Addis Meleskachew

JUNE 2018

UNICEF PROGRAM FOR MHM PRODUCTS SUPPLY CHAIN AND BUSINESS REVIEW

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Contents

Executive Summary ................................................................................................................................ 2

Background ............................................................................................................................................. 2

Scope of the assignment and design ...................................................................................................... 4

Study Design and Target Population ...................................................................................................... 5

Result and Discussion ............................................................................................................................. 7

Dimensional results .............................................................................................................................. 14

Conclusion and Recommendations ...................................................................................................... 20

Menstrual Products Market Analysis ................................................................................................... 21

Background of the market assessment exercise .................................................................................. 22

Summary of Market Findings ............................................................................................................... 23

Proposed Solutions ............................................................................................................................... 30

Recommendations................................................................................................................................ 32

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Executive Summary

Women and girls who use unhygienic alternatives for sanitary pads not only face health

issues, but also miss school and the freedom to work and play even out of school. Indeed,

most girls in rural Ethiopia do not use adequate female hygiene products and have very

limited access to WASH facilities to keep themselves hygienic at the time of menstruation.

This lack of use negatively affects their self-esteem and participation in education and

development and ultimately, in society.

Small scale enterprises have responded by developing low-cost methods of sanitary pad

production coupled with innovative models for distribution and marketing. In this business

model women are supposed to be included in all the value chain as entrepreneur, producer,

distributor, promoter and consumers as well. The UNICEF project is aiming to address the gap

of both the knowledge and product accessibility with this program.

Background

Globally, lack of accessible and affordable sanitary pads has been known to have far reaching

implications on the social, psychological and physical health of teenage girls and young

women. In Ethiopia, access to sanitary pads and information on reproductive health is

concentrated only in major centers and less in the rural and peri-urban areas. The problem

of adequately managing menstruation has been identified in women and may hinder

educational development through increased school absenteeism. Whilst good menstrual

hygiene remains an important factor in maintaining the physical and mental wellbeing of

women, menstrual hygiene management remains a poorly addressed area.

Most school girls in Ethiopia are not receiving adequate support from home, schools, or the

community. To address this, UNICEF Ethiopia is implementing a project, begun in 2016, with

the objective of ensuring the safety, dignity and empowerment of adolescent girls at the

same time contributing to the retention of adolescent girls in schools at the critical time of

menstruation. The four-year program is designed to be in line with national priorities and

direction, and seeks to empower girls and women of low to middle income in six regions:

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Amhara, Afar, Somali, Oromia, Gambella and Southern Nations, Nationalities and Peoples’

(SNNP). Part of the program aims to support local production of menstrual hygiene

management materials and increase access to the product at an affordable price. UNICEF

have supported cooperatives with male and female members by training and establishing

enterprises to eventually support the availability of the product in the abovementioned

regions.

The program entails a comprehensive component of Social Behavior change communication

(SBCC) of school girls, boys and surrounding communities targeting:

• Providing basic pre and post menarche information

• Enhancing boys’ involvement

• Tackling social/cultural beliefs and taboos in the community

• Upgrading WASH/MHM facilities, establishment of safe spaces

• Strengthening/creating the supply chain for sanitary pad production for rural

consumer.

Part of the advocacy program also aims to address the inclusion of MHM into the Health

Extension Program (HEP), extra education curriculum and establishment of standards for

reusable and disposable sanitary pads at national level.

This assignment was mainly focusing on assessing the performance of production and

distribution of MHM materials in selected woredas as well as assessing the impact of

supporting facilities to convey the behavior change activities in school communities. In view

of that, the report emphasises understanding the context and challenges of local producers

from the supply point of view and their method of availing their products to the target groups.

Menstrual Hygiene Management (MHM) in Ethiopia is a topic that has gained increasing

attention in recent years from various actors, including the water and sanitation, education,

and health communities, mainly because of its potential impact on school attendance. To

manage menstruation hygienically and with dignity, it is essential that women and girls have

access to water and sanitation, a private place to change sanitary cloths or pads, clean water

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and soap and a clean place to dry pads if reusable. Though menstruation is a natural process,

in most parts of Ethiopia it is taboo and rarely discussed. The impact of poor menstrual

hygiene on the psycho-social wellbeing of women and girls (e.g. stress levels, fear and

embarrassment, and social exclusion during menstruation) should also be considered in such

kinds of program.

Despite the support and some initiatives happening on the ground, in Ethiopia accessing

MHM products at an affordable price for the girls and women remains a big challenge due to

the following factors:

• Awareness and knowledge about menstruation

• Supply and access of menstrual protection materials

• Provision of physical WASH infrastructure in school

There are also health issues to consider in addition to the cultural taboo, myth and product

availability. Poor protection and inadequate washing facilities may increase susceptibility to

infection, with the odor of menstrual blood putting girls at risk of being stigmatized. (Kirk &

Sommer 2006).

Scope of the assignment and design

Initially, the was divided into phase I - assess the success and sustainability of the current

Amhara sanitary pad producers, and the change that they have had within community and

phase II was to focus on the other project implementing areas Oromia, SNNP, Gambella, Afar,

and Somali), to assess the business feasibility and opportunities. However, due to different

factors on the ground (security and access), the assessment was done in one phase. This

report comprises of this phase and recommended strategies.

The objectives of this study were to:

o Assess project progress and analyse bottlenecks for local producers

o Assess the business sustainability, feasibility and opportunity

o Assess user challenges, best sales and marketing strategy.

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After a thorough assessment and analysis of those abovementioned areas this exercise has

included developing a context-based workable document of possible options for establishing

effective supply chain of local sanitary products. Accordingly, this report entails

recommended supply options, marketing approaches, and business plans for each region.

Study Design and Target Population

The Supply Chain System development exercise in general and the field assessment was

conducted by involving all partners and stakeholders engaged at both program and market

level. It also used the research methodologies of secondary data collection and Benchmark

research which rely on participants’ knowledge of the conditions.

