[Type here] SC Strategies to combat menstrual myths and protect women’s health in India Scope of the problem Up until adolescence, girls and boys in India attain roughly the same levels of education, health, and workforce participation outcomes. However, upon puberty, girls begin to diverge from boys and see increasing limitations in their social mobility and personal agency. Though there are over 355 million menstruating women in India, insufficient menstrual hygiene management is a significant barrier to women’s experiences. Access to clean facilities, menstrual products, and reproductive health resources categorize this as a health issue, but its implications spread to educational attainment, financial stability, social mobility, and individual autonomy. Menstruation is still a taboo topic in many spheres of women’s lives in India. In some areas, 71% of Indian girls report not knowing about menstruation prior to their first cycle. Young women in Rajasthan report feeling shock, fear, anxiety, and guilt regarding their cycles, which emphasizes the heavy psychological toll a lack of education and awareness leads to. Financially, approximately 70% of women in India cannot afford sanitary products and 23% of young girls drop out of school when they reach puberty due to lack of clean, private toilets. In fact, 40% of government schools lack a functioning toilet, and another 40% lack a private women’s restroom. At home, millions of women are barred from entering the kitchen, interacting with family members, or praying during menstruation. Some essentially banish their young women to menstruation huts called gaokors[footnoteRef:1]. [1: https://www.theguardian.com/global-development/2015/dec/22/india-menstruation-periods-gaokor-women-isolated] Origins of the taboo on menstruation The taboo against discussing menstruation can be traced to cultural and religious roots wherein women are considered impure during their cycles, but women across the country are taking to the streets to break the silence and normalize menstruation. What strategies might be effective in reducing this taboo? Because these taboos affect health, educational and financial opportunities, and originate from culture, religion, lack of education and infrastructure, the solutions must be just as holistic. Some examples from the research are: cleaner toilets in schools, court cases supporting women’s rights, education for adolescent girls and their school teachers, and low-cost sanitary napkins[footnoteRef:2]. As I continue this research, I am interested in finding early legislation that either supports or denies menstruation resources to women. [2: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4408698/] Current and possible interventions As the amount and level of women in the Indian workforce grows, from 28.5% in 1994 to 43% in 2012[footnoteRef:3], women gain more financial independence and more of a political voice. Increasingly, organizations like the Bill and Melind ...

1. [Type here]
SC
Strategies to combat menstrual myths and protect women’s
health in India
Scope of the problem
Up until adolescence, girls and boys in India attain roughly the
same levels of education, health, and workforce participation
outcomes. However, upon puberty, girls begin to diverge from
boys and see increasing limitations in their social mobility and
personal agency. Though there are over 355 million
menstruating women in India, insufficient menstrual hygiene
management is a significant barrier to women’s experiences.
Access to clean facilities, menstrual products, and reproductive
health resources categorize this as a health issue, but its
implications spread to educational attainment, financial
stability, social mobility, and individual autonomy.
Menstruation is still a taboo topic in many spheres of women’s
lives in India. In some areas, 71% of Indian girls report not
knowing about menstruation prior to their first cycle. Young
women in Rajasthan report feeling shock, fear, anxiety, and
guilt regarding their cycles, which emphasizes the heavy
psychological toll a lack of education and awareness leads to.
Financially, approximately 70% of women in India cannot
afford sanitary products and 23% of young girls drop out of
school when they reach puberty due to lack of clean, private
toilets. In fact, 40% of government schools lack a functioning
toilet, and another 40% lack a private women’s restroom. At
home, millions of women are barred from entering the kitchen,
interacting with family members, or praying during
menstruation. Some essentially banish their young women to

2. menstruation huts called gaokors[footnoteRef:1]. [1:
https://www.theguardian.com/global-
development/2015/dec/22/india-menstruation-periods-gaokor-
women-isolated]
Origins of the taboo on menstruation
The taboo against discussing menstruation can be traced to
cultural and religious roots wherein women are considered
impure during their cycles, but women across the country are
taking to the streets to break the silence and normalize
menstruation. What strategies might be effective in reducing
this taboo? Because these taboos affect health, educational and
financial opportunities, and originate from culture, religion,
lack of education and infrastructure, the solutions must be just
as holistic. Some examples from the research are: cleaner toilets
in schools, court cases supporting women’s rights, education for
adolescent girls and their school teachers, and low -cost sanitary
napkins[footnoteRef:2]. As I continue this research, I am
interested in finding early legislation that either supports or
denies menstruation resources to women. [2:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4408698/]
Current and possible interventions
As the amount and level of women in the Indian workforce
grows, from 28.5% in 1994 to 43% in 2012[footnoteRef:3],
women gain more financial independence and more of a
political voice. Increasingly, organizations like the Bill and
Melinda Gates Foundation, governments, donors, and private
companies have taken in interest in these issues and four trends
of interventions have arisen. They are: Education, Menstrual
Hygiene Management (MHM) Products, Sanitation, and Policy.
These interventions fall into the operational and political levels
of political economy analysis. None of them fall into the
technical bracket as widespread academia and technical know -

