The Enabling Environment for Menstrual Health and Hygiene

M enstrual health and hygiene (MHH) is essential to the well-being and empowerment of women and adolescent girls. Attaining adequate MHH requires access to at least three intersecting elements: (i) access to female-friendly facilities, which is critical for menstruators to have a place in which to safely and privately change their menstrual products and manage their hygienic needs; (ii) access to information and knowledge on sexual reproductive health to understand the natural menstrual cycle and to overcome stigmas and misinformation; and (iii) access to quality and affordable menstrual products to absorb menstrual blood and enable mobility and active participation in social life. Each of these three elements is in turn influenced by an enabling environment—the set of laws, processes, business environment, and policies—that influence product availability and pricing, discriminatory practices on social stigmas, or the standards on design of public sanitary facilities.

for girls in Kenya to report no prior knowledge of menstruation before their first menarche (Mason et al. 2013), and many of them associate menstruation with shame, fear, and confusion (McMahon et al. 2011).Widespread taboos claim that menstruators are polluted, which restricts their engagement in social life, such as interacting with men or eating certain foods (FSG 2016).Because of associated stigma, the school curriculum in Kenya fails to treat the topic adequately, and girls remain uniformed and embarrassed to seek out information.One study found that only 12 percent of girls reported feeling comfortable receiving information on menstruation from their mothers (House, Mahon, and Cavill 2012).
Access to menstrual products is another challenge.A study in 2015 found that 65 percent of Kenyan girls and women were unable to afford adequate products because the cost of a package of sanitary pads was equivalent to the daily wage of an unskilled worker (SHOPS 2015).Lack of access to menstrual products can have severe implications on sexual reproductive health.A randomized control trial in Kenya found that 10 percent of 15-year-old girls self-reported having transactional sex to obtain sanitary pads (Phillips-Howard et al. 2015).

Overview of MHH-related Policies in Kenya
Government policies and legislation can create the enabling environment to facilitate access to MHH-friendly facilities, information and knowledge on menstrual cycles, and quality and affordable menstrual products.To meet this end, the government of Kenya has introduced several policies and legal reforms.In 2004, the government repealed the value added tax on sanitary padsone of the first countries in the world to do so (Welham 2020).In 2011, it reduced import duties on menstrual products (Jurga, Yates, and Bagel 2020), and then in 2016, the government removed duties on the raw materials needed to produce them.In parallel to these tax reforms, the government began to legally address the issue of access to products.In 2011, it introduced an annual national budget allocation of $3 million to fund the distribution of free sanitary pads in schools (Hallett 2016).In 2017, an amendment to the Kenyan Education Act mandated that schools provide "free, sufficient, and quality" sanitary pads to every girl registered at school, thereby cementing the government's commitment into law.Most recently, in 2020, the government approved the Menstrual Health and Management Policy 2019-2030, which lays out a road map to ensure that menstruators have access to information, menstrual products, and services and facilities, as well as the ability to dispose of menstrual waste safely.MHH strategies are developed by the Ministry of Health, county departments, and relevant stakeholders, which are also responsible for putting in place a sound monitoring and evaluation framework for this policy.

Outcomes of Policies to Date
To date, the tax reforms introduced by the government appear to have had minimal effect on the price of imported and locally made products.The price of sanitary pads in Kenya remains one of the highest in the region (Rossouw and Ross 2020), and commercial products are still unaffordable for most of the population (FSG 2016).Kenya's menstrual product market is largely uncompetitive, with one single multinational corporation (i.e., Procter & Gamble) controlling 63 percent of the market share with its brand of sanitary pads (Fox 2020).In the 12-year period between the first and last tax policy introduction, the cost of a pack of eight sanitary pads fell by 17 percent-from $1.20 in 2004 to closer to $1 in 2016.With more than half of the population living on less than $1 a day, the cost was still out of reach for many (Hallett 2016;Fox 2020).In an assessment of the effects of tax cuts on product affordability, Ross and Rossouw (2020) found that between 2013 and 2018 sanitary pads became 10 percent more affordable due to a real price decline (adjusted to inflation), which translated to only an annual increase in affordability of 1.7 percent.In other words, even with a price decline over time, the products remain unaffordable for the vast majority of the population.
Other policies introduced by the government have similarly mixed effects.Evidence remains inconclusive on the effects of the mandate to provide free sanitary products to schoolgirls.No study to date has demonstrated whether the provision of sanitary products has a direct correlation with school attendance (Austrian et al. 2021;Phillips-Howard 2016).However, the existence of the mandate does advance women's rights in terms of paying attention to MHH and recognizing the importance that affordable and quality menstrual products play.Moreover, anecdotal evidence suggests that the series of policies implemented since 2004 is corroding the stigma attached to menstruation and leading to more open public discussions and national debates around the topic.Table 1 summarizes each policy intervention, highlighting the advocacy behind getting it institutionalized and the evidence of its effects.

