Colombo Telegraph

Menstrual Hygiene, A Necessity Not A Luxury

By Amita Arudpragasam

Amita Arudpragasam

Of 4.2 million menstruating women in Sri Lanka, only 30% use disposable sanitary napkins.[1]Given the stigma surrounding menstruation, many Sri Lankans – including policy makers – are unaware of the impacts of poor menstrual hygiene management (MHM). [2]This is worrying because poor MHM poses significant health risks including urogenital infections and cervical cancer. Additionally, poor MHM may adversely impact female educational performance and female labour force participation.

The problem is not that Sri Lankan women don’t know that menstrual hygiene is important or that they don’t know how to practice better menstrual hygiene.[3]Menstrual health products, like sanitary napkins, are simply too expensive. Indeed, as noted below, the annual cost of good menstrual health management can equal the amount the average household would spend on a two-month supply of rice!

On September 19th Sri Lanka’s Finance Minister indicated that sanitary napkins would be exempted from Cess. This is good progress towards making menstrual hygiene products affordable, however eliminating border taxes won’t fully address poor MHM. By itself, this policy may only advantage a wealthy subset of Sri Lankan women. To impact lower and middle-income households, I recommend the government also exempt sanitary napkins from the Value Added Tax (VAT) and Nation Building Tax (NBT). I further recommend the government provide subsidised menstrual hygiene products to women who cannot afford them.

Health Risks 

The health risks associated with poor MHM include bacterial vaginosis (BV) and urinary tract infection (UTI).[4]A 2017 hospital-based cross sectional study shows that the incidence of UTIs in Sri Lanka is increasing and that increasing resistance is likely to add a significant burden to Sri Lanka’s health budget. UTIs, while common, should not be taken lightly. If untreated, microbes can spread from the urinary tract and cause permanent damage to the kidneys.[5]Cases of BV, another health risk associated with poor MHM, reportedly doubled in Sri Lanka between 2006 and 2010.[6]Numerous studies show that women with BV may be at higher risk of early or preterm birth, loss of pregnancy, pelvic inflammatory disease and the acquisition of sexually transmitted infections.

Studies also consider poor menstrual hygiene a risk factor for cervical cancer[7]- which incidentally, is the second-most common type of cancer for Sri Lankan women.[8]According to the HPV Information Center, “current estimates indicate that every year 1721 [Sri Lankan] women are diagnosed with cervical cancer and 690 die from the disease.”

A controlled study of 486 women concludes that, compared to women using disposable pads, women who used reusable absorbent pads were more likely to have symptoms of urogenital infection or to be diagnosed with at least one urogenital infection. Gynaecologists recommend products such as disposable sanitation napkins (pads), tampons or cups for better menstrual hygiene. Because such products are intimately linked to a woman’s well-being, they are not ordinary consumer goods, but ought to be considered necessities.

Menstrual Hygiene is currently a Luxury

Of the 70% of menstruating Sri Lankan women who do not use disposable sanitary napkins[9]many will use semi-hygienic reusable alternatives such as cloths or rags. Why? Despite useful programs to raise sexual health awareness, including by the UN, many women cannot afford better sanitary products.

Indeed, buying domestically manufactured pads can cost 1.2 – 3.7 % of an individual’s income.[10]Good menstrual hygiene management requires a change of sanitary napkins every 2 – 6 hours for the 3 – 6 days per month that a woman menstruates.[11]A domestically manufactured sanitary napkin costs Rs. 11.5, while its imported counterpart costs Rs. 22.[12]This means that every year a menstruating female must spend at least Rs. 1656 on sanitary napkins if her flow is light and cycle short, or Rs. 4968 if her flow is slightly heavier and cycle longer.[13](Imported products, which are twice as expensive, were not included in this calculation). A woman with a heavy menstrual flow and longer cycle can thus expect her annual expenditure on menstrual hygiene products to equal the amount her entire household would spend on a two-month supply of rice![14]

Women living in rural areas will be most impacted by high-cost sanitary products – not just because household incomes are lower in these areas. Poor sanitation and water access in rural areas can make washing reusable alternatives for women extremely difficult.[15]  When reusable alternatives are not properly washed and dried, the impacts on health are severe.

