taken accordingly.  Coordinators follow up the cases and submit progress reports.

Key players and institutions are members of the CM, empowered people who are able to take quick decisions without the need to refer to superiors.

Interview, CPD

The CM for DI are established to ensure efficient coordination and interaction of stakeholders in the implementation of DI policies. 

The CM is a focal point of power.

Interview, managers, NGO

In the CM, the leadership role is with regional governors, the mechanisms are operating on the regional level, not on the municipal level.  NGOs are not represented, except as suppliers of social services.

Despite planned discussions of cases the CM convenes only for the toughest ones and for the ones that cannot be solved without the active involvement of all stakeholders.

The CM is extremely operational; it does not convene for each case but for the toughest cases only.  The remaining cases are solved through the practical activity of all services.  For example, the Ministry of Interior and the RHI are the authorities that are most difficult, yet they cannot say “no” to the Regional Governor.  The Regional Governor is the leader of this CM, while its permanent members are the persons who have the authority to make decisions “here and now;” these are not people who must report and wait  At the beginning some members tried to shun but me reminded them that they had the power.

Interview, managers, NGO

Several factors condition the changes in the implementation of mechanisms vis-à-vis the original idea:  first, this is the relatively high number of players.

There is no need to tell the personal story of a child in detail to 50 persons.  CM encompassed many people!

Interview, manager, municipality

Second, it was established that often the situation could not wait for a meeting to take place, and it was much easier and faster to solve the case through a personal contact between participants. ”It takes people to solve problems, not institutions.  The CM, as it is designed on paper, is redundant.  The CM for us is the everyday work, it seems something quite artificial to me” /Focus group, Regional Administration/.

Now, it takes but a phone call to solve a case.

Interview, manager, SARD

The CM was originally designed as a working forum for discussing cases;  gradually it evolved more into a seminar-type forum convening on specific topics intended to prevent placement in institutions, for coordination of all DI projects, and for particular issues such as “the relocation of incubators from the FMSCC to the neonatal unit” (Rousse), ”the forthcoming inauguration of the SGH for children with disabilities” (Pazardjik), ”alternative social services” (Pernik), ”follow-up of DI as a whole” (Montana).

The number of their sessions was relatively low in view of the ambitious tasks initially set, namely the discussion of specific cases.  It must be noted that meetings of various formats and on various topics of stakeholders take place at the local level.  This makes it relatively difficult to classify these meetings as CM- or non-CM sessions.  Participants report a small number of discussed cases and emphasize the communication and thematic discussion of the whole DI process instead.  For the region of Rousse in particular, 4 – 5 CM sessions took place specifically over a two-year period;  in the region of Montana monthly working meetings take place both in connection with the CM and in connection with other different DI challenges;  in the region of Pernik the majority of meetings are thematic, on various issues of DI;  in the region of Pazardjik, 3 meetings on specific cases took place.


  • Changing roles of CM players

The CM was designed as an instrument for effecting communication and coordination of managers.  Participants embark thereupon through their managerial roles in order to take part in decision-making on specific cases or to facilitate such cases.  A characteristic feature of the CM is that it is not established in purely administrative terms;  instead it is NGO-initiated and has clear objectives, overcomes administrative mechanisms and red-tape, which, in turn promotes motivation for participation.  In addition, the CM transcends the vertical arrangements and translates them into horizontal ones, ”establishing a community of coworkers who feel supported,” representing ”governance which relies on mutual synchronization (“we tend to synchronize as fish in a shoal do…” /Focus group, Regional Administration/.  The CM plays the role of DI of institutional structures.

The first council, mechanism, that is not still-born.

Interview, SARD manager

This happens in a relatively informal environment in which leadership is being delegated to the person who works closest to the problem and gathers data.

All of us use a single email, a single mouse, we are all one telephone call apart, so that we can finish all that needs to be finished.  Otherwise it would not be possible.

Interview, SARD manager

As to the roles of the participants in the CM, two options emerged from interviews.  The one is in terms of abandoning the administrative roles and immersing in the specifics of the case.  This model is effectively in contradiction with the rationale of the mechanism and brings a different meaning to meetings – they are more occasions to confer about a given case and/or for intervision.

We use the meetings to say how proud we are of some achievement, to be heard, to share success stories.

Focus group, Regional Administration

The other option is a CM as a ”mode of enactment of traditional roles” /Focus group, Regional Administration/ which is consistent with the rationale of the designing of the CM.  This takes place through the teaming up of working groups, upon the emergence of an idea to be implemented, the introduction of an extra regulation, and ”the deriving of a new quality from the fact that a CM has convened” /Focus group, Regional Administration/.  A relevant example is the initiative to close down a second FMSCC in the region of Pazardjik.

The general impression is that in the different regions the CM functions in different ways.  This is evidenced by the number of sessions, the extent to which participants are active, the handled cases, as well as the changing of roles.

  • The understanding of and the attitude towards the DI

The change of attitudes towards and the understanding of the DI process takes place through a process of trainings, working meetings, and participation in key public events – round tables.  Despite the similar approach, the different regions have their specifics depending on previous experience, the regional planning, the availability or lack of an adequate number of quality social services.

A shared trait in the attitude of players across the board is the sense of pride with the achievements, and even some degree of competition, comparing with the successes and results of peers.  An example is the visions of DI – ”DI – Priority for the Region” (Montana), “The First SI-Free Region in the Country” (Rousse), “Our Regional Strategy – a Manual for Other Regions to Follow” (Pernik)”, ”Let’s Have Local Communities on Board in the DI Process” (Pazardjik).

We will not have institutions for children, few SGH for specific cases, and substitute care.

Interview, SARD manager

Interviewees said that they had participated in different roles in the DI for many years and in this sense they were aware what it was about and how it needed to happen.  Similar results were obtained as well from a comparative study of attitudes of CM members.  They ”evaluate in an optimistic and positive way their own professional competence.  

The contribution of HHC is in terms of complementing the understanding with new knowledge and skills related to the involvement of and the interrelation among sectors, to the fact that the process is a comprehensive one and depends on the attempts of every single participant, and “three is no turning back” /Focus group, Regional administration/. It must be noted that the professional community comes to increasingly understand the role of the family in the whole process, ”we need to help parents more, not that much children” / Focus group, Regional administration/.

We all work for one and the same cause … to have children with their families.

Focus group, Regional administration

The relations among the members of the CM change and obtain new meaning, they start supporting each other and working together.

We did not have a single case in which a coworker failed to make efforts when asked for assistance.

Focus group, Regional administration

Probably the external factor and, of course, the financial support, along with the clear awareness of the irreversibility of the process, were key.

