I N C L U S I O N I N WAT E R CASE STUDY The Enabling Environment for Menstrual Health and Hygiene © U.S . Bu rea uo f Ed ucati onal an d Cu ltural Affairs girls’ latrine, which is necessary for hygienic purposes. Only 32 KENYA · AUGUST 2022 percent of schools surveyed had a private place for girls to change. M enstrual health and hygiene (MHH) is essential to the Inadequate female-friendly infrastructure does not only cause an well-being and empowerment of women and adolescent inconvenience for women and girls in managing their menstrua- girls. Attaining adequate MHH requires access to at least three tion, but also exposes them to the risk of gender-based violence. intersecting elements: (i) access to female-friendly facilities, In an informal settlement within Nairobi, 68 percent of women which is critical for menstruators to have a place in which to safely reported experiencing violence, in part due to limited access to and privately change their menstrual products and manage their private toilets (Corburn and Hildebrand 2015). hygienic needs; (ii) access to information and knowledge on sex- In terms of access to information and knowledge, it is common ual reproductive health to understand the natural menstrual cycle and to overcome stigmas and misinformation; and (iii) access to quality and affordable menstrual products to absorb menstrual Figure 1 blood and enable mobility and active participation in social life. Elements Required for a Holistic Approach Each of these three elements is in turn influenced by an enabling to MHH environment—the set of laws, processes, business environment, and policies—that influence product availability and pricing, dis- criminatory practices on social stigmas, or the standards on design of public sanitary facilities. Kenya stands out with its comprehensive policies and regulations related to menstrual health and hygiene, including being one of the first countries to have introduced tax reforms on menstrual hygiene products in an effort to make such products more afford- able. Despite momentum at the national policy level, women and girls in Kenya continue to face significant challenges in ade- quately and safely managing their menstrual health and hygiene. The experience and lessons learned in Kenya can therefore bene- fit other countries at earlier reform stages. Research in Kenya points to barriers to a holistic approach to MHH (see figure 1). In relation to supportive facilities, for instance, a study of 62 rural primary schools found that most schools (84 percent) had separate latrines for girls, but the maj­ ority (77 per- Source: World Bank. cent) had no lock, which is critical for privacy (Alexander et al. Note: MHH = menstrual health and hygiene. 2014). Only 13 percent of schools provided water in or near the Case Study: Kenya The Enabling Environment for Menstrual Health and Hygiene  |  2 for girls in Kenya to report no prior knowledge of menstruation with one single multinational corporation (i.e., Procter & Gamble) before their first menarche (Mason et al. 2013), and many of them controlling 63 percent of the market share with its brand of sani- associate menstruation with shame, fear, and confusion (McMa- tary pads (Fox 2020). In the 12-year period between the first and hon et al. 2011). Widespread taboos claim that menstruators are last tax policy introduction, the cost of a pack of eight sanitary polluted, which restricts their engagement in social life, such as pads fell by 17 percent—from $1.20 in 2004 to closer to $1 in 2016. interacting with men or eating certain foods (FSG 2016). Because With more than half of the population living on less than $1 a day, of associated stigma, the school curriculum in Kenya fails to treat the cost was still out of reach for many (Hallett 2016; Fox 2020). In the topic adequately, and girls remain uniformed and embarrassed an assessment of the effects of tax cuts on product affordability, to seek out information. One study found that only 12 percent of Ross and Rossouw (2020) found that between 2013 and 2018 san- girls reported feeling comfortable receiving information on men- itary pads became 10 percent more affordable due to a real price struation from their mothers (House, Mahon, and Cavill 2012). decline (adjusted to inflation), which translated to only an annual increase in affordability of 1.7 percent. In other words, even with a Access to menstrual products is another challenge. A study in 2015 price decline over time, the products remain unaffordable for the found that 65 percent of Kenyan girls and women were unable to vast majority of the population. afford adequate products because the cost of a package of sani- tary pads was equivalent to the daily wage of an unskilled worker Other policies introduced by the government have similarly mixed (SHOPS 2015). Lack of access to menstrual products can have effects. Evidence remains inconclusive on the effects of the man- severe implications on sexual reproductive health. A random- date to provide free sanitary products to schoolgirls. No study to ized control trial in Kenya found that 10 percent of 15-year-old date has demonstrated whether the provision of sanitary products girls self-reported having transactional sex to obtain sanitary pads has a direct correlation with school attendance (Austrian et al. (Phillips-Howard et al. 2015). 