March 27, 2019 (Lepanto Institute) — Catholic Relief Services is currently in the middle of a national fund-raising campaign, and Catholics all around the country have been contacting the Lepanto Institute, asking if CRS is still involved in the promotion of contraception. Sadly, the answer is a resounding “yes.” Last year, we reported that CRS is a dues-paying member ($56,000 per year) of an organization called InterAction, which actively lobbies Congress for the expansion of contraception and the end of the Mexico City Policy. Last week, we reported how CRS Executive Vice-President William O'Keefe testified before Congress to request nearly $9 billion for USAID, PEPFAR, and the Global Fund, which comprise the largest distributors of contraception and condoms throughout the world.
Our latest report on a CRS project (which can be read in full by clicking here) shows that from 2013 to 2018, Catholic Relief Services participated in a project which had the stated objective of spreading contraception to vulnerable women living in poverty in rural areas of Madagascar. CRS's role in this project was to create a self-sustaining financial mechanism that would provide funding to Community Health Volunteers, whose job (among other things) it was to teach women all about contraception and to sell them various pills and devices.
The USAID Mikolo Project, which ran from August 2013 to July 2018, was a continuation of another project in Madagascar called SanteNet2. At the close of SanteNet2 in March of 2013, USAID noticed that its efforts to spread contraception through Community Health Volunteers was not achieving the level of independent sustainability it had hoped. In January of 2013, USAID conducted an “Assessment of Community Health Volunteer Program Functionality in Madagascar” wherein it sought “how to finance the CHV program to make it sustainable.” The report said:
Recommendations included determining how to finance the CHV program to make it sustainable. One representative called for a line item in the Government budget at decentralized levels to cover CHV services. Another said that some FP services were free at health centers but that CHVs had to ask for a fee to recoup the costs of medicines and supplies, though the service was free. This particularly applied with medications that were purchased through the community. Poverty in remote areas precluded asking for contributions from the communities.
Analamanga's community representatives were concerned about stimulating and sustaining CHVs' motivation. They acknowledged the efforts CHV had to make and cited a need for financial incentives. One representative explained that the work interfered with a CHV's personal (especially marital) life, since many were approached at night, especially for MNCH emergencies. In one case, a CHV's husband opposed his wife's CHV activity due to the frequent disruptions. Financial incentives, e.g., compensation for travel expenses, could help retain CHVs. Providing resources to communities to organize incentives was suggested.
The answer to this problem of providing incentives for CHVs to continue their work in the community (and away from their homes and farm work) while making sure the project was self-sustaining (as in, not reliant upon outside funding) came in the form of Savings and Internal Lending Communities (SILC).
An October 2015 USAID document titled “COMMUNITY HEALTH WORKER INCENTIVES IN MADAGASCAR: LESSONS LEARNED” explained that:
The most common financial incentives across all interviewed CHWs included per diem for attending trainings and meetings, user fees from the sale of medicines and commodities, performance-based financing (PBF) incentives, and referral payments for FP [family planning] services. Some CHWs were also involved in program-supported savings and internal lending communities (SILCs) and income generating activities, while others received free enrollement [sic] in community health insurance schemes.
There are two basic elements to the project which must be understood in order to grasp the problem: Community Health Volunteers (CHV) and their role in promoting contraception; Savings and Internal Lending Communities (SILC) and their role in financing CHVs.
Community Health Volunteers and Contraception
The role of the Community Health Volunteers (CHVs) is very clear. They are to provide service delivery for various health-related issues in rural communities, including contraception. The Final Performance Evaluation of the Mikolo Project, which was published in Dec. of 2017, gives a concise explanation for the use of CHVs in the project:
Working in eight of Madagascar's 22 regions, in 43 Districts, 506 communes and 3,557 fokontany (communities) over the past three years, the Project has re-established a strong community based service delivery mechanism through the strengthening of the quality of service delivery by more than 6,500 community health volunteers (CHV). By focusing on communities which are greater than five kilometers from a nearest health facility, the Mikolo Project is ensuring that the most underserved of Madagascar's population are receiving quality integrated health services for women and children under five years old. CHVs are the community linchpin in ensuring a strong continuum of care by:
- offering family planning services to women of reproductive age, including youth …
In the very first report for the Mikolo Project (1 August–30 September 2013) it was established that the promotion and distribution of contraception was a priority. The report identifies on page 7 what it referred to as sub-purpose 2 of the project, namely, “increase the number of CHVs, fortify linkages with providers of long-acting and permanent methods (LAPMs) of FP, and improve commodity security.” In other words, CHVs were to be used as mules for contraception throughout the community.
