UNICEF and Menstruation Poverty Among School Girls in Ethiopia
By Kalkidan Antonios
What steps has UNICEF taken to reduce menstruation poverty among school girls in Ethiopia?
According to the Equal Measures 2030 report, 193 countries summited in 2015 to draft 17 Sustainable Development Goals (SDGs) they would achieve by 2030 (Equal Measures 2030, 2019). One of these key goals was to work toward a world without gender inequality. Providing all women with direct access to sanitation and equal access to education are one goals of the 2030 Sustainable Development Goals (SDGs). In 2019, Equal Measures 2030 (EM2030) analyzed how well these goals were being met, and found that, collectively, countries have barely succeeded in fulfilling them. Looking closely at which SDGs have shown progress, the EM2030 Gender Index indicates that Sub-Saharan African countries have low index scores which means that progress is only being made on about 50% of the SDGs. One of the SDGs that Sub-Saharan African countries fail to meet is SDG 6, which provides women with direct access to sanitation. Ethiopia, for example, scores 48.3% on the EM2030 Gender Index. This paper intends to analyze the steps that UNICEF has taken to alleviate this lack of care and reduce period poverty among school girls in Ethiopia.
So, why is Ethiopia falling behind in providing sanitation access to school girls? In 2016, UNICEF and the World Health Organization partnered to create a joint monitoring program (JMP) to study menstruation health management (MHM) in 46 schools in six regions of Ethiopia (UNICEF WASH, 2017). The joint monitoring program defines MHM in three fundamental parts: women’s access to sanitary products during menstruation, a woman’s access to private toilets where she can change and dispose of her used sanitary products at any time during her period, and a woman’s access to clean water and soap to wash herself during her period. The four baseline surveys done by UNICEF in the six regions show that school girls usually do not have access to MHM education before their first period. Cultural stigma also discourages parents from educating their children about MHM. Lack of access to water for clean and private toilets in schools and lack of access to sanitary pads are also noted in the report.
In 2014, UNICEF created “MHM in Ten,” a ten-year goal to improve menstruation health hygiene for women worldwide (Penelope A. Phillips-Howard et al., 2016.) A mid-term report was designed to review different initiatives taken by stakeholders to reduce period poverty in developing countries (Sommer et al., 2021). One of the “MHM in Ten” goals was for government officials and NGOs to integrate menstruation health hygiene offices and training resources into the education sector. The report indicates that women still lack access to MHM resources because governing bodies do not have specific policies regarding MHM. The report also states that the lack of MHM policies is consequently followed by a lack of funding for proper MHM facilities, sanitary product manufacturing, and training stakeholders, which, within the scope of this paper, are teachers, students, and community members more broadly.
According to the UNICEF baseline research report, Ethiopia's current government-sponsored MHM education is not readily available for students (UNICEF WASH, 2017). In addition, only two out of every ten girls in Ethiopia have access to adequate sanitation in their schools. The existing school-based MHM centers are not built properly to accommodate the need for privacy for girls, clean running water, or disposal bins for sanitary products. while 89% of girls living in urban areas depend on disposable sanitary pads, as well as 49% of girls in rural areas and 13% of girls in nomadic regions, the research report cites that the prices of disposable sanitary pads make them inaccessible for many in Ethiopia, and that aid organization handing out sanitary pads is only a short-term solution to the basic needs of women.
The lack of proper MHM education is displayed through the cultural misconceptions that communities have towards menstruation in Ethiopia. According to the UNICEF baseline research report, menstruation bloodstains are seen as a result of a woman’s involvement in sexual activity or terminating a pregnancy. Because of this, girls who stain during menstruation are more likely to be shamed by their community. Many underage girls reported being afraid to ask their parents for money to buy sanitary pads out of fear of getting punished for having “sexual activity before marriage.” UNICEF (2017) recorded the following student testimonial from the Amhara region:
“If my father understood that I am resting because of menstruation, he would blame me as if I got pregnant and lost my virginity. One of my neighborhood women told him that menstrual bleeding is a natural attribute. But he was not convinced.... To figure out who made me ‘pregnant’, he even met my civics teacher a couple of times, thinking that I was pregnant [and that my teacher might know or be able to confirm]. Because my father was stubborn to get convinced and nagged me repeatedly, I wish I had died by then. To this end, I attempted to commit two unsuccessful suicides.” (P.49)
Married women in some regions, primarily rural areas, have reported not sharing their menstruation cycles with their husbands because they would be asked to sleep separately. The report also shows that a girl's menstruation is seen as a sign of sexual and emotional maturity, and girls who menstruate are subjected to early child marriage, especially in rural regions of Ethiopia. Women are also excluded from social gatherings during their periods. In some regions, the UNICEF baseline survey shows that up to 83 percent of girls are not permitted to attend religious ceremonies during their menstruation.
