Menstrual management in schools in Summary report Menstrual hygiene management in schools in South Asia Summary report

Written by Tracey Keatman, Sue Cavill and Thérèse Mahon

This report provides a summary of the status of menstrual hygiene management (MHM) in schools in South Asia. It describes the context for MHM in schools and recent progress in implementation of MHM services. It identifies progress and gaps in achieving sustainable and inclusive MHM services in schools at scale and draws together opportunities for further promoting and mainstreaming MHM in schools in South Asia. This summary is accompanied by: • Eight country snapshots that provide a brief overview of the status of MHM in schools in Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan and Sri Lanka. • A synthesis report on the overall status of MHM in schools in South Asia. The analysis is based on an extensive literature review and key informant interviews with MHM practitioners and advocates in each of the eight South Asia Association for Regional Cooperation (SAARC) member countries and working at the regional or global level.

Cover photo: Kishwar, 15, in front of the girl-friendly washroom WaterAid and UK aid helped install at her high school, Muzaffargarh district, Pakistan. WaterAid/Sibtain Haider

2 Menstrual hygiene management in schools in South Asia Summary report

Menstrual hygiene Context Progress South Asia is home to more adolescents – The country snapshots reveal that significant around 340 million – than any other region experience of implementing effective menstrual management in schools (UNICEF, 2016)1 and India has the world’s hygiene and WinS programmes has been highest number of 10- to-24-year-olds with an amassed across most countries in the region. estimated 356 million.2 Around half of these in South Asia adolescents are female. Key components of MHM services At adolescence, differences become in schools more visible and gender inequalities may • MHM-friendly WASH facilities: adequate also take hold, thus “puberty can mark number, in a safe location, age specific, an accelerating trajectory into inequality” gender-segregated, clean, provide privacy (UNFPA).3 with features such as doors and internal “It felt like we are not allowed to do locks, easy access to supply for anything now… When we did not have washing body and clothes, adequate lighting, our , we were allowed to go rubbish bin with lid inside cubicles anywhere but now they say that we must for disposal and associated waste disposal not go anywhere.” Schoolgirl in Nepal.4 chains, handwashing stations with soap and water, and mirrors. Management and Educating adolescent girls brings substantial accountability mechanisms should be in returns including faster economic growth, place to ensure MHM services are provided reduced child marriage, delayed pregnancy, in a sustainable manner. increased -being, fostering democracy and • Accurate, age-appropriate and pragmatic improving women’s political participation.5 information: text books that provide The South Asia region has been at the practical MHM guidance as well as biological forefront of innovation in policy and practice information. Girls report preferring to receive to ensure that water, and hygiene information before , as well as (WASH) services in low and middle-income afterwards. countries (LMIC), including those in schools, • Social support: Girls do not want to pay attention to the needs of menstruating be teased or subject to restrictions and girls and women. Good progress has been taboos while menstruating. Practical and made in the region in improving the availability emotional support is required from peers (e.g. of WASH facilities in schools in recent forums where girls can talk and exchange years and many countries have included experiences), men, boys, teachers and WASH in schools (WinS) standards in their parents. This includes ensuring everyone policy and programming guidelines. For receives information about MHM so they can school sanitation, there was a 21% reported understand what girls are experiencing and increase in coverage from 2008-2013 in can provide support (e.g. resources, guidance, South Asia (UNICEF, 2015).6 Additionally, in patience, etc.) to help break down barriers. 2011, national governments of South Asia • Materials and their effective disposal: committed to The Colombo Declaration from Girls want to use (and dispose of) their SACOSAN, including to: “raise the profile preferred materials for sanitary protection of WASH in schools with the objective of and have the possibility of accessing ensuring that every new and existing school at emergency supplies in school if needed. every educational level has functioning, child- Access to pain relief could also help improve friendly , separate for girls and boys, with concentration in class. facilities for menstrual hygiene management.”7

