Menstruation in rural India - a report. by Leena Jain

A REPORTMENSTRUAL HYGIENE IN VILLAGES

CONTENTS

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FOREWORD ACKNOWLEDGEMENT

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INTRODUCTION THE INSTITUTE - NATIONAL INSTITUTE OF DESIGN THE DESIGN COURSE - STRATEGIC DESIGN MANAGEMENT THE INSPIRATION MODULE - PUBLIC POLICY AND DESIGN

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VIRPURA CONTEXT ABOUT VIRPURA LOOKING BEYOND THE COMMON LENS

3 .1 .2 .3 .4 .5 .6

4 ABOUT THE PROJECT BACKGROUND & INITIAL BRIEF PROCESS PROPOSAL PHASES DELIVERABLES TIMELINE

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PHASE I DISCOVER INTRODUCTION SECONDARY RESEARCH PRIMARY RESEARCH

5 .1 .2 .3

PHASE II DEFINE INTRODUCTION PROBLEM STATEMENT GAP IDENTIFICATION

6 .1 .2 .3

7 .1 .2 .3 .4

PHASE IV DESIGN INTRODUCTION IDEATION SYSTEM DESIGN SYSTEM PROTOTYPE

145

PHASE III DEVELOP INTRODUCTION METHODOLOGY INSIGHT SYNTHESIS

8 .1 .2 .3 .4

103 167

PHASE V DELIVER INTRODUCTION IMPLEMENTATION FEEDBACK RECOMMENDATIONS

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179

EPILOGUE CONCLUSION LEARNINGS GLOSSARY BIBLIOGRAPHY

Creating awareness for menstrual hygiene among rural women: A case study of Virpura Village of Gujarat

FOREWORD

Women and girls constitute half of India’s population..1 Yet, gender disparities remain a critical issue in India impacting women and girls’ education, health, and workforce participation. Talking of health, it is only now, that the world is looking towards the issue of menstrual health and hygiene. Menstruation is a milestone event in a girl’s life and the beginning of reproductive life. Hence, all aspects of menstruation need to be understood by adolescent girls. Large number of girls have scanty knowledge about menstruation until their first experience because menstruation is something that is not frequently talked about in homes. A better understanding of the good menstrual hygiene is crucial for the education, health, and dignity of women and girls. Being an important element of sanitation that is in the closet, there is a need to duly address challenges around it. Most of the time adolescent girls are unprepared – in terms of knowledge, skills, attitudes and resource availability to go through their menstrual cycle. This has been associated with serious health issues such as genital tract infections, urinary tract infections, and bad odour.2 Unhealthy menstrual practices are: not irregular genitalia cleansing or the usage of an unclean cloth, using leaves etc. These practices result into future long-term ill effects such as - Premature births - Stillbirths - Miscarriages - Infertility problems - Toxic shock syndrome - Carcinoma cervix 3 There is a difference between prior awareness about menstruation and menstrual hygiene and their relativity to reproductive health among rural and urban women and adolescent girls (AGs). Research indicates that a vast information gap exists among adolescent girls regarding prior awareness about menstruation and menstrual hygiene which do have an impact on the practices during menstruation. Hence, this project was done to estimate the magnitude of perceived understanding of menstrual hygiene as well as to find out the relation between the knowledge, attitude, and practices about menstruation.4

With this background, the current project was carried out to explore the knowledge, attitude, and practices about menstrual hygiene and the magnitude of perceived reproductive morbidity among adolescent school girls and women in the village of Virpura in the Sanand district, Ahmedabad, India. This is a mission-driven community based project supporting existing women of the community in creating medium-scale, sustainable social change, rough strategy, evaluation, and research. This project aimed to help stakeholders at two levels — individual and collective — and address one of the vital challenges existing today; awareness about menstrual hygiene and sanitary practices. It involved partnering with stakeholders from the Individual users, Anganwadi, Panchayat to the Government. I seek to re-imagine social change by identifying ways to maximize the impact of existing resources, amplifying the new Government’s scheme to help advance knowledge and practices, and inspiring the agents of change within the community to achieve a greater impact. As part of my mission, I, also wanted to directly support the learning communities, such as the school discussion forum and the Shared Value Initiative to provide the tools and relationships that empower the agents of change. While pursuing Strategic Design Management(SDM), I always thought about the role of strategy being a catalyst in changemaking but today, I can say it with conviction that SDM has changed the way I perceive and translate thoughts and perspectives towards change. This course has managed to break my biases and allowed me to communicate, lead and manage visions and inspire self-growth.

ACKNOWLEDGEMENT

As per the NID curriculum, a graduation project enables students to have the vision to seek for a project that empowers them to communicate and translate their theoretical knowledge into solving a meaningful real-world challenge. A project guide in any graduation project plays the vital role of an eye-opener to the mind. The devoted focus and attention along with knowledge and experiences helps students to constantly sculpt their project with adequate mentorship, direction, resources, references and multiple perspectives. To design and implement strategical interventions during my duration of the graduation project, Dr. Mihir Bholey (Project Guide) has given me the freedom of creative responsibility to explore different paths to reach my project outcome. The critical feedback based on his expertise in the sanitation field has been a pillar of importance in building my project without which it wouldn.t have been possible. His classes on Public Policy Design, Understanding Human Social Behavior allowed me to think beyond the conventional way, thus, encouraging me to take up a challenging project. A society oriented project over the usual corporate design challenges was guided by him nimbly while scaling up my confidence and increasing the ability to dedicated achievement in my approach. I would also like to thank Mrs. Krishna Amin (Dean of NID, Gandhinagar) for being always being keenly interested in my project and guiding me with the smallest of perspectives which were edgy to help me achieve perfection. I cannot proceed without thanking Mr. Krishnesh Mehta and Mr. S.Guruprased (Coordinators of SDM) for being my constant supporters, always emphasizing on learning the key principles and concepts, and looking for the impactful insights. Their teaching methods have always been based on real live examples and not case-studies which kept the topic always relevant and timeless.

interest in my project. His ability to visualize my ideas about change-making practices in Virpura into community building was of utter importance. Also, the support provided by School Principal Mr.Ratilalji at every step in terms of space utilization as well enthusiasm for change-making. This graduation project has been of a great learning experience. I would like to dedicate this project to my parents for consistently supporting my dreams and ambitions. Theyâ&#x20AC;&#x2122;ve taught me to think big and strive hard to reach my goals. Thank you Joseph Rajini Asir for being like a rock to keep me anchored and motivating me to throughout. This project would be incomplete without valuable inputs and assistance from my SDM peers who have continuously inspired me. Special mention to my close friends, Harshil, Gurmet, Aayush, Mayuri, Radhika, Manu, Shilpa, Akhil, Aliza, Himanshu, Vrushti and Garima for constantly motivating me and helping me through this journey. Special thanks to Leena who helped me in layouting the content of this document.

My first interaction with Virpuraâ&#x20AC;&#x2122;s Anganwadi teacher, Mrs Devikaben Thakur was very overwhelming. During this journey, she along with her husband, Mr. Bijalbhai Thakur, kept me aware about the village dynamics and geared me up to keep chasing my dreams about change-making in Virpura. Their involvement in the project was very valuable. I would also like to thank Mr. Sagarbhai (Sarpanch, Panchayat of Iyava) for taking equal 11

National Institute of Design Paldi, Ahmedabad

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INTRODUCTION THE INSTITUTE - NATIONAL INSTITUTE OF DESIGN THE DESIGN COURSE - STRATEGIC DESIGN MANAGEMENT THE INSPIRATION MODULE - PUBLIC POLICY & DESIGN 13

THE INSTITUTE NATIONAL INSTITUTE OF DESIGN

National Institute of Design, the premier design school of India is an autonomous body under the Department of Industrial Policy and Promotion, Ministry of Commerce and Industry, Government of India. NID is recognized by the Department of Scientific and Industrial Research under Ministry of Science and Technology, government of India, as a scientific and industrial design research organization. It is located in the affluent south-west area of Paldi, Ahmedabad, National Institute of Design. The establishment of NID was a result of several forces, both global and local. The late 1950s saw a confluence of these forces, and this time would be a significant one for Indian culture and education. This was a time of reappraisal and reconstruction in a newly independent India. A young nation was confronted with the mammoth task of nation building, of balancing age old traditions with modern technology and ideas. That year raised the demand for rapid industrialization, which is when Mr. Pupul Jayaker(notable writer on Indian craft tradition and founder of Handlooms and Handicrafts Export Council - HHEC) make prominent conversations with American designer Charles Eames at Museum of Modern Art in New York. In 1957 the Government of India requested the Ford Foundation to invite Charles and Ray Eames to visit India. Eameses travelled to all parts of the country, meeting and talking to writers, craftspeople, architects, scientists, industrialists, educators and philosophers.

remain part of NID to the present day. NID is a unique institution with many problem- solving capabilities, depths of intellect and a time-tested creative educational culture in promoting design competencies and setting standards of design education. The rigorous development of the designer’s skills and knowledge through a process of ‘hands on-minds on’ is what makes the difference. The overall structure of NID’s programme is a combination of theory, skills, design projects and field experiences supported by cutting edge design studios, skill & innovation labs and the Knowledge Management Centre. Sponsored design projects are brought into the classroom to provide professional experience. Interdisciplinary design studies in Science and Liberal Arts widen the students’ horizons and increase general awareness of contemporary issues. Today, NID has reached a pioneering position and has been declared ‘Institution of National Importance’ by the Act of Parliament, by virtue of the National Institute of Design Act 2014.5

On April 7, 1958, the Eameses presented the India Report to the Government of India. The Eames Report (also called as the India Report) defined the underlying spirit that would lead to the founding of NID and beginning of design education in India. The Report recommended a problem-solving design consciousness that linked learning with actual experience and suggested that the designer could be a bridge between tradition and modernity. The Report called upon future designers to re-examine the alternatives of growth available to the country at that time. Based on the recommendations made in the India Report, the Government of India with the assistance of the Ford Foundation and the Sarabhai family established the National Institute of Industrial Design, as it was originally called as an autonomous all-India body in September 1961 at Ahmedabad. Reviving the philosophy of the Bauhaus design movement of learning by doing, unique curriculum and revolutionary educational philosophy still 15

THE COURSE -

STRATEGIC DESIGN MANAGEMENT

In todayâ&#x20AC;&#x2122;s rapidly changing Volatile, Uncertain, Complex and Ambiguous (VUCA) world, businesses are increasingly required to have the ability to create opportunity out of the ambiguous, tangibility out of the intangible and create worth and wealth out of the constraints. This can only be achieved by the capability and the capacity to continuously contextually reinvent, renovate and â&#x20AC;&#x2DC;designâ&#x20AC;&#x2122; their business strategies, processes, tools and techniques. The competitive edge of the enterprises of the future will be dependent on their ability and agility to dynamically steer and realign their modes of operation and further increasingly on their ability to master the intangibles and the multifarious. Basically, organizations will either win or perish based on their ability to detect and deliver to both, the minds and hearts of the consumers by being able to sense and serve not only what is wanted but also forecast and provide what maybe wanted in a way that is biophilic-seeking to improve, evolve and enrich the life and lives rather than just be profit maximizing. Businesses today have to be inclusive and holistic and maximize worth and dignity rather than just revenues. Such businesses require leaders who, apart from being entrepreneurial, can adroitly envision and decode the future, simplify the complex and offer enchantment. Such leaders have the ability to design contextually relevant imaginative, creative, transformational and intuitive strategies, business processes, tools and techniques rather than just copy, follow and run the operations. They have the ability to design and make the future present. Management and leadership practices of today are found wanting to meet these requirements and direly need re-imagination. Design as a discipline has been addressing these issues and Strategic Design Management (SDM) is a programme specifically designed powered by design methodologies to meet these demands and fill these gaps. The SDM programme is not a MBA programme in Design or another MBA branch/specialization, nor is it meant to manage designers and design projects. SDM is about redefining and redesigning management processes, strategies and leadership paradigms through strategic design interventions. The SDM programme seeks to use, embed and innovatively apply the design based creative, empathic, integrative, systemic, synergetic, holistic and human centric skills and approaches to business, organizational and management processes, tools and techniques to make them more efficient, effective and efficacious.

The SDM programme envisages creating professionals who are whole brained and balanced in the heart, head and hands and thereby have the ability to understand and serve from the rural to the urban, local to the global, crafts to corporate, private to public, individual to social, self to culture, proprietary to governmental, logical, sensory to emotional, material to spiritual, across gens BB, X, Y & Z, jobs to entrepreneurship sectors. Professionals trained to produce entraining, stress and fear free, playful and yet highly productive and innovative work environments that value each individual in their terms and inspire imaginative and creative contribution. This is achieved by novel inputs and courses that enable a deeper understanding of the human, social and organizational behaviors, motives, intents, desires and drivers and how these can be used to design strategies that help achieve the organizational goals and deliver the legitimate value, worth and wealth. The SDM curriculum strives to enhance the sensitivity and perceptivity and develop a strong ability to have creative and innovative approaches to looking at life and business processes. The courses are offered in a highly experiential and transformational way and include live projects, industry and rural exposure, field studies, environmental exposure and immersive and participative live-in case studies in social and corporate sectors. The courses range from the basics in design and management to design research, social behavior, cognitive neuroscience, multi-sensory processes, entrepreneurship, playfulness and gamification, designing strategies, aesthetic appreciation, behavioral economics to neuro-marketing, experience design, design audit to service and systems design, creative strategic leadership that ultimately lead to an ability to design contextually effective strategies, policies, business processes, tools and techniques for any and all sectors.6

THE INSPIRATION MODULE - PUBLIC POLICY & DESIGN

Public policies are the fundamental principles behind the set of rules and regulations citizens are expected to follow. Theyâ&#x20AC;&#x2122;re applicable to a host of social, moral, economic, ecological and other aspects of the society and the reflection of the intent of the government towards its social commitments and priorities. In other words; what the government thinks will be important to ensure harmony and to achieve larger social good amidst conflicting interests and priorities. They cover a wide gamut of issues: law, public health, transportation, urbanization, manufacturing, sanitation, environment, education, design to name a few. Rising democratization and participatory governance have made public policies all the more challenging. Policy process deals with problem identification, policy formulation and policy execution. Thus, requires the process of comprehensive, integrated understanding concerning the society, its needs and aspirations and the stakeholdersâ&#x20AC;&#x2122; perspective. If better policy leads to better governance, better governance is also a reflection of better policies.

employment guarantee, public health, transportation, urbanization and many more. They need design intervention at several levels to become more effective. This course helped me learn the key concepts and processes of public policy. The basics of how to establish the link between Public Policy and Design, which work hand in hand but both interdependent. The role of design in improving service delivery in sectors like healthcare, sanitation, transportation etc., which majorly pushed me to think about the sanitary practices of women. Then how would it different for different sectors of the society. Then the project in itself has now become the art of the application of design process including creative thinking, critical thinking and systems thinking in enhancing policy performance.

The application of design in the contemporary times is not just confined to form, function and aesthetic. Itâ&#x20AC;&#x2122;s now much more strategic and works at the intangible levels as well. Design thinking is being used to make mental models, generate policy alternatives and innovate processes and systems that we work with. This includes application of the key concepts of design such as creativity, innovation, critical thinking, systems thing in areas of social service design and public policies. Many developed nations like UK, Singapore among other are trying to bridge the gap between policy delivery and design to bring social change. UK Design Council for example is making endeavors in this area by sensitizing designers about public services and policies governing them. Opportunity Labs in Singapore is teaming up with engineers, architects, social scientists and policy managers to create an interdisciplinary environment to overcome the pressing social challenges policies deal with. In turn, it also creates opportunity for the public managers and other professionals to appreciate the creativity and innovation of design in problem solving. India being a welfare state makes a large number of policies to deliver social good ranging from mid-day meal to primary education, rural 19

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VIRPURA CONTEXT ABOUT VIRPURA LOOKING BEYOND THE COMMON LENS 21

CONTEXT

100% 90%

No discussion on the process of menstruation

Unaware of the importance of washing menstrual cloth

Menarche: The first occurrence of menstruation

87%

Used old cloth as menstrual absorbent

86%

Completely unprepared

79%

Low self confidence

64%

Felt scared

60%

Missed school on account of menstruation

47%

Mothers did not agree on girls knowing before onset

44%

Felt embarrassed and humiliated over restrictions

33%

‘Never’ washed cloth before using first time

It is important to understand what few important words we use day-to-day mean, and how simple design interventions along with positive attitudes can make a lasting difference to the lives of every adolescent girl and woman. The following definitions are helpful for the entire project to be relevant.

Hadn’t heard of sanitary napkins

Menstruation; ‘monthly periods’: A biological process in a woman where each month blood and other material is discharged from the lining of the uterus. Menstruation occurs from the onset of puberty until the menopause, except during pregnancy. Menstrual Hygiene/Menstrual Hygiene Management: (i) articulation, awareness, information and confidence to manage menstruation with safety and dignity using safe hygienic materials together with (ii) adequate water and agents and spaces for washing and bathing with soap and (iii) disposal of used menstrual absorbents with privacy and dignity. Menstrual waste: Includes a used sanitary cloth, napkin, towel or pad that contains blood.

Statistics around AGs & menstruation Statistics Source: Unicef (2012): Girls today, Women tomorrow study. Other studies include: A.C. Nielsen and Plan India (2010). Sanitation protection: Every Women’s Health Right.

Sanitation: The concept of sanitation includes (i) disposal of human excreta by cesspools, open ditches, pit latrines, bucket system etc. (ii) liquid and solid waste disposal, food hygiene, and personal, domestic as well as environmental hygiene (iii) home sanitation, safe water Personal hygiene: Personal hygiene involves those practices performed by an individual to care for one’s bodily health and well being, through cleanliness.

Source: woman's care

Menstruation is a natural, normal biological process experienced by all adolescent girls and women, yet it is not spoken about openly causing unnecessary embarrassment and shame. It is still a taboo in India and it is common for people across society to feel uncomfortable about the subject. India’s 113 million adolescent girls are particularly vulnerable at the onset of menarche. At this time they need a safe environment that offers protection and guidance to ensure their basic health, well-being and educational opportunity is realized. Yet a recent survey found that in 14,724 government schools only 53% had a separate and usable girl’s toilet.7 At home the situation also need to improve as 132 million households do not have a toilet (2015), leaving adolescent girls and women to face the indignity of open defecation. However, safe and effective menstrual hygiene, is a trigger for better and stronger development for adolescent girls and women. Also, according to 2011 census, 89% of India’s rural population have no toilets. The rags used in lieu of sanitary pads may predispose these women to various reproductive tract infections because it is difficult for them to keep these used rags clean and free of harmful bacteria. Equipping adolescent girls with adequate information and skills on menstrual hygiene and its management helps in empowering them with knowledge which enhances their self-esteem and positively impacts academic performance. However, awareness regarding menstrual hygiene and sanitary practices is a social issue that cannot be addressed by working in schools alone. In order to ensure that adolescent girls and women have the necessary support and facilities, it is important that the wider society, communities and families must challenge the status quo and break the silence around menstruation. There is a need to change family and community norms and beliefs in this regard. Not being able to talk about their experience and having limited information means that menstruation becomes something to be ashamed of and to hide, and is consequently ignored in families, schools and communities In many families, the mother has limited experience in explaining the management of menstruation with regard to schooling, mobility or outdoor activities Communities should be aware of the barriers to menstrual hygiene management that girls face in school, as well as their role in enabling girls to successfully manage menses in school and at home. It is therefore the responsibility of those with influence – including government of officials and teachers, and researchers like me to find appropriate ways to talk about the issue and take necessary actions.

ABOUT VIRPURA

As per the 2011 census, Gujarat State comprised 26 districts, sub-divided into 225 talukas, having 18225 villages and 348 towns. In 2013, 7 new districts were created, raising the total number of districts to 33 and talukas to 248. Gujarat has a geographical area of 1.96 lakh sq. km and accounts for 6.19 percent of the total area of the country (Directorate of Economics and Statistics, GoG, 2015). Ahmedabad district is the most urban and most populous district in Gujarat. It ranks 8th in terms of population among districts in India. As per the Census of 2011 (Registrar General of India, Census, 2011), the rural areas are characterized by 539 villages inhabited by a population of about 11.5 lakhs. Virpura village is located in Sanand Tehsil of Ahmedabad district in Gujarat, India. It is situated 5 kilometers away from sub-district headquarter Sanand, 20 kilometers away from district headquarter Ahmedabad and 50 kilometers away from the NID, PG Campus in the Sanand district. The total geographical area of village is 608.03 hectares. It functions under the larger panchayat of a neighboring village, Iyava (often referred as para gaam). It is situated off the Viramgaam-Sanand highway, the entry to the village is through a railway line crossing which is open from 7am- 7pm only. The local language spoken is Gujarati. The way I landed at Virpura is through the ESI foundation which directed me towards the Ambuja cement foundation and Virpura happened to be one of the several villages adopted by the foundation as a part of itâ&#x20AC;&#x2122;s CSR activities. This foundation supports its social responsibility through interventions in areas of health & sanitation, infrastructural and educational developments in the village. After gaining access to the village through members of the Ambuja cement foundation I visited the community multiple times to interact with a variety of people across all age groups to understand their culture and identify overall needs which are spatial, sanitation and educational. Virpura has a total population of 850 people. There are about 204 houses in the village. It holds the entire population under the 5 Vas (caste based living spaces) and 192 families. The Vas that exist are Thakur, Chunara, Nayak, Senva and Patel. The primary occupation of the people is farming and animal husbandry. But, due to industrial revolution many men and women of the family with no land or animals work at near by factories.

