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SSS0010.1177/03063127221122457Social Studies of ScienceParthasarathy

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Social Studies of Science

How sanitary pads came to save

2022, Vol. 52(5) 637­–663
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DOI: 10.1177/03063127221122457
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the marketplace

Shobita Parthasarathy

Abstract
International development institutions, governments, and social entrepreneurs have become
increasingly enthusiastic about ‘inclusive innovation’ which, to solve problems in low- and
middle-income countries, focuses on the development of technologies for and by the poor.
Inclusive innovation differs from previous development efforts by focusing on devices instead
of infrastructure, claiming to be based on scientific evidence, and relying on market logics to
achieve humanitarian ends. Proponents argue that, informed by grassroots efforts, these
interventions have enormous potential to catalyze economic, social, and political change. How
are the market and technological imperatives of inclusive innovation shaping the international
development agenda? What do inclusion and innovation mean in this context? What can inclusive
innovation tell us about the proliferation of initiatives that promote technology for public good,
from responsible innovation to public interest technology? This article examines these questions
through a case study of menstrual hygiene management (MHM) innovation in India. Rather than
providing solutions to self-evident development problems, inclusive innovation shapes both
development problems and solutions simultaneously, in areas where scientific and market ways of
knowing converge. These ways of knowing claim to be legitimate because they are rooted in local
knowledge and expertise. MHM in India became a problem, and low-cost disposable sanitary pads
an inclusive innovative solution, because of the involvement of Indian researchers and innovators,
and Indian girls and women as consumers and producers. However, in the process they reinforced
narrow understandings of both inclusion and innovation in international development. Inclusion
efforts may be wrapped up in political economies that shape and limit their transformational
power by prioritizing scientific, technical, and market expertise.

Keywords
gender, India, inclusive innovation, menstruation, international development

University of Michigan, Ann Arbor, MI, USA

Correspondence to:
Shobita Parthasarathy, Ford School of Public Policy, University of Michigan, 4202 Weill Hall, 735 S. State
Street, Ann Arbor, MI 48109, USA.
Email: shobita@umich.edu
638 Social Studies of Science 52(5)

The world of international development is shifting. For decades, international organiza-

tions and Western governments invested in technically complex infrastructure projects to
improve conditions in low- and middle-income countries. This undoubtedly produced
benefits, but critics argued that these projects were simply extensions of cultural imperi-
alism rendered seemingly apolitical through technology (Escobar, 1995; Ferguson,
1990). In addition, public health and environmental challenges persist and global eco-
nomic inequality is increasing (OECD, 2013). A new generation of social enterprise
incubators, venture funds, philanthropies, and NGOs, alongside traditional development
institutions, have responded to these concerns with what many call ‘inclusive innova-
tion’, an umbrella term that generally refers to technology for or by low-income and
marginalized communities (George et al., 2012; Heeks et al., 2014).
Rather than attempting societal or environmental transformation through large-scale
electrical grids, roads, or dams, inclusive innovation focuses on novel devices designed
to benefit individuals quickly and directly often with humanitarian aims (Collier et al.,
2017; Irani, 2019). Organizations invest in these devices on the basis of their projected
utility and then aim to circulate them through markets. In the short term, the logic goes,
marginalized communities have access to crucial items and jobs making them, and
innovators gain revenues through economies of scale (Prahalad, 2005). In the long term,
new markets will help low-income consumers participate in the larger economy and
ultimately lift themselves out of poverty (Cross, 2013; Elyachar, 2012). Investors also
suggest that inclusive innovation fosters technological solutions at their most efficient
and effective. The US Agency for International Development’s inclusive innovation
effort, Development Innovation Ventures (DIV), describes its mission as funding
‘breakthrough solutions to the world’s most intractable development challenges’
(USAID, 2021). ‘By funding innovation and focusing on rigorous evidence’, it states,
‘DIV impacts millions of lives at a fraction of the usual cost.’ Similarly, UNICEF’s
Office of Innovation (2021) notes: ‘From climate change to gender equality to mental
health, our goal is to move the needle at the intersection of issue and innovation … for
meaningful, sustainable impact’.
Inclusive innovation’s proponents, including some science and technology studies
(STS) scholars, also often characterize it as a democratic approach to the problems of
development (Fressoli et al., 2014; Smith et al., 2016). It is decentralized, with partici-
pants from the public, private, and nonprofit sectors across low, middle, and high income
countries. It often includes the contributions of indigenous ‘grassroots’ innovators who
may have little formal technical training but who develop solutions based on their deep
expertise about the local context (Dutfield, 2006; Gupta, 2012). Investors also seem to
pay particular attention to local needs as they decide which ‘little development devices’
to support (Redfield, 2016). It thus joins a suite of initiatives promoted by governments,
scholars, and the private sector around the world designed to prioritize public needs in
technology development, including responsible research and innovation, public interest
technology, and public participation in technological decision-making (Ely et al., 2014;
McGuinness & Schank, 2021; Stilgoe et al., 2013).
This article examines the political economy of this turn toward inclusive innovation
for international development. What counts as inclusive innovation? What do inclusion
and innovation mean in this context? What kinds of knowledge does this approach
Parthasarathy 639

privilege? How is inclusive innovation shaping the international development agenda,

and what are the implications for low-income and marginalized communities around the
world?
Focusing on the case of menstrual hygiene management, specifically low-cost dispos-
able sanitary pads in India, I argue that inclusive innovations are not simply responses to
the self-evident problems of international development. Rather, inclusive innovation and
the development problems they solve tend to be co-produced (Jasanoff, 2004), in areas
where scientific and market ways of knowing converge. Put differently, this epistemic
convergence shapes the definition of development problems and evaluation of the solu-
tions. And, it constrains understandings of both inclusion and innovation in international
development.

The case of MHM innovation

Today, menstrual hygiene management (MHM) is treated as a serious problem affect-
ing girls and women across low- and middle-income countries, including India (Bobel,
2018; Bobel et al., 2020). There is worldwide concern that cultural myths and taboos,
coupled with inadequate tools to manage menstrual blood, are affecting health and
education in the short term, and gender equity and empowerment in the long term.
Governments, civil society organizations, donor agencies, private companies, and aca-
demic researchers have invested heavily in addressing the issue. And it has stimulated
great media interest, from news stories by the BBC, France 24, The New York Times,
and The Hindu to a blockbuster Bollywood movie and an Oscar-winning documentary
short.
But 20 years ago, the MHM problem didn’t exist. It was not mentioned at the 1995
World Conference on Women convened by the United Nations (UN) in Beijing, or in the
UN’s Millennium Development Goals in 2000. How and why did it become a problem?
Some researchers have suggested that the recent attention to MHM is the result of scien-
tific evidence and successful political framing in terms of global priorities including
gender equity, quality education, and access to sanitation (Sommer et al., 2015). But this
assumes that MHM is an obvious problem that simply became more visible due to effec-
tive advocacy.
I argue instead that the type of scientific knowledge generated, combined with the
epistemology of inclusive innovation, produced the MHM problem. STS scholars have
repeatedly demonstrated how the knowledge used to inform policymaking shapes both
what counts as a problem and how it is solved (Jasanoff, 2005; O’Connor, 2001;
Parthasarathy, 2017a). As international development institutions relied more on eco-
nomic expertise, for example, the problems of low- and middle-income countries
(LMICs) were characterized as the fault of an overly active state and a constrained pri-
vate sector (Babb, 2001; Goldman, 2005). The appropriate response then became dereg-
ulation and privatization. Similarly, I demonstrate how the MHM problem resulted from
its convergent construction by public health researchers and inclusive innovation propo-
nents as an urgent, widespread problem with a simple, market-generating solution: low-
cost disposable sanitary pads. It benefitted from synergies between the scientific drive
toward generalizability and the market orientation toward scale.
640 Social Studies of Science 52(5)