3 1 Menstrual hygiene management in schools in South Asia Summary report

Enabling environment MHM-friendly WASH facilities An enabling policy and institutional Significant progress has been made on environment is essential for the key ensuring that separate toilets are available for components of MHM services in schools to be girls and boys; indeed, this is now the norm in provided for all girls and sustained. most countries and in some cases there are additional spaces for managing MHM. Several governments have started to integrate good MHM practice into national norms, Although many of these interventions standards or guidelines related to WinS. The have been small-scale, they have served importance of MHM has been acknowledged as demonstration projects for the school in drafts of national technical standards or community and local government. For instance, guidelines related to WinS. India, Pakistan, in Pakistan, WaterAid and its partners have Nepal, and Bangladesh have a large number designed MHM-friendly WASH facilities that of stakeholders engaged in MHM, and their are lockable and gender-separated with at governments have been working to strengthen least one toilet or washroom equipped an MHM into the curriculum and/or their national opening leading to an incinerator or dustbin technical guidelines for WinS. for disposal of MHM materials. There are also handwashing facilities and a supply of The importance of MHM in WinS is recognised sanitary pads in case of emergency. WaterAid in several national education, WASH and has also trained caretakers on operations and sexual and (SRH) maintenance (O&M) and the establishment related policies and strategies. For instance, of O&M funds. MHM is part of the overall in Bangladesh and Pakistan, MHM is a school WASH training package where key component of UNICEF’s Ending Child teachers learn skills for making reusable Marriage project involving pads. In Bangladesh, the Government’s of adolescent girls and boys as well as School Learning Improvement Plan (SLIP) strengthening adolescent clubs for promotion allocates funds to every school to support of MHM. MHM is the focus of several working the construction, rehabilitation and O&M of groups or coordination mechanisms (sectoral school WASH facilities. The Ministry of Primary or cross-sectoral) across the region. Such and Mass Education has agreed to increase collaboration results in improved coordination the SLIP fund in 2018 and have a dedicated and communication on the topic. budget for O&M of school WASH facilities Most education management information in the 4th Primary Education Development systems (EMIS) and national survey data tools Programme. do not yet incorporate MHM indicators except where school toilet data is gender segregated. Accurate, age-appropriate Still, there are some good examples where programmes monitor factors relevant to MHM pragmatic information in project-related assessments and baseline To address the lack of appropriate MHM surveys. WaterAid and their partners in Nepal educational materials, efforts have been made and Pakistan are developing the capacity to improve the capacity and teaching resources and accountability of local stakeholders of teachers who deliver this information in the for monitoring MHM in schools, using tools classroom and to publish more girl-friendly like Community Score Cards so that School materials e.g. in Afghanistan, UNICEF and Management Committees have evidence with the Ministry of Education (MoE) are preparing which to demand funds for MHM-friendly guidelines8 and an interactive booklet, also WinS services. available as an audiobook, for girls about menarche and myths.

4 Menstrual hygiene management in schools in South Asia Summary report

Various other MHM informational materials Materials and their effective have been developed for use in specific WinS disposal programmes. In Bangladesh, a variety of teaching and learning materials as well as Cloth remains most common, particularly innovative outreach approaches have been in rural areas. There are many initiatives to developed, such as school-level awareness promote locally made reusable sanitary pad campaigns and awards for good facilities.9 options, ranging from handmade pads to micro- enterprises producing pads. Brands of sanitary Another approach encourages peer-to- pads are widely available across the region peer MHM learning by supporting existing but in many places the supply chain is weak. girls’ groups to focus on menstrual hygiene Menstrual cups and other absorbents that are education. In Southern India, these groups inserted into the vagina, such as , are are supported by a focal teacher or community not widely used. health worker. Additionally, several non- governmental organisations (NGOs) have been In Pakistan, to improve pad disposal, the supporting the training of teachers or the direct Department of Education is preparing teaching of MHM as an extracurricular activity. standards for waste management in schools, including MHM waste disposal, to avoid pads Technology has helped accelerate outreach. In being disposed of in latrines, which can cause Pakistan, girls with mobile phones have been blockages; a particular problem in the context targeted with SMS-based polls and livechats of poor O&M of school WASH facilities.11 on MHM.10 In India, innovative online content (e.g. WaterAid’s #noshame in menstruation Other recent disposal innovations include Thunderclap and animation, and Menstrupedia) disposal pits connected to the toilet and Procter and Gamble’s “Touch the Pickle” superstructure with a chute (Bangladesh), campaign for sanitary protection has also had although the efficacy of this approach is wide reach among girls with internet access. yet to be assessed. Other countries (such as Bhutan) have menstrual pits for burying Social support sanitary waste. Used materials may also be disposed of in the solid waste systems, School management, teachers, other staff and although many schools in the region (including parents are increasingly aware of the MHM Sri Lanka and the Maldives) lack an effective needs of girls and female school staff. School- waste disposal service. based health and nutrition services or school- based counselling services support girls to get advice on menstruation, request pain killers Gaps and challenges or a sanitary pad or cloth, underwear or find a Despite significant progress, critical gaps space to rest. Several MHM champions exist remain. across the region (including sports stars) and have also clearly contributed to the progress. Many countries in South Asia have been Enabling environment proactive in promoting Government engagement and leadership each May, particularly India, Nepal, Bhutan, at national level for MHM varies across the Pakistan, Afghanistan and Bangladesh. region. There are a number of activities at early stages, at small or pilot scale, rather than a comprehensive response. The enabling environment also includes national monitoring of MHM in schools. Few countries monitor MHM in national monitoring systems. Projects and programmes monitor and evaluate MHM 5 Menstrual hygiene management in schools in South Asia Summary report

