Policy to Practice: Insights from Implementation of a School-Based Sanitary Napkin Distribution Program in Odisha, India

Policy to Practice: Insights from Implementation of a School-Based Sanitary Napkin Distribution Program in Odisha, India | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Policy to Practice: Insights from Implementation of a School-Based Sanitary Napkin Distribution Program in Odisha, India Shyama Desaraju, Nishisipa Panda, Rudra Prasad Panigrahy, Bhuputra Panda This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4259211/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 16 Jul, 2025 Read the published version in Health Research Policy and Systems → Version 1 posted 9 You are reading this latest preprint version Abstract Background For optimal menstrual hygiene among women and adolescent girls, access to affordable menstrual products, sanitation facilities, education, privacy, and destigmatization are essential. Recognizing this need, the Indian government has implemented various interventions to improve menstrual hygiene practices and personal hygiene among schoolgirls. In Odisha, an easternmost state in India, one such key initiative is the ‘Khushi’ program, a collaboration between the Health and Education departments. This program provides free sanitary napkins to all girls in standards 6–12 across the state. Our study explores the perspectives and challenges associated with implementing the ‘Khushi’ program in Odisha. Methodology : This paper emanates from a larger study examining the situation of menstrual health and hygiene in Odisha, conducted from September 2021 to December 2022. The focus of this paper is on qualitative findings related to implementation of the ‘Khushi’ program. In-depth interviews were conducted with key stakeholders, including officials from health and education departments, and school personnel involved in program implementation. Focus group discussions were held with schoolgirls of 6–12 standard to explore their experiences and perceived challenges regarding menstrual hygiene practices within the school environment. Further, review of program documents and relevant government policies was also undertaken. Results Analysis of data concerning experiences, enablers, and systemic roadblocks associated with implementing the ‘Khushi’ program yielded five key themes: ( 1 ) Approach to micro-planning, ( 2 ) Interdepartmental convergence, ( 3 ) Indenting and supply chain, ( 4 ) Capacity building, and ( 5 ) Monitoring and supervision. The study underscores the importance of designing and implementing a comprehensive behavior change strategy, that should capitalize on the existing collaboration between the health and education departments, while addressing identified weaknesses. These weaknesses include 'knee-jerk' planning and implementation without proper preparedness, limited coordination between departments, and overburdened frontline workers. Conclusion ‘Khushi’ is a state-specific initiative which has the potential to bring a paradigm shift in the menstrual health behaviour of school girls. Government may need to adapt a comprehensive strategy, including strengthening menstrual hygiene management (MHM)-friendly school infrastructure, imparting education and sensitization to implementing partners and beneficiaries alike, and integrating environment-friendly menstrual hygiene products in the program. Adolescent health Menstrual health Free sanitary napkin School health Odisha Background Menstruation, a natural physiological process often stigmatized and marginalized in many cultures, is fast emerging as a predominant driver of gender equity ( 1 – 4 ). The United Nations recognises safe and dignified menstruation as a fundamental need for every woman which it further emphasises upon as a crucial milestone in advancing Sustainable Development Goals (SDGs) ( 5 – 7 ). Further, governments worldwide are progressively working towards de-stigmatization of menstruation, and enhancing access to infrastructure, information, products and services in pursuance of SDGs ( 8 – 10 ). Access to clean absorbents, private space for changing pads, disposal of used pads, and availability of soap and water for personal hygiene constitute the backbone of effective menstrual hygiene management (MHM) ( 6 ). Evidences from low- and middle-income countries (LMICs) consistently indicate that over 50% of females experience challenges in achieving adequate MHM ( 11 – 15 ). Various factors including age and socio-economic status (SES) influence menstrual behaviour ( 16 ). Adolescent girls, particularly in LMICs bear the maximum brunt of poor MHM in terms of several psychological and socio-economic barriers ( 17 ). For instance, they grapple with feelings of shame, fear, embarrassment, poor social support and cultural taboos. Moreover, in school settings, the need for a private space for changing pads is acutely felt. Recent assessment of water, sanitation and hygiene (WASH) situation in schools across many states in India have all pointed out towards non-availability of gender segregated water, poor level of sensitization of teachers, lack of self-confidence among girls and existence of non-supportive environment as major impediments. Consequently, chronic absenteeism from school, distraction from mainstream education and frequent infections affect lives of school girls ( 2 , 3 , 18 – 21 ). Given that adolescents constitute about 16% of the world's population ( 22 ), urgent attention is critical to address their menstrual hygiene needs. Off lately, schools have emerged as focal points for increasing menstrual awareness. Apparently, collaborations between the health and the education department is crucial to address some of the gaps related to MHM infrastructure, information and products at school level ( 18 ). Emerging models such as "MHM in Ten" consortium, comprising of the United Nations agencies and civil society organisations, intend to complement this inter-sectoral collaborative effort ( 13 ). Governments have invested heavily on enhancing MHM ambience in schools ( 23 ); involving access to Water, Sanitation, and Hygiene (WASH) facilities and providing sanitary pads ( 24 – 27 ), while imparting menstrual education ( 28 – 31 ). Optimal access to MHM product and services is on the top of the agenda of Government of India and many state governments. For instance, the Ministry of health and Family Welfare launched the Menstrual hygiene program as early as 2011 to promote menstrual health amongst adolescent girls ( 32 ). Similarly, launching of SABLA Yojana in 2011, RMNCH + A in 2013 and RKSK in 2014 have collectively contributed to empowering adolescents ( 33 – 35 ). In Odisha, a state in eastern India, the state government launched free distribution of disposable sanitary pads, popularly called the ‘Khushi’ program in 2018 for girls in Grade 6–12, enrolled in government and/or government-aided schools. The main objective of the program was to improve menstrual health and hygiene and to reduce school drop-outs ( 36 ). However, there is paucity of scientific evidence related to the obstacles encountered in implementation and functioning of ‘Khushi’ program and a lack of efforts to document the valuable lessons learned to guide future actions. This gap may have been exacerbated by the COVID-19 pandemic, which necessitated overwhelming focus on effective COVID management in both national and international contexts ( 37 ). To address this gap, this study aims to explore perspectives and barriers of implementing ‘Khushi’ program in Odisha. It further delved into the user experiences and identified systemic barriers hindering the adoption of safe menstrual hygiene practices within the school environment. Demand-centric challenges, supply-driven barriers and systemic bottlenecks are the facets of scientific enquiry. The demand-centric dimensions have already been presented in a recently published paper ( 38 ). Methodology Study settings This manuscript emanates from a larger study conducted in 3 districts (Bhadrak, Koraput and Balangir) of Odisha, India on situational analysis of MHM ( 38 ). Our study sites represented the coastal, tribal and under-developed regions, respectively. Senior officials of the Health and Family Welfare department guided the research team in selection of the districts. Study design and participants We adopted a cross-sectional study design, using a mixed-method approach for data collection and analysis. To explore the perspectives and experiences of stakeholders on activities undertaken under the ‘Khushi’ program, officials of health and education departments, and school staff involved in program implementation, constituted the sample universe. Brief description about the characteristics of key informants who participated in the IDI is given in Table 1 . Further, six focus group discussions were also conducted with school girls of Class VI-XII, to explore their experiences and perceived barriers regarding menstrual hygiene practices within the school environment. Additionally, a desk review of program documents and relevant government policies was undertaken. Table 1 Characteristics of in-depth interview respondents Level Health department Education Department State Dept. of Health and Family welfare ( n = 1) OSMCL (Odisha State Medical Corporation Limited) ( n = 1) National Health Mission ( n = 1) - District District Program Management Unit officials ( n = 3) - Block Block ware house in-charge ( n = 6) Medical Officer in-charge ( n = 3) CRCCs ( n = 3) School - Headmaster ( n = 4) Nodal teacher ( n = 6) Warden of Ashram schools ( n = 2) Data collection tools and techniques In-depth interviews (IDI) and focus group discussions (FGD) were conducted with the key stakeholders. An IDI guide was developed through iterative process, followed by piloting and contextualization. The principal investigator reviewed the study tools both in English and local language (Odia) for accuracy and consistency. All IDIs and FGDs were conducted in Odia language which were subsequently transcribed and translated into English for analysis. The research team involved in data collection was trained by the principal investigator and co-investigators; data collection was carried out during September 2021-November 2022. The team members conducted the IDIs and FGDs along with a field investigator familiar with the local dialect. All the IDIs and FGDs were conducted at a place and time convenient to the participants, and the researchers clearly explained the study objectives and obtained their consent for audio-recording the interview, beforehand. Respondents voluntarily participated in the study, were not given any financial incentive for participation. The interviews and FGDs lasted between 30–60 minutes. The sample size was determined using data saturation technique. Total of 30 IDS were conducted with participants from the health and family welfare department working at state, district, and block levels, and the school and mass education department responsible for overseeing the ‘Khushi’ program at the block and school levels. Further, six FGDs were held with 6–7 adolescent girls, each, from rural and urban schools, government and Ashram schools who are the primary beneficiaries. All steps were taken to maintain confidentiality and anonymity of the study participants. Data analysis Data collection and analysis was undertaken in a parallel manner to look for gaps in the information being collected. The transcripts were anonymized by assigning unique identifiers and secured in a password-protected computer accessible only to the research team. Atlas.ti. 8 software was used for text coding and categorization. Thematic analysis by Braun and Clark ( 39 ) guided the data analysis. This process required the authors to read and re-read the transcripts to identify potential themes. Transcripts were analysed alongside the original recordings to look for inconsistencies and ensure deeper understanding. In the next step, SD and NP independently assigned codes to text segments of the transcripts; discrepancies, if any, were collectively resolved. In the third step, similar and related codes were combined and grouped into distinct themes. Themes were refined based on the data and those themes which didn’t have enough data to support were discarded. Finally, each theme was clearly defined, analysed, and given a precise name; relevant quotes were used to illustrate the themes. Results Analysis of systemic bottlenecks related to implementation of ‘Khushi’ program yielded five major themes: ( 1 ) Approach to micro planning; ( 2 ) Inter-departmental convergence; ( 3 ) Indenting and supply chain; ( 4 ) Capacity building; and ( 5 ) Monitoring and supervision. Theme 1: Approach to micro planning The ‘Khushi’ program was appreciated by all respondents for its effectiveness