Making menstrual health a welfare priority: Insights from three states

Public policies on menstrual health have mainly focussed on distributing sanitary napkins to women and girls. However, in this note, Tanya Rana shares some insights gained from conversations with frontline workers in Bihar, Madhya Pradesh and Rajasthan which reveal the need for making more comprehensive menstrual health services available. She highlights that menstrual health schemes suffer from poor programme implementation, and a lack of training for frontline workers. She recommends that convergent thinking in planning can solve for these lacunae.

“No teenager or mother comes to us to discuss menstruation”
– an Accredited Social Health Activist (ASHA) from Bihar.

In India, conversations around menstruation are still taboo. In an extreme incident a few months ago, an adolescent girl was murdered by her 30-year old brother, who assumed his sister’s period stain was a sign of an ‘affair’. Issues like this raise an important question: what measures has the state been taking to prioritise menstrual health?

Menstrual health, defined as the state of “complete physical, mental, and social wellbeing” during menstruation, is a public health prerogative (Hennegan et al. 2021). The lack of comprehensive provisions for menstrual health can lead to inadequate access to hygienic menstrual products or sanitation facilities and perpetuate misinformation, with implications for not just the menstruator, but also society as a whole.

So far, public interventions on menstrual health have mainly focussed on the distribution of sanitary napkins to women and girls (Rana 2022a). Recently, the Supreme Court has also pushed the Union government to frame a national policy on providing free sanitary napkins to girls in schools. However, there are several challenges to scheme delivery which impede comprehensive menstrual health for women and girls in India. Some of these challenges include low awareness of menstrual hygiene among women, girls, and even service providers; inadequate programme funds; poor communication from health workers; and expensive menstrual products, among others (Rana 2022b).

To understand how some of these challenges manifest and the state’s role in delivering this key service, the Accountability Initiative at the Centre for Policy Research (CPR) conducted a series of interviews with front-line workers (FLWs) – Anganwadi workers (AWWs), ASHAs, and auxiliary nurse midwives (ANMs) – in Bihar, Madhya Pradesh, and Rajasthan. This article draws on some of the key insights on existing services in these states, how women and girls engage with them, and the role of FLWs in delivering these services.

A brief overview of the status of menstrual health

According to the National Health Family Survey-5 (NFHS-5), approximately 78% of women and girls in India use hygienic menstrual methods¹. However, there are variations at the state level. Between the three states of Bihar, Madhya Pradesh, and Rajasthan, Bihar has the lowest use of hygienic menstrual methods by women and girls (59%), followed by Madhya Pradesh (61%), and Rajasthan (84%). The use of cloth is also higher in Bihar (at approximately 68% ) compared to the other two states, where approximately 65% and 44% of women and girls use cloth, respectively.

The NFHS also suggests that very few (approximately 32%) of women engage with their health worker. For these three states, this engagement is even lower than the all-India average – approximately 25%, 29% and 24% of women in Bihar, Madhya Pradesh and Rajasthan, respectively, had contacted a health worker in the last three months.

FLWs provide last mile services and promote health seeking behaviour in communities. However, due to battling multiple responsibilities, low compensation and poor recognition for their work, the health system has deprived them of the means to perform their task effectively (Sinha et al. 2021). Correspondingly, this impacts the delivery of critical health services, including menstrual health, at the grassroots. As previously highlighted, this lack of engagement, combined with systemic barriers, can restrict safe, informed, and hygienic menstrual health practices. The following sections includes highlights of our conversation with FLWs which bring this to the fore.

Poor programme planning and limited scope of schemes

Conversations with FLWs across the three states suggest that no Union schemes are currently operational. In Bihar, however, a state scheme, the Mukhyamantri Kishori Swasthya Yojana, which transfers Rs. 300 annually to school-going girls However, a bureaucrat from Bihar indicated that there is no data to evaluate if households are utilising this money to buy pads (Rana 2023).