The tools used to collect data at the field level included:

1. Focus Group Discussion (FGD)

o Students (girls & boys)

o Women (out of school)

The targets for the FGDs were girls and women who are the product users. Women and girls

were targeted to assess any user challenges in accessing products and challenges in relation

to attending class or doing any routine activities during their period.

2. Key Informant Interview (KII)

o Health bureau, education bureau officers, teachers and MHM club counselors

were interviewed.

These groups were interviewed to gather various information including their experience in

supporting producers, and to identify user associated challenges to access MHM products

including in schools. Discussions have taken place with the reusable product producers in

Amhara, Oromia (Shone and Sire) and Jigjiga producer of Somali to understand their level of

engagement in the production, purchase of raw material, business management and future

plans in regards to their business growth.

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3. Participatory Field Observation

o Safe space and MHM product, WASH facilities (including latrine, washing

facility and water)

o BCC supporting tools (poster, school friendly print materials, billboards, promo

materials at the production places)

Detail of the geographic and administration location of the study area presented in Map

annexed

The table below is list of wordas and study sites in all region

Region Woreda Participants

Female Male

Gambella

Gog 12 11

Lare 10 8

Somali Jigjiga 11 5

Degahabour 13 7

Afar

Asayita 10 5

Brhale 10 0

SNNPR East Badaoacho 17 5

Gibe 10 7

Amhara

Maksegnit (Enfranz) 13 3

Basoliben 10 3

Oromia

Shone 3 5

Sire 14 5

Merti 13 6

Total number of FGD participants 146 70

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Result and Discussion

All the results presented in this part of the document are drawn from a qualitative study

conducted in the following dates:

1. Oromia - Shone(Feb 2-3/18)

2. Gambella – Gog and Lare (Feb 6-10/18)

3. Somali – Jigjiga and Degahabur (Feb 20-24/18)

4. Afar – Asayita and Berehale (March 19-22/18)

5. SNNPR – East Badowaocho and Gibe (April 10 – 13/18)

6. Amhara – Basoliben & Maksegnit (April 17-20)

7. Oromia- Sire & Merti (17 -19/18)

Program Findings (school Interventions)

The assessment excluded any girls who had not started menstruating. However, it was

decided to include primary schools in our study. Often in rural Ethiopia primary schools

students are older than the average urban students. In most countries girls are estimated to

start their periods around the age of moving between primary and secondary school. We

completed the FGDs in six regions of 13 woreda with 146 female students and 70 male

students.

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Menstrual Hygiene Management: Hardware

Sanitary pads

The choice of sanitary protection is very much a personal decision based on cultural

acceptability. It is often influenced by access to finance, WASH supplies and affordable

options. Many girls interviewed in this assessment cannot afford disposable sanitary pads on

a monthly basis, or those who can pay do not have easy access for the products nearby. 27%

of school girls in this assessment have never used sanitary pads, and instead use alternatives

such as rags, blankets, or whatever absorbent materials are available before they start to

access it from the school.

Although, cloths/cloth pads might be sustainable sanitary option, it must be hygienically

washed and dried in sunlight. However, the focus group discussion revealed that some of the

girls are still ashamed of washing and drying it and are doing this out of sight.

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“I hid my sanitary cloths under the bed to dry, out of shame. I even do this during late

night when everybody fall asleep”

Primary school girl in SNNPR (East Badowacho)

This experience is common in Amhara where many of the participants shared similar stories.

The primary school director in Amhara (Basoliben) said that several girls have dropped out of

school because of stigma associated with the inability to have sanitary pads. This, in the long

run, restricts girls from accessing education.

Two key findings about sanitary pads in all regions:

o Provision of free products had a positive impact in two ways:

o It gave girls exposure to new, quality and applicable methods of handling

menstruation

o It supported in school girls who are not able to pay for pads consistently

o However, most of girls across the regions reflected that sustainability of pads

provision can be a problem. For this reason, students suggested the following

options:

o Supporting low-cost local production offers a more sustainable solution

than free provision of menstrual hygiene products.

o Train students to prepare their pads at home with appropriate and

available products.

o Except Gambella region, reusable product are favoured against the disposable pads.

It is perceived as economical, practical and sustainable for school girls.

Infrastructure

Girls who lack adequate sanitary materials may miss school each month during their period.

If girls attend schools which lack adequate latrines and water supplies to comfortably change

sanitary materials and wash themselves in privacy, they will be unable to remain comfortably

in class. To measure the effect of all these facilities and BCC intervention on the learning and

teaching process in school, we measured school absenteeism in relation to MHM. However,

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schools haven’t implemented an organized recording tool to show us their current data to

compare with the last two – three years.

We asked teachers if there is any change on the performance and absenteeism of girls.

“Two – three years before, our girl students were not comfortable to attend classes when they

menstruate due to poor infrastructure. Even if they come to class they can’t attend their class

attentively due to fear of blood stain on their cloth resulting shame. But now, the facility is

somehow good and allowing them to attend their class. Since 2016 our girl’s attendance is

progressing and now it is improving by 90%”

Degehabur primary School director

“Girls are now determined to attend school

throughout menstruation, since there is

sufficient facilities with emergency sanitary

pads provision. Four of the top student in this

school last year were girls and we also expect

more this year. I believe this program had a

significant impact on this result.’’

High School Director in Merti Woreda

With the questionnaire we had aimed to ascertain whether menstruation was a cause of

absenteeism:

“In a normal month, how often have you missed school because of the reasons including:

housework, looking after younger brothers or sisters; illness; menstruation?

Only a few students responded that household chores might obliged them to stay at home,

but pain during menstruation affects class attendance. In all UNICEF intervention woredas,

school WASH infrastructures are in a good shape and significantly encourage girl student

attendance.