3. how already exists on how to intervene effectively and
relatively affordably. For example, a hollow outhouse of sorts
can be built for only Rs. 5500, while a sanitary facility for an
entire school can be added for roughly Rs. 50,000 (USD
$715)[footnoteRef:4]. Thus, the implementation of these falls
more into an operational context. The only area that may require
technical innovation is the creation of hyper-low-cost sanitary
products. [3: https://www.rand.org/blog/2014/08/womens-
menstrual-hygiene-in-india-the-health-and-environmental.html]
[4: http://www.thealternative.in/business/10-toilet-designs-for-
rural-india/]
Both education and MHM policy require political will and
influence which has yet to be triggered. In regions where a
curriculum has been created, and the operational hurdles have
been passed, states often lack the political will to implement
teacher trainings or even allow NGOs to lead workshops.
Conversely, provision of Menstrual Hygiene products and
implementation of sanitation initiatives is more of an
operational issue. Even though low-cost pads have been
innovated, the taboo against them and the lack of selling points
leaves women without access.
Building toilets is one intervention from the ones listed above
that has actually seen bounds of improvement during the past
decade majorly due to reasons other than women’s
hygiene[footnoteRef:5]. The percentage of households with
access to a toilet grew from under 40% in 2014 to 70% on
average by 2017 due to Prime Minister Modi’s Clean India
Mission which funds the construction of 111,100,000 toilets
(USD$30 billion) in rural areas. To date, over 92 million toilets
have been built and over 550 thousand villages have been ruled
open defecation-free[footnoteRef:6]. An important point to note
in these developments is that the frame has not been one of
women’s access to sanitary toilets or education specifically,

4. rather one of uplifting the entire nation to an international
standard. The framing of these interventions is clearly an
important one moving forward, and a strategy I will discuss in a
later section. In the next stage of this project, I would be
interested in mapping girls education statistics onto the new
toilet statistics to see where the improvements correlate and
where opportunities still exist. Another important note is the
issue of monitoring and evaluation—there is yet to be
independent verification of the numbers mentioned
above[footnoteRef:7]. [5: https://brilliantmaps.com/indian-
toilets/] [6:
http://swachhbharatmission.gov.in/sbmcms/index.htm] [7:
https://brilliantmaps.com/indian-toilets/]
Figure 1 Brilliantmaps.com
While toilets/sanitary interventions are framed as a general
public health and wellness need and help MHM as a side-effect,
the Education and Product spheres of intervention are indeed
framed MHM issues and have become focuses of NGO and
private interventions that I will discuss within the Kingdon and
Health Pyramid frameworks.
Researchers understand what interventions are effective in
reducing taboos and protecting women’s health, but what gets
these solutions on the table? Where does the political will come
from to build clean toilets in India’s poorest towns? How will
the officials in a corrupt political environment with religiously-
backed campaigns support MHM initiatives? What elements
compelled India’s Supreme Court to rule in favor of women?
Generally, there does not appear to be a particular trend
regarding which Indian states are more successful at policy
interventions other than a case-by-case basis. However, gender
parity is be an important proxy for menstrual hygiene access.

5. McKinsey Global Institute categorized Mizoram, Kerala,
Meghalaya, Goa, and Sikkam as the five most equitable regions
while Uttar Pradesh, Bihar, and Rajasthan are considered the
most unequal. In this memo, I will begin examining a couple of
these regions based on public health frameworks.
Where is Menstrual Hygeine on the Agenda: Maharashtra &
Kerala?
Using Kingdon’s stream framework, we can examine where
in the agenda-setting process menstrual hygiene
falls[footnoteRef:8]. Applying Kingdon’s framework precisely
becomes difficult when the particular topic of menstrual
hygiene has not reached the national agenda and there is
significant variation from state to state and even within a single
state. It becomes important then to choose a specific local case
and hash it out step by step to glean insight for the national
level. [8: Howlett et al Ch 4]
For now, I will discuss the examples of Maharashtra, considered
one of the worse-off regions with over 223 menstrual huts. The
ethnic groups where this is most prominent are the Gond and
Madiya[footnoteRef:9]. Here, most of the women do not enjoy
the practice of staying in the huts but feel they must maintain
their traditions and customs. Most of these huts do not contain
kitchens, clean toilets, or beds, so some actors have recognized
the practice as a problem, placing menstrual hygiene i n the
“problem stream.” Another important part of placing menstrual
hygiene in the problem stream is the presence of social media.
The #periodforchange and #happytobleed campaigns grew out of
public and celebrity reactions to the stigma around
menstruation[footnoteRef:10]. [9:
https://www.theguardian.com/global-
development/2015/dec/22/india-menstruation-periods-gaokor-
women-isolated] [10: https://www.bbc.com/news/world-asia-
india-34900825]