This construction of the MHM problem and its sanitary pad solution were particularly
politically powerful because they rested on two forms of knowledge – science and the
market – that claimed, in the words of Spivak (1999), to allow the subaltern to speak
(Saffari, 2016). This was particularly important at the dawn of the 21st century, in light
of frustrations among increasingly vocal civil society groups and LMIC governments
that the interventions promoted by Western countries do not adequately consider local
priorities (Halliburton, 2017; Khagram, 2004).
Scientific knowledge about MHM is generated almost exclusively through Knowledge,
Attitudes, and Practices (KAP) surveys, developed in the 1960s to help family planning
experts understand the circumstances of girls and women across Southern countries.
Initially, these experts used KAP data to demonstrate community ‘desire’ for contracep-
tion, and ultimately justify a global population ‘problem’ to Western donors (Murphy,
2017). In the process, researchers taught these methods to their Southern counterparts,
and it is now used across multiple areas of public health. In the MHM case, researchers
used survey and interview data to identify ignorance about menstruation and related
practices and opportunities for change. But unlike the first generation of studies, these
studies also claim grassroots legitimacy because they were conducted almost exclusively
by Indian researchers; as a result, they cannot be easily dismissed as Western neocolonial
interference.
The market-based solution also seems fundamentally democratic. Girls and women
seem free to purchase and use the pads, and participate in social enterprises to produce
them. Furthermore, the primary innovator comes not only from India but from modest
means, and thus is treated as having an authentic understanding of the best solution.
Together, the scientific and market ways of knowing shaped the MHM problem as seri-
ous and based on local knowledge, large, familiar to elite Indian and Western audiences,
and easily solved with a commodity.
India is a particularly important site for this analysis because it has long had a hetero-
dox approach to innovation. While Western countries define innovation almost exclu-
sively in terms of technically complex, novel, scalable, and commodifiable objects, India
explicitly values makeshift innovation culturally with its own Hindi term (jugaad) as
well as in scientific and business practices (Radjou et al., 2012; Sekhsaria, 2018). It has
also always emphasized local innovation, from Gandhi’s attention to ‘village industries’
to the government’s import substitution policies that began with India’s independence
and lasted into the 1990s (Chibber, 2003; Engel, 2015; Williams, 2018). More recently,
Indian Institute of Management professor Anil Gupta built on these legacies by establish-
ing NGOs that identified and amplified low-cost innovation developed by people with
limited technical training or financial resources (Dutfield, 2006). This includes the
National Innovation Foundation (NIF) funded by the Indian government. Finally, much
of the Indian population integrates indigenous knowledge systems into their daily lives
and health care, which the government validated in 2014 through the creation of a
Ministry of Ayurveda, Yoga, Naturopathy, Unani, Siddha, Sowa-Ripga, and Homeopathy.
This reverence for indigenous knowledge systems has only increased in recent years,
with the dominance of Hindu nationalism in Indian politics (Subramaniam, 2019). Given
this history, there was great potential flexibility in how the government approached
inclusive innovation. It might have challenged the construction of a MHM ‘problem’ or
Parthasarathy 641

turned to a solution rooted in indigenous knowledge. But as we shall see, instead MHM
became an opportunity for the Indian government, NGOs, and entrepreneurs to advance
particular understandings of inclusion and innovation that centered Indians and aligned
with the priorities of Western development organizations and ideologies, while exclud-
ing those it deemed inconvenient.
This case study analysis (Yin, 2017) is based on mixed qualitative methods including
document review, interviews, and ethnographic observation, and is part of a larger study
on inclusive innovation in international development. Document analysis included a sys-
tematic review of the academic, policy, private, and non-profit sector literature world-
wide related to MHM, with a focus on the past 20 years of documents written by
researchers, domestic and international NGOs, philanthropic organizations, social inno-
vators, and social enterprise incubators involved in MHM in India. This includes 136
academic articles about MHM in low- and middle-income countries, with 40 focused on
India. I also examined how the Indian media has approached and discussed menstruation
over the same period. In analyzing all of these documents, I paid particular attention to
how they characterized the MHM problem and possible solutions, including how this
was reflected in the design of research studies, presentation of findings, introductions,
and conclusions. I also collected and analyzed documents that outlined the turn toward
inclusive innovation and its implementation more broadly, including policy reports from
international organizations such as the OECD, international and domestic program web-
sites, academic articles, and funding records. Here, I investigated imaginaries (Jasanoff
& Kim, 2015) of both inclusive innovation and the problems it is trying to solve.
In addition to this document review, I conducted 50 open-ended, semi-structured, in-
person interviews with researchers, entrepreneurs, and NGO and government personnel
involved with menstrual health and hygiene management, primarily in India but also in
the United States and Europe, from 2015 to 2019. I identified these subjects initially
through document analysis, but as interviews proceeded I asked subjects who else they
thought I should interview. This allowed me to understand MHM networks and develop
a more complete picture of who was involved and understand their relationships.
However, to prevent bias in this sample, I continued to use document review to identify
additional individuals and potential MHM networks. In the interviews, I asked subjects
about the history and scope of the MHM problem, solutions, possible challenges in
implementing these solutions, and how they might be overcome. I also spoke with 10
individuals at social enterprise incubators and development organizations involved in
promoting inclusive innovation either within India or at the international level about
their vision for this work, the challenges they face, how they are overcoming them, and
specific examples of success. Where relevant, I spoke with this latter group about MHM
as an example of inclusive innovation. Finally, I visited two sanitary pad-making social
enterprises and attended two MHM training sessions in different regions of India.
The interviews and ethnographic observations were crucial to my analysis, as they
helped me understand the history of MHM and interpret the documents that I had already
discovered. Often, they pointed me to additional important documents and events that I
needed to incorporate into my analysis. Overall, they helped to ‘triangulate’ my findings,
to ensure that I had developed a complete picture but also that my interpretations held
across the different data sources (Luker, 2010). While interview and observational data
642 Social Studies of Science 52(5)

was crucial and validated my interpretation of the documents, I do not include any
explicit quotes from interview subjects in this paper. This is largely because the docu-
ments provided extensive contemporaneous accounts of the emergence of the MHM
problem, which I judged as more powerful than retrospective ones. In addition, in some
cases I wanted to preserve interview anonymity, which can be challenging given the
density of MHM networks in India.