Further explaining sub-purpose 2, the report goes on to state that the project will be ensuring that the curricula for training CHVs includes instructions on how to inject hormonal contraception, Depo Provera.
What is clear from this information is that Catholic Relief Services would have known from the very beginning of this project that the spread of contraception was integral to its success. In fact, in the portion of this report which delineates CRS's responsibilities regarding the establishment of microfinance institutions is a statement that CRS will not be asked to provide service delivery related to family planning and reproductive health:
CRS will not be asked to provide service delivery related to family planning and reproductive health. Specifically, it is expected that CRS will lead all activities related to microfinance. Drawing from international and Madagascar specific experiences, CRS will facilitate the establishment of commune-level COSAN Savings and Loans Funds (CSLF)/Village Saving and Loans Associations (VSLAs). CRS will establish partnerships with Microfinance Institutions and determine the demand for client centered loan products available through COSANs.
The role of CHVs in the promotion and distribution of contraception is made abundantly clear in dozens of documents, but a USAID report titled “USAID/Madagascar and Community Health Volunteers: Working in Partnership to Achieve Health Goals” explains on page 9, under the heading “CHV Package of Services,” the contraceptive services provided by CVHs in Madagascar:
Volunteers also provide community-based family planning services. These services include counseling, pregnancy screening, method eligibility screening, and provision of short-acting contraceptive methods. CHVs inform and refer clients for long-acting and permanent methods available through mobile outreach and private and public service providers. CHVs socially market many of the products that they distribute; this modest income serves as a motivation for CHVs and sets Madagascar apart from other countries that pay direct stipends. CHVs also provide a link to youth peer educators in the community to reproductive and other health services.
Savings and Internal Lending Communities
As explained earlier, Catholic Relief Services' role in the Mikolo Project was to “lead all activities related to microfinance.” In June of 2018, MSH (the lead on the Mikolo Project) published an article explaining how the SILCs work and the relationship between the SILCs established by CRS and the Community Health Volunteers. It is important to note that this is the first time that SILCs would be used to finance a health-related project.
In rural Madagascar, people have limited access to savings programs or credit. This impacts community health when people cannot afford to pay for health care. In partnership with Catholic Relief Services (CRS), the USAID Mikolo Project promoted the creation of savings and internal lending communities (SILCs) at the Fokontany (village) level to encourage individuals and families to regularly save income and to provide them with access to credit on favorable terms.
CRS first developed the SILC approach for general community development, and USAID Mikolo implemented it for the first time in the field of public health. SILC groups offer easy access to financial services for households and health care providers, especially women, as well as social capital. The main objective of SILCs is to provide funding, borrowing, and savings opportunities for community members.
SILCs are groups of 15-25 community members that meet on a weekly basis. Each member contributes money into the SILC fund. Members can borrow money at a fixed interest rate, e.g. to start up a small business. After a full cycle (9-12 months), the total savings accrued throughout the period are distributed to members based on how much each has saved, as a percentage of the overall savings.
This idea of SILC groups is not new to Madagascar; however, what makes the USAID Mikolo model unique is that the underlying premise is that rural development is inherently connected with health. USAID Mikolo-supported SILC groups enable members to both improve their livelihoods and lead healthy lives.
In fact, community health volunteers (CHVs) participate in the SILC groups not only as members, but also as health educators to improve quality of life by considering personal and family health. Life in a rural village is very difficult, and without financial stability simple healthy behaviors may seem out of reach for many families, such as purchasing needed medicines, soap, family planning methods, or healthy food. CHVs encourage these behaviors, and with the SILC program these and other health-promoting activities can become regular habits rather than unattainable conventions.