3.2.2 Enhanced Quality of Plans for DI

  • The quality of the plans for DI begins with teamwork, formation of skills, and interaction of all professionals

The professionals related to the enhancement of the quality of the plans for DI of FMSCC fall into different groups and have various roles.  First and foremost come the staff and the head of the FMSCC who are directly engaged in care-giving and have responsibility for the children.  The implementation of a project for reforms also involves the coordinators of the Direction: Family Project.  Next come, of course, social services, followed by other stakeholders such as municipalities, RHI, SARD, general hospitals, regional governors’ offices etc.  Local HHC coordinators come on board additionally and work most closely with the MH coordinators under the Direction: Family Project.

The leading element in the preparation of players in DI is training – providing of knowledge and formation of skills as to how to place the child in the center and follow and observe his/her best interest.  Due to the specifics of the DI process related to changing attitudes and relations from institutional to individualized ones, working with many and versatile players requires, among other things, focusing on the understanding of the essence and importance of DI and on efforts for team-based interactions.  The objective is to internalize DI as a value, to have professionals share common attitudes and goals, as well as to have good direct communication.

There were several important trainings.  A training program took place for the CM members with 6 main modules and topics on teamwork, DI process, and information on the “new” services for the target group.There were also ad-hoc trainings of the staff of FMSCC (under arrangements with the, additional meetings and discussions. It is important to clarify that the work on closing the 8 institutions was divided between Direction family and the HHC project to avoid double funding. Therefore HHC provided complimentary activities to Direction family. The training of the professionals involved in DI was a responsibility of Direction family. Their public tendering process failed and the trainings were delayed. At the end of 2013 when children were moved out and reconstruction works were half way through, MH asked HHC to conduct the trainings which the organization did at the end of 2013 even outside the HHC planned project activities. These delays though produced frustrations and anger among the professionals. (The systematic challenges that the public tenders have made was raised by HHC with the EC and in the Government report card 2013).

Still, the participants in the evaluation share that the HHC trainings focused on developing  awareness about the DI process and on changing attitudes.  Teaching methods were interactive and promoting involvement of participants in discussions and role-playing.

The contribution of HHC is in terms of changing attitudes of people because they demonstrated examples of children with disabilities that were already taken out.  There were many discussions, as well as games based on role-playing.

Focus group, FMSCC

The change of attitudes of staff is reflected in their motivation to work in the area of other social services and to become foster parents.  These, however, are isolated cases in each of the four regions. 

They do not look for a job. They look for the same job.  And we cannot blame them.  They have worked for 15 – 20 years.  They are used to the premises, to the work they do, to the things they do not do.  They would have loved to have the process stop.

Interview, manager, municipality

The overall involvement and change of motivation for engagement can be achieved through a longer training process and coming to know in detail the specifics of social work and change of models – from the medical to the social model.  Interviewees, however, did not say anything about other activities in connection with the work with institutions staff.  This is debatable from several standpoints.  Firstly, the organization has substantial previous experience in the area of DI of institutions which demonstrates that active work with staff is crucial for success.  Secondly, these professionals do provide care for the kids, and is good to have them on board for the team-based interaction.  Last, but not least, the quality of DI as a process is contingent upon improvement of quality of care-giving for children placed in SI.  It must be noted that there is great likelihood that some members of the SI teams will work for the new services for this target group.  Their attitudes at some point might become hindrances to DI compromising its smooth roll-out.

  • Overcoming of the institutional model is linked to an individualized approach to the needs of the child and his/her family(evaluation and plan)

The established multidisciplinary teams with members from different state and municipal structures have the task of carrying out the assessment of the children placed in FMSCС and their parents.  The contribution of HHC is in terms of providing a sample form for the assessment, training the teams, and providing financial support for the process.  Again, to avoid double funding HHC supported only the assessment of families who lived outside the municipalities of the target institutions, because assessments are the responsibility of MH Direction family. MH could do assessment outside their territories.

Additionally in some districts HHC were involved as partners in the decisions-making about the child care. This was not a requirement and depended on the region and the people from the MH teams.  In some cases HHC offered additional re-assessment of children with disability to ensure that they can live in a family environment. These HHC interventions made evident that a much smaller number of children would need the special residential care (for which institutions were lobbying) and that more children with disability would be reintegrated and placed in foster care.

The assistance of HHC in terms of providing transport enabling the CPD and MH coordinators to visit and evaluate on-site the capacity of parents and family environment is invaluable.  This is helpful in the process of making the best decision of taking every child out of the institution and placing him/her in a family environment.

HHC provide the logistics, transport, arrangements, evaluation forms of kids in FMSCC.  HHC have a supporting function, the CPD do the evaluation, but they do so according to the methodology and with the tools provided by HHC.

Interview, NGO coordinator

Professionals use the available “instrument”, although they describe it as “cumbersome.” 

The instrument for evaluation is good but some questions are repeated, this makes it cumbersome.

Interview, social worker, FMSCC 

3.2.3 Children Entering Pilot Institutions

  • The placement of newborn infants in the pilot institutions is discontinued as a whole

According to data from the MH and HHC, after the launching of the Direction: Family Project in 2012 and especially in 2013, placements in FMSCC gradually decline, and in 2014 such instances are but isolated.  The trend indicates that at the beginning of the implementation of the MH project, children are reintegrated, placed with families of immediate and extended family members or get adopted, while the number of placements with foster families subsequently grows, at the expense of all the rest.  One of the reasons is probably the implementation of a government project focused on the development of foster care across the entire country. After the initial assessments children who could be easily reintegrated went home. The rest needed more work with the family for reintegration or were free for adoption, or needed foster families which were not available until October 2012. This is why in 2013 most children went for adoption and foster care. An additional factor was that the building works was planned to start in May 2013 and the remaining children were fostered or prepared for reintegration or adoption. This prevented further institutionalization.

A total of 185 children were taken from the pilot FMSCC, including: 21 reintegrated with their biological families, 95 placed with foster families, 61 adopted; 6 placed in SGH, and 2 placed on other facilities.  Since the inception of the project in 2011 until the present moment 8 children died.  38 children were placed in the restructured FMSCC /data as of 31.12.2013./

According to data of HHC as of 27.03.2014, the FMSCC in the four studied areas host a total of 13 children below 3 years of age, but there are still children above 3 – a total of 24.

Region Children 0-3 Children above 3
Montana 1 child  12 children
Pazardjik 5 children  8 children
Pernik 2 children 3 children
Rousse 5 children 1 child

In the course of the evaluation some of the disabled children above 3 years of age got already relocated to SGH opened under the Childhood for All Project, while disabled children younger than 3 years of age were still on the premises of the FMSCC and will remain there until the future service of “specialized residential care for children up to 7 requiring constant medical care” is introduced.”