There is a Virpura Prathamikshala (often referred as Nisad) which educates actively the kids upto 8th standard. Male and female literacy rate is average, but people are very active, and always making efforts in knowing the works of government officials. It has around 385 female population out of the total population. There is a Sorath Mahila Vikas Mandal (SMVM) set up by Ambuja Cement Foundation in the village which is led by the Anganwadi teacher Devikaben. This Mandal is about empowering Sakhi(s) with the awareness about micro-credit system and income generation activities and it is linked to local bank in Iyava. There are religious gatherings that happen at the Ramji Mandir as well as Shiva Temple within the village. Also, a place is allocated to hold panchayat meetings which is currently not being utilized. The reason I finalized on Virpura as my project site was because it was relatively smaller than a regular village, and it has the least amount of political interferences. It largely functions autonomously and wanted to engage with a community that brought out itâ&#x20AC;&#x2122;s challenges through constant interactions.

Map of Virpura

LOOKING BEYOND THE LENS

In rural India, as a whole, menstruation is a taboo induced with stigma not permitting discussion or even information seeking. Because of shame and superstitions associated with this monthly biological occurrences, the women are impacted by poor menstrual hygiene. Women spend several days menstruating within their lifetime, with very real and practical needs. From childhood, a girl is taught to sacrifice for others, not to think of herself, to feed everyone else in the family first. This is the definition of a ‘good woman’ therefore she is conditioned to neglect herself. If girls and women are to live healthy and productive lives, with dignity, menstrual hygiene is a priority. In majority of rural areas, there is complete neglect of menstrual hygiene due to low awareness levels and lack of access to sanitary products. Repeated pregnancies, abortion etc., add to her poor nutritional status and she continues to remain anaemic all her life. This project was also to break the stereotypical myths of the society and sensitize adolescent girls (AGs) and women of Virpura (Sakhi) to see beyond what is just told to them through ancestral stories. Stigma around menstruation and menstrual hygiene is a violation of several human rights8, most importantly of the right to human dignity, but also the right to non-discrimination, equality, bodily integrity, health, privacy and the right to freedom from inhuman and degrading treatment from abuse and violence (WSSCC 2013).9 The taboo of menstruation helps to inflict indignity upon millions of women and girls, but it also does worse. Menstruation has a pronounced effect on the quality of and enjoyment of education than do other aspects of puberty. Research confirms that the onset of puberty leads to significant changes in school participation among girls. It involves a learning component as well as elements which affected by the school environment and infrastructure. These include access to menstrual hygiene materials, latrine and places to change, safe water and sanitation, and good hygiene practices like hand-washing with soap. Without these, school environment is unhealthy, gender discriminatory and inadequate. Actually, there is a relation between menstrual hygiene and school drop-out of girls from the higher forms (grade four and five) of primary and secondary education (see also water sanitation and gender). In spite of the fact that Millennium Development Goal (MDG) 2 (achieve universal primary education) has been accomplished in the lower forms of primary education

in many developing countries, the participation of girls, in particular in Africa and Asia, lags far behind the participation of boys in the higher forms of primary and secondary education.10 Besides the fact that girls at Virpura are married off at an early age in some cultures, many girls are kept at home when they start menstruating, either permanently (drop-out) or temporarily during the days they menstruate. When girls get left behind this eventually also lead to school drop-out. In my graduation project, hence, I have tried to work on this multifaceted issue related to women’s health in the rural setting. The evidences compelled me to consider that the pressing need to address it in a holistic manner engaging not only the women and adolescent girls (AGs) but also the environment that surrounds them and the culture and society as a whole. Generally, when we look at any new space, place, people or culture all we think how do we connect, associate or differ from it. But, in this project I wished to go beyond this set frame of the mind. Everybody looks at the challenges as a problem but I have tried to look at it as a process in order to avoid any kind of social taboo, stigma when dealing with women health issues, menstrual hygiene or sanitary habits. Also, menstruation according to me is a natural physiological and biological process which needs equal care as for other processes in the body. Everybody is different and has its own limitation, hence I have looked at menstruation beyond the stigma associated to it with respect and diligence. In view of the socio-economic conditions under which women in India were constrained to lead their lives from time immemorial, they were often labeled as abla, which (in Hindi) means ‘without power’ (‘a’ in Hindi meaning ‘No’ and ‘bal’ meaning ‘Power’). Admittedly, women are making outstanding contribution in several areas, but on a limited level and there is urgent need to strengthen the existing infrastructure and creating new facilities for their development. This project is all about making the Sakhi(s) aware about the changes that have occurred in the world of health care, including, sustainable affordable MHM products and, through habit of good practices empower them to make independent choices for their personal well-being. In the more liberal twenty-first century with more opportunities opening to them, they have forayed into all spheres. It has been established by now that they can excel in equal measure provided they are given opportunity. Yet most of them continue to suffer 29

from gender discrimination, violence and unfair treatment due to stereotyped mind-sets. This project on menstrual hygiene, reproduction cycle awareness and healthy sanitary practices is a welcome addition to the youthful AGs and an extension toolkit that contains useful information for enhancing the knowledge of Sakhi(s), particularly in the area of health & sanitation, reproductive cycle, accessing public services/ schemes and economic empowerment, direly needed by them at grassroots level. AG(s) and Sakhi(s) will understand the various functions of reproduction and importance of menstrual hygiene practices. In addition they will also get to know about the biological cycle behind it. I am confident enough that this project on Menstrual Hygiene will bridge the gap and bring awareness about a public health issue of paramount importance.

(Caption)

3 .1 .2 .3 .4 .5 .6

ABOUT THE PROJECT BACKGROUND & INITIAL BRIEF PROCESS PROPOSAL PHASES DELIVERABLES TIMELINE 31

BACKGROUND & INITIAL BRIEF

Initial Approach:

Initial Project Brief:

While on a look-out for my graduation project, the focus was to scout a project that would align with my enthusiasm to work towards social sector especially the rural development. As strategic designers and design thinkers we are skilled to bring out an impactful change through empathetic and consciously designed strategies, products, services or systems, however, I was inclined to dedicate this project on how women today strive to build a culture around in their families but forget to care and think about themselves &/or their well-being. Moving beyond systems or services, Personal Well-Being is now being explored to cultivate the best of habitual practices, approaches to health and hygiene and government strategies to support it. With this blooming thought, I approached Environmental Sanitation Institute (ESI) to experience and study different aspects of Health, Sanitation and challenges around rural set-up such as Lilapur, Godhavi which are adopted by them. The purpose was to comprehend the current health scenario and translate research into creating responsible insights which could possibly foster a culture of well-being within the rural set-up.

Initially, the brief for the graduation project was discussed and motivated by my guide understanding my interest. We had been wanting to explore, learn and develop a research with valuable insights in the field of health, hygiene and sanitation at Virpura. The expected outcome of the project would be a complete research and a possible implementable system set-up regarding any health challenge faced by people in the Virpura. As the project involved lot of human connect, emotions and belief system deliverables were kept open-ended to start with.

Later through ESI, Ambuja Cement Foundation (ACF) happened and they routed me towards Virpura. This village was warm, open and welcoming since day one of my visit and stuck the right chord to my purpose. The intention was to become facilitator who mediates between the people of the community and other stakeholders to set up the system/process for awareness and implementation. Here I was not the sole decision maker. I visited the Anganwadi teachers house to have a starting conversation about Virpura and to know the possible challenges that the village is facing in general. From here began the journey to establish trust and steer the project organically. Community based development projects entail an act of reflection as the facilitator actualized the process of upgradation from ‘how something is’ to ‘how it could be’. Learning processes cannot be biased. They required information on what we have done or what others have done. It was important to know to whom these lessons will apply – why and how? The process informed one about how to restructure or reorganize in the present time and how one can strategize differently next time.

To design interventions to improve sanitary practices among rural women. 33

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PROCESS INITIAL PROCESS RESEARCH METHODOLOGY

INITIAL PROCESS .I

At the start of the project, it was open-ended in terms of the topic for research in health and sanitation but the purposeful direction was still developing. To get clarity, I began the project with few questions into the community that would lead to define the problem statement. The first week was reserved to scope various possibilities, understand the perspectives of the community about varied things like waste, health, hygiene & sanitation and the mind-set of the people in Virpura. Being new to the community, it was necessary to achieve the basic understanding and trust with the community, their personal vision for health and sanitation; and the expectation with my presence. It would have been difficult to visit anyoneâ&#x20AC;&#x2122;s house and talk without they knowing me or vice-versa, hence, I thought why not start with the school. So my objective to interact with community started in three ways;

Formal & Informal Conversations in the School Approach: Daily short interactions with School Principal, teachers and kids at the assembly times were considered a leverage point to deduce what is the scenario of the village in each Vas, family or individually. These conversations were extremely unplanned and organic but the objective was to derive on certain understanding that would direct about how well are kids acquainted with the waste, health facilities and sanitation within the village. Few fun interactive activities were done in the school to break the ice with the kids and be like a peer to them.

2 3

Informal Conversations with Every Vas Approach: After few days when kids were well-versed with me coming to school, calling my name when I entered the village, I started visiting the community. Until this time my only visits happened to Virpura Prathamikshala and back. It had become easier to visit the different vas because a connection to school was established. The family members knew that I was associated to the Nisad because their kids would come back talk about the activities/conversations done in the school with me and the trust was building. Short interactions with group of Sakhi(s) were considered a leverage point to deduce roles do they play within the family dynamics and social dynamics. These conversations used to go in the flow of group interest but the objective was to derive on certain common points that would direct about how well are Sakhi(s) are acquainted with the waste, health, hygiene and sanitation.

Informal Conversation with Individual Families Approach: The purpose of this was to decipher the common understanding related to health, sanitation and personal hygiene, what exactly are the expectations of the stakeholders involved in the village, the vision for themselves and how exactly they function in the community. The dialogue was to seek an individualâ&#x20AC;&#x2122;s perspective and thoughts to proceed with common aspirations to achieve.

RESEARCH METHODOLOGY .II

Once the problem statement is well identified and framed, the next step begins with research. Research be it secondary or primary is an essential source to derive the actual facts and figures that lay the foundation for any challenge. The research is a time taking process that must result is some crucial findings. These findings have a possibility to be converted into unique insights that are important enough to give shape and direction to the identified problem. The journey of research to coming up with insights is entitled as insights because the end to go

to the next stage is decided by the quality of insights the user has arrived at. This project was carried out based on qualitative research method which used focused discussion groups, semistructured interviews with 30 women of Virpura Village in the Sanand District in the age group of 14-54 years.The participants included unmarried girls AG(s) in their early teens, married women till the age of 54 yrs. years.

PRIMARY RESEARCH SCHOOL

VAS

INDIVIDUAL HOMES

Tools or Technique used

Informal conversations and playful activities

Focussed Discussion Groups and Metaphorical Survey Forms

Semi-Structure Personal Interviews

Questions Addressed

General view about Waste and Sanitation

General view about Waste, Health, Hygiene and Sanitation

Informal conversations and playful activities

Audience

School Principal, School Teachers and Students

Grandmother/Daughterin-law of the families

Sakhi(s) or Adolescent Girl (AGs) of the family

Data Collection

Unstructured dialogue to text

Descriptive answers and verbal dialogues

Dialogues to text

INITIAL FINDINGS

1 2 3 4 5 6

While people of the community are aware of best waste and sanitation practices but there are no strong actions towards practicing it. The understanding of personal well-being and hygiene is minimal.

Though toilets exists, the adaptability of older generations to using it is difficult

Menstrual hygiene definitely doesnâ&#x20AC;&#x2122;t make any difference to many people.

With day-to-day responsibility, it is difficult for women of the house to take out time to understand personal well-being and work towards it. Some houses are not aware of their physiological bodies, menstruation, MHM products available in the market, reproduction cycle, contraception, waste disposal methods, sanitary practices. Reason could range from no/limited access to newspapers, television, Mahila Vikas Mandal, Anganwadi collaborations, Panchayat meetings, Government schemes, RTI etc.

INITIAL OUTCOMES

1 2 3 4 5 6

The activities/initiatives taken by the Government lack alignment with respect to they what they aspire to achieve and how many have access to participate in it Due to unaligned objectives, there is an inconsistent approach to bring in social change.

So as to achieve quick results, there is a need to go to the root-cause of existing rich tradition knowledge that ideally could be converted into practical solutions. Hence, the change is impactful and achievable.

Since the community at Virpura is opening up to take steps towards making change on a personal and social front, yet there is a missing a process that would bind people with a common understanding.

On gaining widespread exposure and perspectives towards health, hygiene and sanitation, there is a requirement to establish own guidelines or approach towards this agenda.

All the above reasons are contributing to make an understanding that there is lack of awareness, social pressure and missing implementation process at grassroot-level. 37

.3 .I .II

PROPOSAL REVISED PROJECT BRIEF VISION & SCOPE OF WORK

REVISED PROJECT BRIEF .I

Creating awareness for menstrual hygiene among rural women: A case study of Virpura Village of Gujarat

This project is based on understanding a community at two levels (tangible and intangible) and identify key areas of design intervention. During this project I would gain holistic understanding of the Virpura Community, all the stakeholders involved, their needs and the intertwining of its various cultural aspects/ behaviors/ way of living through design. The name Sambandh means relationship which is what defines my ties to the community of this village, and their ties to self, Sakhi(s) and surrounding.

To design a strategic systemic process that would enable rural AG(s) and Sakhi(s) to revisit their bodies with awareness about menstrual and sanitary practices, sexual health and personal hygiene.

Scope the current menstrual awareness scenario within the Sakhi(s) of Virpura. Discover the social barriers faced by Sakhi(s) and AG(s) that hinders the process of personal hygiene and well-being. Sensitize and train women so as to encourage them to look after their and families well-being. Design sustainable interventions which can be practiced in everyday life without extra effort to make it relevant and socially appropriate to adapt 39

the design thinking process

VISION & SCOPE .II

There is a profound need for a paradigm shift towards a systematic and focused intervention which, without doubt requires various service providers (governmental and non-governmental) to seriously consider coherent and convergent action plan dealing with this much evaded issue. The core vision of this project is to act as a catalyst to bring together different perspectives related to menstrual hygiene and tie them together in their everyday life. The core project is executed and documented on the basis of the design thinking model.

7 Dâ&#x20AC;&#x2122;s of the process

DECIPHER

DEVELOP

the existing social context, indispensable need and purpose of social change.

clarity about terms like menstruation, reproduction cycle, sexual health, menstrual and sanitary practices, personal hygiene and well-being amongst the Sakhi(s).

DETERMINE

DERIVE

the social challenges within Virpura which diminish the opportunities for Sakhi(s) to come together to voice their needs.

the challenges that have compelled Sakhi(s) and AGs to stay aloof from personal hygiene and sanitation

DISTINGUISH

DISCOVER

existing aid/government schemes/ strategies/partnerships across the globe for solving similar problems.

the diversity at Virpura in terms of people, community living spaces, habits, and their behavior, drivers, ability to deal with problems, till what level do they understand personal hygiene, how would they like be assisted in their everyday challenges before introducing the idea of a system/process/ toolkit

7 DESIGN interventions on identified insights, build socially contextual system/ process that can seamlessly push personal hygiene and also create a sustainable culture which gets accepted without loss in respect, dignity and integrity of womanhood in Virpura

SCOPE OF THE PROJECT Personal hygiene in an rural-setup is mostly driven by the community and their mind-set. The study was confined to the village Virpura part of Iyava Village in the Sanand District, Ahmedabad. The vision of this project is to decipher the current social scenario at Virpura around health and sanitation and strategize to redirect it towards awareness driven change. Introduction of new system/process will be a practicing model that can help Sakhi(s) and AG(s) of Virpura to realize the need to change and learn simultaneously and keep themselves including their families aware and hygienic. It will also open channels for communication across different Vas and enhance the approachability between the School, Panchayat and other stakeholders involved. 43

PHASES

Phase 01

Phase 02

DISCOVER

DEFINE

Deciphering the rural setup, existing awareness and deriving challenges to intervene into the personal spaces of Sakhi(s)

Bringing Sakhi(s) and AG(s) to common awareness across Virpura, thus developing common understanding and motivation.

Each Vas (residential division) in the village has their own way of leading life with value systems and principles. The purpose of this phase is to identify a common thread of reference for Sakhi(s) and AG(s) at Virpura through which they relate to menstrual awareness and hygiene. Typically, there is a stigma around talking about ideas that directs towards menstruation or anything related to it. For some itâ&#x20AC;&#x2122;s about family system, communication barrier could be another, or for some it is a need they were looking for a long time which becomes the driving factor. It is vital to comprehend the factors that are hindering the environment of personal hygiene and discover the motivating force that becomes a leverage point for the Sakhi(s) and AG(s) to signify to and meaningfully overcome these challenging gaps whilst designing a dedicated system/ process for awareness and implementation to happen.

This phase will indicate towards defining the motivating factors among Sakhi(s) and AG(s) that are required to inspire them toward menstrual hygiene and sanitary practices. This will aid in mapping the challenging gaps between the aspirations of the Sakhi(s) and AG(s) about personal hygiene system/process, their participation level and their inclination to continue working towards it. These gaps will help to improvise and help define the methodology to be used to make maximum Sakhi(s) and AG(s) to participate willing.

Phase 03 DEVELOP Ideating to bring in possible strategic solutions derived from insights with the participation of Sakhi(s) &AG(s) to bring in change. This phase will help to proceed with derived important insights to discover where the system/process/stakeholder are struggling within Virpura to develop the required awareness. This phase will also help us to develop some methodology to incorporate small behavioural adaptations and to make Sakhi(s) confident to believe in the purpose of the project so as to ideate on local strategies they could function on smoothly.

Phase 04

Phase 05

DESIGN

DELIVER

Building a sustainable independent systematic processes,communication platforms, product accessibility for Sakhi(s) & AG(s) with minimal adaptation.

Making the designed system/process sustainable without any dependencies and improvising it with constant feedback.

These findings and methods will be deciphered into designing a system/process which will act as facilitator to motivate and spread the vision of the company among all the departments. These enthusiastic Sakhi(s) and AG(s) will act as an motivators and support system in sensitizing other Sakhi(s) and AG(s) by learning and leading menstrual awareness and personal hygiene projects within Virpura.

This phase is the most important phase for the Virpura. The designed system/process that gets functional through the Sakhi(s) and AG(s) in lead and my support should be continued when I would leave Virpura. Also, how the feedback that gets received for the system is involved into making the system/process robust. Also, if the system delivers the way it is envisioned it will help inspire more Sakhi(s) and AG(s) not only in Virpura but also in para village Iyava to start with.

DELIVERABLES

Create a common awareness about menstrual hygiene and sanitary practices with a defined systemic process

Develop an active community platform through meetings within the Virpura which keeps inspiring and motivating each-other to grow bigger each day.

Designing workshops/ activities for Sakhi(s) and AG(s) around re-visiting their bodies with awareness about menstrual and sanitary practices, sexual health and personal hygiene.

Setting up a self sustainable systemic process which empowers them to access comfort during menstruation with minimal change in lifestyle and belief systems.

.6 TIMELINE

PRIMARY RESEARCH 21st June - 11th July, 2018

SECONDARY RESEARCH 8th June - 20th June, 2018

FINALIZING PROJECT STAGES 28th May - 7th June, 2018

RESEARCH AREA & GOALS 20th May - 27th May, 2018

FORMULATING PROJECT BRIEF 3rd May - 20th May, 2018

FINAL CHANGES & DELIVERABLES 27th August 2018- 4th September, 2018

FEEDBACK COLLECTION & RECOMMENDATIONS Till 7th November, 2018

IMPLEMENTATION 18th August - 27th August, 2018

SYSTEM PROTOTYPING 11th August - 17th August, 2018

IDEATION | DESIGNING 15 July - 10th August, 2018

INSIGHT GENERATION & SYNTHESIS 11 July - 15th July, 2018

(Caption)

4 .1 .2 .3

PHASE 01 DISCOVER INTRODUCTION SECONDARY RESEARCH PRIMARY RESEARCH

INTRODUCTION

The Virpura community currently has over 850 residents who primary have farming and animal husbandry as their occupation. The Entire village is divided by the borders of Vas system. Geographically, their houses are mostly confined to their farmlands. Internal movement with village is high as compared to inter-village or city. Discover, Phase 01, is intended to decipher what culture is infused within Virpura after industrial revolution and consumerism through how people interact, daily routine, autonomy and commonly; accessed spaces, accepted beliefs and values. In the process understanding a new place, time was an essential factor. Stemming from my core interest and passion, and investing ample time, the challenge was to dig out deeper layers beyond the existing Vas setup, ways of communication, sensing whether the need for menstrual awareness and hygiene exists and what are the roadblocks on the journey. As per the current scenario, each and every women across urban setup are considering their menstrual hygiene and sanitary practices as one of the priority. This topic is bursting with immense amount of ambiguity, confidentiality and half-baked knowledge. To build an awareness around it a safe space creation to is a must. But it is important to know whether this is the same need that the Sakhi(s) and AG(s) in Virpura require to be met and how it can help in changing the comfort in life of the Sakhi(s) and AG(s) through strategically designed interventions and practices. Go-along method

Research Methodology These findings have a possibility to be converted into unique insights that are important to give shape and direction to the identified problem. The journey of research to coming up with insights is entitled as insights because the end deliverable to go to the next stage is decided by the quality of insights the user has arrived at. Initiation to decipher the community at Virpura, Discover Phase 01 is designed to first establish a clarity in the process through secondary research. The secondary research focuses on charting the approach of government in the sectors related to health, sanitation and menstrual hygiene. Gathering all the possible data, statistics, schemes, policies, guidelines, perspectives about how all the mentioned sectors functions. Deciphering this, the next stage is highlighted on studying the impact of these schemes, policies within Virpura making it the primary research. From basics of knowing the terms to defining the accessibility channel, this phase is dedicated to emphasize the findings on menstrual hygiene and sanitary practices. The primary research led to the deriving the meaningful problem statement that could lead to right design interventions.

