From Taboo to Policy: The Story of Menstrual Hygiene Management in India

Introduction and Brief History

The topic of menstruation is shrouded in taboos, myths, misinformation, and stigma in both private and public spheres.  Such taboos and misinformation creates health, dietary, mobility, educational, economic, and sanitational restrictions on menstruators’ bodies. Menstrual blood, and by extension menstruators, is perceived as polluting, forcing them to hide their menstrual cycles, wash and dry clothes in damp and dark spaces, limit nutritional intake, make-do with limited access to products and knowledge, and deal with the resulting health issues and infections.

However, there has been an increasing awareness of the sanitation needs of menstruators in public health policies and international declarations. The Menstrual Hygiene Policy in India has made a significant journey from being non-existent to being celebrated and finding a place in public health, education, and sanitation frameworks. In the 1970s-1990s, there was a deep, embarrassed silence around menstruation in policy frameworks, often guided by existing menstrual stigma in India: it was not a topic fit for parliamentary discussions. The silence was characterised by restricted access to a limited range of period products (often expensive and plain unavailable) as well as menstrual health education in India.

Menstrual Hygiene Management (MHM) in India gained traction from 2000 to 2005, with non-governmental organisations implementing nationwide campaigns. Around this time, it started gaining more attention in International declarations and policies. From 2005 to 2010, MHM gained momentum, now being included in public health infrastructure and policies, the introduction of menstrual products, and public discourse.

International Attention and Declarations

Prior to 2010, sanitation needs of menstruators have been brought up in several International declarations and policy frameworks, such as Convention on Elimination of All Forms of Discrimination Against Women (CEDAW), International Covenant on Economic, Social and Cultural Rights (ICESCR), Convention on the Rights of the Child (CRC), SACOSAN Declaration (2008). A brief mapping out of MHM policies might be helpful:

1. 2012: International Recognition

Menstrual hygiene needs were explicitly mentioned for the first time in the UN General Assembly Resolution on Sanitation, addressing the harmful impact of inadequate sanitation facilities on the health and well-being of menstruators. Urging member states to provide safe WASH services and addressing socio-cultural taboos, this resolution laid the groundwork for future MHM policies.

2. 2014: Launch of Menstrual Hygiene Day

WASH United launched Menstrual Hygiene Day on May 28 (signifying the menstrual cycle: 28th day (average cycle length) of the fifth (average duration of menstruation) month) to combat menstrual stigma and advocate for policy change. This sparked social media movements, global campaigns, and partnerships, amplifying global dialogue on MHM, leading to shifts in national policies in countries like India.

3. 2015: MHM in SDGs

MHM found a place in the Sustainable Development Goals (SDGS), instrumental in providing governments with a framework for policy structuration and implementation. 

1. SDG 3: With health as its focus, it promotes reproductive health and hygiene.

2. SDG 4: With its focus on education, it links menstruators' educational rights to the provision of adequate and safe WASH facilities in schools.

3. SDG 5: Gender equality calls for the dismantling of menstrual stigma and discrimination, urging States to take necessary actions.

4. SDG 6: Sanitation needs are deeply intertwined with menstrual health.

   
   

4. 2016: Menstrual stigma as a dignity issue

The UN Special Rapporteur on Water and Sanitation Report designated MHM as inherently linked to dignity, urging states to provide stigma-free environments, accessible products, menstrual health education in workplaces and educational institutes, and policy reforms. 

5. 2017: Inclusion of MHM in Schools

World Banks’ guidelines outlined steps to include menstrual education in school curriculum, promoted sex-specific toilets, teacher training on MHM education, and distribution of free or subsidised period products, guiding governments to include MHM in school policies. 

6. 2019: Menstrual Products Taxation

1. The UN Human Rights Council passed the resolution explicitly linking MHM to human rights. It called upon states to eliminate menstrual products taxation, invest in MHM infrastructure, and improve data collection processes.

2. UNICEF’s Guidelines advocated for MHM-friendly schools, highlighting the necessity for safe sanitation facilities, menstrual health education, and distribution of free or subsidised menstrual products.

   
   

7. 2023: Elimination of Period Poverty

1. The UN Human Rights Council passed a resolution on Menstrual Justice advocating for universal access to free menstrual products in schools and prisons, inclusion of MHM in climate-adaptation strategies, and elimination of period poverty by 2030.