The parallel births of inclusive innovation and a new

development problem
The first attempts to highlight and address an MHM problem came in the mid-2000s, just
as excitement about inclusive innovation was emerging in business and policy circles.
For years, the Indian government had invested in initiatives to stimulate grassroots entre-
preneurship, including microloans targeted toward people with limited incomes (Sharma,
2008). But in 1999, it established Swarnajayanti Gram Swarojgar Yojana (later renamed
the National Rural Livelihood Mission, NRLM), which encouraged the formation of
‘self-help groups’ (SHGs) usually made up of 10–15 women with little wealth, who
could use microloans to start small businesses. NRLM provided SHGs with microloan
assistance, capital investments, and training in sewing, handicrafts, and other skills to
support these enterprises (Lahiri-Dutt & Samanta, 2006; Radhakrishnan, 2022). At the
same time, Indian Institute of Management professor Anil Gupta began to argue that, in
order to truly uplift low-income and otherwise marginalized communities, they needed
to be respected as innovators (Dutfield, 2006; Gupta, 2012; Parthasarathy, 2017b).
Despite their limited resources, these ‘grassroots’ or ‘frugal’ innovators, as he called
them, were developing scores of technologies to improve their lives that could produce
broad benefits. They were, after all, experts in their own lives and circumstances. So, he
created the NIF and other NGOs – based mostly in northwest India – to foster and amplify
this innovation. Others followed Gupta’s lead, including for example the Rural
Innovations Network (now VillGro), established in South India in 2001.
Meanwhile, two business school professors at University of Michigan, Indian immi-
grant C.K. Prahalad and Stuart Hart, published a 2002 article arguing that multi-national
corporations were missing a huge ‘fortune at the bottom of the pyramid’ by not develop-
ing products and services for the poor (Prahalad & Hart, 2002). Companies could pro-
duce innovative products targeted to this market and not only profit, they suggested, but
also expand the economy and eventually improve the purchasing power of low-income
communities. They could, in sum, do well by doing good. Three years later, Prahalad
published The Fortune at the Bottom of the Pyramid, which expanded the argument and
included case studies (Prahalad, 2005). The book received glowing reviews in the busi-
ness media, and praise from Bill Gates (‘a blueprint for fighting poverty’) who had
recently created his foundation, and former Secretary of State Madeleine Albright (‘if
you are looking for fresh thinking about emerging markets, your search is ended’).
Prahalad then advised both multi-national corporations and the Indian government on
‘bottom of the pyramid’ strategies (Knowledge at Wharton, 2009; Merx, 2004).
Attention to MHM came from another corner of the international development world,
but would quickly be interpreted in the context of inclusive innovation. Archana Patkar,
Parthasarathy 643

director of Indian consulting group Junction Social and an established expert in the
water, sanitation, and hygiene (WASH) sector of international development, and her col-
league Sowmyaa Bharadwaj, published the first paper in 2004 (Bharadwaj & Patkar,
2004). They reviewed the challenges that menstruating girls and women faced in devel-
oping countries, basing the analysis on a survey of 85 WASH professionals worldwide.
However, they focused their attention on South Asia and drew on their knowledge of the
region. Both were Indian development experts educated and based in India, so they could
claim deep understanding of the disadvantaged girls and women they had served through-
out their lives.
Based on these insights, Bharadwaj and Patkar (2004) concluded that girls and women
across developing countries were susceptible to serious illness because they lacked the
facilities to properly wash and dry either themselves or the recycled cloth (which often
came from old garments) they commonly used to absorb menstrual blood. Girls and
women were also hurt by cultural restrictions, ranging from avoiding certain foods to not
going to the temple while they were menstruating. The few who used disposable sanitary
napkins did not have the infrastructure to dispose of them properly, thus hurting the envi-
ronment. They classified this as poor menstrual hygiene management and suggested that
girls might miss or even drop out of school, compounding the problem.
They appealed to WASH professionals by linking menstruation to prevailing develop-
ment priorities: Both gender equality and universal primary education were Millennium
Development Goals, and there was growing attention to girls’ empowerment as the key
to accelerating international development (Moeller, 2018; Murphy, 2017). And, they
argued, there were simple solutions available. They recommended more inclusive latrine
design, including private facilities with lockable doors, running water, and receptacles
for safe disposal of menstrual products. As we will see, this option would quickly disap-
pear in the MHM discourse perhaps because it required government involvement and
could not produce a neat commercial solution.
Bharadwaj and Patkar were also the first to suggest the ‘production and social market-
ing’ of sanitary napkins, criticizing the customary approach. ‘Research and development
efforts have been limited to commercial ventures that even today are unable to market
products that are affordable for the poorest of the poor’ (Bharadwaj & Patkar, 2004, p. 4).
While they did not explicitly refer to the ‘fortune at the bottom of the pyramid’, they
emphasized the need to innovate to serve low-income communities.
Around the same time, two other international development experts were also focus-
ing on MHM. American public health researcher Marni Sommer and Canadian develop-
ment worker Jackie Kirk published a short article in a newsletter funded by the UK
government’s Department of International Development, the University of London, and
Oxfam, and a more detailed white paper that appeared on a number of NGO websites
related to the WASH sector.
Like Patkar and Bharadwaj, Kirk and Sommer (2005, 2006) worried that poor MHM
affected girls’ education. In support, they offered small case studies from India, Nepal,
and Sudan to show that girls knew little about menstruation and hygienic management
methods, and were often subject to incorrect ‘myths and taboos’ that restricted their lives
in significant ways. But this evidence did not show a clear MHM problem with impacts
on education. So, they called for more research, and emphasized the importance of
644 Social Studies of Science 52(5)

capturing girls’ voices: ‘[MHM] solutions … should be developed based on the insights
of the girls themselves … girls are “knowers” of their own lives, of the challenges they
face and of possible solutions for these’ (Kirk & Sommer, 2006). Systematic scientific
research, they suggested, could allow girls to express their preferences and identify inter-
ventions using systematic and objective methods that would be legible to Western experts
and institutions.
Development institutions took notice. Patkar spoke at a 2005 UNICEF roundtable
meeting focused on the relationship between WASH and education. With representa-
tives from US, European, and LMIC governments, NGOs, and international organiza-
tions in attendance, she emphasized the link between poor MHM in schools and poor
attendance:

Formal education is not accommodating to menstruating girls. The prospect of travelling long
distances to school, sitting for long periods of time, staining their clothes with blood, and being
noticed and teased by boys makes adolescent girls feel anxious and uneasy. Their psychological
discomfort is compounded by physical symptoms such as stomach cramps, headaches and
fatigue, which are often aggravated by malnutrition – resulting in frequent absenteeism, with a
negative impact on school performance and completion. (UNICEF and IRC, 2005, p. 81)

Almost immediately, despite the various solutions proposed in the white papers, UNICEF
and the South Indian state of Tamil Nadu established a low-cost sanitary pad donation
program for adolescent schoolgirls in 2006. They purchased these pads from small ven-
dors across the country, but primarily from SHGs (Business Standard, 2020; The Hindu,
2008, 2009). UNICEF and the Tamil Nadu government provided SHGs with training as
well as sanitary pad-making machines and other materials to encourage the development
of small enterprises. They then purchased the pads for heavily subsidized distribution
through local schools but SHGs could also sell them independently.
This initiative – which soon spread across the country – engaged low-income women
as both consumers and producers. The major global companies manufacturing disposa-
ble sanitary pads, like Procter & Gamble and Kimberly Clark, had been reluctant to
expand their markets to low-income and rural areas in Southern countries (Shrivastava,
2010). (It is unclear why they made these decisions, but it is possible that these compa-
nies were concerned that if they produced cheaper, poor-quality sanitary pads their
brands might be tarnished, and that offering higher quality products at a lower price
would shift customers away from more expensive options.) UNICEF and state govern-
ments across India took advantage of this gap, and in the process created a program that
would produce economic benefits in both the short and long term. Responding to the
program’s expansion to a rural and low-income district in West Bengal, Lori Calvo,
UNICEF’s state representative, observed: ‘It is a good initiative by self-help women’s
groups of Purulia. It is helping them financially and also spreading awareness on hygienic
menstrual practices, which otherwise gets neglected’ (Menon, 2008). Women would start
businesses and gain income and thereby empower themselves immediately, while also
destigmatizing menstruation by participating in its commodification. Girls would stay in
school and eventually achieve better and higher paid employment thanks to low-cost
disposable sanitary pads.
Parthasarathy 645