Other reasons the State should care

Aside from the aforementioned health risks, poor MHM should be of concern to the state for three other reasons:

Impact on Education:Menstrual hygiene products can improve pain management and prevent staining. In a survey of adolescent Sri Lankan girls slightly more than a third claimed to miss school because of menstruation; 68% – 81% cited pain and physical discomfort and 23% – 40% cited fear of staining clothes to explain why. Extrapolating from these results, Sri Lankan girls loose (very conservatively) approximately 1.3 million learning days every year.[16]And school absenteeism may only be one way in which educational performance is impacted. This study suggests that poor MHM may impact concentration and engagement, even if girls do go to school.

Impact on female labour force participation:Sri Lanka’s low female labour force participation rate (35.9%) is predicted to cost the country 20 Billion USD by 2025.[17][18]While cheaper menstrual hygiene products will not completely fix low labour participation rates, they are still critical from an economic perspective. For example, a study on apparel sector workers in Bangladesh found that providing subsidized menstrual hygiene products resulted in a drop in absenteeism and an increase in productivity. Because employees in the Sri Lankan apparel sector are also predominantly women, access to cheaper menstrual products can help this sector be more productive.

Normative Obligations: Many evidence-based studies demonstrate that shame, insecurity, anxiety and fear of stigma are correlated with menstruation. Menstrual cramps can already be painful, but when a woman cannot afford basic menstrual hygiene, she faces additional indignity and embarrassment. Activists have begun to reframe access to menstrual hygiene products as an issue of human rights. When menstrual hygiene is unaffordable the right to healthcare, education and work is effectively impeded. Although access to healthcare in Sri Lanka is not a judicially enforceable constitutional right, it is a directive principle of state policy.[19]The constitution thus recognizes the state’s normative obligation to provide healthcare to its citizens. Currently, menstrual hygiene – a prerequisite for good health –  is the reserve of the Sri Lankan upper class.

Policy Recommendation: How to make menstrual hygiene affordable

In the last decade, several countries have begun to exempt sanitary products from taxes.[20]For example, this November, a Delhi high court noted that sanitary napkins were a necessity rather than a luxury. India’s Goods and Services Council subsequently exempted sanitary napkins from the year-old goods and services tax regime in July 2018.

Exempting products from taxes is not alien to Sri Lankan practice either. Under certain conditions, cigarettes and liquor are exempt from NBT.[21]Items like helicopters and designer pens are exempt from VAT. And the Inland Revenue Department’s Schedule of Tax Exempt Goods and Services often contains several health-related items including non-cosmetic drugs and pharmaceutical products. Wheel chairs, hearing aids, and spectacle frames are also VAT-exempt.[22]

This memo outlines three possible ways to make menstrual hygiene more affordable:

1) Eliminate Cess and PAL 

Sanitary napkins are either imported or domestically manufactured. Due to border taxes, imported napkins can be twice as expensive as domestically manufactured napkins. Domestically manufactured napkins are subject to a VAT of 15 percent and NBT of 2 percent. Imported napkins, however, are also subject to a general import duty of 30 percent, import Cess of 30 percent and a Port and Airport Development Levy (PAL) of 7.5 percent. Advocata Institute notes, “imported sanitary napkins and tampons in Sri Lanka are taxed at over 100% their landed cost.”

While a general duty exemption may be difficult to negotiate, the government could relatively easily exempt imported menstrual hygiene products from PAL and Cess. Indeed, the government recently announced plans to eliminate Cess. Assuming prices fall by the same amount as the exemptions (i.e. a 100% pass-through), imported napkin prices will fall by approximately 22.4% from Rs. 22 to Rs. 17 per napkin.[23]However, if the resultant price of imported napkins remains higher than the price of domestically manufactured napkins, this policy approach will only benefit the small subset of wealthier women who could already afford more expensive imported napkins.

One could counter that reducing border taxes will increase local market competition and so lower the price of domestically manufactured napkins – but this is not guaranteed. Indeed, assuming a competitive market, lowering border taxes can have one of several unpredictable knock-on effects. For example, domestic manufacturers may: 1) exit the market, 2) improve the quality of their products, 3) lower the price of their products, or 4) not alter their behaviour at all. An indirect price reduction is thus not guaranteed. If the price of domestically manufactured pads does not change, the impact on the average Sri Lankan woman is of little consequence. The cheaper domestically manufactured pads that were unaffordable before the border tax exemption will still be unaffordable.