in WinS through knowledge, attitudes and Accurate, age-appropriate, practice (KAP) or baseline surveys. There pragmatic information are currently no multi-stakeholder platforms on MHM in Afghanistan, the Maldives or A wide range of myths, taboos, norms and Sri Lanka. traditional beliefs and practices around menstruation persist across South Asia, Hard-to-reach women and girls face multiple affecting girls’ and women’s ability to manage challenges to effectively address their MHM their periods. In many countries, there needs in schools including those marginalised are restrictions on girls’ activities during by geography, caste or ethnicity, disability, menstruation – particularly related to religious disasters and the ultra-poor. activity, food and social participation. Several organisations are working to address Integrating topics relevant to MHM into some of these challenges, for example: the school curriculum remains a challenge, WSSCC and the Ministry of City Planning alongside teachers’ confidence and willingness and are developing an MHM to teach the subject. Often the national training tool kit for visually impaired people in curriculum includes MHM for secondary Sri Lanka; The London School of Hygiene pupils, but for many girls this comes after and Tropical Medicine and WaterAid are menarche. The curriculum usually only researching the barriers faced by adolescent covers physiological processes relating to girls with disabilities relating to MHM in menstruation rather than emotional and Nepal; WaterAid is demonstrating accessibility practical aspects of MHM or sexual and audits and appropriate standards in Nepal reproductive health. Teaching and learning e.g. adapting toilets for wheelchair users; the materials and MHM in the curriculum could be MoE in Bhutan aims to ensure accessible further developed. Where teachers do not play WASH facilities in schools are available and a direct role in hygiene and , has published Guidelines for Differently Abled some government programmes mandate health Friendly Construction. However, girls with assistants to play this role. These programmes special needs may be forced to stay at home have witnessed limited roll-out and success during menstruation as schools do not have due to the existing heavy workloads of health the staff or facilities available to support them. staff (e.g. India, the Maldives).

MHM-friendly WASH facilities Social support Effective O&M of school WASH facilities Women can play a role in challenging remains a major challenge. Where facilities restrictions and practices that limit girls’ ability exist, they may not be MHM-friendly – i.e. to stay in school after menarche. However, lockable doors, access to water, showering without the right information, older women can or changing option, lighting and a bin with lid perpetuate cultural and religious taboos around inside cubicles. menstruation. There is a clear need to build In some countries, WinS is allocated a specific the capacity of parents and other relatives as government budget line, in others O&M is well as the wider school community to ensure chronically under-funded. O&M is typically that MHM in schools has traction and that perceived to relate only to the physical efforts are sustainable. In India, WaterAid and infrastructure for WinS facilities. In fact, some Vatsalya proactively engaged boys and men of the greatest MHM challenges relate to the who then provided support for MHM in their lack of systems and supply chains for hygiene roles as peers, fathers, teachers, sanitation ‘software’, such as keeping facilities clean and masons, school management and district level the low availability of consumables such as leaders. soap, water and emergency sanitary materials. 6 Menstrual hygiene management in schools in South Asia Summary report

