The National Family Health Survey (NFHS)-4 data released in 2015-16 makes for a grim reading and the data on the number of women in each state who use hygienic protection methods during menstruation even more so. In most states, more than half the women in the age group 15-24 do not have access to menstrual hygiene supplies; population wise, that is more than half of all women in India. Some states, however, perform better than others. What lies beneath this disparate performance? Here, using data from the NFHS-4, we reflect on the importance of state-level initiatives.
Menstrual hygiene key to keeping girls in school
The role that access to menstrual hygiene plays in keeping girls in school is well-documented. Lack of access to proper hygienic conditions can increase the risk of reproductive tract infections. During their periods, young women struggle to go to school because of the poor quality of toilets, or worse, none at all.
The chart below presents an interesting correlation – states which have more women with access to menstrual hygiene also have more women who stay in school longer. Lower school attendance rates for women can, in turn, be linked to second-order benefits like improvement in economic growth, reduction in fertility rate and others. But beyond the instrumental benefits of a focus on menstrual hygiene – keeping girls in school and second-order effects – access to menstrual hygiene goes to the dignity of a citizen, and is, therefore, a core welfare that the state should provide.
Role of states
It is in the context of the importance of menstrual hygiene that the role of states must be considered. Some academic scholarships have examined the ability of states in a federal set-up to influence social and developmental outcomes. This specific focus on states is relevant because we need to know more about what states can do in influencing development indicators. One could not find a more startling example than this chart to begin unpacking the role of states (and state-level institutions) in influencing development.
Scholarly work is highlighting the role that states can play in a federal set-up and the role of sub-nationalism in enhancing development outcomes. The state list and the concurrent lists, and the federal set-up in India provide the backdrop against which the role of states can be examined. Studies conducted across new state borders, in villages which have similarities to each other owing to the fact that they were formerly part of the same state, provide conditions to examine the differences in effects of state-level policies. State-level bureaucratic reform can play a big role in ensuring delivery of welfare programmes – for instance, a focus on delivery of welfare programmes in Chhattisgarh has ensured access for the poor. Across the border, in Madhya Pradesh, a focus on agriculture has lessened the focus on welfare delivery. Sub-nationalism (including feelings of ‘we-ness’ or togetherness among members of a state) has been linked to positive development indicators.
The existing differential in development between states has the potential to further widen the gap in access to hygienic protection during menstruation, the consequences of which are disproportionately likely to be borne by the poorest, most disadvantaged women. Wealthier and better-developed states (such as Tamil Nadu and Kerala) do better on both the fronts – they are both able to provide better access to menstrual hygiene/toilets, and also provide other conditions that would keep women (and other children) in schools (e.g. milk to all children, iron supplementation to reduce anaemia, etc.)
Girls remaining in school is linked to economic advancement for the state, which could, in turn, facilitate better access and conditions. The figure below shows that the most populous states with lower levels of human development – West Bengal, Uttar Pradesh, Bihar – rank among the worst in providing access. The lack of an enabling infrastructure could mean that generations of young women go to ill-equipped schools, lack hygienic means of protection and their lack of formal schooling excludes them from the labour market.
Steps to improve access to menstrual hygiene
Some states are indeed making efforts to improve access to menstrual hygiene. Several efforts have been made to provide sanitary napkins to school-going girls. Maharashtra offers sanitary napkins to women at Rs 5; Kerala does something similar through the ‘She Pad’ scheme; Tamil Nadu planned to install napkin vending machines in schools, and has a free napkin programme for women launched in 2011. However, while these seem to all have been launched with a lot of fanfare, little information is actually available (in English) about performance and reach of these programmes and efforts by other states.
The data confirm the gap that could emerge from a differential focus – one way to understand this is to examine how the proportion of women with ten or more years of schooling has changed over time. The NFHS-3 data, from ten years ago, is a useful benchmark in this context. The absolute improvement, in terms of percentage points, shows that Kerala and Tamil Nadu, despite their relatively high bases, showed the maximum improvement in the last ten years. While states like Gujarat, Madhya Pradesh and Assam come at the bottom, firmly establishing that a lack of focus from the state on this issue can widen the gap.
An even more important method would be to measure if the access to menstrual hygiene has an effect on this second order measure, namely improvement in the percentage of women staying in school.
An unfortunate limitation of some efforts by states is that they focus on the provision of sanitary napkins. A focus on sanitary napkins in policies propagate the idea that pads are sufficient to address the challenge of lack of access to menstrual hygiene. Problems for women, particularly girls in school, also relate to the access to having an area to change, and then dispose of napkins – pads are therefore necessary, but not sufficient. Nonetheless, such initiatives provide hope that a core issue for women’s health is on the agenda for some states.
In the months leading up to the 2014 parliamentary elections, it was impossible to miss the several articles on the ‘Gujarat model’, a state-level initiative to provide basic infrastructure and a conducive business environment in the hope that the trickle-down benefits are widely experienced. Yet, Gujarat, a relatively rich state at the time of NFHS-3, has now caught up with Uttar Pradesh in terms of the percentage of women having ten or more years of education, whereas comparable states, such as Karnataka, Punjab, Haryana and Himachal Pradesh have done much better and are on their way to catching up with the leaders – namely Kerala and Tamil Nadu. Such data, and the broader thinking on the limitations of the Gujarat model, firmly establish the importance of state-level efforts in a federal set-up, the need for a specific focus on menstrual health in addressing gender inequities in education. States’ initiative can be at the centre of important reform.
Sarayu Natarajan is a doctoral candidate at the King’s India Institute, King’s College London and likes learning about politics and policy. Nilakantan R.S. works as a data scientist for a tech start-up and looks at politics from that vantage point.