Mumbai: The use of sanitary napkins has increased from 50.7% to 54% between 2014 and 2015, driven by a government scheme to promote menstrual hygiene. But the scheme suffers from multiple problems--the quality and supply of sanitary napkins, lack of awareness and unsafe disposal techniques, according to an IndiaSpend analysis of government reports.

The scheme for promotion of menstrual hygiene among girls between 10 and 19 years of age was launched by the ministry of health and family welfare (MoHFW) in 2011. It covers rural areas in 107 districts across 17 states. In 2014, the scheme was merged with the Rashtriya Kishor Swasthya Karyakram (RKSK) which works in the area of adolescent health.

The sanitary napkins distributed under the scheme are manufactured by rural self-help groups. Quality control measures are left to the states. The expenditure on the scheme has gone up from Rs 2,433.51 crore in 2014-15 to Rs 3,703.88 crore in 2016-17, revealed a reply to the Lok Sabha, the lower house of the parliament.

Accredited social health activists (ASHAs)--local women who are roped in to implement the project--are supposed to sell a pack of six napkins for Rs 6. They are allowed to keep one rupee per pack sold and the remaining Rs 5 is donated to the state/district treasury. As a further incentive, the ASHAs also receive a free pack of napkins every month.

Traditionally, women used cloth for protection during menstruation, washing and reusing them repeatedly. Those who are poor use rags, ash, or husk. Lack of menstrual hygiene results in diseases such as urinary/reproductive tract infections as well as bacterial vaginosis which is the proliferation of bacteria in the vagina.

A study by Rutgers, an organisation for sexual and reproductive health and rights, revealed that for the absorption of the menstrual blood, 89% Indian women used cloth, 2% used cotton wool, 7% sanitary pads and 2% ash, IndiaSpend had reported on June 19, 2017. Among those who used cloth, 60% changed it only once a day. These practices could explain why 14% of girls reported menstrual infections.

Menstruation is still taboo in many parts of India. Mothers rarely discuss period hygiene with daughters because 70% of them believed it to be a “dirty” subject, as per the study.

The fourth round of the National Family Health Survey (NFHS-4) released in 2015-16 found that 48% of women (aged 15-24) in rural areas practise menstrual hygiene. Only in seven of India’s 36 states and union territories did 90% or more women in the 15-24 age-group use hygienic protection during menstruation.

Between 2014-15, of the 16 states surveyed, Rajasthan, Punjab and Kerala reported a decrease in the utilisation of sanitary napkins by 8.2 to 26.5 percentage points.

Supply of napkins sometimes delayed by up to three months

The quality of napkins used was poor in Odisha, Rajasthan and Kerala. This means that they had a low absorption rate or inadequate dimensions that increased the likelihood of leakage. Sanitary napkins reportedly ran out of stock in Arunachal Pradesh, Bihar, Jammu and Kashmir, and Maharashtra. However, a satisfactory uptake of sanitary napkins was noted in Bihar, Jharkhand, Odisha, Jammu and Kashmir, Andhra Pradesh, Maharashtra and Gujarat, according to the 10th common review mission (CRM), an annual progress report published by the National Health Mission (NHM) in 2016.

The uptake of sanitary napkins under the scheme was low in Himachal Pradesh and Odisha due to mediocre quality. Delhi was reported to have faced an irregular supply of sanitary napkins, as per the ninth CRM report in 2015. Moreover, no sanitary napkins were distributed in Chhattisgarh in that particular period, revealed a 2015 Comptroller Auditor General (CAG) report.

The wait to receive sanitary napkins can be as long as three months, a glitch which was termed “self-defeating” by a senior health official.

Another CAG 2015 report in Maharashtra highlighted the issue of low quality which was hampering sales: Between 2012 and 2014, 65% of allocated sanitary napkins were sold.

Union health minister Jagat Prakash Nadda stated to the Rajya Sabha in 2016 that the government was aware that the scheme had not been rolled out in West Bengal despite the fact that there are potentially 30 million (approximately a third of the state’s population) beneficiaries in the state.

Utilisation of funds across the country stood at 7.36% in 2014-15, 29.8% in 2015-16 and 19.72% in 2016-17. High focus states--Uttar Pradesh, Uttarakhand, Bihar, Himachal Pradesh, Chhattisgarh, Jammu and Kashmir, Jharkhand, Madhya Pradesh, Odisha and Rajasthan--showed higher utilization rates: 7.36%, 32.74% and 34.18% in 2014-15, 2015-16 and 2016-17, respectively, according to a reply to the Lok Sabha in August 2017.

Low awareness and poor training

Both the CRMs and the Maharashtra CAG report flagged the absence of monthly meetings which the ASHAs were supposed to organise in order to raise awareness about menstrual hygiene among adolescent women.

The CRM 2015 specifically stated that ASHAs in Karnataka, Uttarakhand and Haryana did not hold the meetings mostly because they were not trained. The peer education component of the RKSK was realised only in Tamil Nadu, according to the 10th CRM.

“During the early years of the scheme, the aim was to reach approximately 20 states, and over 150 districts,” said Arundhati Muralidharan, manager-policy at WaterAid India. “In its current state, the scheme seems to be active in limited states and districts. Furthermore, the focus has been more on sanitary pad distribution, and less on awareness.”

The success of the scheme would depend on comprehensive planning and implementation that reaches not just girls and women but also their influencers, she added.

Unsafe disposal poses environmental hazard

A CAG report from Tamil Nadu underlined the issue of unsafe sanitary napkin disposal. The presence of plastic renders these napkins non-biodegradable. To set up masonry choolas that enable their safe disposal, Rs 1.92 crore was allocated to 32 districts. But only Rs 57 lakh was used, and that too only in 19 districts.

A response to the Lok Sabha in April 2018 reaffirmed that they are indeed non-biodegradable and also stated that the government has not received any proposals regarding innovations around eco-friendly menstrual hygiene products.

IndiaSpend sent an email to JP Nadda, the minister for health and family welfare, on June 12, 2018, and sought to establish contact with him over the phone the same day and then again on June 13, 2018, to seek a comment. There has been no response so far. This story will be updated if and when there is a response.

(Pallapothu, an MSc student from the Symbiosis School of Economics is an intern with IndiaSpend.)

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