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“When you are here in school during menstruation you can access water, safe space

to rest without interruption, water and toilet which is private, with water and a place

to dispose used pads. Above all our teachers understands you regarding this matter

than your family, so you will be safe here”

Primary school girl in SNNPR (East Badowacho Woreda)

In schools such as in Somali Region (all the three schools visited in Jigjiga & Degahabur), Afar

(Berhale) and Oromia (Shone and Merti) the safe spaces are isolated from the other classes.

In Somali, it is even separated with a fence from the main compound with a sign indicating

girl’s room. Girls were asked if they don’t want to be watched by other students when they

come to use the safe space, as it is giving a very clear indication that the girl is menstruating.

Most of the respondents, except Gambella students, explained that MHM issue in school is

becoming one of the agendas with visible progresses.

“The more we talk about it, and when boys

see how much emphasis is given in school

(seeing the safe spaces, sign boards and

events) the issue is becoming very normal.

And we expect more support from them.”

Primary school girl in Oromia (Merti)

“In the beginning it was very hard to use this class especially when boy are around. But now

they get used to it and know the purpose and don’t tease on us.”

Primary School girl in Shone (Oromia)

“There is nothing to be ashamed of. It is natural and even mentioned in our Quran. Our

brothers are now helpful. We also have boys’ club member.”

High school girl in Jigjiga (Somali)

There are also challenges highlighted by female students including inadequate cleaning

supplies such as soap. Proper latrine utilization and consistent flow of water is also a

problem. In most of the visited schools (90%) there is access to latrines, safe space and

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washing spaces including shower and handwashing devices. However, in Afar, Enfranz in

Amhara, East Badowacho in SNNPR and Degehabour in Somali, schools have a high scarcity

of water.

Knowledge and attitude about menstruation

Both girl and boy students as well as male and female teachers were asked to assess their

knowledge and attitude on menstruation. The school community hadn’t had a chance to

acquire adequate knowledge of reproductive health in general, and menstrual hygiene in

particular, which leaves them susceptible to myths and misconceptions. To fill this gap, the

current MHM club is contributing a lot in providing education at informal knowledge sharing

sessions, and formal events (not widely). A small number of trainings (Somali, Amhara, SNNPR

and Oromia) have been undertaken by the teachers and counseling club counselors.

However, there is still a gap in efficient use of available media including school mini media,

organizing targeted events and message dissemination methods. In general, Somali students

have a relatively high subject matter knowledge and Gambella is the lowest. The following

quotes are taken from the FGDs to show their level of understanding.

“It is a normal growth phenomenon in girls”; “It is a gift from God for female and a sign for

having babies”; “It is sign of maturity for girls”

From boys FGD in Gambella region (Gog) one of the participant said; “It is a disease on female

from age of 15, for few days in each month” Sadly, most of the male participants in the FGD

have agreed with this statement.

Amhara (Enfranz) region girls FGDs

“It is a normal growth phenomenon in girl; and a gift from God to bear baby and ensure

continuation of the generation”; “It is a sign of maturity and biological phase of girls.”; “It is

from Allah, not a sign of any abnormality”

Somali region FGDs discussion both with boys and girls revealed that there is a relatively

better knowledge about period.

“It is growth phenomena in girls, when she reaches that age. It has an advantage for having

baby, health life, and directly related with reproduction.” (Girl student in Degahabour)

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In another girl FGD a

participant said “My parents

told me that when a girl reach

at age 15, she will experience a

blood from her reproductive

organ, and it is a normal

growth phenomenon.” A

teacher in Somali explained the

source of menstrual hygiene

information and said “It is not

only us who are educating both

girls and boys in school. It is in

Quran and every member of

our community knows the

advantage and meaning of

menstruation.” However, we

can’t say that there is no gap of information in the region. “There is still myth and

misconception within the community” said the health bureau representative. “There is a need

to educate and aware the community to help girls to be effective in all their duties”

Some girls in school however are also not taking it as a normal phenomenon practically, even

though they expressed this view.

“I don’t want to discuss about menstruation with people, both about handling or health issue.

I considered it as my own secret and do not want to share this subject with other person

especially with male.”

Male teacher

A school Director at Selam Primary school in Amhara region

witnessed his initial resistance to give free class to open a

safe space in the school. Due to his previous attitude and lack

of knowledge about menstruation he refused to entertain

the question. As he said “this is school we all here for teaching

and learning process, we should not worry about girls’

menses and allocate resource for that”. However, after

getting training and education about the subject matter he is

leading the school by incorporating MHM services. He added

that when he was a high school student he was teasing and

bullying girls during their period. Now he regrets in all his

previous actions and wants to support girls in the school and

work on awareness raising for both teachers and students.

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In one of the FGDs of boy students, boys said that they are not aware about the sanitary pad,

and eager to know what it is physically. They said they need to know this to support girls in

all aspects fo MHM.

Father tried to shoot his daughter (a story told by Selam school teacher – Amhara)

“A man who does not have any knowledge about menstruation, didn’t see his mother, wife or

his sister cloths with blood. All women in his life never openly discuss about their period. But

he saw his 13 years old daughter with a cloth with blood, he thought she had sex and at that

age and got mad and tries to kill her with gun”

Girls who participated in the study from Amhara and Gambella claim they have experienced

bullying and teasing from boys at least once or knew a friend who faced this problem during

her period. Girls from Somali region also have similar experience “this is a very sensitive topic

to discuss with boys and men, so we don’t usually openly discuss this one with them as we

afraid of teasing”.

Knowing the media habit of the target group is also one of the critical issues to convey the

targeted message to the target population. Accordingly, the FGD revealed that woreda health

offices, health centers, health extension workers, kebeles, and local media are the main

sources of health information in the community. Local media (TV and radio) are the most

influential and acceptable in all of the study areas, though the MHM task force are not fully

utilizing all across the regions.

