The CLTS Knowledge Hub has just published the latest issue in the Frontiers series- Breaking the next taboo: Menstrual Hygiene within CLTS.  This issue of Frontiers of CLTS illustrates how Community-led Total Sanitation (CLTS) programmes can be expanded to address menstrual hygiene management (MHM) in schools and communities to alleviate these stresses on women and girls. It shares learning, recommendations, innovations and experiences from Plan International, WaterAid, WSSCC, UNICEF, WASH United, Grow and Know and USAID/WASHplus.

Earlier this year, I got to see first hand what MHM projects look like in practice and what a difference they make in girls and women’s lives in Uganda.

‘Sanitation- a good thing to do, we need to be smart and clean in all we do’

After hearing these lines of a sanitation song in Achilet Primary School in Tororo, they played as a daily radio jingle in my mind. Whilst this has been rather annoying at times, it is also testimony to their strength and effectiveness. I later learned another sanitation anthem from other participants in the Pan Africa annual review meeting in Uganda who had visited different communities. We even sang this during the course of the annual review meeting, with much enthusiasm and fervour- imagine, if you will, 30 adults from 8 different African countries, the Netherlands, Australia, the UK and US swaying and gesticulating whilst singing ‘and if we change behaviour, and if we change behaviour, and if we change behaviour, we lead a better life’.

The field visit to Achilet School in Tororo was part of a week-long workshop for the Pan Africa Programme in which the CLTS Knowledge Hub has been a partner over the last 5 years. You can find out more about this programme here. Whilst there were many interesting discussions during the week, the red thread (pardon the pun) that was woven through my stay in Uganda was that of MHM, both in schools and communities. I learned a lot about the on the ground realities, innovations and challenges of raising awareness of and finding practical solutions for menstrual hygiene in rural communities and schools.

Achilet- a model of integrated programming

The school we visited in Achilet had 936 children, with classes consisting of up to 70 children each. Participatory school governance as well as interventions around menstrual hygiene integrated into CLTS had been introduced. With Plan’s support, new blocks of school latrines had been erected. We saw separate facilities for girls and boys- nice newly painted blocks, with murals depicting the do’s and don’ts of using the latrines: ‘Don’t smear latrines with faeces’, ‘Don’t play on the water tank’ and ‘Wash your hands with soap after using the toilet’ for example. There was a separate washroom for girls so that they can get changed and clean themselves during their periods, as well as a disability friendly latrine with ramp access and handrails.

As we inspected the latrines, five pupils, three girls and two boys joined us- they were the members of the School Sanitation Committee/School Health Club and were very confident and enthusiastic in telling us about their activities. What struck me most was the apparent ease with which both girls and boys talked about menstruation and menstrual hygiene- it was clear that they were not only well informed but also comfortable with the topic- an achievement that many adults in the so called developed world can only aspire to- in my experience, not many boys or men for example in my peer groups are clued up about menstruation or feel comfortable talking about it.

Afripads, mooncups and many questions

After the annual review meeting I joined Plan staff from the Netherlands and Australia on a monitoring visit to Lira, where one of two bigger MHM programmes is being implemented (the other is in Tororo). The programme is a partnership between Plan and Afripads, the producers of reusable washable pads. The project works in schools with teachers, students and school health clubs to improve the knowledge and attitudes around reproductive health and how girls can manage their periods. The goal of the project is to enable 100,000 rural women and adolescent girls to manage their menstruation effectively and hygienically in Tororo, Lira and Kamuli districts.

During the long car journey up to Lira, Sharon from Plan NL, Tom from Plan Australia delved straight into discussions around menstruation and the different products available- luckily our driver Henry didn’t seem to mind all this- the fact that he has three daughters and as part of his job with gets to listen to all sorts of conversations and is therefore au fait with all sorts of otherwise taboo subjects probably helped. Without at this stage knowing much about the project, it was clear that affordability and sustainability are two of the issues being faced by the project. As part of the partnership, Plan subsidises the pads in Plan programme areas so that the vendors (community members who have been trained in business skills and menstrual hygiene awareness) can sell them at more affordable prices to the communities. The original idea was that as sales went up, Plan’s financial input could decrease and eventually cease but it seems that this may be harder in practice.

Remembering a study I read a while ago and my own positive experience with the mooncup, we also discussed the feasibility of promoting, selling and producing menstrual cups akin to what are called mooncups, divacups or rubycups in Europe, the States and Australia. I remembered reading a study about trial of these cups in Kenya some years ago that was positive in its outcome. Besides the possible cultural and social norms and ideas that may be barriers to encouraging the use of something that has to be inserted into the vagina, we also wondered how something that costs around £20/$50 could be made affordable in the development context? Currently, a number of the producers of these cups do have programmes where customers in developed countries can purchase them for women in developing countries.

Tom wondered if, given the low cost of producing condoms these days, a similar method and production could be found for making menstrual cups- the highest cost would probably be the initial investment in moulds. None of us knew what the availability, cost and feasibility of producing the surgical grade silicone out of which the cups are made are. I am interested in seeing whether there are any other studies or programmes that promote cups instead of or alongside pads as they reduce waste and are more environmentally friendly, as well as being easy to use (even without water), discreet, friendly to the body and long lasting (the time scale given by the companies selling them is 10 years). I would be interested in hearing from those with experience in this area.

Getting everyone on board: schools, health workers and community members

In Lira, we had three activities lined up to learn more about the MHM project, its progress and challenges:

• a visit to Abia Primary School where a menstrual hygiene awareness programme was taking place,
• joining a menstrual hygiene awareness raising through a community drama performed by Village Health Workers in a community in Abwoch village in Aleptong District
• and finally some meetings with Afripads dealers and their customers in Abia.