2) Eliminate VAT and NBT 

While exempting sanitary napkins from PAL/Cess can indirectlyreduce the price of domestically manufactured napkins, a VAT and NBT will directlyreduce the prices of these products. Assuming 100% pass-through, VAT and NBT tax exemptions can lower the price of domestically manufactured sanitary napkins by approximately 17% from Rs.11.5 to Rs. 9.55.[24]This price reduction will encourage at least some women that were previously unable to afford sanitary napkins to start buying napkins. Together with the removal of border taxes, new firms (local and international) will be encouraged to enter the market for sanitary napkins. This increased competition can further drive down the prices of sanitary napkins.

Opponents of this policy may argue that lowering taxes will cause a significant drop in government revenue. However, given that that so few women currently buy menstrual hygiene products – any resultant loss of government revenue is likely to be minimal.[25]In any case, the long run health, educational and labour losses the country will incur if women do not practice better menstrual hygiene outweigh any such losses.

3) Provide subsidized products to low-income households

Some women may not be able to afford sanitary napkins even if the above tax policies drive prices to Rs.10 or below per napkin. If the government wants to impact these women, it can sell subsidized menstrual hygiene products in Lanka Sathosa outlets, provide free products in schools (particularly where there is poor access to water) and to low-income families who are already registered for social welfare schemes such as Samurdhi. This approach allows the government to promote eco-friendly and biodegradable products that limit the amount of waste created.[26]

Such approach is not without precedent, particularly since there is increasing global awareness about the risks associated with poor menstrual hygiene. For example, the Indian government began selling subsidized biodegradable sanitary napkins in May this year at INR 2.5 per pad. In June 2017 Eva announced a campaign to distribute free sanitary napkins to women in rural regions in partnership with the Ministry of Women and Child Affairs and the National Child Protection Authority of Sri Lanka. Such programs must be institutionalized, as part of state policy, to have long-term impacts.[27]

From a normative standpoint, it is clear why good menstrual hygiene shouldn’t be a luxury good available only to a select group of women. From a practical standpoint, this article demonstrates how the entire country can benefit when menstrual hygiene becomes affordable.

Acknowledgements

The author would like to thank the Census and Statistics Department for promptly providing retail data, the Sri Lankan industry experts who shared their knowledge, and Chris Avery and Ben Waltmann for their invaluable insights on taxation theory.

Full version: https://aarudpra.wordpress.com/2018/09/21/menstrual-hygiene-a-necessity-not-a-luxury/

Endnotes:

[1]https://roar.media/english/life/in-the-know/menstrual-waste-taxes-and-cups-the-impact-of-bleeding-in-srilanka/

[2]This author prefers to use the term menstrual healthmanagement, to emphasize the health risks associated with poor management of menstruation. She also recognizes that “hygiene” is often associated with impurity or uncleanliness and may reinforce existing stereotypes surrounding menstruation. However, because ‘hygiene’ is the term used frequently often in this literature, the author regretfully reproduces it in order to prevent confusion.

[3]Page 34, 35 of UNICEF’S KAPB study notes, “knowledge about menstrual hygiene, in terms of maintaining hygiene during menstruation, was high among adolescent girl students. The key reasons cited for bathing during menstruation were cleanliness, keeping free of germs and prevention of infections.” Indeed, over 85% of adolescent girls surveyed accepted that it was important to maintain hygiene during menstruation (periods) to prevent infections.

[4]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4488331/

[5]https://jamanetwork.com/journals/jama/fullarticle/1150097

[6]Bacterial Vaginosis: Global Status, by Gideon Informatics, Inc. Dr. Stephen Berger.

[7]Also see: https://www.ncbi.nlm.nih.gov/pubmed/14716127

[8]http://www.sundaytimes.lk/170625/news/a-vaccination-to-prevent-cervical-cancer-246620.html

[9]https://roar.media/english/life/in-the-know/menstrual-waste-taxes-and-cups-the-impact-of-bleeding-in-srilanka/

[10]Median per capita monthly income is Rs. 11,307 based on page 9 of the “Household Income and Expenditure Survey 2016.”