Dimensional results

The following results of the research are categorized under six dimensions; presented

graphically in below, the brief concepts are the following; if locally produced MHM materials

are available and promoted for the intended community it is assumed that the materials will

be accepted by the girls and women. However, these only are not enough parameters. Hence,

this assessment will also see accessibility, affordability, appropriateness, and sustainability of

the product.

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All the above wheels would drive smoothly if it is well lubricated with a sound supply chain

system.

Appropriateness

Among the regions it is only Amhara that have a proper business established. Somali and

Oromia have some initial initiatives which are producing the reusable pads. The businesses in

all three regions are not consistent. The amount of sanitary pads produced by each of the

local women’s business groups are insignificant compared to the total demand in the locality.

Accordingly, the reusable pads are not widely known and market tested to ask their

experience except in Amhara.

One of the issues raised in Amhara was about the branding issue. The “Mariam Saba”

products have been provided in schools under the brand name “Mariam Saba” and people

relate this with religion (as Mariam means Mar, the mother of Jesus). Some girls don’t like to

use this product as it seems to desecrate the name of the Holy Mother Mary and is sinful.

Some of the respondents (6%) confused the local production with this brand and avoid to use

Affordability

Acceptability Appropriateness

Sound

supply chain

managemen

t

Accessibility

Sustainability

Profitability

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it. They suggested to change the brand so that they will use it without “fear of committing

sin.”

Acceptability

Cultural taboos reduce acceptance of feminine hygiene products. Reusable pads need to be

dried in the sun and are thus visible to others, which is taboo in many places (Women’s global

toolkit 2013).

In the research we tried to find out the acceptability of reusable sanitary pads, even in the

regions where currently not produced. Girls who participated in most of the FGDs said they

would accept the product if it is produced locally. In most cases the reason for accepting it is

economic issue rather than considering its attributes.

“I would prefer to use reusable sanitary pad, because I will wash and reuse it again for so

many times.”

FGD participants from Gambella.

“You cannot compare the economic benefit of reusable pad over disposable one. We are

students and entirely depending on our family income, we all prefer the reusable pad”.

FGD participants from Amhara.

Though the products are widely acceptable because of their economic advantages over

disposable pads, there are also quality concerns on both of them from school girls. One FGD

participant in Amhara region said:

“I heard that some of the disposable pad might be substandard, and those products might

cause infection and even cancer, so both the reusable and disposable pad need critical

attention during production”

Enterprises should also take a part in addressing cultural taboos through community events

involving both men and women. Programs at the village level include awareness sessions and

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plays to destigmatize taboo subjects. Employing salespeople who are sensitive, empathic

and trusted by the target group facilitates uptake (Economist 2013)

Accessibility

Without the effort of social enterprises, many women would lack access to products because

the market is dominated by bigger industrialized products whose distribution networks are

limited in rural areas. Micro and small enterprises ensure accessibility through local

production, which minimize transport requirements and door-to-door sales if they are well

organized, supported by the local government structure with appropriate inbound and

outbound supply chain.

However, the established sanitary pad producers in Amhara region are currently facing

challenges to secure inputs mainly fabric to produce the pad. The waterproof backing fabric

for pads, for example, is not manufactured in Ethiopia and has to be imported through limited

suppliers which can restrict supply. The experience of producers and users of the reusable

pad reflect the following:

“We have close work relation with school gender club, we sell the pad for the club sometime

on credit. The club will pay us back after they sold it. We didn’t do a big promotional campaign

to enter and compete to the market. Hence, we cannot say that we are addressing the

problem by availing it at the large markets for women at large”

KII participant of local sanitary pad producer in Amhara region (BasoLiben).

“I know the workplace of sanitary pad producer, for me it is on the way from home to school,

I will go there and buy the pad”

Girls FGD participant in Amhara region.

Affordability

Low income customers can currently afford the locally produced sanitary pads because

enterprises keep the costs low. The cost of the pads are still enough to keep the women’s

groups profitable although this depends on the continuation of the current prices. It is

assumed that there is a very short supply chain, which eliminates middlemen and avoidance

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of marketing cost. Nevertheless, limited access to input materials and non-regulated pricing

across woredas varied recommended retail price. In one woreda the price of a reusable pad

made by a women’s business group is 10 birr each and in the other woreda is 7 birr each. Lack

of uniformity and standard on the pack limit as well as quality determines how affordable the

product will be and at which level of standard and quality. Girls generally four reusable pads

for year – two for the daytime and two for the night time.

All participants were responding to the affordability related questions by comparing the price

of reusable and disposable sanitary pad.

“Currently the price of reusable sanitary pad is 10 birr for 1 piece which is affordable. But there

are also girls who are unable to get the money to buy the pad. Around 70% of the family are

poor and their economic status is based on small trade and daily laborer.”

KII attendant from school in Amhara region.

“The price of reusable sanitary pad for me is affordable, because I can reuse the pad for six

months only washing after use”

FGD participant in Ethio Somali region.

Women, children and Youth affairs office heads and girls clubs in different regions

recommend government and partner organizations should subsidize the price of the product

to make it affordable for disadvantaged group of the community, to ensure full coverage of

MHM. Majority of the students prefer the reusable one due to its economic advantage.

There is also a misconception about disposable sanitary pads which may facilitate the market

potential for reusable pads:

“It easily expires and spoil than the locally produced pad, due to its factory process” Student

in Amhara elementary school

Profitability

Enterprises are selling products at a price pre-determined by the health bureau and UNICEF.

However, groups didn’t really comprehend what profit margin they are expected to earn.

Business members are engaged in a diversified revenue stream which can generate profit

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such as sewing clothes which is totally different to this project. Though they already

understand that the MHM production and sales will generate a good profit, they seem

comfortable with what they are doing right now and have very little entrepreneurial

motivation and skills to expand their businesses further. UNICEF provides all the start-up

grants, machine and fabrics, and they didn’t put any matching contribution for this business.

