W at e r G l o b a l P r a c t i c e A WPP Topic brief Providing Sustainable Sanitation Services for All in WASH Interventions through a Menstrual Hygiene Management Approach Summary A gender-inclusive approach to sanitation through Menstrual Hygiene Management (MHM) is needed to ensure that the benefits of sanitation and hygiene are truly universal. The key takeaways from this brief are: (1) the need to do contextual research before proposing an intervention, ideally by working with a ­ gender specialist; and (2) the value of working through Water, Sanitation, and Hygiene (WASH) interventions © Stephan Bachenheimer/World Bank. integrate the key pillars of MHM (box 1). to ­ Background (MHM)  approach.1 This note presents some of the With support from the Water Partnership Program knowledge gained through this event and some recent (WPP), the Rural Water Supply and Sanitation research findings on the topic. As MHM cuts across Thematic Group (Rural WSS TG) organized a learning many development sectors, it aims to be relevant event on integrating gender in rural sanitation and to development practitioners looking for practical hygiene through a Menstrual Hygiene Management resources to integrate this approach into interventions The authors (Meleesa Naughton, Water and Sanitation consultant; Lilian Pena P. Weiss, Senior Water and Sanitation Specialist, World Bank; and Miguel Vargas-Ramirez, Senior Water and Sanitation Specialist, World Bank) gratefully acknowledge the support of the Water Partnership Program (WPP). For more information on World Bank activities related to the Rural Water Supply, contact Miguel Vargas-Ramirez (mvargasramirez@worldbank.org). For more information on the World Bank’s work on gender in WSS, contact any of the Gender Coordinators of the World Bank’s Water Global Practice though worldbankwater@worldbank.org. 1 Box 1. What Is Menstrual Hygiene Management (MHM)? Various components are considered essential to MHM. The first is that women and adolescent girls be able to use clean materials to absorb or collect menstrual blood, and to change them in privacy as often as necessary throughout their menstrual period. MHM also involves being able to use soap and water for washing the body as required, and having access to safe and convenient facilities to dispose of used menstrual management materials. Further, women and girls must have access to basic information about the menstrual cycle and how to manage it with dignity and without discomfort or fear. Source: WHO/UNICEF 2012. in the water sector, but also in health, education, • Social and cultural norms that lead to women and girls’ social protection, community development, and other exclusion during menstruation; these norms vary related development programs. widely between and within countries, and may range from not being allowed to touch water and plants, In recent years, issues deriving from the lack of ade- cook, clean, socialize, or sleep in one’s own bed while quate MHM have been coming to the fore in the WASH having their period (Sumpter and Torondel 2013). sector, particularly in relation to girls reportedly missing school because of poor MHM. Improved MHM is directly • The lack of a suitable space for washing, chang- linked to fulfilling several of the proposed Sustainable ing, and disposing of materials used during their Development Goals, including Goal 4 (Ensure inclusive menstruation; and equitable quality education and promote lifelong • Being afraid of being made fun of. learning opportunities for all), Goal 5 (Achieve gender However, while there is plenty of evidence that equality and empower all women and girls), and Goal 6 girls tend to miss school during or after the onset of sustainable management of (Ensure availability and ­ menstruation, there is a lack of research linking men- ­ water and sanitation for all) (United Nations Department struation directly to school absenteeism; similarly, no of Economic and Social Affairs 2015). evidence could be found that directly associated MHM The extent to which women and girls’ activities are with a decrease in labor productivity in later years affected by menstruation varies, depending on the (Sumpter and Torondel 2013). Yet the onset of men- context, but remains significant throughout their life, struation may be an indirect cause of school absentee- particularly in low-income countries. ism: in many cultures, menstruation is considered a rite of passage from childhood into womanhood, sig- Economic and Social Impacts naling that girls are ready for marriage (Joshi, Buit, Many studies argue that inadequate MHM forces many and Gonzalez-Botero 2015). This may result in girls girls to miss class or drop out of school altogether quitting school early: data from Tanzania and South (Sahin et al. 2015; WSSCC/UN Women 2015). When Sudan indicate that early marriage and pregnancy are asked about the reasons for not attending school or the main causes of girls dropping out of school, not work, girls and women point out the following factors: MHM issues per se (Sahin et al. 2015). Even so, girls • The lack of gender-friendly and private sanitation are directly or indirectly affected by menstruation to and hygiene facilities; varying degrees, depending on the specific context • The unavailability of menstrual materials; (Sahin et al. 2015). 