To decipher and understand a community, engagement was needed and this could happen through becoming a part of the community. Later, the process began with developing clarity amongst Sakhi(s) and AG(s) around terms like health, sanitation, reproduction cycle, sexual health and the meaning of menstruation, menstrual and sanitary practices, personal hygiene and well-being, different types of MHM products, women support groups. On the basis of these as references, the next step was to discover how differently and creatively I had to tackle in this rural-setup keeping in mind the respect and dignity of each individual in Virpura. Based on these findings the direction of the project was steered. 55

Secondary research is conducted to determine a theoretical knowledge of all the key concepts, existing data in that particular field, and developing focused research area within this project. While the key areas are Menstrual Hygiene and Sanitary Practices, it is important to understand the development of these ideas/concepts and their presence in the todayâ&#x20AC;&#x2122;s context when moving towards change. The key objective of the secondary research is to decipher the relevant parameters to be leveraged which would help in long run during the project journey.

.2 .I .II .III .IV

SECONDARY RESEARCH HEALTH IN INDIA SANITATION IN INDIA MENSTRUAL HYGIENE IN INDIA SECONDARY RESEARCH DISCOVERY

HEALTH IN INDIA .I

Shareeramaadyam khalu dharmasadhanam, which translates to “The body is the means for performing good deeds” is an ancient Indian saying attributed to Manu and quoted by many including Kalidasa. This could be interpreted as viewing physical health as a means of fulfilling social and spiritual responsibilities, thus emphasizing the role of health beyond the care of the physical body. The World Health Organization (WHO) definition of health arguably fits with this idea where health is defined as “a state of complete physical, mental and social well being and not merely the absence of disease of infirmity” (WHO, 2015). This definition, a part of the preamble to the constitution of the WHO, changed the approach to health as a positive outcome rather than merely on negative concepts such as the “absence of disease.”11

Human Development Index

Health is a kind of human capital as well as an input to producing other forms of human capital. Expenditures on health, as well as on education, are considered as an investment in human resources contributing to productive capacity of any country. An improvement in health contributes to economic development through improved productivity and lesser cost burden of treatment, resulting in improved economic welfare not only of the individuals, but for the society as a whole. Availability of an accessible and affordable health care system is essential for enabling good health care to the population of the country. This calls for close partnership between Centre, State Governments and various stakeholders. In India, public health is the concern of state governments since health is a state subject; however, a few health-related programs are funded by the central government. Health policies in India have focused on multiple issues such as infectious disease control, improvement in nutrition as well as maternal and child health, mental health awareness and care, health care accessibility, health care affordability, and employees’ insurance programs. The public health system in India is designed to not only provide curative medical care but also preventive and promotive health services. One of the most important tasks is to enable the public health system to effectively deal with any new health problems that might emerge in the future.

Human and Health Development, Ahmedabad

Human Development is a development paradigm which is beyond mere rise or fall of national incomes. It is about creating an environment where people can develop their full potential and lead productive, creative lives in accordance with their needs and interests. People are the real wealth of nation. Development is thus about expanding the choices people have to lead lives that they value. The District Human Development Report is a document which gives the present status of Human Development in different talukas of the District. Human Development report highlights three important pillars which are: Education, Health and Livelihood12

Ahmedabad district is the most urban and populous district in the state of Gujarat. Population-wise, the district is ranked 8th in India out of the total 640 districts in the country (Census, 2011). According to the Census 2011, about 84.04% of the population lived in urban areas and 15.96% population lived in rural areas. The areas where Ahmedabad district performs well are: the proportion of expectant mothers who deliver in institutions; immunization of young children against tuberculosis, measles and polio; and meeting the Government of India norms of the average rural population served by government health centres. The district (excluding Ahmedabad City) has achieved institutional delivery rates of ~98%. However, several other districts have achieved 100% and Ahmedabad ranks 11th out of 26 districts on this indicator.

Rural Health in Ahmedabad Public Health Infrastructure Facility In terms of providing health services and the norms for the average rural population served by Primary Health Centres(PHC), Sub-Centres and Community Health Centres (CHC), Ahmedabad district generally performs well. Rural healthcare system of the Government of India is a three tier system. The sub-centre is the most peripheral and first contact point between the primary health care system and community members. Sub-centres are established in order to improve the interpersonal communication for health education, to promote behavioral change and to provide some of the basic health services (Indian Public Health Standards, 2013). As per the standard norms, there should be one sub-centre per every 5000 population in plain areas and per 3000 population in hilly/tribal areas. Services such as antenatal care, essential child care, postnatal care, adolescent healthcare, contraception and water-sanitation need to be provided by sub- centres (NRHM, 2013).

(Caption)

The Primary Health Center (PHC) is the first contact point between the village community and a medical officer. PHCs are the first referral units and are established to provide curative and preventive health care to the rural population with emphasis on preventive practices and to promote healthy behaviors. The PHC is considered as the backbone of the rural health care system in India and covers a population of 20,000 in hilly, tribal, or difficult areas and 30,000 populations in plain areas with 6 indoor/observation beds. It is the first referral unit for 6 Sub- Centres and refers out cases to Community Health Centres (CHC) (30 bedded hospital) and higher order public hospitals located at sub-district and district level (National Rural Health Mission (NRHM), 2012). The CHC is a 30 bedded hospital. It is a second referral unit for 4 PHCs. CHCs haves specialized healthcare services (Indian Public Health Standards, 2013). Each CHC caters to approximately 80,000 populations in tribal/hilly/desert areas and 1,20,000 population for plain areas. A CHC provides specialist care in medicine, obstetrics and gynaecology, surgery, paediatrics, dental and AYUSH.

the Government of India norms, except for the CHCs in Sanand, Dholka and Viramgam which are overburdened.

Health Personnel at CHCs

Table shows the number of sub- centers, PHCs and CHCs in Ahmedabad district in 2012-13.

Availability of the healthcare facility and infrastructure needs to be accompanied by the availability of healthcare professionals and this in turn depends upon whether the posts get sanctioned and once sanctioned, whether the posts get filled. Availability of the healthcare professionals looks highly uneven if we compare the population served by each CHC. Most of the posts are not sanctioned, but even after they are sanctioned, many are not filled up.

Taluka wise average population served by SCs, PHCs and CHCs, 2013-14

This was calculated by dividing the number of health centers by the rural population of that taluka since these centers are meant to serve people residing in villages. As shown in Table 4.22, at the taluka level, Daskroi had the highest number of sub-centres (46) whereas Mandal had the lowest (14). Daskroi had the highest number (7) of PHCs as well. Except Daskroi and Bavla, where there are 2 CHCs each, all other talukas in Ahmedabad had one CHC in 2013-14. The average population served by CHCs is high in Sanand, Dholka, and Viramgam indicating the need to strengthen the capacity of these CHCs. In general, the average population served by the public health centers in Ahmedabad district met

Health personnel at CHCs in the talukas of Ahmedabad District (2013)

What needs urgent attention is that 5 out of 12 CHCs in the district have no specialized doctors and rely on the services of MBBS graduates, thus defeating the purpose of establishing CHCs, which is also what is witnessed in Iyavaâ&#x20AC;&#x2122;s PHC. 59

SANITATION IN INDIA .II

Individual Health and hygiene is largely dependent on adequate availability of drinking water and proper sanitation. There is, therefore, a direct relationship between water, sanitation and health. Consumption of unsafe drinking water, improper disposal of human excreta, improper environmental sanitation and lack of personal and food hygiene have been major causes of many diseases in developing countries. India is no exception to this. Prevailing High Infant Mortality Rate is also largely attributed to poor sanitation. The rural sanitation programme in India was introduced in the year 1954 as a part of the First Five Year Plan of the Government of India. The 1981 Census revealed rural sanitation coverage was only 1%. The International Decade for Drinking water and Sanitation during 1981-90, began giving emphasis on rural sanitation. Government of India introduced the Central Rural Sanitation Programme (CRSP) in 1986 primarily with the objective of improving the quality of life of the rural people and also to provide privacy and dignity to women. The Primary Health Center (PHC) is the first contact point between the village community and a medical officer. PHCs are the first referral units and are established to provide curative and preventive health care to the rural population with emphasis on preventive practices and to promote healthy behaviors. The PHC is considered as the backbone of the rural health care system in India and covers a population of 20,000 in hilly, tribal, or difficult areas and 30,000 populations in plain areas with 6 indoor/ observation beds.

Today it connotes a comprehensive concept, which includes liquid and solid waste disposal, food hygiene, and personal, domestic as well as environmental hygiene. Proper sanitation is important not only from the general health point of view but it has a vital role to play in our individual and social life too. Sanitation is one of the basic determinants of quality of life and human development index. Good sanitary practices prevent contamination of water and soil and thereby prevent diseases. The concept of sanitation was, therefore, expanded to include personal hygiene, home sanitation, safe water, garbage disposal, excreta disposal and waste water disposal. A comprehensive Baseline Survey on Knowledge, Attitudes and Practices in rural water supply and sanitation was conducted during 1996-97 under the aegis of the Indian Institute of Mass Communication, which showed that 55% of those with private latrines were self-motivated. Only 2% of the respondents claimed the existence of subsidy as the major motivating factor, while 54% claimed to have gone in for sanitary latrines due to convenience and privacy. The study also showed that 51% of the respondents were willing to spend upto Rs.1000/- to acquire sanitary toilets. Keeping in view the above facts, the CRSP was improved. In the new format, CRSP moves towards a “demand driven” approach. The revised approach in the Programme titled “Total Sanitation Campaign (TSC)” emphasizes more on Information, Education and Communication (IEC),

It is the first referral unit for 6 Sub- Centres and refers out cases to Community Health Centres (CHC) (30 bedded hospital) and higher order public hospitals located at sub-district and district level (National Rural Health Mission (NRHM), 2012). The CHC is a 30 bedded hospital. It is a second referral unit for 4 PHCs. CHCs haves specialized healthcare services (Indian Public Health Standards, 2013). Each CHC caters to approximately 80,000 populations in tribal/hilly/desert areas and 1,20,000 population for plain areas. A CHC provides specialist care in medicine, obstetrics and gynaecology, surgery, paediatrics, dental and AYUSH.

Human Resource Development, Capacity Development activities to increase awareness among the rural people and generation of demand for sanitary facilities from 1999. This will also enhance people’s capacity to choose appropriate options through alternate delivery mechanisms as per their economic condition. The Programme is being implemented with focus on communityled and people centered initiatives. Children play an effective role in absorbing and popularizing new ideas and concepts. This Programme, therefore, intends to tap their potential as the most persuasive advocates of good sanitation practices in their own households and in schools.

The concept of sanitation was earlier limited to disposal of human excreta by cesspools, open ditches, pit latrines, bucket system etc.

The aim is also to provide separate urinals/toilets for boys and girls in all the schools/ Anganwadis in rural areas in the country.

The main objectives of the Total Sanitation Campaign (TSC) are as under:

1 2 3 4 5 6

Bring about an improvement in the general quality of life in the rural areas. Accelerate sanitation coverage in rural areas to access to toilets to all by 2012. Motivate communities and Panchayati Raj Institutions promoting sustainable sanitation facilities through awareness creation and health education. In rural areas, cover schools by March 2008 and Anganwadis by March 2009, with sanitation facilities and promote hygiene education and sanitary habits among students. Encourage cost effective and appropriate technologies for ecologically safe and sustainable sanitation.

Develop community managed environmental sanitation systems focusing on solid & liquid waste management.13

The â&#x20AC;&#x153;Nirmal Bharat Abhiyanâ&#x20AC;? (NBA) the successor programme of the TSC, was launched from 2012. The objective was to accelerate the sanitation coverage in the rural areas so as to comprehensively cover the rural community through renewed strategies and saturation approach. Nirmal Bharat Abhiyan (NBA) envisaged covering the entire community for saturated outcomes with a view to create Nirmal Gram Panchayats. Under NBA, the Incentives for IHHLs were enhanced and further focussed support was obtained from MNREGA. However there were implementation difficulties in convergence of NBA with MNREGA as funding from different sources created delays. To accelerate the efforts to achieve universal sanitation coverage and to put focus on sanitation, the Prime Minister of India launched the Swachh Bharat Mission on 2nd October, 2014. The Mission Coordinator shall be Secretary, Ministry of Drinking Water and Sanitation (MDWS) with two Sub-Missions, the Swachh Bharat Mission (Gramin) and the Swachh Bharat Mission (Urban), which aims to achieve Swachh Bharat by 2019, as a fitting tribute to the 150th Birth Anniversary of Mahatma Gandhi, which in rural areas shall mean improving the levels of cleanliness in rural areas through Solid and Liquid Waste Management activities and making Gram Panchayats Open Defecation Free (ODF), clean and sanitised. The Mission shall strive for this by removing the bottlenecks that were hindering the progress, including partial funding for Individual Household Latrines from MNREGA, and focusing on critical issues affecting outcomes.14

Rural Sanitation in Ahmedabad Ahmedabad district is primarily urban and has a distinct advantage of well-developed physical infrastructure, better sanitation systems, service and industrial jobs, banking facilities, and educational institutes. Its proximity to the capital city of Gandhinagar gives provides several administrative and communication resources. Despite these achievements in urban infrastructure and high growth, there persists sharp rural-urban disparity in several indicators. One of the most surprising finding is the gross inadequacy in basic sanitation systems. 61

Open defecation remains pervasive in rural areas of the district exposing people to the risks of fecal contamination and other water-borne diseases. Addressing open defecation needs to go beyond the construction of toilets, since data suggests that toilet construction targets have been more or less met in the district. We have recommended that community perception about hygiene and sanitation and their practices needs to be understood and lessons drawn should be included in planning and implementation of sanitation programs. Successful strategies such as Community Led Total Sanitation (CLTS) where behavioral change is triggering-walk of shame, should be adopted with the help of NGOs and local leaders to bring a shift in the way people understand hygiene and health. Given our previous discussion on lack of adequate sanitation facilities in rural areas of the district and high prevalence of open defecation, a review of the “Nirmal Gujarat” (introduced in 2007) scheme is perhaps crucial. Rural Housing and Rural Development department indicates that the state of Gujarat has undertaken the “Nirmal Gujarat Scheme” (previously known as the Total Sanitation Campaign) to ensure clean environments in the villages. The scheme involves building toilets for both Above Poverty Line (APL) and below Poverty Line (BPL) families and a regulatory framework for scavenging work. The following chart shows the achievement percentage in meeting the targets of building household latrines by talukas in the district for the year 2010-2011 and 2013-2014. It is surprising that though over 50 percent achievement “targets” have been met in most talukas, open defecation remains pervasive. Non-availability of data by social group categories (APL/BPL and by caste groups) make evaluation of the scheme difficult. Since, data across India suggest that absence of household sanitation systems and open defecation are common among lower socio-economic groups (e.g. Dalit communities), it is possible that these “targets” were achieved in more affluent communities. Data suggested that majority of rural talukas in Ahmedabad district have more than 50 percent of households that report relying on open defecation.

The rural talukas of Ranpur, Detroj-Rampura , Sanand and Viramgaam report very high levels of open defecation suggesting poor quality sanitation and higher likelihood of exposing people to water-borne communicable diseases resulting from faecal contamination. This is surprising since the target of toilet construction has been often met successfully over the last few years (2010-2015).

Health personnel at CHCs in the Talukas of Ahmedabad District (2013)

MENSTRUAL HYGIENE IN INDIA

Promoting adolescent health is an important part of the Reproductive and Child Health component of the National Rural Health Mission. If girls and women are to live healthy and productive lives, with dignity, menstrual hygiene is a priority. In majority of rural areas, there is complete neglect of menstrual hygiene due to low awareness levels and lack of access to sanitary products. Taboos and myths surrounding menstruation limit girlsâ&#x20AC;&#x2122; access to schooling and socializing, adding to the existing gender discrimination. In India, menstruation and menstrual practices are clouded by taboos and socio-cultural restrictions for women as well as adolescent girls. Limited access to products for sanitary hygiene, and lack of safe sanitary facilities could prove to be barriers to increased mobility and the likelihood of resorting to unhygienic practices to manage menstruation. Traditionally in India, it appears that there are some strategies: use of old clothes as pads by recycling them, and use of ash or straw, which offers no protection, and endangering menstrual hygiene with long term implications for reproductive health. Anecdotal evidence suggests that the lack of access to menstrual hygiene (which includes sanitary napkins, toilets in schools, availability of water, privacy and safe disposal) could constrain school attendance and possibly contribute to local infections during this period. Therefore, creating awareness and increasing access to the requisite sanitary infrastructure related to menstrual hygiene is important.

facilities supporting Menstrual Hygiene Management - Adolescent Resource Centers (ARCs): Counselling of adolescent girls on puberty and Menstrual Hygiene Management

Roles of various ministries on MHM

- Menstrual Hygiene Management promotional activities - Water, Sanitation and Hygiene related facilities supporting Menstrual Hygiene Management - Provision of disposal mechanisms - Provision of funding for IEC and training

.IV

Ministry of Women and Child Development (MWCD) - Training of Anganwadi supervisors and workers - Access to absorbents via Self Help Groups; production of Sanitary Napkins at the village level by Self Help Group run units; marketing and demand generation of Sanitary Napkins - Reaching out to out of school girls through SABLA, Integrated Child Development Services, Self Help Groups under Mahila Arthik Vikas Mahamandal - Shelter Homes: Menstrual Hygiene Management promotional activities and supply of sanitary napkins; disposal mechanisms established; trained staff; Water, Sanitation and Hygiene related

Ministry of Human Resource Development (MHRD) - Training of Nodal teachers for providing support to girls and boys on puberty related issues; and support to girls with regards to Menstrual Hygiene Management in schools and Kasturba Gandhi Balika Vidyalayas = Access to absorbents at the school level and teaching to make absorbents for self-use in schools and Kasturba Gandhi Balika Vidyalayas = Water, Sanitation and Hygiene related facilities supporting Menstrual Hygiene Management = School Management Committee sensitized to enable gender sensitive decisions supporting coping of girls to puberty and menstruation; reaching out to fathers and sensitizing them on Menstrual Hygiene Management so they can be supportive and make appropriate decisions - MRMs Trained on Menstrual Hygiene Management and act as peers to promote menstrual hygiene practices and management Ministry of Drinking Water and Sanitation (MDWS)

Ministry of Health and Family Welfare (MHFW) - Rashtriya Kishor Swasthya Karyakram(RKSK) & Adolescent Reproductive Sexual Health: Counseling of adolescent girls on puberty and Menstrual Hygiene Management - Educational sessions with school going girls and boys by the

medical teams of Rashtriya Bal Swasthya Karyakram visiting the schools. - The Adolescent Girls Anaemia Control Programme: Counselling and support to adolescent girls on how to improve their diets; weekly iron and folic acid supplementation for out of school girls through Integrated Child Development Services and school girls within educational institutions - Menstrual Hygiene Scheme: Menstrual Hygiene Management promotional activities in the community; distribution and supply of sanitary napkins; disposal mechanisms established; training of ASHA

Tribal Development Department (TDD) - Training of teachers and residential staff in Ashram schools and madarasas - Menstrual Hygiene Management promotional activities - Regular supply of sanitary napkins - Disposal mechanisms established - Water, Sanitation and Hygiene related facilities supporting Menstrual Hygiene Management

Rural Development Department (RDD) - Access to absorbents via Self Help Groups under the fold of National Rural Livelihoods Mission - Production of Sanitary Napkins at the village level by Self Help Group run unit; marketing and demand generation of Sanitary Napkins - Menstrual Hygiene Management awareness among women and mothers to be oriented; Water, Sanitation and Hygiene as part of the agenda of the Self Help Groups and Voluntary Organizations under National Rural Livelihoods Mission

Overview of MHM policies

Schemes/Programs promoting Menstrual Hygiene and Sanitary Practices The Menstrual Hygiene Scheme(MHS) This scheme is implemented by the National Rural Health Mission (NRHM) under the Ministry of Health & Family Welfare. The National Rural Health Mission (NRHM) was launched by the Honâ&#x20AC;&#x2122;ble Prime Minister on 12th April 2005 under the Ministry of Health & Family Welfare, to provide accessible, affordable and quality health care to the rural population, especially the vulnerable groups. The Union Cabinet vide its decision dated 1st May 2013, has approved the launch of National Urban Health Mission (NUHM) as a Submission of an overarching National Health Mission (NHM), with National Rural Health Mission (NRHM) being the other Sub-mission of National Health Mission. NRHM seeks to provide equitable, affordable and quality health care to the rural population, especially the vulnerable groups. This scheme aims at promoting menstrual hygiene combines health education for adolescent girls in rural areas, providing a regular supply of sanitary napkins and enabling other sanitation

measures such as access to water and toilets in schools and in the community through convergence with other programmes. Building on existing experience in the country, this scheme also promotes the active participation of women self help groups in the manufacturing of sanitary napkins. It will not only generate economic livelihood for the people in the villages, but will also promote local demand and distribution at a relatively low cost. Existing national health programmes such as the Adolescent Reproductive and Sexual Health (ARSH) and the Adolescent Education Programme (AEP) include a range of interventions for adolescent girls and boys who are in school and out of school. While pilot interventions to promote menstrual hygiene exist, the scheme for menstrual hygiene provides an opportunity for states to implement these in multiple districts. This scheme for promotion of menstrual hygiene builds on and strengthens interventions for adolescent girls by creating a forum for discussion on menstrual health and hygiene, and distribution of sanitary napkins. The scheme emphasizes the involvement of the local women’s groups, VHSC, and the ASHA in the promotion of menstrual hygiene. We hope that the scheme for menstrual hygiene serves as a platform to discuss other issues related to adolescent reproductive health. It provides for a package of health education and supply of sanitary napkins. But promoting menstrual hygiene also involves behaviour change among other influencers such as older women, access to safe water and clean toilets. States are expected to strengthen convergence with programmes such as the Total Sanitation Campaign (TLC) and the Sarva Shiksha Abhiyan to leverage support for building and improving water and toilet facilities in the community and in schools.' The route of enabling self help groups to manufacture sanitary napkins opens an avenue for economic empowerment and raising awareness among older women as well. Ensuring quality control of the sanitary napkins and safe disposal after use are critical component of the programme and states will need to pay attention to this. The Ministry of Health and Family Welfare has been implementing this scheme for promotion of menstrual hygiene among

adolescent girls in the age group of 10-19 years primarily in rural areas as part of the Rashtriya Kishor Swasthya Karyakram. The scheme has the following objectives: - To increase awareness on menstrual hygiene among adolescent girls = To increase access to and use of good quality sanitary napkins among adolescent girls residing primarily in rural areas = To ensure safe disposal of sanitary napkins in an environmentally friendly manner. The scheme was initially implemented in 2011 in 107 selected districts in 17 States wherein a pack of six sanitary napkins called “Freedays” was provided to rural adolescent girls for Rs. 6. From 2014 onwards, funds are now being provided to States/UTs under National Health Mission for decentralized procurement of sanitary napkins packs for provision to rural adolescent girls at a subsidized rate of Rs 6 for a pack of 6 napkins. The ASHA will continue to be responsible for distribution, receiving an incentive @ Rs 1 per pack sold and a free pack of napkins every month for her own personal use. She will convene monthly meetings at the Anganwadi Centres or other such platforms for adolescent girls to focus on issue of menstrual hygiene and also serve as a platform to discuss other relevant SRH issues. A range of IEC material has been developed around MHS, using a 360 degree approach to create awareness among adolescent girls about safe & hygienic menstrual health practices which includes audio, video and reading materials for adolescent girls and job-aids for ASHAs and other field level functionaries for communicating with adolescent girls.15