2. WHO advocated for MHM as part of their universal health coverage goal, focusing on sexual and reproductive health services, and promoted research on menstrual disorders. 

While several reports have revealed stark differences in international declarations and ground realities (WHO/UNICEF Joint Monitoring Programme Report revealed high drop-out rates of female students due to lack of sanitation and MHM facilities in schools), it becomes crucial to continue efforts to eliminate period poverty, perhaps not by 2030, but sometime soon.

Menstrual Hygiene Policy in India

Including MHM in policy frameworks encouraged the Government of India to ensure affordable and accessible MHM services and period products to adolescents, primarily targeting rural spaces. The following are some of the key schemes:

1. Rajiv Gandhi Scheme for Empowerment of Adolescent Girls (SABLA) 2010 targeted (in-school and out-of-school) adolescent females (aged 11-18 years), both in rural and urban areas, with Anganwadi centres (AWCs) as their focal points. Integrating MHM education into life-skills training, the training module remained heavily reliant on AWC workers and peer educators. 

   
   

2. The Menstrual Hygiene Scheme (MHS) was introduced under the National Rural Health Mission in 2011. It aimed to tackle menstrual stigma through hardware and software solutions, involving Accredited Social Health Activists (ASHAs) and female educators. The ASHAs provided menstrual health education in communities via AWC meetings and door-to-door visits. They were also responsible for procuring and selling “Freedays,” government-subsidised sanitary napkins. Similarly, female nodal teachers were responsible for not only imparting MHM education but also stockpiling sanitary napkins in schools. 

   
   

3. Rashtriya Kishore Swasthya Karyakram (RKSK), introduced in 2014, targeted both male and female adolescents. It integrated menstrual health education into their ARSH (Adolescent Reproductive and Sexual Health) component, compounding life-skills training, gender-based violence, nutrition, and mental health education. Similar to MHS, it also relied on ASHA workers for the distribution of “Freedays.” 

4. Menstrual Hygiene Management: National Guidelines (2015) was introduced under the Swachh Bharat Mission-Gramin, emphasising on both hardware and software solutions for ensuring safe menstrual hygiene management in India.

5. 
   

   1. Hardware solutions included sex-specific toilets with adequate water supply, ventilation, and light, privacy features such as functional latches and changing spaces, comfort features such as hooks and niche to place sanitary napkins, and disposal systems such as mandatory dustbins and installation of incinerators. 

   2. Software solutions included promotion of menstrual health education in India through IEC materials, school programmes for both male and female students, teacher training for male and female staff, and training of administrative officers such as district officers. 

      
      

MHM National Guidelines emphasises dignity and confidence in a menstruator, urging states to enforce a holistic policy scheme. In school sanitation policies, particularly Swachh Bharat Swachh Vidyalaya, we find an integration of these solutions in their infrastructural and behavioural guidelines.

https://swachhbharatmission.ddws.gov.in/sites/default/files/Guidelines/Menstrual-Hygiene-Management-Guidelines.pdf

Pitfalls and Challenges Of Menstrual Hygiene Management in India

While these MHM policies exhibited attempts to promote accessible products, community engagement, and systemic integration, they are characterised by several limitations:

1. There is an inherent prioritisation of sale of sanitary napkins, and a lack of clear guidelines on fund and resource allocation.

   
   

2. The policies lack clear guidelines on data collection and management, reducing the impact and monitoring assessment.

   
   

3. Most of the schemes address rural adolescents, leaving urban adolescents facing significant, if not similar, menstrual stigma unaddressed. 

   
   

4. The policies added responsibilities on adult menstruators (AWC, ASHA workers, and female nodal teachers), thereby reinforcing menstruation as a female-only issue. 

   
   

5. There is limited inclusion of male family and community members. MHM National Guidelines explicitly mentioned them for the first time, but their roles were limited to learners, rather than being trainers. 

   
   

6. Implementation of these policies fails to address systemic and social barriers, with inadequate school infrastructure and the absence of regular menstrual health education, leading to continued drop-out and absenteeism rates.

   
   

7. These policies also suffer from intersectional blindness, failing to address caste, class, disability, and religious dynamics which reinforce such menstrual stigma in India, limiting access to menstrual products and knowledge, mobility, economic and social participation.