2 Providing Sustainable Sanitation Services for All in WASH Interventions through a Menstrual Hygiene Management Approach Health Impacts Figure 1. The Four Pillars of a Comprehensive MHM Program, Ideally Incorporated in WASH Many reports link the use of unsuitable absorption mate- Interventions rials to health issues: for instance, when girls and women don’t dry materials properly, this can lead to infections (Wateraid 2012). However, the research to support this 1. Knowledge, link remains poor (Sumpter and Torondel 2013). The 2. Facilities that attitudes, and practices provide privacy for health impacts of menstruation can also affect girls indi- surrounding changing, washing, menstruation, including rectly: early marriages and pregnancies sometimes have and drying menstrual improved access to materials; water and a profound impact on the girls’ health and that of their accurate and soap; and disposal contextual information facilities babies (WHO 2014) (Williamson 2013). on menstruation The link between sexual health and MHM is com- plex but of the utmost importance (Joshi, Buit, and 3. Materials for 4. Institutional and managing policy measures, Gonzalez-Botero 2015). Surveys conducted in several menstruation that including capacity countries revealed that schoolgirls can be involved in are culturally building, advocacy, acceptable, dedicated MHM sexual activities with males during school to generate contextually policies and budgets, income for meeting their basic needs, including san- available, and and M&E of MHM a ordable plans itary items; in all countries surveyed, it was believed that having sex would end the pain associated with menstruation. This further raised the girls’ risks of Source: Based on Wateraid 2015. unwanted early pregnancy, various health issues, and Note: MHM = Menstrual Hygiene Management; M&E = monitoring and leaving school early (Sahin et al. 2015). evaluation. Environmental Impacts Ideally, a comprehensive MHM program should incor- The lack of adequate disposal facilities for menstrual porate interventions designed around four pillars, as materials, particularly in public places, leads women outlined in figure 1 (Wateraid 2015); however, it may be and girls to try to dispose of their menstrual waste in difficult to design and implement a stand-alone project secret, often causing environmental harm (WSSCC/ focused on MHM practices. By contrast, WASH projects UN Women 2015). It is worth noting that this is a sig- provide a unique entry point for these interventions, nificant issue in developed countries as well, where as they deal with the hardware (facilities and materi- flushing menstrual waste down the toilet continues als) as well as the software (knowledge, attitudes, and to cause costly blockages and breakage of sewerage practices) while engaging at the policy and institu- systems. tional level. Approach Knowledge, Awareness, Attitudes, and Practices To better address menstrual hygiene in the develop- Surrounding Menstruation ment sector, it is imperative to start by building the Unsurprisingly, the first wish of many women and capacity and confidence of WASH development prac- girls is for information on menstruation (Sahin et al. titioners to integrate MHM into development projects 2015; WSSCC/UN Women 2015). In light of the social, and programs. Gender and social development special- economic, and health impacts discussed earlier, infor- ists should be the first port of call in this context, as mation on menstruation may well have the largest they can provide advice on how to do so. potential impact. WASH programs, particularly WASH Providing Sustainable Sanitation Services for All in WASH Interventions through a Menstrual Hygiene Management Approach 3 in schools and health centers, are a very good entry • Basic, separate sanitation facilities that provide point to provide information on MHM and initiate ­ privacy for females; broader discussions on issues related to menstruation. Since WASH programs already entail the training of • Soap, water, and space for washing hands, private parts, and clothes; students and staff on sanitation and hygiene issues, education and information on menstruation and MHM • Places for changing and disposing discreetly of can easily be made part of these efforts. materials used for managing menstruation. Successfully integrating MHM in WASH programs Materials requires formative research aimed at understand- The choice of materials to manage menstruation is ing contextual knowledge, awareness, attitudes, based on cultural acceptability and user preferences. and practices, and at defining the focus of MHM Decisions will be shaped by the availability and afford- education programs. The information and materials ability of materials; and the water and sanitation provided to support the