SABLA The Rajiv Gandhi Scheme for Empowerment of Adolescent Girls (RGSEAG) also called SABLA is under the Ministry of Women and Child Development Department.Its implementation is being facilitated by infrastructure of Integrated Child Development Services (ICDS).16The ICDS aims to impart Immunization, Supplementary Nutrition, Health check-ups, Referral services, Pre-school education(Non-Formal), Nutrition and Health information. The services of Immunization, Health Check-up and 65

and Referral Services delivered through Public Health Infrastructure under the Ministry of Health and Family Welfare.17 SABLA is Initiated on 30-9-2010 piloted in 9 selected districts (134 blocks) of Gujarat viz. Banaskantha, Dahod, Kutch, Panchmahal, Narmada, Ahmedabad, Jamnagar, Junagadh, Navsari. The target group is 11-18 years Adolescent Girls(AGs). The Rajiv Gandhi Scheme for Empowerment of Adolescent Girls (RGSEAG) also called SABLA, is rightly named after our former Prime Minister Rajiv Gandhi’s abiding concern for empowering (making them Sabla) women. Currently being operated in 200 districts of the country, the coverage of SABLA Scheme is likely to be expanded in near future. The objectives comprising under SABLA are: - Enable self-development and empowerment of AGs; - Improve nutrition and health status of AGs; - Spread awareness among them about health, hygiene, nutrition, Adolescent Reproductive and Sexual Health (ARSH), and family and child care; - Upgrade their home‐based skills, life skills and vocational skills; - Mainstream out‐of‐school AGs into formal/non formal‐education; and - Inform and guide them about existing public services, such as PHC, CHC, Post Office, Bank, Police Station, etc. Along with this SABLA provided development through resource materials which are: SABLA Module: A comprehensive module for training and education of adolescent girls in local language. SABLA Module focuses on changes and needs during adolescents, Adolescent, Reproductive Health and child care and life skills and information about legal rights and responsibilities and related. SABLA Pothi: A comprehensive card, counselling and IEC material for recording weight, height, Body Mass Index (BMI), Iron Folic Acid (IFA) supplementation, referrals and services received under SABLA. The card also maintains important milestones in the girl’s life like joining school, leaving school, marriage. Adolescent girls maintain the Kishori Cards and Sakhi and Sahelis assist them. SABLA Training kit: Assist AGs in understanding various health, nutrition, social and legal issues. The kit comprises of games and

activities so that the AGs enjoy while learning. Sakhi and Saheli will be trained to use the Kit for imparting peer education. The contents of the kit are apron on the anatomy and physiology of female body, Mehandi Book, Recipe Book, Sanitary Napkins, Flash cards on legal issues, health and nutrition issues, Mirror to detect anaemia, Snakes & Ladder, deck of playing cards with health, nutrition and legal issues.

Menstrual Hygiene management18 Menstrual hygiene management is an integral part of the Swachh Bharat Mission Guidelines (SBM-G) The Menstrual Hygiene Management Guideline is issued by the Ministry of Drinking Water and Sanitation to support all adolescent girls and women It outlines what needs to be done by state governments, district administrations, engineers and technical experts in line departments; and school head teachers and teachers. In considering the specific sanitation and hygiene requirements of adolescent girls and women, state governments and district administrations have a responsibility for putting in place the framework. This framework highlights the essential elements of a menstrual hygiene management programme that should be integrated in to other government schemes.

Menstrual hygiene management in the Swachh Bharat (G) guidelines Funds available under the IEC component may be used for IEC in this matter and to raise awareness and skills on Menstrual Hygiene Management in all places and speci cally amongst adolescent girls in schools IEC plans should include this component for raising awareness among all stakeholders Funds under the SLWM components can also be used for setting up of incinerators in schools IEC plans should include this component for raising awareness among all stakeholders Issues relating to women’s personal hygiene namely menstrual hygiene are to be focused under the SBM (G) Girls and women have hygiene and sanitation needs linked to their menstrual cycle Women suffer in the absence of knowledge about safe practices on MHM There are several examples where CSOs and SHGs have worked with the community, informed them about menstrual hygiene practices and also developed economic models to meet the demand for sanitary napkins This is one area where CSOs and SHGs can play a key role A survey in Uttar Pradesh found that adolescent girls know too little about menstruation and menstrual hygiene management Therefore, in addition to making sure that every household has a toilet, governments and all stakeholders must make sure that: 1. Every adolescent girl and woman, and their families, including men and adolescent boys, must have awareness, knowledge and information so that menstruation is understood and can be managed safely with con dence and dignity. 2. Every adolescent girl and woman must have easy access to sufficient, affordable and hygienic menstrual absorbents during menstruation 3. Every adolescent school girl must have access to a separate

use it. This requires that all state, district and local authorities, including schools, communities and families create an environment where menstrual hygiene management is seen as acceptable and normal. SUVIDHA Government of India announced the launch of ‘SUVIDHA’ scheme under the Pradhan Mantri Bhartiya Janaushadhi Pariyojana (PMBJP). ‘Swachhta, Swasthya and Suvidha’ are the touchstones that this product will ensure for the underprivileged Women of India: Shri Ananthkumar. Union Minister for Chemicals & Fertilizers and Parliamentary Affairs, Shri Ananthkumar announced the launch of ‘Suvidha’, the 100% Oxo-biodegradable Sanitary Napkin, under the Pradhan Mantri Bhartiya Janaushadhi Pariyojana (PMBJP), here today. The affordable sanitary napkin will be available for Rs. 2.50 per pad at over 3200 Janaushadhi Kendras across India and would ensure ‘Swachhta, Swasthya and Suvidha’ for the underprivileged Women of India. This step taken by the Department of Pharmaceuticals will ensure the achievement of Prime Minister Shri Narendra Modi’s vision of Affordable and Quality Healthcare for All, the Minister said while addressing the media. Shri Ananth kumar said that this is a special gift for all Women on the occasion of International Woman’s day, as this unique product would ensure Affordability, Hygiene aa well as Ease of use and disposal for them. SUVIDHA napkins would be physically available at all Janaushadhi Kendras in the country by May 28, 2018 – World Menstrual Hygiene Day, the Minister informed. According to the National Family Health Survey 2015-16, about 58 percent of women aged between 15 to 24 years use locally prepared napkins, sanitary napkins and tampons. Further, about 78 percent women in urban areas use hygienic methods of protection during menstrual period; only 48 percent women in rural areas have access to clean sanitary napkins. Shri Ananthkumar said that this is one of the most important requirements in ensuring the Health Security to that section of Women in India who still use unhygienic aids during menstrual period due to non-affordability of some of the popular brands of 67

sanitary napkins available in the market today. Such unhygienic aids cause fungal infections, Reproductive Tract Infection, Urinary Tract Infection, Cervical cancer and also make women vulnerable to infertility. Moreover, the disposal of non- biodegradable sanitary napkins available today creates a huge environmental problem. The 100% biodegradable SUVIDHA napkin would ensure Swachhta, the Minister added. Addressing the media on the occasion, Minister of State for Chemicals & Fertilizers, Road Transport & Highways, Shipping, Shri Mansukh Lal Mandaviya explained the term ‘Oxo-biodegradable’ to the media. The Minister said that a special additive is added in the SUVIDHA napkin which makes it biodegradable when it reacts with oxygen after it is used and discarded. Further, Shri Mandaviya said that the average price of sanitary napkins available in the market today is around Rs. 8 per pad, whereas now with the launch of the SUVIDHA napkins at Rs. 2.50 per pad, this will go a long way in making the basic hygiene requirement aid for Women affordable for the underprivileged sections. Speaking about the supply chain management under the PMBJP scheme, Shri Mandaviya said that the Ministry has been continuously fine-tuning the supply chain and monitoring it through an online tracking software to ensure uninterrupted supply of essential medicines on the PMBJP Kendras across the country. 19

MHM Product Choices Managing menstruation in a hygienic way involves not only access to basic sanitation facilities, soap and water but also to so-called menstrual absorbents. Every adolescent girl and woman should use menstrual absorbents based on informed choice. Indian adolescent girls and women use different menstrual absorbents, not all of which are ‘hygienic’, however no girl should face ridicule or shame in this situation. Rather efforts should be made to increase access to hygienic options. The choice and preference for an option depends on individual preference, price, availability in the local market and convenience Simple, clear and factually correct information helps girls to decide which menstrual absorbent to use, free from judgement by 69

MENSTRUAL ABSORBENTS: ADVANTAGES & DISADVANTAGES

Hygienic menstrual absorbents helps adolescent girls to manage menstruation effectively, safely and comfortably freedom from the fear of leakage or unpleasant odour increases a girlâ&#x20AC;&#x2122;s ability to be at school during menstruation. Girls cannot predict when menstruation will start, therefore schools should have a ready supply of sanitary napkins or clean cloths. Menstrual Absorbent: Natural materials (e.g. mud, cow dung, leaves)

HYGIENIC PRODUCTS MENSTRUAL ABSORBANT Locally made reusable napkins

Advantages: Free, locally available Disadvantages: High risk of contamination; negative health impact; difficult and uncomfortable to use; less absorbent

UNHYGIENIC PRODUCTS MENSTRUAL ABSORBANT

The table does not include tampons and menstrual cups, as they are not commonly available or used in rural India

DISADVANTAGES

Can be used for 6-12 cycles; more costeffective than disposable options; income generation opportunity; Environment-friendly as degrade on disposal

Not always absorbent enough or the correct shape; requires adequate laundering in a private space with a water supply and soap and a sun-lit place to dry and air the clothes.

Can be used for up to 12 Commercial reusable sanitary cycles; costeffective, yet more expensive napkins

ADVANTAGES

DISADVANTAGES

Newspapers, plastic bags, strips of sari, towel, bedsheets

Easily available, washable; reusable

Requires laundering in a private space with a water supply and soap and a sun-lit place to dry and air the cloths; odour risk if reused without adequate laundering; chafing if used while damp

Tissues, Toilet paper

Easily available in the local market; average absorption

Loses strength when wet and can fall apart; difficult to hold in place

Good absorption properties; easily available locally

Difficult to hold in place; an expensive commodity

Cotton wool

ADVANTAGES

than locally made; environment-friendly compared to disposable napkins; a high standard and hygienic product quality

Menstrual absorbent Commercial disposable sanitary napkins

Often available, except in remote locations; range of sizes and types available in some locations; Well-designed through research and development

Costs may be prohibitive to potential users; requires adequate laundering in a private space with a water supply and soap and a sun-lit place to dry and air the cloths; not widely available

Costs are prohibitive to many potential users; generate a lot of waste and not environmentfriendly; Need to assure proper disposal

Approximately 88% of women in India use homemade products (e.g., old cloth or rags) to manage their menstruation. The main reasons for using cloth-based product are: personal preference and familiarity, lack of access to or affordability for highquality commercial sanitary pads, and lack of sufficient information about pads. Some girls also use locally made cotton cloth. In a study of 164 adolescent girls in rural Gujarat, 68% said their first choice was a new soft cloth (falalin), while 32% said sanitary pads, and none of them preferred old cloths.21

Premium disposable sanitary pads have the biggest market share of any commercial product, with sales in 2015 worth INR 19 billion (~US$277M), growing at 15% per year.22 Currently, standard sanitary pads without wings have the biggest market share (57%) followed by ultra-thin pads (35%),23 which are growing at a faster rate given their appeal among Indian women and girls who wear western clothes. Three international brands occupy two- thirds of the market share: Procter and Gamble (P&G), Johnson & Johnson (J&J), and Kimberly-Clark (KCC). Smaller brands like Saathi, Sofy, Wonder Wings and newer entrants like Bella have leveraged the awareness created by established brands and have increased the competition by offering products at lower prices.24 The presence of low-cost unbranded products from manufacturers in China, Ukraine, and Malaysia is rapidly increasing.25

Eco Femme is a women-led social enterprise founded in 2010 based in Auroville, Tamil Nadu. Their goal is to create environmental and social change through revitalising menstrual practices that are healthy, environmentally sustainable, culturally responsive and empowering. They produce and sell washable cloth pads, provide menstrual health education and open dialogues on menstruation all along the way. Our not-for-profit outreach work Pad for Pad: menstrual health education and free pad gifting programmes to adolescent girls and Pads for Sisters: menstrual health education and process for introducing cloth pads to marginalised women. Cloth pads are discounted so as to be affordable.27

National and state governments are outsourcing low-cost pads from such sources and providing it free to girls in schools and communities; however, the availability of these pads as well as the quality varies significantly.

Organisations supporting MH-related Activities

Many organisations like Goonj are trying to make cheap, affordable sanitary napkins for women. Addressing the gaps and challenges of menstrual hygiene and management for the last women by engaging comprehensively with all key stakeholders. Breaking the culture of shame and silence around menstruation for the last women in rural and slum India and addressing their menstrual hygiene challenges. Motivating urban masses to contribute cloth for making â&#x20AC;&#x2DC;MY Padsâ&#x20AC;&#x2122; cloth sanitary pads for women who struggle even for this basic.26

Saral Design, founded by four IIT Bombay graduates, is one such company thatâ&#x20AC;&#x2122;s working on both affordability and the bottom line. Rather than go head-on against the big MNCs, they are tapping unserved areas of India where accessibility of pads is an issue. By using the ASHA workers in rural India, Saral is establishing a doorto-door sales network.28

Jayashree Industries is one of the early inventors of a low-cost disposable sanitary pad manufacturing machine in India. Today, these machines are sold to SHGs and NGOs across 27 states in India.29 This social enterprise has inspired several other innovators (e.g., Aakar Innovations).

Menstrupedia is a for-profit enterprise that has designed and developed a comic book on menstruation adapted to the local context to provide awareness and education on MHM to adolescent girls.

Supports the Ministry of Health and Family Welfare to develop a National Adolescent Health Strategy Rashtriya Kishor Swasthya Karyakram (RKSK), which includes clear guidelines for providing education, awareness, and support for better MHM. 30 Supports self-help groups to develop low-cost sanitary pads. 31

Supports the development of India’s national MHM Guidelines. Provides leadership training for stakeholders, policy makers, and decision makers on MHM. 32 WASH(water, sanitation and hygiene)in Schools33 which aims to increase the number of girls completing primary school and This involves partnering with the government to provide MHM entering secondary school, with MHM as a key strategyeducation, counselling in schools, 34 and installing sanitary pad vending machines. 35

Game-based MHM Curriculum, currently being piloted and tested in a few states with the goal of empowering girls to overcome the stigma around menstruation. 36,37,38 The game also engages boys as supporters and teachers so that they can be available for sustained guidance. Menstrual Hygiene Day39 Advocacy effort to elevate the issue of MHM within the development sector. • The Great WASH Yatra, 40,41 (Nirmal Bharat Yatra) a mobile carnival that engaged over 16,000people in schools and communities across 5 Indian states on sanitation, including MHM

Provides information about menstruation to women and girls and men and boys to address taboos. WaterAid • Adapts existing WASH services for MHM needs, i.e., ensuring space to wash menstrual cloth. 42 Provides access to MHM products (hygienic clothes or disposable sanitary pads). Rains key stakeholders (district-level health and frontline workers). Generating awareness about menstrual health and hygiene via workshops in rural areas. Distribution of 3 reusable sanitary pads for women which can be used up to a year and a half.

(Caption)

Secondary Research Discovery Education and Awareness - Girls received inadequate education on menstruation premenarche. Post-menarche, education programs focus on the biological aspects of puberty, with limited focus on psychosocial needs. Awareness programs are common, but are limited to product use, constrained by weak facilitators, and rarely target influencers. - There have been several government programmes to address these gaps in the human development indicators. But focus has been primarily on providing services (access) rather than understanding whether these services are utilized or not. For example as part of Sanitation campaigns (e.g. The Total Sanitation Campaign, Nirmal Bharat Abhiyan, Swachh Bharat Abhiyan etc) lakhs of toilets have been constructed improving access to sanitation, but open defecation remains a pervasive problem, especially in the rural parts of the district. - Cultural practices, hygiene routines, and community attitudes related to menstruation limit girls’ use of existing toilets, particularly during menstruation. Current national level efforts to improve sanitation do not prioritize MHM or influence relevant community norms. Disposal solutions for menstrual waste are largely unexplored. Current programming does not prioritize vulnerable populations.

Implementation - Implementation of existing policies remains a challenge due to limited capacity on the ground. - Limited human resource capacity: Although MHM programs leverage health workers (e.g., ASHAs, counsellors) and teachers to provide MHM education, their comfort in discussing sensitive topics, particularly when talking to boys, varies and the quality of

their training programs is inconsistent. Additionally, as noted in the Education and Awareness section, few adolescents and youth see health workers as a resource for such information. - Market barriers: The MHM Guidelines recommend increasing access to MHM products by outsourcing production and distribution of pads to self-help-groups. However, as noted in the Product section above, despite efforts to leverage SHGs, they have struggled to create awareness of sanitary pads and serve as a high volume platform for manufacturing pads. Measurement of impact of these programs is often limited to outputs. Although the MHM Guidelines suggest that effective MHM will ultimately result in an improved ability for adolescent girls to stay in school, there is little to no data collected to build this evidence. Currently, the Swachh Bharat Mission (SBM) reports only on progress of physical infrastructure, i.e., toilets constructed.43 Similarly, KPIs within the MHM Guidelines are limited to outputs such as “the percentage of state level orientations organized on MHM” or the percentage of schools with a separate functional toilet block for girls.”

Accessibilty - We also noted that government data collection (at district level) has primarily focused on program outlays and services (such as number of schools built, PHCs, toilets etc.), and less on the (quality of) outcomes such as student learning and retention, functioning of health services and utilization of health, sanitation and clean fuel facilities. The problem is particularly severe in the health sector. Despite a large network of trained health workers through the government sponsored programmes, there remains an acute dearth of detailed, population-based, anthropometric measures that are crucial in evaluating nutritional needs of the children. Another data related concern that needs attention is designing appropriate measures and studies that help both the researchers and the government in identifying the correlates/ determinants of health, education and livelihood based indicators. - Equity and inclusion issues are of significance in the sanitation

and hygiene sectors. Providing access to the different categories of people who are not able to access and use safe sanitation facilities shall be a priority of the implementing agencies. Issues relating to women’s personal hygiene namely menstrual hygiene are to be focussed under the SBM(G). Girls and women have hygiene and sanitation needs linked to their menstrual cycle. Women suffer in the absence of knowledge about safe practices on Menstrual Hygiene Management (MHM). - Keeping in view these issues, people need to know how government machinery is going to tackle and handle these issues. The state-level health statistics report provides no information on the extent to which staff positions are filled up in rural health centres of different districts—an information gap that needs to be addressed. One of the best way to know is just file an RTI (Right to Information) with the appropriate authority and access to information with-held by them. - The majority of women and girls in India use homemade products to manage their menstruation. Commercial pads are expensive for low income users, and low-cost pads vary in reach and quality.

Policy - The recent national MHM Guidelines area critical step towards a collaborative and integrated solution to MHM. Policymakers continue to functioning silos and need greater alignment, accountability, and strategies for implementing the guidelines at the state level. There are immediate opportunities to leverage the national momentum in India to improve menstrual health, particularly for adolescent girls. Priorities include strengthening the facilitator capacity to deliver awareness training, improving the reach and quality of low-cost pads, and improving targeting of influencers. Girls’ ability to manage their menstruation is influenced by broader gender inequities across India and can be hindered by the presence of discriminatory social norms. There may be opportunity to leverage MHM as a less sensitive entry point to address sexual and reproductive health topics, such as reproductive rights and teenage pregnancy prevention, and improve a girl’s empowerment at large, but research and

programming are still nascent. - Only a few national programs targeting MHM recommend holistic solutions, and in practice, solutions often remain siloed. RKSK is one of the only programs that prioritize the provision of sanitary pads and the provision of sustained support and information on menstruation through counsellors. However, as indicated in the Product Section above, information is often limited to instructions on product use. Similarly, the recent MHM Guidelines recommend the role of the Ministry of Drinking Water and Sanitation to include building sanitary infrastructure and conducting awareness programs to change community attitudes about accessing sanitation during menstruation. However, in practice, the emphasis of the Ministry to date has largely been on building toilets. - Ministries are encouraged to converge and work together according to the MHM Guidelines, however, ministries are still in the process of operationalizing the guidelines. MHM Guidelines mention the need for convergence across departments to improve MHM. However, the guidelines lack clarity on what convergence might look like in action, i.e., who specifically will coordinate or oversee the coordination across departments and levels. This is particularly important because various policies and programs across Ministries overlap in their goals. For example, RKSK and SABLA both prioritize creating awareness about MHM among adolescent girls; however, there is limited clarity on how a counsellor under RKSK’s Adolescent Friendly Health Clinics and an ASHA worker supported by SABLA may complement each other’s efforts.

