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Lessons Learned from High-Quality Residential Care Centers Around the World: A Visual Story

  • Hy V. HuynhEmail author
Original Paper

Abstract

Evidence shows that orphaned and separated children (OSC) in resource-poor societies are more likely to experience maltreatment in the forms of neglect, discrimination, malnutrition, and emotional, physical, and sexual abuse than their non-orphaned peers. As the number of OSC rapidly increases in low- and middle-income countries (LMICs), it is important not to discount high-quality residential care centers (RCCs) as suitable options on the continuum of alternative care for OSC. This statement should not be taken to mean that residential care is always the best care option for OSC but that all alternative care options should be carefully evaluated to determine the best and most suitable fit for a child and their current needs. This essay uses photos as well as empirical data and non-empirical observations from several modern-day high-quality RCCs in LMICs to gather lessons and best practices on how to address child maltreatment. In summary, the high-quality RCCs in LMICs observed typically focused on holistically enriching and improving their centers at the child, organizational, and environmental levels to the greatest extent possible.

Keywords

Residential care center Group home Institution Orphanage Orphan Orphaned and separated children Quality care High-quality care Child maltreatment 

According to UNICEF (2017), there are an estimated 140,000,000 children worldwide who have lost one or both parents and millions more who have been permanently separated from both parents (hereafter referred to as orphan and separated children [OSC]). High mortality among young adults from diseases and conditions such as malaria, tuberculosis, HIV/AIDS, pregnancy complications, and natural disasters are significantly responsible for the increasing number of orphans (Thielman et al. 2012). Millions more children are separated and in need of supportive living environments because their biological parents are: (a) unable to provide food, shelter, and safety, (b) forced to leave their children and seek employment elsewhere, or (c) physically or mentally unable to care for their children (Thielman et al. 2012).

The majority of OSC live in sub-Saharan Africa and Southern and Southeast Asia in low-resource societies that are poorly equipped to meet the social, educational, and health care needs of orphans (Thielman et al. 2012). Evidence shows there are numerous negative outcomes associated with being an OSC in a low-resource society, including traumatic grief, compromised cognitive and emotional development, less access to education, and a greater probability of being exploited for child labor (Whetten et al. 2009). Researchers widely acknowledge that orphans in low-resource societies are more likely to experience maltreatment in the forms of neglect, discrimination, malnutrition, and emotional, physical, and sexual abuse than their non-orphaned peers (Deininger et al. 2003; Gray et al. 2015; Makame et al. 2002; Morantz et al. 2013; Nichols et al. 2014). OSC are in need of living environments that both protect them from further maltreatment and promote their well-being.

For children without adequate parental care, ensuring alternative care is provided is agreed to be a public responsibility (UN General Assembly 2009). As a result, local and international communities have put into place various alternative care options in support of the millions of affected children and their households, including residential care (e.g. residential care centers [RCCs], group homes, “orphanages”), and community-based family care (e.g. extended family members’ homes, adoption, foster care). These alternative care options are intended to provide children with a rehabilitative experience in a safe, secure environment that can protect them from further maltreatment.

The extent to which residential care settings negatively affect children’s development and well-being has become a central debate for international aid policy affecting low- and middle-income countries (LMICs) with large populations of OSC. Certainly, there has been a long-documented history of child maltreatment in residential care centers for children with severe disabilities, particularly in European, Eastern European, and North American contexts (Blatt and Kaplan 1966; Melton et al. 1998). In regard to residential care for OSC, several studies of infant orphaned children who lived in socially and emotionally deprived institutions in Eastern Europe have also concluded that institutional care is damaging to the development of young children relative to foster care (Nelson et al. 2007; Smyke et al. 2002; Smyke et al. 2007; Tizard and Hodges 1978; Tizard and Rees 1975; Van Ijzendoorn et al. 2008; Zeanah et al. 2005). Moreover, these studies demonstrated powerful negative effects of deprivation on infant development and positive development when the infants were moved to live with well trained and paid foster parents. At the same time, these studies of infants in a very specific and negative caregiving environment have often been generalized by policymakers to justify a belief that all residential care settings across countries and continents must have the same poor caregiving characteristics: high child-to-caregiver ratios, shift work, low compensation for caregivers, regimented and non-individualized care, and a lack of psychological investment in the children (Juffer and Series 2008).

