Making life better for girls and women in Nepal – month after month
Although menstruation is a natural process signaling a girl’s entry into womanhood, in many low-income countries such as Nepal, adolescent girls and women face significant challenges when it comes to managing menstruation health hygienically, with dignity, security and confidence. With German technical assistance, Nepal has begun to tackle this challenge.
Cultural constraints, lack of access to accurate information, lack of facilities and suitable sanitation in schools and homes can restrict menstruating women and girls from participating fully in society. Social, cultural and religious factors and taboos also play a strong role in influencing attitudes and beliefs about menstruation. In addition, high costs and lack of availability of sanitary pads mean women have to rely on less hygienic options, such as dirty rags, ashes or dried leaves. As a result, menstruation can often be a very traumatic process.
Eighty percent of Nepalese are Hindu, and hold strong beliefs about ritualised purity. Chhaupadi refers to the ancient belief that women are “unclean” during menstruation and consequently they are not allowed to touch water or food in the kitchen or “contaminate” sacred sites. Many temples have signs outside which say “No menstruating women allowed”. During menstruation, girls and women are banished from their families and communities, and forced to live in often shocking conditions in cowsheds or even caves. There are huge risks associated with Chhaupadi – including the possibility of being attacked by wild animals, being raped and being isolated in an emergency. Last winter at least one woman died in a cow shed in freezing conditions.
Although Chhaupadi was officially banned in 2005 and a law was passed in 2017 criminalising the practice, it is still most widely adhered to in poor, remote mountain villages in the Mid- and Far-Western Regions of Nepal. However, a recent study conducted by the Nepal Fertility Care Centre (NFCC) amongst 1,500 women in the capital Kathmandu showed that many educated, urban women are also subjected to these restrictive practices, which not only can have fatal consequences for girls and women, but can also exclude them from actively participating in daily life, work and education and perpetuate entrenched gender inequity.
Even where such extreme practices are not so prevalent, lack of access to affordable sanitary pads combined with poor sanitation facilities and lack of water and functioning toilets, all combine to make menstrual hygiene management (MHM) extremely difficult and undignified. Many otherwise perfectly healthy girls are unable to attend school for several days each month because there are no toilets, water or soap for handwashing and no means of discreet disposal of soiled sanitary pads. As a result, this can lead to high drop-out rates for girls from school.
Taking a closer look at the problems
There is now a growing awareness of the extent and consequences of these problems. A study commissioned in 2016 by the Support to the Health Sector Programme (S2HSP), which Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH implements on behalf of the German Federal Ministry of Economic Cooperation and Development, surveyed 528 girls from eight districts and found that 90% of girls in hard-to-reach rural places in Far- Western Nepal use unhygienic cloth rags during their periods.
Laxmi Tamang is a freelance consultant who in 2017 was involved in the largest study to date carried out by Population Services International in 12 districts of Nepal to obtain in-depth insights on adolescent girls’ understandings of menstruation (including their behaviour, beliefs and practices), key influencing factors regarding these attitudes, and their knowledge about and access to menstrual hygiene management products and services. ‘We were surprised by the extent of these restrictive practices,’ says Laxmi. ‘In some areas girls are not even allowed to touch and therefore read books during their periods.’ The research established that many of these practices are reinforced by mothers, families and religious leaders, who claim that God will punish people who do not observe them.
What used to be a Hindu taboo has also spread to other communities
Laxmi Tamang says that although many of these practices were in the past associated with the higher Hindu castes from the mountains, as attempts have been made to dismantle the caste system and there has been greater mixing of castes, restrictive menstrual practices have actually increased amongst other groups.
‘My own family is from the east of Nepal and we are Buddhists, but until I was in my late teens, my sister and I also followed restrictive practices of not entering a kitchen or temple when menstruating until one day the daughter of a monk told my mother that it is not required in our religion and that menstruation is a completely natural thing,’ says Laxmi ‘My mother then put an end to the restrictive practices, but the truth is that before that we simply didn’t know.’
The earthquake as a turning point
Sanumaya Rana, the Municipality Health Coordinator in Bidur, Nuwakot District, believes the devastating earthquake that hit Nepal in April 2015 was a turning point. Previously taboo issues surrounding MHM were highlighted and exacerbated when thousands of women and girls were forced into temporary shelters. People began to talk about the issues for the first time. Many international NGOs came in to help and distributed commodities such as disposable pads which were previously either unavailable or unaffordable. However, there was often no hygienic means of disposal says Laxmi. ‘I remember seeing disposable pads that had been thrown into a river, which was used for drinking water further downstream. It was not good for the environment.’
German Cooperation to improve menstrual health and dignity in Nepal
The Support to the Health Sector Programme has been working closely with the government of Nepal since 2015 to address these issues through an intervention that includes (amongst other strategies) school-based education, and the manufacturing of reusable and disposable low-cost sanitary pads. Under the umbrella of both the Ministry of Health and Population and the Ministry of Education, this programme started with over 500 schools in the 14 districts most affected by the earthquake as well as other districts in the Mid- and Far-west regions. It aims to raise awareness and break down taboos surrounding menstruation by training teachers and health workers to address these issues and better educate both girls – and boys – about MHM. It also teaches pupils how to make reusable sanitary pads and has assisted with the setting up of community-led social enterprises to produce low cost sanitary pads and provide employment and income for local women. “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 products and advice on practices,” says Valerie Broch Alvarez, Senior Technical Adviser for GIZ’s health programme in Nepal.
