“Going to school has become so much more convenient since I have started taking Freedays from ASHA didi. The napkins are soft and comfortable, and so easy to use,” says Nisha, an adolescent girl from Thakurpura, a small village located in Kathua district in Jammu and Kashmir.
Nisha is one of the beneficiaries of the Menstrual Hygiene Scheme (MHS) under the National Health Mission (NHM), which was launched for the promotion of menstrual hygiene among adolescent girls (10-19 years). This is one of many positive initiatives that aims at tackling MHM-related challenges across the value chain of awareness, access, use and waste treatment.
Apart from improving the access to affordable sanitary napkins through Accredited Social Health Activists (ASHA), MHS plays a pivotal role in creating awareness among adolescent girls about safe and hygienic menstrual health practices which includes audio, video and reading materials. Owing to the stigma associated with menstruation, it is important for government authorities along with ASHAs and non-profit organisations to work towards interventions that share information for understanding menstrual hygiene management (MHM) as a health concept.
The government is committed to providing necessary support to states and union territories for improving outcomes related to MHM. For FY 2019-20, Rs 64.61 crore has been allocated through the NHM to 14 states/UTs for decentralised procurement of sanitary napkins.
In addition to this, seven states are implementing the MHS using MHM funds from the previous financial year. As a part of this, a pack of six sanitary napkins for Rs 6 is provided to girls across India. The government understands that the challenges faced by adolescent girls in accessing quality MHM, and these multi-layered challenges cannot be tackled by improving access alone. It requires the creation of a sustainable ecosystem.
The MHM ecosystem consists of awareness, safe usage of menstrual products and access to menstrual waste disposal facilities. Keeping this in mind, 7,470 Adolescent-Friendly Health Clinics (AFHCs) across India are providing clinical and counselling services on diverse adolescent health challenges including menstruation through trained counsellors and experts. AFHC clinics are the backbone of Rashtriya Kishor Swasthya Karyakram (RKSK), the government’s flagship programme for holistic development of 253 million adolescents in the country.
To encourage discussion about health issues including menstruation among adolescents, a peer educator programme ‘Saathiya’ has been launched where two male and two female adolescents are selected per 1,000 population in 214 districts.
But the mammoth task of providing MHM facilities to around 120 million adolescents girls in India cannot be fulfilled only by RKSK interventions. We have initiated multi-stakeholder collaborations with different ministries, state governments, educators and NGOs.
Schools will play a key role in accelerating the progress on MHM. Just like Nisha from Thakurpura, negative social attitudes towards menstruation and a lack of access to toilets in school is discouraging many girls from attending classes while on their period. Taking note of that, the Ministry of Drinking Water and Sanitation launched the Menstrual Hygiene Management Guidelines for schools and households to address specific sanitation and hygiene requirements of adolescent girls and women. Apart from separate toilets and safe menstrual waste mechanisms for girls, the guidelines also call for the sensitisation of men, boys, communities and families about menstruation.
The newly launched School Health Programme under Ayushman Bharat where teachers are supposed to act as health ambassadors to inform students about health and disease prevention through interesting activities, will also complement the government’s efforts.
In addition to guidelines, the media has proved to be an effective vehicle for sensitising people about menstruation. India has managed to challenge the status quo and slowly alter its attitude towards MHM in the last few years. This is also reflected in the focus on MHM in popular culture with the success of films such as Padman, Period. End of the Sentence (documentary) and First Period (short film), which have contributed to demystifying taboos. The positive impact of these films can also be seen in rural villages, where women entrepreneurs are earning a living and creating livelihood streams by manufacturing different kinds of sanitary products.
Given India’s vast socio-economic diversity, we should start by understanding the different contexts and needs of girls in the country. Such large-scale data collection and analysis efforts can help us to understand fundamental questions like who adolescent girls prefer to approach for information on MHM, what MHM products they prefer and how challenges related to menstruation are linked with issues of limited resources and poverty.
For example, in the latest edition of the National Family Health Survey (NFHS)-4 (2015-16), it was observed that around 57% of women between the ages of 15 and 24 use a hygienic method of MHM. This was the first time indicators related to menstrual hygiene product use were added in the NFHS. These data points helped us to further focus on improving access to menstrual hygiene products in communities.
Similarly, such repositories of data can be leveraged to create MHM interventions which will ensure minimum overlap between programmes and policies of different ministries, inclusiveness of vulnerable populations such as girls living in institutions and streets, and address the needs of diverse users. These interventions driven by collaborative action of our partners will enable us to improve menstrual health and hygiene for girls in the poorest socioeconomic environments.
This is just the beginning, and there is now a need to take forth this momentum and maximise impact of the efforts. We need to break down silos and work in a holistic manner. From engaging a range of stakeholders across the government, media, non-profits and community members surrounding girls, to bridging data gaps to reveal specific, socio-geographical contextual needs, working in collaboration might be the most promising way forward.
Ajay Khera is deputy commissioner for the Child Health Program at the Ministry of Health & Family Welfare, Government of India. He is also in charge of the Adolescent Health Program. He is a medical graduate with a post-graduate qualification in Public Health, with more than 25 years of experience in Public Health programs at the national level.