On the other hand, studies that were designed to compare residential care to community-based family care and which include data from a broader array of cultural and situational contexts find more nuanced results. In several studies based in low- and middle-income countries [LMICs], children in residential care centers were found to fare as well as or better than those in community-based family care on a variety of health outcomes (Aboud et al. 1991; Braitstein et al. 2013; Embleton et al. 2014; Hong et al. 2010; Merz et al. 2013; Otieno et al. 1999; Wolff et al. 1995). Whetten et al. (2009) found that children in residential care centers across five LMICs (Cambodia, India, Kenya, Tanzania, and Ethiopia) fared better than those in community-based family care settings on several outcomes, including physical health, behavioral and emotional health, intellectual functioning, and memory. They also reported great variability between individuals within care settings (larger than variability between sites or variability between care settings within a site), and they discovered that residential care vs. community-based family care settings explained only 0.3–7% of the variability in child outcomes. In other words, the study found the same continuum of low- and high-quality care among residential care as there were in community-based family care.

Indeed, when searching for the best alternative care option for orphaned or separated children, few would deny that opportunities within the extended family or in other community-based family care settings should be seriously considered. However, given the wide variety of reasons children become orphaned or separated and find themselves living outside their immediate family environment, it is reasonable to suggest that all alternative care options should be carefully and equally evaluated to determine the best fit for a child and his/her current needs. For example, a child may be better off in a high-quality family placement with adequate resources and caregiving skills than in a socially and emotionally deprived RCC stricken with child maltreatment. At the same time, a child will likely be better off in a high-quality RCC that attends to appropriate standards of child care and protection when their extended family care setting is possibly a worse living environment because of previous sexual abuse, stigma and discrimination against orphans, mental health concerns, or other special needs. Because low-quality care exists in both residential and community-based family care settings when placements are not adequately monitored and kept up to standard, it is important that all community-based family care options be held to similar standards of assessment as residential care in regard to their suitability and necessity for a child.

When the complex context of all care options is disregarded and the focus is placed on a dichotomized “either-or” choice set of residential care vs. community-based family care, harmful blanket policies can be put into practice that move children from one type of care setting to another without careful consideration of whether or not the new care setting better meets the needs or interests of the children. In some cases, governments and NGOs focus exclusively on residential care as the main option for OSC and their affected households without adequately addressing individual children’s needs and the quality of care within residential care settings. In other cases, the focus is exclusively on moving children to community-based family care settings while not allowing other care options to exist, therefore running the risk of taking children out of high-quality residential care and putting them in worse community-based family care options that lack adequate monitoring and case management systems. Thus, it is important for OSC to have a continuum of high-quality alternative care options that can meet their individual interests and needs, and it is reasonable to include high-quality RCCs as one of these suitable options.

Over the past decade, I have lived, traveled, and worked as both a child welfare practitioner and a researcher in several LMICs based in Southeast Asia, sub-Saharan Africa, and Central America. In these roles, I had the privilege of working closely with various residential care centers for orphan and separated children around the world. Early in my career as a child welfare practitioner, I worked with eight different RCCs in one city in Vietnam and went on weekly visits to meet with the directors, caregivers, and children. Throughout these site visits, I developed a deeper interest in understanding what specific components, features, and characteristics of these RCCs mattered most for child well-being. These eight RCCs within the same city seemed to vary across all possible dimensions, such as the number and age of children and the gender distribution of the children they housed, including all female, all male, and mixed-gender institutions. They varied by the length of time that they have been in operation and by the characteristics of the directors, caregivers, and staff. They varied in urban vs. rural settings, in size and space, and also in funding; and consequently, had different levels of quality and standards of care.

In one particular residential care center in Vietnam, I was accepted into what felt like a big and supportive extended family. For four years, I considered it my home away from home, a place where I made meaningful memories and deep personal connections with every caregiver, staff member, and child. It was a place where everyone looked after each other and supported one another, a place with loving caregivers and staff, and children who consistently went onto university or fulfilling careers. It was a place that carefully assessed each individual child’s needs and simultaneously supported children for whom community-based family care simply was not an option, while also providing support for children who desired to stay with or be reintegrated into their families and community. This RCC did not have the most abundant financial resources and could only support up to 30–40 children at one time, but it was the quality of care that stood out. By all accounts, my experience with this residential care center felt completely different from the “institutions” described in the former Soviet Union and Eastern European studies.