Despite the existence of a state scheme, the FLWs we spoke to in Bihar were not aware of it. FLWs still try to engage with the target audience on this topic in community settings. When asked about the kind of menstrual health services available in their community, an ASHA worker said:

“I am not aware of any such services. But whenever there is a Mata Samiti²meeting, we talk about menstrual hygiene and healthy practices, like using pads, to the women and the teenagers present.”

Another ASHA shared that they discuss menstrual health during door-to-door visits. Even then, there is no active participation by mothers or pregnant women.

In Madhya Pradesh, a scheme called Udita was launched in 2015. Under the scheme, Udita corners were set up at Anganwadi centres to supply pads to women free of cost. However, with no supply of pads from the government since 2016, FLWs have taken it upon themselves to make pads available to women and girls at a subsidised cost using existing untied funds. As an AWW mentioned:

“At present, there are no ongoing schemes for promoting menstrual health. Some time back a related scheme [Udita] was launched but I do not have detailed information about it. Sanitary pads are not given by the Health and Women and Child Development departments. There are no medical dispensaries in the village due to which women and adolescent girls are not able to get pads. That's why we get pads from dispensaries and give them to the citizens at a reduced cost. But we don’t get any separate funds for this, we do this out of our own volition."

The scope of these planned interventions is also limited and tilted towards distribution of sanitary pads. But pad distribution is only one aspect of menstrual health. In addition to making pads available, enabling services such as sanitation and water facilities, transportation, etc. contribute to comprehensive menstrual health.

In Rajasthan, for instance, the Udaan scheme has been operational since 2021. Under this scheme, girls and women up to 45 years of age are entitled to one free packet containing six sanitary pads each month. FLWs are also eligible to receive pads under this scheme. Pads are distributed at Anganwadi centres and schools. Entries are made on the Udaan application as per girls’ and women’s Aadhaar and Jan-Aadhaar card details, and FLWs also communicate how to use pads and take care of one’s menstrual health.

While the scheme has made sanitary napkins available free-of-cost, an ASHA indicated that it does not confront the challenge of proper disposal. Consequently, several sanitary napkins are often found littered in the village. This limitation in the scope of this scheme prevents it from ensuring comprehensive menstrual hygiene.

Barriers to participation and dissemination for FLWs

According to an AWW in Madhya Pradesh, the presence of men in local committees hinders the ability of FLWs to bring up issues surrounding menstrual health:

“Menstrual health is mostly not discussed in the health committee or Panchayat planning. Because men are also involved in these meetings, women do not want to raise this issue. Women are hesitant to talk about periods in front of other women, so to expect them to keep the matter in front of men is a far stretch.”

In the case of Bihar and Rajasthan too, FLWs are either not invited or do not participate in planning for any activities at the village level. An AWW in Rajasthan, for instance, stated that she did not know whether her Panchayat prioritises menstrual health in its. Their existing work burden also pre-empts their involvement in these conversations. She said:

“In the Panchayat, attention is paid to the construction of buildings and roads. Not everyone is able to attend the Panchayat meetings held twice a month. There are no conversations about sanitation, not even about littering. People are also least interested in it. There are no [public] toilets in my Anganwadi centre but, thankfully, there are toilets and water facilities in people’s houses.”

When it comes to learning about menstrual health, ANMs and ASHAs in Bihar revealed that they have not received any formal training on this subject. Persisting supply shortages of medications also makes their job difficult. In Bihar, an ASHA worker who was guided by the ANM on how to conduct these conversations with women and girls stated:

“I have not received any separate training about menstrual health. But [ANM] has told us about maintaining cleanliness during periods, consulting a doctor if there are acute or persistent difficulties, and to take iron tablets if one is feeling weak during the time of month. I use the same information while talking to women; but I haven't received a refresher on this in a while. Also, we don’t receive excess iron tablets which we can distribute in relation to menstrual health. The medical facilities in the village are still lacking due to which most of the people still use cloth.”

Similarly, in Madhya Pradesh, AWWs are sometimes guided by ANMs. One ANM, however, suggested that they also do not receive any training:

“We do not get any training in this regard as of now. When it comes to training, the doctor here says that since I am an experienced worker and there is not much use for more training. They train the new ANMs about this.”