in promoting menstrual hygiene practices and encouraging the use of sanitary pads among adolescent girls, both in rural and urban areas. The program addressed the critical issue of inaccessibility of sanitary products (due to lack of Availability, Accessibility and Affordability) for adolescent girls. Furthermore, the program was commended for its initiative to introduce sanitary pads at a crucial stage around menarche, fostering the development of healthy menstrual hygiene habits early on. Additionally, the program facilitated open discussions about menstruation within school settings. “…when we started giving pads, they started sharing about their menstruation-related issues. It is then we also came to know that they were using clothes earlier” (School staff). “ …. most of our students belong to poor families, and also their mothers don’t discuss this topic often, so most of them were unaware about pads and their proper use when we first distributed.” (School staff) However, some, criticized the program for lacking a structured approach to ensure sustainable menstrual hygiene behavior among adolescent leading to reduced absenteeism and improved academic parameters. Respondents emphasized the need for a structured approach to address the multi-faceted issue of menstrual hygiene. This approach, they argued, should include efforts to raise awareness, strengthen school infrastructure and consistent supply of sanitary napkins. A majority of the respondents, from the education department, viewed ‘Khushi’ primarily as a sanitary napkin distribution program with minimal focus on sustained awareness generation. They reported that initial information sessions on menstrual hygiene practices delivered by health department personnel were discontinued, leading the program to become more focused on pad distribution and less on education. “Government is just distributing it, but with limited efforts of awareness generation, it would have no impact” (School staff). “Initially, during distribution, a doctor and ANM came, and counselled about the usage of pads, and when to change it and how to dispose it, and then distributed the pads. Thereafter no one came” (School staff) “….and don't give timely supply then everything fails, without consistency it will not work, if we disrupt the process then we won’t give substantive results” (School staff) Furthermore, the program was seen as inadequate in addressing factors that contribute to school absenteeism during menstruation, such as, menstruation-related discomfort and cultural restrictions on girls’ movement. “Some girls experience stomach pain so they don't come. Not having privacy in the schools also restricts them from coming to school” (Block official). “I get severe stomach pain; hence I sleep on my stomach (prone) to put pressure or use hot compression to relieve pain. So, I don’t go to school during that time” (FGD girls) Participants also highlighted challenges with WASH (Water, Sanitation and Hygiene) infrastructure in schools, which often doesn’t meet menstrual hygiene standards. This lack of adequate privacy and disposal facilities create hygiene and sanitation concerns for both students and staff. “The Government should do something about the disposal problem. When pads are provided, it is obvious that the girls will use it and then dispose it. For that there should be some facility at schools, which is, currently lacking.” (School staff). “If the girls dispose pads in school, it will be a challenge for us because we don’t get people to clean such things”. (Teacher). Theme 2: Inter-departmental convergence Officials from both education and health departments opined that ‘Khushi’ program seamlessly integrates with the existing school health initiatives. They believe it leverages their established partnership and facilitates efficient outreach to beneficiaries. However, district authorities raised concerns about the increased workload placed on the frontline workers from both departments due to the program’s implementation. "Our collaboration involves joint programs with the health department, where medical officers educate girls on various issues. The school also participates in existing health programs, such as administering deworming medications and iron folic acid tablets to children." (School staff). “We are happy to partner with the government on this initiative, because, in rural areas, many girls experience infections related to menstrual hygiene. ‘Khushi’ is giving them a hygienic option" (School staff) "For us, it's too much... I feel a lot of pressure because of it; it is an extra workload. We have a shortage of staff, so on the day of pad distribution, we have to suspend classes because we don't have additional manpower available." (School staff) . Additionally, health department’s concerns included: lack of female "nodal teachers" in some schools and reluctance of some of the teachers to address sensitive topics like menstruation, citing unclear guidelines. While health department informants perceived a lack of commitment from the education department, the latter expressed dissatisfaction with health department's limited support in pad distribution, awareness generation, and supportive supervision. "Someone from the health department should come as a resource person and also oversee the distribution; they can give a broader perspective than us." (School staff). “The health department should work more closely with schools to sensitize the children” (School staff) The challenges of day-to-day coordination between both the departments were conspicuous at the district level, as compared to the block and the school levels where a sense of personal relationship, local innovation and belongingness played buffer role in navigating through the challenges of co-ordination. A critical communication gap was identified, particularly regarding keeping beneficiary numbers up-to-date. This resulted in inadequate allocation of resources for adolescent girls because the health department relies on an outdated list of beneficiaries provided by the education department during the program launch, which excludes girls who have reached menarche or recently joined the school following the high school transformation initiative. “For ‘Khushi’, I have created a WhatsApp group, in which the Head Master from every school is added. We share important supply and distribution related information in that group, and we get very good response as well.” (Block official). “We are receiving supplies based on old data. Currently, the student strength has increased, so some girls are not receiving the supplies” (District official). Theme 3: Indenting and supply chain Review of reports and documents indicates that an estimated 1.7 million beneficiaries receive quarterly sanitary napkins under ‘Khushi’ program with an annual government expenditure of roughly INR 500 million ( 40 ). All girls from Class VI-XII, regardless of menarche status, are eligible as per the existing guidelines. The health and family welfare department is responsible for procurement and distribution of pads through Odisha State Medical Corporation Limited (OSMCL), after testing quality compliance by a national laboratory. Often OSMCL selects three lowest quoting vendors to avoid supply shortages and for ensuring timely delivering to schools. Despite of having a seemingly robust procurement system, timely delivery of pads at the block level warehouse continues to pose challenges. None of the sample districts had received quarterly stocks on time, often resulting in erratic delivery and insufficient storage capacity at block points. The same problem was also expressed by beneficiaries. “Before the order is placed, a sample of the pads is sent to the national testing laboratory for quality control and the order is placed after receiving the quality control reports. The whole process takes about 1-1.5 months. Therefore, the process is started with delivery times in mind” (State health official) . “Last distribution was done in October 2021, for the last 11 months we have not received any stock” (Block official) “We have received twice only… Last time I got when I was in class 9th and then once in 10th, this year, that’s it” (FGD girls). “Sometimes they send stock even before the distribution is done. Once we had around 40 to 45 carton boxes and they sent it again so all together we had around 90 to 100 carton boxes” (Block Official). Delay in distribution of pads to schools often results in stock accumulation, risking expiry or damage. Suppliers responsible for delivery of pads up to the block points lack effective communication with storage point personnel, leading to inconvenience in delivery and storage. Further, the “fixed cost for movement of the stock from the block storage point to the schools (INR 0.90/pack) also creates operational difficulties” , said one respondent on condition of anonymity. “When the stock arrives here, we are worried about the place to store it” (District official) “Once the stock came in the evening, unloading couldn't happen same day, they said we need safety, we need to alert the police, at night 9 pm I had to go to the police station to alert them, until late night I was with them” (Block official) “… we try to deliver the stock to four or five schools on the same route, to minimize transportation cost. We negotiate hard and keep good rapport with the vehicle owners to manage at this cost” (District official) The health department is mandated to transfer the transportation cost to the education department which in turn pays to the Cluster Resource Centre Coordinators (CRCC) responsible for transporting stock from the Block storage unit to the school storage points. However, in some districts another working model was existing as pointed out by some respondents, in which the health department engages a third-party and directly pays for movement of such stocks ( Table 2 ). Table 2 Supply chain working models District name Mechanism of stock transportation (from block storage unit to school storage point) Status Person/Agency responsible Payment mechanism Balangir and Koraput Third-party Directly paid through health department Notwithstanding supply irregularities, payment-related delays are non-existent. Bhadrak CRCCs Health to education department to CRCCs Disrupted supply chain due to delay in payment to CRCCs Theme 4: Capacity building Respondents felt capacity building of the service providers and managerial cadre needed due emphasis from the district administration. For example, despite the need for web portal training on stock management (e-’KHUSHI’), the in-charge officials across all sample districts lacked adequate training on the portal and warehouse management, resulting in their inability to effectively manage storage points. "The state is asking us to update stock information in the software (e-’KHUSHI’). But they didn't provide any physical training to the concerned individuals, instead they sent an e-manual." (District Official) . "When new stock arrived, it was placed in front of the old stock. When distribution resumed, it started from the front, and by the time we reached the old stock, it had already expired." (Block official) Nodal teachers trained by the health department were seen as crucial stakeholders in the ‘Khushi’ program responsible for health messaging, stock management and distribution monitoring. However, frequent transfers and postings left many schools with untrained staff ill-equipped to handle the complexities of implementing the program. As a result, all the sample districts felt that ‘Khushi’ is increasingly becoming a pad distribution program, with less emphasis on awareness generation. "The teachers keep changing, and when a new teacher takes charge, she is unaware of the process. There should be manuals for them to refer to whenever they have any doubts" (District official). “The health functionaries are oriented already, but the Educational functionaries are sensitized only in one or two forums which is not adequate” (District official). Theme 5: Monitoring and supervision Participants in this study highlighted challenges related to poor level of monitoring owing to insufficient fund allocation and delayed reimbursements for such activities. This restricts the frequency and scope of field visits to distribution points. Further, the respondents mentioned that currently there is very limited use of the web-based application for real-time monitoring and stock updating. Most of the respondents felt the need to establish and strengthen an independent review and feedback mechanism under the program. "We are unsure if the school teachers are genuinely apprising the children or just handing over the packets to them. How can we know?" (District Official) The health officials emphasized the need for a collaborative platform