Years later, I joined the Positive Outcomes for Orphans (POFO) research team and was introduced to the largest multi-country sample of residential care centers across five low- and middle-income countries (Cambodia, India, Kenya, Tanzania, and Ethiopia). In a sample of 83 randomly selected residential care centers, our research team found that a wide range of child care models were represented, each with very diverse resources, cultural traditions, and risk/resilience features that served as protective environments in the face of extreme hardship. We also found that, on average, modern-day residential care centers looked very different from the early documented institutions. For example, in some residential care centers, caregivers lived on site, worked long hours, and may have only been paid in room and board. Many residential care centers also grew out of the community to meet the need of caring for the increasing population of orphaned children and were a part of the community in a way that perhaps early institutions were not. These modern-day residential care centers were not family-style community care nor foster care, but they also did not look like the institutions described in Eastern European contexts. So, one begs the question: if these modern-day residential care centers represented a new kind of care structure that minimized the harm and maltreatment documented in the early Eastern European institutions, could it be important to protect these organic care structures in parts of the world without other support systems in place?

As my exposure to different low- and high-quality RCCs around the world grew with my travels and work, I kept coming back to the question of how certain high-quality RCCs were addressing child maltreatment (i.e. neglect, discrimination, malnutrition, and emotional, physical, and sexual abuse) in more holistic and novel ways that went beyond meeting basic needs. Concurrently, as I got more involved with the POFO Study as a researcher, I found that many of my early observations that I made as a practitioner actually had empirical weight behind them. Particularly, in a follow-up POFO study that I recently led that examined child psychosocial well-being across “high” and “low” levels of quality of care in five LMICs, I found negligible differences in psychosocial well-being between residential- and community-based family care settings, suggesting the important factor in well-being is actually the quality of care within a setting rather than the setting of care (Huynh et al. In Review). As I continue my work as a researcher, I find myself more determined to understand what specific components, features, and characteristics of RCCs matter most for children.

Throughout my time working in these modern-day residential care centers (most notably in Vietnam, Cambodia, El Salvador, and Ethiopia), I have made a few main observations of how high-quality residential care centers in LMICs were striving to address child maltreatment of OSC. As a humanitarian photographer, I also sought to tell this story visually as there is scant visual documentation of what RCCs look like outside a Western context. Fortunately, I was given the rare opportunity to document some of these centers visually, an opportunity that is usually inaccessible to outside visitors or foreigners. I took this opportunity very seriously, with many ethical considerations in mind, by making sure to explain my consent and protection-focused process to everyone involved. Only then did I move forward with asking for photo consent by the directors, caregivers, staff, and youth. As a result, most of my photos from residential care centers focus on specific components, features, and characteristics of the living environments and shy away from any human subjects.

Observation #1: High-Quality RCCs Holistically Address Children’s Development and Needs

Quality Caregiving

One of the very first observations that I made was how the quality of caregiving seemed to really matter for child well-being. According to O’Donnell et al. (2008), “quality of caregiving” can be defined as good when there is an identified caregiver (parent or guardian) who provides the child with a stable, nurturing, and emotionally secure environment. The relationship between the caregiver and child should also provide physical and psychological security for the child. Indeed, attachment theory (Bowlby 1983) emphasizes the importance of early experiences with a few warm and socially-emotionally responsive adults who are relatively stable in the child’s life. Consequently, these early experiences can help the child develop a foundation of appropriate social-emotional development and long-term mental health.

In one study, The St. Petersburg-USA Orphanage Research Team found that very limited caregiver-child social-emotional interactions can be responsible for developmental delays, and after a caregiver training intervention was introduced, results showed substantial improvement in children’s physical, mental, and social-emotional development (Juffer and Series 2008). Through our own POFO study, our team was also able to illustrate the important role of quality of caregiving and found it to be more predictive of better child psychosocial well-being than the specific setting of care (Huynh et al. In Review). (Fig. 1)
Fig. 1

A non-governmental organization called Whole Child International (WCI) focuses on improving child care centers and residential care centers in El Salvador through an educational training intervention directed towards local government, directors, and caregivers. Pictured are a caregiver and a young child engaging in 1-on-1 play in one of the RCCs