That woman sent by the MH, started storming around, she stopped supplying me with kids.

Interview, coordinator, MH

It is an indisputable fact that in 2014, and in some instances even in 2013, no infants or young children got placed in the four studied institutions, except in cases of children with a very severe physical condition requiring round-the-clock medical care.  Additionally, infants at risk from the four regions are not placed in FMSCC in neighboring regions.

Stopping the placement of children in FMSCC, however, is not a one-off act, but a complex process that has undergone different stages.  In the majority of locations placements stopped because of the good joint work for prevention at the level of the maternity ward and the community on the part of all DI players – CPD, social services suppliers, maternity wards, MH and HHC coordinators, and in the most difficult cases – because of the commitment of the participants in the CM.  Only a single instance of placing children in a facility in a neighboring municipality was reported.

In 2012, despite the work for prevention, between 3 and 5 children were placed in FMSCC every month.  Because of the concerns that “with this rate, we will not be able to close down the FMSCC,” the MH and HHC coordinators initiated a meeting for the designing of a mechanism to discontinue placements.  The new mechanism for interaction is laid down as a straightforward algorithm of work defining the responsibilities of all participants.  This mechanism proved its effectiveness over the following months.  Nevertheless, it was not just that placements failed to decrease, but they even went up in a certain period of time, in a neighboring municipality too.  This situation again mandated revisiting of the mechanism and analysis of placements.  As a result, consensus for focusing of efforts and assuming the responsibilities for the work on prevention by designated persons and a designated institution, especially in maternity wards, was achieved. 

“The experience highlighted the need to have the same persons dealing with this constantly.”

Interview, MH coordinator

  • The placements of specific groups of children at risk(preterm babies and children with disabilities) pose a challenge for the social and health systems 

“The restructuring … through preparatory measures” …” of FMSCC is still not over, and as one medical specialist put it during the interview, ”the FMSCC is neither closed nor functioning.”  The staff goes to work, in an uncertainty associated with pending competitive recruitment procedures for new teams and managers of future services that have not been launched yet.  The children with disabilities who cannot be cared for in a family environment, even though they may not be necessarily abandoned, are still placed in FMSCC because this is the only place in which they can get 24-hour medical care.

The situation in the institutions in which wards for preterm babies have been established over the years, is specific.  One such FMSCC was described as ”an enormous institution with a baffling variety of challenges” /Interview, NGO coordinator/.  The closing down of these wards becomes ”the ultimate test, putting at stake the closing down of the institution itselfand the implementation of the reform as a whole /Interview, NGO manager/ because these very wards over the years have become a gate to the system of care-giving.

In the course of our work we realized that this was the incubator, this is the actual gate providing children for the facility.

Interview, NGO coordinator

Let us see how this works.  Babies born ahead of term do not get birth certificates and are not recorded anywhere formally until they reach a given weight.  “As per an automated, well-designed system between the doctors at the FMSCC and the hospital” /Interview, NGO coordinator/, prematurely born babies at risk and babies with malformations are moved to the FMSCC ward, with no warrant from the Social Assistance Directorate, and therefore they are non-existent for the child protection system.  Interviewees said that the majority of these babies are from Roma families or from communities that are vulnerable and/or at risk.  Babies are placed at FMSCC, without informing the parents and without parents’ wishing to abandon the baby.  Moreover, the access of parents to this ward of FMSCC is difficult, if not impossible.

It was like a forbidden land where no one was allowed to enter and from where no information whatsoever escaped.

Interview, NGO coordinator

Studying and working with family does not start until after the baby gains the required weight and the CPD get notified of the existence of the “case.”  “In 80% of cases this response comes irreversibly late/Interview, NGO coordinator/.

The attempts of two coordinators (MH and HHC) ”slowly but surely, with all the legitimate means” /Interview, NGO coordinator/, as well as the decision of the MH itself for closing down of the ward at the FMSCC, led to keeping all pre-term babies at the general hospital’s neonatal unit.  The change of the point of intersection of the two systems led to change of roles and responsibilities – the health care system has to file a report in case of risk, while the social system has to assume responsibility for support.  This change made the “new players” face a whole lot of questions that are still unanswered.  Some of the questions refer to the large number of babies, the duration of their stay at the unit, the difficult communication among the systems, and the burdensome administrative procedures.

We cannot have a baby stay in the care of the hospital for 4 months; we are not a long-term care facility.  These babies start posing danger to the rest, the one- or two-day old ones.  There is no relevant clinical path that would allow the baby to be kept at the hospital, we are no social facility.  But I keep them in.

Interview, general hospital manager

It takes time and focused efforts to make the two systems work well together.  Interviewees said that now “opinions of medical specialists cannot be trustedand often there is pressure exerted on them to place children in a family environment /Interview, manager, general hospital/

We do not have the right to give an opinion.  We have to prove to the social workers that it is not appropriate for the child to go to the place suggested by them.  There are kids that could be placed with foster families, but are associated with a risk.  When they are placed in smaller towns and villages, they are far off from the main facility.  And then negotiations begin as to why not the village but the city? 

Interview, manager, general hospital

3.2.4 Reintegrated Children, Sustainability of Reintegration

  • The support of HHC for the improvement of the living environment and care for children results in a decision on the part of the CPD to return children to their biological families

According to Ministry of Health data, the number of children from FMSCC reintegrated in their native families is lower than the numbers of adopted children and of children placed in foster care (FC).  Reintegration includes support of the family, so that the family decides to have the child in their care and provide the appropriate conditions.  A typical feature with reintegration is that the relations have been preserved.  Interviews showed that in families bonded together where the parents were unwilling to abandon their children, the in-kind and the financial support by the HHC was crucial with respect to the decision of the CPD to reunite the family.  One example is T., whose story was told time and again by all interviewees in one of the region, a story that proved to be so telling, moving, and meaningful.

  1. resided with her fivechildren and spouse in a municipal housing, the only costs that they paid being electricity and water bills.  They cultivated a small garden and grew vegetables.In winter they lived in a single room.  In spring, the children moved to the other two rooms.  In 2013 the CPD visited several times and told the family to render the walls, to clean up, but the family did not have money even to pay the electricity bill.  They only got child allowances, and the mother was pregnant with the sixth baby.  During one of the visits the social workers were escorted by police to collect the children …

“They took them all.  They put them in the car.  I tore my clothes, cried in the street.  The kids started crying, shouting “Mummy, mummy!”  They cannot make it without me.”

The father, enraged, threatened those around him with an ax, which made the police officer hand-cuff him.  Children were separated and placed in different facilities, according to their age.  The mother visited them regularly.  “We do not miss a week to go and see them.  The kids cry, and shout, want to come back home to me.”