UNICEF’s state-level programs elevated the MHM problem in the Indian develop-
ment policy landscape. But it also shaped the problem itself. It focused on the sanitary
pad solution, rather than on better or private latrines or MHM training. And while there
had been very little evidence that poor MHM affected education, the program’s focus on
adolescent girls and distribution strategy in schools validated this framing. Lizette
Burgers, who led UNICEF’s WASH program in India and had participated in the Oxford
Roundtable where Patkar spoke, explicitly drew the connection as she described the
program: ‘Given the fact that adolescent girls face a considerable amount of embarrass-
ment due to lack of information on time, being not guided by even peers and lack of
affordability for sanitary napkins, their school attendance and over all confidence level
suffers’ (Burgers, 2008). For Burgers the problem was also widespread. And, although
she defined the problem in cultural terms, with girls facing ‘embarrassment’, not being
‘guided’ by peers, not receiving proper ‘information on time’, it could be solved with an
object.
The low-cost sanitary pad, and the problem it solved, seemed legitimate in part
because it offered a seemingly simple, scalable, market-generating solution at a time
when India and the world were becoming increasingly enthusiastic about the promises of
inclusive innovation for international development. It addressed gender equity by help-
ing girls stay in school and destigmatizing menstruation, and stimulating entrepreneurial
activity among women. Thus, the market solution seemed fundamentally democratic.
SHGs seemed to be free to make and sell the pads, and girls seemed to choose to accept
them. Rather than a top-down, large-scale intervention like a hydroelectric dam, UNICEF
and state governments seemed to be simply supporting the subaltern as they decided how
to empower themselves. But this characterization also obscured how girls’ and women’s
choices had already been constrained by those constructing the MHM problem and its
solution.

Producing a problem at scale, through science

The MHM story had only just begun. As UNICEF, state governments, and girls and
women started to invest in the technology, over the following few years public health
experts established an evidence base that constructed an MHM problem that was similar
across contexts. This would help justify the potential benefits of the sanitary pad solu-
tion, because it could be easily standardized and scaled (Pfotenhauer et al., 2022).
The Gates Foundation, the UK’s Department of International Development, universi-
ties, and small NGOs funded this work. Researchers presented their findings widely, in
scholarly journals but also in venues that would attract attention from development pro-
fessionals, including policy reports and meetings such as a new annual conference on
‘Menstrual Hygiene Management in Schools’ convened by UNICEF with leadership
from Marni Sommer. In these venues, they emphasized that the MHM problem was
urgent, global, and based in girls’ and women’s ignorance, but could be solved quickly
and easily with a commodity.
MHM research could have gone in multiple directions, given the diversity of cultural
and religious practices related to menstruation around the world (Buckley & Gottlieb,
1988; van de Walle & Renne, 2001) and the recent adoption of some LMIC menstrual
646 Social Studies of Science 52(5)

practices in Western countries (Castro, 2020; Koskenniemi, 2021). In the United States,
for example, decades after switching to disposable products to manage their menstrua-
tion, young women are now demanding cloth absorbents as an environmentally sustain-
able alternative (Makhijani, 2022). Anthropologists might have investigated how girls
and women managed their menstruation on a day-to-day basis, including the logics and
indigenous knowledge systems that underlie them. This could include attention to man-
agement tools and their social and cultural meaning, and the variations in menstrual
practices across regions and lifestyles including celebrations (Good, 1982). They could
have examined the guidance that Ayurveda and other knowledge systems offered on how
to manage menstrual problems including dysmenorrhea (Karunagoda et al., 2011; Patil
et al., 2015). Or, given the explicit attention to the centrality of girls’ and women’s voices
in Sommer and Kirk’s papers, researchers might have paid particular attention to how
these girls and women innovate to manage their menstruation while still adhering to
cultural expectations. We could have seen social scientists use deliberative methods to
elicit community needs and priorities in an open-ended way. Historians might have
uncovered how Indian and other women had approached and managed menstruation
over time, valuing the intellectual work they had performed over centuries. They might
have also investigated whether and how colonial governments or international develop-
ment institutions had influenced sanitation infrastructure. But such studies would have
required far greater investments of time and resources, and may not have provided the
authority and generalizability that comes with quantitative scientific methods. They also
may not have concluded that there was a problem at all.
Instead, virtually all of the research in the emerging MHM field adopted the knowl-
edge, attitudes, and practices (KAP) method that, as mentioned above, had originated in
the field of family planning and population studies in the late 1960s and since spread
across international development and public health (Cleland, 1973). KAP methods pri-
marily involve surveys, but occasionally include interviews and focus groups; it is
viewed as a rigorous approach that can capture the status and needs of populations and
allow development professionals to justify programs. Study design, including the que-
ries, is usually standardized across contexts. This makes it easier for local researchers in
under-resourced areas to assume leadership roles and for the studies to be implemented
in a range of contexts. It also produces quantitative assessments whose findings can be
statistically verified and that are often characterized as being generalizable to a larger
population. This then facilitates interpretation and comparability of research results. Its
proponents claim authority to inform development decisions on the basis of the method’s
scientific credibility and apparent capacity to elicit the needs and preferences of the tar-
gets of development interventions, as well as the inclusivity of the research community.
This method shaped the MHM problem itself. Framed by the early agenda-setting
papers by Patkar, Bharadwaj, Sommer, and Kirk, KAP researchers in India and else-
where asked respondents about their knowledge regarding menstruation, management
tools used, restrictions and prohibitions during menstruation, and school attendance and
performance. In other words, they started with the assumption that there was a problem
and that it was an individual one. It also had the same characteristics across contexts,
including ignorance and lack of access to appropriate management tools. The purpose of
the surveys and interviews was then to assess severity. There was no case where MHM
Parthasarathy 647

was not seen as a problem at the outset. Consider, for example, the most comprehensive
survey in India to date, including 1800 adolescent girls across three geographically dis-
parate states. Summarizing adherence to cultural myths and taboos, it observed that 88%
of girls observed religious ‘restrictions’ (e.g. not going to the temple), 83% observed
‘restrictions’ on exercise, 20% described different sleeping arrangements, and 7% had
restricted food choices (Sivakami et al., 2019). The data analysis did not note the clear
differences in adherence to restrictions. Instead, it concluded: ‘Most girls were not aware
of menarche and faced barriers and restrictions when menstruating, consistent with past
studies across India’ (p. 10). Similarly, a survey of 160 rural girls in West Bengal found
that 86.25% of respondents believed menstruation was a physiological process, while
others saw it as a curse of God (6.25%), a disease (5%), or a sin (2.5%) (Dasgupta &
Sarkar, 2008). Instead of seeing this data as a positive sign, the study authors focused on
other signals of ignorance. ‘It was observed in this study that 86.25% girls believed it to
be a physiological process whereas in a similar study conducted in Rajasthan by Khanna
et al., nearly 70% believed that menstruation was not a natural process. It was very sad
to observe in the present study that most of the girls did not know about the source of
menstrual bleeding and more than half of the girls were ignorant about the use of sanitary
pads during menstruation’ (Dasgupta & Sarkar, 2008). It was unclear why the findings
varied, as there were no major differences in the study samples. But to researchers, the
differences didn’t seem to matter much. Instead, they shifted attention to other areas of
documented ignorance.
Researchers also saw the problem as global. There were MHM KAP studies across
Latin America, the Middle East, Africa, and South Asia, often conducted by researchers
based locally. After all, KAP’s standard battery of questions about menstrual knowledge
and practices allowed researchers from across the world to participate easily and contrib-
ute to a global field, which would provide them with opportunities to publish and present
their findings in both national and international venues. The UNICEF-sponsored MHM
conferences often featured country-specific reports on KAP findings, which reinforced
the idea that poor MHM had standard attributes and was simply more severe in Southern
countries. Indian research reports usually began by characterizing a single, widespread
problem and then focusing on a specific Indian site. One survey of adolescent girls in
Delhi, India’s capital, published in the International Journal of Reproduction,
Contraception, Obstetrics, and Gynecology and co-authored by India-based researchers
began,