The business enterprises are working with schools which will accelerate distribution and

assure the business viability. Though there are no recorded and registered activities, we

observed that there is ample demand both from community and school environment which

enables the business to be profitable and sustainable.

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Conclusion and Recommendations

1. Scaling up is possible with cost-effective and standardized production. Promotion,

branding and effective marketing would make the program more impactful and

successful in both income generation and helping the poor rural women and girls at

the same time. Partnership with women’s groups and other actors, such as local

business, NGOs, and government, can also facilitate growth and replication.

2. Program partnership with appropriate institutions who are currently working on girls

and education, media utilization at both regional and federal level should also be

strategized.

One of the interested partner that we have talked to is Girl Effect who have a plan to

aggressively work on MHM and reproductive health in schools in partnership with

media (TV and radio) and private sector.

Annex: the interview and short paragraph about their plan

3. The regional MHM taskforce should also be strengthened by incorporating TVET, and

SMEs as members to fully utilise the sanitation marketing platform in all regions. In

almost all regions task forces are not functional and have no clear working document

on the subject of MHM. All task forces do not include the job creation opportunity

and food security as a member. To scale up this business model working with this

institution is crucial.

4. The behavioural change communication program in schools should be supported with

proper BCC materials and equipped mini media with a standard and appropriate

content to be consistently aired for the school community. The woreda health bureau

should coordinate the awareness raising and education sessions with school programs

to convey consistent messages to the target groups.

5. The Amhara school program is unique because of the production of underwear in

addition to pads and should be taken to scale. Underwear is a big problem for rural

students even if the MHM product is available in market such as Gambella.

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Menstrual Products Market Analysis

In 2015, UNICEF started the MHM program in school which is designed to be sustainable with

a market-based approach reliant on the sale of pads to generate incomes for producer

groups. Currently, the women’s groups are active in one region (Amhara), where users have

clearly expressed their satisfaction with the product. Furthermore, the project has been

instrumental in empowering and building the capacity of the female business group members

in the region.

Other regions including Oromia and Somali have some initiatives led by the health bureaus

which have no clear business structure to review their performance. The initiatives in both

regions rely heavily on the health bureau for purchasing the input material to distribution to

the target groups.

This MHM market landscape analysis provides UNICEF with a clear outline of how different

actors can reinforce their efforts to meet the needs of girls in school as well as women in rural

Ethiopia, considering market constraints, cultural barriers and knowledge towards acceptable

MHM on the user level. The assessment also shows how market activities can influence

market and market players as well as the behaviour of the target population, with the goal of

improving the health and life status. When informed demand for products and services is met

with quality supply, this will result in an increase in hygienic MHM and eventually a reduction

in school absenteeism.

The public health community has recently focused on improving the menstrual hygiene

management in schools and supporting market systems to better serve target groups.

However, the public and private sectors (including commercial and social marketing) haven’t

coordinated to maximize market efficiency, equity, and sustainability in addressing the gap

of MHM product for rural girls in Ethiopia. Greater efficiency in the market increases

sustainability by better strengthening the public and private supply chain. Creating more

efficient markets also increases equity by ensuring all groups can access products and

services.

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One of the tools used to measure performance of the current market is coverage of the need

(the number of persons needing a product or service and/or the number of products or

services required to meet the total needs). Market improvements should seek to ensure that

all groups have equal awareness of and access to products and services. In regions we visited

differences have been observed about knowledge, product (especially about the reusable

one), practice and awareness about the service given by the MHM clubs.

In addition to these key measures, an initial market assessment captures information about

the drivers and barriers of MHM behaviours among the target population as well as the

market landscape including its players (e.g. product distributors).

Background of the market assessment exercise

In order to assess the current performance of the menstrual hygiene products market, we

conducted a market landscaping which included a literature review, analysis of secondary

data to assess the potential demand, coverage, and collection of primary data with

consumers (school girls in primary and secondary schools and women and adolescents out of

school) in selected woredas in six regions. Players in the supply chain were also interviewed

using in-depth interviews (IDIs) and focus group discussions (FGDs).

The supply chain players included textile manufacturers and reusable and disposable pad

producers. In addition, wholesalers, and distributors at the woreda level were also

interviewed.

The primary data collection conducted is summarized in the table below

Market player Interview

Woreda wholesaler 6 Interviews

Rural drug outlets 5 Interviews

Kiosks 12 Interviews

School girls 12 FGDs

School boys 12 FGDs

Women / girls out of school 6 FGDs

23

In addition, woreda health, education and water bureau staff were interviewed separately as

well as in group discussion. In regions like Somali and Gambella, the Bureau of Women and

Children’s Affairs is taking part in the established task force and presented in the discussion

at woreda.

Summary of Market Findings

Market Information

Despite efforts made by the Government of Ethiopia to support domestic manufacturing,

access to MHM products varies across the country and remains highly inconsistent in rural

and remote regions. Women and girls, particularly in study areas, rely on homemade

alternatives especially before this intervention (FGDs result). Among girls who had never

bought sanitary pads, most of the respondents said they do not buy because of two reasons:

availability in the local market and high price of the product.

Commercial disposable sanitary pads are used almost exclusively by women and girls in peri

urban areas in the study. The high price of disposable pads is due largely to high-import taxes,

limited domestic manufacturing options, and distribution challenges. There are few

disposable pad companies in Ethiopia: Procter & Gamble (P&G)’s Always, Eve sanitary pads,

Comfort pads, Lotex and Lady Style pads. P&G’s Always are imported while the rest are

manufactured in-country. The recent increase in in-country manufacturing has been

supported by the Ethiopian Government which has provided significant subsidies including

low-cost leases for manufacturing plants to companies that manufacture in Ethiopia and has

imposed significant taxes and regulations on all imported goods. Despite these efforts to

increase the availability of locally produced disposable sanitary pads, disposable sanitary pads

are currently only available in urban areas.