to address coordination challenges between the education and health departments. This platform could facilitate discussions on identified issues and the development of solutions to prevent their recurrence or escalation "We provide the supplies up to the storage point, and then the Education department takes over. They follow the guidelines, but we do not receive any feedback from them, and there is no meeting between both departments to analyse and resolve implementation issues. There is no established structure or format to review ‘Khushi’." (District Official) Discussion Odisha government's ‘Khushi’ program aims to improve access to safe menstrual hygiene products for schoolgirls and in turn reduce school absenteeism / drop-outs; our research identified bottlenecks (mostly systemic) and opportunities for intervention (Table 3 ) in order to improve upon the key thematic domains of approach to micro-planning, interdepartmental convergence, indenting and supply chain management, capacity building, and monitoring and supervision. Table 3 Bottlenecks and proposed interventions to strengthen ‘Khushi’ implementation Identified Bottleneck Proposed intervention Approach to micro planning Assess system’s readiness and identify actionable gaps for redressal Develop strategies and allocate resources for sustained behaviour change of school girls Poor inter-departmental convergence Engage with collaborating departments on a regular basis to discuss and flash out common challenges Establish unambiguous communication channels and delineate responsibilities Allocate resources for hiring, training, monitoring and supervision Disrupted supply chain Decentralize budgeting and inventing Train block officials on indenting, inventory and stock management Introduce phased automation of inventory and stock management Appoint supply chain manager at block level Engage third-party for warehouse-to-stock delivery, with payments facilitated by the health department Limited capacity building Train block ware house in-charge on inventory and stock management Orient school staff on awareness generation and process documentation Inadequate monitoring and supervision Ensure financial envelope and timely reimbursement of monitoring activities Establish monthly review mechanism at block level and quarterly at district level, Encourage bottom-up feedback Our findings indicate that mere distribution of free sanitary napkins may not be sufficient to achieve the dual objectives of improved menstrual hygiene behaviour and reduced school absenteeism. Respondents felt strongly about the need to focus more on undertaking activities aimed at strengthening implementation of various activities under ‘Khushi’ program. Sustained improvement in the behaviour of school girls with regard to menstrual hygiene management practices and reduction of school absenteeism are organically linked to improved academic performance ( 41 ), though there is limited evidence linking menstruation with higher rate of absenteeism ( 42 ). Analysis of longitudinal health data of adolescents in India on menstruation and school attendance was inconclusive ( 43 ), which is similar to the findings of another study conducted in Malawi ( 44 ). We found that discomfort due to menstrual cramps and lack of appropriate infrastructure at schools were pointed as reasons for absenteeism from school during menstruation, which is in sync with few other studies ( 45 ); fear of getting stains on clothes and lack of proper disposal of used pads/clothes was more of a challenge for the girls from Government schools as compared to private schools ( 19 ) ( 46 ). A study in Malawi also reported similar findings where girls experienced challenge in schools due to lack of appropriate toilet facility ( 47 ). A randomized control trial (RCT) in Kenya found sanitary napkin distribution did not culminate in increased school attendance ( 48 ). This signifies that provision of free sanitary pad distribution cannot be a complete solution to achieve reduction in school absenteeism; an MHM-friendly school infrastructure is a critical pre-requisite ( 49 ). However, the potential of schools in developing a conducive environment and supportive infrastructure for dignified menstruation is yet to be tapped under ‘Khushi’ program. Initiating dialogue on menstruation in schools necessitates sensitization of teachers and ‘peer champions’ in delivering appropriate messages on as sensitive topics as menstruation, menstrual health and hygiene, and sexual and reproductive health ( 50 ). The importance of schools in raising mass awareness on health issues has often been well recognized; the health department has also frequently used such platforms to drive the health agenda, but the efforts mostly get narrowed down to distribution of products, such as, IFAs, deworming tablets, or sanitary napkins. Studies have also shown that in India the school curriculum is not aptly used to raise awareness about the issues of reproductive health ( 51 ). School teachers need to be empowered to improve knowledge and practices of girls about reproductive health ( 52 ). A vast majority of girls from rural areas are enrolled in government schools. Therefore, while the debate on appropriateness of information to girls at the right age and in the right way continues to divide the opinion, the first source of information / misinformation on the subject for a young girl continues to the mother/sister/relative ( 38 ) who themselves are grappling with fear and cultural taboos ( 41 , 48 , 53 ). A study in Ethiopia concluded that educational interventions on MHM and provision of MHM kits resulted in decreased school absenteeism among girls ( 54 ). On the other hand, a mere sanitary napkin distribution program would undermine the capacity of a girl to make an informed choice without accompanying information, education, and communication (IEC) ( 55 ). Like other logistics-intensive programs, ‘Khushi’ also has many a day-to-day challenges on logistics and supply chain management. Appropriate forecasting, warehouse and inventory management, transportation, delivery and distribution have several bottlenecks that need redressal ( 56 , 57 ). A study on logistics management in Ghana by Bossert et al ., concluded that centralization of planning, budgeting, information management system and inventory control was associated with greater success ( 58 ). Service providers and managers encounter heavy workload and insufficient guidelines for better coordination; guidelines ought to be developed and percolated down to the sub centre level to address these gaps ( 59 ). The ‘Khushi’ program has led to improved access to sanitary pads for most girls; however, the rural ecosystem is not yet fully developed to manage the large amount of menstrual wastes emerging out of mass use of disposable sanitary products ( 60 ). Moreover, this dimension has long been poorly addressed which could pose considerable challenges to the environment in the long run ( 61 ). Incremental shift to more sustainable, eco-friendly and bio-degradable sanitary pads is a desirable state which some studies in Nepal and Kenya have agreed with. Hence, serious efforts need to be initiated to promote such products in a phased manner ( 53 ). To enhance the trustworthiness of the study, triangulation of data sources and analyses was followed. This involved collecting data from multiple key stakeholders within the health and education department at different administrative levels such as blocks, districts, and state. Additionally, to mitigate potential misinterpretation during data analysis, both English and Odia transcripts were utilized. Furthermore, the authors diverse backgrounds in medicine and social science, coupled with their experience in public health, strengthened the conformability of the findings. This study was conducted in select districts chosen through purposive sampling; therefore, the results may not be representative of the universe, and generalization need to be done with caution. However, the challenges and bottlenecks identified through this study are reflective of the overall situation in the State, which could be comparable in similar socio-cultural contexts. Moreover, our study was carried out in the post-COVID period, suggesting that certain challenges could be mitigated over time and through the effective functioning of the system. Conclusion Menstrual health and hygiene of young adolescent girls affects millions of lives across the globe. In India and in Odisha various departments and stakeholders play crucial role in the success of implementing government-sponsored programs. ‘Khushi’ is a state-specific initiative which has the potentiality to bring a paradigm shift in the menstrual health behaviour of school girls. Government may need to invest time and resources for bridging the infrastructural gaps, raise level of competency of service providers and improve the supply chain management practices to ensure successful implementation of the program. Use of technology for automation, building capacity of frontline workforce and financial allocation for program monitoring are the immediate action points to strengthen the program. Challenges related to inter-sectoral convergence could be addressed through periodic stock-taking by officials in the higher rung of the hierarchy. In the long run, it ought to shift towards a more environment-friendly option for product designing and procurement. MHM-friendly school infrastructure, imparting education, sensitizing men and boys, and optimal inter-departmental coordination are crucial mediators for effective behaviour change among school girls. Healthy menstruation of girls would lead to healthy womanhood and a better society. Abbreviations MHM Menstrual hygiene management SDGs Sustainable Development Goals LMICs low- and middle-income countries WASH Water, Sanitation and hygiene RMNCH+A Reproductive, Maternal, Newborn, Child Health and Adolescents RKSK Rashtriya Kishore Swasthya Karyakram IDI In depth interviews OSMCL Odisha State Medical Corporation Limited CRCC Cluster Resource Centre Coordinator FGD Focus group discussions ANM Auxiliary Nurse and Midwife RCT Randomized control trial IFA Iron folic acid IEC Information, Education & Communication DOHFW Department of Health and Family Welfare Declarations Ethics approval and consent to participate Ethical clearance was obtained from an independent ethics committee of the Indian Institute of Public Health (IIPH-B), Bhubaneswar, a unit of Public Health Foundation of India (PHFI). The study was then approved by the State Research and Ethics Committee, government of Odisha, vide letter no. 18003/MS-2-IV-04/2020 (PT-1), dated 13th July 2022. Informed consent was obtained from all the participants. Anonymity and confidentiality of information was ensured all throughout the study period. Consent for publication Not applicable. Availability of data and materials All the data collected and analysed in this study are available with the corresponding author and would be provided upon request. Competing interests Authors declare no competing interests Funding The project was funded by UNICEF, Odisha. Authors' contributions BP conceptualized the study. BP and SD finalized the methodology and developed the data collection tools. SD, NP and RPP were involved in data collection. SD and NP transcribed and translated the data. BP, SD, NP and RPP analysed data. SD and NP prepared the manuscript. BP reviewed and finalized it. All authors have read and agreed to the submitted version of the manuscript. Acknowledgements We are thankful to all the participants who consented to participate in the study and shared their valuable inputs. We acknowledge the contribution of Field Investigators engaged during data collection phase. We are thankful to Government of Odisha, especially the Department of Health and Family Welfare (DOHFW) for approving the project and providing all support during data collection. The Chief Medical Officers of sample districts, officials of the school and mass education department, and school teachers were cooperative, we are thankful to all of them. Authors’ information Nishisipa Panda & Bhuputra Panda Present address: KIIT School of Public Health, KIIT Deemed to be University, Bhubaneswar, India Authors and Affiliations PHFI-Indian Institute of Public Health, Bhubaneswar, India Shyama Desaraju, Nishisipa Panda, Rudra Prasad Panigrahy & Bhuputra Panda References Holst AS, Jacques-Aviñó C, Berenguera A, Pinzón-Sanabria D, Valls-Llobet C, Munrós-Feliu J, et al. 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Glob Health Action. 2021;14(1). WHO-UNICEF. UNICEF-Guidance-menstrual-health-hygiene-2019. . 2019. Hennegan J. The Palgrave Handbook of Critical Menstruation Studies. The Palgrave Handbook of Critical Menstruation Studies. Springer Singapore; 2020. 