Menstrual hygiene management (MHM), practices related to menstrual hygiene during periods,
is a serious problem for adolescent girls in low and middle income countries (LMICs). The
sustainable development goals are influenced directly or indirectly by poor menstrual hygiene,
the achievement of the same is indeed very crucial for the overall development of these young
adolescents and the nation at large. (Sharma et al., 2017).

The papers also constructed the MHM problem as urgent; in the short term, it affected
girls’ and women’s safety. Multiple surveys showed that menstruators often used washed
and recycled cloth, either from old clothing or previous menstrual cycles, to manage their
menstruation (Dasgupta & Sarkar, 2008; Jothy & Kalaiselvi, 2012). They might also
648 Social Studies of Science 52(5)

reuse this cloth during a single period, washing and drying it overnight. Researchers
deemed these methods ‘unsafe’ or ‘very poor’, arguing that such methods were improper
and produced reproductive tract infections:

[I]t is observed that more of rural participants dried them inside the house because menstruation
is considered as impure and dirty and meant to be hidden which reflects the taboos found in the
society …. The secrecy associated with the reproductive health issues hitherto considered taboo
are some of the underlying reasons for the silent spread of RTIs. (Kamath et al., 2013)

Another study supported this claim by producing logistic regression analyses that cor-
related ‘unsafe’ management tools – defined as recycled cloth use – with a variety of
bodily impacts during menstruation including white discharge, pain in the lower abdo-
men, and irregular periods (Khanna et al., 2005).
The studies treated MHM as consequential in the long term because of effects on
education and ultimately, women’s empowerment. One introduction began,

Additionally due to its indirect effects on school absenteeism and gender discrepancy, poor
menstrual hygiene and management may seriously hamper the realization of [Millennial
Development Goal]-2 on universal education and [Millennial Development Goal]-3 on gender
equality and women’s empowerment. (Jothy & Kalaiselvi, 2012)

However, in open-ended interviews about the restrictions practiced during menstruation,

girls did not volunteer that they were prohibited from going to school (Dhingra et al.,
2009; Khanna et al., 2005). And when asked through standard surveys, the results varied
dramatically: 16–58% of girls (depending on the study) reported ever missing school
during menstruation (Dasgupta & Sarkar, 2008; Jothy & Kalaiselvi, 2012). Thus, it was
unclear how much MHM was really linked to educational outcomes. But here too,
researchers didn’t question their assumption that MHM affected education. Any school
absence was a problem.
Finally, these studies framed the MHM problem as easily solvable, with disposable
sanitary pads. This started with the very structure of the KAP questionnaires. As sug-
gested above, almost all asked about the menstruator’s method of absorbing blood,
whether disposable pads, new cloth pieces, or recycled cloth. They then treated any evi-
dence of recycled cloth use (and often, any use of cloth at all) as a problem. After all, one
concluded, ‘Sanitary napkins, if manufactured in hygienic manner, are universally
accepted as a safe method of menstrual hygiene’ (Mahajan & Kaushal, 2017). By con-
trast, they rarely asked about access to private toilet facilities. Menstrual hygiene man-
agement, in other words, was an individual challenge rather than an institutional one.
One study of adolescent girls in Maharashtra state concluded, ‘The girls expressed will-
ingness to use sanitary napkins if they are available at more economical rate. Hence
making low cost napkins available to the girls, can prevent many cases of infections
arising from unhygienic material/cloth used by girls’ (Mudey et al., 2010). The sanitary
pad possibility also seemed feasible with the rise of inclusive innovation. ‘Universalized
use of sanitary pads can be advocated to every girl only by making it available at afford-
able prices (social marketing)’, concluded authors of a survey conducted in West Bengal
Parthasarathy 649

state (Dasgupta & Sarkar, 2008). Even those who acknowledged the Western trend
toward cloth and other reusable absorbents argued that such solutions were untenable in
the LMIC context, where girls were ignorant and susceptible to stigma, and lived in
unsanitary conditions (Scott et al., 2013).
Overall, the structure and focus of these KAP studies defined the MHM problem as
urgent, widespread, and consequential in terms of women’s health and education and
ultimately for equity and empowerment. And they constructed it as a problem of indi-
vidual ignorance and poverty that could be easily fixed through social entrepreneurship.
For donor agencies, governments, and as we will see, even publics to invest in low-cost
disposable sanitary pads, they needed to trust that the MHM problem was large and uni-
form, so that the market could keep growing. KAP studies provided this evidence.
Interestingly, they generated virtually no criticisms, perhaps because few other scien-
tific fields or methodological perspectives were involved, because KAP studies had such
a long and stable history in international development, or because the Indian researchers
could claim cultural legitimacy. Researchers had also, of course, constructed the situa-
tion as dire. A rare exception came from American economists Emily Oster and Rebecca
Thornton, who questioned the relationship between poor MHM and school attendance.
After a randomized evaluation in Nepal, they found that although school records data
was somewhat incomplete, menstruation had limited impact on attendance (Oster &
Thornton, 2011). They also showed that increasing access to disposable sanitary pads
had no effect. This departed from the emerging consensus that girls were missing and
even dropping out of school due to improper means of menstruation. However, these
contradictory findings were barely acknowledged. MHM researchers only cited this
study to justify their calls for more research.
As they constructed the MHM problem, the KAP studies also claimed to represent the
subaltern accurately. Most papers painstakingly described their efforts to represent a
large group of girls or women. They explained sample construction and size, the reso-
nance between their results and other KAP studies, and in the case of surveys, the statisti-
cal significance of their findings. However, they also privileged scientific rigor over
validating the knowledge of low-income and marginalized menstruators; rather than ask-
ing open-ended questions that might produce diversity in the results, their surveys and
interviews were heavily structured so they could be compared. In other words, research
subjects could not inform the structure of the study, whether its focus or the question-
naire. And as discussed above, the use of the KAP method itself erred on the side of
constructing an MHM problem. This could have produced a crisis of legitimacy, particu-
larly in an environment of growing cries to ‘decolonize’ global health (Büyüm et al.,
2020). However, Indian researchers’ prominent role likely allowed them to avoid cri-
tiques that the MHM problem was merely a Western imposition.