Small micro enterprises and NGOs targeted distribution of the reusable products to fill the

product gap in rural areas are gaining momentum.1 2 UNICEF has provided seed money to

1 Mamo, Kuribachew. Interview by Francesca Mazzola and Perri Kasen, "FSG's Interview with SNV World." Personal interview. Addis

Ababa, Ethiopia, November 23, 2015.

2 Harrington, Rory. Interview by Francesca Mazzola and Perri Kasen, “FSG’s Interview with DKT International”. Addis Ababa, Ethiopia.

November 23, 2015

24

small enterprises focused on creating reusable pads. To date there are only few large-scale

reusable pad producers, Mariam Saba (located in Tigray), Maryod (Addis Ababa) and Be Girl

(NGO). Due to the high upfront cost of reusable pads, the reach of reusable pads remains

limited to NGO’s distribution of either free reusable pads or materials for making reusable

pads.

In 2018, PSI Ethiopia’s market performance assessment showed the MHM market share per

brand. Of all the MHM product market, reusable pads took only 4% of the whole market

share. The same survey revealed that while 80% of girls and women at reproductive age live

in rural areas, only 10% of them are accessing MHM products.

Product Attributes

Girls have also been asked about product attributes comparing reusable versus disposable.

The attribute questions included thickness, length, absorbency and pack size. However, most

of the respondents are only concerned about pack size and absorbency. Based on the

assessment result, school girls favored the reusable pad mainly because of its durability (value

for money). However, if money is not a factor then girls prefer the disposable pads as they

do not have to wash and dry them.

The primary MHM product used by women and girls in the study towns varies based on

economic status and awareness rather than its attribute. The assessment indicates that some

women and girls who reside close to urban sites use disposable sanitary pads, while the

majority of women and girls in rural areas use homemade alternatives.

Drivers and barriers to MHM product use

Critical factors that contribute to the regular and consistent use of MHM products include:

knowledge about product options and use, price points, and access to money.

Price:

The high cost of disposable pads makes them inaccessible to the majority of women and girls

in the target area. More than 70% of girls surveyed mentioned that disposable pads are very

expensive for school girls to buy every month and use consistently. Students living in cash

25

crop areas (SNNPR) explained they buy disposable pads every month by themselves. In some

rural areas of Ethiopia, the price of sanitary pads costs one tenth of a poor family’s monthly

income3. Higher cost sanitary pads, such as P&G’s Always, are also not available in many rural

and remote regions except Somali. Average consumer price ranges between 26-30

ETB/packet for locally manufactured disposable pads and 30-40 ETB per packet for imported

disposable pads.

Access to products

Currently, there are few manufacturers based in Addis Ababa, and users complain about their

accessibility and price. There are a number of small kiosks that are supplying these pads to

peri urban and rural outlets, but the supply pattern is erratic as the demand is low.

Sanitary pads are inconsistently available in rural and remote areas across Ethiopia. The

primary MHM products used by women and girls in the assessed places varies based on

economic status and awareness. The assessment indicates that some girls and women,

including those in schools, use disposable sanitary pads, while the majority of women and

girls in rural areas use homemade alternatives as a primary or secondary method for

managing their periods such as rags, blankets, and cotton wool.

Low-cost disposable sanitary pads, targeted at low-income peri urban and rural users, are

entering the market in the study woredas but still have limited reach. These pads are most

commonly from Ethiopia (Eve) and China (Comfort). In regions such as Gambella and Somali,

3 Tamiru, Selamawit, comp. Girls in Control: Compiled Findings from Studies on Menstrual Hygiene Management of Schoolgirls. Ethiopia,

South Sudan, Tanzania, Uganda, Zimbabwe. Addis Ababa: SNV, 2015.

26

imported products are available and have a significant market share especially the P&G’s

Always compared to the other regions, due to humanitarian support for refugee camps. In

Gambella study areas, products distributed for refugees are available for resale, and that

might distort the market. Refugees are often selling these items to gain money for other

priority products.

Distribution channels

Eve and Comfort are widely available in small kiosks, rural drug outlets and mini markets in

semi urban areas (woreda towns). In contrast, reusable pads are not widely available in shops

and go directly to the NGO market. Reusable pads in Amhara and Shone are also not available

in any of the shops and kiosks except the business group work place. The distribution channel

of pads in Ethiopia looks like the below diagram.

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Promotion

Several MHM product interventions focus on teaching girls and women how to make reusable

pads. NGOs have created modules in their puberty and MHM programming on how to create

homemade reusable pads.4 All programs focus on building girls’ and women’s capacity on

safe menstrual hygiene management.

In surveyed areas there was no promotion for visibility, dignity, privacy or promotion with

focusing on empowering girls. The school mini media, health posts infrastructure as well as

any possible touch points are not properly used to promote products or embed the core

messages to the target groups.

Business Review Amhara

Shortage of fabric to produce pads was the major challenge in all the cooperatives under the

study. While two of the required fabrics are produced in Ethiopia, there are limited

wholesalers, all of whom are based in Addis Ababa and do not distribute widely. The

waterproof backing is not manufactured in Ethiopia and is imported from abroad. In addition

to this, members of the cooperative in Amhara complain lack of business management

training:

“We training how to produce sanitary pad locally, but we did not take training on how to

manage our business”.

All local producers are not keeping financial transaction records for their business, however

all of interviewed people have a very positive outlook about this business and are keen to

continue as a group. Mothers in these businesses are not measuring their profit in monetary

value only. They also value being together as a group and friends to talk and share their life

experiences as most of them said and was observed in the field.

4 Abraha, Haileselassie. Interview by Francesca Mazzola, "FSG's Interview with Tiret Community Empowerment Association." Personal

interview. Addis Ababa, Ethiopia, November 25, 2015.