637–652 p. Lowik AJ. The Palgrave Handbook of Critical Menstruation Studies. Vol. 28, Sexual and Reproductive Health Matters. 2020. Vayeda M, Ghanghar V, Desai S, Shah P, Modi D, Dave K, et al. Improving menstrual hygiene management among adolescent girls in tribal areas of Gujarat: an evaluation of an implementation model integrating the government service delivery system. Sex Reprod Heal Matters. 2022;29(2):1–16. Sinha RN, Paul B. Menstrual hygiene management in India: The concerns. Indian J Public Health. 2018;62(2):71–4. Phillips-Howard PA, Caruso B, Torondel B, Zulaika G, Sahin M, Sommer M. Menstrual hygiene management among adolescent schoolgirls in low- and middle-income countries: Research priorities. Glob Health Action. 2016;9(1). Wasan Y, Baxter JAB, Rizvi A, Shaheen F, Junejo Q, Abro MA, et al. Practices and predictors of menstrual hygiene management material use among adolescent and young women in rural Pakistan: A crosssectional assessment. J Glob Health. 2022;12. Sommer M, Caruso BA, Torondel B, Warren EC, Yamakoshi B, Haver J, et al. Menstrual hygiene management in schools: midway progress update on the “MHM in Ten” 2014–2024 global agenda. Heal Res Policy Syst. 2021;19(1):1–14. Kemigisha E, Rai M, Mlahagwa W, Nyakato VN, Ivanova O. A qualitative study exploring menstruation experiences and practices among adolescent girls living in the nakivale refugee settlement, Uganda. Int J Environ Res Public Health. 2020;17(18):1–11. Sourav Ujjwal, Singh Ranjana, Gupta Barakha SA. The Effect of Community-Based Health Education Intervention on Management of Menstrual Hygiene and menstrual disorders among Rural Indian women. Indian J Prev Soc Med. 2021;52(4):191–6. Omidvar S, Begum K. 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Menstrual Hygiene Management in Resource-Poor Countries. Obstet Gynecol Surv. 2017;72(6):356–76. UNICEF. Investing in a safe, healthy and productive transition from childhood to adulthood is critical [Internet]. [cited 2023 Mar 9]. Available from: https://data.unicef.org/topic/adolescents/overview/ Shah V, Nabwera H, Sonko B, Bajo F, Faal F, Saidykhan M, et al. Effects of Menstrual Health and Hygiene on School Absenteeism and Drop-Out among Adolescent Girls in Rural Gambia. Int J Environ Res Public Health. 2022;19(6):1–23. Montgomery P, Hennegan J, Dolan C, Wu M, Steinfield L, Scott L. Menstruation and the Cycle of Poverty: A Cluster Quasi-Randomised Control Trial of Sanitary Pad and Puberty Education Provision in Uganda. Montazeri A, editor. PLoS One. 2016;11(12):e0166122. Montgomery P, Ryus CR, Dolan CS, Dopson S, Scott LM. Sanitary Pad Interventions for Girls’ Education in Ghana: A Pilot Study. PLoS One. 2012;7(10):1–7. Jasper C, Le TT, Bartram J. Water and sanitation in schools: A systematic review of the health and educational outcomes. Int J Environ Res Public Health. 2012;9(8):2772–87. McMichael C. Water, sanitation and hygiene (WASH) in schools in low-income countries: A review of evidence of impact. Int J Environ Res Public Health. 2019;16(3):1–21. Parasuraman G, Vijay V, Balaji S, Nisha B, Dutta R, Jain T, et al. Impact of health education intervention on menstruation and its hygiene among urban school-going adolescent girls in Thiruvallur, Tamilnadu. J Fam Med Prim Care. 2022;11(9):5271. Gupta A, Kumar R, Khera A, Agrawal D, Mohan A, Pandey R, et al. A Strategic Appproach to Reproductive, Maternal, Newborn, CHild and Adolescent Health in India For Healthy Mother and Child. 2013;1–83. Phatak AG. Improving Menstrual Hygiene Management in School Going Adolescent Girls: Experience from Charutar Region of Gujarat, India. Indian J Youth Adolesc Heal. 2020;6(3):13–9. Yang YT, Chen DR. Effectiveness of a menstrual health education program on psychological well-being and behavioral change among adolescent girls in rural Uganda. J Public Health Africa. 2023;14(3). Guidelines O. Operational Guidelines. Strategy [Internet]. 2010;1–66. Available from: http://www.who.int/lep/resources/SEAGLP20062.pdf RKSK: Rashtriya Kishor Swasthya Karyakram [Internet]. [cited 2024 Apr 11]. Available from: https://rksk.in/ SABLA [Internet]. [cited 2024 Apr 11]. Available from: https://wcd.odisha.gov.in/ICDS/sabla Gupta A, Kumar R, Khera A, Agrawal D, Mohan A, Pandey R, et al. A Strategic Appproach to Reproductive, Maternal, Newborn, CHild and Adolescent Health in India For Healthy Mother and Child. 2013;1–83. Available from: http://nrhm.gov.in/images/pdf/programmes/rmncha-strategy.pdf Khushi [Internet]. [cited 2024 Apr 11]. Available from: https://khushi.nic.in/ Srivastava A. Challenges for evaluation practices and innovative approaches: Lessons during COVID-19 pandemic. Eval Program Plann. 2022;92(April):102095. Panda N, Desaraju S, Panigrahy RP, Ghosh U, Saxena S, Singh P, et al. Menstrual health and hygiene amongst adolescent girls and women of reproductive age: a study of practices and predictors, Odisha, India. BMC Womens Health [Internet]. 2024;24(1):144. Available from: https://doi.org/10.21203/rs.3.rs-2751776/v1 Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. Syariah KB, Ilmu G. Child budget 2022-23 [Internet]. Available from: https://finance.odisha.gov.in/sites/default/files/2022-07/Child Budget.pdf Ahmed MS, Yunus FM, Hossain MB, Sarker KK, Khan S. Association between Menstrual Hygiene Management and School Performance among the School-Going Girls in Rural Bangladesh. Adolescents. 2021;1(3):335–47. Benshaul-tolonen A, Zulaika G, Sommer M, Phillips-howard PA. The Palgrave Handbook of Critical Menstruation Studies. The Palgrave Handbook of Critical Menstruation Studies. Springer Singapore; 2020. 705–723 p. Khanna M. The Precocious Period: The Impact of Early Menarche on Schooling in India. SSRN Electron J. 2019; Grant M, Lloyd C, Mensch B. Menstruation and school absenteeism: Evidence from rural Malawi. Comp Educ Rev. 2013;57(2):260–84. Sivakami M, van Eijk AM, Thakur H, Kakade N, Patil C, Shinde S, et al. Effect of menstruation on girls and their schooling, and facilitators of menstrual hygiene management in schools: Surveys in government schools in three states in India, 2015. J Glob Health. 2019;9(1). Pradhan S, Kar K, Samal BP, Pradhan J. Assessment of knowledge and practice of menstrual hygiene among school going adolescent girls in an urban area of Odisha: a cross sectional study. Int J Community Med Public Heal. 2019;6(9):3979. Kambala C, Chinangwa A, Chipeta E, Torondel B, Morse T. Acceptability of menstrual products interventions for menstrual hygiene management among women and girls in Malawi. Reprod Health. 2020;17(1):1–12. Austrian K, Kangwana B, Muthengi E, Soler-Hampejsek E. Effects of sanitary pad distribution and reproductive health education on upper primary school attendance and reproductive health knowledge and attitudes in Kenya: a cluster randomized controlled trial. Reprod Health. 2021;18(1):1–14. Alam MU, Luby SP, Halder AK, Islam K, Opel A, Shoab AK, et al. Menstrual hygiene management among Bangladeshi adolescent schoolgirls and risk factors affecting school absence: Results from a cross-sectional survey. BMJ Open. 2017;7(7):1–10. Joseph N, Mahato V, Pandey A, Mishra S, Prakash G, Gandhi R. Experiences and perception towards reproductive health education among secondary school teachers in South India. Reprod Health [Internet]. 2021;18(1):1–10. Available from: https://doi.org/10.1186/s12978-021-01224-6 Mahon T, Fernandes M. Menstrual hygiene in South Asia: A neglected issue for WASH (water, sanitation and hygiene) programmes. Gend Dev. 2010;18(1):99–113. Evans RL, Harris B, Onuegbu C, Griffiths F. Systematic review of educational interventions to improve the menstrual health of young adolescent girls. BMJ Open. 2022;12(6):1–12. van Eijk AM, Sivakami M, Thakkar MB, Bauman A, Laserson KF, Coates S, et al. Menstrual hygiene management among adolescent girls in India: a systematic review and meta-analysis. BMJ Open [Internet]. 2016;6(3):e010290. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26936906 Belay S, Kuhlmann AKS, Wall LL. Girls’ attendance at school after a menstrual hygiene intervention in northern Ethiopia. Int J Gynecol Obstet. 2020;149(3):287–91. Chatterjee P. Improving menstrual hygiene among adolescent girls in India. Lancet Child Adolesc Heal. 2020;4(6):422–3. Ahmad K, Singh J, Singh RA, Saxena A, Varghese M, Ghosh S, et al. Public health supply chain for iron and folic acid supplementation in India: Status, bottlenecks and an agenda for corrective action under Anemia Mukt Bharat strategy. PLoS One. 2023;18(2 February):1–18. Wendt AS, Stephenson R, Young MF, Verma P, Srikantiah S, Webb-Girard A, et al. Identifying bottlenecks in the iron and folic acid supply chain in Bihar, India: A mixed-methods study. BMC Health Serv Res. 2018;18(1):1–12. Bossert TJ, Bowser DM, Amenyah JK. Is decentralization good for logistics systems? Evidence on essential medicine logistics in Ghana and Guatemala. Health Policy Plan [Internet]. 2007;22(2):73–82. Available from: https://academic.oup.com/heapol/article-lookup/doi/ 10.1093/heapol/czl041 Kim SS, Avula R, Ved R, Kohli N, Singh K, Van Den Bold M, et al. Understanding the role of intersectoral convergence in the delivery of essential maternal and child nutrition interventions in Odisha, India: A qualitative study. BMC Public Health. 2017;17(1):1–12. Garg R, Goyal S, Gupta S. India moves towards menstrual hygiene: Subsidized sanitary napkins for rural adolescent girls - Issues and challenges. Matern Child Health J. 2012;16(4):767–74. Plesons M, Patkar A, Babb J, Balapitiya A, Carson F, Caruso BA, et al. The state of adolescent menstrual health in low- and middle-income countries and suggestions for future action and research. Reprod Health. 2021;18(1):1–13. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4259211","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":291147354,"identity":"085e83f8-a313-4112-aca3-8728190f52e1","order_by":0,"name":"Shyama Desaraju","email":"","orcid":"","institution":"Indian Institute of Public Health, Bhubaneswar","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Shyama","middleName":"","lastName":"Desaraju","suffix":""},{"id":291147355,"identity":"3dcc5c95-54ce-4954-9c77-f16a4c58c5ec","order_by":1,"name":"Nishisipa Panda","email":"","orcid":"","institution":"Indian Institute of Public Health, Bhubaneswar","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Nishisipa","middleName":"","lastName":"Panda","suffix":""},{"id":291147356,"identity":"47af84e1-093c-4ef6-8b90-78ffff1f6fad","order_by":2,"name":"Rudra Prasad Panigrahy","email":"","orcid":"","institution":"Indian Institute of Public Health, Bhubaneswar","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Rudra","middleName":"Prasad","lastName":"Panigrahy","suffix":""},{"id":291147357,"identity":"274a7421-f0ff-4fca-94b0-89da567475a7","order_by":3,"name":"Bhuputra Panda","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9ElEQVRIiWNgGAWjYBACAwlkHg+DDZBkbDxAWEsCXEsaSEsDSVoOg2m8Wsyle8we8/64J88g3fzswZua83Zr2w8DbamxicalxXLOGXNjnoRiwwaZY+aGc47dTt52JhGo5VhabgMuh93IMZPmSUhgbJBIADLYbiebHQBqYWw4TFCLfYNE+jdpnn/nks3OPyROS2KDBJDB23bAzuwGAVssZ6SVG85JS0hukzlTJjm3LznB7AbQlgQ8fjGXSN724I1Ngm2/dPs2iTff7OzNzqc/fPChxganFiBgg5DQZJAIVpmAWzlCCwNUiz1+xaNgFIyCUTASAQCTTF6F/2d4zAAAAABJRU5ErkJggg==","orcid":"","institution":"Indian Institute of Public Health, Bhubaneswar","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Bhuputra","middleName":"","lastName":"Panda","suffix":""}],"badges":[],"createdAt":"2024-04-12 17:44:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4259211/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4259211/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12961-025-01316-w","type":"published","date":"2025-07-16T15:57:15+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":87219444,"identity":"82170fb2-9c49-4196-830a-8b109a6611c4","added_by":"auto","created_at":"2025-07-21 16:04:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":778403,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4259211/v1/fbaca903-3423-47c0-b85b-81ae9ba20536.