6. Within the policy stream, NGOs, researchers, private actors ar e
actively researching solutions and beginning to implement them
autonomously where they can. In one village, Sitatola, the
village’s Panchayat, a local self-governing body, decided to
bring the gaokars closer to the village and put beds in them. A
Maharashtrian organization, Lok Biradari Prakalp, has created a
school to teach 350 girls about menstruation. A local NGO,
Sparsh, actively evaluates and monitors the gaokors and has run
12 workshops in remote villages. One representative tellingly
says, “Because it’s a sensitive topic, we try to educate them
about health and hygiene without mentioning gaokor.” This
comment speaks to the issue of changing the context while
maintaining cultural sensitivity, which I will discuss in the next
section.
Regarding the political stream, governments are experiencing
slight pressure from organizations like the National Human
Rights Commission, which instructed the Maharashtran
government to end the use of gaokors. Yet, the state government
as a whole has not taken any action on the matter. In fact, one
of the only regions where the state has taken a stance on
menstruation is Kerala. In September 2018, the Supreme Court
lifted a ban that prevented women ages 10 to 50 from entering a
Hindu temple in Kerala. In January 2019, when two women
actually entered the temple, it triggered protests and riots
throughout the region. This court case could be labeled the
focusing event within the four-month “routinized political
window” created when the Supreme Court is in session every
year.
One issue with the Kingdon framework is that it is primary
helpful to label events and “streams” retroactively and does not
appear to yield much predictive power. For example, it will be
interesting to examine whether the protests sparked because of

7. the Supreme Court decision will becoming the focusing events
or “random problem windows” through which activists will
move forward on the issues of menstrual awareness. But it will
be difficult to call it a trigger or focusing event until some
action actually does take place. That being said, a recent
documentary, Period. End of Story was published to bring light
to the issue following the January protests[footnoteRef:11].
Media attention further categorizes this as a focusing event.
Regarding the building of toilets as discussed earlier, the public
health framing of the need for toilets may also have created a
spillover problem window which brought attention to MHM
issues. But again, it is hardly possible to preemptively label
events as problem windows. Political windows, on the other
hand, are much more useful as they are more predictable and
provide avenues for policy entrepreneurs. [11:
https://www.economist.com/prospero/2019/01/22/a-new-
documentary-addresses-the-stigma-of-menstruation-in-india]
Framing is another essential component in understanding why
India’s highest court decided to rule against the centuries-old
custom in a country where many women are still banished to
menstruation huts. The courts cited their decision as necessary
to uphold the rights to equality of worship[footnoteRef:12]. In
the judgement, Justice Dipak Misra said, “Patriarchy in religion
cannot be permitted to trump over element of pure devotion
borne out of faith and the freedom to practice and profess one’s
religion.” This frame and the argument surrounding this case
focused on religious freedoms rather than menstrual rights and
women’s rights in general. [12:
https://www.reuters.com/article/us-india-court-temple-
idUSKCN1M80MK]
The issue of framing, for toilets, court cases, and even
education in villages with menstruation huts is important in

8. changing the context surrounding MHM in India.
Friedan’s Health Pyramid: changing the context for menstrual
health
Frieden’s health impact pyramid is a useful lens through which
to examine menstrual health issues in India. I’ll briefly examine
interventions that fall into each level of the pyramid. At the
bottom socioeconomic factors level, WASH initiatives
(“sanitary interventions”) are the most effective and far -
reaching. Access to clean water and sanitary facilities to
maintain a hygienic environment will go a long way to
providing women access to education, public areas, employment
etc. that would have otherwise been inaccessible.
The next level of intervention, Changing the Context is more
MHM-specific and requires targeted efforts. For the issue of
menstrual health, changing the context means normalizing the
issue of menstruation for the Indian populace and creating an
environment where women have the ability to stand up for their
rights and discuss their bodies. This is a tall order, but it can be
broken down into practical interventions. A broad example is
building private girls’ toilets in schools—an intervention that
would make young girls’ default decision, going to school, both
feasible and healthy during menstruation. While building toilets
somewhat also falls into the socioeconomic factors level, it also
applies to changing the context, specifically in schools.
Another effective way to change the context, which NGOs and
private corporate donors are working on is building access to
affordable MHM products. Currently, over 70% of Indian
women cannot afford access to products like sanitary napkins.
Therefore, their default decisions are to use rags to absorb
blood and reuse them, often without sufficient cleaning, which
is a health hazard to the women and those around them. If they
were accessible, cheap and clean pads whether reusable cloth or