2021; Phillips-Howard 2016). However, the existence of the man- date does advance women’s rights in terms of paying attention to Overview of MHH-Related Policies in Kenya MHH and recognizing the importance that affordable and quality Government policies and legislation can create the enabling envi- menstrual products play. Moreover, anecdotal evidence suggests ronment to facilitate access to MHH-friendly facilities, informa- that the series of policies implemented since 2004 is corroding tion and knowledge on menstrual cycles, and quality and afford- the stigma attached to menstruation and leading to more open able menstrual products. To meet this end, the government of public discussions and national debates around the topic. Table Kenya has introduced several policies and legal reforms. In 2004, 1 summarizes each policy intervention, highlighting the advocacy the government repealed the value added tax on sanitary pads— behind getting it institutionalized and the evidence of its effects. one of the first countries in the world to do so (Welham 2020). In 2011, it reduced import duties on menstrual products (Jurga, Yates, Potential Lessons Learned and Bagel 2020), and then in 2016, the government removed Kenya’s experience with policy reforms and laws to address the duties on the raw materials needed to produce them. In paral- needs of menstruators reveals the complexity of the issue at hand. lel to these tax reforms, the government began to legally address Well-intended tax policy reforms do not automatically translate into the issue of access to products. In 2011, it introduced an annual improved affordability for consumers. Many other factors—such national budget allocation of $3 million to fund the distribution as the openness and competitiveness of the market, the resources of free sanitary pads in schools (Hallett 2016). In 2017, an amend- and scale of local enterprises, and the political will to advocate ment to the Kenyan Education Act mandated that schools provide for price and quality control—are all part of the equation of reduc- “free, sufficient, and quality” sanitary pads to every girl registered ing the prices of and expanding access to menstrual products. at school, thereby cementing the government’s commitment into Before deciding to introduce a tax change, it is advisable to con- law. Most recently, in 2020, the government approved the Men- duct a comprehensive assessment and diagnostic of the country strual Health and Management Policy 2019–2030, which lays out landscape to identify the primary drivers behind product prices a road map to ensure that menstruators have access to informa- and accessibility. A diagnostic ought to include, at minimum, an tion, menstrual products, and services and facilities, as well as the understanding of the following: ability to dispose of menstrual waste safely. MHH strategies are developed by the Ministry of Health, county departments, and rel- ¼ The drivers behind the pricing of menstrual products (e.g., evant stakeholders, which are also responsible for putting in place lack of demand, rate of taxes and duties, or uncompetitive a sound monitoring and evaluation framework for this policy. markets) ¼ Production structures and market competitiveness (e.g., in Outcomes of Policies to Date competitive markets, companies are incentivized to drop To date, the tax reforms introduced by the government appear to retail prices) have had minimal effect on the price of imported and locally made ¼ The drivers of demand and the heterogeneity between rural products. The price of sanitary pads in Kenya remains one of the and urban markets (e.g., are users unable to access men- highest in the region (Rossouw and Ross 2020), and commercial strual products because they are unaffordable or unavail- products are still unaffordable for most of the population (FSG able, a stigma is associated with purchasing them, or non- 2016). Kenya’s menstrual product market is largely uncompetitive, commercial menstrual products are preferred?) Case Study: Kenya The Enabling Environment for Menstrual Health and Hygiene  |  3 Table 1 Summary of Each Policy Reform Advocacy. The government that took office in 2002 ran on a promise of gender equality. Within this climate, female parliamentarians championed for improved access to menstrual health products (Fox 2020). In 2004, they succeeded in removing VAT on products and achieved other legal reforms to further gender equality. Value added tax (VAT) Effect. In 2004, although a VAT of 16 percent was removed, the price of products was reduced only minimally. According removal to interviews (Fox 2020), once the tax policy change was introduced, parliamentarians and civil society did not continue 2004 their advocacy on regulation and price control. The reduced VAT was absorbed by multinational businesses dominating a very uncompetitive market. With one single company controlling 63 percent of the market share of menstrual pads, it was not incentivized to drop retail prices (Ross and Rossouw 2020). Moreover, the prices set by the multinational businesses became the benchmark for other brands (Fox 2020). Advocacy. Civil society organizations engaged in budget deliberations as part of the 2010 constitutional requirement enabling citizens to participate in budget-making processes. They advocated the removal of the import tax on sanitary products as a way to address broader gender equality (Fox 2020). In 2011, import duties on menstrual products were removed. Import duty removal 2011 Effect. It was expected that after removing import duties, products would become more accessible and affordable since imported pads were the main product in the market. However, prices remained high and local manufacturing of menstru- al products went down. Local enterprises shifted their manufacturing base to China and imported sanitary pad packs (Fox 2020). Moreover, the government failed to introduce quality regulations, resulting in low-quality disposable products from China entering the market and creating health concerns (Fox 2020). Advocacy. Earlier tax policy reforms broke down some of the stigma attached to menstrual health and hygiene and opened up national deliberations. Sustained public debates on the affordability of menstrual products included the airing of the documentary “Period of Shame” on national television, featuring the challenges young girls in rural areas face because of menstruation, including the lack of menstrual pads. As a result, the decision was taken to spur the local production of menstrual products by removing the 16 percent VAT and 25 percent excise tax on imported raw materials VAT removal on imported (Fox 2020). material Effect. The removal of the excise tax was not enough to decrease the price of locally manufactured menstrual products. 