Potential Lessons Learned
Kenya's experience with policy reforms and laws to address the needs of menstruators reveals the complexity of the issue at hand.Well-intended tax policy reforms do not automatically translate into improved affordability for consumers.Many other factors-such as the openness and competitiveness of the market, the resources and scale of local enterprises, and the political will to advocate for price and quality control-are all part of the equation of reducing the prices of and expanding access to menstrual products.
Before deciding to introduce a tax change, it is advisable to conduct a comprehensive assessment and diagnostic of the country landscape to identify the primary drivers behind product prices and accessibility.A diagnostic ought to include, at minimum, an understanding of the following: ¼ The drivers behind the pricing of menstrual products (e.g., lack of demand, rate of taxes and duties, or uncompetitive markets) ¼ Production structures and market competitiveness (e.g., in competitive markets, companies are incentivized to drop retail prices) ¼ The drivers of demand and the heterogeneity between rural and urban markets (e.g., are users unable to access menstrual products because they are unaffordable or unavailable, a stigma is associated with purchasing them, or noncommercial menstrual products are preferred?)

Summary of Each Policy Reform
Value added tax (VAT) removal 2004 Advocacy.The government that took office in 2002 ran on a promise of gender equality.Within this climate, female parliamentarians championed for improved access to menstrual health products (Fox 2020).In 2004, they succeeded in removing VAT on products and achieved other legal reforms to further gender equality.
Effect.In 2004, although a VAT of 16 percent was removed, the price of products was reduced only minimally.According to interviews (Fox 2020), once the tax policy change was introduced, parliamentarians and civil society did not continue their advocacy on regulation and price control.The reduced VAT was absorbed by multinational businesses dominating a very uncompetitive market.With one single company controlling 63 percent of the market share of menstrual pads, it was not incentivized to drop retail prices (Ross and Rossouw 2020).Moreover, the prices set by the multinational businesses became the benchmark for other brands (Fox 2020).

Import duty removal 2011
Advocacy.Civil society organizations engaged in budget deliberations as part of the 2010 constitutional requirement enabling citizens to participate in budget-making processes.They advocated the removal of the import tax on sanitary products as a way to address broader gender equality (Fox 2020).In 2011, import duties on menstrual products were removed.
Effect.It was expected that after removing import duties, products would become more accessible and affordable since imported pads were the main product in the market.However, prices remained high and local manufacturing of menstrual products went down.Local enterprises shifted their manufacturing base to China and imported sanitary pad packs (Fox 2020).Moreover, the government failed to introduce quality regulations, resulting in low-quality disposable products from China entering the market and creating health concerns (Fox 2020).

VAT removal on imported material 2016
Advocacy.Earlier tax policy reforms broke down some of the stigma attached to menstrual health and hygiene and opened up national deliberations.Sustained public debates on the affordability of menstrual products included the airing of the documentary "Period of Shame" on national television, featuring the challenges young girls in rural areas face because of menstruation, including the lack of menstrual pads.As a result, the decision was taken to spur the local production of menstrual products by removing the 16 percent VAT and 25 percent excise tax on imported raw materials (Fox 2020).
Effect.The removal of the excise tax was not enough to decrease the price of locally manufactured menstrual products.Producers face a host of additional costs that are not mitigated by reduced taxes, such as the cost of equipment and packaging (Fox 2020).Other barriers include small-scale, inadequate distribution channels and limited resources for marketing (FSG 2016).Restricted distribution of local products is particularly acute in remote and rural areas, where women and girls are left with limited options.Despite these hurdles, one study found that Kenya has seen a larger number of social enterprises entering the menstrual health space than other countries in the region (FSG 2016).However, the reach of these local products appears to be limited (Fox 2020).