.3 .I .II .III .IV .V .VI .VII

PRIMARY RESEARCH INTRODUCTION HOW : ASSOCIATING WITH SCHOOL WHO : STAKEHOLDERS WHAT : COMMUNITY MEETINGS WHERE : INTERACTIVE SPACES WHEN : DAILY ROUTINE PRIMARY RESEARCH DISCOVERY

I. INTRODUCTION

With reference to Virpura’s context there is a possibility of the community to wanting certain access, awareness and amenities towards change in their personal hygiene. Though the resources and amenities of Government policies and schemes have reached Virpura, yet there is lack of awareness and exposure to the existing knowledge and faculties’ provided by them. There is less involvement and participation from the Sakhi(s) and AG(s) towards utilising the awareness and facilities’. While Anganwadi and Sarpanch Sabhyas are coming up with providing newer amenities from Government in Virpura, yet the involvement of Sakhi(s) and AG(s) towards it is low. The need for primary research is to decipher some leads that can be translated into insights for designing strategic interventions to foster menstrual hygiene and sanitary practices at Virpura.

The Fundamental Approach: This approach was used to discover the primary research data which would help me blend into the village Virpura and thus, aid me to plan for the core purpose. It begins with understanding the Virpura village, its topography, accesses and Vas through a macro lens so as to see the village from an outsider’s view. The methodology adopted to accumulate data in this approach was through observations, photo documentations, listening to conversations

HOW : ASSOCIATING WITH THE SCHOOL This stage involved to gain access to individual houses through kids and to build trust within the children and hence, community.

WHO: STAKEHOLDERS This stage involved meeting the Anganwadi Teacher and the Ambuja Cement Foundation (Caretaker of Virpura) to know and understand who has invested resources in the evolution of this space and is it open for change. Also, the active stakeholders that would play vital role in the journey of this project.

WHAT : COMMUNITY MEETINGS This stage was to interact with the community, religious or SMVM meetings to know the level of awareness, the mind-set of the people and social/cultural context.

WHERE : INTERACTIVE SPACES This stage was to sense the physical space mapping. Finding about the spaces within the community that are communication friendly, activity friendly, not accessible, safe spaces for discussion etc.

WHEN : DAILY ROUTINE This stage was to figure out the daily routine of the people at Virpura, which would help in planning the times to visit when people could open up to me in the conversation.

(Caption)

.II

HOW

: ASSOCIATING WITH SCHOOL

This stage involved to gain access to individual houses through kids and to build trust within the children and hence, community. In the process of understanding a new place children act as the best ice-breaker. Hence, School was preferred by me to establish link with the community of Virpura. Building on past experiential learnings in SDM curriculum, through the module of understanding social behavior it was symbolic that establishing trust and credibility is important. Hence, visiting school as a facilitator to the students and as a research student to the Principal, School teacher and Anganwadi teacher was the way forward. The Principal, Mr. Ratilalji heads the Virpura Prathamikshala; which is a K-8 day school. In an informal conversation with him as a facilitator I understood his vision for the school and his enthusiasm for change-making. Building on this conversation, I got introduced to the School teachers, Anganwadi teacher, helpers and students after the school assembly as a facilitator to help them learn some new habits related to waste and hygiene. The welcome from the school was warm and accepting. With passing days I spent time with the school children right from the assembly hours till they began their classes. Due to these everyday interactions the students got familiarized with me, and thus, the trust was building. As planned the parents, specially the mothers had become aware that I come to Nisad to educate awareness to the kids. The girls were unaware of their puberty and things related to it. Younger kids were aware of their Vas and hence chose to not be in other Vas groups to interact .

HERE ARE SOME INITIAL FINDINGS :

1 2

3 4 5 6 7 8

Mid-day meals are provided to enrolled students under the scheme.

Anganwadi had moved from previous location in the village into the school which is supported by Government policies/programmes under health and hygiene on mediocre level.

Girls in their puberty werenâ&#x20AC;&#x2122;t aware of the basic terms like masik (menarche), personal hygiene and all the sanitary practices.

The mirroring abilities of the kids in the school was high.

The school assembly area is the largest covered area for other multi-purpose activities.

School students win Khelmahakumbh every year and at least one student of Virpura gets a rank in 10th.Hence, its an active school having emphasis on academic as well as non-academic activities for overall growth of the students.

Understanding of waste and hygiene was low, but they use toilets regularly in the school.

Gender and caste discrimination mildly existed within school. 79

.III

WHO

: STAKEHOLDERS

This stage involved meeting the Anganwadi Teacher and Ambuja Cement Foundation to know and understand who has invested resources in the evolution of this space and is it open for change. Also, the active stakeholders that would play vital role in the journey of this project. One of the essential parameter to proceed further is to identify the right stakeholders who would act as support system in later stages. The one day interactive session was a mix of different stakeholders coming together. This session was organised by Devikaben and me in collaboration to understand the evolution of Virpura in terms of things implemented so far. The interactive discussion was held at Devikaben's home around tea-time, which locates between Nayak and Senva Vas, though she is a Thakur. The attendees for the session were the Ambuja Cement Foundation CSR’s representatives, Sabhyas of the Panchayat In the discussion with them I came to know that toilets construction is now 100% under the Swachh Bharat Abhiyan from their perspective and the SMVM for micro-financing platform they set up is still running. Devikaben is the trained person to hold the monthly meetings. The trainings for Anganwadi and SMVM happen at ESI. Later, I deciphered from their conversation that their active role in Virpura was done and they come on CSR visit mostly once in 2 months for follow-ups. The Sarpanch of the Panchayat visits once in a month and the 2 Sabhyas of the Panchayat in the village reside in two different Vas – Thakur and Senva Vas. The other stakeholders highlighted to me were Kiran Nayak (pursuing B.Com) and her mother Kavitaben who had initially worked for an NGO in other part of Gujarat have settled down in the Nayak Vas. Few challenges that surfaced in the discussion are railway crossing timings (often referred as railway phatak), water supply shortage, primary health centre issues etc which was beyond their scope of work. goal to ignite the minds of many within a function, aware them and also lead towards then to derive new projects or challenges that can be solved.

HERE ARE SOME INITIAL FINDINGS :

1 2 3

Sanitation in terms of latrines is made possible for all. But data on usage is not yet collected.

SMVM monthly meetings occur on the 10th of the respective month but is also, flexible on availability of Sakhi(s).

Lead to enthusiastic AG(s) and a Sakhi from Nayak Vas was established.

The Sarpanch and his Sabhyas from the village are involved on regular basis about the activities occuring with the village.

Accessibility to PHC, SC or CHC wasn’t clear. Basic medicines and first aid kit was available at the Anganwadi.

Devikaben was a empowered woman who don't fear social pressure or patriarchal pressure since her husband and in-laws were in complete support of her work.

.IV

WHAT

: COMMUNITY MEETINGS

This stage was to interact with the community, religious or SMVM meetings to know the level of awareness, the mindset of the people and social/cultural context. This approach revolved around group interactions. After gaining trust from School and Devikaben I started visiting areas close to school and talking to groups of people in general about common places where people meet, what festivals they celebrate . Also, in this go along method few houses were sceptic of my presence. But once I opened up to them saying I visit school for research work their apprehensions vanished and they eased out. The common meeting places I discovered were Shiva Temple and Ramji Mandir where religious meeting happened. The area opposite Shiva temple where earlier Panchayat meetings occurred. The common chowk area in Thakur Vas where SMVM meetings happened. That's when I requested Devikaben to attend one of their SMVM meeting to just talk to women. On her acceptance, we met on the 10th of July at the common chowk area of Thakur Vas at 8pm in the night. The meeting was preceded by Devikaben with my introduction. Language wasn't a barrier since my mother tongue is Gujarati except for the dialect. But I was learning and so were they. The meeting was about collecting July monthâ&#x20AC;&#x2122;s saving amount from other Sakhis to deposit in the Dena Bank, Iyava. Once this was done I had a brief interaction with the Sakhis and the AG(s) from the school present there which majorly comprised of Thakur Vas community. The interaction involved helping them understand why I have come to Virpura, my purpose of exploring in the health and sanitation sector for women emancipation. The interaction then continued by asking what their names are and the things they like to do in the free time. Lastly before leaving I enquired about do they use toilets, any problems related to menstruation and the products they use. They were shy about it initially, nobody spoke anything but since a safe space was created initially they opened up one by one when Devikaben supported. They spoke about how health problems are rampant in this village. People have to travel several kilometers to reach hospital for treatment of patients. Several patients die on the way to hospital due to the phatak timings mentioned above.

HERE ARE SOME INITIAL FINDINGS :

1 2 3 4 5 6

Missing safe sharing spaces. Spaces for inter-Vas interaction were temples, Panchayat meetings and SMVM

Aspirations for health and hygiene werenâ&#x20AC;&#x2122;t put-forth vividly. Open defecation still exists, mostly by the older generation

The Sakhi(s) and AG(s) are not aware of menstrual hygiene thoroughly

The free time is generally 2-4pm and 8-9pm

They celebrate Navratri, Diwali on a large scale.

Swadhay Parivaar get-togethers take place bi-weekly in evenings for males mostly

(Caption)

WHERE

INTERACTIVE : SPACES

This stage was to sense the physical space mapping. Finding about the spaces within the community that are communication friendly, activity friendly, not accessible, safe spaces for discussion etc The space of Virpura has a vital role in achieving the purpose set for it. The communal atmosphere of any place is determined by the people who are living or working there. The physical space is a game-changer parameter, only for effectiveness and understanding to get established as well as engagement and participation to take place., There were few observations that I had made and informal conversations with people from various Vas were carried out to either get details about it or get it validated. These observations directly and indirectly affected their daily life such as interaction, satisfaction, and aspirations. The physical space is seen in separate elements like space, environment, infrastructure, sensations, communication, comfort etc. All these elements together build an environment where initiatives planned in future will collectively contribute and push people to be more accepting and open for participation. The space is widespread, loosely bounded and resonates openness just like the people of Virpura. It is important to understand the nuances within space and people to derive on certain hindrances that could possibly be deteriorating the certain aspects related communication, awareness, health, sanitation and hygiene. Though all these fundamentals interact together to create a space but elements in isolation have to be studied as well. With this reference point, the aim to find out various interaction spaces which exhibit unsaid feelings and emotions that collectively correspond to the atmosphere they are interacting with. At the same time through an unbiased interaction, one could understand the perspectives of the people with their limitations and constraints. It also allowed the me to share my observation with the residents to holistically understand them. The way forward was dependent on these interactions. The general observations made were- There were two shops selling groceries and vegetables - There were no common toilets in the village - The panchayat meeting space was tilled - Every Vas had a common interaction chowk - Construction of a big mandap in farmland opposite to the school-side.

On exhibiting these observations in a casual way with the people of different Vas a general understanding was derived on the spaces that are accessed and utilized for what reasons. In this method behavioural gestures were also picked up which would aid me in the journey during my methodology building.

HERE ARE SOME INITIAL FINDINGS :

1 2 3 4 5 6

Limited inter-Vas interactions- Shops are one the places were inter-Vas communication happens

Interactive spaces are under utilized, and communication happens within individual Vas

Open defecation is still practiced, in spite of toilets in the houses

Afternoon slots are get-together/personal space times for Sakhi(s)

Entire village comes together for weddings, festivals blurring the communal distinctions at the common areas

Dalits are treated as outcasts

DAILY ROUTINE .VI

WHEN

This stage was to figure out the daily routine of the people at Virpura, which would help in planning the times to visit when people could open up to me in the conversation. This approach aimed to open up opportunities for me to understand and build understanding with community, while being one among them and not separated from them. The thought is to become a participant in their daily activity. In this way, the people could carry on their chores and therefore, were able to spend more time with the me, which was the key to building trust. Meanwhile, I got a chance to closely observe the dwellersâ&#x20AC;&#x2122; lives in relation to the existing built environment. This gave a much clearer foresight of the effects of the potential intervention, on the lives of its people. I stayed in the community as well to find out their complete routine for initial understanding. â&#x20AC;&#x2DC;Daily Routineâ&#x20AC;&#x2122; is a mix of personal observations and informal conversations. Their usual day routine describes their functioning around the sun path. Taking cues from the activities the people perform, this technique revealed patterns of behaviour and their personal and public space access, communication channels and time management. Emerging patterns will be taken into consideration to plan further interaction or research. Daily Activities Activities refer to daily task like farming, animal husbandry, filling water or any rest/recreational activities in the afternoon, visiting temple etc. Interactions with people Visiting grocery shop, temples, hospitals, school, meetings Time Management Effective time management can allow me and the people of Virpura to contribute/participate in other activities that would be planned

HERE ARE SOME INITIAL FINDINGS :

1 2

Their day starts at 6 am since farming is easier in comparatively cooler climate

The free time for both genders is from 12-4 which is utilized for lunch, afternoon nap, personal hobbies or watching television because the temperature is at peak during this time

Women are more involved in vegetable farming, animal husbandry, working in factory nearby and cooking for the family

Evening times people spend time in temples, visiting groceries, buying milk from Thakurs.

(Caption)

PRIMARY RESEARCH DISCOVERY

INTERNAL

EXTERNAL

Communication level: - It was clearly evident that there is a communication gap between the Panchayat, Government agencies including information on schemes availability , the intent of implementation possible through collaboration and the understanding of the community towards the same intent.

The government had brought in a policy to ban the use of plastic bags in commercial establishments that aided in our process to curb the use of single use plastic bags and other materials in the village

.VII

Environmental: - Tying most of our conversations around waste and waste disposal came across multiple challenges that had to be dealt with before proceeding to the actual challenge on hand which is initiating a waste cycle system in the village. - The problem of waste also tied up with the prevailing open defecation by the villagers. - Conversations with the Sarpanch revealed that the waste cycle was held back as a measure by the panchayat to bring in compliance towards a no open defecation situation and ensuring that all households would have toilets built.

Logistics: - People want to always want an affordable choice inorder to live an easier comfortable life without compromising on the lifestyle. Taboos/stigmas: - The women of the village also shared situations and instances where poor menstrual practices surfaced - While trying to study the menstrual practices of the women, came to know that they carry limited or no knowledge about their own body and itâ&#x20AC;&#x2122;s bodily functions (especially with regards to reproduction and sexual health) Sustainability: -With regards to the involvement and contribution of the community in the whole process of redefining Virpura it was found that the more involved the youth and children were into disseminating information and bringing people together, the more effective and enthusiastic the contribution from the villagers were.

The government had launched biodegradable sanitary pads at an extremely affordable price which helped us plan the next steps to establish a proper channel of procurement and distribution along with setting up a dispensary in the village. There was a lack of self initiated involvement from the villagers as Virpura is a sub-village of Iyava due to which there were no panchayat meetings that were held in the village where a lot of the above mentioned issues could be spoken about and dealt with.

Bringing Sakhi(s) and AG(s) to common awareness across Virpura, thus developing common understanding and motivation.

5 .1 .2 .3

PHASE 02 DEFINE

INTRODUCTION PROBLEM STATEMENT GAP IDENTIFICATION

INTRODUCTION

For solving complex human associated problems, the define stage aims at identifying the right challenge or problem to come up with a unique solution. Many times, due to incorrect identification of the problem, we end up with solutions that are not easy to drag till the implementation stage. Identification leads to designing the right brief that justifies that the identified challenge/problem has a scope which can lead to ideas and systemic solutions. Identify is the first stage of the systemic process because framing the problem statement rightly and aligning it to the context will help take the project forward. Define phase will direct towards defining the problem statement based on the initial findings mapping. This will help to create a sense of direction for the project which will act towards inspiring people of Virpura them towards menstrual hygiene and sanitary practices. Through the defined problem statement the gaps between the aspirations of the Sakhi(s) and AG(s) about personal hygiene, their participation level until now and their idea of practice around hygiene and sanitation routinely will be identified. This will assist in developing the methodology to be used to make maximise the self-motivated participation of Sakhi(s) and AG(s). Define stage has a impact on cultural mind-sets and behaviours as well as the barriers that may hamper the process. It is presumed that generating awareness and practice around it requires an inimitable thought process and right direction for the facilitator, me, to contribute towards the upcoming initiatives effectively and ultimately accomplish the objective of the project

(Caption)

PROBLEM STATEMENT

Deriving the problem statement based on fundamental approach mentioned in the previous chapter, addressing the 5 W’s – who, what, where, when, and how would be apt. The first condition of solving a problem from the root-cause is understanding the problem in-depth, which can be done by way of a problem statement. A simple and well-defined problem statement will be used by the facilitator to understand the core problem and work towards developing a design solution. It will also provide specific insights into the problem through the methodology used so that appropriate designing decisions could be taken. As such, it is crucial for the problem statement to be clear and unambiguous.

Through this problem statement, a defined methodology could be developed to reach the root cause of the problem regarding menstrual hygiene and thus, a strategic intervention would be designed implemented.

Based on the initial brief, initial findings and gap identification; it was inferred that the Sakhi(s) and AG(s) weren’t even aware of the good sanitary practices, available MHM products and menstrual hygiene.

FINAL PROJECT BRIEF “To identify the factors and co-occurring issues for Sakhi(s) and AG(s) regarding sanitary practices and menstrual hygiene” 93

GAP IDENTIFICATION

DOMAIN

POOR MENSTRUAL HEALTH ASSOCIATED WITH

OVERVIEW

- Restricted mobility - Lack of agency - Lack of dignity / confidence

-Several studies measure restrictions through anecdotal reports; there is a need for more consistent use of empowerment measures. - Widespread anecdotal reports of restrictions and isolation placed upon girls at menarche and during menstruation. - Religious restrictions are most widespread, followed by restrictions from doing household work, sleeping on the routine bed, playing and talking to boys. - Anecdotal link between menarche and changing societal expectations for girls at puberty, like symbol of fertility, sexual readiness, marriage eligibility.

- Prioritization of girls' education. - Absenteeism in school. - School performance - Transition to secondary school.

-Studies show mixed results on relative contribution of MHM to school absenteeism. - Several anecdotal reports of girls missing school due to menstruation, but the link between MGM and girl's school absenteeism has not been confirmed with rigorous research studies, reasons for missing school varied - physical discomfort or pain, lack of facilities at school, fear of staining clothes etc. - Early evidence linking early age of menarche and marriage; evidence of norms where marriage and education are incompatible.

- Incidence of RTIs - Age of sexual debut - Weaker nutrition

-Few studies try to understand the impact of poor MHM and RTIs and UTIs or depression. - Few studies report girls having symptoms of RTI and UTI, particularly among cloth users. However the link between the two is not yet established. - Timing of menarche can be used as a proxy for population nutritional status and early marriage, but this indicator is not being captured to date. - Studies find that girls fear shock, fear, guilt, frustration, and depression at menarche and during menstruation, but the evidence is largely self-reported.

- Environmental hazard due to improper disposal.

-Few quantitative studies looking at India's environmental impact from MHM disposal. - Several studies report disposal habits of women and girls in India, which include throwing sanitary pads in the open, in water bodies, or mixed with other waste, and burial in the mud pit. - Anecdotal reports of drainage, clogging, and manual cleaning of sewage system.

- Work absenteeism

- Overlooked topic in research as focus has been on girls - Very few anecdotal reports of women missing work due to menstruation.

Empowerment

Education

Physical & Mental health

Environment

Economic

Source: FSG - Menstrual health India, Country landscape analysis

(Caption)

Lack of involvement in decision-making

Women and girls are often excluded from decision- making and management in development and emergency relief programmes. At the household level, they generally have little control over whether they have access to a private latrines or money to spend on sanitary materials. Even when gender inequalities are addressed, deeply embedded power relations and cultural taboos persist; most people, and men in particular, find menstrual hygiene a difficult subject to talk about. As a result of these issues, WASH interventions often fail to address the needs of women and girls.

Lack of information and awareness

Young girls often grow up with limited knowledge of menstruation because their mothers and other women shy away from discussing the issues with them. Adult women may themselves not be aware of the biological facts or good hygienic practices, instead passing on cultural taboos and restrictions to be observed. Men and boys typically know even less, but it is important for them to understand menstrual hygiene so they can support their wives, daughters, mothers, students, employees and peers. In the development sector, there is a lack of systematic studies analysing the impact of menstrual hygiene and resources for sharing best practice. This resource aims to address the latter.

Impact on education

Many schools do not support adolescent girls or female teachers in managing menstrual hygiene with dignity. Inadequate water and sanitation facilities make managing menstruation very difficult, and poor sanitary protection materials can result in blood stained clothes causing stress and embarrassment. Teachers (and male members of staff in particular) can be unaware of girlsâ&#x20AC;&#x2122; needs, in some cases refusing to let them visit the latrine. As a result, girls have been reported to miss school during their menstrual periods or even drop out completely. With studies linking child survival more closely to their motherâ&#x20AC;&#x2122;s education level than their poverty level, factors that reduce educational opportunities for girls potentially have wide ranging implications. Impact on health Menstruation is a natural process; however, if not properly managed it can result in health problems. Reports have suggested links between poor menstrual hygiene and urinary or reproductive tract infections and other illnesses. Further research and robust scientific evidence are needed in this area. The impact of poor menstrual hygiene on the psychosocial wellbeing of women and girls (eg stress levels, fear and embarrassment, and social exclusion during menstruation) should also be considered.

