A Summit on menstrual health management held on 11th December 2018 in Kathmandu, Nepal
It is an indication of how far menstrual health issues have come in Nepal that more than 500 participants from all over the country and region attended a Summit hosted by GIZ and the menstrual Health Alliance in Kathmandu on 11th December 2018. Previously shrouded in silence about harmful practices and taboos, menstrual health management has now become a dynamic development issue.
Some 350 people were invited to attend the ‘MenstruAction’ Summit entitled ‘No time to rest: ensuring every girl in Nepal can thrive during her period’, hosted by GIZ and the Menstrual Health Management (MHM) Alliance at the Yak and Yeti Hotel in Kathmandu on 11th December 2018 – but around 450 showed up for a lively and constructive day of discussions and exchange of experiences. It is an indication of just how important the issue has become in Nepal.
Breaking the silence: ‘No time to rest’
The Summit began with a welcome address by Valerie Broch Alvarez from GIZ ‘s Support to the Health sector Programme who said the audience was full of ‘promising and inspiring’ policy makers, researchers, educationists, friends from the media, development partners, technologists and innovators, young volunteers and ‘everyone who shares our conviction that every girl deserves access to better health, wellbeing and empowerment.’
She reminded participants that it had only been two years since Nepal had held its first ever national conference on adolescent sexual reproductive health and rights. At the time the country was still in a state of shock after the 2015 earthquake and struggling to rebuild lives. One of the many preoccupations then was how to support affected girls and women who had been displaced from their homes and to find solutions for their menstrual health and hygiene issues, such as getting hold of affordable menstrual pads. As a result, the German Federal Ministry for Economic Cooperation and Development (BMZ) commissioned Gesellschaft for Internationale Zusammenarbeit (GIZ) GmbH to support an income-generating initiative in two affected areas to produce locally manufactured pads, using imported low-cost machines from India.
Working together to address barriers and taboos
As a result of this conference on adolescent health two years ago, a Menstrual Health Alliance has been established to address the many barriers and taboos around menstruation and coordinate efforts. Today the Alliance comprises 50 organisations working on around 80 initiatives throughout the country. ‘There is now a real commitment, said Valerie Broch Alvarez, to promoting informed choice for women and girls in Nepal – particularly in rural and remote areas – and to break the silence on harmful menstruation taboos.
The aim of the current Summit, she said, was to provide another platform for all the actors working on menstrual health to get engaged and push the MHM agenda forward. ‘We want this meeting to help strengthen a very important movement and collaborative model and to lead to more effective implementation of menstrual health management so that all girls and women in Nepal will be empowered […] what we can achieve together can go beyond our own efforts and imaginations.’
Consolidating ideas and actions
Gunraj Shrestra welcomed participants on behalf of the MHM Alliance and thanked GIZ for its financial support for the Summit. He said that since the Alliance had been set up, it had been conducting a dialogue with key ministries on how to improve MHM. The aim of this Summit, he said, was to consolidate existing ideas and initiatives and come up with recommendations which would form the basis for a Plan of Action to be submitted to government and then cascaded to local areas for implementation.
‘We are trying to go down to the villages and local level. Until we do this we cannot be 100% successful.’ He hoped that all the participants would share their knowledge and skills so that menstrual taboos and restrictive practices could be eliminated in Nepal.
Breaking down taboos about ‘impurities’
Moderator Mandira Maharjan reminded participants that good menstrual health hygiene and awareness was fundamental, but in many parts of Nepal ancient restrictive practices and beliefs meant that many women and girls were regarded as impure and untouchable during menstruation. In most extreme cases they are banished to a “chhaupadi” hut – a cow shed or a cave or hole in the ground, and not allowed in the kitchen or the temple. Although declared illegal in Nepal in 2007 and a criminal offence since 2017, chhaupadi is still widely practiced in remote rural areas, especially in the Far West Region of Nepal. This meeting, she said, provided a great platform to take further action against such harmful practices.
Even where more extreme practices were not followed she said that many women and girls did not have access to affordable and hygienic menstrual pads, proper toilet facilities or running water. As a result they are excluded from participating in family life, education, work, and religious and social activities for an average of 1,400 days in their reproductive lifetime.
Growing global awareness about menstrual issues
In her key note speech, Dr Marni Sommer, Associate Professor for Socio-medical Sciences at Columbia University in the USA, began by saying: ‘It’s extraordinary to see how full this room is. We have been working on this issue since 2004 but it is only now in 2018 that we see such engagement.’ She also welcomed the fact that there were – unusually – many men present at the meeting, adding: ‘These are our allies.’
In her presentation she talked about the global progress that had been made in MHM over the last 14-15 years as it has broadened from being largely a water and sanitation issue, to a multi-faceted social, health, gender and educational issue. In the last two years there had been so much action and interest, new measures and interventions, media interest and laws. The question now, she said, was: ‘where do we go from here?’ She praised Nepal’s efforts to address these issues and said it had become a model for countries around the world.
What is Menstrual Health Management?
Dr Sommer said that in order to mobilise and advocate effectively, it is first necessary to try to define what Menstrual Hygiene Management (MHM) means, and she quoted WHO and UNICEF’s Joint Monitoring Programme definition from 2012.
‘Women and adolescent girls are using a clean menstrual management material to absorb or collect menstrual blood, that can be changed in privacy as often as necessary for the duration of a menstrual period, using soap and water for washing the body as required, and have access to facilities to dispose of used menstrual management materials. They understand the basic facts linked to the menstrual cycle and how to manage it with dignity and without discomfort or fear.’