   

   
   

Conclusion

Menstrual hygiene management in India exists in an odd juxtaposition: taboos, misinformation, and menstrual stigma exist alongside progressive attempts to eliminate period poverty. While menstrual hygiene policies advocate for subsidised sanitary napkins and have exempted taxation of period products, taxation on raw material requirements for sanitary napkin production has been increased from 12 to 18%, leading to an increase in the cost of sanitary napkins. Additionally, inadequate and fragmentary implementation of hardware solutions of toilets and incinerators has rendered MHM facilities non-functional in schools and workplaces. To truly eliminate period poverty, policy approaches must prioritise intersectional needs, enforce monitoring mechanisms, create strict guidelines for budget and resource allocations, and include both menstruators and non-menstruators as learners, trainers, and advocates for menstrual health in India. 

References: 

1. About Menstrual Hygiene Day. (n.d.). Menstrual Hygiene Day. Retrieved November 14, 2023, from https://menstrualhygieneday.org/about/about-mhday/

2. Anand, T., & Garg, S. (2015). Menstruation-related myths in India: Strategies for combating it. Journal of Family Medicine and Primary Care, 4(2), 184–188. https://doi.org/10.4103/2249-4863.154627

3. Bhattacharya, T. (2017). Social reproduction theory: Remapping class, recentering oppression. Pluto Press.

4. Coleman, R. M. (2011). The human right of sanitation for all: A study of India. Global Business and Development Law Journal, 24(1), 1–30.

5. Garg, S., Sharma, N., & Sahay, R. (2001). Socio-cultural aspects of menstruation in an urban slum in Delhi, India. Reproductive Health Matters, 9(17), 16–25. https://doi.org/10.1016/S0968-8080(01)90004-7

6. Goel, P., Kumar, R., Meena, G., Singh, T., & Garg, S. (2017). A community based cross sectional study on menstrual hygiene among 18-45 years age women in a rural area of Delhi. International Journal of Biomedical Research, 8(6), 302–308. https://doi.org/10.7439/ijbr.v8i6.4165

7. Hochschild, A. R. (1983). The managed heart: Commercialization of human feeling. University of California Press.

8. Inter-Agency Standing Committee. (2020). Guidelines on menstrual hygiene management in emergencies. https://interagencystandingcommittee.org/

9. Jain, D. (1996). Valuing work: Time as a measure. Economic and Political Weekly, 31(43), WS46–WS57. https://doi.org/10.2307/4404708

10. Kapur, A. (2016). Right to sanitation: A gender perspective. In Right to sanitation in India: Nature, scope and voices from the margins (pp. 45–60). Forum for Policy Dialogue on Water Conflicts in India.

11. Kansal, S., Singh, S., & Kumar, A. (2016). Menstrual hygiene practices in context of schooling: A community study among rural adolescent girls in Varanasi. Indian Journal of Community Medicine, 41(1), 39–44. https://doi.org/10.4103/0970-0218.170964

12. Khakhariya, N. (2024, July 15). GST impact on sanitary napkin manufacturers. The Times of India. https://timesofindia.indiatimes.com/city/rajkot/gst-impact-on-sanitary-napkin-manufacturers/articleshow/111740148.cms

13. Mason, L., Nyothach, E., Alexander, K., Odhiambo, F. O., Eleveld, A., Vulule, J., ... Phillips-Howard, P. A. (2017). “We do not know”: A qualitative study exploring boys’ perceptions of menstruation in India. Reproductive Health, 14(1), 1–12. https://doi.org/10.1186/s12978-017-0435-x

14. Ministry of Drinking Water and Sanitation, Government of India. (2015). Menstrual hygiene management: National guidelines.

15. Ministry of Health and Family Welfare, Government of India. (2014). Rashtriya Kishore Swasthya Karyakram.

16. Ministry of Women and Child Development, Government of India. (2011). Rajiv Gandhi Scheme for Empowerment of Adolescent Girls.

17. Mohite, R. V., & Mohite, V. R. (2016). Menstrual hygiene practices among slum adolescent girls. International Journal of Community Medicine and Public Health, 3(7), 1729–1734. https://doi.org/10.18203/2394-6040.ijcmph20162033

18. Muralidharan, A., Patil, H., & Patnaik, S. (2015). Unpacking the policy landscape for menstrual hygiene management: Implications for school WASH programmes in India. Waterlines, 34(1), 79–91. https://doi.org/10.3362/1756-3488.2015.008

19. Nagar, S., & Aimol, K. (2010). Knowledge of adolescent girls regarding menstruation in tribal areas of Meghalaya. Studies of Tribes and Tribals, 8(1), 27–30. https://doi.org/10.1080/0972639X.2010.11886610

