Beyond the pad: Breaking barriers to menstrual health and equality

In Rwanda’s eastern district of Bugesera, 43 year-old mother of two girls, Anne, who has asked to be referred to by an alias has decided to use pieces of cloth for her periods because she could no longer afford sanitary pads with her monthly income due to the increase in their price. “I need at least 3,000 Rwf every month to be able to get each one of us one package of sanitary pads.” Not only has the price of pads become an issue, but also access to adequate facilities in schools is also one of the major challenges. “My parents try to find me one package per month, but when my period finds me at school, I don’t find a decent room where to wash so I could change my pad and underwear. I just go to the usual toilets and put on the pad on the same underwear without even washing myself. So it feels uncomfortable coming back in class feeling unclean and blood smells,” says Uwase who is 14 years and 18-year-old Nzamabazamariya from Gasabo district who usually faces the similar predicament. These females' situation is not an unusual issue as there have been different challenges around Menstrual Health Management locally and globally including period poverty. Statistics on period poverty and menstrual hygiene management in Rwanda shows that at least 20 percent of schoolgirls, particularly in rural areas, miss up to 50 days of school per year . At least 500 million women and girls globally lack access to the facilities they need to manage their periods. Meanwhile 1.25 billion women and girls have no access to a safe, private toilet; and 526 million don’t have a toilet at all. Apart from different reports, different Activists and CSOs have raised attention to this issue and to advocate for affordable Sanitary pads and their accessibility, among other issues on different occasions such as the Menstrual hygiene Day this year. What has Rwanda done in response to this issue? In 2019, the government added sanitary pads to the list of goods that are VAT exempted in a bid to ease their affordability. “In 2012, The Ministry of Education in partnership with the Ministry of Health launched the Girl’s room initiative as one of the strategies to address the needs of girls in a holistic manner. It provides a safe environment for girls who have an unexpected period or those with menstrual problems at school. The room is supposed to be equipped with sanitary pads, towels, painkillers, a bed, water, and soap among other hygiene tools,” says the Director General of Policy Analysis at the Ministry of Education (MINEDUC), Rose Baguma. In addition to the Girl’s room, the Comprehensive Sexuality Education (CSE) has been incorporated in the curriculum to equip students with necessary information about their body including menstrual hygiene management; School health clubs have been established in schools as a forum in which students may discuss about all health issues including the menstrual hygiene management and the producing of the Information Education Communication (IEC) and the Behavior Change Communication (BCC) materials to be put in the girl’s room for more information about menstrual management. There have also been several other interventions by government partners to contribute to finding solutions to this issue, like the manufacturing of locally made reusable sanitary pads and many more. According to the Director General of Policy Analysis at MINEDUC, the target was to have the girl’s rooms in all schools from primary to university level. However, due to different factors including financial issues, that target has not yet been achieved. As per the 2021/2022 education statistics, the availability of the girl’s rooms increased in primary schools from 55.8% in 2020/21 to 57.1% in 2021/2022, in general and professional secondary schools the rooms increased from 80.5% in 2020/2021 to 81.5% and in TVET schools the rooms increased from 76.2% to 81.0%. Not achieving the target after more than 10 years of implementation of the Girl’s room initiative has a number of reasons. “The main challenge in implementing this initiative, is linked to the financial resources for construction and equipping the rooms like Lack of enough funds to expand access to all schools, Insufficient hygiene materials, lack of adequate facilities (eg. water) in some schools and the quality of some of the rooms (sub-standards),” says Baguma. According to different activists, a positive step was made in terms of bringing conversations on board to break the silence around menstruation and raising awareness. But still there is a lot that needs to be done. “I appreciate that even conversations were brought on board but I feel more needs to be done in terms of increasing the efficiency of these girls’ rooms for example, and bringing experts on board, thinking of strategic locations as well as bringing menstruators concerns and views at the centre,” said Amina Umuhoza, a period activist and founder of SAYE/Dukataze, a local organisation that promotes conversations on menstruation. The increase in prices of Sanitary materials, gender and social norms around menstruation and lack of sufficient sex education are still the main reasons behind the persistence of period poverty in Africa and elsewhere. “Before, I used to buy a pad for 600 Rwf but now it is 1000 Rwf, and there was one brand that I used to buy 500 Rwf but I no longer find it on the market,” said Mukamana, a young mother in Musanze district, in Rwanda’s Northern Province. While some activists advocate for the decrease in price, Amina thinks otherwise because to her, people need to change how they perceive such issues because period poverty is a human rights issue. “Regarding the VAT exemption and the reduction of prices, I don’t see why menstrual sanitary materials are for sale in the first place! These are basic needs in a menstruator’s daily life, they should be free and accessible. People need to change that narrative,” added Umuhoza. She further says that social and cultural norms are still a big issue. “To respond to a long term solution of sanitary pads accessibility, reusable pads were introduced but menstruators still fear using them because they won’t be able to wash them and put them on the sun