Food Security

High-quality RCCs consistently provided enough food for the children. These centers were able to obtain their food in socially acceptable ways that did not resort to emergency food supplies, scavenging, begging, stealing, or other coping strategies. In one study by (Weinreb et al. 2002), severe child hunger was reported to be associated with higher levels of psychosocial distress among school-aged children, and other studies suggest improving the nutritional status of infants and children is also associated with improved motor development, mental development, and cognitive ability (Berkman et al. 2002; Grantham-McGregor et al. 1991; Husaini et al. 1991; Pollitt et al. 1993; Waber et al. 1981). Through our own research, we also found food security to predict child-level psychosocial well-being (Huynh et al. In Review). (Figs. 2 and 3)
Fig. 2

Not only do high-quality RCCs have consistent, well-balanced meals, but there are also special meals to mark certain celebrations and holidays. Pictured is a youth from an RCC in Vietnam helping to prepare for an abundant holiday meal

Fig. 3

A good sign of adequate food security is a routine meal schedule. Pictured above is a consistent meal “menu” for a center based in El Salvador

Access to Health Care Services

In the high-quality RCCs I have observed, children also had access to basic health care services and appropriate medical treatment when ill as well as access to health education opportunities and other preventative care measures. Many of the high-quality RCCs I observed had trained health workers on staff and/or small health clinics integrated into the center. (Fig. 4)
Fig. 4

Some RCCs have their own health clinics on campus and trained health workers on staff, such as this RCC in Cambodia. This small health clinic was built next to the staff offices and was in convenient walking distance to the small residential homes where the children and caregivers lived

At the very least, these RCCs had access to a pharmacy, health clinic, or hospital nearby. Many of these RCCs also prioritized and hosted health and nutrition workshops facilitated by students and professionals throughout the school year. One can easily hypothesize that inadequate access to health care services is inextricably linked with poorer physical health, and it is widely acknowledged that physical ill-health is linked to more mental health disorders and illness (Patel and Kleinman 2003). (Fig. 5)
Fig. 5

An abundant amount of health supplies from a volunteer-led “mobile clinic” program is brought to an RCC in Vietnam. The health supplies are distributed by professional health care providers to children residing in the RCC as well as children from the surrounding community

Access to Educational Opportunities

In every high-quality RCC I visited, all of the children were either enrolled in and attending a nearby school in the community or were enrolled in vocational skills training or apprenticeship programs, in the case of transition-age youth who were finishing high school and approaching graduation from the center. (Fig. 6)
Fig. 6

Several children from an RCC in Vietnam walk a few blocks every day to their public elementary school together. The children at this RCC are not home-schooled, but rather attend schools in town as a strategy to help integrate them into the wider community

Not only were public school fees always taken care of, but there was often individually tailored support in the form of extra tutoring or professional mentorship to meet children’s specific educational needs. At the RCC where I worked in Vietnam, the staff paid close attention to our transition-age youth and upcoming graduates and their specific educational opportunities and needs. Early on, our staff facilitated strengths-based workshops to identify natural aptitudes to help prepare and support these upcoming graduates with their transition and next steps. (Fig. 7)
Fig. 7

After identifying two students’ aptitudes for art, their RCC staff ensured that they had all the extra tutoring they needed to adequately prepare for their highly competitive entrance exams into arts-based academic fields. Pictured above are the two students on a class-related drawing excursion. These two young adults are currently finishing university, one majoring in graphic design and the other in architecture

Positive Youth Development / Life Skills Programming

Another good marker of a high-quality RCC was the embracing and existence of positive youth development (PYD) programming for the children. Positive youth development can be understood as an intentional, pro-social approach that engages youth in a way that is productive, constructive, and strengths-based (Larson 2000). Over the past decade, I have observed various PYD programs that were often supported and facilitated by local and international community members and stakeholders. These PYD programs focused on a range of topics from life skills, identity development, psychosocial capacity, health prevention and promotion, and cultural and extracurricular programming. Some of the most innovative PYD programming I have seen creatively integrated activities and content that were engaging to youth, including summer sports camps, farming and gardening, swimming instruction, computer programming and coding classes, photography and film-making, and community service-learning trips. Of course, the more sustainable and long-term these PYD programs were, and the more they were integrated into the greater structure of the RCC, the better. I have been fortunate to have been involved in many great models and examples of PYD programs, and I believe it to be a critical resiliency-based preventive intervention approach in addressing child maltreatment. (Fig. 8)
Fig. 8

