Tackling menstrual health taboo in Uganda

AFRIpads has its origins in unlucky timing. Volunteering in rural Uganda in 2008, Sophia Grinvalds was caught unprepared one month and couldn’t find sanitary products in the village, so she sent her boyfriend to the nearest town, 40 minutes away by motorbike. Realizing their neighbors faced similar stress each month, the couple decided to do something. AFRIpads emerged, now one of Africa's largest manufacturers of reusable sanitary pads.

Long taboo, menstrual hygiene management is entering the mainstream. “When we started, MHM wasn't even an acronym,” Grinvalds recalled. Eight years on, Uganda’s Ministry of Education hosts monthly meetings on the topic and is producing a manual for schools. Globally, advocacy groups have marked Menstrual Hygiene Day each May 28 since 2014. Sales at AFRIpads, meanwhile, doubled from March 2015 to July 2016, with up to 70,000 washable pads now produced per month at a plant — largely staffed by women — in Masaka, southwest Uganda.

From aid to commercial market

Around 30 percent of Ugandan women and girls use disposable products, Grinvalds estimates. Usually imported, these sell for around 3,500 shillings or more for a pack of 10 pads (just over $1). Most women instead use pieces of cloth or foam mattress, toilet paper, newspaper or banana plant fibers — which are unhygienic, ineffective and uncomfortable. Some girls complain of chafing so painful they can’t walk to school.

Small-scale production of washable pads is common in Africa, but their success varies. Africa Educational Trust initially trained women and girls in northern Uganda to make sanitary pads from locally sourced materials, a spokesperson told Devex. But users reported inconsistent quality and comfort, so since June 2016 the nongovernmental organization distributes AFRIpads instead.

AFRIpads’ as many as 200 NGO clients in 2016 range from church groups buying 50 packs at a time, to major international organizations, including Save the Children and the International Federation of the Red Cross. “Most women report that [the pads are] soft and very comfortable and do not cause skin irritation,” said Racheal Waithaka, a public health manager at the Kenya Red Cross. Another benefit is the low overall cost, she added.  

Cracking the consumer market is the next challenge for AFRIpads. In July 2015 they launched a new retail brand, So Sure — the same product they supply to relief organizations, but with “more aspirational” and consumer-facing branding, said Grinvalds, who added that they’re also more affordable than disposables at just under $2 for a two-pack that lasts one year. AFRIpads sells the product to consumers in Kenya and plans to open an office in Malawi in September to handle NGO and individual customers there.

More than a product

Over 50,000 packs of So Sure were sold in the first half of this year. But reaching the last mile consumer remains “a major challenge” because of underdeveloped distribution infrastructure and time needed to build brand awareness and trust, said Grinvalds. AFRIpads tackles this in part by working with partners — Living Goods, a social enterprise, and international development organization BRAC — whose networks of community health promoters sell products door-to-door.

Distribution and access are key, agreed Emily Wilson-Smith, co-founder and director of Irise International, a hybrid charity and social enterprise based in Jinja, Uganda. “There’s a tendency to focus on the product — but that’s the easy bit,” she said.

Irise sells their own brand of reusable cloth pads, also distributing disposable pads and menstrual cups, but they place equal focus on ensuring the demand exists. Talking to girls helps address common misconceptions about menstrual health, and is also “a subtle way to start conversations” about more sensitive reproductive health issues, Wilson-Smith said. Irise’s outreach also covers organizations, health workers and communities — including men, who often control the family budget. Awareness activities include radio adverts appealing to a father’s desire to see his daughter graduate, or to his status in the community.

While reusable pads are a better option where disposal is problematic, they do require a shift of mindset, the Red Cross’s Waithaka said: users must overcome shyness about washing and hanging used pads, or carrying them around all day to wash at home. And the need to overcome conventional practices isn’t exclusive to reusables.

“[Buying sanitary pads] is not seen as a necessity, especially when a makeshift alternative exists,” said Moses Musaazi, founder of Technology For Tomorrow, a research and development arm of Makerere University, and inventor of MakaPads, claimed to be the only over 90 percent biodegradable, super-absorbent, commercially produced pad in the world. But, he said, the idea of buying a pad for certain occasions, such as going to church, “has begun to trickle into people’s minds.” Small quantity packs — MakaPads come in packs of three, sold at 700 shillings ($0.20) — makes them more accessible, while using papyrus, an abundant, local and absorbent material, also keeps costs low.

Competing brands

For six years, T4T’s only major client was the U.N. High Commission for Refugees, an agreement that saw the company selling up to half a million packs per year and directly employing 240 people, also involving refugees in the supply chain. Last year, though, UNHCR put a stop to all orders, raising quality concerns.

Musaazi said that MakaPads have been quality certified by Uganda’s national standards body every year since 2006; he sees UNHCR’s decision as a case of “reject[ing] a local product in favor of imported pads.” It’s unclear if this was indeed a factor — a UNHCR spokesperson told Devex only that refugees “weren’t always happy with the product” and had not been using them as much as hoped. However, Wilson-Smith, describing the challenge of building brand recognition, said that people can be “suspicious of African products.”

T4T is negotiating a new memorandum with UNHCR and the Ugandan government, according to Musaazi, and in the meantime marketing MakaPads directly to schools. They also hope to capitalize on the government’s drive to keep girls in school by ensuring adequate sanitary supplies: “We hope we will be part of their supply chain,” he said.

There are opportunities abroad, too: MakaPads have previously been sold in Mozambique, South Africa, Tanzania and Kenya, Musaazi said. In Sierra Leone, Australian nonprofit One Girl has been selling them for several years as part of their MHM and entrepreneurship program — and are looking to expand the program thanks to the success of MakaPads, One Girl told Devex.

Ultimately, a mix of products and some healthy competition is good news for women and girls everywhere. As Callum Smith, head of operations at Irise, put it: “Girls deserve choice, especially affordable choice.”

Making Markets Work is an online conversation to explore what’s being done to make global health care markets accessible to people at the base of the pyramid. Over 10 weeks, we will amplify the discussion around effective health financing, analyze key challenges blocking universal market access in the health care supply chain, and explore the key strategies to make markets more effective. Join us as we look at this important issue, and share your thoughts by tagging #MakingMarketsWork and @Devex.