Producing local sanitary pads
The village of Semjong situated in the beautiful green hills of Dhading District was devastated by the earthquake in April 2015: All but a handful of the 1065 homes were completely destroyed, leaving only dust and rubble. In an attempt to promote post- earthquake recovery, since January 2017 GIZ has been working with the Semjong Village Development Committee (VDC) and Sikre VDC in Nuwakot district to set up small social enterprises with women, including the production of low-cost sanitary pads based on an innovative design of Mr. Muruganantham Arunachalam from Coimbatore, India, who has marketed a simple and easy manufacturing process, as described in a previous feature.
The programme conducted a feasibility study, facilitated the procurement of the machines and initial raw materials and conducted technical training with two women’s cooperatives for production in two pilot districts. The machines arrived in May 2016 and were installed in Semjong, Dhading District and in Sikre Nuwakot Districts a few months later. The machines cost around 3,000 Euros and can each produce 1,600 sanitary pads per day, at a unit cost of six Nepali rupees (0.4 cents) per pad.
While these units faced initial start-up difficulties which had to be addressed through training, mentoring and coaching, they now provide employment for a small but growing number of women and supply affordable pads to their remote local communities. By the end of 2017, the Semjong cooperative had produced and distributed around 6,000 packs of eight sterile, absorbent and biodegradable, chemical-free sanitary pads. Similarly, the Sikre cooperative and its enthusiastic team have recently also started its production.
One member of the Semjong cooperative was recently elected to the post of Deputy Mayor for the municipality, reflecting the high regard for this social initiative in the community. It has also inspired several other organisations to replicate the model and search for sustainable alternatives to MHM.
Addressing environmental concerns
Innovative ideas can sometimes also bring with them a host of new problems. For example, if sanitary pads became increasingly available and affordable, more will be used, and that in turn creates a problem of disposal. ‘Before introducing a solution, we need to think through all possible problems and pitfalls including the real impact on the environment,’ says Valerie Broch Alvarez, Senior Technical Adviser for GIZ in Nepal. ‘We are currently launching a pilot study to develop a comprehensive programme on school waste management – with a focus on menstrual products waste – to empower schools and communities to promote hygiene, sanitation and environment issues by involving students as change agents.’
Of course, the best way to manage menstrual waste is to avoid creating it in the first place, by for example using reusable menstrual pads. However, this is not always convenient or feasible for all girls and women, especially where it is difficult for them to wash and dry the pads discreetly. There are instances when disposable pads can give Nepali women a great deal of freedom – especially if they are away from home during their menses and are unable to wash pads daily.
‘Each option has its strengths and weaknesses,’ says Valerie Broch Alvarez. ‚Girls should have the personal choice to use the method that is right for them.’ Although the programme is promoting the use of reusable pads in schools, other products such as tampons, menstrual sponges and cups are also being considered. Each of these choices is associated with different constraints, ranging from cultural attitudes and water supply to access and availability. When exploring options within a community, all these factors need to be considered.
Broadening the debate
After the earthquake in 2015, the German-supported programme subcontracted Nepal Fertility Care Centre (NFCC), an NGO based in Lalitpur, to implement the school based activities on MHM in Dhading District. Pema Lhaki, NFCC’s Executive Director, calls herself a “menstrual-activist” and says much has now been done to improve access to menstrual products and reduce the stigma associated with menstruation. ‘When I originally said that we needed to talk about MHM, people laughed and said are you serious? These things simply weren’t being discussed at all. Now it is a big topic – everyone is talking about it and lots of organisations have jumped on the bandwagon. It’s a big change, and it makes me happy.’ But, she says, there are bigger infrastructural and social issues that will also need to be addressed.
‘If you really want to destigmatise menstruation and make sure women are not discriminated against, you need to change mind sets. Education is the key, especially if you can talk to girls before they start menstruating,’ says Pema. This can be done through school curricula, better training of health workers and teachers and providing relevant information in local languages. ‘This is a start, but many young people are outside the school system and are illiterate, so we need to find other informal entry points as well as through schools – and, very importantly, we need to talk to the boys as well, before they become men who enforce restrictive practices. Above all, we need to disassociate menstruation from religion.’
A sanitary revolution has started to break down taboos
In the development and humanitarian sectors menstruation has generally been considered a hygiene issue. However, Germany’s development cooperation approach in Nepal is taking a more holistic and rights-based view, in accordance with the UN’s Sustainable Development Goals of focusing on girls’ and women’s empowerment and equity, health and education. One important issue that it has just begun to address in its negotiations at federal and local level is the fight against luxury taxes on menstrual products. All of these initiatives have not only helped to promote women’s MHM, dignity and social inclusion, they have also helped to break the silence on a hitherto taboo subject. This in turn has contributed to girls’ and women’s empowerment and resilience and to the respect paid to them and their gender-specific needs. ‘We need to be proactive rather than reactive when it comes to menstrual rights,’, says Pema Lhaki, ‘and we need to have clarity of vision to bring about effective change.’
As a next step, the German-supported programme is planning to host a national menstrual hygiene management summit for the end of 2018 to bring together all the key national and international players and organisations working on the topic. The summit, which will be documented on Healthy DEvelopments, will showcase innovative and sustainable menstrual products and seek to establish strategic partnerships between the different perspectives (for example, education and learning, policy and regulation and waste management) and strengthen collaborative, systemic approaches to improving menstrual health and hygiene in Nepal and beyond.
By Ruth Evans and Valerie Broch Alvarez