Impact on sustainability

Women and girls often find menstrual hygiene difficult due to a lack of access to appropriate sanitary protection products or facilities (eg a private space with a safe disposal method for used cloth or pads and a water supply for washing hands and sanitary materials).

Neglecting menstrual hygiene in WASH programmes could also have a negative effect on sustainability. Failing to provide disposal facilities for used sanitary pads or cloths can result in a significant solid waste issue, with latrines becoming blocked and pits filling quickly. Failure to provide appropriate menstrual hygiene facilities at home or school could prevent WASH services being used as intended.

Lack of social support

Additional challenges in emergencies

Lack of access to products and facilities

Taboos surrounding menstruation exclude women and girls from many aspects of social and cultural life as well as menstrual hygiene services. Such taboos include not being able to touch animals, water points, or food that others will eat, and exclusion from religious rituals, the family home and sanitation facilities. As a result, women and girls are often denied access to water and sanitation when they need it most.

Women and girls face particular challenges in emergency situations, where they may be forced to live in close proximity to male relatives or strangers. Their usual coping mechanisms for obtaining sanitary protection materials, bathing with privacy, and washing or disposing of menstrual materials are disturbed. In some cases, conflict restricts their movement and makes it difficult to collect water or find somewhere to manage menstruation safely and with dignity. With little or no money to buy soap and nonfood items such as buckets and bowls, it is impossible to maintain personal hygiene or wash and dry sanitary materials properly. 97

6 .1 .2 .3

PHASE 03 DEVELOP INTRODUCTION METHODOLOGY INSIGHT SYNTHESIS

INTRODUCTION

Stemming from the gaps identified and the problem statement defined it was required to reach the deeper layers of the issues identified. To overcome the fear that the Sakhi(s) or AG(s) carry of not knowing anything or being proved unaware, the aim was to develop interactive methodology which ultimately provides the root-cause to existing issue for lack of awareness regarding menstrual hygiene and sanitary practices. This methodology building will incorporate small behavioural adaptations and to make Sakhi(s) confident to believe in the purpose of the project. Through this methodology one can draw upon existing knowledge of a community, observations, surveys and own professional knowledge, in the design process. Design process that entailed back-and-forth interaction with communities to acquire insights and feedback to gauge the root-causes.

(Caption)

101

.2 .I .II .III

METHODOLOGY INTRODUCTION ACCESS AWARENESS

I. INTRODUCTION

Having the problem statement so private yet generic, a prerequisite was to maintain the sense of respect, dignity and integrity of people at Virpura through the in-depth result. Also, since the topic involved taboo induced with stigma around it comfort and confidentiality of each Sakhi and AG was a uncompromised priority. The methodological choice made was the blend between qualitative and quantitative data; as lot of intangible experience is involved which canâ&#x20AC;&#x2122;t be quantified. Qualitative data was formulated on the descriptions based on empathy, experience, non-verbal and verbal communication, while quantitative data was analysed in the form of numbers through surveys, space mapping etc.This project was carried out based on qualitative research method which used focussed discussion groups, semi-structured interviews with 30 women of Virpura Village in the Sanand District in the age group of 14-54 years.The participants included unmarried girls AG(s) in their early teens, married women till the age of 54 years.

AWARENESS 1. Approach: Discussing their levels of awareness through focussed questions 2 Research technique. Observations, Informal Focussed Conversations, Go-along method 3. Research type: Qualitative 4. Critical mass / sample size: Sakhi(s) of different/same Vas â&#x20AC;&#x201C; 7-8 APPREHENSIONS 1. Approach: Knowing their apprehensions, taboos, experiences at personal level 2 Research technique: Personal semi-structured interviews 3. Research type: Qualitative 4. Critical mass / sample size:. Around 30 Sakhi(s) and AG(s)

Interaction at Thakur vas

Three Stage Approach: ACCESS: Find out the accesses/habits that the Sakhi(s) and AG(s) have related to health, sanitation, and menstrual hygiene at personal, family and community level. AWARENESS Find out the levels of awareness that they have regarding the terms related to general health, sanitation and menstrual hygiene at self, government and country level. APPREHENSIONS Find out apprehensions, social stigma, personal experiences they carry related to their own health, sanitation and menstrual hygiene at personal level.

Research Methodology Stages ACCESS 1. Approach : Knowing their access points with their scope of the environment 2. Research technique: Observations and Metaphorical Survey 3. Research Type: Qualitative + Quantitative 4. Critical mass / Sample Size: Sakhi(s) of Each Vas (10-12) and AG(s) at school in 7/8th standard (12+10)

103

.I ACCESS

To find out the accesses/habits that the Sakhi(s) and AG(s) have related to health, sanitation, and menstrual hygiene at personal, family and community level an ice-breaking activity was required which was fun, interactive as well as focussed towards the purpose. Knowing the fact that many Sakhi(s) werenâ&#x20AC;&#x2122;t literate but educated I thought of creating a metaphorical survey which is pictorial. To witness different ways of seeing this method as a strategic move was used. Thus the survey, was formulated to know and understand their perceptions about certain pictures they observed and decipher. This activity of filling the metaphorical survey was carried out in the school as well as women in different Vas. Since I wasnâ&#x20AC;&#x2122;t yet completely familiarised face in the Village Devikaben acted as as a facilitator with me at school and Vasâ&#x20AC;&#x2122; to pull in more participation. The only precaution to provide support and warmth to people who could not read or write but were interested to participate. The average participants from each Vas were 10-12 and in school all the girls from 7th and 8th standard, which is about. The metaphorical survey is as follows:

Gaining accessibility to converse irrespective of so many men around

105

(Caption)

The form includes elements under three broad categories: Context- members in the family, count of girl child &/ boy child Health- PHC accessibility, vices consumption in the family Sanitation Practices - Open defecation/use of toilets, waste disposal methods Menstrual Hygiene – Awareness about Menstrual absorbent Findings through Access Stage As mentioned earlier, all these individual participants contributed collectively if someone could read/write to develop a positive vibe that was encouraging for the activity to be taken in the right spirit. After describing these individual elements in the given metaphorical survey, some valuable findings were quite evident that are not supporting the primary research was carried out. Health = Accessibility to PHC was ambiguous. - They contacted private hospitals which were expensive for their monthly expenses. - Few of them weren’t even aware of permanent doctor facilities available at Iyava, who came on rounds at Virpura once a week. - Level of Service was not provided by official doc Sanitation = Many women pointed others open defecation habits –i individually/family level or social groups they visit with - Few houses still have no toilets were discovered which contradicted the count provided by Ambuja cement foundation - No waste collection system exists hence waste disposal happens at bund, at the periphery of the village was disclosed for the first time. Burning of dry waste often happens at household in community level. - Harmful gases for health with plastic burning - Consumption of plastic bags as temporary storage device is high

QUANTITATIVE DATA

7 80% 10%

houses have no toilets

women use cloth

of AG(s) continued using menstrual absorbent provided by the school

Inorganic waste is dumped in backyard releasing toxic gases

Menstrual Hygiene - Most women use cloth (referred as time-piece) hence couldn’t recognise it - Some women knew it because their girl children at school received it - Stigma/Taboo/Discomfort still persisted to carry on the conversation around it 107

AWARENESS .II (Caption)

Once a sense of acceptance and involvement in their daily routine was established. Gathering them together for quick meetings through go-along method was easier. The other gap that was observed and identified-lack of awareness Hence, to find out the levels of awareness that they have regarding the terms related to general health, sanitation and menstrual hygiene in Virpura; focussed discussion group using go-along method was initiated. This stage was to also about gathering a sense of which Sakhi(s) are comfortable with camera being introduced for the first time, which eventually would lay would serve as a selection platform for personal interview. A informal focussed group discussion involved experience based qualitative research where questions were asked about their perceptions about specific terms, attitudes toward change, beliefs they have been following since their community, opinion or ideas. Every Sakhi(s) were free to talk with anyone present there including me; it encouraged discussions with other participants. It also, help to spot the motivated Sakhi(s) from each Vas who could help in future. It generally involved group interviewing in which a small group of 8 to 12 Sakhi(s) from same or different Vas were staying. It is led by a moderator (me) in a loosely structured discussion of various topics of interest like health, sanitation and menstrual hygiene.

Closing questions Do they talk about menarche to their daughters/granddaughters? Do you have any questions for me? Along with this, the other research methodology performed in the school with the children was to divide them into smaller groups and asked them to collect waste from surrounding/houses and segregate it according to wet waste/dry waste. This helped in sensitize the students about types of waste. The sanitary practice related to this which was carried out later was called the â&#x20AC;&#x153;kholo, khau,bhegu karo. On the counties of 1,2,and 3. The activity might not have stuck but even now when you ask any kid how to dispose the waste they say, kholo, khao, bhegu karo. From this activity the insights generated are mapped below. Findings through Awareness stage - Types of waste generated in Virpura - there is no existence of dustbins - Identification of the common dumping places - More consumption of tobacco near school premises due to presence of shop

Starting Questions: Who all have and use toilets? As we spoke of Pad/Cloth you use, would you wish to elaborate on it further? What is gila kachra/sukha kachra Background Questions How and where do you dispose your waste Why do you all use cloth? Where do you buy it from? What is the tradition of your community around menstrual practices Any social taboos observed and faced?

109

APPREHENSIONS .III

After this stage, relations with few Sakhi(s) was home like and it was a must to visit their house if I have visited Virpura. It had become a ritual eventually. When you fear something you carry apprehensions within you. This approach was dedicated towards get closer to the root-cause and identify the apprehensions towards self-awareness and hygiene because it started from self to society as compared to other gaps/methodology findings. Hence, building on that trust, in-order to find out apprehensions, social stigma, personal experiences they carry related to their own health, sanitation and menstrual hygiene through semi-structured personal interviews were carried out. At previous stages, the reflections were more seeming and observable. The intent of personal interviews was to focus on deriving specific insights that are veiled beneath the social behaviour and their attitude towards the self. Virpura has a diverse group, hence identifying certain behavioural aspects would help deriving cohesive responses. The objective of this research method is to understand the mindset of the actual and understand how they perform their daily tasks and understand the need for innovation. People have personal meanings attached they have attached to health and hygiene which is reflected in their daily activities and dialogue, hence it is necessary to decipher their meaning and how they see it. The objective of this is to uncover the lacking and personal barriers that exist in Virpura. Being a village of 850 people, there was a constraint to personally interview everyone. The methodology adopted in the scenario was to identify people who are understand the context of the earlier methodologies well and could communicate with comfort on the stigma surrounded topic. So the thought was to identify through filtration of following categories (1) early post-menarche 0 to 1 year post-menarche, (2) post-menarche 1 to 3 years post-menarche, and (3) late post-menarche 3+ years post-menarche up to 18 years old. Interviews were also conducted with 8 influencers including mothers, teachers. Community health worker Binal belong to ASHA wasnâ&#x20AC;&#x2122;t available during the entire project timeline.

built was strong hence, the Sakhi(s) and AG(s) were to be more candid during interview session was presumed and would be willing to speak in depth and reveal common patterns which are acting as barriers.

The Questions for interviews were: - Your experience of first period - Who told you about menarche and when ? - What do you use ? - Where do you buy it from ? - What is the cost of it ? - What is menstruation ? - How does it happen ? - Your perspective on hygiene around it - Taboos faced - Disposal of the absorbent (fabric) - Any awareness about Govt policies/schemes in the village like SUVIDHA? - Would you participate in cloth pad making workshop? - Any sex education in the school happened?

Based on filtrations across the different Vas, Sakhi(s) and AG(s) were interviewed after having an informal conversation. The bond 111

Interviews 113

BHUMI 14 years old, lives Senva Vas. Bhumi does not like going to school on the days she menstruates because she feels uncomfortable to use restroom in the school toilet because the cloth moves. More importantly She is frustrated at the fundamental shifts occurring in her life: “I wish it (menstruation) would not happen to me. Since I got my period, my mother told me I cannot play outside, I should come home straight from school, I should not sleep next to my brother, and I should behave like a grown up.” She has no knowledge about why menstruation happens and when she asked her mother she avoided by saying its body heat.

“I wish it (menstruation) would not happen to me. Since I got my period, my mother told me I cannot play outside, I should come home straight from school, I should not sleep next to my brother, and I should behave like a grown up.” 115

MANISHA 17 years old, lives with her parents and younger brothers in Thakur Vas. She got her first period in school 6 months back. Every morning, she wakes up at 6 am and helps her mother fill water from the village water hose, cook, and clean before she goes to school. Like her mother, Manisha uses cloth to manage her menstruation. She disposes of her used menstrual cloth in the field, where she goes to defecate, and then, walks back home to wash and clean herself. Following her motherâ&#x20AC;&#x2122;s advice, Asha stays at home on the days she is menstruating, but her mother tells her brother and her father that she is unwell and she cannot cook. By which they understand she is in her periods. She has no awareness about her menstrual body parts, process of menstruation, products to use or menstrual hygiene.

She has no awareness about her menstrual body parts, process of menstruation, products to use or menstrual hygiene. 117

KIRAN 19 years old, lives Nayak Vas and is aware that menstruation is linked to a woman’s ability to have children—she learned that in her school’s biology class. She got her first period when she was at school and her mother had gone to her maternal house. So her friends mother taught her how to use the pad and menstrual hygiene around it. She herself buys the sanitary pads from the market every month . Even if she does not have a pad, she is not worried. She knew her college provides her free pads provided by the State Government. Although she dislikes the free pads because of their poor quality, she knows they are useful in an emergency. But the whisper pads are expensive and they do rash at times. She plays sports in college even when she has her periods.

“Why shouldn’t I?” she asks. That said, Kiran does face isolation at home during menstruation if her grandmother is visiting them. She asks her to sleep separately. She says, “Yes, sometimes I feel like I am in a jail, and in pain but other times I am happy that I have to do less house chores.”. Though she knew menstruation is linked to getting married easily and bearing children she didn't understand the menstruation process taught back then in biology class. Also, she doesn't have sex education in the school. 119

ASHA 21 years old, lives in Prajapati vas. she was trained by her mother to use timepiece for periods and she is awrew about the stayfree sanitary napkins but could dare yet to use it because of stigma around. On asking why menstruation happens she answered,"It happens to all so happens to me as well I use two folded cloth each day of period and reuse it until 3-4 months and then throw it away after wash near the bund in a plastic bag."

"It happens to all so happens to me as well I use two folded cloth each day of period and reuse it until 3-4 months and then throw it away after wash near the bund in a plastic bag." 121

KANAK 25 years old, lives behind the school and is aware that menstruation is linked to a woman’s ability to get married. She got her first period when she was at home and at the age of 15 years. Kanak uses cloth to manage her menstruation since 10 years now. She buries her used menstrual cloth in the field. She has toilet at her home so doesn't face issue related to open defecation during periods. The cost of the cloth(timepiece) she purchases is INR 15 from the visiting vendor who is male and voiced her uncomfort in purchasing from him. Her mother taught her how to use cloth .She always asked “Why can’t I cook, pray or serve the food during menstruation?” The only answer she received was, “This is how it is an this is how it would be.”. She elaborated that earlier her period cycle was of 12 days and she used to get worried and .feared telling her mother. Later things fell in place on its own She is aware of her body parts but not the process of menstruation nor complete sanitary practices during that time.

She now knows about sanitary napkins through TV ads but never bought it thinking it's too higher aspiration for a family she belongs to. 123

PADMA ben 31 years old, stays in Thakur Vas. Since she had discussed about whisper pads in one of their Mahila meetings. She has educated her daughter for the same. â&#x20AC;? Its is the story of self growth is what i have taught my daughter just like school training that happened at Iyava once." She bund is closest to my house ease of throwing it into the paper is possible. I can't enter my brinjal farms during my periods nor do i cook my mother law does both the things.I feel supported."

I can't enter my brinjal farms during my periods nor do i cook my mother law does both the things.I feel supported." 125

SHILPA ben 34 years old, stays in Chunara Vas. Since cotton was worshipped in our community I never used cloth or sanitary napkin but rags of cloth stitched on panty and later wash it for my masik. Earlier her mother used to make it for her then she learnt it and now my children use the same.”The day I got my period everyone in the community celebrated and fed me lapsi. I was shocked with what is happening to my body and here the entire community was celebrating.It was a different experience”. After which when she asked why everybody celebrated when she was in pain, the only answer she received was by her mother , ” Its is the story of fertility you will know once you become a mother”. Her menstrual days last for 3 days and hence she is happy the way it is. She doesn’t want to now also know why menstruation happens but is ok if her children want to. Also, her daughter is a drop-out from the school because of the same reason.

”The day I got my period everyone in the community celebrated and fed me lapsi. I was shocked with what is happening to my body and here the entire community was celebrating. It was a different experience” 127

DEVIKA ben 36 years old, mother of two sons stays in belongs to Thakur but stays between Chunara and Nayak Vas. She is the Anganwadi teacher and a Mahila mandal leader. She is aware of ASHA workers, government scheme SABLA. She has taken Kishoris(AG(s)) to iyava for some training program on menstrual health. She herself uses whisper extra long pads because she is aware of her heavy flow. “I find it very expensive but I can't do cloth because I can’t bear the smell nor the wetness it gives me in the cloth. I do get rashes but what to do”. She was taught by her mother about menstruation and how to use the pad and followed the social taboos. "Now being the only women in the house I don't care about menstruation related taboos but feed by family well by cooking also on those days. If I had a daughter now I would teach her what I have learnt. At times girls who come to me asking for free pads from Government I have no answer because they stopped coming after first month of distribution by ASHA worker a year back. ASHA worker stopped coming

and would send her sahayak Chandrikaben to survey and send some other reading materials."

:...At times girls who come to me asking for free pads from Government I have no answer because they stopped coming after first month of distribution by ASHA worker a year back. ASHA worker stopped coming.." 129

SITA ben 40 years old, is a grandmother to the eldest daughters grandchild.She used to use nothing because she had just two day period and less flow so her panties would just suffice.But she talked about her second daughter ans her pain during periods who uses a cloth.I had referred to my menarche as blood potty in adulthood" and then her mother told her that its called masik and happens every month." She had agreed for pad making workshop due to her free schedule for whole day since only the carpenter husban earns for the family and also, she was constructing new toilet for her extended family.

"I had referred to my menarche as bloody potty in adulthood" 131

KAILASH ben 50 years old, staying in the Senva Vas. She doesnâ&#x20AC;&#x2122;t remember her first period but on pestering she opened up. She said he got her period when she was 15 years old, and â&#x20AC;&#x153;the moment i got my period I ran to the water tank of my house and sat there for hours and cried in pain. I thought I was hurt under while playing.â&#x20AC;?Later her mother told me that it is called masik" and she would get it henceforth every month and she has to do nothing but wear 2 ghagras during that time. Since that time she never asked anything and still carries fear of blood.

"the moment i got my period I ran to the water tank of my house and sat there for hours and cried in pain. I thought I was hurt under while playing" 133

Findings

The stories illustrate womens’ diverse experiences with menstruation across Virpura, within Vas, and between exposure to urban areas and age groups. Sakhi(s) and AG(s) face common problems with menstruation and MHM such as poor awareness about menstruation, limited access to MHM products, or poor sanitation. Challenges related to menstruation may also be reflective of broader issues of poor economic stature and limited resources. However, despite variations in level of income and education, girls’ experiences with menarche, menstruation and MHM do signal more fundamental issues of lack of awareness, gender inequality and discriminatory social norms at play. The experience of menstruation is even more challenging for vulnerable menstruating girls—i.e., out-of-school girls, girls with physical or mental disabilities. Health - Emergency ambulance couldn’t come in leading to death in the family. - Tubectomy was done due to lack of awareness about reproduction cycle - Accessibility to gynaecologist is remote for period pain and excessive loss of blood = Monthly health check-up and vaccinations happen at the school for children and critical community members through Anganwadi

- Disposable pads are considered “aspirational” by girls and tend to symbolize mobility and freedom from worry. - Cotton is worshipped as Goddess hence, sanitary napkin is a bane to the Chunara community so the AG(s) have been using rags of old cloth stitched to panties because of beliefs and traditions. - Most AG(s) are aware of new MHM products like sanitary napkins but don’t know how to use them. - No cooking, working in farm, praying and sitting on khatiya when menstruating - Some bury menstrual waste, some burn it and some reuse it - Grandmothers never wore anything while menstruating hence, suggest similar things to their granddaughters - No awareness about government scheme/ biodegradable sanitary pads named “SUVIDHA” was known - Only ladies of Senva Vas were enthusiast to become a part of cloth pad making team. = Anganwadi provides support and understanding of women body and menstruation but nobody is aware = Another barrier is the access to sanitary napkins, for various reasons, including the high price of pads manufactured by large FMCG. There is also the issue of the lack of availability of sanitary napkins in vicinity.