In short, CRS is responsible for creating local microfinance groups called SILCS, which in turn provide funding to CHVs, whose mission is to spread contraception to women in the village.
To put into perspective the effectiveness of CHVs in promoting and spreading contraception, this chart, which is on page 95 of the final evaluation we cited earlier, illustrates how “new users of family planning” was by far the most popular service provided.
Further Evidence in Video
Catholic Relief Services knew fully well that it was being used by USAID in order to create a financial engine for the spread of contraception through Community Health Volunteers. The project itself identified CRS as being responsible for all matters pertaining to microfinance, it showed how CHVs were being funded by these microfinance groups, and it showed how one of the primary missions of the CHV was to introduce and spread contraception. The very fact that CRS had a disclaimer indicating that it would not be directly responsible for the delivery of family planning is further indication that CRS knew exactly what this project was about.
But another and more direct piece of evidence comes from CRS itself.
On YouTube, USAID had uploaded a series of videos on the Mikolo Project intended to explain various aspects of the project itself. Several of these videos had closing credits showing that they were written, produced, and owned (copyrighted) by Catholic Relief Services itself.
In one video, titled “Promoting Saving and Lending Communities to Improve Access to Health,” the narrator explains the relationship between CHVs and CSLF, saying:
The primary goal of the project is to increase the use of primary healthcare services to local community and the adoption of health enhancing behavior. The project relies on human capital to achieve this goal. The establishment of CSLF or Cosen Savings and Loans funds, which are savings groups of community health volunteers is one way to achieve this. The CSLF presents an opportunity for community health volunteers to have access to financial opportunities such as credit and savings. This practice also enables them to develop their social capital into the community health volunteer's professional network.
While the narrator for the video is saying this, the B-roll footage shows a CHV entering a woman's hut, where he pulls out a box of something from his backpack (image above). Blowing the picture up (left) reveals that the box being taken from the backpack is a box carrying the label “Confiance.”
A few seconds later, the contents of the box are set out on the table while the CHV examines the instructions on the back of the box. The contents included a small vial and a syringe (see the image below). According to a document produced by Family Planning Watch, a project of Population Services International, Confiance is an injectable contraceptive equivalent to Depo-Provera, produced by the Pfizer corporation.
This video, along with this report, was sent to Catholic Relief Services in September of 2018. After several months, Catholic Relief Services claimed that the video, which bears its closing credits and its copyright, was not its video and that a local production company mistakenly attached CRS's credits and copyright to the end of the video. Not only is this explanation the same kind of thing CRS said about the government documents indicating that CRS was involved in the promotion of contraception in the SAIDIA Project, and the inventory reports showing that CRS had received and distributed 2.25 million units of contraception in Project AXxess, but since CRS was specifically identified as having been responsible for all of the matters pertaining to microfinances, there simply isn't any other entity for whom this video would have been made.
After receiving CRS's explanation that the video isn't actually theirs, we have discovered that the original now has the ending credits and copyright attributed to CRS blurred out. However, the Lepanto Institute saved the video in case something like this should happen. You can see the original version with the closing credits at the link here.
There is absolutely no way of denying that Catholic Relief Services played a willing role in a project designed to spread contraception to poor people in rural Madagascar. The project identified the spread of contraception by Community Health Volunteers as a priority from the very beginning. The Community Health Volunteers were being funded by the microfinance communities called SILCs, and those communities were being established by Catholic Relief Services.
Another way of looking at this is that the CHVs are legalized drug-dealers (contraception instead of heroin), and CRS created the self-sustaining mechanism that would keep them funded.
CRS may claim that its role in the project was very small, but what it overlooks is that its small part was also one that was vital to the overall “success” of the project. The battery on a car is a very “small part,” but without one, a car won't go anywhere.
But one more thing CRS has to atone for is the grave scandal it caused to the Malagasy people. On June 26, MSH and USAID Mikolo announced the role of the Mikolo Project in helping to draft Madagascar's new law that allows universal access to contraception and enables CHVs to provide short-term contraception. While CRS may not have played a direct role in the drafting of this new law, because of its participation in a gravely and intrinsically immoral project, the name of the Church is now attached to this result.
Published with permission from the Lepanto Institute.