Transition-age youth from multiple RCCs in Vietnam participate in a group exercise for a creative leadership program called “Lighthouse,” a project-based program that used the concepts of design thinking and critical service-learning to equip youth with tools to execute their own service-learning projects for their communities

Observation #2: High-Quality RCCs Have Healthy Organizational Climates with Thoughtful Standards and Practices

Healthy Organizational Climates

Many of the high-quality RCCs I have witnessed had commitments to creating and sustaining healthy organizational and staff climates, which can be defined as what the organization or staff are like in terms of practices, policies, procedures, and routines (Ostroff et al. 2012). In these high-quality RCCs, staff were equally valued and aligned in both mission and goals in a way that promoted greater engagement, teamwork, and higher staff morale. Staff were also encouraged to be creative and collaborative in problem-solving and would work together with other community members or organizations to improve the organization. There was often supportive and strong leadership that provided clearly defined structure and order but also ample opportunities for necessary adaptation and change. Support for caregiver staff, specifically, was also apparent in the form of weekly check-in meetings, continued caregiver training opportunities, and intentional caregiver timetables and vacation schedules to both prevent staff burnout and promote continuity of care. Indeed, in a study by Thielman and colleagues (Thielman et al. 2012), caregiver health was the strongest and most consistent predictor of child health, therefore affirming that there should be more emphasis on organizational strategies to support caregivers and their health.

Thoughtful Standards and Practices for Caring for Children

High-quality RCCs often have well-established protocols and policies that prioritize both child privacy and protection from abuse and exploitation. Maltreatment in the form of emotional, physical, and sexual abuse and exploitation of orphaned children is commonplace in high-prevalence HIV/AIDS areas and has historically been common in low-quality residential care and community-based family care. Without the safety provided by loving and committed caregivers and adults, many OSC are vulnerable to maltreatment such as unacceptable child labor or sexual exploitation, such as sex trafficking and early marriage. Many high-quality RCCs have a number of child protection policies in place to prevent abuse and exploitation from both the staff and caregivers as well as outside visitors. For example, many high-quality RCCs have limitations on photography from outside visitors (which explains why most of my photos do not have identifying features of children) or policies that place mandatory background checks on volunteers. For the residential care center that I worked closely with in Vietnam, I helped create a child’s rights-based manual to transform their global volunteer program in a way that prioritized children’s rights, including their rights to privacy and protection.

Observation #3: When it Comes to Care Setting, High-Quality RCCs Approximate “Family-Like” Environments

At the environmental level of RCCs, there seems to be a few general best practices and standards related to the physical and social-emotional environment that help address child maltreatment, all of which are related to the concept of approximating “family-like” environments as closely as possible.

Physical “Family-Like” Environment

Many of the high-quality RCCs I have visited look very different in structure than the single monolithic institutional buildings that people often think about. Instead, they often look like a community of several small, residential, “family-like” homes, with plenty of green space, safe and soft spaces, and designated active areas and resting areas. They often have other buildings that house libraries, extra classrooms, health clinics, and staff offices. Whole Child International (WCI) contends that the general environment of residential care should be “home-like” to provide feelings of security and comfort and that certain materials can help recreate this “family-like environment.” They believe that a well-designed group care environment can prevent challenging behavioral issues, promote children’s individual and social development, and, ultimately, create a landscape conducive to providing high-quality care. (Figs. 9 and 10)
Fig. 9

Many modern-day RCCs around the world consider the local architecture and cultural context when designing their houses, such as this RCC in Cambodia. On this RCC’s campus is a row of small, traditional wooden Khmer houses that sit next to each other

Fig. 10

This bright colored pavilion and playground sit in the middle of several small “family-like" homes in this RCC in Ethiopia. All of the homes are surrounded by ample amounts of trees and green space

Inside the individual residential homes and units are often personal decorations and comfortable furniture, just as any family home would have. Awards, diplomas, and graduation photos adorned mantles and celebrated every individual child’s achievements. (Figs. 11 and 12)
Fig. 11

This kitchen and dining area reflect the personal tastes of the caregivers and children residing in this small “family-like” home on the campus of an Ethiopia-based RCC. A full kitchen cabinet reveals an eclectic assortment of decorative dishware