Sanitation = Open defecation is used by our older generation due to claustro phobia ness in the bathroom = Few houses can’t access toilets belonging to same familycommunity but living separately - No waste collection vendor is ready to collect waste due to dump yard space is closed under the legal notice - Consumption of plastic bags is top down and bottom up Menstrual Hygiene - No awareness about genitals, since mothers were drop-outs of 7th/ 8th standard or they themselves are. - Awareness about process of menstruation, menstrual practises and reproduction cycle is really low - Their menstrual cloth makes them feel wet and sweaty all-time. = = They feel uncomfortable washing the cloth absorbed with blood and smell it holds. 135

.III INSIGHT SYNTHESIS

Based on the different research techniques, the major findings have clarified the current cultural/social challenges and awareness lacking within Virpura. These findings collectively define how a woman is functioning with hidden hindrances which act as larger barriers in the process of awareness and hygiene. Small or big, such barriers have transformed the mindset of the Sakhi(s) and AG(s) to adjust or be blinded. Because society, Government on the large tends to overlook such trivial issues that are situated in the deeper layers of human culture, the policies and schemes seems not to be adding any value. This results in disparity rather than uncertainty to break-through some radical change. While findings are just the foundation, the next step is to locate the inferences onto the system and derive insights that can lead to some solutions that can attempt at an eradication or minimisation of such barriers so as to bringing awareness and practices into the system. Hence, the first step is to categorize the findings among four major headings : Individuals, Mindset, Society and Practice. Mapping findings under respective categories we dig out the deeper issues that are cumulate into bigger ones. The insights are derived based deeper level of findings. The next phase is denoted by insight synthesis. It can also be referred to as breakthrough change. In this phase, the focus shifts from improvement to strategic change. Gaining new understanding from the gaps identified from the research phase and findings from in-depth research are the aspects on which key insights build up. Strategic design intervention emerges from insights that are powerful enough to be translated into process or system set up. It aims at using the logical shift to sweep into the community to build a culture/habit. After pooling all the findings the insights are categorised, thus to pull out key insights to start designing the system solutions. Need a platform for Community voices(Norms, beliefs, traditions) : Individually everybody has similar problems and issues, but nobody knows where to voice them so that they could be addressed. Hence, need for a platform for channeling the needs of the community is required.

Community attitudes and perceptions about menstruation and the availability of disposal infrastructure influences how women and girls dispose their menstruate waste. Hence,there are environmental concerns about the increasing share of disposable sanitary pads.Even when toilets are available, cultural practices and hygiene routines as well as community attitudes related to menstruation limit the use of existing toilets, particularly during menstruation.

Need to educate through awareness and knowledge (of menstruation, products and their use) : Knowledge and awareness about the right practices, thinking is missing which leads to creation of new community practices which act as vice to the human body. Hence, address from the grass-root level which is physiological, biological and ecological is the basic need for community.Girls do not consistently have access to education on puberty and menstrual health because it is not mandated by the Government.The majority of girls in India lack of awareness about menstruation before menarche Disposable pads are considered â&#x20AC;&#x153;aspirationalâ&#x20AC;? by girls and tend to symbolize mobility and freedom from worry. The momentum menstrual health has gained in India over the past decade has been led in part by the growth in the MHM product market. However, current efforts to improve MHM are missing opportunities to address menstrual health more holistically. Need for affordable accessibility(economic, practical and comfortable): Girls do not have consistent access to preferred, high-quality MHM products. Women and girls lack access to appropriate sanitation facilities. Last-mile distribution of sanitary pads, including both premium and low-cost, remains a challenge across India. Implementation of existing policies remains a challenge due to limited capacity on the ground. Lack of adequate sanitation disproportionately affects women. Limited access to functioning toilets remains a barrier and disproportionately impacts menstruating girls and women. Although the national MHM Guidelines identify responsibilities of various ministries, there is lack of clear direction on how to operationalize convergence, i.e., coordination on the ground. Government programs present significant opportunity for scale, but lack human resources capacity. There is limited private sector encouragement to improve 137

access to products, sanitation, or awareness. No alternative access to easy, comfortable and affordable tools Need for Mind-set level change (Habits, lifestyle, customs derived from): Most adolescent girls in India rely heavily on their female influencers, particularly mothers for information on menstruation. However, mothers do not know or feel comfortable discussing menstruation; their advice is often limited to period management and tends to reinforce negative beliefs. The identified gaps and findings have a possibility to be converted into unique insights that are important enough to give shape and direction to the identified problem. The journey of research to coming up with insights is entitled as insights because the end deliverable to go to the next stage is decided by the quality of insights the user has arrived at.Menstruation is closely linked to reproductive health, and therefore considered a taboo subject in India along with sex-education. Need for sustainable system (Robust, dynamic and alternative): A self-sustaining process based system which helps the community to engage into without dependencies needs to exist. This system would be developed along with local knowledge into consideration and through involvement of community.With this vision implementation is much more owned and belonged based, hence chances of sustainability would higher.

Existing resources that Roopa isn’t aware of

Roopa Before Interventions why am i not able to talk to anyone about my monthly bleeding sessions ! it hurts and i don’t even know why this happens to me.

Anganwadi and school

Government agencies

Panchayat support it’s so dark here

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7 .1 .2 .3 .4

PHASE 04 DESIGN

INTRODUCTION IDEATION STRATEGIC DESIGN INTERVENTIONS SYSTEM PROTOTYPING 141

INTRODUCTION

As we know there is a huge gap between the policies/ schemes started from Government to support Women and Child development, not enough support is present on-ground to support these initiatives/programmes. To make people value these schemes like the SABLA, it is extremely important to create an supporting environment where doesn't provide involvement and awareness. Seeing at parameters like people, community, space, time, aspirations and shared values it is clear that shared culture is a common thread tying all of all them together. A culture of awareness and practice can only be achieved once all these elements work in a harmonisation. Creating awareness tackles all the gaps in the systems which reduce the ability of practicing the same awareness. Mapping the root-cause to their effects helped derive clarity in the big picture which is the addressing the most fundamental problems that require immediate attention. Based on collective insights in each category ideation phase will help to design strategic solutions in this chapter. The outlined ideation will help minimize the challenges faced by the community of Virpura holistically to work towards the purpose of the project.

143

IDEATION

Once the challenge is scoped and insights are derived, the next step is to transform insights into ideas. Ideation is the core element of any process. The importance of ideas is such that the more creative and empathetic they are the narrative and new the solution outcome would be. The ideate phase is hence a requirement for Virpura to think beyond communal ideas and evolve to a point where ideas are cultural and implementable in give contect. Because ideation leads to the type of culture we need to achieve, hence it is the most important stage of the process of the system. Researching and implementing methodology confirmed my perception: to inspire people to change their behaviour, you cannot blame or shame them for what they believe or what they have done in the past. Instead, you have to give people a way to move away from their opinion, or their apathy, to an awareness of information that is new or was previously rejected. You then give them small steps to take to move from awareness to action. If you use this approach to motivating behaviour change, people tend to adopt a new frame of mind because they do not feel judged when they are informed about a new alternative. This awarenessraising approach enables people to act in their own self-interest and in the interest of others without triggering their defensiveness. These field-tested insights are one reason why the principles and practices work. They reflect an appreciation of how to lower resistance to change. The solution to overcoming these gaps is driven with an aim to bind all community members who are inclined to achieve change and awareness within their daily life. One must come up onto a common platform wherein there can learn, share and collaborate through their individual knowledge, expertise and skills for solving some daily issues with the Panchayat and other community members. These solutions will, directly and indirectly, address all the gaps and unite all the people of Virpura at all social levels within a interconnected understanding of what to achieve. These solutions will align with the expectations/aspirations of the villagers and they with Panchayat re-define their roles and responsibilities so as to see an impact within Virpura.

Intervention Ideation Process Process 1: Encourage effective communication and support platforms - As issues exist is in the silos within Virpura, it is important for people of to come forward and communicate in a way that encourages effective solutions through idea sharing, collective implementation etc. Here a process of setting discussion platform for community started to finding solutions for various issues. Process 2: Develop a culture of Awareness and sharing knowledge - Derived from the key-insights, it is clear that the first step towards empowering Sakhi(s) and AG(s) is to develop a culture of awareness from bottom up level where the they can open to accepting information and thus, sharing ideas and knowledge to others. Here started the idea of “Mari Sakhi” workshops. Process 3: Building a tool for creating awareness about hygienic practices - From experiences I have learnt that if a system has to be robust all three phases should be present awareness, practice and then sustenance. This process to dedicated towards building a tool which Sakhi(s) and AG(s) explore, involve in their daily life and thus adapt to the new provided awareness and change. This tool is ‘Suvidha’ biodegradable pads. Process 4: Training for creating awareness and sustenance Learning is an ongoing process, only training Sakhi(s) and AG(s) wouldn’t lead to stronger impact. Participation is low due to lack of resources or necessary things needed to function which lead to visible outcomes. There is a need for a system/process that will sustain the awareness, learning and allow scope of changemaking in the lives of people of Virpura. The idea of setting up dispensary/cloth pad making workshop started.

145

Oh itâ&#x20AC;&#x2122;s not plugged in !

147

STRATEGIC DESIGN INTERVENTIONS

Process 1: Encourage effective communication and support platforms The purpose of designing such a platform that acts a common link between all the stakeholders is to ultimately see the effect of community building. This process must lead to see the visible impact of awareness and collaboration in people from different Vas by a shift of thinking process to solve issues or challenges related to daily life. Once we achieve the purpose of this process, the villagers within the Virpura will develop faith towards changemaking through new thinking patterns and would be willing to engage/participate further. In was hour of the need that the people of Virpura, come together and voice their needs and requirements so as to move towards solution forming and People being as open in space was as open to change-making. To achieve some spatial, policy or scheme level changes involvement of all stakeholders at same time would be required for collaboration and quick solution finding. The aim is ultimately to bring all of them together, create an open dialog to discuss village issues, scale and priority, solutions, timeline and distribution of responsibility. Also, helping women to group and represent their concerns through representatives or voicing it by self.

Design: Using School as the neutral space, a community meeting had to be organised to flag community issues which were raised individually by most of them. Hence a meeting with the respective stakeholders involved would not only benefit the process of channelizing issues but also in finding solutions with collaborative efforts. Stakeholders involved: Sarpanch Head, Panchayat Sabhyas, Ambuja Cement Foundation CSR representatives, School Principal Based on all the insights, thoughts and purpose to achieve the designing of the â&#x20AC;&#x153;Community Meetingâ&#x20AC;? was designed as follows. It was planned to be done once in three months with all stakeholders present along with the community. The first meeting would be facilitated by me and the sustainability would be with handed over to the Sabhyaâ&#x20AC;&#x2122;s of Virpura. As a facilitator, the points that have come from individual houses related to toilets, railway crossing line and water supply issues would be discussed to get a better clarity on each topic individually Activity to keep people engaged while waiting for all members to come would be procuring buttermilk from all houses and distribute it to the all the members when they come or thirsty along with mapping their houses, so as to know how many participants participated.

Thought: This intervention is designed to build the process of developing strategic solutions collaboratively taking into consideration the various insights gathered, gaps discovered, opportunities perceived, to make lives of the people of the Virpura community challenge free. The core of this solution will be to voice out challenges faced in the daily life which get highlighted and address collectively to get a wholesome perspective and thus, leading to solution finding. This solution will solve the negativity, transparency and miscommunication that is present from different levels so as to achieve complete understanding of the real problem. This solution is designed to specifically to balance out all the stakeholders to understand and build a better community space to dwell in

Experiential Takeaway: The core experiences that the participants would get 1. Involvement in solution finding and decision making would be transparent, less time taking and real time 2. Confidence in what they feel and can express their voice since its an open discussion 3. Motivation that things will go somewhere and come back in positive ways 4. Make people of Virpura empowered to believe in change making and aware of the systemic levels of operations with respect to Government practices

149

Process 2: Develop a culture of Awareness and sharing knowledge through Mari Sakhi workshops in the School Virpura being as open in space was as open to changemaking. To achieve a radical paradigm, shift in thoughts to create empowering, comfortable and, system based model for implementation, complete support from school and Anganwadi teacher would be required.

Thought: This strategic intervention is designed taking into consideration the various insights gathered, gaps discovered, opportunities perceived, to make Sakhi(s) AG(s) more aware of menstrual hygiene and sanitary practices and its core value in daily life. The core of this solution will be to sensitize and create awareness among Sakhi(s) and AG(S) who will later seek interest in working on these initiatives to build a culture that will be progressing in the future. This solution will solve the taboos and stigma from different levels so as to achieve awareness cumulatively. This solution is designed to specifically to strike out all the barriers taboos/stigmas/ stereotypes/myths from within the minds of an individual around menstrual hygiene and sanitary practices.

Design: With School being the learning and change-making in the lives of children extended their support for Sakhi and AG growth and learning as well. The larger aim is to achieve a radical change in the Virpura community, but for that, the active Sakhi(s) and AG(s) have to be involved completely by collectively efforts of the Sarpanch, School Principal, Anganwadi Teacher, youth leaders from AG(s). These people must impart the enthusiasm to implement progressive ideas and spread awareness by encouraging and supporting initiatives, activities, processes, systems and policies that drive the awareness and build a culture encouraging and supporting initiatives, activities, processes, systems and policies that drive the awareness and build a culture that is continuously growing. In-order to start this workshop,

approval from School Principal was required. Sarpanch was to be kept in the loop for any financial requirement . Along with that it was important to know which policies, schemes had reached the Anganwadi related to Sakhi(s) and AG(s). Based on this a workshop had to be developed which will be facilitated to build a platform to discuss about menstruation and health in Anganwadi with young girls expecting puberty and Sakhi(s) of all ages with the aim of all coming together for the betterment of their self, family and community health, sanitation and hygiene. The next was to plan the content for the workshop. With the purpose to achieve above mentioned topics to discuss designing of the “Mari Sakhi” was as follows. Stakeholders involved: Sarpanch , School Principal, Anganwadi Teacher, AG(s) youth representative and community Sakhi(s) and AG(s) Process - It was planned to be done on the every 1st week of the month during afternoon time of 3-4pm - The first meeting would be facilitated by Devikaben, Kiran & me. - The use of SABLA pothi would be used for references - Awareness in terms of – what is menarche, menstruation with help of diagrams, menstrual cycle, reproduction cycle and lastly, practices to follow during that time. - The support of the movie “Story of Menstruation” by Disney,1946 would be shown to all the participants during this explanation for better understanding. - Lastly a small activity of “kharu ke khatu” will happen which is based on stereotypes/myth breaking - Questions and feedback

Experiential Takeaway: The core experiences that the Sakhi(s) and AG(s) would take back are 1. Culture of awareness will be initiated which will work towards bringing in acceptance to change in mental, emotional, physical and behavioural level 2. A visual memory guide would be presented to know about their own body and thus, later they could narrate it to their families, children or others Sakhi(s) or AG(s) for inspiring 3. A support group would be formed to discuss further over and after workshop would be formed for regular discussions etc 151

Process 3: Building a tool for creating awareness about hygienic practices Now that the Sakhi(s) and AG(s) are aware of the process of menstruation and hygiene how would they start changing or practicing. Hence to keep the system robust there was a need for generating a habit/practice that they could engage in their daily life to adapt to change with the world moving. Hence with the announcement of Suvidha scheme in march, and oxobiodegradable pads getting dispensed into the market from 25th May it is a good time to implement the government scheme in Virpura. *This menstrual absorbent was tried by me personally for two months before ideating on this idea. The rejection for reusable cloth pad was due to the discomfort around washing pads which most women felt including me.

Thought: . This strategic intervention is designed taking into consideration the parameters like human behaviour related to habit forming. . The insights gathered, schemes that can be executed and ease in implementation to make Sakhi(s) AG(s) to participate and practice with hygiene in their daily life. . The core of this solution will be to adapt and develop an awareness and inculcate a practice among Sakhi(s) and AG(S) about alternative menstrual absorbents. . The people will later seek interest in working on these initiatives to build a culture that will progress into a sustainable future. solution . This solution will solve the hesitation from different levels to achieve implementation towards awareness. It is designed to specifically to strike out all the challenges related to anxiety/myths from within the minds and bodies of an individual around menstrual hygiene and sanitary practices. Also, this dispensary would be launched in the first â&#x20AC;&#x153;Mari Sakhiâ&#x20AC;? workshop.

Design: Suvidha dispensary is a way of making the Sakhi(s) and AG(s) feel empowered by the 3A approach i.e, access, awareness

and affordability. The larger aim is to achieve a radical change into their lifestyle with new habit forming. In order to achieve this implementation within the Virpura community, the Sakhi(s) and AG(s) have to be involved completely by collectively efforts of the Sarpanch, School Principal, Anganwadi Teacher, youth leaders from AG(s) and the Government scheme functionality. These people must impart the enthusiasm to implement progressive ideas and spread awareness by encouraging and supporting this initiative/process and scheme with the system laid out and that drives the change-making. In-order to start this workshop, approval from Anganwadi space was required. A tie-up with one of the Bhartiya Janaushadhi Pariyojana store had to be established. Sarpanch was to be kept in the loop for financial requirement. Along with that it was important to know how the sanitary napkins affect the lives of the people Based on research, insights and my bond with them there was a fair idea that this dispensary should pick up in the village because of the 3A approach which is easy access, cheap affordability and complete awareness about it. Information to be dispensed as a form of awareness would be: - Hygienic practices during menstruation - Carry on all the normal activities of the day. - Keep the area around the genitals clean. - Bathe every day without fail. - After excretion clean yourself from front to the back. Do not clean in the reverse direction, as that may give infections. - Wear clean under clothes. - Wear cotton cloth/pad/sanitary napkins. - Whenever the sanitary pad/cloth become wet and feels uncomfortable, change it. One may have to change two to three times a day at least. - Do not dry the cloth/pad in dark places for it will get fungal infection. - Wash the cloth in clean water and dry it in the sun. The sunlight kills the germs. - The cloth needs to be stored in clean bag in a clean place .

Care during Menstruation Diet: Several beliefs are prevalent about diet during menstruation. In several places milk and fruits are taboo at this time. Girls 153

loose blood every month therefore it is very important for them to consume a balanced and iron-rich diet such as green leafy vegetables to replace this loss. Mental Tension: A girl/woman may feel tense during menstruation. One of the reasons may be lack of complete information about periods. In several homes, girls are made to sit separately, are not allowed to enter the kitchen and temple due to which they develop a sense of inferiority. Girls need love and sympathy at this time. It is essential to change these beliefs. Cleanliness: Since the mouth of the womb (cervix) is open during menstruation, any infection can easily reach the womb and egg. It is necessary to bath daily to prevent this. One should also wash the vaginal opening with soap and clean water. A clean cloth should be washed and dried in the sun. If the cloth used during menstruation is unclean there is a possibility of infection in the reproductive organs. Adolescent girls living in slums in cities do not have place to wash and dry the cloth, so they use any dirty cloth. By doing this there is a possibility of infection in the uterus. Infection may cause itching and boils may be present in the vagina.

Sexual health - Sex education is a broad term used to describe education about human sexual anatomy, sexual reproduction, sexual intercourse, reproductive health, emotional relations, reproductive rights and responsibilities, abstinence, contraception, and other aspects of human sexual behaviour. - Sex education may also be described as “sexuality education”, which means that it encompasses education about all aspects of sexuality, including information about family planning, reproduction (fertilisation, conception and development of the embryo and foetus, through to childbirth), plus information about all aspects of one’s sexuality including Sexually Transmitted Infections (STIs) and how to avoid them, and birth control methods.

Use of Sanitary Pads/Cloth - It’s very important to maintain hygiene and cleanliness when girl has periods. When blood comes out, one should use sanitary pads. - Make a sanitary pad by folding a clean old piece of cloth a few times or use available sanitary napkin. - Change the pad every time it gets soaked. - Wash the cloth properly with soap and dry them in the sun. - Wash yourself with water every time you go to urinate or you change the pad. - Store the washed and dry pads in a clean plastic bag till the next menstrual cycle.

Process - SUVIDHA is to be procured from a Bhartiya Janaushadhi Pariyojana store in Ahmedabad. A connection had to be made where the incoming flow of pads is present and would continue - Funds have to be raised from Sarpanch for the first cycle. - The installation of the dispensary of pads is planned in the Anganwadi to break social boundaries - The launch of it is planned on the same day as the workshop. - Hence, the awareness is taken forward by the product. - Devikaben would be taking care of the stock and registry and Hiteshreeji for further stock, or if any Sakhi(s) and AG(s) requires assistance - The way of disposing the sanitary pad has to be explained appropriate as much as practices around using it. - The affordability and accessibility has to be highlighted for more engagement

Management of Menstruation - Girl should remember her menstrual cycle. - Every girl should maintain menstrual calendar to avoid unexpected inconvenience. - Girl must remember menstrual date. - Keep one pad in bag to manage menstrual flow and be alert and plan for next menstruation. - Dispose pad in proper manner – wrap the used pad/cloth in an old newspaper and throw them in dust bin. - Burning the used pad/cloth is the best method. - Don’t throw used pad/cloth in latrine, they can block them.

Stakeholders involved: Sarpanch Sagarbhai, School PrincipalRatilalji, Anganwadi Teacher Devikaben, and the pharmacist and owner of Bhartiya Janaushadhi store Hiteshree Gohel and community Sakhi(s) and AG(s)

Experiential Takeaway: The core experiences that the Sakhi(s) and AG(s) would take back are 1. Accessibility to the product within the village along with affordability leading to behavioural change 2. An experiential tool-kit to use it first hand and provide feedback to the system, making it a continual process and not just one time investment 3. A support group would be formed to discuss further over and after workshop would be formed for regular discussions, queries

Process 4: Training for creating awareness and sustenance Learning is an ongoing process, only training Sakhi(s) and AG(s) wouldnâ&#x20AC;&#x2122;t lead to stronger impact. Participation is low due to lack of resources or necessary things needed to function which lead to visible outcomes. There is a need for a system/process that will sustain the awareness, learning and allow scope of changemaking in the lives of people of Virpura. *This menstrual absorbent was tried by me personally for two months before ideating on this idea. The rejection for reusable cloth pad was due to the discomfort around washing pads which most women felt including me.