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Policy to Practice: Insights from Implementation of a School-Based Sanitary Napkin Distribution Program in Odisha, India","fulltext":[{"header":"Background","content":"\u003cp\u003eMenstruation, a natural physiological process often stigmatized and marginalized in many cultures, is fast emerging as a predominant driver of gender equity (\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The United Nations recognises safe and dignified menstruation as a fundamental need for every woman which it further emphasises upon as a crucial milestone in advancing Sustainable Development Goals (SDGs) (\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Further, governments worldwide are progressively working towards de-stigmatization of menstruation, and enhancing access to infrastructure, information, products and services in pursuance of SDGs (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Access to clean absorbents, private space for changing pads, disposal of used pads, and availability of soap and water for personal hygiene constitute the backbone of effective menstrual hygiene management (MHM) (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEvidences from low- and middle-income countries (LMICs) consistently indicate that over 50% of females experience challenges in achieving adequate MHM (\u003cspan additionalcitationids=\"CR12 CR13 CR14\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Various factors including age and socio-economic status (SES) influence menstrual behaviour (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Adolescent girls, particularly in LMICs bear the maximum brunt of poor MHM in terms of several psychological and socio-economic barriers (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). For instance, they grapple with feelings of shame, fear, embarrassment, poor social support and cultural taboos. Moreover, in school settings, the need for a private space for changing pads is acutely felt. Recent assessment of water, sanitation and hygiene (WASH) situation in schools across many states in India have all pointed out towards non-availability of gender segregated water, poor level of sensitization of teachers, lack of self-confidence among girls and existence of non-supportive environment as major impediments. Consequently, chronic absenteeism from school, distraction from mainstream education and frequent infections affect lives of school girls (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR19 CR20\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Given that adolescents constitute about 16% of the world's population (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), urgent attention is critical to address their menstrual hygiene needs.\u003c/p\u003e \u003cp\u003eOff lately, schools have emerged as focal points for increasing menstrual awareness. Apparently, collaborations between the health and the education department is crucial to address some of the gaps related to MHM infrastructure, information and products at school level (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Emerging models such as \"MHM in Ten\" consortium, comprising of the United Nations agencies and civil society organisations, intend to complement this inter-sectoral collaborative effort (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Governments have invested heavily on enhancing MHM ambience in schools (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e); involving access to Water, Sanitation, and Hygiene (WASH) facilities and providing sanitary pads (\u003cspan additionalcitationids=\"CR25 CR26\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), while imparting menstrual education (\u003cspan additionalcitationids=\"CR29 CR30\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOptimal access to MHM product and services is on the top of the agenda of Government of India and many state governments. For instance, the Ministry of health and Family Welfare launched the Menstrual hygiene program as early as 2011 to promote menstrual health amongst adolescent girls (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Similarly, launching of SABLA Yojana in 2011, RMNCH\u0026thinsp;+\u0026thinsp;A in 2013 and RKSK in 2014 have collectively contributed to empowering adolescents (\u003cspan additionalcitationids=\"CR34\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Odisha, a state in eastern India, the state government launched free distribution of disposable sanitary pads, popularly called the \u0026lsquo;Khushi\u0026rsquo; program in 2018 for girls in Grade 6\u0026ndash;12, enrolled in government and/or government-aided schools. The main objective of the program was to improve menstrual health and hygiene and to reduce school drop-outs (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, there is paucity of scientific evidence related to the obstacles encountered in implementation and functioning of \u0026lsquo;Khushi\u0026rsquo; program and a lack of efforts to document the valuable lessons learned to guide future actions. This gap may have been exacerbated by the COVID-19 pandemic, which necessitated overwhelming focus on effective COVID management in both national and international contexts (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). To address this gap, this study aims to explore perspectives and barriers of implementing \u0026lsquo;Khushi\u0026rsquo; program in Odisha. It further delved into the user experiences and identified systemic barriers hindering the adoption of safe menstrual hygiene practices within the school environment. Demand-centric challenges, supply-driven barriers and systemic bottlenecks are the facets of scientific enquiry. The demand-centric dimensions have already been presented in a recently published paper (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy settings\u003c/h2\u003e \u003cp\u003eThis manuscript emanates from a larger study conducted in 3 districts (Bhadrak, Koraput and Balangir) of Odisha, India on situational analysis of MHM (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Our study sites represented the coastal, tribal and under-developed regions, respectively. Senior officials of the Health and Family Welfare department guided the research team in selection of the districts.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and participants\u003c/h2\u003e \u003cp\u003eWe adopted a cross-sectional study design, using a mixed-method approach for data collection and analysis. To explore the perspectives and experiences of stakeholders on activities undertaken under the \u0026lsquo;Khushi\u0026rsquo; program, officials of health and education departments, and school staff involved in program implementation, constituted the sample universe. Brief description about the characteristics of key informants who participated in the IDI is given in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eFurther, six focus group discussions were also conducted with school girls of Class VI-XII, to explore their experiences and perceived barriers regarding menstrual hygiene practices within the school environment. Additionally, a desk review of program documents and relevant government policies was undertaken.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of in-depth interview respondents\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth department\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEducation Department\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eState\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDept. of Health and Family welfare (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003eOSMCL (Odisha State Medical Corporation Limited) (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003eNational Health Mission (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistrict\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDistrict Program Management Unit officials (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlock\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBlock ware house in-charge (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003cp\u003eMedical Officer in-charge (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCRCCs (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchool\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHeadmaster (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e \u003cp\u003eNodal teacher (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003cp\u003eWarden of Ashram schools (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData collection tools and techniques\u003c/h2\u003e \u003cp\u003eIn-depth interviews (IDI) and focus group discussions (FGD) were conducted with the key stakeholders. An IDI guide was developed through iterative process, followed by piloting and contextualization. The principal investigator reviewed the study tools both in English and local language (Odia) for accuracy and consistency. All IDIs and FGDs were conducted in Odia language which were subsequently transcribed and translated into English for analysis.\u003c/p\u003e \u003cp\u003eThe research team involved in data collection was trained by the principal investigator and co-investigators; data collection was carried out during September 2021-November 2022. The team members conducted the IDIs and FGDs along with a field investigator familiar with the local dialect. All the IDIs and FGDs were conducted at a place and time convenient to the participants, and the researchers clearly explained the study objectives and obtained their consent for audio-recording the interview, beforehand. Respondents voluntarily participated in the study, were not given any financial incentive for participation. The interviews and FGDs lasted between 30\u0026ndash;60 minutes. The sample size was determined using data saturation technique. Total of 30 IDS were conducted with participants from the health and family welfare department working at state, district, and block levels, and the school and mass education department responsible for overseeing the \u0026lsquo;Khushi\u0026rsquo; program at the block and school levels. Further, six FGDs were held with 6\u0026ndash;7 adolescent girls, each, from rural and urban schools, government and \u003cem\u003eAshram\u003c/em\u003e schools who are the primary beneficiaries. All steps were taken to maintain confidentiality and anonymity of the study participants.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eData collection and analysis was undertaken in a parallel manner to look for gaps in the information being collected. The transcripts were anonymized by assigning unique identifiers and secured in a password-protected computer accessible only to the research team. Atlas.ti. 8 software was used for text coding and categorization. Thematic analysis by Braun and Clark (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e) guided the data analysis. This process required the authors to read and re-read the transcripts to identify potential themes. Transcripts were analysed alongside the original recordings to look for inconsistencies and ensure deeper understanding. In the next step, SD and NP independently assigned codes to text segments of the transcripts; discrepancies, if any, were collectively resolved. In the third step, similar and related codes were combined and grouped into distinct themes. Themes were refined based on the data and those themes which didn\u0026rsquo;t have enough data to support were discarded. Finally, each theme was clearly defined, analysed, and given a precise name; relevant quotes were used to illustrate the themes.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eAnalysis of systemic bottlenecks related to implementation of \u0026lsquo;Khushi\u0026rsquo; program yielded five major themes: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Approach to micro planning; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Inter-departmental convergence; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Indenting and supply chain; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) Capacity building; and (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) Monitoring and supervision.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eTheme 1: Approach to micro planning\u003c/h2\u003e \u003cp\u003eThe \u0026lsquo;Khushi\u0026rsquo; program was appreciated by all respondents for its effectiveness in promoting menstrual hygiene practices and encouraging the use of sanitary pads among adolescent girls, both in rural and urban areas. The program addressed the critical issue of inaccessibility of sanitary products (due to lack of Availability, Accessibility and Affordability) for adolescent girls. Furthermore, the program was commended for its initiative to introduce sanitary pads at a crucial stage around menarche, fostering the development of healthy menstrual hygiene habits early on. Additionally, the program facilitated open discussions about menstruation within school settings.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;when we started giving pads, they started sharing about their menstruation-related issues. It is then we also came to know that they were using clothes earlier\u0026rdquo; (School staff).\u003c/em\u003e \u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003e\u0026hellip;. most of our students belong to poor families, and also their mothers don\u0026rsquo;t discuss this topic often, so most of them were unaware about pads and their proper use when we first distributed.