28

Key areas of the business model review include:

Market context

• Market size of MHM products in Ethiopia

• Current users

• Potential users

• Existing brands

• Key programs in MHM business

• UNICEF

Structure of business model

• Value chain map - current actors and linkage

• Price sensitivity analysis, market prices for MHM pads, willingness to pay by girls/women

Support network around business model

• Existing support mechanisms and actors working in the network

• Length of involvement

• Financing

• Current gaps in service of network model

• Profit and loss analysis inputs (in each recommended business model) - Annexed with this

document

Key Challenges: organization

All the business groups visited in Amhara, Oromia and Somali are not legally registered as a

business entity to get appropriate support from the concerned government party including job

creation and food security, TVET and MFIs. A big challenge in Amhara, Enfranz Woreda were

working premises. It is known that the woreda SMEs are given shade for legally registered

business groups in all regions. Other major gaps identified include:

• Business groups’ focus are on direct sales and sometimes on institutional (for school) sales

but not on retail.

• No dedicated or assigned team member for a specific assignment in the group - no clear

organizational structure

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• No record and registration of the business daily activities, not linked to the MFIs for

further financial and business management support

Proposed Solutions

• Legal registration as a business entity and securing appropriate working premises for

existing as well as planned groups

• After securing a legal identity, train women on how to keep financial records to make the

business more sustainable. Training would better equip the women’s groups to monitor

their businesses’ performance, and continuously improve their efficiency so that they can

become more profitable and sustainable over time.

• Assign a clear responsibility matrix based on their competency. This can be done with the

support of woreda small and micro enterprises as they know members closely.

Key challenges

Production and sales are currently done on an opportunistic basis rather than planned. Business

groups do not have planned production, sales and distribution pattern for both retail and

institutions.

Proposed Solutions

If there is a dedicated team member in the women’s groups each of them will have plan for

production, sales and targeted promotion. In addition, the following activities should be

considered.

• Supporting partners, including UNICEF and government stakeholders, should facilitate

institutional sales to better promote and address wider group

• Develop targeted partnerships with local organizations (NGOs) and schools to purchase a

targeted amount of pads on a regular basis

• Recruiting small kiosks to avail products nearby beneficiaries

However, it should also be noted that institutional sales also have a risk of missing out key market

segments which can provide consistent and guaranteed pad purchase (retailing for ‘community’)

if the group’s sales force mainly focus on easy markets.

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Input material supply is unavailable on the local market

UNICEF has been the sole provider of all textiles to the business groups so far. However, they

already are running out of stock and some groups have stopped production. Owing to the fact

that the groups do not currently incur costs directly, the costs are deflated. These costs must be

accounted for once UNICEFs support is reduced.

• Risks to sustainability: If the problem of input materials is unaddressed, production

might occur with substandard input materials which would adversely affect the

quality and perception of the product. Groups may also get frustrated and withdraw

from this business.

Proposed Solutions

1. Through time UNICEF support should focus on sustaining the business by facilitating

different alternatives for the business enterprises. Facilitating social franchising business

(Ref. Annex - detail of the social franchising business in this scenario) to deal with reusable

pad producers is one of the recommended solutions to enable business enterprises to

continuously access business support, consistent material supply as well as streamlining

acceptable working standards. Business groups will find it easier to transition if they are

not reliant on UNICEF for vital inputs in their production process as most of them currently

feel like they cannot continue without this support.

2. Partnership with textile factories: there are several textile factories in the regions who

can produce the input materials except the waterproof backing. One of the factories

located in Dukem (Oromia- Al-aser textile) has expressed their willingness to make

additional investment if there is a guaranteed demand. Bahir Dar textile factory have also

been supportive and promised to continue the support for Amhara producers though

there was very limited follow-up both from UNICEF and government partners to make the

partnership and support continual. During our visit to Amhara, the team couldn’t meet

both the university and factory counterparts.

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As we have already ensured that there is interest to produce appropriate material locally

and a guaranteed sustainable market, there is a need to continue mapping the textile

factories and coming up with partnership modalities.

3. Partnership with Disposable pad producer (Lilak)

Currently, Lilak the lotex pad producer is importing raw materials and producing pads

locally. The company is targeting urban middle and upper class at the price of 27ETB for

(8-10) pieces average. The marketing manager of the company gave us an interview and

explained their plan to produce low cost high quality products to target the low income

rural and semi urban girls and women of reproductive age if they can manage to import

raw materials with easy bureaucratic process and considerable tax reduction. During our

discussion they expressed their interest to use the established micro enterprises for

distribution network and sign partnership agreement with them in all regions. UNICEF

should also take a part of lobbying and advocacy in coordination with other partners on

tax reduction (exemption for pad production process).

4. To enhance acceptance, enterprises should adapt products and packaging to customers’

need and wants, sell them in kits, and distribute it through locally trusted partners and

create local brands.

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Recommendations

A phase by phase business model transition may be needed as follows

PHASE I

1. The current business model should continue with strong support from UNICEF and

government stakeholders

• Legalization

All established and supported enterprises should be legally registered and organized

as a legal business entity/ organisation

a. Capacity building (business management, production, sales and promotion)

b. Woreda SME and MFI should take a follow up responsibility from UNICEF so

that they will have a proper, scheduled and consistent follow up that helps

the business to grow both financially and technically

• Proper market linkage

a. Institutional – with NGOs who buy and provide pads for their beneficiaries

and schools

b. Commercial – local retail outlets and drug stores including wholesalers and

small kiosks

c. Strengthen their own shop by providing shop (shade) through the woreda

SMEs or rent a small kiosk

d. While supporting mechanisms in schools are being established, consider

subsidising girls and their families so they can continue to purchase the pads.