During my time in Addis Ababa, the capital of Ethiopia, I noticed women who practiced Orthodox Christanity standing outside church gates, and I learned that women were deemed unclean during their menstruation and were not allowed to enter church grounds.
Figure 1
UNICEF’S interventions and challenges
This next section of the paper looks closely at the Menstruation Health Hygiene projects implemented by UNICEF in three regions of Ethiopia. It also discusses UNICEF’s impact on the Federal Health Ministry of Ethiopia in its work to reduce period poverty across the country. Recently, the Canadian International Development Agency (CIDA) granted a fund to UNICEF and the Southern Nations and Nationalities Health Bureau to launch Menstruation Health and Hygiene programs in 10 schools in 10 Southern Nations, Nationalities, and People’s Regions (SNNPR) (Haile, 2022). The project goal included providing school girls access to basic sanitation like clean and safe toilets, running water, soap, sanitary pads, and menstruation awareness programs for the school community. Kale Primary School is located in the Chenca district and has a total student population of 453 students, 238 of which are female. In 2020, UNICEF and the SNNPR Health Bureau built an MHM office at Kale Primary school. The MHM office has toilets, including waste baskets for girls to dispose of used sanitary products privately. Washrooms are equipped with a shower, soap, and a wash dish which the students can use to wash reusable sanitary pads or stained cloth. The MHM office has rooms equipped with beds that female students can use when they experience menstruation cramps, and it also provides female students with free disposable sanitary pads during the school year.
UNICEF and SNNPR train female teachers to oversee the MHM office, educate the school body about menstruation, and provide education and support to female students regarding menstruation health hygiene. The project’s impact is clear: of the 238 female students attending Kale Primary School, not a single student dropped out or skipped classes due to issues related to menstruation. Bethlehem Yoseph, a seventh grader at Kale Primary school, shares that she had her first menstruation in 4th grade while singing the national anthem at school as she did with her classmates every morning. She recounts that the male students were teasing her, and she was forced to go home because of Kale's lack of proper bathrooms. Bethlehem struggled to focus on school due to fear of being harassed by students and lack of access to basic sanitation in Kale. Bethlehem contemplated dropping out of school, seeing that her grades began to drop because she stayed home and missed classes during her menstruation. Bethlehem can now continue her education without missing classes because of the MHM office at Kale primary school. During her menstruation, Bethlehem goes to the MHM office to get sanitary pads and wash instead of going home. She no longer feels threatened by male students because the MHM office has conducted menstruation awareness sessions to educate the school body.
Although the Kale Primary school MHM office is an exemplary model by the district's Health Office, students like Bethlehem have noted that they do not have the financial means to afford sanitary pads outside of the ones the school provides. Only ten districts in the SNNPR have launched MHM offices, but many more schools in the region do not have MHM-inclusive facilities for female students. UNICEF and SNNPR’s health bureau have been working on teaching the community about menstruation health and deconstructing religious and cultural taboos surrounding the lack of access to affordable sanitary pads. The lack of MHM offices in other schools, or more broadly, still pose a problem for students like Bethlehem, who will eventually graduate and leave Kale Primary school.
According to a 2022 UNICEF report, in the Benshalgul Gumuz region, CIDA pledged $119,410 to support UNICEF in its efforts to reduce malnutrition and provide sexual health access to young women in the region (Nurgi, 2022). UNICEF initially trained health workers and teachers on MHM intervention and these workers were sent out into the community to spread awareness through door-to-door canvassing and meeting with religious and community leaders. UNICEF partnered with the local education bureau to build fully equipped washrooms in seven regional schools, including Shekole Primary school in the Homosha district and Bambasi primary school in the Bambasi district. The washrooms that were built have toilets, private sanitary pad disposal bins, and handwashing stations with clean water reserve tanks. According to the report, UNICEF partnered with I Plan Ethiopia and Pharo Foundation to build an MHM office in Shekole Primary School. Halima Abdulahi is the MHM officer in Shekole primary school. Her role includes holding education sessions on Menstruation Management and Hygiene and supplying the school girls with sanitary pads, undergarments, and soaps. The MHM office here has similar features to that of Kale Primary School.
Shekole and Bambasi Primary schools' MHM offices have expanded their efforts by organizing a gender working group that includes male student members. The gender group focuses on engaging the school body in breaking menstruation stereotypes and preventing gender discrimination and violence toward women. According to the UNICEF report, Skekole’s gender working groups have reported that the presence of the MHM office in the school has encouraged dialogue and decreased the female school dropout rate. Fatuma is an 8th grader at Shekole Primary School. Fatuma experienced her first menstruation in school, and she got training from an MHM officer and received sanitary materials whenever needed. Fatuma now plays an active part in educating friends in her local community about MHM. As stated in the report, UNICEF’s challenge in working in the Bensahngul Gumuz region is continuing the supply of clean water and expanding MHM offices to other schools in the district. UNICEF’s work critically depends on continuous funding sources from project partners.