\u0026rdquo; (School staff)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, some, criticized the program for lacking a structured approach to ensure sustainable menstrual hygiene behavior among adolescent leading to reduced absenteeism and improved academic parameters. Respondents emphasized the need for a structured approach to address the multi-faceted issue of menstrual hygiene. This approach, they argued, should include efforts to raise awareness, strengthen school infrastructure and consistent supply of sanitary napkins. A majority of the respondents, from the education department, viewed \u0026lsquo;Khushi\u0026rsquo; primarily as a sanitary napkin distribution program with minimal focus on sustained awareness generation. They reported that initial information sessions on menstrual hygiene practices delivered by health department personnel were discontinued, leading the program to become more focused on pad distribution and less on education.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Government is just distributing it, but with limited efforts of awareness generation, it would have no impact\u0026rdquo; (School staff).\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Initially, during distribution, a doctor and ANM came, and counselled about the usage of pads, and when to change it and how to dispose it, and then distributed the pads. Thereafter no one came\u0026rdquo; (School staff)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;.and don't give timely supply then everything fails, without consistency it will not work, if we disrupt the process then we won\u0026rsquo;t give substantive results\u0026rdquo; (School staff)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFurthermore, the program was seen as inadequate in addressing factors that contribute to school absenteeism during menstruation, such as, menstruation-related discomfort and cultural restrictions on girls\u0026rsquo; movement.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Some girls experience stomach pain so they don't come. Not having privacy in the schools also restricts them from coming to school\u0026rdquo; (Block official).\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I get severe stomach pain; hence I sleep on my stomach (prone) to put pressure or use hot compression to relieve pain. So, I don\u0026rsquo;t go to school during that time\u0026rdquo; (FGD girls)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Participants also highlighted challenges with WASH (Water, Sanitation and Hygiene) infrastructure in schools, which often doesn\u0026rsquo;t meet menstrual hygiene standards. This lack of adequate privacy and disposal facilities create hygiene and sanitation concerns for both students and staff.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The Government should do something about the disposal problem. When pads are provided, it is obvious that the girls will use it and then dispose it. For that there should be some facility at schools, which is, currently lacking.\u0026rdquo; (School staff).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;If the girls dispose pads in school, it will be a challenge for us because we don\u0026rsquo;t get people to clean such things\u0026rdquo;. (Teacher).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2: Inter-departmental convergence\u003c/h2\u003e \u003cp\u003eOfficials from both education and health departments opined that \u0026lsquo;Khushi\u0026rsquo; program seamlessly integrates with the existing school health initiatives. They believe it leverages their established partnership and facilitates efficient outreach to beneficiaries. However, district authorities raised concerns about the increased workload placed on the frontline workers from both departments due to the program\u0026rsquo;s implementation.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"Our collaboration involves joint programs with the health department, where medical officers educate girls on various issues. The school also participates in existing health programs, such as administering deworming medications and iron folic acid tablets to children.\" (School staff).\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We are happy to partner with the government on this initiative, because, in rural areas, many girls experience infections related to menstrual hygiene. \u0026lsquo;Khushi\u0026rsquo; is giving them a hygienic option\" (School staff)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\"For us, it's too much... I feel a lot of pressure because of it; it is an extra workload. We have a shortage of staff, so on the day of pad distribution, we have to suspend classes because we don't have additional manpower available.\" (School staff)\u003c/em\u003e.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Additionally, health department\u0026rsquo;s concerns included: lack of female \"nodal teachers\" in some schools and reluctance of some of the teachers to address sensitive topics like menstruation, citing unclear guidelines. While health department informants perceived a lack of commitment from the education department, the latter expressed dissatisfaction with health department's limited support in pad distribution, awareness generation, and supportive supervision.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\"Someone from the health department should come as a resource person and also oversee the distribution; they can give a broader perspective than us.\" (School staff).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The health department should work more closely with schools to sensitize the children\u0026rdquo; (School staff)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e The challenges of day-to-day coordination between both the departments were conspicuous at the district level, as compared to the block and the school levels where a sense of personal relationship, local innovation and belongingness played buffer role in navigating through the challenges of co-ordination. A critical communication gap was identified, particularly regarding keeping beneficiary numbers up-to-date. This resulted in inadequate allocation of resources for adolescent girls because the health department relies on an outdated list of beneficiaries provided by the education department during the program launch, which excludes girls who have reached menarche or recently joined the school following the high school transformation initiative.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;For \u0026lsquo;Khushi\u0026rsquo;, I have created a WhatsApp group, in which the Head Master from every school is added. We share important supply and distribution related information in that group, and we get very good response as well.\u0026rdquo; (Block official).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We are receiving supplies based on old data. Currently, the student strength has increased, so some girls are not receiving the supplies\u0026rdquo; (District official).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eTheme 3: Indenting and supply chain\u003c/h2\u003e \u003cp\u003eReview of reports and documents indicates that an estimated 1.7\u0026nbsp;million beneficiaries receive quarterly sanitary napkins under \u0026lsquo;Khushi\u0026rsquo; program with an annual government expenditure of roughly INR 500\u0026nbsp;million (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). All girls from Class VI-XII, regardless of menarche status, are eligible as per the existing guidelines. The health and family welfare department is responsible for procurement and distribution of pads through Odisha State Medical Corporation Limited (OSMCL), after testing quality compliance by a national laboratory. Often OSMCL selects three lowest quoting vendors to avoid supply shortages and for ensuring timely delivering to schools.\u003c/p\u003e \u003cp\u003eDespite of having a seemingly robust procurement system, timely delivery of pads at the block level warehouse continues to pose challenges. None of the sample districts had received quarterly stocks on time, often resulting in erratic delivery and insufficient storage capacity at block points. The same problem was also expressed by beneficiaries.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Before the order is placed, a sample of the pads is sent to the national testing laboratory for quality control and the order is placed after receiving the quality control reports. The whole process takes about 1-1.5 months. Therefore, the process is started with delivery times in mind\u0026rdquo; (State health official)\u003c/em\u003e.\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Last distribution was done in October 2021, for the last 11 months we have not received any stock\u0026rdquo; (Block official)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We have received twice only\u0026hellip; Last time I got when I was in class 9th and then once in 10th, this year, that\u0026rsquo;s it\u0026rdquo; (FGD girls).\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Sometimes they send stock even before the distribution is done. Once we had around 40 to 45 carton boxes and they sent it again so all together we had around 90 to 100 carton boxes\u0026rdquo; (Block Official).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eDelay in distribution of pads to schools often results in stock accumulation, risking expiry or damage. Suppliers responsible for delivery of pads up to the block points lack effective communication with storage point personnel, leading to inconvenience in delivery and storage. Further, the \u003cem\u003e\u0026ldquo;fixed cost for movement of the stock from the block storage point to the schools (INR 0.90/pack) also creates operational difficulties\u0026rdquo;\u003c/em\u003e, said one respondent on condition of anonymity.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;When the stock arrives here, we are worried about the place to store it\u0026rdquo; (District official)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Once the stock came in the evening, unloading couldn't happen same day, they said we need safety, we need to alert the police, at night 9 pm I had to go to the police station to alert them, until late night I was with them\u0026rdquo; (Block official)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e\u0026ldquo;\u0026hellip; \u003cem\u003ewe try to deliver the stock to four or five schools on the same route, to minimize transportation cost. We negotiate hard and keep good rapport with the vehicle owners to manage at this cost\u0026rdquo; (District official)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe health department is mandated to transfer the transportation cost to the education department which in turn pays to the Cluster Resource Centre Coordinators (CRCC) responsible for transporting stock from the Block storage unit to the school storage points. However, in some districts another working model was existing as pointed out by some respondents, in which the health department engages a third-party and directly pays for movement of such stocks \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cem\u003e).\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSupply chain working models\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDistrict name\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eMechanism of stock transportation (from block storage unit to school storage point)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eStatus\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePerson/Agency responsible\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003ePayment mechanism\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBalangir and Koraput\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThird-party\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDirectly paid through health department\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNotwithstanding supply irregularities, payment-related delays are non-existent.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBhadrak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCRCCs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHealth to education department to CRCCs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDisrupted supply chain due to delay in payment to CRCCs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eTheme 4: Capacity building\u003c/h2\u003e \u003cp\u003eRespondents felt capacity building of the service providers and managerial cadre needed due emphasis from the district administration. For example, despite the need for web portal training on stock management (e-\u0026rsquo;KHUSHI\u0026rsquo;), the in-charge officials across all sample districts lacked adequate training on the portal and warehouse management, resulting in their inability to effectively manage storage points.