HHC provided in-kind support to the family – a baby bed with all the necessary things, paid the electricity bill, and had the house rendered and cleaned up as per the requirements.  Seven months after being placed in facilities and the birth of a new baby, the kids one by one got reunited with their family.

Interview, biological parent

  • The support of HHC for the protection of the interests of the family results in reuniting kids with their parents

Of course, the psychological support and encouragement provided by HHC to parents, the confidence and the sense for them of not being alone in a time of crisis, are no less important.  The stories told by the HHC coordinators and parents indicate that often the actions of the representatives of state authorities are questionable, it is clear that the institutional system provides them with the sense of security they need for themselves rather than for the children.  The practice of resorting to FMSCC has been established for many years as the more secure, more protected place for the life, and especially for the health of children.  It is exactly in these cases that the HHC coordinators play the role of “guardians of families against the system.” 

If I need support, I will go to her (HHC coordinator – author’s note).  I have no trust at all in the CPD.  If I happen to tell them something, they are quick to press me.  I can tell her anything.  I have known her for so long, she is so nice to me and to the kids.  She managed to stop the social workers from coming to me and calling me on the phone all the time.  She is my guardian.

Interview, biological parent

A telling example is the case of a poor Roma family who challenged the system and got a victory in court, managing to reverse the imposed measure of “taking the children away from the family.”

The signal for required support was received from a health-care facility.  During a routine medical check of the youngest child, eight months old at the time, the doctor reported that the baby was severely underweight and referred the child to a hospital for stabilization.  The HHC coordinator visited the mother and the child in hospital;  upon discharge from the hospital, the coordinator provided to the mother all the supplies required for child-care.  The coordinator put down a list of the feeding regime for the baby and gave the list to the mother to post and follow at home.

The family shared their house with relatives.  A CPD check reported that the kids seemed ill with pneumonia, that the house was not clean, that there was smell of toilet.  The children were taken from the home with the assistance of police.  The mother was told that the children were going to be taken to the doctor.  The children were placed in institutions.

HHC assisted the parents in finding jobs and improve their financial status and living conditions.  Despite the efforts made, the CPD social worker refused to have the children reunited with their family.

The mother took the case to court pleading wrongful seizure of children.  She was supported by the HHC coordinator who paid the attorney fees.  On all four cases the court ruled in favor of the mother, and the children got reunited with their family.

“Most of the families would not fight for their children because they get demotivated… with all those endless requirements.”

Interview, SARD manager 

Of course, the issue of in-kind support and the fact that it cannot be separated from the whole process of formation of skills for better care-giving is debatable.  During visits to some families, it was reported that some of the amenities and furniture supplied by HHC were not used as intended (the baby-bed was turned into a wardrobe), the parents and children continued to occupy one single room despite the availability of other rooms, the home was not clean.

This indicates that the process of reintegration in the biological family starts from the protection, in-kind support, and counseling.  Yet there starts the work of the service providers to continue with the more in-depth and long-term work with the parents to support them in the developing process of parenting.

3.2.5 Children Prevented from Going to Institutions 

  • The support of HHC for the improvement of the living environment and care for children is a crucial factor for keeping the child in the biological family

Active prevention is the “the trademark of HHC.”  It starts from evaluating the needs, this evaluation resting on the strengths of the family.  They do not ask: “Do you want to take care of your child?”  Instead they ask: “What do you need to take care of your child?”  The family is actively involved in the process of finding a solution and identifying their own needs.  Often solutions are suggested by the families themselves, the professionals failing to think of such solutions because “we do not live in his/her world.” /Interview, NGO manager/.

The reasons for child abandonment are “cruelly trite” /Interview, NGO manager/ – lack of money to buy food, nappies, lack of heating.  Active prevention is effective because it provides an immediate response to a crisis and is not confined to in-kind support, and sometimes cash support, but is in terms of informing the mother in an understandable and straightforward way about the options for assistance available in the social system, as well as for psychological support.  Through their program, the HHC professionals manage to prove that “total intervention” /Interview, NGO manager/ is possible, i.e. that there is an alternative to placement of children in institutions.

The mechanism of applying active prevention was one and the same in the studied regions and it followed several steps:

  • The maternity ward sends a report to the CPD(Montana) or SSC (Rousse and Pazardjik) and/or to the HHC coordinator himself/herself (Pernik).
  • An on-site visit and meeting with the mother takes place immediately.
  • The collected information is provided to the HHC coordinator in a report(Montana).
  • For the purposes of effecting timely intervention, the HHC coordinator is initially briefed about the case over the phone(in Montana the CPD and the CSS enjoy the amenity of free cellphone communication) or at a meeting of the multi-disciplinary team (Pazardjik), or at a joint visit directly to the maternity ward. 
  • The decision as to the type of support in the particular case is taken by the HHC coordinator, upon jointly analyzing the information with all the parties involved, including the parents, and in some cases – upon liaising with the management of the organization.
  • The support is conditional on a particular commitment and deadline for the family.

Interviews with parents indicate that prevention cases are subsequently subject to monitoring only by the HHC (Pazardjik) or by the HHC and the social services supplier (Rousse).  Depending on the specifics of each case, the HHC coordinators visit and meet with parents to monitor the case for a period between 6 months to nearly 2 years.

Here is a case study (P., mother of a two-year-old child) that is particularly indicative in this respect.

The mother was a labor migrant abroad, returning to this country when pregnant.  She concealed her pregnancy in order to get employed.  She and her mother got a room in the house of a relative in a small village.  Shortly thereafter she gave birth and was hesitant, because of the lack of money and proper conditions, whether to keep the baby-girl.  “I did not want to leave her, yet at the same time I could provide no proper conditions…, it would have been a torture for the baby.  A box of formula cost BGN 20.  I just could not provide for her.”

At a meeting with a social worker from the SSC and the HHC coordinator, the mother accepted the proposal for in-kind support from the organization – nappies, baby carriage, bed, clothes.  The organization also supplied one-off aid to pay the rent and electricity bill, as well as assistance to the mother for obtaining 50% of the child allowances in the second year after the birth of the child.  The support lasted for around 1.6 years but “I try to cope by myself.”

Interview, biological parent

Active prevention which includes in-kind support and counseling is sustainable because it is used at the moment when bonding happens between parents and child.

  • The support from HHC to facilitate the care-giving in foster families in the first month of placement is an extra factor preventing children from going to institutions.

The FC service is resorted to 

  • Whenever none of the options for reuniting a child from a FMSCC with his/her biological family is applicable
  • As an alternative care to stop placements in FMSCC of children who subsequently get adopted
  • As an alternative care to stop placements in FMSCC of children who subsequently getreintegrated in their biological families.