According to UNICEF’s reports in the Tigray region, groups/programs such as, World Vision, the OneWash program, and UNICEF, along with the financial support of the UK, jointly worked to build an MHM office in Kessanet Primary School (Gulliver, 2022). This office includes similar features to the ones listed above, and female students also have access to sanitary pads they can take whenever needed. UNICEF has also made MHM books accessible in the local language so that students and staff can educate themselves on the issue. The report shows that schools with MHM offices have the lowest female student dropout rate due to menstruation-related issues. Kessanet Primary School reports that after the implementation of its MHM offices, eight out of ten honor roll students are female. Kessanet’s gender working group has also been working to be more inclusive to female students that are disabled by learning sign language because those in the group believe that these students are the most marginalized in MHM issues.
Female students at Kessanet Primary School disclosed that they do not have access to affordable sanitary pads outside of school, which is one of the challenges UNICEF has to reduce period poverty amongst school girls. The UNICEF report also emphasizes that continuous donor funding is essential to help expand the MHM offices in other regional schools. So, why are UNICEF’s MHM projects predominantly in rural regions? According to the four baseline surveys done by UNICEF and the Joint Monitoring Program, only 59% of girls from rural regions and 31% from nomadic regions have background knowledge and access to MHM facilities and products (UNICEF WASH, 2017). By comparison, 61% of girls living in urban settings have background knowledge and access to MHM facilities and products.
According to a UNICEF report, The Federal Ministry Of Health in Ethiopia has been actively working with various sectors to educate citizens and launch MHM programs in different regions (UNICEF, 2020). The outreach identified that many people are unaware of the reality of period poverty, and many women struggle to afford sanitary pads and resort to products that seriously affect and could damage their reproductive health. For example, I have heard of women who have had to use rags and cow dung to stop menstruation. UNICEF has been working with the Federal Ministry of Health to create a guideline on sanitary products manufactured in the country (UNICEF, 2020). UNICEF has also been creating guidelines on MHM facilities for different institutions, and they are working to make MHM facilities more inclusive to disabled women. UNICEF has spearheaded MHM projects that have impacted over 106,500 students in Ethiopia.
There are consistent challenges that stand out from the regional analysis that was done, and a major one is that UNICEF faces financial constraints as it hopes to expand MHM offices into more schools and regions. UNICEF has appealed to get $351.1 million in aid towards solving critical humanitarian needs like health, nutrition, child protection, education, and MHM facilities in Ethiopia (UNICEF, 2022). UNICEF has received $64.6 million, only 27% of its total appeal goal.
According to the situation report, UNICEF lists its response and funding status in relation to Ethiopia's critical humanitarian needs. Only 26% of Ethiopian school girls have access to MHM facilities, and these facilities only get 13% of the funds they need.
Another critical factor challenging UNICEF’s intervention is the rise of climate change and food insecurity. Farmers across the country struggle to yield crop production because of shortages, rain, flooding, and soil erosion (UNICEF, 2022). This crisis has forced UNICEF to shift its funding priorities to providing essential nutrition and healthcare over building MHM facilities. According to the Humanitarian Situation Report, released in June 2022, approximately 401,000 children in Ethiopia are out of school due to food insecurity resulting from drought, and 50% have been out of school since 2019. The third challenge for UNICEF is the rise of conflict in Ethiopia that has forced 2.53 million school-aged children out of school. With an increase in the amount of children no longer in school, and public infrastructure damaged, it is hard to focus on creating and building MHM offices in schools, and educating teachers and communities about menstruation health. Ethiopia needs a local, more sustainable solution to help school girls that is less dependent on foreign aid and investment.
Figure 2
Recommendations
During my early teens, I had an incident where my parents could not afford a sanitary pad for me. My period cycle came, and I had to walk to school without a sanitary pad, using tissue paper in school to keep me from staining my clothes. As a young woman, menstruation is a hallmark of my physical, mental and emotional growth. I feel more in touch with my femininity during this time, replete with the cycle of being stuck in bed, bloated, watching Netflix, and eating chocolate. However, that time of the month also reminds me of the shame and fear I went through alone that day in school. I promised never to share the incident with my family or friends and die with this secret. Nevertheless, I found the courage to share my story with my roommate one evening, and our conversation convinced me to do something about fighting period poverty.