Thought: This strategic intervention is designed taking into consideration to keep the initiatives taken running and functional with improvisation through feedback. This process will help in developing a model for implementation beyond Virpura and thus impact as many lives as possible. Sustainability is only possible if the system/process gets accepted and adaptation to change happens.So the following design steps are taken such that the systems becomes a habit

Design: Making Sakhi(s) and AG(s) the Mari Sakhi ambassadors who promote the Suvidha scheme in the week continually. Also, channelise the Sakhi(s) and AG(s) to the ASHA worker Binalji if the need be for the right intervention at the right time. Stake-holders involved: Anganwadi Teacher Devikaben, AG(s) youth representative Kiran, Kanak, Sunita and Bhumi. From Sakhi(s) Padmaben (Thakur Vas), Sitaben (Senva Vas), Shilpaben (Chunara Vas), Chandrikaben (Patel Vas) and Kavitaben (Nayak Vas)

Experiential Takeaway: Ownership and belongingness towards creating change Involvement Virpura development activities

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SABLA yojana

157

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Sagarbhai

Ramaben

SYSTEM PROTOTYPING .I .II

INTRODUCTION ENVISAGED LIMITATIONS

INTRODUCTION .I

Deciphering of a problem to creating the system prototype, has been a long journey of people, policies and processes. This next phase of the project is to do a system prototyping validation in Virpura. This validation was the first step to see whether the design interventions suggested should be continued and also take immediate response or feedback from the community. With the community meeting, Mari Sakhi workshop and launch of Suvidha dispensary, the implementation had to be checked on following parameters 1. Would they attend such a meeting? 2. Do you care about Menstrual awareness and how do you see yourself contributing towards Mari Sakhi workshop? 3. How and where would you be accessing the Suvidha dispensary school or elsewhere in the village?

Name: Sagarbhai Persona: Sarpanch Vas: Iyava Feedback: Yes, I would be taking part in the community meeting, not as a job but to understand what the villagers have to say. About Mari Sakhi workshop and Suvidha dispensary my contribution would be funds for it and making sure the if you need any assistance in procurement. And please would you want to continue this in Iyava as well.

Name: Kiran Persona: graduation student Vas: Nayak Feedback: Yes, I would be taking part in the community meeting, as a responsible participant and community member.I would be voicing about the lethargy that exists as well as gender discrimination happens for certain situations mildly. About Mari Sakhi workshop and Suvidha dispensary my contribution would be being a participant, consumer as well as to take this awareness forward.I would like to contribute in helping Devikaben with Suvidha dispensary as well.

Name: Ramaben Persona: priestess of temple Vas: Patel Feedback: Yes I will come for the community meeting it is a long due. I need to know some process within the village where are they stuck. I am not sure I will make it for the Mari Sakhi meeting but I will try.Also, about Suvidha, I am glad it starting the Kishoris definitely would need it and I am going to tell them to shift their adaptability towards it when they come to temple like every evening.

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ENVISAGED LIMITATIONS .II

Participation There would be no or very less participation. Stakeholders do not turn up because of fear of answering. Just so this doesn't happen constant go-along method was required to remind people about the meeting. Communication High chances of miscommunication, heated arguments during meeting were assumed. Crossing the sensitivity line in any of the systemic process and thus, the whole effort falls apart. Gatekeeping overpowers because of which transparent communication becomes difficult. Just so all this doesnâ&#x20AC;&#x2122;t happen the meetings had to be facilitated for the first time before they become independent and sustainable. Learning All the participants might not absorb the training/workshop at equal pace. AG(s) are less aware and new to this stage. Also, all the members of the community would not be able to attend. To overcome this, all the training material was made available in the Anganwadi and can be accessed anytime. Fear of missing out There would be a possibility that people couldnâ&#x20AC;&#x2122;t turn up for the first meetings and then they would feel left out, hesitated, inactive or not involved. Hence, to remove that stigma monthly meeting were thought of, such that the ones who attended the first meeting pull in their Sakhi(s)/AG(s) for the next one and be more involved Failing to implement If implementation is not achieved, the ideas and prototypes will be not translate into the culture of awareness imagined and the practices to impart

8 .1 .2 .3 .4 .5

PHASE 05 DELIVER

INTRODUCTION IMPLEMENTATION FEEDBACK OUTCOME RECOMMENDATIONS 163

INTRODUCTION

To achieve envisioned system, where people are too comfortable, there is a resistance to learning and adopting new process and approaches was a difficult path. In such a setup, the young AG(s) also suffer. Their potential and capabilities get side-lined. They absorb a mind-set to just focus on what they see in the daily routine rather than looking at the bigger picture. To foster a culture of awareness and practice, a platform young AG(s) as well as adults had to be brought in. A system/platform that will help in achieving some active participation drive in the process. This systemic solution will focus on a creating common understanding for the stakeholders involved to solve wicked problem ,and also finding a collaborative group of people who will aim at aligning their initiatives to the processes defined and transform an idea to implementation. Eventually, over the period of time, awareness created and tools for practices provided to the AG(s), will create a close network of young leaders who believe in driving changes in Virpura not only in school but in society. They will be visionaries who will sensitize more and more people and collectively create visions for future. Hence, this phase was about finally delivering the designed intervention into the community. It is most important phase for Virpura as it acts as the tangible driver for intangible changes in the mind-sets of the people to the behavioural shift aim to achieve is that the functional designed systemic processes should get the AG(s) in lead constantly going even when I would leave Virpura. Also, how implementation of the feedback for the system is involved into making the system/process robust. Also, if the system delivers the way it is envisioned it will help build inspiration not only in Virpura but also in para village Iyava to start with.

165

IMPLEMENTATION

The semi-final stage of the process is the implementing stage. The toughest challenge in any system is to convert ideas to implementation. What the mind aspires is difficult to translate into adaptation. Lack of Implementation on the ground is the keyinsight. Since the implementation is never achieved on ground from Governments side, the schemes are bundled and forgotten. This is leading to a variety of schemes/policies going down the drain without any action to implement. Implementation will not just convert policies/schemes into final deliverables but it will also lead to a visible impact on culture within Virpura. The community can see how the process and approach is helping them create awareness and comfort in their daily life.. After designing the system, the next step in the journey of the project was to push the processes into implementation gear. The implementation began with early validation based casual conversation to make community, and the stakeholders aware that a big milestone is coming towards their journey with me. After these casual conversations, time was to fix the date for each of these milestones to be actually implemented on the ground. After an interactive session with Sarpanch Sagarbhai Thakur dates were finalized since he would be a participant. Also, funds of INR 4000 provided by him at the moment he heard heard about Suvidha dispensary. The dates for the community meeting was 18th August, 2018, such that he can visit after his school timings and so would the Virpura school be empty same time.

Community Meeting Date: 18th August, 2018 Participants: Panchayat members of Virpura and Iyava, All age group people (men, women, boys and girls) from village, School staff and principal, Members from Ambuja cement foundation and me Meeting Platform: School assembly place Time: 6PM â&#x20AC;&#x201C; 8PM (after consultation with villagers) Agenda: Bring village authority and villagers to a common platform create an open dialog to discuss village issues, solutions, timeline, distribution of responsibility. Now the community meeting was designed in the open space of School wherein the active community members would be seated gender wise. It was open to all meeting. were taken through a journey of what they have signed up for and how would their journey look like. Mapping about the people visiting was done. The count of the people attending it was around 65. I facilitated the meeting starting with the small implementations that already have taken place and bigger aim that we aspire to achieve. The meeting session was interactive wherein the active members voiced their issues/challenges in the broad categories of: Railway Line Crossing timing, Health Forms for Toilet and lastly shortage of Water Supply. These topics were open to discussion with social pressure worries associated to it but were excited to be a part of this journey. The unresolved matter was waste collection cycle Post the session, the final resolutions were made that railway line crossing would be put on highest priority. The forms for toilet construction would be handled by Sabhyas and people could approach them. And finally, new pipeline work for water and sewage is already started in Iyava, next it would come in Virpura.

167

Mari Sakhi Meeting with Launch of Suvidha Dispensary Date: 24th August, 2018 (vaccination day in the school) Participants: All age group Sakhi(s) and AG(s) from village, School teachers and Anganwadi teachers, Health Check-up Doctor/ Vaccination doctor of the school. Meeting Platform: Anganwadi Space Time: 2PM â&#x20AC;&#x201C; 4PM (after consultation with villagers) Agenda: To educate Sakhi(s) and AG(s) with the aid of visual medium to know more about their menstruation, hygiene and Sanitary practices. After that a demo on how to use Suvidha pad and how it is like the SABLA scheme through Government. The Mari Sakhi meeting started with introduction of all the participants and the thought of Accessibility, Awareness and Affordability was contextualized. Devikaben and I facilitated the proceedings. Using the Sable Pothi Apron and Story of Menstruation movie we explained the entire menstruation process along with related body parts and functionality. Later, social taboos around pads, menstruation, reproduction cycles were discussed. Topics like conceiving were asked, on who is the boy/ girl child dependent, any schemes related to girlâ&#x20AC;&#x2122;s menstruation was asked, long menstruation cycle is normal or not? etc Then the Suvidha scheme and its use was demonstrated. Disposal method was discussed. After that a short activity was played where after the awareness participants had to answer true/false for the myths/facts put across. Later on questions and answers were related to pads, cloth, absorption, affordability. Someone also asked will this dispensary be running forever or it's a one time thing. This showed that people would use it and we decided to not keep it a one time thing.

IMPLEMENTATION 169

FEEDBACK

Name: Meena Persona: Pregnant Woman Vas: Dalit Feedback about Meeting: Aakar acha laga. Shikyatein door hui Feedback about Mari Sakhi: Abhi to khokse hu. Dusre bacche ke waqt aasani hogi Feedback about Suvidha: Maine toh abhi se kharid ke rakh liye hai kyunnki baccha honk eke baad turant hi shuru ho jayega tab kaha lene bhagungi agar ye khatam hog aye toh Name: Asha Vas: Thakur Feedback about Meeting: Main to meeting attend nai kari pan hu school ma chaas peeva aai thi tyare main railway phatak badhal sambdhiyu. (I dont attend the meeting but I did come to drink chaas and over heard about railway phatak) Feedback about Mari Sakhi: Mara Vas aaji aaya nothi. Pan have aavse toh maine kabhar che ke hu sambhali sakis. Aa mari Sakhi meeting ti main khub faydo thayo che. I haven’t had my menarche yet. (But I feel prepared to atleast face it when it happen. This Mari Sakhi meeting me has benefited me a lot.) Feedback about Suvidha: Humna ek packet lai ne muki dais mara pocket money ti karan sastu che. (I will buy and keep one packet from my pocket money as it is affordable)

"Main vaparva shuru karidhidu che. Kapda ti saru che karan sastu and saaf che. Ane hu kagad main wari ne nakhu chu." (I have already bought it and used it. It’s better than cloth because its cheap cleaner and not sweaty)

Name: Kanak Vas: Just behind the school Feedback about Meeting: Main toh kai didu badhani same ke bol bolt oh kyarti chalu che pan thatu kem nai. (I voiced my opinion to Sarpanch saying everybody keeps talking it is going to happen but when?) Feedback about Mari Sakhi: Tame ghare aavine pehla maine puchuyutu ke main maasik sukam thaiyeche khabar che? Main na padi thi. Pan aaj koi bhi maine puchse ke hu koi ne puchis to toh hu kai saku chu and mari aas paas na loko nai bhi kais (Earlier when you hd come to take my interview you had asked me do you know why menstruation happens and how? I was mum because I wasn't aware, but now if anyone asks me I can tell it and now can spread the same awareness.) Feedback about Suvidha: Main vaparva shuru karidhidu che. Kapda ti saru che karan sastu and saaf che. Ane hu kagad main wari ne nakhu chu. (I have already bought it and used it. It’s better than cloth because its cheap ,cleaner and not sweaty) 171

OUTCOME

1 2 3 4 5 6 7 8

The most impactful outcome has been to achieve a facilitation connection between different stake-holders, right from creating menstrual awareness to providing Sakhi(s) and AG(s) accessibility to the affordable MHM products. with Virpura. From the time of implementation of Mari Sakhi, the first batch of pads have been procured for around 52 women who have signed up for the new system.

Majority of the people who have availed the Suvidha pads service are AGs.

The community meeting organised had an attendance of 118 people across all ages. including 13.2% (42 out of 316 in number) women were present for the meeting. The core vision of the project to act as a catalyst to bring together different perspectives related to menstrual hygiene and tie them together in their everyday life was accomplished due to this strategic solution of Community meeting platforms, Mari Sakhi Workshop and Suvidha dispensary There is now a strong ownership that has come out in the village youth who have agreed and shown participation and leadership qualities throughout the project. An agreement has been drawn between Virpura and the Bharatiya Janaushadhi Pariyojana store, Satellite Road, Ahmedabad, to regularly supply medicines and sanitary pads on a monthly basis due to the strategic intervention that I created. Though the conversation taboos between two genders has not been completely broken, the women of the village have found a common platform to come forth and discuss their bodies, selves and aspirations freely thereby becoming the support system for each other. 173

RECOMMENDATIONS

1. Disposal of these Suvidha pads is not yet completely known. Apart from the fact that the its is oxo-biodegradable which means, that when it reacts with oxygen it start degrading, the time of decomposition isn’t mentioned. Also, the my recommendation for this is that we could provide an natural accelerator with the packets to aid the process of decomposition which comes with the packet. Like maggi masala. 2. The packaging of Suvidha is plastic, which is not as sustainable as the pad is which contradicts the whole point of pads being biodegradable. Hence a systematic method to reuse the packages/dispose them efficiently. 3. The fututre development of this study could be carried out for developing a system design project starting from creation of awareness to the dignified disposal of the menstrual waste. 4. The gap of lack of implementation challenges related to existing schemes and policies could be resolved through developing a strong collaborative channel which connects various stakeholders could be proposed.

MHM Products :Support market-based solutions to innovate and distribute low-cost, yet high-quality sanitary pads at scale - Low-cost pads that are manufactured through low-cost machines using a decentralized model have limited production capacity and vary in quality. Market- based interventions including technological innovations to increase capacity of lowcost machines are needed to increase scale, capacity, and quality of pads produced as part of the decentralized model. - Centralized manufacturing systems(e.g., corporations)make pads at scale, but have limited reach in remote rural areas. Additional research is needed to understand the underlying distribution challenges in specific regions, the price point that women and girls are willing to pay for the product, and user product preference, thus improving the supply chain management. - Support innovation of products which are environmentally friendly, culturally appropriate, and affordable given the environmental concern with disposable Sanitation

5. Given the current national momentum on menstrual health coupled with significant need, there is an immediate opportunity for the field to improve the effectiveness of existing efforts and better support for girls’ experience of menarche, menstruation, and MHM in India. These immediate priorities are outlined below: 6. Education and Awareness: Strengthen the capacity of influencers—teachers, community health workers (CHW), mothers—to improve programming effectiveness - Targeting teachers and CHWs presents an opportunity for sustainably scaling access to education and awareness on menstrual health, particularly through national programs(e.g., RKSK). MHM curricula already exist.What is needed is to build facilitator capabilities to provide education and psycho-social support at scale. - Programming that educates mothers is rare. There is a need for evidence-based programming on enabling mothers to provide accurate information on MHM and appropriate ongoing support at scale.

- Address the burgeoning problem of disposing menstrual waste in an environmentally safe and affordable manner - Given the lack of discourse on disposal issues in the Indian MHM sector,three parallel approaches are -essential: - Convene multisector stakeholders (i.e., government, corporate, NGOs, social enterprises, researchers, innovators) to align on a common vision for disposal. o Conduct longitudinal research to understand the long-term impact of incinerators on health and environment so that the field can make an informed decision about how to manage the disposal of menstrual waste. - Explore innovative solutions to dispose sanitary pads in an environmentally friendly, safe, culturally appropriate and scalable manner. - It is also crucial to continue improving access to sanitation by embedding girl- friendly design and features as part of the national sanitation campaign, Swachh Bharat Mission, and 175

explore market-based as well as community-based sustainable solutions to sanitation infrastructure maintenance. Policy - Increase the on-the- ground capability to implement the national MHM Guidelines effectively - Assign MHM specific performance indicators to various Ministries and identify an MHM Champion across Ministries. - Strengthen the implementation by building the capacity of frontline workers and CHWs (to improve awareness and education); connect state and district. governments to the MHM producers who provide low-cost, high quality products â&#x20AC;˘ Study effective implementation in select state(s) and replicate lessons learned.

https_%2F%2Fwww.unicef.org%2Fwash%2Fschools%2Ffiles%2FIndia_MHM_vConf.pdf

.1 .2 .3 .4

EPILOGUE CONCLUSION LEARNING GLOSSARY BIBLIOGRAPHY

177

CONCLUSION

Menstrual Hygiene is the necessity in this modern world and not a aspiration. It shouldn’t be something that the woman has to wait to find it on a menopause journey. It should be something that the girl in her budding stage should be gifted to preserve and build upon. Through the the entire project journey i have realised it is every woman’s role to be the light of the house but not at the cost burning one’s self just because the power of electricity wasn’t explored. The second realisation is that, menstrual awareness is low because it is yet a philosophical ideal but not practiced. It takes a woman days, months and years to come out of social stigma and self-anxiety to explore new habits of hygiene involved with menstruation like thinking of a new product. From talking about it to, buying a new product to trying the product, adapt to that product and finally making it a practice. She goes through self, family, society, country and then world taboos to conquer the ultimate sense of comfort. The research section evidently reveals that menstrual practice is easy to say but is extremely difficult to imbibe the awareness, make it a daily need and practice dedicatedly to achieve it. This project at Virpura is to scout for the most crucial aspects that are hindering the pace of adopting new processes, practices or products towards menstrual hygiene and sanitation. These hindrances are then cumulated to see the overall problems that can be solved with a systemic solution. The purpose of the solutions was to bring clarity to the community and show them newer ways of treating their body and well-being in a personal context. Engaging from the start through human connect, removal of the mental blocks to gain sufficient awareness about menstruation and its aspects, the solution then shifted to creating a strong network of Sakhi(s) and AG(s) who are inclined individuals who think of the achieve personal growth and hygiene.

179

LEARNING

LEARNING Learning is the first and foremost requirement driver to changemaking. Learning was a continuous process to experience it all levels of the hierarchy. It was important to learn the new concepts which will be a strong foundation for future projects. Learning for me was on both terms tangible as well as intangible, internal and external wrt project, topdown and bottom up in terms of Virpura stakeholders and ultimately is was to satisfy my head,hand and heart. My primary learnings began by understanding the peopleâ&#x20AC;&#x2122;s challenges which evolved into intensive research on the existing policies that could tackle the existing challenges that were present. Secondary learnings taught me that though policies are well planned and meticulously budgeted, by the time it trickles down it has a possibility to lose essence and hence it was very vital to actively involve stakeholders from various levels actively involved in a decentralised manner for more freedom of operation and change. My next learning was how to do the field research which relates to sensitive issues addressing to the audience where taboos, social stigmas and lack of awareness is rampant.Without empirical research application of the designed strategic interventions wouldn't have been possible. My final learning was that until the design in implemented and monitored closely, the ideals that are planned donâ&#x20AC;&#x2122;t necessarily reflect change. Since we are dealing with an ever changing dynamic environment where humans are placed at the center, the ability to deal with disasters in implementation through gentle corrective measures would ensure longevity and sustainability. Accessibility and affordability both play a crucial role during the stage of implementation. Iâ&#x20AC;&#x2122;ve learned that while concepts are exciting, the onground engagement and implementation is very enriching and is an essential part of further developing the concepts. We do carry a lot of ideals for ourselves from the west, but the moment we slip into a state of mind where our own culture and rooting is forgotten, it results in chaos. Looking at western concepts of implementations for comparative concept building is good while comparative growth analysis and methods of adaptation needs to happen through collaboration and setting rigid standards.

The other learning is that this model is based on Virpura but with investment of more time it could become refined research model. This ould help develop a model which can be implementsble on state, ountry and global level. Another learniing was that when the setting changes the from urban to rural the approach of handling the subject menstrual awareness, hygiene and sanitary practice changes which leads to inclusive empathisation. It was great learning experience all along this journey not only with team virpura but also, my guide, Mihirji, SDM co-ordinators, peers, and my supportive friend circle.

181

GLOSSARY

ARC

Adolescent Resource Centre

SBSV

Swachh Bharat: Swachh Vidyalaya

ASHA

Accredited Social Health Activists

SHG

Self Help Groups

AWC

Anganwadi Centre

STI

Sexually Transmitted Infections

BPL

Below Poverty Line

SMVM l

Sorath Mahila Vikas Mandal

CHC

Community Health Centre

TDD

Tribal Development Department

CRC

Cluster Resource Centre

UNDP

United Nations Development Programme

GCERT

Gujarat Council of Educational Research and Training

VUCA

Volatility, Uncertainty, Complexity and Ambuiguity

GDP

Gross Domestic Product

WASH

Water, Sanitation and Hygiene

HDI

Human Development Index

WDR

World Development Report

HDR

Human Development Report

WHO

World Health Organization

ICDS

Integrated Child Development Services

WSSO

WSSO Water & Sanitation Support Organization

INR

Indian Rupees

JnNURM

Jawaharlal Nehru National Urban Renewal Mission

MHM

Menstrual Hygiene Management

MHS

Menstrual Hygiene Scheme

MNREGA

The Mahatma Gandhi National Rural Employment Guarantee Act

MoHFW

Ministry of Health and Family Welfare

MoDWS

Ministry of Drinking Water and Sanitation

MoUD

Ministry of Urban Development

MoHRD

Ministry of Human Resource Development

MoWCD

Ministry of Women and child Development

NAHS

National Adolescent Health Strategy

NGO

Non-Governmental Organization

NPE

National Policy on Education

NRHM

National Rural Health Mission

PHC

Primary Health Centre

RDD

Rural Development Department

RKSK

Rashtriya Kishor Swasthya Karyakram

SABLA

Rajiv Gandhi Scheme for Empowerment and Adolescent Girls

SBM(G)

Swachh Bharat Mission (Gramin)

183

BIBLIOGRAPHY

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