Interestingly, the staff of FMSCC fails to recognize FC as a future career opportunity.  There are few examples of nurses and care-givers becoming foster mothers and taking up children from a FMSCC in their care.

They sort of cannot assume a round-the-clock responsibility for care-giving for children.  They prefer to have regular working hours instead.

Interview, FNSCC principal 

HHC provides to foster families in-kind support only in the first month – nappies, formula, clothes, baby carriage etc.  In one area a foster family got a summer vacation.

Additional support is provided for children with disabilities and very young children, since their upbringing is more difficult and requires motivation.  Such is the case with a disabled child requiring medical interventions.

Foster parents have taken care of 7 children since 2007.  Most of them subsequently got adopted.

Currently they have an eight-month-old baby in their care, placed with them straight from the maternity ward when the baby was just seven days old, and a 5.6-year-old girl with cerebral palsy placed with them from a FMSCC.  This is the first time the family takes care of a disabled child.

The girl underwent 2 surgeries of her legs; a third surgery pending.  HHC covered the transport costs for the foster family to another town.  HHC also provided support in terms of nappies, baby food in the first month.

“If it were not for HHC, things would have been much harder… On the one hand we had our commuting covered.  And the kids – the more they interact with people, the better for them.  And if these people really know how to interact with kids, the benefit is even greater.”

Interview, foster parent

3.3 Usefulness 

  • The HHC program and the benefits for the professional community

The assessment of the organization and its program by the majority of stakeholders interviewed is extremely positive.

A representative of the municipal administration said that the HHC experts participate in very important working groups at the national level, they have managed to deserve this, and in these groups their opinion and experience tend to change policies and legislation, which is a contribution.

The general evaluation of the HHC program is that it is successful, useful, necessary in the future too, the reasons being the resources available to the organization – professionals with extensive experience, both in the local and international context, and considerable financial resources.

In fact it is so successful for the following reasons – first, they have a good idea of things, second – they enjoy the benefit of having financial support.  This is the only organization that helps like this – no other does this.  Their financial support simply exemplifies a different work model and in fact delivered and delivers.  This is the proper way to close down an institution.  There are no kids there any more.

Interview, manager, a municipality 

The impact of the program is on all covered groups – families, professionals in the social and health sphere, CM participants.  For the majority of those the interaction with the organization results in:

  • Change of attitudes
  • Enhancing the quality of work
  • Personal professional development

The implementation of the HHC program comes to prove the fact the in-kind support is an important part of the prevention process because the major reason for abandonment in a large share of cases is poverty.  In this sense the results and the achievements of the HHC program inform the DI process about this important component that needs to be present in the next effort of planning of measures.

  • The HHC program and the change in the lives of children and their families

The benefits for the children and the families are in terms of the chance they get to enjoy support and live together.

Hundreds of kids are prevented from going to institutions and hundreds of kids leave these “abominable” institutions.

Interview, NGO manager

Similar is the evaluation of a mother who received support from HHC.

The greatest benefit was that I did not abandon my kid!  She was to go straight to the Facility.  I do not even want to think about it.  This is horrible!...  They would have taken her right away, there are families.  Had I abandoned her, I would have never found peace of mind.  It was so difficult for me.  I so much didn’t want to.  Therefore I am so grateful to them! So much!  Now I am so happy with my baby!

Interview, a biological mother

Changes can be reported at several levels, regardless of whether the topic is prevention or reintegration, namely:

  • Improvement of the actual living conditions of families– housing, furniture, employment of parents
  • Improvement of the capacity for care-giving for children – clothing, toys, food
  • Improvement of the civil status of parents and children – birth certificates, ID documents
  • Improvement of the health status of children – medicines, healthcare
  • Improvement of opportunities for child development – nurseries, other additional services
  • Improvement of family relations
  • Formation of skills for parents for reliable and safe care and nurturing self-confidence
  • Enhancing the opportunities for safety and protection for parents themselves.

Of course, some professionals are concerned that sometimes the benefits turn into obstacles.

When we start providing assistance to parents, they get used to this, as if we were bound to do this.  They fail to mobilize.  Therefore I do not provide a large amount of resources but instead provide support to the family to mobilize itself and to look for ways to handle difficulties.

Interview, NGO coordinator

As non-positive can be described the attitudes of various professionals towards the mode of support from HHC.  They believe that it often results in misuse and excessive care-giving and sometimes fails to bring about mobilization of the resources of beneficiaries themselves.

  • I disagree.  It is better to teach them to cope by themselves, not to support them.Parents tend to misuse this.  Let us not turn them into consumers. /Interview, Principal, FMSCC/
  • We spoilt the families.  We provide excessive care-giving to them. /Interview, CPD manager/
  • There is excessive support to foster families. /Focus group, SSC/

As to the quality of life of children who are still at SI, no information is available whether there is a change in the care-giving and support on the part of staff attributable to the MH, responsible for the work inside the institutional setting.

Qualitative Study on the Prevention Program

The goal of this study was to evaluate the effect of social workers’ interventions which aimed at helping disadvantaged families to meet some of their and their children’s basic needs in order to prevent these families from placing their children in social institutions. The data encompasses three data points per subject – prior to intervention, immediately after the intervention and a six months follow-up.Our sample consisted of 227 children in total (though not all of them had a complete data record as explained above). 117 (52%) were male. The average age of the children (in years) was equal to 0.57 years. The average age of boys was equal to 0.53 years . The average age of girls was equal to 0.62. The average age of children’s mothers was equal to 26.52 years (s.d.= 7.14) at the time of the intervention. The average age at which the mothers gave birth was equal to 25.48. Demographic variables (i.e. children’s and mothers’ ages, gender) were entered into our statistical analyses in order to check whether these moderated in some way the effect of the intervention in question.

The data comes in likert type scales (scores ranging between 1 and 5) and the sum of several (more than or equal to 5) different risk factors (the number of the risk factors ranges between 5 and 9). Each set of likert scales and each set of risk factors refers to a particular aspect of families’ capabilities of meeting their children’s needs: Quality of Life, Family and Social Relationships, Behaviour in the Family, Physical and Mental Health, Education and Employment and Household.


Quality of Life 

There is a significant difference between the first and the second measurements (p=0.000) and between the first and the third measurement (p=0.000). However there was no significant difference between the second and the third measurement (p=0.967).

Thus it appears that that the intervention significantly improved the families’ living conditions with this improvement persisting after six months.  It is easy to see that different cities show different dynamics. For example the city of Pernik starts from a comparatively low initial level of Quality of Life but achieves remarkable improvement. On the contrary, the city of Tyrgovishte shows relatively little gain from the intervention.(Figure 1.)






