German Development Cooperation (GDC) through GIZ has been working on menstrual health issues around the world recently and in Nepal since 2015. In Nepal, this programme is funded by the German Federal Ministry for Economic Cooperation and Development (BMZ) and the Ministry of Health as the Programme Executing Agency.
Currently, GDC and other development partners support the Family Health Division of Nepal’s Department of Health Services in cooperation with the Department of Education to implement a school-based program to improve menstrual health and hygiene management in over 500 schools. The schools are located in the 14 districts most affected by the 2015 earthquake as well as other districts in the Mid and Far-west development regions. This programme focuses on increasing general awareness of issues surrounding menstrual health as well as training resource persons, teachers, and health workers in how to educate girls and boys about menstrual health and hygiene management (MHM). The programme also aims at teaching lower secondary and secondary school students how to make reusable sanitary pads.
I was attracted to Nepal by an interesting job offer with GDC’s health sector programme focusing on the health of women, children, and adolescents. I arrived in Kathmandu three months before the devastating earthquake in April 2015. One day after the earthquake, our team was already supporting the Ministry of Health in the immediate response at the central level and in a few affected districts. My experience working in post-disaster Haiti came in handy during this period. As an ardent and experienced supporter of girls and women, my focus during the response and after–has been on sexual and reproductive health needs.
Having spent time with girls and women in many countries around the world, I understand how crucial it is to invest in the potential of girls and women to transform societies. Girls and women are valuable drivers of development, and one of the simplest things we can do to empower them is by giving them access to menstrual health and hygiene education and advice on practices.
However, in many low-income countries, such as Nepal, adolescent girls face significant challenges in managing their menstruation hygienically and with security, dignity, and confidence. Cultural constraints, lack of access to accurate information, lack of facilities, and inadequate sanitation in schools and homes can restrict girls from managing menstruation and participating fully in society. Due to the high costs of sanitary napkins and lack of availability in some places, girls may turn to less hygienic options, such as dirty rags, ashes, dried leaves, corn husks or sand. Furthermore, a lack of proper toilets and sanitation facilities can make menstruation a very traumatic process. UNICEF and the WHO define a state of good menstrual hygiene management as “when girls and women use the clean material to absorb or collect menstrual blood; can change this material in privacy; and have access to soap, water, and disposal facilities for used materials”.
Social and cultural factors also play a strong role in influencing attitudes and beliefs regarding menstruation. In the far and mid-western regions of Nepal, menstruating women are considered ‘untouchable’, dirty and impure and are separated from their families for the duration of every menstrual period. This practice is known as chhaupadi, and despite the fact that the supreme court of Nepal declared chhaupadi illegal in 2005, the harmful practice still continues, particularly in the country’s western region.
These challenges girls and women face in managing their menstruation restrict them from fully participating in society and can also have negative impacts on health, education, and human rights.
GDC works closely with the government of Nepal to address these issues through a multilevel intervention that includes (amongst other strategies) school-based education, the production of homemade sanitary napkins, and the production of low-cost sanitary pads, which I will go into more detail about later.
In the wake of the earthquake, a menstrual health and hygiene management programme was developed and implemented in the 14 districts most affected by the earthquake. Under the umbrella of both the Ministry of Health and the Ministry of Education, school teachers and health workers were trained on menstrual health and hygiene management information and education as well as on how to make reusable sanitary pads locally. The programme is seen as successful. In Dhading, for instance, the programme benefited 4148 adolescent girls from 42 schools in 2016. In this current year, we are expanding to additional schools in Dhading, Nuwakot, and Rasuwa and in Banke in the Mid-west development region in order to reach a higher coverage.
We also focus on training trainers in menstruation health and hygiene management to enhance the capacity of resource persons, teachers, and health workers. After the training, the participants are expected to conduct their own MHM sessions effectively and act as focal people for relevant issues in schools and the community.
There is another project in the works to produce low-cost sanitary pads. Semjong VDC in Dhading and Sigre in Nuwakot were recently chosen as pilot districts to implement the sanitary pad production unit. The main aim of this pilot project is not only to increase access and availability of sanitary pads but also to establish an income-generating activity for women in post-disaster districts.
For a long time, GIZ has been supporting the Ministry of Health to disseminate information on sexual and reproductive health. However, it is difficult to evaluate change that occurs based on information dissemination. Combining information campaigns with other solutions (such as the low-cost sanitary pad production) can yield better and directly measurable results, with wider coverage.
To tackle issues surrounding menstruation, innovators around the world are working to provide alternative solutions. One such innovation is the low-cost sanitary pad machine devised by Arunachalam Muruganantham, an inventor and social entrepreneur from Coimbatore, India. In May 2015, we invited him to the first national conference on “Adolescent Health and Development” where he gave a TED TALK on starting the “sanitary revolution”. Representatives from the government and civil society heard his talk and were inspired to tackle issues around menstruation. The machines are now being piloted in Nepal.