Materials and their Opportunities effective disposal Cross-sectoral integration and Widespread adoption rates of disposable coordination: Regionally, the discourse sanitary pads are mixed due to the ongoing is moving away from menstrual hygiene to costs and the lack of disposal options in consider menstrual health more broadly, schools. In several countries, efforts have been requiring better cross-sector collaboration, made to develop and manufacture lower- particularly between WASH, health cost products. Unfortunately, these are often and education sectors to build national regarded as less effective than international/ convergence. Better engagement with the national brands, as materials are reportedly health sector, for example, could help WASH lower quality and insufficiently absorptive. actors consider pain management which is Locally made reusable sanitary pad options are often needed to help girls stay in class. Several also being promoted, although manufacture is countries have already established national time consuming and effectiveness depends on coordination mechanisms for MHM actors to the materials available. identify national priorities; momentum requires resources, clear roles and responsibilities, and In some South Asian countries, reusable pads political will to be maintained. and cloths are not hygienically dried in the sun, but hidden in drawers or the rafters of roofs, Materials and supply chains: There are due to embarrassment or socio-cultural beliefs increasing opportunities to facilitate the supply about menstrual blood. of sanitary products, either with international companies or smaller scale private sector Disposal options for used sanitary materials enterprises. Many countries are improving remains an underdeveloped aspect of most the reach and quality of MH products by MHM services.12 Until recently, school strengthening the whole supply chain. incinerators were viewed as an appropriate Disposal of used products requires further solution in much of the region. However, these innovation. Partnering with the private sector tend to be operated infrequently by caretakers offers opportunities for improving access and have high maintenance costs. Furthermore, to commercial sanitary products that meet the environmental impacts of incinerators as a quality standards, as well as disseminating long-term solution are not well understood.13 good practice on MHM to girls and women. In KAP surveys, girls reveal they often prefer For example, Procter and Gamble’s sanitary to take the used pads home for disposal protection brands have developed a puberty There is a lack of information about which and confidence-building education programme materials are easier to destroy, compost or that is delivered free of charge in the countries recycle. As more girls of reproductive age have in which they operate. Wider engagement with access to disposable pads, dealing with higher the private sector may accelerate progress, quantities of menstrual waste will require including linking with waste management attention and pragmatic solutions in WinS service providers and encouraging social programmes and waste management systems. responsibility among commercial pad suppliers around disposal. A long-term view is needed across the entire service chain for MH materials supply and disposal, with the identification of context- specific solutions in consultation with girls.

7 Menstrual hygiene management in schools in South Asia Summary report

Quality programme design and monitoring: Equity: Efforts aimed at leaving ‘no one behind’ Despite progress at the policy and advocacy are underway, including better accessibility level, in many countries programmes remain and safety of school facilities including for at pilot level with little evidence of scalable girls with disabilities; however, this remains a design. More attention is needed in refining gap. Community-based outreach programmes, and testing pilots and assessing the potential alongside the focus on MHM in schools, to scale up, as well as a better understanding could be scaled to reach out-of-school girls. of programme costs and outcomes to Reaching girls in remote or inaccessible determine what programme elements regions that lie beyond normal supply chains can work best at scale. Different ways of requires more attention. measuring outcomes of MHM programmes are also required including how to measure stress and self-efficacy. Several initiatives are References underway to demonstrate how the collection 1 of MHM data could be improved. Monitoring Extracted from https://data.unicef.org/topic/adolescents/ adolescent-demographics/ for the Sustainable Development Goals 2 The Power of 1.8 Billion: Adolescents, Youth and the (SDGs) offers an opportunity to get an MHM Transformation of the Future ASIA, UNFPA, 2014. indicator in national EMIS, facilitating progress 3 http://www.unfpa.org/press/unleash-power-adolescent- measurement and reporting, and incentivising girls-sdg-generation-propel-progress-people-planet-says- action. unfpa 4 Quoted in: Menstrual hygiene management in Udaypur and Information and communication Sindhuli districts of Nepal, Morrison, J. et al, WaterAid/HERD, platforms: Efforts to ensure MHM is 2016. 5 Herz, B. & Sperling, G. B. (2004) What Works in Girls’ included comprehensively in the curriculum Education Evidence and Policies from the Developing World, are underway in several countries and could Council on Foreign Relations, Giving Women Economic be replicated. This is supported by efforts to Opportunity: Initiatives, The World Bank, New improve the quality and availability of age- Lessons: The power of education adolescent girls, Population Council (2009). appropriate, replicable and user-friendly 6 Advancing WASH in Schools Monitoring, UNICEF 2015. information and education materials on MHM 7 https://www.unicef.org/srilanka/Colombo_declaration_(4_ (including visual and other tools for differently- pages).pdf abled or less literate girls) and teacher training. 8 Menstruation Matters: Guideline on Menstrual Hygiene MHM actors are also beginning to emphasise Management for Teachers in Afghanistan (UNICEF, 2017) girls’ voices to challenge social norms around which will be available in Dari and Pashto languages. 9 WaterAid Bangladesh and Shorno Kishoree Network menstruation (for instance in the We the Future Foundation. platform, Twitter and Facebook) and demand 10 On MH Day 2017 in Pakistan, U-Report (a social messaging accountability from duty bearers for better tool) was used to answer MH questions and UNICEF hosted facilities in schools. a three-hour live chat through the platform targeting all 25,000 registered U-Reporters. Over 2,500 questions were received from girls and boys across the country via free SMS messages. 11 WASH United and UNICEF, 2017. 12 WASH United and UNICEF, 2017. 13 FSG, 2016.

This material has been funded by UK aid from the Department for International Development (DFID). However, the views expressed do not necessarily reflect the Department’s official policies.

8