teaching of MHM must be ­ facilities that can be accessed. It is therefore critical tailored to local  conditions, to ensure that they are ­ that any program aimed at supporting women or girls truly relevant and reflect local needs. Multiple exam- with menstrual hygiene materials involve them in the ples exist of formative research on this topic, which planning, discussions, and decisions about the materi- ­Wateraid 2012; Task Teams can use as templates ( als to be supported. WSSCC/UN Women 2015). Two broad issues need to be addressed under this topic Capacity building of teachers is also critical to ­ ensuring as part of MHM programs: the sustainability of such interventions. When done right, engaging with men and boys can  contribute to • Facilitating the availability of culturally appropriate breaking the taboos changing cultural norms and ­ and adequate materials to manage menstruation around menstruation (Mahon, Tripathy, and Singh 2015). However, engagement with boys and men in the • Facilitating the reuse or disposal of used menstrual hygiene materials. context of MHM must remain cognizant of power and sexual dynamics—for instance, training male teachers Facilitating the Availability of Menstrual Hygiene provide MHM advice to young girls may not always to ­ ­Materials be appropriate (Joshi, Buit, and Gonzalez-Botero 2015). Some initiatives (box 3) have invested in facilitating the production of sanitary pads, which can be grouped Facilities in three broad categories (Wateraid 2015): A systematic review of the importance of water and  sanitation in schools highlighted that insuffi- 1. Handmade, reusable sanitary pads (Wateraid 2012) cient water and sanitation to duly manage menstrua- 2. Sanitary pads made for commercial sale by small- tion in schools results in discomfort and staying scale enterprises (box 2) away  from  school during menstruation (Jasper, Le, 3. Sanitary pads or other menstruation materials com- and Bartram 2012). In this context, initiatives aimed at mercially produced on a large-scale. providing adequate sanitation and hygiene facilities in schools and health centers (as well as in any other While the provision of menstrual materials may public setting, if appropriate) should take into account ­ seem  like a logical way to improve MHM, it is the following criteria, in order to facilitate MHM by worth  highlighting that even in a context where women and girls (Wateraid 2012): girls stated that they missed school because of 4 Providing Sustainable Sanitation Services for All in WASH Interventions through a Menstrual Hygiene Management Approach Box 2. Key Resources for Integrating MHM in the WASH Sector The Menstrual Hygiene Matters resource book and training guide toolkit are the most comprehensive resources on MHM in developing countries (Wateraid 2012, 2015). The 2015 WSSCC/UN Women Initiative on MHM is an excellent example of documenting knowledge, attitudes, and practices on menstruation. Finally, a special issue of Waterlines dedicated to MHM provides additional reference material showcasing MHM initiatives in different contexts (Shahin 2015). Box 3. Providing Menstrual Hygiene Materials to Girls and Women: The Experience of Sustainable Health Enterprises in Rwanda Ms. Julian Kayibanda of Sustainable Health Enterprises (SHE) was the guest speaker for the learning event organized by the Rural Water Supply and Sanitation Thematic Group (RWSS TG) with the support of the WPP on integrating gender in rural sanitation services through a MHM approach. SHE is a social enterprise dedicated to improving MHM for women and girls in Rwanda, and focuses on the following activities: (1) providing education and information on menstruation, aimed at debunking stereotypes; (2) reclaiming local resources—that is, banana fiber—to produce low-cost sanitary pads; and (3) investing in and empowering local entrepreneurs to produce low-cost sanitary pads. According to SHE, 18 percent of women and girls in Rwanda miss out on work or school every year because they cannot afford to buy menstrual pads. Apart from the larger issues of health and dignity, this represents a potential Gross Domestic Product (GDP) loss of $215 per woman per year in Rwanda (i.e., $115 million in potential loss of GDP per year). SHE therefore aims to help women jumpstart social businesses to manufacture and distribute affordable menstrual pads, as well as to provide health education and advocacy for improved MHM. One of the main takeaways from Julian’s speech was that implementing such a comprehensive MHM program takes time: SHE was established in 2007, but did not start producing pads on a commercial scale until 2013. SHE also had to review its branding and marketing strategy to better appeal to their target group. Empowering school teachers to educate girls about MHM was considered essential to the mission of the organization. Source: Kayibanda 2013. menstruation, providing free menstrual materials knowledge, attitudes, and practices  surrounding did not greatly improve girls’ school attendance menstruation. For the WASH