According to the Global Citizens Report, billions of pounds of waste are produced from non-reusable sanitary pads yearly (Rodriguez, 2021). One of the raw materials used in making non-reusable pads is plastic. The trash produced by these pads will take approximately 500 to 800 years to disintegrate into the soil, releasing toxic substances into the ground and air. Human blood is considered biohazard waste, so when women dispose of non-reusable plastic sanitary pads, they end up in landfills, water bodies, and animal grazing areas, potentially contaminating water used for drinking and agriculture. The second major issue with non-reusable hygienic pads is that they are expensive to buy for each menstrual cycle in the developing world. For groups of people who can barely afford their daily bread, how would they be able to afford a sanitary pad? And in strongly patriarchal homes, women's health is seldom a priority when money is tight. Even in parts of the developed world, some groups of women financially struggle to afford pads.
As an undergraduate, my Ethiopian friend and I signed up for an entrepreneurship class after a conviction that my childhood embarrassment could fuel a campaign against period poverty. We started researching the cause of period poverty. In 2020 we sent out a questionnaire to a public school in the capital city of Ethiopia, Addis Ababa. Out of the 20 girls we surveyed, 7, or 35%, missed classes because they lacked access to sanitary pads 11 (Gordon CEL, 2020). We came up with the idea for Meskerem: a nonprofit educational platform designed to teach Ethiopian women how to make their own reusable, biodegradable hygienic sanitary pads.
The goal of Meskerem is to empower women by teaching them how to make reusable pads instead of handing out finished products. We also created a free video guide and a brochure to teach others. The women can also use our free educational content to mass-produce and sell these products for profit. Our goal is to teach female students in local schools by doing a weekend workshop. We make sanitary pads reusable and biodegradable, using cloth fabrics like cotton fabric and towels that women can easily access in their local market or home. Sanitary pads made from these fabric materials can be hand washed after use and last up to a year. To practice what I preach, I myself have fully transitioned to using cloth sanitary pads for the past year, and I do not plan to return to non-reusable pads anytime soon. When finally disposed of, these pads will disintegrate into the soil much faster than plastic ones.
In April 2020, the Meskerem educational platform won second place in Gordon College's annual Social Venture Challenge and received an award of $3,000 in seed money. We are now working on training our first round of volunteers who will teach the female students we surveyed at the pilot school.
Students like Fatuam and Bethlehem can temporarily receive sanitary pads from their MHM offices in their schools, but how will they manage their menstruation when transitioning out of primary school? I ask this because their primary concern, according to the UNICEF report, is that their families cannot afford to buy sanitary pads for them (Haile, 2022). What if UNICEF or the Ethiopian government adopted a project that teaches girls like Fatuma and Bethlehem how to make their reusable sanitary pads from locally sourced fabrics? Fatuma and Bethlehem can teach their friends that do not attend the same school and sustain themselves during school breaks and once they move to high school. The work that UNICEF is doing to build MHM offices in schools should continue because school girls need privacy, freedom, and access to practice menstruation hygiene, but these offices cannot be the only solution.
Thanks to UNICEF and the JMP Baseline Report, the Ethiopian federal government has a guideline for the issues related to MHM in Ethiopia. The government has also been given guidelines on the construction of MHM offices, which have overall positively impacted girls' education and reproductive health, especially in rural regions. The federal government should take on the responsibility for budgeting, funding, and creating policies to implement MHM offices through different schools in Ethiopia. The federal government will need to financially support the implementation of MHM offices in rural and government schools, while private schools should be held accountable for adding an MHM budget each fiscal year. In partnership with the Ministry of Education, the federal government will need to train all teachers in MHM education, regardless of sex, to help aid school girls during their menstruation (UNICEF WASH, 2017). Teachers also carry the responsibility of shaping the attitudes of all students towards MHM, as they are respected in their communities, which gives them the power to break the cultural misconceptions around menstruation. According to Immigration and Law Review, taxes are one of the reasons for the increased prices of sanitary products (Ward, 2021). Ethiopia's import tax on sanitary products decreased from thirty to ten percent in 2020. It has also planned to eliminate the tax on locally produced sanitary pads in the coming years, encouraging local producers to increase production (USAID, 2021). I believe that teaching students how to make their own inexpensive, reusable sanitary pads from locally-sourced materials can go a long way in addressing menstruation health, especially in Ethiopia’s rural regions. Menstruation Health Hygiene is critical in fulfilling the SDGs by 2030. Otherwise, school girls' lack of access to education and basic sanitation will force them to miss work or classes and will cause them to get exposed to infections related to improper reproductive care and products. Lack of access to direct sanitation and sanitation products creates roadblocks to the SDGs goals, especially those related to women’s access to education and health.
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