Low-cost disposable sanitary pads: The ideal solution

As KAP studies constructed a single MHM problem using scientific methods, the Indian
government, social enterprise incubators, NGOs, and philanthropic foundations rein-
forced its importance as they fostered the market-generating solution. They, too, defined
MHM as urgent, standard across the country, and solvable with a simple technology that
650 Social Studies of Science 52(5)

could produce a range of cascading benefits for the economy. And as we will see, the
solution seemed more legitimate because it not only engaged women across the country
as newly empowered economic actors but also highlighted the contributions of a grass-
roots innovator.
Indian NGOs and entrepreneurs had addressed the needs of low-income menstruators
on a small scale for years, from offering clean cloth absorbents to educating them about
hygiene (Finley, 1999). But this work had received little attention or funding; after all,
MHM had not been a development problem. But as KAP studies proliferated, and there
was growing interest in social entrepreneurship, investment in MHM technology for the
poor grew. In 2006, the year that the UNICEF-Tamil Nadu program began, the prestig-
ious Indian Institute of Technology in Chennai, the capital of Tamil Nadu state, recog-
nized a small-scale machine that manufactured low-cost sanitary pads as that year’s ‘best
innovation for the betterment of society’. VillGro helped the inventor, Arunachalam
Muruganantham, establish Jayaashree Industries and develop a business model selling
his machine to women’s self-help groups (VillGro, 2008).
Muruganantham fit both Anil Gupta’s vision of grassroots innovation and conven-
tional Western ideas about invention and inventors. From Coimbatore in Tamil Nadu,
Muruganantham had developed the machine after getting married and learning about
menstruation and the high cost of disposable sanitary pads (Sandhana, 2011; Venema,
2014). Although he had less than a high school education and worked lower skilled jobs,
he had always been a tinkerer. After years of trial and error, and risking both his marriage
and social ostracism because of his obsession with the taboo subject of menstruation, he
developed a machine that would produce affordable, disposable sanitary pads. The
machine was inventive both because it was small in comparison to the huge factories
used by multinational corporations, and it produced cheaper pads.
Muruganantham’s invention validated the MHM problem. He, like the Indian
researchers performing KAP studies, claimed to represent the needs of the subaltern
through his own experiential knowledge. But Muruganantham also translated these pri-
orities into a market-generating technology that would interest the growing number of
entities interested in inclusive innovation. Indeed, the UNICEF-Tamil Nadu sanitary pad
donation program purchased Muruganantham’s machines to help SHGs produce the
pads.
By 2009, NIF had further certified Muruganantham’s solution and the MHM problem
by giving him a grant from its Business Development and Micro Venture Innovation
Fund and helping him patent the invention. In describing his invention for NIF,
Muruganantham emphasized its emancipatory potential, bringing together rhetoric from
the UNICEF-Tamil Nadu initiative and the KAP studies: ‘This [sanitary-pad making]
machine heralds a new revolution in personal hygiene, for women across all sections of
society, while creating [a] potential perennial revenue stream for small scale entrepre-
neurs, and self help groups by deploying a self-sustaining micro-enterprise model’
(National Innovation Foundation, 2009). It is notable that the description emphasizes the
economic impacts on small scale entrepreneurs as much as the benefits for personal
hygiene.
In 2010, India’s central government announced that it would take over UNICEF’s
program and expand it nationwide (INVC, 2010). All girls would have access to heavily
Parthasarathy 651

subsidized disposable sanitary pads: Girls living below the poverty line could purchase a
pack of six for 1 rupee, while girls above the poverty line would pay 5 rupees. As with
the smaller scale programs, SHGs would produce the pads with initial capital investment
and training from the government.
This program validated both the MHM problem and how the KAP studies had
defined it. P.K. Pradhan, director of the National Rural Health Mission that oversaw the
program, observed that the scheme ‘marks a step forward in the adolescent reproductive
and sexual health programmes in the country. Promoting menstrual hygiene will yield
several dividends. Apart from addressing the very real need of ensuring the comfort and
dignity of girls, it could promote school attendance and retention’ (National Rural
Health Mission, 2010, p. 7). To the Indian government, MHM had serious consequences
for girls’ health and education.
Of course, just as MHM research could have taken multiple directions, so too could
solutions. The Indian government could have provided menstruators with cloth absor-
bents, aware that girls already using recycled cloth might find them easier to adopt (or
easier for their mothers to teach them), and that disposal of synthetic sanitary pads could
create environmental and other challenges particularly in rural areas (Kaur et al., 2018).
It could have focused on better hygiene education. Or, it could have chosen to build bet-
ter toilets; after all, it was in the midst of the Total Sanitation Campaign, which promoted
latrine construction to address open defecation (Hueso & Bell, 2013). But these options
were more complicated. The sanitary pad route allowed the government to invest in an
Indian grassroots innovation and SHGs while agreeing with the hygiene concerns gener-
ated by development organizations both at home and abroad. The solution wouldn’t just
provide short term benefits, but would help women become entrepreneurs and leaders.
According to Minister of Health and Family Welfare Ghulam Nabi: ‘Building on existing
experience in the country, this scheme also promotes the active participation of women
self help groups in the manufacturing of sanitary napkins. It will not only generate eco-
nomic livelihood for the people in the villages, but will also promote local demand and
distribution at a relatively low cost’ (INVC, 2010, p. 5). In sum, the market-generating
solution helped MHM become a problem in India. The national government (and later,
the states, which took over implementation) purchased Muruganantham’s machine and
donated it along with materials and training to local self-help groups, who would then
sell the pads back to the government. Some SHGs also secured microloans, which
allowed them to sell these pads independently to local women, thereby expanding the
low-cost disposable sanitary pad economy.
The central government encouraged local health workers known as ASHAs, who
would distribute the pads, to provide girls with MHM awareness training. But in prac-
tice, the sanitary pad was the main mechanism for societal transformation.

In its totality, the scheme aims to increase awareness among adolescent girls on Menstrual
Hygiene, increase access to and use of high quality sanitary napkins to adolescent girls in rural
areas and will ensure safe disposal of sanitary napkins in an environmentally friendly manner.
At the community level, ASHA will be responsible for ensuring an adequate supply of Sanitary
napkins for adolescent girls who require them. The Sunday meeting by ASHA would be the key
forum to enable this regular supply. ASHA will also contact girls in their homes who are unable
652 Social Studies of Science 52(5)

to attend meetings to ensure that they have a supply of Sanitary Napkins. The role of ASHA in
supplying the sanitary napkins is one suggested option. States are free to select other mechanisms
in keeping with local context. Incentive for ASHA is built in the scheme, she will get [1 rupee]
for every pack she sells. (INVC, 2010)

The Indian media reinforced this approach in 2011 by giving wide attention to a survey
conducted by international polling firm AC Nielsen with support from Plan India, a large
NGO focused on the rights of children. The results seemed credible not only because of
its scope (surveying 1033 girls and women of menstrual age and 151 gynecologists
across nine Indian states) but also because it resonated with both the design and findings
of MHM KAP research and seemed to allow girls and women to speak. However, its
results suggested a much more severe problem than had been published in the academic
literature. The Times of India reported that the study found that ‘only’ 12% of India’s
menstruating women used disposable sanitary napkins, characterizing this as a serious
problem (Sinha, 2011). It observed further that the others used ‘shocking alternatives’
like ‘rags’, ashes, and husk sand. And it reported that girls missed 5 days of school in a
month due to menstruation, and 23% actually dropped out completely after they started
menstruating. It also suggested that on average women missed 2.2 days of work during
their periods. These statistics were outliers compared with other KAP study findings, and
were much more alarming. But nobody questioned them, perhaps because the experts
who might have raised questions hoped they would produce action.
Media outlets and NGOs fixated on the low rate of disposable sanitary pad use identi-
fied in the survey. An article in the Press Trust of India observed, ‘The figure is abysmal,
compared to countries like China, where majority of women use sanitary napkins …’
(Press Trust of India, 2011; see also Sandhana, 2012). The study generated domestic
NGO activity as well, including a Sanitary Pad Bank established by The Tee Foundation,
which mobilized urban Indian women to donate disposable pads (Tee Foundation, 2019).
Meanwhile, both Indian and international organizations interested in inclusive inno-
vation, including the World Bank and Ashoka Foundation, responded with grants and
fellowships to sanitary pad entrepreneurs in India and elsewhere including Muruganantham
(EcoFemme, 2019; Goonj, 2018; World Bank, 2021). Prominent Indian philanthropic
foundation Dasra issued a report validating the inclusive innovation approach (Dasra,
2014).