When operated by five to seven women on a single shift basis, each pad-making machine is able to produce 1600 pads per day (480,000 per year) at a cost of six Nepali rupees (0.05 USD) per pad. The machines cost approximately 3500 USD per piece. The pads are biodegradable and contain no harmful chemicals, and are an alternate option to cloth napkins.
The main idea behind this innovation is to help women in rural and hard-to-reach areas obtain access to affordable sanitary pads while simultaneously providing them with a means of income and economic empowerment through a sustainable and scalable business model.
GDC is piloting the use of these machines in two districts. After conducting a feasibility study in selected working districts, two VDC women’s cooperatives were identified to pilot the project. The machines arrived in May 2016 and were installed in Semjong, Dhading District and in Sigre Nuwakot Districts a few months later.
Kishan Sana Cooperative, one of the cooperatives, has since been invited to several exhibitions and fairs and enjoying media attention for being the first ever low-cost sanitary manufacturing project in Nepal. This group is trying to tackle taboo issues such as menstrual hygiene while also promoting economic empowerment of women in rural areas.
Menstrual health and hygiene is a persistent issue in Nepal, but it is seldom spoken about due to religious and socio-cultural reasons. However, having a local group of women producing low-cost sanitary pads has many important impacts. Some of these impacts which we hope to see from the LCSP project include:
- Women from rural areas learn to become self-sufficient and become active partners in creating a healthy environment within their community. This occurs mainly through income-generating activities and economic empowerment.
- Essential discussions on MHM begin at various levels, much beginning with the women groups. This helps to break the silence around menstruation and challenge harmful practices and negative gender perceptions in the communities and beyond.
- Establishing and manufacturing low-cost sanitary napkins improves hygiene and rural health.
- More choice becomes available to girls. Sanitary pads of different qualities and price ranges become available at the local market, including local pads at a comparatively low price to commercial brands.
- Because MHM is a cross-cutting issue, producing low-cost pads enhances cooperation between sectors and sub-sectors such as education, WASH, and health.
- Women cooperatives can begin to challenge negative perceptions and gender discrimination.
- Men and boys are also exposed to MHM issues and hopefully, support the girls and women within their families to a healthier life during menstruation. The notion that MHM is just a “woman problem” can begin to be challenged.
One particular challenge is the lack of technical expertise among women we would like to see operating the machines. More vocational training for girls and women that focus on technical aspects is needed. On a broader scale, while cooperatives have certain expertise in managing their administration and business, they should be further supported in optimizing their production processes and business, product marketing strategies, and focusing on the technical aspects of the machinery and production. Lastly, product registration can be a difficult task, which we hope the district administration can support us with.
Muruganantham’s machines have innovated and produced one simple, economic and acceptable solution. They are low-cost and made with cheap raw materials, which has helped the innovation to scale up enormously in India. But such a machine is not the only innovation working in the field of MHM. There are several initiatives that are working to provide solutions at various levels in different parts of the world. It is important to explore different options before importing the machine to Nepal.
There are also other kinds of menstrual management alternatives including cloth pads, tampons, and menstrual cups. Each option has its strengths and drawbacks, and disposable sanitary pads are necessarily the only or best option. Rather, it is about choices. Girls should have the personal choice to choose the method that is right for them, although these choices are often highly influenced by aspects such as cultural attitudes, water supply, access and availability of hygiene material. Hence, it is very important to consider cultural values and contextual factors before exploring options within a community.
Innovative ideas help to develop solutions to problems. But these solutions sometimes bring with them a host of new problems to be tackled. For example, with the introduction of low-cost sanitary pads, there will be an increase in the usage of pads, which creates a problem for disposal. Before introducing a solution, think through all possible problems and pitfalls.
Even good MHM practises and policies can fail in the absence of infrastructural facilities. Hence it is important to address barriers to water and sanitation for the hygienic management of menstruation with privacy and dignity. The first step would be to ensure access to and availability of a clean water supply, private latrine facilities, and options for disposal of sanitary products. Due to the impact of menstruation on education, it is very important that school girls have access to water and gender-segregated toilets on the school site.
It is also important to change the perception that menstruation is a “woman’s issue” only. To challenge negative perceptions and gender discrimination, it is essential that men and boys also understand the process and support the women within their families to practice good menstrual hygiene. Menstrual health management is an essential topic for all people and must be addressed for the betterment of all society.
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Valerie Broch Alvarez served as a Senior Technical Adviser for Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH in Nepal. She is involved with a health sector program focusing on the health of women, children, and adolescents.