sector, the parallels (Montgomery et al. 2012; Oster and Thornton 2011; with sanitation marketing are obvious: programs Sumpter and Torondel 2013). This highlights the must truly understand the needs and preferences of need to conduct ­formative research into the broader the users to ensure uptake. Providing Sustainable Sanitation Services for All in WASH Interventions through a Menstrual Hygiene Management Approach 5 Facilitating the Reuse or Disposal of Used Menstrual contextual research through WASH investment lend- Hygiene Materials ing and Technical Assistance. When making reusable or disposable sanitary pads  available, it is important to ensure girls and Note women have facilities at their disposal to wash 1. The Rural WSS TG would like to thank the guest speaker for  this  event, Ms. Julian Kayibanda, for sharing her insights on and  dry those pads (Wateraid 2012) or dispose of MHM in Rwanda. Ms. Julian Kayibanda is the former Chief them. In South Sudan, students who used sani- Operating Officer of SHE (http://sheinnovates.com), a  social tary pads stated that they used the nearby forest ­ enterprise dedicated to improving MHM for women and girls in Rwanda. or the existing latrine to dispose of the used pads; percent of the girls threw used pads in the dry 47  ­ pit latrine, 16 percent flushed them down the toilet, Bibliography and the remaining 37 percent threw them away in the Jasper, C., T-T Le, and J. Bartram. 2012. “Water and Sanitation in Schools: forest (Sahin et al. 2015). A Systematic Review of the Health and Educational Outcomes.” International Journal of Environmental Research and Public Health (9): 2772–87. Policy and Institutions Joshi, D., G. Buit, and D. Gonzalez-Botero. 2015. “Menstrual Hygiene Management: Education and Empowerment for Girls?” Waterlines 34 (1): At the policy and institutional level, efforts to improve 51–67. MHM may include the following activities: Kayibanda, J. 2013. “Making Sanitation Work for Women and Girls.” Rural • Building the capacity of staff working in the WASH, Water Supply and Sanitation Thematic Group Brown Bag Lunch. November 14, 2013. education, and health sectors, to ensure that gen- Mahon, T., A. Tripathy, and N. Singh. 2015. “Putting the Men into der-friendly infrastructure design is considered Menstruation: The Role of Men and Boys in Community Menstrual (Wateraid 2015). Hygiene Management.” Waterlines 34 (1): 7–14. • Advocating a change in school curriculum so that Montgomery, P., C. R. Ryus, C. S. Dolan, S. Dopson, and L. M. Scott. 2012. “Sanitary Pad Interventions for Girls’ Education in Ghana: A Pilot Study.” menstruation is taught alongside sexual education, PLoS One 7 (10). to ensure that male and female schoolchildren have Muralidharan, A., H. Patil, and S. Patnaik. 2015. “Unpacking the Policy a better understanding of the biological process at Landscape for Menstrual Hygiene Management: Implications for School puberty and beyond. WASH Programmes in India.” Waterlines (January): 79–91. • Calling for dedicated MHM policies and ring-fenced Oster E., and R. Thornton. 2011. “Menstruation, Sanitary Products, and School Attendance: Evidence from a Randomized Evaluation.” American budgets for their implementation. Economic Journal: Applied Economics 3 (1): 91–100. • Developing specific monitoring and evaluation Shahin, M. 2015. “Guest Editorial: Tackling the Stigma and Gender Marginalization Related to Menstruation via WASH in Schools (M&E) systems to monitor the outcomes of policies Programmes.” Waterlines 34 (1). and budget allocations, including gender-specific Sumpter C., and B. Torondel. 2013. “A Systematic Review of the Health and data. Social Effects of Menstrual Hygiene Management.” PLoS One 8 (4). Sahin, M., S. Tamiru, K. Mamo, P. Acidria, R. Mushi, C. Satya Ali, and Conclusion and Next Steps L. Ndebele. 2015. “Towards a Sustainable Solution for School Menstrual Hygiene Management: Cases of Ethiopia, Uganda, South-Sudan, Tanzania, The WASH sector provides a unique entry point for and Zimbabwe.” Waterlines 34 (1): 92–102. advancing the MHM agenda, given its potential for the United Nations Department of Economic and Social Affairs (UNDESA). development of girls and women. 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WASH Targets and Indicators 2015. “Menstrual Hygiene Management: Behaviour and Practices in the Post-2015—Recommendations from International Consultations. WSSCC. Kedougou Region, Senegal.” WSSCC. Providing Sustainable Sanitation Services for All in WASH Interventions through a Menstrual Hygiene Management Approach 7 © 2017 International Bank for Reconstruction and Development / The World Bank. Some rights reserved. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. This work is subject to a CC BY 3.0 IGO license (https://creativecommons.org/licenses​ by/3.0/igo). The World Bank does not necessarily own each component of the content. It is your responsibility to /­ determine whether permission is needed for reuse and to obtain permission from the copyright owner. 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