Free distribution of products 2011
Advocacy.: In 2011 the government of Kenya announced the National Sanitary Towel Program and set aside $3 million to fund the free distribution of sanitary pads to low-income schools.
Effect.The policy was a pre-election promise by the government, but it was not adequately implemented or monitored (Fox 2020).A survey of 62 primary schools in rural western Kenya found that only 10 percent reported always providing sanitary pads despite the program mandate (Alexander et al. 2014).There are also anecdotal reports of corruption, such as suppliers providing less than the agreed-upon product quantity, and the deterioration of quality, including suppliers lowering the quality to obtain government contracts (FSG 2016).Because sanitary pads are inaccessible or unaffordable for many menstruators, girls may give the pads they receive in schools to their mothers, aunts, or other female family members.a Moreover, research to date has failed to make a connection between supplying adolescent schoolgirls with menstrual products (e.g., sanitary pads or menstrual cups) and seeing an effect on school absenteeism (Phillips-Howard et al. 2016;Austrian et al. 2021).Girls who have dropped out of school and refugees are left out of school programs (FSG 2016).

Basic Education Amendment Act 2017
Advocacy.A national level, multi-sectoral Menstrual Hygiene Management (MHM) Task Group within the Hygiene Promotion Technical Working Group, led by the Ministry of Health, was instrumental in advancing the legal reform of the Basic Education Amendment Act (Fox 2020).The law provides schoolgirls who have reached puberty with free sanitary towels.
Effect.As noted previously, Fox (2020) found that the government's school distribution program is under-funded and plagued with a variety of inefficiencies.

National Menstrual Hygiene Management Policy 2019-2030
Advocacy.A national level multi-sectoral MHM Task Group within the Hygiene Promotion Technical Working Group, led by the Ministry of Health, was instrumental in advancing the national MHM policy.
Effect.The national policy is too nascent to observe impacts, however, its implementation is tied to performance indicators.National and local governments together with stakeholders will collaboratively develop common national-, county-, and community-level indicators to monitor performance and measure changes.Strategies and interventions will be continually monitored and regularly evaluated.

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This case study was written by Gaia Hatzfeldt and Sarah Keener of the Water Global Practice Social Inclusion Team, in close collaboration with Lewnida Sara of the Water Global Practice Africa East Team.The case study benefited from the contributions of Janet Mule, principal public health officer of the Kenya Ministry of Health, and Tobias Omufwoko, chief executive officer of WASH Alliance Kenya.
Connect with the Water Global Practice www.worldbank.org/waterworldbankwater@worldbank.org https://blogs.worldbank.org/waterhttps://twitter.com/WorldBankWaterAssessments may reveal that tax policy changes are not the most effective tool to ensuring menstrual products are affordable, particularly for low-income consumers.Other fiscal solutions, such as subsidies or cash-transfer programs or incentives for local enterprises and social entrepreneurs to produce locally, may be better suited for the context.And if tax policy changes are pursued, they may need to be complemented with other levers, such as quality and price controls, to achieve their aims.
Pursuing other policy reforms aside from, or in addition to, tax policy changes, comes with its own set of benefits and challenges, as the case study of Kenya demonstrates.For example, programs that provide menstrual products to schoolgirls may be an effective way of tackling issues of affordability and accessibly for large swaths of users.However, for such programs to be effective, tightened accountability and robust systems for monitoring are required to ensure products actually reach the target groups.Worthy of exploration is whether a government mandate has an effect on incentivizing more entrepreneurs to manufacture menstrual products, given the creation of an expanded market.
Despite some of the challenges in implementing Kenya's policy changes, a major achievement is the open and public discussion of menstrual health and hygiene today.Sustained advocacy and policy deliberations have helped destigmatize the topic and place it at the center of national discourse.With menstruation historically associated with deep-rooted shame and taboos, this progress is no minor feat.

Source:
Original for this publication.a.Based on an interview conducted on April 6, 2022, with Tobias Omufwoko, chief executive officer of WASH Alliance Kenya; and Janet Mule, Principal Public Health Officer, Kenya Ministry of Health.