Figure 1. Quality of Life 











  1. Family and Social Relationships

The intervention produced a significant improvement in the psychological climate in the families which not only persisted but increased during the six months period following the intervention (ps<0.05). Again, families residing in different cities improved in similar rates after the intervention in question

  1. Behaviour

The intervention produced a significant improvement in the variable in question which increased during the six months period following the intervention (ps<0.05). None of the other demographic variables produced any significant effects on the dependent measure nor did they interact with the primary independent factor.  

  1. Physical and Mental Health

The statistical analysis yielded a significant effect F(2, 14.002)=14.026, p=0.000. There is a significant difference between the first and the second measurement (p=0.002) as well as between the first and the third measurement (p=0.001). There was no evidence for a difference between the second and the third measurement (p=0.953). The different cities show different trajectories (Figure   2.) 




  1. Education

Only 28 (12.3%) subjects were evaluated on the measure and not all of these had a complete data record. This amount of missing data renders any further analyses and conclusions inappropriate.

6.Employment and Household

There is evidence that the intervention was associated with significant increase on the dependent measure and this effect didn’t vanish during the six months follow up significant difference between the first and the second measurement (p=0.000) as well as between the first and the third measurement (p=0.000). There was no evidence for a difference between the second and the third measurement (p=0.338).  (Figure 3)

Figure 2. Physical and Mental Health by Period and Region











Figure 3. Employment and Household







The studied intervention as a whole exerted significant effect on the set of dependent variables. Moreover it appears that the immediate effect of the intervention is actually quite large. None of the demographic variables showed significant effects, nor did they interact with the primary independent variable. The interventions improve all areas of family wellbeing. They exerted considerably smaller effect on the Behaviour. This probably should come as no surprise. The Behaviour variable measures stable behavioral patterns which are unlikely to change drastically overnight regardless of any individual intervention. The other variables (with the exception of Family and Social relationships) measure more or less the socio-economic level of adaptation which is easier to influence directly by material (e.g. financial) and social (e.g. directing subjects to courses teaching professional skills) means. There is no relationship between Education and Employment as well as between the demographic data and the interventions results. The regions are influenced similarly by the interventions.

All risk factors Risk factors decreased after the interventions (Figure 4.  Family and Social Relationships, Figure 5. Physical and Mental Health).

Figure 4.  






Figure 5. Physical and Mental Health by Period and Regions












There are differences between regions regarding the interventions’ effect. Pernik, Russe, Montana and Sofia are cities where the risk factors dramatically decreased whereas Turgovishte and Plovdiv were less affected by the interventions. Education and Employment and Household (Figure 6) have similar effect – intensive decrease of the risk factors and permanency of its effect after the 6th-month period.

Figure 6. Employment and Household by Region    









The intervention improved the families’ conditions on all outcome measures. Moreover there was no indication that this effect diminished six months after the intervention. In some cases there was even statistically significant shift between the second and the third measurement and whenever such a shift was present it was in the direction of more favorable conditions.

The Physical and Mental Health variable render less promising results than those interventions related to socio-economic interventions which tend lead to significant improvement in families’ general wellbeing status which suggests that social programs incorporating such interventions are a fertile enterprise.

The trajectories of change in the different regions differ. Their common trend is show in the Figure 2. The differences are hypothesized to be the results of the demographic profiles of the regions or on the competency of the professionals. This relates more often to the  Physical and Mental Health and the Quality of Life variable.

Qualitative Study on the Reintegration Program

The goal of this study was to evaluate the effect of social workers’ interventions which aimed at helping disadvantaged families in creating better environments for their children which were returned in the families after spending some time in social institutions.

The data encompasses three data points per subject/family – prior to intervention (i.e. while the child is still at the institution or immediately after she is returned to its family), immediately after the end of the intervention (the interventions last different amounts of time for the different families depending on the needs of the particular family) and a six months follow-up (i.e. six months after the end of the intervention).

The data is also the same as in the case with the Prevention Study. The same six areas of familys’ capabilities of meeting their children’s needs were evaluated. They were : Quality of Life, Family and Social Relationships, Behaviour in the Family, Physical and Mental Health, Education and Employment and Household.

The sample consisted of 42 children in total from 8 regions. 23 (55%) were male.  All of our subjects had the first two data points but only 34 (81%) had completed the study as the study was conducted before the 6th-month period after the intervention.(i.e. only 34 subjects were measured after the follow up period). The average age of the children studied (in years) was equal to 1.52 years. The average age of boys was equal to 1.43 years , the average age of girls was equal to 1.63. The difference between the average ages of boys and girls was not significant. The average age of children’s mothers was equal to 30.14 years at the time of the intervention. The average age at which the mothers gave birth was equal to 28.62 . We see that the children in this study are a bit older than the ones participating in the Prevention Study. The same holds true for the ages of the mothers as well as the ages which the mothers gave birth at.

This sample size was much smaller than the sample size obtained for the Prevention Study and therefore the conclusions based on the current data should be regarded with more caution.


  1. Quality of Life

The analysis show significant increase in this area which persists after the second measurement (6 months later). There is a significant difference between the first and the second measurements (p=0.000) as well as between the first and the third measurements (p=0.000). The difference between the second and the third data points was not significant (p=0.823).

  1. Family and Social Relationships

The wellbeing with respect to Family and Social Relationships increases after the intervention (p=0.000) and there is a significant difference between the first and the second measurements (p=0.000) as well as between the first and the third measurements (p=0.000). The difference between the second and the third data points was not significant (p=0.564). Thus it appears that the intervention was associated with an immediate and significant gain in families’ wellbeing with respect to Family and Social Relationships and this effect persisted throughout the six months follow up period. This means that the effect of the intervention not only persists throughout the six months follow up period but actually increases even without active involvement by the social workers.

Figure 1 below shows the different growth curves for the different regions.

Figure 1










Most of the lines cluster together at their initial points (except for the two lines describing the growth rates for Montana and Gabrovo which show considerably lower starting points). It can also be seen however that the growth curves for the different regions are quite different (e.g. compare the steeply rising curve for the Gabrovo city with the relatively flat curve for the Pernik city).

  1. Behaviour

There is a significant difference between the first and the second measurements (p=0.001) as well as between the first and the third measurements (p=0.003). The difference between the second and the third data points was not significant (p=0.523). Thus it appears that the intervention was associated with an immediate and significant gain in families’ wellbeing with respect to Behaviour and this effect persisted throughout the six months follow up period

  1. Physical and Mental Health

There is a significant differences between all three data points (all ps<0.05). The intervention correlates with a significant increase in families’ wellbeing with respect to Physical and Mental Health and this effect is present six months after the intervention as well (i.e. the wellbeing with respect to Physical and Mental Health continues to improve for at least six months after the removal of the intervention).