outside. In their community, they still consider issues around menstruation a taboo” She also added that even in public bathrooms, it is still impossible to bring people to provide pads the same way they provide toilet paper. “So, the need to work on shifting mindsets is still crucial and it goes hand in hand with providing sex education to provide a safe and supportive environment for menstruators and this is not the government’s responsibility only but the private sector and the community as well,” Umuhoza concluded. The Ministry of Gender and Family Promotion had not responded to our request for a comment by press time. “Society needs to get rid of this narrative that normalising menstruation means being vulnerable. Menstruation is something women should cherish and handle it with dignity in full privacy,” says Mudahogora Chantal a Senior Clinician and Psychotherapist at Solid Minds, a private mental health clinic in Kigali, Menstruation health and mental health are intertwined According to the Psychotherapist, menstruation is an individual experience. “Menstruation may lead to different mental changes such as simple/severe mood swings, anxiety and low energy due to hormonal imbalance, but all of these changes vary depending on the body,” Mudahogora adds. Menstruation itself is not an illness, but changes the body, although it is not supposed to lead to any kind of vulnerability but due to different factors it might result in an illness and sometimes it gets severe. “Mental health has strong connection to reproductive health. for example, If a menstruator has poor diet, insufficient rest, stress and other issues, her periods might be very painful or lead to heavy bleeding which might also lead to iron deficiency.” Mudahogora added. She also added that if menstruation is not handled with proper care and hygiene it may result in UTIs (Urinary Track Infections). So, she strongly recommends the usage of proper hygienic materials and their proper maintenance. Side-bar Fact box: Aside from Rwanda, what have other East African Countries and their development partners done? (Information from a desk review) Kenya Different initiatives such as removing taxes on period products (2004) and raw materials (2016) were implemented. Free Sanitary Towels Program for 3.7 million girls in public primary schools since 2011. Activists like Milcah Hadida distribute pads via bicycle, reaching 2,300 girls in five months. ZanaAfrica's hybrid model of products and education impacting 50,000 girls. Miss Koch Kenya (MKK) intervenes against socio-economic issues that contribute to the disempowerment of young women in Kenya and provides free pads to girls in slums, when possible. Uganda Innovative Initiative since 2015 to improve access to menstrual care. Tax removal on sanitation products in 2017. Village initiatives of making reusable pads, educating 4,800 boys and girls. The Ganda Boys' donations supporting 2,000 girls. Love Uganda Foundation runs programs in line with “Menstrual Hygiene Management.” This provides education and resources to girls and women about menstruation and how to manage it safely and hygienically. Tanzania According to the World Bank and The Citizen to the Tanzanian government has developed policies to integrate menstrual hygiene management (MHM) into health and education sectors. Efforts include eliminating VAT on sanitary products to make them more affordable. Organizations such as Maji Safi Group run Feminine Hygiene Groups where girls learn about hygiene, health, and puberty. These groups also provide reusable sanitary products like menstrual cups and pads. The Yorghas Foundation has provided sanitary pads and soaps to school-aged girls in Moshi, Kilimanjaro region, to ensure they do not miss school during their periods. The Tanzanian government, in partnership with UNICEF, has pledged to significantly increase access to sanitation facilities. This effort includes improving school sanitation to help keep girls in school and combat period poverty. During the COVID-19 pandemic, UNFPA Tanzania ensured that adolescent and youth-friendly centers remained open, providing essential menstrual hygiene products and information to women and girls. How are sanitary pads affordable and accessible according to available data? This figure helps compare the prices across these countries, highlighting the affordability and accessibility issues. Overall Period poverty rates in countries. These are the most recent poverty rates for Kenya, Rwanda, Tanzania, and Uganda, based on the World Bank Open data which also may be equivalent to the number of people who can buy/access pads. Analysis of Sanitary Pad Accessibility Across Kenya, Rwanda, Tanzania, and Uganda This analysis combines data on sanitary pad prices and national poverty rates to estimate accessibility in each country. Interpretation: While the price range for sanitary pads varies within each country, we can estimate accessibility based on the national poverty rate and the average price of a pad. Here's how: Average Pad Price: Assume an average price for each country: Kenya: ($0.39) Uganda: (($0.94 + $1.88) / 2) = $1.41 Tanzania: (($0.55 + $1.29) / 2) = $0.92 Rwanda: (($0.60 + $1.50) / 2) = $1.05 Accessibility: We can't definitively say which percentage has access, but we can estimate based on poverty rates: Kenya: If the average pad costs $0.39 and 35.8% live in poverty, then a significant portion likely struggles with access. Uganda: With pads averaging $1.41 and a poverty rate of 42.1%, affordability becomes a bigger challenge. Tanzania: Pads averaging $0.92 and a poverty rate of 27.2% suggest a potentially better situation compared to Kenya and Uganda. Rwanda: Pads averaging $1.05 and a poverty rate of 38.2% suggest a situation similar to Kenya. Limitations: This analysis assumes everyone within the poverty line has the same income. In reality, some may have disposable income for sanitary pads. It doesn't consider the frequency of pad changes or the number of pads needed per cycle. Availability in rural areas might be lower than in urban areas. The writer is a feminist activist and multimedia journalist

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Beyond the pad: Breaking barriers to menstrual health and equality