• Promotion

a. Branding and promotion is crucial to standardise across the board and establish

a strong market share. Standard packaging and number of pads in packet should

also be the same for every woreda so that buyers would think that the product is

a known and accepted standard product

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b. The promotion should be supported by visible promo tools to commercialise and

attract outbound supply chain actors that the product is potentially good to

invest

• Creating effective and consistent supply for the producers

a. Having a discussion and partnership with regional textile factories at this point is

crucial to ensure consistent supply of the product. UNICEF gave the first round

production material but continuously the textile factories are interested to

supply for the market if there are guaranteed sales.

b. Having an agreement with Merkato wholesaler to supply pad material inputs

regionally. As the wholesalers wouldn’t be attracted for a small supply all the

enterprises in the region should cooperatively arrange an agreement to buy

supplies on a schedule basis.

Features of the business model

Inbound supply

• In place a regional agreement

with supplier (Merkato)

wholesaler / regional textile

factory to ensure continuous

supply of the appropriate input

materials

Women business group

• Target low income females

• Capacity building for women

entrepreneurs along the

supply chain

• In place appropriate &

workable organogram

Product

• Offer branded, quality &

standardized alternative

• Customize product by size &

Package

Promotion & communication

• Offer informal & formal

education, including religious

events, school medias, health

information dissemination

infrastructure

• Synergy b/n stakeholders

Place/distribution

• Sell in bulk: Schools, woreda

health posts, regional hospitals,

drug stores…

• Stock at retail outlets directly and

through wholesalers

Community distribution

• Create dedicated sales and

promotion team from the

group that would be paid on

a commission basis

• Door-to-door via sales agent

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Cost Factor

Reusable sanitary products sell for birr 8-10 apiece, 70 percent less than branded disposable

products. The upfront cost is higher for reusable products (women’s group reusable pads cost

50 birr per packet (five reusable pads) versus 27 birr for branded disposable pads (8-10 pads).

But the six-month cost is only 8 birr per piece while the disposable pad needs every month

investment.

Pad production cost is estimated about 6 birr apiece with pads selling for 10 birr. One person in

the group has the capacity to produce at least 50 pads per day. They are also allowed to do

garment sewing business aside to make them profitable and sustainable in the market. It is

assumed that one garment sewing service requires the same amount of time needed to make

five sanitary pads. This means enterprises will spend much time making a garment compared to

pads, and therefore this business line should allot scheduled time and budget to support pad

production which includes production costs including maintenance and some input materials.

Revenue stream

Apart from the sanitary pad production, sales enterprises in Amhara are trained on how to sew

underwear which will have a high sales turn over if it is well designed and enable them to produce

a quality product.

Financial Viability

Although there is no proper registration and recording process from the beginning of the

establishment to determine how much profit has been earned by the existing enterprises, they

still are willing to buy input materials after selling their products which shows us that they are

attracted with the profit and demand for the product. Eventually this should ensure the financial

viability of this business. Until this assessment period, 90% of the product sales were for schools.

If there is a sound distribution pattern and promotional strategy, there will be promising market

share in this industry.

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Price setting

Fee setting should be the responsibility of the women’s groups themselves. It should be

recalculated to match the market dynamics in the operating environment. The following are

considerations that need to be looked at in setting the prices:

• Current and future operating costs

• The issues of cost recovery and financial sustainability of the women’s groups

• Historical and current price by women’s groups in the towns

• Capacity and willingness to pay

Organization and staffing

To make this plan effective requires sound and workable organization management and staffing.

At the time of this assessment, the women’s groups are not legally registered as a group and

have no clear structure. Accordingly, the following organizational and staffing plan is proposed

for the women’s groups:

• Add a member who is a 10+/TVET graduate who can understand and perform in

financial and business languages

• Assign a dedicated responsible person on promotion

• Assign dedicated sales and production team

Description

• Create a sales workforce in the community that proactively develops sales

relationships.

Specific features:

a. Establish a sales team - mobilize and establish a sales team of 3-4 people per

woreda who would engage in selling the MHM products and under wear

b. Define their mandate - the sales team would be given defined job

responsibilities to facilitate their effectiveness

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Rationale

• Increased sales. The sales agents will sustain relationships with retailers, institutions

and end customers in order to drive increased consistent sales

PHASE II

The current sanitary pad production model relies significantly on support from UNICEF to help

source inputs and all the upfront investment. Hence, to better equip the business groups it is

crucial to upgrade them to a formal business entity and appropriate and tailored business

training should be delivered to enable them to monitor their businesses’ performance, and

continuously improve their efficiency so that they can become more profitable and sustainable

over time.

Facilitating social franchising will be a better solution to realize the continuity of women’s

groups. This model entails the following advantages for this business:

• Faster and more cost-effective scaling as it replicates a tried and tested model and

network in the industry for both inbound and outbound supply and logistics.

• Improvement through systematic transfer of know-how and ongoing learning similar

to commercial franchises. Gain access to an operations manual and also

communicate their learning to the rest of the network

• Monitored standardization which contributes to delivery of similar quality under one

brand umbrella across the network and will enhance the reputation.

• Funding employed in a proven system, sustainable model with ongoing support from

franchisor.

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Potential Partners Summary of interest and opportunities

Mariam Saba

Al Aser Textile

Girl Effect

Interest: To produce appropriate textiles in country if there is a guaranteed market and sales potential Potential Opportunities: This or other textile factories may not rely on the rural SME businesses to start new production. But if there is a corporate agreement regionally or a franchisee who can facilitate for rural areas there will be an opportunity to ensure continuous supply

Interest: To work with concerned stakeholders for the growth of MHM product market and eventually contribute to girls’ social, economic and psychological welfare Potential Opportunities: Mariam Saba can leverage its network in both outbound and inbound logistic and supply management with standardized product to reach through SMEs for rural girls/women

Interest: To improve girls’ lives mainly through branded communication activities

Opportunities: Girl effect can leverage its close ties with different media to strengthen advocacy and awareness activates nationwide and build markets by engaging private sector. Girl effect can also serve as an institutional buyer of the pad, given that production adheres to the standard. The organization is planning to undertake a communication campaign on MHM targeting school girls via different mediums

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Proposed Business Model

39