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"The state is asking us to update stock information in the software (e-\u0026rsquo;KHUSHI\u0026rsquo;). But they didn't provide any physical training to the concerned individuals, instead they sent an e-manual.\" (District Official)\u003c/em\u003e.\u003c/p\u003e\u003cp\u003e \u003cem\u003e\"When new stock arrived, it was placed in front of the old stock. When distribution resumed, it started from the front, and by the time we reached the old stock, it had already expired.\" (Block official)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eNodal teachers trained by the health department were seen as crucial stakeholders in the \u0026lsquo;Khushi\u0026rsquo; program responsible for health messaging, stock management and distribution monitoring. However, frequent transfers and postings left many schools with untrained staff ill-equipped to handle the complexities of implementing the program. As a result, all the sample districts felt that \u0026lsquo;Khushi\u0026rsquo; is increasingly becoming a pad distribution program, with less emphasis on awareness generation.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"The teachers keep changing, and when a new teacher takes charge, she is unaware of the process. There should be manuals for them to refer to whenever they have any doubts\" (District official).\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The health functionaries are oriented already, but the Educational functionaries are sensitized only in one or two forums which is not adequate\u0026rdquo; (District official).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eTheme 5: Monitoring and supervision\u003c/h2\u003e \u003cp\u003eParticipants in this study highlighted challenges related to poor level of monitoring owing to insufficient fund allocation and delayed reimbursements for such activities. This restricts the frequency and scope of field visits to distribution points. Further, the respondents mentioned that currently there is very limited use of the web-based application for real-time monitoring and stock updating. Most of the respondents felt the need to establish and strengthen an independent review and feedback mechanism under the program.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"We are unsure if the school teachers are genuinely apprising the children or just handing over the packets to them. How can we know?\" (District Official)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe health officials emphasized the need for a collaborative platform to address coordination challenges between the education and health departments. This platform could facilitate discussions on identified issues and the development of solutions to prevent their recurrence or escalation\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\"We provide the supplies up to the storage point, and then the Education department takes over. They follow the guidelines, but we do not receive any feedback from them, and there is no meeting between both departments to analyse and resolve implementation issues. There is no established structure or format to review \u0026lsquo;Khushi\u0026rsquo;.\" (District Official)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOdisha government's \u0026lsquo;Khushi\u0026rsquo; program aims to improve access to safe menstrual hygiene products for schoolgirls and in turn reduce school absenteeism / drop-outs; our research identified bottlenecks (mostly systemic) and opportunities for intervention (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cem\u003e)\u003c/em\u003e in order to improve upon the key thematic domains of approach to micro-planning, interdepartmental convergence, indenting and supply chain management, capacity building, and monitoring and supervision.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBottlenecks and proposed interventions to strengthen \u0026lsquo;Khushi\u0026rsquo; implementation\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIdentified Bottleneck\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProposed intervention\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eApproach to micro planning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAssess system\u0026rsquo;s readiness and identify actionable gaps for redressal\u003c/p\u003e \u003cp\u003eDevelop strategies and allocate resources for sustained behaviour change of school girls\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoor inter-departmental convergence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEngage with collaborating departments on a regular basis to discuss and flash out common challenges\u003c/p\u003e \u003cp\u003eEstablish unambiguous communication channels and delineate responsibilities\u003c/p\u003e \u003cp\u003eAllocate resources for hiring, training, monitoring and supervision\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisrupted supply chain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDecentralize budgeting and inventing\u003c/p\u003e \u003cp\u003eTrain block officials on indenting, inventory and stock management\u003c/p\u003e \u003cp\u003eIntroduce phased automation of inventory and stock management\u003c/p\u003e \u003cp\u003eAppoint supply chain manager at block level\u003c/p\u003e \u003cp\u003eEngage third-party for warehouse-to-stock delivery, with payments facilitated by the health department\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLimited capacity building\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTrain block ware house in-charge on inventory and stock management\u003c/p\u003e \u003cp\u003eOrient school staff on awareness generation and process documentation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInadequate monitoring and supervision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEnsure financial envelope and timely reimbursement of monitoring activities\u003c/p\u003e \u003cp\u003eEstablish monthly review mechanism at block level and quarterly at district level,\u003c/p\u003e \u003cp\u003eEncourage bottom-up feedback\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOur findings indicate that mere distribution of free sanitary napkins may not be sufficient to achieve the dual objectives of improved menstrual hygiene behaviour and reduced school absenteeism. Respondents felt strongly about the need to focus more on undertaking activities aimed at strengthening implementation of various activities under \u0026lsquo;Khushi\u0026rsquo; program.\u003c/p\u003e \u003cp\u003eSustained improvement in the behaviour of school girls with regard to menstrual hygiene management practices and reduction of school absenteeism are organically linked to improved academic performance (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e), though there is limited evidence linking menstruation with higher rate of absenteeism (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Analysis of longitudinal health data of adolescents in India on menstruation and school attendance was inconclusive (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e), which is similar to the findings of another study conducted in Malawi (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). We found that discomfort due to menstrual cramps and lack of appropriate infrastructure at schools were pointed as reasons for absenteeism from school during menstruation, which is in sync with few other studies (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e); fear of getting stains on clothes and lack of proper disposal of used pads/clothes was more of a challenge for the girls from Government schools as compared to private schools (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). A study in Malawi also reported similar findings where girls experienced challenge in schools due to lack of appropriate toilet facility (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA randomized control trial (RCT) in Kenya found sanitary napkin distribution did not culminate in increased school attendance (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). This signifies that provision of free sanitary pad distribution cannot be a complete solution to achieve reduction in school absenteeism; an MHM-friendly school infrastructure is a critical pre-requisite (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). However, the potential of schools in developing a conducive environment and supportive infrastructure for dignified menstruation is yet to be tapped under \u0026lsquo;Khushi\u0026rsquo; program.\u003c/p\u003e \u003cp\u003eInitiating dialogue on menstruation in schools necessitates sensitization of teachers and \u0026lsquo;peer champions\u0026rsquo; in delivering appropriate messages on as sensitive topics as menstruation, menstrual health and hygiene, and sexual and reproductive health (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). The importance of schools in raising mass awareness on health issues has often been well recognized; the health department has also frequently used such platforms to drive the health agenda, but the efforts mostly get narrowed down to distribution of products, such as, IFAs, deworming tablets, or sanitary napkins. Studies have also shown that in India the school curriculum is not aptly used to raise awareness about the issues of reproductive health (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). School teachers need to be empowered to improve knowledge and practices of girls about reproductive health (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). A vast majority of girls from rural areas are enrolled in government schools. Therefore, while the debate on appropriateness of information to girls at the right age and in the right way continues to divide the opinion, the first source of information / misinformation on the subject for a young girl continues to the mother/sister/relative (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e) who themselves are grappling with fear and cultural taboos (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e). A study in Ethiopia concluded that educational interventions on MHM and provision of MHM kits resulted in decreased school absenteeism among girls (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). On the other hand, a mere sanitary napkin distribution program would undermine the capacity of a girl to make an informed choice without accompanying information, education, and communication (IEC) (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eLike other logistics-intensive programs, \u0026lsquo;Khushi\u0026rsquo; also has many a day-to-day challenges on logistics and supply chain management. Appropriate forecasting, warehouse and inventory management, transportation, delivery and distribution have several bottlenecks that need redressal (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e). A study on logistics management in Ghana by Bossert \u003cem\u003eet al\u003c/em\u003e., concluded that centralization of planning, budgeting, information management system and inventory control was associated with greater success (\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e). Service providers and managers encounter heavy workload and insufficient guidelines for better coordination; guidelines ought to be developed and percolated down to the sub centre level to address these gaps (\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe \u0026lsquo;Khushi\u0026rsquo; program has led to improved access to sanitary pads for most girls; however, the rural ecosystem is not yet fully developed to manage the large amount of menstrual wastes emerging out of mass use of disposable sanitary products (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e). Moreover, this dimension has long been poorly addressed which could pose considerable challenges to the environment in the long run (\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e). Incremental shift to more sustainable, eco-friendly and bio-degradable sanitary pads is a desirable state which some studies in Nepal and Kenya have agreed with. Hence, serious efforts need to be initiated to promote such products in a phased manner (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e To enhance the trustworthiness of the study, triangulation of data sources and analyses was followed. This involved collecting data from multiple key stakeholders within the health and education department at different administrative levels such as blocks, districts, and state. Additionally, to mitigate potential misinterpretation during data analysis, both English and Odia transcripts were utilized. Furthermore, the authors diverse backgrounds in medicine and social science, coupled with their experience in public health, strengthened the conformability of the findings. This study was conducted in select districts chosen through purposive sampling; therefore, the results may not be representative of the universe, and generalization need to be done with caution. However, the challenges and bottlenecks identified through this study are reflective of the overall situation in the State, which could be comparable in similar socio-cultural contexts. Moreover, our study was carried out in the post-COVID period, suggesting that certain challenges could be mitigated over time and through the effective functioning of the system.