  1. Education

The team didn’t subject this variable to statistical analyses because only 14 (33%) subjects were evaluated on the measure. Moreover not all of these had a complete data record. This amount of missing data renders any further analyses and conclusions inappropriate. This problem is more or less avoided with the same variable when it is measured by the number of risk factors present during the three periods.

  1. Employment and Household

The statistical analysis confirms the apparent upward trend – F(2, 35.686)=29.468, p=0.000. There is  a significant difference between the first and the second measurements (p=0.000) as well as between the first and the third measurements (p=0.000). The difference between the second and the third data points was not significant (p=0.433). Thus it appears that the intervention was associated with an immediate and significant gain in families’ wellbeing with respect to Employment and Household and this effect persisted throughout the six months follow up period.  (i.e. the degree of well being with respect to this measure didn’t seem to decrease six months after the removal of the intervention).

None of the demographic factors correlated significantly with the outcome measures. All regions are equally affected by the interventions The Risk Factors decreased with time. It seems that the age of the mother matters. The older mothers seem to maintain more riskier environment for the children. This tendency is present during the third measurement assessment.

General Recommendations

The recommendations apply both to the Prevention and Reintegration Studies.

  • Control groups should be employed in order to rule out alternative explanations for the observed trends. In other words only proper control groups can ensure that the above described trends reflect genuine causal influence of interventions of this kind on the families’ wellbeing.


  • The evaluations should be made by professional psychologists who are blind to the hypotheses of the studies as well as to which group (i.e. control or experimental) the evaluated participants belong to.
  • The Education variable should be either entirely reformulated or discarded for future studies of this kind and especially for studies which aim at young children and infants.
  • Precise completion of data collection should be ensured to eliminate missing data.
  • A separate study should be conducted which compares the developmental curves of children subjected to reintegration with those of children not subjected to the intervention in question and still remaining in the institutions. Such studies are extremely rare in the literature and a study like this would potentially be of tremendous scientific and social value. Moreover Bulgaria seems to be a nice country for such a study to be carried out since the social reforms here are far from finished and there are plenty of institutions which might serve as control group(s).

3.4 Sustainability

HHC has been recognized as a successful and reliable partner on the part of the SACP, MH, and local authorities.  This is evidenced by the signed CM for work in new areas of intervention, as well as by the demand for support for the new services for children with disabilities /SGH/ and the “new” residential service for children of 0-3 that is pending legislative codification and introduction.

The sustainability of the model can be seen in terms of the people who were trained and the attitudes of professionals.  Some professionals who were in the organization and currently hold positions in other organizations, transfer experience and work and communications model.

I transferred all this (the HHC model – author’s note) here, and all the operations are so easy, we did away with mail

Interview, manager, SARD

The main CM established at the regional level could continue operating in a different way in every one of the regions.  Probably for the purposes of enhancing its sustainability, focus, and consistence, it is good to pool the efforts of all existing “mechanisms,” “councils,” “committees” and other DI means of communication.  It is relevant to have stronger representation of NGOs, their involvement no to be limited to the role of social services suppliers.

The instruments used by HHC will continue to be employed by participants and case managers.

It will be difficult to employ the main components of the program in the immediate operations with clients for prevention and reintegration without the organization.  The main reasons for this are in terms of lack of structures and non-enhanced capacity of existing structures.  All participants in interviews and groups explicitly share their wish that the organization continue to exist and expand its scope of operations with new target groups in terms of age and disabilities of children.  This is especially true for in-kind support which, as of the present moment, cannot be taken over by state and local structures.

Provision of financial resources here is more difficult and slow.  I am sick and tired with having someone else support the state; the state instead has to take on its duties.  It is good to have them;  it is terrible, if they are not there.

Focus group. CPD

Even though addressing a valid concern, it is interesting that there are no legal regulations that prevent CSS (about 100 in the country) to offer in-kind support in addition to counseling and consultations. Still, many big service providers are reluctant to have these expenditures but are also reluctant to seek additional resources like food, medicine, furniture from citizens and donors.  These attitudes need to be changed.

Counseling, psychological support and early intervention in connection with infants at risk coupled with in-kind support, cannot be supplied by the CPD, according to all interviewees.  It is arguable whether the “new” services that will be introduced as a result of the restructuring of the FMSCC – family and consultancy center, center for maternal and children’s health, day center for children with disabilities for children between 0 and 3, center for early intervention, special residential care for children up to 7 requiring constant health medical care – could effectively offer this support.  Moreover, these services have no legislative arrangement, and there are concerns that it would not be possible to use them by referral from the CPD.

The CPD cannot take on these activities, while the social services do not work with the 0-3 age group and with children with disabilities.

Interview, SAA expert

As to reintegration, the majority of tasks in the pilot regions have been solved for the target group of children.  There are no placements [in institutions]; only specific and severe cases that could not be reintegrated go to FMSCC, and for these cases alternative options are sought.

Maybe at some point in time we will become redundant.

Interview, NGO expert

The HHC statistical information shows that out of 43 reintegrated children only 2 have gone to foster care which means that the method used by HHC proves to be successful contrary to the attitudes shared by the professionals that reintegration is a difficult process. HHC’s method in the field of reintegration relies on partnership with the service providers, HHC long-term provision of in-kind support, service provider’s working on the parenting skills, HHC monitoring the families 6 months after the discontinuation of support. In times of crises some children are moved temporarily to foster care or in cases of chronic difficulties are registered for adoption. This model can be studied further to follow the development of the children and the parenting skills of the family.

With respect to prevention, the approach seems comprehensive and working, but it is difficult to achieve sustainability given the lack of capacity in the social system for flexible and timely in-kind support.

Families at risk need them (HHC, author’s note) and they have to stay and work.

Focus group, social workers, SSC

This is especially true taking into consideration the fact that social structures are very reliant on this support, they are even over-reliant.  During interviews, representatives of the social services said that they very much relied on the very in-kind support provided by the organization.

We took those for granted, we over-rely on those (HHC, author’s note).

Focus group, CPD

Conclusions and Recommendations

4.1 Conclusions

On relevance

  • The HHC program is relevant with respect to the planned and realized process of DI of children from0 to 3, as well with respect to the process of closing of eight pilot FMSCC under the Direction: Family 
  • The HHC program was planned and implemented in a systemic way, taking into account the need to involve all stakeholders and providing for interventions focusing on the latter.
  • The HHC program builds upon previous experience in relation to closing of institutions and covers the two main components of the DI process – reintegration and prevention.
  • The HHC program includes an “instrument” for conducting assessment of needs of children and families, participation in the evaluation process, support to families for reintegration.
  • The HHC program includes the “active prevention” model centered on the leading element of providing in-kind support and counseling.
  • The HHC approach is different from the approach employed by the other participants. “fast, flexible, timely,consistent with the needs of families; it is effected by means of changing attitudes and motivation, and its specifics are set by coordinators locally.