2016 Producers face a host of additional costs that are not mitigated by reduced taxes, such as the cost of equipment and packaging (Fox 2020). Other barriers include small-scale, inadequate distribution channels and limited resources for mar- keting (FSG 2016). Restricted distribution of local products is particularly acute in remote and rural areas, where women and girls are left with limited options. Despite these hurdles, one study found that Kenya has seen a larger number of social enterprises entering the menstrual health space than other countries in the region (FSG 2016). However, the reach of these local products appears to be limited (Fox 2020). Advocacy.: In 2011 the government of Kenya announced the National Sanitary Towel Program and set aside $3 million to fund the free distribution of sanitary pads to low-income schools. Effect. The policy was a pre-election promise by the government, but it was not adequately implemented or monitored (Fox 2020). A survey of 62 primary schools in rural western Kenya found that only 10 percent reported always providing Free distribution of sanitary pads despite the program mandate (Alexander et al. 2014). There are also anecdotal reports of corruption, such products as suppliers providing less than the agreed-upon product quantity, and the deterioration of quality, including suppliers 2011 lowering the quality to obtain government contracts (FSG 2016). Because sanitary pads are inaccessible or unaffordable for many menstruators, girls may give the pads they receive in schools to their mothers, aunts, or other female family members.a Moreover, research to date has failed to make a connection between supplying adolescent schoolgirls with menstrual products (e.g., sanitary pads or menstrual cups) and seeing an effect on school absenteeism (Phillips-Howard et al. 2016; Austrian et al. 2021). Girls who have dropped out of school and refugees are left out of school programs (FSG 2016). Advocacy. A national level, multi-sectoral Menstrual Hygiene Management (MHM) Task Group within the Hygiene Promo- Basic Education tion Technical Working Group, led by the Ministry of Health, was instrumental in advancing the legal reform of the Basic Amendment Act Education Amendment Act (Fox 2020). The law provides schoolgirls who have reached puberty with free sanitary towels. 2017 Effect. As noted previously, Fox (2020) found that the government’s school distribution program is under-funded and plagued with a variety of inefficiencies. Advocacy. A national level multi-sectoral MHM Task Group within the Hygiene Promotion Technical Working Group, led by National Menstrual the Ministry of Health, was instrumental in advancing the national MHM policy. Hygiene Management Effect. The national policy is too nascent to observe impacts, however, its implementation is tied to performance indica- Policy tors. National and local governments together with stakeholders will collaboratively develop common national-, county-, 2019–2030 and community-level indicators to monitor performance and measure changes. Strategies and interventions will be continually monitored and regularly evaluated. Source: Original for this publication. a. Based on an interview conducted on April 6, 2022, with Tobias Omufwoko, chief executive officer of WASH Alliance Kenya; and Janet Mule, Principal Public Health Officer, Kenya Ministry of Health. Assessments may reveal that tax policy changes are not the most doi.org/10.1186/s12978-021-01223-7. Corburn, Jason, and Chantal Hildebrand. 2015. “Slum Sanitation and the Social effective tool to ensuring menstrual products are affordable, par- Determinants of Women’s Health in Nairobi, Kenya.” Journal of Environmental and ticularly for low-income consumers. Other fiscal solutions, such as Public Health 2015 (2015): 209505. 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Primary School Attendance and Reproductive Health Knowledge and Attitudes in https://assets.publishing.service.gov.uk/government/uploads/system/uploads/ Kenya: A Cluster Randomized Controlled Trial.” Reproductive Health 18 (179). https:// attachment_data/file/1008503/Query-50-Ethiopia-taxation-sanitary-products1.pdf. This case study was written by Gaia Hatzfeldt and Sarah Keener of the Water Global Practice Social Inclusion Team, in close collabora- tion with Lewnida Sara of the Water Global Practice Africa East Team. The case study benefited from the contributions of Janet Mule, principal public health officer of the Kenya Ministry of Health, and Tobias Omufwoko, chief executive officer of WASH Alliance Kenya. Connect with the Water Global Practice www.worldbank.org/water worldbankwater@worldbank.org https://twitter.com/WorldBankWater https://blogs.worldbank.org/water © 2022 International Bank for Reconstruction and Development / The World Bank. Some rights reserved. 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