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eMenstrual health and hygiene of young adolescent girls affects millions of lives across the globe. In India and in Odisha various departments and stakeholders play crucial role in the success of implementing government-sponsored programs. \u0026lsquo;Khushi\u0026rsquo; is a state-specific initiative which has the potentiality to bring a paradigm shift in the menstrual health behaviour of school girls. Government may need to invest time and resources for bridging the infrastructural gaps, raise level of competency of service providers and improve the supply chain management practices to ensure successful implementation of the program. Use of technology for automation, building capacity of frontline workforce and financial allocation for program monitoring are the immediate action points to strengthen the program. Challenges related to inter-sectoral convergence could be addressed through periodic stock-taking by officials in the higher rung of the hierarchy. In the long run, it ought to shift towards a more environment-friendly option for product designing and procurement. MHM-friendly school infrastructure, imparting education, sensitizing men and boys, and optimal inter-departmental coordination are crucial mediators for effective behaviour change among school girls. Healthy menstruation of girls would lead to healthy womanhood and a better society.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eMHM\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Menstrual hygiene management\u003c/p\u003e\n\u003cp\u003eSDGs \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Sustainable Development Goals\u003c/p\u003e\n\u003cp\u003eLMICs \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;low- and middle-income countries\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWASH \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Water, Sanitation and hygiene\u003c/p\u003e\n\u003cp\u003eRMNCH+A \u0026nbsp; \u0026nbsp; \u0026nbsp;Reproductive, Maternal, Newborn, Child Health and Adolescents\u003c/p\u003e\n\u003cp\u003eRKSK \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Rashtriya Kishore Swasthya Karyakram\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIDI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;In depth interviews\u003c/p\u003e\n\u003cp\u003eOSMCL \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Odisha State Medical Corporation Limited\u003c/p\u003e\n\u003cp\u003eCRCC\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Cluster Resource Centre Coordinator\u003c/p\u003e\n\u003cp\u003eFGD \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Focus group discussions\u003c/p\u003e\n\u003cp\u003eANM\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Auxiliary Nurse and Midwife\u003c/p\u003e\n\u003cp\u003eRCT \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Randomized control trial\u003c/p\u003e\n\u003cp\u003eIFA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Iron folic acid\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIEC \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Information, Education \u0026amp; Communication\u003c/p\u003e\n\u003cp\u003eDOHFW \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Department of Health and Family Welfare\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical clearance was obtained from an independent ethics committee of the Indian Institute of Public Health (IIPH-B), Bhubaneswar, a unit of Public Health Foundation of India (PHFI). The study was then approved by the State Research and Ethics Committee, government of Odisha, vide letter no. 18003/MS-2-IV-04/2020 (PT-1), dated 13th July 2022. Informed consent was obtained from all the participants. Anonymity and confidentiality of information was ensured all throughout the study period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eAll the data collected and analysed in this study are available with the corresponding author and would be provided upon request.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eAuthors declare no competing interests\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThe project was funded by UNICEF, Odisha.\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026apos; contributions\u003c/h2\u003e\n\u003cp\u003eBP conceptualized the study. BP and SD finalized the methodology and developed the data collection tools. SD, NP and RPP were involved in data collection. SD and NP transcribed and translated the data. BP, SD, NP and RPP analysed data. SD and NP prepared the manuscript. BP reviewed and finalized it. All authors have read and agreed to the submitted version of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eWe are thankful to all the participants who consented to participate in the study and shared their valuable inputs. We acknowledge the contribution of Field Investigators engaged during data collection phase. \u0026nbsp;We are thankful to Government of Odisha, especially the Department of Health and Family Welfare (DOHFW) for approving the project and providing all support during data collection. The Chief Medical Officers of sample districts, officials of the school and mass education department, and school teachers were cooperative, we are thankful to all of them.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNishisipa Panda \u0026amp; Bhuputra Panda\u003c/p\u003e\n\u003cp\u003ePresent address: KIIT School of Public Health, KIIT Deemed to be University, Bhubaneswar, India\u003c/p\u003e\n\u003cp\u003eAuthors and Affiliations\u003c/p\u003e\n\u003cp\u003ePHFI-Indian Institute of Public Health, Bhubaneswar, India\u003c/p\u003e\n\u003cp\u003eShyama Desaraju, Nishisipa Panda, Rudra Prasad Panigrahy \u0026amp; Bhuputra Panda\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHolst AS, Jacques-Avi\u0026ntilde;\u0026oacute; C, Berenguera A, Pinz\u0026oacute;n-Sanabria D, Valls-Llobet C, Munr\u0026oacute;s-Feliu J, et al. 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Reprod Health. 2021;18(1):1\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"health-research-policy-and-systems","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"hrps","sideBox":"Learn more about [Health Research Policy and Systems](http://health-policy-systems.biomedcentral.com/)","snPcode":"12961","submissionUrl":"https://submission.nature.com/new-submission/12961/3","title":"Health Research Policy and Systems","twitterHandle":"@HarpsJournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Adolescent health, Menstrual health, Free sanitary napkin, School health, Odisha","lastPublishedDoi":"10.21203/rs.3.rs-4259211/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4259211/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eFor optimal menstrual hygiene among women and adolescent girls, access to affordable menstrual products, sanitation facilities, education, privacy, and destigmatization are essential. Recognizing this need, the Indian government has implemented various interventions to improve menstrual hygiene practices and personal hygiene among schoolgirls. In Odisha, an easternmost state in India, one such key initiative is the \u0026lsquo;Khushi\u0026rsquo; program, a collaboration between the Health and Education departments. This program provides free sanitary napkins to all girls in standards 6\u0026ndash;12 across the state. Our study explores the perspectives and challenges associated with implementing the \u0026lsquo;Khushi\u0026rsquo; program in Odisha.\u003c/p\u003e\u003ch2\u003eMethodology\u003c/h2\u003e \u003cp\u003e: This paper emanates from a larger study examining the situation of menstrual health and hygiene in Odisha, conducted from September 2021 to December 2022. The focus of this paper is on qualitative findings related to implementation of the \u0026lsquo;Khushi\u0026rsquo; program. In-depth interviews were conducted with key stakeholders, including officials from health and education departments, and school personnel involved in program implementation. Focus group discussions were held with schoolgirls of 6\u0026ndash;12 standard to explore their experiences and perceived challenges regarding menstrual hygiene practices within the school environment. Further, review of program documents and relevant government policies was also undertaken.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAnalysis of data concerning experiences, enablers, and systemic roadblocks associated with implementing the \u0026lsquo;Khushi\u0026rsquo; program yielded five key themes: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Approach to micro-planning, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Interdepartmental convergence, (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Indenting and supply chain, (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) Capacity building, and (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) Monitoring and supervision. The study underscores the importance of designing and implementing a comprehensive behavior change strategy, that should capitalize on the existing collaboration between the health and education departments, while addressing identified weaknesses. These weaknesses include 'knee-jerk' planning and implementation without proper preparedness, limited coordination between departments, and overburdened frontline workers.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003e\u0026lsquo;Khushi\u0026rsquo; is a state-specific initiative which has the potential to bring a paradigm shift in the menstrual health behaviour of school girls. Government may need to adapt a comprehensive strategy, including strengthening menstrual hygiene management (MHM)-friendly school infrastructure, imparting education and sensitization to implementing partners and beneficiaries alike, and integrating environment-friendly menstrual hygiene products in the program.\u003c/p\u003e","manuscriptTitle":"Policy to Practice: Insights from Implementation of a School-Based Sanitary Napkin Distribution Program in Odisha, India","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-18 03:14:58","doi":"10.21203/rs.3.rs-4259211/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-02-22T04:52:49+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-22T04:48:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"122713555754136035608959577834070481795","date":"2025-02-22T03:51:31+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-15T04:58:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"159962413403650293463483591715530412769","date":"2024-05-26T03:19:29+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-05-20T22:53:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-15T03:46:44+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-15T03:46:44+00:00","index":"","fulltext":""},{"type":"submitted","content":"Health Research Policy and Systems","date":"2024-04-12T17:39:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"health-research-policy-and-systems","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"hrps","sideBox":"Learn more about [Health Research Policy and Systems](http://health-policy-systems.biomedcentral.com/)","snPcode":"12961","submissionUrl":"https://submission.nature.com/new-submission/12961/3","title":"Health Research Policy and Systems","twitterHandle":"@HarpsJournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3d59f7f7-8fc1-4994-8982-2c956822e34b","owner":[],"postedDate":"April 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-07-21T16:03:23+00:00","versionOfRecord":{"articleIdentity":"rs-4259211","link":"https://doi.org/10.1186/s12961-025-01316-w","journal":{"identity":"health-research-policy-and-systems","isVorOnly":false,"title":"Health Research Policy and Systems"},"publishedOn":"2025-07-16 15:57:15","publishedOnDateReadable":"July 16th, 2025"},"versionCreatedAt":"2024-04-18 03:14:58","video":"","vorDoi":"10.1186/s12961-025-01316-w","vorDoiUrl":"https://doi.org/10.1186/s12961-025-01316-w","workflowStages":[]},"version":"v1","identity":"rs-4259211","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4259211","identity":"rs-4259211","version":["v1"]},"buildId":"CiT4i_kKBbxQbnFL0ufpk","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}