On effectiveness

Building the capacity of local authorities 

  • Professionals with management authority participate in the CM for the DI as focal points of power”.
  • The understanding of and the attitude towardsDI of the participants in the CM develop sustainably towards irreversibility of the process and need for support to families.
  • The main task of the CM is to take synchronized decisions on specific cases, and the implementation of this task is accompanied with enhancement of professional competencies.

Improving the quality of life of children in eight institutions

  • The conditions for achieving quality DI plans are team work, formation of skills, and interaction of all professionals.
  • Transcending the institutional model is related to an individualized approachtowards the needs of the child and his/her family.
  • The support of HHC for theimprovement of the living environment and care for children led to a decision on the part of the CPD to reunite children with their biological families.
  • The support of HHC in favor of protecting the interests of the familyleads to reuniting children with their parents. 

Improving quality of life of children at risk through alternative forms of care-giving and supporting services

  • Placement of new-born infants in the pilot institutions is discontinuedas a whole
  • Placement of specific groups of children at risk(prematurely born infants and children with disabilities) pose a challenge for the social and health systems.
  • The support of HHC for theimprovement of the living environment and care for children is crucial for children’s remaining with their biological families.
  • The support of HHC for facilitating care-giving of children in foster carein the first month of placement is an extra factor preventing placement of kids in institutions. 

On usefulness

  • The HHC program is a life-changer with respect to children and their families by improving living conditions and nurturing good parenting skills.

On sustainability

  • The sustainability of the HHC program is effected through theskills and attitudes of professionals trained. 
  • The new mechanism of horizontal communicationcould be implemented in different models in the DI process.
  • The designed and approved instrumentfor evaluation of needs and risk will continue to be employed by participants and case managers.
  • It will be difficult to implement the major components of the programin the direct work with clients for prevention and reintegration without the organization. HHC has promoted  AFS and has faced resistance from some of the service providers who think that AFS is in conflict with their professional roles. The State can change these attitudes through realigning with the CSSs. Additionally, a change in the law can enable social benefits based on individual needs assessed by SA officers in partnership with CPDA. These benefits will not be available on an emergency basis (crisis in-kind provision can be done only by the service providers who have their budgets in advance, have accumulated material donations and are mobile and flexible enough), they will be an important financial resource for addressing some more serious underlying issues the families face and will be a second band of support.

Changing the way service providers operate and introducing individualized benefits based on family needs assessment can be the basis for change.


4.2 Recommendations

This part presents information on the areas requiring improvement and on the possible options for action in the short and in the long term, to enhance the effectiveness of work, and, above all to ensure sustainability of the program.  The recommendations come as a result from the analysis of interviews and focus groups that have taken place and are consistent with the expectations of participants vis-à-vis the entire DI process and specifically vis-à-vis the HHC program.  They fall into several areas, in accordance with the key aspects of the process and the program.  The recommendations are directed towards the organization not only in its capacity of a partner in the implementation of specific projects on the national and local level, but also in its capacity of an active player in the planning of DI policies.


  • With respect to legislation – to effect legislative amendments promoting needs-based benefits,  fast, timely financial and in-kind support to families.
  • With respect to the role of the service providers– they have to provide long-term  flexible support that is based on continuous evaluation of risks and strengths of the family. The HHC model of collaborating with other providers and resources to build a supporting community around the family has to be followed.
  • With respect to foster care – to redirect efforts away from seeking quantitative results towards improving the selection of aspiring foster parents.  To provide targeted support /in-kind and in terms of counseling/ to families caring for infants and young children with disabilities and specific medical needs.


On the CM:

  • In order to involve all participants in the DI, it is relevant to attract more NGOs and to incentivize representatives of smaller municipalities.
  • In order to achieve consistence and a targeted approach, it is good to make efforts for integrating all DI mechanisms and councils at the regional level.

On prevention:

  • To achieve sustainability and employment of the successful model for active prevention in the future, it is necessary that the experience gained by HHC and their partners is promoted further through lobbying for legislative and regulatory amendments for the purpose of building a mechanism for in-kind support of families.

On reintegration:

  • In order to achieve integrity of the approach it is advisable to exert efforts and to sustain the work in the direction of establishment of a model for preservation of responsibilities and development of skills of parents in case a child is separated from the family environment for a certain period of time.All professionals working in the child welfare field, including CPD have to be proactive and engaged in an on-going assessment of the case. Especially in the cases of reintegration where attachment between the family members is at risk, the HHC model of provision of security through continuous support has to be followed.  
  • It is necessary to employ the model of reintegration in case of placement with a foster family or in a residential-type service, starting at the moment of taking the child out of the biological family.

On old structures and new services:

  • When reapplying the program in other areas it is relevant to step up the efforts for improving quality of life of children while they are still in SI.

GM comment: it is a question whether MH as a partner can be asked to follow HHC requirements, including regarding the above. It seems that HHC has found a method to keep a partnership with MH which allows HHC to work in a hierarchical system of DI project management and at the same time to promoting egalitarian relationships with families, members of the Coordination mechanisms etc.  

  • For the purposes of achieving the objectives of DI, it is good to keep up the support from HHC to local authorizes in the elaboration, implementation, and sustainability of the new services intended to replace the FMSCC.

GM comment: it is not easy because of the competition between different service providers. Still the profile of HHC is different and different is the approach. This has to be announced as the profile of HHC so that the local authorities recognize the specificity of the organization

  • The training of professionals who would be engaged in the delivery of the new services needs to be systematic and targeted, with an emphasis on work with families.  Supervisions need to be provided.

GM comment: again, like in the above comment, the profile of the HHC that need to  crystallize will build a specialized training that will not fall a victim of the double funding.



  1. HHC is evolving as an organization who is a system-changer and because of this an organization that is very successful in doing reforms.
  2. The key to the successful interventions are built into the elements of the “ACTIVE” and the HHC members consistently follow those in all its activities thus building communities
  3. Some of the successful approaches are not studied yet. Some of those are:  partnership, teamwork, listening and understanding families, working with severe poverty, developing attachments in the field of reintegration.
  4. The development of the work of HHC has to be studied further in relation to the well being of the children involved but also in relation to the specific programs the team has developed. Hopefully this study will address the need for community development as a social work method in the post-totalitarian context of Bulgaria.       




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