[S]ocial businesses in this sector are filling the critical gap of availability of material to manage
menstruation. They are undertaking research to either develop low-cost, good quality and bio-
degradable material, or develop machines that can be used by self-help groups to manufacture
sanitary napkins locally. Most of them partner with non-profit organizations to complement
their efforts of demand generation within communities. They are currently at an early stage and
require funding and capacity building support to develop their models and business strategy as
well as procure grants for research and innovation. Supporting social businesses and non-profit
organizations to complement each others’ work will result in a more comprehensive and
scalable solution that capitalizes on the strengths of both entities. (p. 80)

Just ten years after the first agenda-setting paper, the availability of a simple, market-
generating solution coupled with the KAP studies had established MHM as a crucial
Parthasarathy 653

problem of international development. KAP researchers and traditional development

actors in UNICEF and the Indian government, but also institutions focused on market-
generating innovation like VillGro and NIF, had now certified it. It seemed to provide the
perfect opportunity to leverage a grassroots way for India to catch up to modernity. But
at its heart there was a paradox. On the one hand it allowed India to engage in economic
development on its own terms and claim an independent approach to innovation. But
on the other, the innovation itself was a synthetic solution that embodied a Western
worldview.

Managing critique
One might imagine resistance to the tightly coupled MHM problem and solution from
multiple groups, most notably girls and women from low-income and marginalized com-
munities. But they were the least powerful, and had few choices about, for example, the
types of enterprises they might start or whether they would accept free sanitary pads
from schools. Meanwhile, public health experts, international organizations, and the
Indian government claimed that they were simply amplifying these voices. It is perhaps
not surprising, then, that there was little opposition to the growing MHM-based sector.
One exception was Sinu Joseph, from Indian NGO Mythri Speaks. She began her
work as a menstrual health educator in 2010, providing both training and low-cost dis-
posable sanitary pads to adolescent girls in free government schools in her home state of
Karnataka. But she became increasingly uncomfortable with her work and the assump-
tions it embodied. When she ran out of disposable pads to donate and resources to pur-
chase more, she began to ask girls about their use of menstrual absorbents. Many, she
found, believed that the disposable pads were ‘super absorbent’ and used them for
extremely long periods of time, changing them only once or twice a day (Mythri Speaks,
2013). She worried that this use would actually create the health problems she was trying
to solve. She also observed that many low-cost disposable sanitary pads were of poor
quality. Pads made by Muruganantham’s machine, for example, seemed to last for a short
period of time (some reported only an hour), the material inside clumped, and sometimes
didn’t come off properly (the glue sticks) so it rips apart messily (Mythri Speaks, 2016).
Another Indian NGO, the Menstrual Health Alliance, echoed these observations and
asked the government to establish and enforce quality guidelines. Joseph also wondered
about the environmental impacts of sanitary pad disposal especially when India already
had serious sanitation issues. Others have since validated this concern, worrying that
disposable pads would stress India’s already limited sanitation infrastructure and increase
health risks for those (including manual scavengers) who collect and sort waste
(Garikipati & Phillips-Howard, 2019).
Finally, Joseph questioned the conventional characterization of indigenous practices
as unfounded myths and taboos. This began after girls repeatedly asked her why they
were restricted from certain foods and activities during their period, and hearing other
menstrual health educators dismiss such concerns. She wondered, ‘With what right do
we dismiss someone else’s belief when we neither know the origin of such practises, nor
its significance in the practitioner’s family? … What if there was indeed some ancient
story of menstrual magic hidden in these rituals, which we would lose out on in our
654 Social Studies of Science 52(5)

arrogance of rubbishing these questions?’ (Mythri Speaks, 2014) These questions led
Joseph, a Christian, to spend years investigating ancient Ayurvedic and other indigenous
practices. She ultimately changed her approach to menstrual education, focusing on how
these practices empowered Indian women, and published a book on indigenous knowl-
edge related to menstruation (Joseph, 2019).
We might expect that these user responses might modulate the enthusiasm of MHM
and sanitary pad proponents (Oudshoorn & Pinch, 2003; Sharma, 2020). In fact, Joseph
has repeatedly tried to bring these concerns to development experts and policymakers
through blog posts and in public talks. But her concerns are largely dismissed. Her TED
talk on Ayurvedic knowledge about menstruation was removed from YouTube because it
purportedly spread misinformation (Mythri Speaks, 2018). Similarly, in 2015, she articu-
lated some of her concerns at the International Conference on Menstrual Health and
Reproductive Justice in Boston. Boys dropped out of school at even higher rates when
they reached puberty, she noted. Should they, too, receive disposable sanitary pads?
Attendees responded with polite applause, but she was largely ignored. One NGO repre-
sentative suggested that she ‘modulate’ her remarks to build allies (Joseph, 2017). Even
though Joseph represented a contrary subaltern voice, by then science and the market had
stabilized a grassroots-driven innovative solution to a global problem. They did not need
Joseph’s support, and had the power to define her perspective as untruthful.

Inclusive innovation as the way forward

Low-cost disposable sanitary pads in India, and specifically Muruganantham and his
machine, soon became an iconic example of the promise of inclusive innovation for
international development. In 2014, Muruganantham shared the stage with Bill Gates
and US National Institutes of Health Director Francis Collins on a panel focused on
‘Creating cultures of innovation’ at a Gates Foundation Grand Challenges meeting. Time
magazine named him one of its 100 most influential people in the world (Gupta, 2014).
In 2016, he won the Padma Shri, India’s fourth-highest civilian honor. In 2019, the
Women Leaders Global Forum, co-chaired by the OECD, World Bank, and World
Economic Forum, awarded him the ‘Power, together’ award. By 2021, Muruganantham
had installed more than 1300 machines in 27 Indian states and seven other countries
(Jayashree Industries, 2020).
Muruganantham’s story validated Anil Gupta and NIF’s ideas that there was
untapped genius among those with modest means and a limited technical background,
and that harnessing it would produce broad social and economic benefits. It under-
scored C.K. Prahalad’s emphasis on untapped markets at the ‘bottom of the pyramid’.
And of course, it resonated with the stories of famous Western innovators: men who
had experienced extreme hardship to bring their crucial inventions to the world. A New
York Times profile referred to Muruganantham as a ‘popular’ innovator who could
cater to previously ignored constituencies (Bhattacharjee, 2016; Venema, 2014). And
the Gates Foundation and other development organizations could use his technology to
demonstrate how markets could be leveraged to address poverty. Muruganantham’s
website embraced this role. It noted his origins ‘from a poor background in the South
of India’, and identified two problems his machine solved: the high cost of disposable
Parthasarathy 655