9. disposable or menstrual cups where culturally acceptable, would
become women’s default choices. Producing such pads cheaply
and selling them in local markets in unassuming packaging even
in rural areas would be a good first step.
Access to menstrual education and awareness for both girls in
and out of school is also an important part of changing
context—if girls knew at an early age how their bodies were
going to change and how to practically deal with changes, the
trauma and social stigmas would, by exposure within a few
generations, cease. Unfortunately, government has volleyed this
intervention to NGO initiatives due to a lack of political will
and teacher willingness.
Changing the context in the most rural areas of India, where
indigenous populations like the Gond and Madiya live will
probably be the most challenging. Already, these groups are
marginalized and lack resources, which adds another barrier.
Firstly, there is little trust between these tribes and a national
government they believe is trying to steal their
land[footnoteRef:13]. In their situation, it will be particularly
important for NGOs to work with local Panchayat and tribal
leaders to come up with innovative solutions perhaps beginning
with teaching women how to practically manage their periods
and slowly moving toward further MHM interventions. [13:
https://www.downtoearth.org.in/news/community-forest-
rights/gond-tribals-madhya-pradesh-government-fight-for-4000-
hectares-of-land-58397]
The next level, long-lasting protective interventions in for
menstrual health come in the form of policy decisions like the
Supreme Court case in Kerala. This is essentially a long-lasting
protection of menstruating women’s rights if not their health
directly. Another example would be regular access to a women’s
health nurse or doctor, something rural India struggles with—

10. only 3% of India’s doctors live and work in rural
areas[footnoteRef:14]. One solution that has been proposed is a
menstrual leave policy where women can leave work due to
their periods. Western feminists have criticized this intervention
as a way to separate women from the workforce and allow
discrimination. Others say it allows women to take a break
during a time that is strenuous on their bodies, similarly to how
a pregnancy might be treated. Nonetheless, it provides a
possible solution, which locals ought to weigh in on to make a
decision. [14:
https://www.bmj.com/content/351/bmj.h5195/rapid-responses]
Finally, in the clinical interventions and counseling and
education route, all roads point to the wealthy. India certainly
has the facilities to deal with clinical interventions in urban
areas, but for rural Indian women, access to an OB GYN is
significantly out of reach. Over time, these interventions should
also become a priority.
Research Design
Moving forward, I would like to continue to build an overview
of India’s 29 states levels of access to menstrual rights in each.
A region/town with plenty of clean toilets, access to cheap
sanitary napkins, open temples etc will be ranked high, while a
region/town with a dearth of these elements will be ranked low.
I will focus on the regions with the highest reported gender
parity, Mizoram, Kerala, Meghalaya, Goa, and Sikkam, to begin
looking at successful interventions in those areas and see how
they originated and developed. My hunch is that framing has
been an essential part of creating broad interventions to support
women. From all the articles I read, specifically those about the
broadest interventions, menstruation was rarely if ever
mentioned while general public health, international standards,
or educational attainment frames were much more common.

11. I would like to reach out to some of the NGOs involved in
creating interventions, like Sparsh and WASH India to access
some of their reports and stories of creating a political shift.
Hopefully then I’ll be able to understand what the political
factors were that helped get some of these interventions on the
table. Was there some sort of trigger such as a protest or death?
Was it a question of funding? Did the religious community have
a change of heart? One question I have not discussed in depth
yet is the role of the religious communities, and how Christian,
Muslim, and Hindu religious communities interact with
menstrual health interventions.
Ultimately, I would like to examine the political process
used to establish some of the effective interventions across
India and figure out how they could be replicated in other
regions of the country, especially when the government takes
responsibility rather than passing it to NGOs. The broad
question I would like to answer is “In what situations do Indian
government entities (local, regional, or national) effectively
intervene for women’s menstrual health and how can such
interventions be replicated across the country?”