Fig. 12

A colorful and comfortable living room adorned with personal photos and decorations is a common component of each small house in this RCC based in Ethiopia. This RCC includes a total of 15 small family-like homes

Social-Emotional “Family-Like” Environment

Perhaps just as important to approximating a “family-like” environment is the actual “social-emotional” environment of the RCC. Most high-quality RCCs I have encountered have a way of operating that largely resembles a big and supportive extended family. There were often lower child-to-caregiver ratios so that caregivers did not undertake too many child-rearing responsibilities at once. There was often a culture of community integration, where community peers from nearby neighborhoods would visit and play with the children residing in RCCs. Children in these high-quality RCCs were also often assigned one primary caregiver, and the child remained in the same group from entry until graduation.

In addition, there were often mixed-age groups, where older children looked after and took care of the younger children as if they were siblings and where actual biological siblings were maintained in the same groups. Gong et al. (2009) showed that sibling separation resulted in substantial anxiety, anger, and depression among orphans in both residential care and community-based family care, suggesting that keeping siblings together should be a key consideration in the placement of OSC in residential care. Moreover, some researchers wonder if the mutual peer-to-peer OSC support could be one of the most important and overlooked protective factors for children living in RCCs, given evidence that shows positive peer relationships for maltreated children can moderate psychosocial well-being, including self-esteem, stress, depression and anxiety, and a sense of security and support (Bagwell et al. 2001; Bolger et al. 1998; Ezzell et al. 2000; Waldrip et al. 2008) (Fig. 13).
Fig. 13

Two pairs of older boys and girls from an RCC in Vietnam are seen walking together through a park. The youth have grown up together in the RCC starting from an early age and call and consider each other “siblings”

Conclusion

The proposition that every OSC should be raised in a community environment that is family-based is an ideal to be striven for but perhaps may work better in theory than in practice, until improved systems are in place. As the number of OSC rapidly continues to increase in LMICs and as more research suggests children in high-quality residential care can fare as well as or better than those in community-based family care, it is important not to discount high-quality RCCs as a suitable option on the continuum of alternative care for OSC. This statement should not be taken to mean that residential care is always the best care option for OSC but that all alternative care options should be carefully evaluated to determine the best and most suitable fit for a child and their current needs.

Although this photo essay was not intended to be an exhaustive list of “ingredients” for high-quality residential care, there is much to be learned from modern-day high-quality RCCs in LMICs and the holistic ways that they are intentionally addressing all aspects of child maltreatment. Not all of the high-quality RCCs I came across in LMICs across Southeast Asia, sub-Saharan Africa, and Central America had abundant financial resources either, but they did all focus on holistically enriching and improving their centers at the child, organizational, and environmental levels to the greatest extent possible. Future research is needed to create tools and measures that could monitor and evaluate the quality of care within all residential care and community-based family care settings. These measures will likely have to be adapted for different child demographics as well as socioeconomic and cultural contexts. There is also a need for more research that determines what good child outcomes look like in different socioeconomic and cultural contexts and further research that teases out the causality of specific characteristics within these care settings and contexts that are associated with improved child outcomes. Additionally, more research is needed to help stakeholders understand what kind of monitoring and evaluation or case management systems are most needed to effectively support and advocate for the well-being of orphaned and separated children across all types of care settings.

In summary, the high-quality RCCs I observed typically strived (a) to address children’s needs holistically (through quality caregiving, food security, access to health care services and educational opportunities, and positive youth development and life skills programming, (b) to create and sustain healthy organizational climates with thoughtful standards and practices, and (c) to approximate “family-like” environments, both physically in structure and social-emotionally as an organization. I hope that the photo component of this essay helped visually illustrate some of these best practices and standards within high-quality RCCs, particularly in the LMICs I have worked in around the world (Fig. 14).
Fig. 14

A children’s mural in process observed on one of the main walls of a Cambodia-based RCC. This RCC has grown to accommodate sixty-six children ages 3-17 along with 51 staff members. They previously did not accept children under age 6, but the founder began accepting children as young as 3 when she saw how young children in the community were being affected by maltreatment such as neglect and child trafficking

Notes

Compliance with Ethical Standards

Conflict of Interest

The author declares there are no conflicts of interest.

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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Center for Health Policy & Inequalities Research, Duke Global Health InstituteDuke UniversityDurhamUSA

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