Menstrual hygiene management in India, Ethiopia & Niger

Menstruation is a key component of a woman’s life. Yet it remains a taboo in many cultures, including in India, Ethiopia & Niger, where the issue has been consistently overlooked, underestimated, and underfunded.

In India, 52% & in Ethiopia over 70% of adolescent girls learn about menstruation after menarche from an older sister or peers at school. Due to lack of awareness, many girls adopt unhygienic practices to manage their menstruation, which can have negative impacts on their health. Girls feel less confident because of the lack of sanitary facilities at schools and of the unavailability of better sanitary products. This contributes to drops in their school and eventually, negative impacts on their school performance. This impacts their ability to attend school or work in appropriate conditions. Ultimately, poor menstrual hygiene perpetuates stigma and gender inequality

KOIS is trying to structure an impact bond in Africa, and one in India, to fund solutions for this issue.

Terms of the bond

  • Status: Structuring the deal with aim to launch in 2020

  • Target population: adolescent girls in India

  • Potential impact metrics: health and/or educational related outcomes

  • Duration: 3-5 years

  • Amount: $6 to 8M

The project

Menstrual Hygiene Management (MHM) involves action on multiple levels: raising awareness, creating access to sanitary products, building toilets and disposal services. A growing body of evidence shows that holistic MHM has a positive influence on education, health, gender equality, as well as society at large. Better-educated girls become empowered women that invest in their families and contribute actively to economic growth and political stability, breaking the vicious circle of poverty.

KOIS initiated a feasibility study for the creation of a Development Impact Bond in technical partnership with the Water Supply and Sanitation Collaborative Council (WSSCC), a UN entity that is a global advocate for adequate and equitable sanitation and hygiene for all, as well as paying special attention to the needs of women and girls including MHM. The objective is to empower adolescent girls by implementing a holistic MHM programme, comprised of three interventions: awareness raising, access to affordable sanitary products and building MHM friendly sanitary infrastructure.

Building on previous work in India (see learnings from the field below), KOIS delivered a feasibility study for the creation of a Development Impact Bond, in partnership with the French development agency (Agence Française de Développement). The objective is to empower women and girls by implementing a holistic MHM programme encompassing awareness raising and access to affordable sanitary products as well as MHM-friendly sanitary infrastructure.

In 2020, KOIS will structure the DIB, with an objective to launch the instrument at the end of the year.

"MHM is a thematic area that cuts across healthcare, WASH and education. Through our impact bond, we will be able to improve adoption of adequate menstrual hygiene practices – thereby improving outcomes across these sectors. At present, players are focusing on delivering care across specific parts of the value chain – such as awareness or access to products. There is a need to combine efforts and show proof of concept."

Pallavi, Senior Analyst, KOIS Mumbai

Expected impact

  • 65,000 to 100,000 adolescent girls in rural India served

  • 200,000 to 700,000 women and girls served across Niger and Ethiopia

  • Increase in dignity, self-esteem and confidence of girls

Learnings from the field: our feasibility study in India

In July 2017, WSSCC and KOIS teams went on a field visit to Amroha and Saharanpur, Uttar Pradesh, to understand the WASH, Health and Education systems under government supervision and to assess the high-level potential of the region with respect to the impact bond.

The field visit was the opportunity to meet with district administration authorities, key government department heads in Health, WASH, Education, as well as key NGOs working in the region on MHM and Swachh Bharat Mission (SBM) district team. We also visited government schools and interacted with adolescent girls and boys, teaching and non-teaching staff, as well as with Accredited Social Health Activists (ASHAs), Anganwadi workers and Auxiliary Nursing Midwifes (ANMs). Lastly, we visited Open Defecation Free (ODF) and non-ODF villages to interact with women and girls.

We identified, both in Amroha and Saharanpur, a critical need for awareness around MHM for adolescent girls. Indeed, Uttar Pradesh figures among the most conservative states of India and mothers are generally not the main source of information on menstruation for their daughters as it remains a taboo. As a result, girls’ understanding of menstruation is limited to the use of a sanitary napkin/cloth but does not include any knowledge around the biological process underlying menstruation and why it occurs. For example, most young women and girls thought that periods occur for cleaning the body of its impurities. No woman in this study had an idea of correlation of periods to reproduction and childbirth.

Our team held another conversation with young women whose mothers had never allowed them to go to temples while on their periods. Indeed, women on their periods are seen as ‘ashudhh’ or ‘not pure’ and face restrictive customs during their menstruation. Moreover, many of them told us they faced menstrual pain, but to avoid visiting local health centres, usually run by males, they would prefer to take rest or practice self-medication.

Some schoolgirls complained during the community-focused group discussions about the quality of sanitary pads that are distributed free-of-charge at school, while some mentioned that they did not receive any from their school. Some admitted that they sometimes shared it with their mothers and sisters. Most women in villages use old cloth while young girls use a combination of both cloth and pads, the latter being used when leaving the household. In some schools where separate toilets for girls are available, they still do not change pads at school, because of filthy toilets and lack of water, as well as of disposal options.

Lastly, disposal of sanitary pads or cloth remains a critical issue. The used sanitary pads or cloth at school are being disposed of in dust bins or school toilets and then thrown into pits, while in villages, they are being thrown in the open air or burned. The health, WASH and education officials all recognize the growing health and environment hazard from incorrect disposal of pads and are keen to address this problem.

These findings are being used to structure an Impact Bond, find investors as well as service providers in the areas identified.

Sources: MJ Open, Menstrual hygiene management among adolescent girls in India: a systematic review and meta-analysis (india), UNICEF, 2018(Africa); Dasra Foundation, Dignity for her report; Dasra Foundation, Dignity for her report; UNICEF

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