In the Principal’s office at Abia Primary School numbers, a handwritten poster showed numbers of students in each of the grades/standards which led us into discussion with one of the teachers about reasons for high drop out rates among girls in Standard 7 (at about 15 years of age). We discovered that this was not only due to menstruation as we had assumed but linked to high prevalence of child marriages in the area. Even though this is now illegal, many parents get around the problem by arranging this in secret, eg by taking cows to the market as if to sell them, when in fact they are the dowry.

The students performed a poem and several drama skits for us. While they clearly knew a lot and had taken on all the messages, they were much more reserved and shy than the pupils in Achilet. Of course this may have been related to having mzungu visitors but Plan programme staff also told us that this is an area where there had been a lot of conflict and displacement and that therefore perhaps levels of trust in outsiders and feelings of safety in sharing were lower.

It also felt like they were more or less repeating what they had been taught- I suspect that with large classes the teaching style is more or less call and response, with students repeating the teacher’s words.  My suspicion that the poem and drama had not been composed by the pupils themselves was later confirmed. From a mindset and behaviour change point of view, I wondered how deep this kind of learning can go and whether there is enough real understanding and ownership of the subject matter for it to carry over into real and lasting change in the children’s lives? I presume that this is a wider issue around teaching and education style in many countries and it may have been thrown into particularly sharp relief for us in its contrast to the CLTS principles of not educating but letting communities to their own conclusions.

One of the main issues raised by the children, several of whom were using Afripads, was where to hang them to dry. There were not many places where they could be hung discreetly and hygienically and after some discussion of options (hanging them inside a shirt on the line), one of the school governors also promised to put up a line inside the dormitory of the boarding section.

Period drama

We also had the privilege of being able to attend an awareness raising on MHM in a community in Aleptong District. This was conducted through a community drama performance by the Village Health Team drama group which told the story of a girl getting her first period.  Her story leads from being ridiculed and being threatened to be married off by her father to her family and herself gradually understanding menstruation and menstrual hygiene better until eventually the father buys Afripads so the girl can continue her education. The drama concluded with a song and a dance as well as some comedy style interaction between an MC and the community. It was well done, fun to watch (even without understanding the words) and made the messages easy to understand, whilst touching on many of the taboos and myths surrounding the subject (we had heard quite a few of these from the students at both schools, eg when you get your period, you are ready for marriage, sex cures period pains, etc)

Several members of the Village Health team drama group are also Afripads vendors, so after the show, they went on to demonstrate and sell packs of Afripads to interested community. Observing this and the seemingly strong emphasis on Afripads at the expense of home made options and information on how to keep the latter safe and clean, raised some questions for us visitors: is there possibly too strong a link between the awareness raising and this particular product? A bit like in CLTS where community action may be slowed down if a particular latrine type is introduced after triggering, sets a standard that some may not be able to afford and gives the message that there are no other equally good alternatives. On the other hand, I think this issue also refers to a wider question around the balance or tension inherent in a programme such as this one: making products available to the poorest whilst also encouraging entrepreneurship and improving livelihoods for the vendors. All of us felt that perhaps more could have been said and shown about how to make good home made pads out of cotton, how to keep them clean etc. On a more positive note, the drama was so well done, that it occurred to me that perhaps the drama group could work with the school to make the menstrual hygiene awareness raising activities more fun, accessible and engaging for the pupils.

Afripads- Improving local livelihoods

In our meeting with Afripads vendors we heard about the positive impact on their livelihood that this new activity had had: one male vendor, Daniel, reported that he had bought a beehive with the proceeds from selling Afripads, which then became an additional means of generating income to pay for clothes and school fees for his children. A woman vendor, Margaret, had bought a pig which subsequently gave birth to 8 piglets with a value of 80,000 shillings each. Dorcus was able to buy three goats to supplement her income from selling tomatoes.

As in the schools, what struck me during both the post drama community discussion and the conversations with Afripads dealers and their customers was the engagement of men in the subject- their ease and interest were inspiring.  Those who had bought pads described their benefits in terms of ease, comfort, feeling ‘smart’, cost-effectiveness and the ability to continue with their day to day lives or in the case of girls, their education, without interruption. What also seems worth mentioning is that some of the dealers shared that when people cannot afford to buy the packs of pads outright with money, they are open to part exchanges, for example people paying by giving them produce instead.

Affordability and sustainability

Nevertheless, the issues that have come up in the Afripads project in Uganda are affordability of pads and sustainability of this system of distributing them. Currently, pads come in packs of 5 and cost 5,000 Uganda Shillings in the areas where Plan is subsidizing them though the project. Their regular price is 10,000-11,000 shillings without subsidy. So the question is- what will happen when the programme ends? And is it possible to sell different sized packs of pads rather than just the 5 pack so people can buy what they can afford and add more pads to their collection over time? Can Afripads find a way to lower production and can they and the vendors still make a business out of this, whilst also reaching poorer populations?

Finding out more

The visit to the the MHM projects in Uganda made one thing very clear- there is much to learn and find out about. One great place to start learning more about existing experiences and learning around MHM implementation and its integration with CLTS programming is Frontiers issue 6, Breaking the next taboo: Menstrual Hygiene within CLTS.

So have a read and let us know your thoughts. And if you have experience of integrating MHM into CLTS, do get in touch with us.

Petra Bongartz is Research Officer: Strategy, Communications and Networking at the CLTS Knowledge Hub.