20. Santra, S. (2017). Assessment of knowledge regarding menstruation and practices related to maintenance of menstrual hygiene among the women of reproductive age group in a slum of Kolkata, West Bengal, India. International Journal of Community Medicine and Public Health, 4(3), 708–712. https://doi.org/10.18203/2394-6040.ijcmph20170744

21. Sinha, R. N., & Paul, B. (2018). Menstrual hygiene management in India: The concerns. Indian Journal of Public Health, 62(1), 71–74. https://doi.org/10.4103/ijph.IJPH_113_18

22. Sivakami, M., van Eijk, A. M., Thakur, H., Kakade, N., Patil, C., Shinde, S., ... Phillips-Howard, P. A. (2019). Effect of menstruation on girls and their schooling, and facilitators of menstrual hygiene management in schools: Surveys in government schools in three states in India, 2015. Journal of Global Health, 9(1), 010408. https://doi.org/10.7189/jogh.09.010408

23. Sommer, M., Caruso, B. A., Sahin, M., Calderon, T., Cavill, S., Mahon, T., & Phillips-Howard, P. A. (2016). A time for global action: Addressing girls’ menstrual hygiene management needs in schools. PLOS Medicine, 13(2), e1001962. https://doi.org/10.1371/journal.pmed.1001962

24. Sphere Association. (2018). The Sphere Handbook: Humanitarian charter and minimum standards in humanitarian response (4th ed.). Sphere. https://spherestandards.org/handbook/

25. Sridhar, D., & Gautami, N. (2017). Menstrual health status and cultural practices of tribal adolescent girls. International Journal of Community Medicine and Public Health, 4(11), 4120–4124. https://doi.org/10.18203/2394-6040.ijcmph20174648

26. Thakur, H., Aronsson, A., Bansode, S., Stalsby Lundborg, C., Dalvie, S., & Faxelid, E. (2014). Knowledge, practices, and restrictions related to menstruation among young women from low socioeconomic community in Mumbai, India. Frontiers in Public Health, 2, 1–12. https://doi.org/10.3389/fpubh.2014.00072

27. Udayar, S. E., Kruthika, K., & Devi, P. V. (2016). Menstrual hygiene practices among adolescent girls residing in tribal and social welfare hostel in Andhra Pradesh: A community based study. National Journal of Community Medicine, 7(8), 681–685. https://njcmindia.com/index.php/file/article/view/1030

28. United Nations General Assembly. (2012). Resolution on sanitation for all (A/67/L.75). United Nations Digital Library. https://digitallibrary.un.org/

29. United Nations Human Rights Council. (2019). Human rights to safe drinking water and sanitation (A/HRC/RES/42/5). United Nations Digital Library. https://undocs.org/A/HRC/RES/42/5

30. UNICEF. (2019). Guidelines on menstrual health and hygiene. UNICEF. https://www.unicef.org/a

31. United Nations Educational, Scientific and Cultural Organization (UNESCO). (2022). Progress on drinking water, sanitation, and hygiene in schools: 2000-2021. UNESCO. https://unesdoc.unesco.org/

32. van Eijk, A. M., Sivakami, M., Thakkar, M. B., Bauman, A., Laserson, K. F., Coates, S., & Phillips-Howard, P. A. (2016). Menstrual hygiene management among adolescent girls in India: A systematic review and meta-analysis. BMJ Open, 6(3), e010290. https://doi.org/10.1136/bmjopen-2015-010290

33. WaterAid. (n.d.). Menstrual health resources. WaterAid. Retrieved July 10, 2023, from https://www.wateraid.org/

34. Wendland, C., Yadav, M., Stock, A., & Seager, J. (2019). Gender, women and sanitation. In J. B. Rose & A. Jiménez-Cisneros (Eds.), Water and sanitation for the 21st century: Health and microbiological aspects of excreta and wastewater management (pp. 1–15). Michigan State University. https://doi.org/10.14321/waterpathogens.4

35. World Bank. (2017). Menstrual hygiene management in schools: A toolkit for schools and teachers. World Bank Group. https://www.worldbank.org/

World Health Organization (WHO) & United Nations Children’s Fund (UNICEF). (2020). Progress on drinking water, sanitation, and hygiene in schools: Special focus on COVID-19. WHO/UNICEF Joint Monitoring Programme. https://washdata.org