It was the dogs that alerted him, their barking incessant and irritating, drawing him toward the small bundle they encircled. What had gotten into them? He shooed them away, bending low to see why they were agitated. Shocked, he saw a newborn, tiny chest heaving with every breath, his body listless.

The hospital said the baby suffered from sepsis, a severe infection, treatable with antibiotics. After a brief hospital stay, the infant was brought to a crisis nursery run by Alliance for Children Everywhere (ACE) Zambia, where nurses, social workers, and caregivers diligently provided for him. As the Zambian police completed their required investigation and report, months passed. Until the report was complete, foster care, adoption, or reunification with the child’s biological family were not possible under Zambian law.

As time passed, the baby, now named Victor,[1] received the compassionate care of ACE Zambia staff. Six months passed, then a year, while Victor remained in the crisis nursery. Though physically healthy and well-cared for, it soon became clear he wasn’t reaching the standard developmental milestones for a child his age. In spite of the caring encouragement of staff, at one year old, Victor didn’t pull himself up to stand by the furniture or hold onto hands to take his first unsteady steps.

Victor was missing one thing that could help him overcome these challenges – a family. Research has shown[2] that the reliable, consistent presence of a caring parent or caregiver is an essential factor for healthy development of children.

But for Victor, the opportunity to live with a family was taking too long. By the time the police report was completed and permission given for Victor to be placed in a home, his physical delays made it harder for him to find one. Though ACE Zambia staff reassured families that Victor’s delays could be overcome by family placement, families were worried they were symptomatic of further special needs. Eventually, a family for Victor was assessed, trained, and ready to bring him home.

Two months later, Simon Kanyembo, the Director of Social Services with ACE Zambia, went to visit Victor in his new home. To his delight, Simon saw he wasn’t just improving, Victor was walking! While thrilled to witness this profound progress, the contrast also highlighted Simon’s concern for children who remain in institutionalized care. It “is not the right place for them… A family (is needed) for every child.” He continued, “The best way is what the Bible teaches us – like when Jesus came to earth, a family was prepared for him.”

Caring for Orphaned and Vulnerable Children in Zambia: A Case Study

This desire to see all children in families is why ACE undertook a case study on family-based care in 2020. Family-based care refers to care for children in the context of a genuine family, whether the child’s biological family or an alternative family, like in foster care. They recognized that though they have transitioned to a family-based model of care, their emergency nurseries hold children who are not legally able to be released or haven’t been matched with a foster or adoptive family. These unique circumstances gave ACE Zambia an opportunity to study the outcomes for children placed in permanent families and those children retained in their residential care facility, congregant or group living settings for children often referred to as orphanages.[3]  Drawing on a growing body of research in combination with their own monitoring and evaluation (M&E), the purpose of ACE Zambia’s study was “to shed light on positive outcomes when family-based care is prioritized.”

Its results are striking.

Better Outcomes for Children

Data from ACE Zambia’s case study reveals that family-based care led to significantly better outcomes for children’s development and health. Though children in ACE Zambia’s residential care facilities were provided appropriate nutrition, a more-than-adequate child-to-adult ratio, dedicated and qualified staff, nurse, teachers, engaged social workers, and significant financial investment, they fell behind developmentally. They weren’t able to reach 50% of progress toward standard development milestones in 3 of 4 categories of development. Language development in particular suffered, with children in the institutions on average only progressing to 36.25% of the standard development milestones.

In contrast, family-based care resulted in significantly better developmental outcomes for children. Children raised outside of residential care for their first 18 months, reached 85% or above on three of four milestones and above 65% on all milestones. The ACE report shows, “The M&E data on quality of care indicates that institutional care leads to significant missed milestones… and improvement in these milestones of human development occur once a child is placed in an appropriate home.” This confirms existing research, as described by Faith to Action, “In seminal studies, children raised in biological, foster, and adoptive families demonstrate better physical, intellectual, and developmental outcomes as compared to children living in institutional care” (Faith to Action, 2014).

While children in residential care weren’t making adequate progress toward development milestones, they also weren’t reaching median weight-for-age according to WHO standards. Some children, in spite of receiving appropriate nutrition, were losing weight. They were also at a higher risk of needing serious medical intervention. For example, in December 2019, a wave of illness swept through the institution, causing 50% of children to need prescription medication and 25% to require hospitalization. In contrast, children in family-based care saw a pattern of reduced hospital and medical visits.

More Effective Operationally

Operationally, the case study showed positive outcomes for family-based care as well, establishing that family-based care is operationally more effective and results in significant savings. For the study, ACE Zambia looked at direct versus indirect programming, comparing the cumulative or “lifetime” cost of a specific program or the cost spread out over the years of impact for the child.

On an annual per child cost, family-based care costs about 40% of a single year at their institution for infants to toddlers. While the first year of placement with a family has more initial costs, when factoring an average of 13 or more additional years of family care at no or reduced cost, it drops down to just $317 annually to support a child in a family.  Even if a child receives family care for only five years, when compared to institutional care the cost is $825 annually, or $4,125 for five years of family-based care compared to $29,670 for five years of institutional care. Using this comparison, placement of one infant with a family would result in a savings of $25,545.

According to the study, “A savings of $25,545 would support 28 children for two full years of nutrition services and prevention of child abandonment. So, for every child we can reunify with a family member, we can support 28 children in our prevention program… Reunifying a majority of children in our emergency nursery and temporary home could save significant funding over the next five years, funds that can be spent on prevention and transforming systems of care.”


It can be easy to skim over numbers and statistics. Numbers are dehumanizing and hard to process yet they’re a necessary and important way to measure the effectiveness of residential care and family-based care on the lives of real children. For ACE Zambia, the numbers are clear. “Our conclusion is that even with significant investment of resources and personnel, institutional care cannot provide the positive benefits of family-based care. We recommend that a policy of rapid family-based care, emergency foster care, and a goal of deinstitutionalization be formally adopted at a governance and executive level, and annual work plans be built to achieve this goal.”

Case studies, percentages, and statistics – of course, little Victor knew nothing about these. For Victor, numbers weren’t important. All that mattered was, for the first time, he felt secure enough to take wobbly, unsteady steps into a loving family member’s arms.

[1] Child’s story is from the Collaborate 2019 CAFO conference. His name has been changed for privacy and protection.

[2] Faith to Action. (2014).

[3] In this article, “residential care facilities” is referring to ACE Zambia’s residential care facilities.

This publication was made possible through the generous support of the American people through the U.S. Agency for International Development under Partnerships Plus cooperative agreement number 7200AA18CA00032, funded September 28, 2018, and implemented by JSI Research & Training Institute, Inc. The contents are the responsibility of the Faith to Action Initiative a project of Tides and do not necessarily reflect the views of USAID or the United States Government.