In Rajasthan, even though Anganwadi centres are the site of pad distribution and dissemination for proper usage, AWWs have not received any training.

Starting conversations about menstrual health

While poor programme planning and low engagement with FLWs are challenges confronting the delivery of comprehensive menstrual health services, there have been some positive developments in raising public awareness about menstruation. In this respect, the Udaan scheme in Rajasthan has been a welcome move. FLWs mention the increasing interest in the topic as a result of TV and newspaper advertisements. An AWW remarked about community involvement in menstrual health conversations:

“A programme regarding the same is run in government schools near us. It has happened two or three times so far. Senior officials are also present for the same. During the event, the teachers at school and other officials discuss menstrual health. The women and girls of the village participate in it.”

An ASHA in Bihar indicated that things have improved over time, even though active discussion is still very limited at the community level:

“There is no discussion at the community level. Issues related to menstrual health are also not discussed during [Village Health Sanitation and Nutrition Day (VHSND)]³due to paucity of time. I talk about menstruation and hygiene when I do door-to-door visits. People themselves do not talk about menstruation. Yet both women and school-going girls are more aware about these issues than in the past.”

In Madhya Pradesh, an ANM shared that educated women and adolescent girls are more aware about safe menstrual health practices; however, discussion on the subject remains limited:

“The ones who are not educated hesitate to talk about periods. Educated girls don't hesitate or shy away from the conversation, but they don't engage in the discussion as well. They simply listen to us. No one talks about menstruation here. Not a single woman or teenager has come to talk to us about it themselves. Most people consider periods to be impure here.”

An ideal way forward – A lesson from Bihar

We spoke to an Indian Administrative Service (IAS) officer based in Bihar, who asserted the importance of community mobilisation at the grassroots (Rana 2023). In his stint as Purnea’s District Collector, he came up with an action plan for menstrual hygiene management (MHM) in the district. This plan leverages existing community networks through Jeevikas (women’s self-help groups) and has trained them to drive the prioritisation of menstrual health in villages. In the same conversation, he highlighted female officers’ use of “abstract words” to describe menstruation. Training the key actors of service delivery could then serve the dual purpose of normalising conversations around menstruation and also help them perform their tasks effectively.

Further, this plan has also attempted to operationalise the Union government’s Swacch Bharat Mission’s Phase 2 to provide adequate dustbins to households and build pad incinerators in the village. The scheme’s integration with the action plan is an important example of convergent thinking. The plan delineates the responsibilities of departments such as health, education, Integrated Child Development Services (ICDS), Schedule Caste/Scheduled Tribe (SC/ST) welfare, Panchayati Raj Institution (PRI), etc., and their role in MHM planning. Convergent thinking in planning is useful for breaking down departments’ siloed way of working and lessening the burden on certain actors. With multiple actors involved, and clear responsibilities outlined, convergent thinking may also help mainstream conversations around menstruation at the official level.

When it comes to ensuring comprehensive menstrual health, although the Supreme Court’s call for a national policy is positive, but it must also not be seen as a magic bullet, as it only addresses a narrow aspect of the overall problem. The interviews with FLWs suggest that the gaps persist at the programme and implementation levels. An ideal way forward, therefore, must not only acknowledge menstrual health as a public health challenge but also align planning with convergent thinking for effective service delivery through last-mile actors.

These interviews were first featured as a part of the ‘Inside District’ series of the Accountability Initiative, Centre for Policy Research. The interview excerpts in this article have been translated from Hindi to English. All interviews can be found here.

Notes:

This includes locally prepared napkins, sanitary napkins, tampons, and menstrual cups.
Mata Samitis comprise 7-12 members, including ASHAs, AWWs, one person from Care India, and mothers. In Bihar, the Samitis are held once a month, majorly for health-related discussions.
Village Health Sanitation and Nutrition Days (VHSNDs) are community-based events, conducted every month to improve nutritional and health outcomes in the village.