sanitary pads, and ‘the issue of rampant unemployment amongst the poor in rural,
urban and semi-urban areas of all developing nations.’ (Jayashree Industries, 2020) He
characterized his machine as ‘Small is beautiful’, using the title of economist E.F.
Schumacher’s (1973) book, which had launched the appropriate technology movement
in the 1960s (Cherlet, 2014; Pursell, 1993).
But unlike appropriate technology, which also focused on small scale interventions
as the key to international development, inclusive innovation saw market generation
as crucial. Multiple movies and documentaries showcasing Muruganantham’s
machine underscored this dimension. The Oscar-winning documentary short film
Period. End of sentence highlighted a self-help group in Uttar Pradesh, in North India,
that received one of Muruganantham’s machines and other training and equipment to
start a disposable sanitary pad-making business. These materials came from The Pad
Project, a US-based NGO established by educators and students who learned about
the problem of ‘period poverty’ and Muruganantham’s machine at the UN’s Annual
Commission on the Status of Women in 2013 (The Pad Project, 2022). Like the KAP
studies, the 26-minute film demonstrates adolescent girls’ lack of knowledge about
menstruation and sanitary pads, and highlights statistics about the link between inad-
equate MHM and education. But it also showcases the stories of SHG members, and
how participation in the social enterprise is transforming their lives. It opens, for
example, with an interview with a young woman who dreams about becoming a spe-
cial investigator with the Delhi police, and suggests that the confidence and resources
created through the sanitary pad-making enterprise will allow her to follow her
dreams. Later, the filmmakers emphasize that the SHG decided to brand their sanitary
pads under the name ‘Fly’, because they want women to ‘soar’. The film’s success –
in addition to its Oscar win, it is distributed globally by Netflix – has allowed The Pad
Project to expand its activities, including placing nine of Muruganantham’s machines
in two countries.
The film’s strength lies in how it establishes the legitimacy of inclusive innovation for
international development. Like both KAP studies and the Indian government, it demon-
strates how the technology represents the desires of Indian girls and women who have
been traditionally disadvantaged. It provides evidence that girls and women readily
embrace it and use it. The market becomes a catalyst for them to achieve their dreams,
underscoring the idea that the technology is rooted in democracy.
As the MHM case became the iconic example of inclusive innovation, it reinforced
the idea that science and the market represented the public interest better than the gov-
ernment. After all, the technology was no panacea and the government could have regu-
lated it in multiple ways. India’s government deployed incinerators at schools to facilitate
disposal, but of course menstruators discarded the pads everywhere. Furthermore, incin-
erating plastics could create new, and potentially more toxic, forms of air pollution
(Chadha, 2015). And, there was essentially no quality control for these low-cost pads.
UNICEF, the Indian government, and the other organizations involved in promoting the
pads often referred to the importance of ‘high quality’ materials, but the Bureau of Indian
Standards (BIS) maintained only a voluntary certification system on the physical compo-
sition of sanitary pads, and the menstrual hygiene program left additional standard-
setting and oversight up to states (Bureau of Indian Standards, 1980). But none of these
656 Social Studies of Science 52(5)

shortcomings were seen as important enough to require regulation or otherwise modulate

uptake. The public, it seemed, had determined that the risks were not significant. In this
view, role state’s role was simply to create the conditions to foster innovation and the
marketplace, which would ultimately benefit society.

Conclusion
This analysis shows that inclusive innovation does not simply provide grassroots solu-
tions to the obvious problems of international development. Rather, it is shaping our
understanding of development problems themselves. MHM became a development con-
cern not just because it had been identified in the scientific literature and then promoted
by policy entrepreneurs (Kingdon, 1984). Rather, the scientific and market ways of
knowing the problem made a difference. Public health researchers quickly converged on
the KAP approach, which brought with it the assumption that MHM was a global prob-
lem, and then focused on characterizing it. Meanwhile, MHM became a more urgent
concern when UNICEF, the Indian government, and organizations dedicated to inclusive
innovation identified the low-cost disposable sanitary pad as an ideal solution not only
because it helped low-income girls and women with their menstruation but also because
it could stimulate gender equity and economic empowerment through the participation of
SHGs. The KAP studies took advantage of this growing support, and used emerging
sanitary pad entrepreneurship to argue that the problem they had identified was impor-
tant, singular, and easily solved. This surely helped to increase MHM’s profile in the
international development world, as an opportunity to score an easy win. But the KAP
studies and low-cost disposable sanitary pad solution were also able to amplify MHM
because they seemed politically legitimate. KAP studies claimed to capture the voices of
the subaltern in quantitative, often statistically significant ways, while sanitary pads
became successful because they were produced and consumed by Indian girls and women
and invented by an Indian man.
These scientific and market ways of knowing also shaped inclusion and innovation.
In some ways they expanded definitions of both by including more LMIC experts and
institutions, even those like Muruganantham who lacked formal technical training. And
innovation now included seemingly mundane interventions that had been reimagined for
new audiences. However, they also largely excluded girls and women as knowers or
innovators. While the KAP methodology claimed to represent their voices, it patholo-
gized traditional practices and characterized their behaviors as ignorant. Practitioners of
indigenous knowledge systems, and girls and women’s innovations to manage their men-
struation for centuries, were rendered primitive. Simultaneously, the epistemology of
inclusive innovation made it impossible to consider interventions that might not generate
markets but might sustainably serve the needs of Indian girls and women, like better
latrines. Overall, it was a missed opportunity to value the knowledges of Indian girls and
women, which could have produced a different kind of empowerment. Ultimately, even
in a place like India that has a more expansive view of technology, inclusive innovation
is driving development toward problems that have not just easily measurable, but also
commodifiable, solutions. And gender equity is defined by participation in these markets
as producers or consumers.
Parthasarathy 657

These findings should concern STS scholars and others dedicated to bringing the
public interest more explicitly into technological design and implementation even
beyond the domain of international development. This includes those invested in enhanc-
ing public participation in technological development in order to ensure political legiti-
macy and societal benefit, as well as those anticipating the ethical, social, and equity
dimensions of emerging technology in order to inform its governance. The analysis pro-
vided here suggests that efforts at inclusion cannot escape the prevailing political econo-
mies of innovation that tend to privilege scientific, technical, and market perspectives. It
should force us to reflect on how this context constrains our understandings of innova-
tion, inclusion, responsibility, and participation, and then consider how we might free
ourselves to develop more democratized approaches.

Acknowledgements
I am grateful to Sergio Sismondo, Monamie Bhadra Haines, Kelly Moore, and two anonymous
reviewers for their invaluable comments on this manuscript, and to Dina Emam for her research
assistance. Thanks also to audiences at York University, University College London, Northwestern
University, and Hong Kong University of Science and Technology, where I presented previous
versions of this article. Finally, I deeply appreciate the time and insights my interviewees
provided.

Funding
The author disclosed receipt of the following financial support for the research, authorship, and/or
publication of this article: This research was supported by University of Michigan’s Institute for
Research on Women and Gender, Office of Research, and Ford School of Public Policy.

ORCID iD
Shobita Parthasarathy https://orcid.org/0000-0001-5635-464X

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Author biography
Shobita Parthasarathy is Professor of Public Policy and Women’s and Gender Studies, and Director
of the Science, Technology, and Public Policy Program, University of Michigan. She is the author
of Patent Politics: Life Forms, Markets, and the Public Interest in the United States and Europe
and Building Genetic Medicine: Breast Cancer, Technology, and the Comparative Politics of
Health Care. She is writing a book about inclusive innovation for international development.