[11]Exact figures will depend on individual flows, but the parameters used here are based on Menstrual Hygiene Management Guidelines published by the UNICEF

[12]On September 8th2018, imported Whisper napkins cost Rs. 22 per napkin (440 Rs. for 20 napkins), while domestically manufactured Eva napkins cost Rs. 11.5 per napkin (230 Rs. for 20 napkins). These brands were used to model prices as they are market leaders in the imported and domestic categories respectively.

[13]Light flow is defined here as a woman who menstruates 3 days a week and requires a new pad every 6 hours (4 pads a day), while heavy flow and long cycle is defined as a woman who menstruates 6 days a week and requires a new pad every 4 hours (6 pads per day).

[14]The average monthly household expenditure on rice in 2016 was Rs. 2,452. See Table H2 in the “Household Income and Expenditure Survey 2016.” A two-month supply of rice would cost this household Rs. 4904. As established previously, a woman with heavy flow and long cycle must spend Rs. 4968 per year to maintain good menstrual hygiene.

[15]According to a 2016 Word Bank study, unlike in urban areas, where piped water supply is the norm, less than 15 percent of Sri Lanka’s rural population has access to piped water, and the rest continue to experience the inconveniences associated with fetching water either from dug wells in the yard or from a distance (pg 21).  Further, while 90% of urban and rural populations have access to toilet facilities within their premises, in rural regions there is a higher possibility of polluted groundwater in the household compound given the number of individually constructed toilets across rural Sri Lanka (pg 30).

[16]The 1.1298 million figure is based on conservative calculations. Figures used in calculations are based on the 2002 School and Census Report (which records that there are 991,063 adolescent girls or girls in grade 7 and above), the UNICEF KAPB study (which notes that of these adolescent girls, 38% or 376,604 will miss at least one day of school per month), and the author’s projection of the number of school days these girls will miss per year (very conservatively taken as 3 school days missed per year, given school holidays).

[17]According to the Department of Census and Statistics’ 2015 Labour Force Survey data, of the working age population, only 35.9% of females were engaged in the labour market, compared to nearly 75% of males. (see: http://www.ips.lk/talkingeconomics/2017/07/27/women-in-the-sri-lankan-workforce-dissecting-education-and-female-labour-force-participation/)

[18]See: https://www.mckinsey.com/~/media/McKinsey/Featured%20Insights/Gender%20Equality/The%20power%20of%20parity%20Advancing%20womens%20equality%20in%20Asia%20Pacific/MGI-The-power-of-parity-Advancing-womens-equality-in-Asia-pacific-Full-report.ashx

[19]Article 27 2 (c) of Sri Lanka’s constitution notes that, “the realization by all citizens of an adequate standard of living for themselves and their families, including adequate food, clothing and housing, the continual improvement of living conditions and the full enjoyment of leisure and social and cultural opportunities.” Sri Lanka also ratified the International Covenant on Economic, Social and Cultural Rights on 11 June 1980.

[20]In 2000, the UK reduced VAT on sanitary napkins. In 2004, Kenya repealed its VAT on pads and tampons to lower the cost for consumers. Nigeria and Mauritius followed suit. In 2015, Canada repealed a Federal tax on tampons. And since 2016, 24 of 40 US States have eliminated taxes on menstrual products.

[21]http://www.ird.gov.lk/en/Type%20of%20Taxes/SitePages/nation%20building%20tax(nbt).aspx

[22]Ibid.

[23]Price projections are modelled on imported Whisper napkins, which cost Rs. 22 per napkin. See table for calculations and assumptions.

[24]Price projections are modelled on imported Eva napkins, which cost Rs.11.5 per napkin. See table for calculations and assumptions.

[25]Assuming that of the 1.26 million women who use pads, 70% of women have light flow (144 pads per year) and the rest have heavy flow (432 pads per year), about 290 million pads will be bought every year. Because NBT + VAT account for Rs. 1.48 per napkin, then the total government revenue lost as a result of this policy will be approximately Rs. 430 million.

[26]To learn more about the waste created as a result of disposable sanitary napkins, see: https://roar.media/english/life/in-the-know/menstrual-waste-taxes-and-cups-the-impact-of-bleeding-in-srilanka/

[27]The Ministry Women & Child Affairs did not respond to requests for details on the duration of this initiative, the cost, and the number of households impacted.

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