This would be achieved, she said, through a holistic approach of ensuring that girls have access to supportive facilities, accurate MHM information, and the supplies they need. Fostering a critical mass of champions within countries, an idea that resonated from the MHM in Ten agenda to transform schools for menstruating girls from 2014 – 2024, was, she said, the next step to implementing change – ‘and that’s happening in this room’. Globally, however, there were still many challenges as millions of girls started their first period every year and need support and information.
Dr Sommer said that although many of the initiatives taken so far have focussed on schools, there was a lot more to learn about other types of vaginal bleeding experiences (such as post-partum or miscarriage bleeding). Conversations about menstruation should, she said, begin earlier, before a girl first starts her period. Education plans also need to have a budget line for segregated toilets and for emergency stocks of menstrual pads to be kept at school so that girls are supported while menstruating at school. In particular, said Dr Sommer, there’s a very long way to go on disposal and waste management. As more pads are distributed and used, the environmental problem of how to dispose of them urgently needs to be addressed, in both developed and developing contexts.
Building a cross-sectoral approach
There is growing recognition, said Dr Sommer, that MHM is cross-sectoral issue that impacts health, education, jobs and equality and it affects it our ability to achieve the global Sustainable Development Goals. It was, she said, essential to keep women and girls at the centre of focus of this work: ‘They know their bodies and what they need.’ The Summit would be a fantastic opportunity to decide together what needed to be done in the coming years. Dr Sommer concluded by saying ‘If you want to go fast, go alone. If you want to go far, go together.’
Janie Hampton, founder of the World Menstrual Network showed a short video from Malawi about the enthusiastic uptake of menstrual cups amongst Girl Guides there, and how cups are increasingly the preferred option to reusable or disposable sanitary pads.
This was followed by a spoken word performance from 16-year old Malvika Neupane in which she described how her initial excitement about her first period had soon been replaced by embarrassment and dread: ‘My days were now divided into ‘pure’ and ‘impure’ days. It was a shameful thing to talk about. And if this was how it was for me as a city girl, how would it be for rural girls? We heard about a girl who died from smoke suffocation in the chhaupadi hut. Girls like us suffer every day because of these taboos.’
Sharing ideas and innovations
A variety of ideas and solutions were displayed at an interactive innovations fair throughout the Summit, and these drew a great deal of interest from participants. The displays included several low-cost, reusable or biodegradable menstrual pads and reusable period underwear, as well as different types of menstrual cups, period subscription boxes and mobile applications for delivering products and information. Nepal’s first menstrual pad vending machine and details about an innovative sanitary bin collection scheme were also on display, along with projects using comic books on menstruation, interactive theatre and collaborative film making to improve knowledge and information about menstrual issues.
A virtual reality film using headsets gave participants a vivid experience of the discomfort and isolation of chhaupadi huts. The results of a school art competition entitled ‘One day. One life. Our period’ were also displayed around the venue and prizes awarded to the winners.
Beauty with purpose
Nikita Chandak, former Miss Nepal 2017, showed a video entitled ‘Beauty with purpose’ she had made in which she visited women in rural communities to find out about the various practices and beliefs surrounding Chhaupadi. ‘I heard that many NGOs make frequent visits – but villagers didn’t want outsiders telling them that the traditions they have been following for such a long time are bad,’ she said. ‘I also understood that it’s all about mind sets. This mentality has been in our heads so long we think twice about entering the kitchen or religious places. The mentality needs to be changed gradually.’ She remembered feeling ashamed and embarrassed as a teenager whenever menstruation was mentioned and said that attitudes need to change.
Making the film she had also found that although menstrual pads were available, they were not affordable. One lady featured in the video only had two sets of clothes. During her period she clutched the lungi between her thighs and washed it overnight. ‘We need to look at ways of helping people who cannot even afford the cheapest menstrual pads.’
Changing people’s lives through MHM
Dr Paul Rueckert, Programme Coordinator for GIZ’s Support to the Health Sector Programme in Nepal told participants that despite the many challenges faced in organising the Summit, he was very impressed by the number of people who had attended and happy to see the commitment and enthusiasm evident in the meeting. When GIZ had first started working on MHM issues after the earthquake, there were only around five organisations working on menstrual hygiene – now there were 50 organisations and 80 initiatives, so ‘the scene has completely changed’. He said GIZ was very proud to be a part of this development, and was committed to supporting the work that had been started ‘because better MHM changes lives’.
Dr Marni Sommers also said that she was ‘unbelievably impressed with what is happening in Nepal and the lessons for others. There’s so much energy and commitment and passion for change.’ Another participant from Pakistan said that he had been very inspired by the way boys and girls, women and men had sat together to discuss these difficult issues.
Youthful voices for change
The Summit concluded with a powerful and moving poem entitled ‘Five Days’ recited by teenager Deepa Bohara, a member of Word Warriors, a poetry collective based in Kathmandu. She said that the strongest weapon against menstrual taboos and restrictions was words.
Dr Rueckert brought the Summit to a close by remarking that he was particularly impressed and encouraged to see the number of young people attending the meeting. ‘This is the future – you will make the change in this country.’ The youngest participant – an 11-year-old girl –was asked for her opinion of the meeting and said: ‘I learned that we should not be afraid of what we are and if we bleed.’