Worldwide, millions of children live in institutions, which runs counter to both the UN-recognised right of children to be raised in a family environment, and the findings of our accompanying systematic review of the physical, neurobiological, psychological, and mental health costs of institutionalisation and the benefits of deinstitutionalisation of child welfare systems. In this part of the Commission, international experts in reforming care for children identified evidence-based policy recommendations to promote family-based alternatives to institutionalisation. Family-based care refers to caregiving by extended family or foster, kafalah (the practice of guardianship of orphaned children in Islam), or adoptive family, preferably in close physical proximity to the biological family to facilitate the continued contact of children with import ant individuals in their life when this is in their best interest. 14 key recommendations are addressed to multinational agencies, national governments, local authorities, and institutions. These recommendations prioritise the role of families in the lives of children to prevent child separation and to strengthen families, to protect children without parental care by providing high-quality family-based alternatives, and to strengthen systems for the protection and care of separated children. Momentum for a shift from institutional to family-based care is growing internationallyour recom mend ations provide a template for further action and criteria against which progress can be assessed.

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UNICEF and the International Children's Palliative Care Network undertook a joint analysis in three sub-Saharan countries-Zimbabwe, South Africa, and Kenya-to estimate the palliative care need among their children and to explore these countries' capacities to deliver children's palliative care (CPC). This report concerns the findings from South Africa. The study adopted a cross-sectional mixed-methods approach using both quantitative and qualitative data obtained from primary and secondary sources. CPC need was estimated using prevalence and mortality statistics. The response to the need and existing gaps were analysed using data obtained from a literature review, interviews with key persons, and survey data from service providers.The findings show very limited CPC service coverage for children in the public sector. In addition, services are mainly localised, with minimal reach. Less than 5% of the children needing care in South Africa are receiving it, with those receiving it being closer to the end of life. Barriers to the delivery of CPC include fear of opioid use, lack of education on CPC, lack of integration into the primary care system, lack of policies on CPC, and lack of community and health professional awareness of CPC needs and services. Estimating the need for CPC is a critical step in meeting the needs of children with life-threatening conditions and provides a sound platform to advocate for closure of the unacceptably wide gaps in coverage.

IntroductionAdvances in biomedical technologies provide potential for adolescent HIV prevention and HIV-positive survival. The UNAIDS 90–90–90 treatment targets provide a new roadmap for ending the HIV epidemic, principally through antiretroviral treatment, HIV testing and viral suppression among people with HIV. However, while imperative, HIV treatment and testing will not be sufficient to address the epidemic among adolescents in Southern and Eastern Africa. In particular, use of condoms and adherence to antiretroviral therapy (ART) remain haphazard, with evidence that social and structural deprivation is negatively impacting adolescents’ capacity to protect themselves and others. This paper examines the evidence for and potential of interventions addressing these structural deprivations.DiscussionNew evidence is emerging around social protection interventions, including cash transfers, parenting support and educational support (“cash, care and classroom”). These interventions have the potential to reduce the social and economic drivers of HIV risk, improve utilization of prevention technologies and improve adherence to ART for adolescent populations in the hyper-endemic settings of Southern and Eastern Africa. Studies show that the integration of social and economic interventions has high acceptability and reach and that it holds powerful potential for improved HIV, health and development outcomes.ConclusionsSocial protection is a largely untapped means of reducing HIV-risk behaviours and increasing uptake of and adherence to biomedical prevention and treatment technologies. There is now sufficient evidence to include social protection programming as a key strategy not only to mitigate the negative impacts of the HIV epidemic among families, but also to contribute to HIV prevention among adolescents and potentially to remove social and economic barriers to accessing treatment. We urge a further research and programming agenda: to actively combine programmes that increase availability of biomedical solutions with social protection policies that can boost their utilization.

Over the past decade, there has been increasing global attention to mitigating the impacts of the HIV/AIDS epidemic on children's lives. Within this context, developing and tracking global child vulnerability indicators in relation to HIV and AIDS has been critical in terms of assessing need and monitoring progress. Although orphanhood and adult household illness (co-residence with a chronically ill or HIV-positive adult) are frequently used as markers, or definitions, of vulnerability for children affected by HIV and AIDS, evidence supporting their effectiveness has been equivocal. Data from 60 nationally representative household surveys (36 countries) were analyzed using bivariate and multivariate methods to establish if these markers consistently identified children with worse outcomes and also to identify other factors associated with adverse outcomes for children. Outcome measures utilized were wasting among children aged 0-4 years, school attendance among children aged 10-14 years, and early sexual debut among adolescent boys and girls aged 15-17 years. Results indicate that orphanhood and co-residence with a chronically ill or HIV-positive adult are not universally robust measures of child vulnerability across national and epidemic contexts. For wasting, early sexual debut, and to a lesser extent, school attendance, in the majority of surveys analyzed, there were few significant differences between orphans and non-orphans or children living with chronically ill or HIV-positive adults and children not living with chronically ill or HIV-positive adults. Of other factors analyzed, children living in households where the household head or eldest female had a primary education or higher were significantly more likely to be attending school, better household health and sanitation was significantly associated with less wasting, and greater household wealth was significantly associated both with less wasting and better school attendance. Of all marker of child vulnerability analyzed, only household wealth consistently showed power to differentiate across age-disaggregated outcomes. Overall, the findings indicate the need for a multivalent approach to defining child vulnerability, one which incorporates household wealth as a key predictor of child vulnerability.