An Opportunity To Address Menstrual Health and Gender Equity

An Opportunity
to Address
Menstrual Health and
Gender Equity
About FSG
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CONTENTS
2 Executive Summary
4 Report Contents
4 Methodology
5 Overview
5 An Unexplored Problem
6 The Journey through Adolescence
10 Menstrual Health and Links to Life Outcomes
14 Defining the Problem

14 Role of Community and Influencers
15 Girls’ Experiences with Menstrual Health
22 Summary
23 A Siloed Response
23 Landscape of Actors
25 Current State of Menstrual Health Interventions
35 Conclusion
36 Opportunities
38 Closing Thought
39 References
AN OPPORTUNITY TO ADDRESS MENSTRUAL HEALTH | 1

EXECUTIVE SUMMARY
Menstruation is a monthly challenge for billions of women and girls worldwide. On

any given day, more than 800 million girls and women between the ages of 15 and 49 are
menstruating.1 A study in South Asia found that 33% of girls in school had never heard of
menstruation prior to experiencing menarche, and 98% of girls were unaware that menstrual
blood came from the uterus.2 It is estimated that more than half of women and girls in low-
and middle-income countries (LMICs) use homemade materials as their primary or secondary
method for managing their periods.3 In Ethiopia, research showed that 25% of girls do not
use any commercial products to manage their menstrual flow and isolate themselves during
menstruation.4
Challenges with menstruation go beyond practical management to issues that affect the girl
and her role in the community. Menarche, the onset of menstruation, often signifies an abrupt
change for girls as they transition from childhood to adulthood. After menarche, expectations
about sexual purity and social submissiveness emerge for young girls,5 while boys undergo-
ing puberty face new pressures to demonstrate their virility and manhood through sexual
conquests.6 Menstrual health is an encompassing term that includes both menstrual hygiene
management (MHM) as well as the broader systemic factors that link menstruation with health,
well-being, gender, education, equity, empowerment, and rights.7
The analysis of the evidence and response to menstrual health challenges reveal:
STATE OF THE EVIDENCE

• Qualitative research studies emphasize that girls experience shame, embarrassment, and dis-
comfort during menstruation because they lack access to affordable and preferred products,
private and safe facilities, and education about menstruation and how to manage it.
• Evidence about the impact of poor menstrual health on other health, development, and
empowerment outcomes is scant, not statistically significant, and largely inconclusive,
suggesting a need to invest in targeted research to mobilize targeted players in the field.
Specifically, evidence on the relative importance of MHM to school absenteeism is mixed
2 | FSG
and varies significantly across geographies.8,9,10,11,12,13,14
THE FIELD’S RESPONSE

• Momentum from donors, governments, and other private players has increased to address
problems related to menstrual health, but the focus to date has largely been on “hardware”
(e.g., products and facilities).
• Players tackling issues related to menstrual health are also disparate and isolated in their
approaches to reaching girls and their influencers. Despite the link between menstruation
and reproductive health, the sexual reproductive health sector has paid limited attention to
the issues related to menstruation until recently.
• Efforts to date to address girls’ menstrual health have largely focused on physically able and
in-school girls.
• Few governments, corporations, or NGOs are looking at menstrual health as a systemic

problem, and thus, they are missing the opportunity to address the problems sustainably
and at scale. Rigorous evaluations of menstrual health programming to understand what
works and is replicable at scale have been limited.
PROGRAMMING AND POLICY INNOVATIONS

• Few market-based solutions provide affordable, high-quality MHM products to low-income
consumers in LMICs.
• Despite the emphasis on sanitation infrastructure, menstrual waste collection and disposal
needs greater attention, as it is an under-prioritized area in most user-centric sanitation
programming.
• Puberty programs and curricula largely target girls and often neglect to include their influ-
encers.
• Although there are some powerful positive examples, national governments have lacked
ownership of menstrual health, limiting opportunities for coordinated responses to men-
strual health challenges.
Girls’ experience with menstruation is inextricably linked to a broader set of changes affecting
girls during puberty. The field needs to explore how menstruation can serve as an opportu-
nity to access girls at a critical transition point in their lives. Because stakeholders have finite
resources available to address issues facing adolescents, understanding the links between men-
strual health and a broader set of norms can help to identify whether there is an opportunity to
influence a cross-cutting set of outcomes and set girls on a longer-term path to success.

Report Contents
An Opportunity to Address Menstrual Health and Gender Equity covers 1) the state of the
evidence linking menstrual health to outcomes; 2) a brief landscape of the problem and the
menstrual health sector, including areas of progress and existing gaps; and 3) conclusions and
perspectives on opportunities for the field.
Methodology
This report is prepared with support from the Bill & Melinda Gates Foundation (Foundation). It
provides an assessment of the menstrual health sector and identifies opportunities for the field
to improve girls’ dignity and empowerment.i This analysis is the result of a review of over 150
peer-reviewed articles and grey literature, interviews with 37 global experts, 70-plus interviews
with experts and practitioners in India, Kenya, and Ethiopia, and a review of relevant program-
ming focused on menstruation, MHM, and sexual reproductive health. The research focused
on sub-Saharan Africa and Asia, priority areas for the Foundation, and was complemented by
a sampling of research from developed countries and emerging economies (e.g., the United
States, Germany, and China). The research focuses on girls’ journeys through adolescence
between ages 10 and 19.
The research also includes an in-depth assessment of the state of menstrual health in India,
Kenya, and Ethiopia driven by an extensive literature review and set of conversations with
experts and practitioners. The report intends to provide an overview of the current landscape
and outline programmatic, policy, and advocacy approaches that could address menstrual
health needs. This assessment included 126 interviews with adolescent girls in the following
categories: (1) early post-menarche (0 to 1 year after menarche); (2) post-menarche (1 to 3
years after menarche); and (3) late post-menarche (3-plus years after menarche up to 18 years
old). Interviews were also conducted with 55 influencers including mothers, sisters, teachers,
and community health care workers. The interviews with adolescent girls and influencers were
led and conducted by Routes 2 Results and their in-country partners in India (Rajiv and Anju
Bala Bhatia, founders of Fact-Indepth), Kenya (Carolyne Muthoni Njihia, founder of Measure
Associates), and Ethiopia (Feven Busa, qualitative research expert, and Efera Busa, research
director, at Waas International).
i Empowerment is the process by which a girl expands her current and future ability to make and act on strategic life choices. Empow-
erment outcomes can include agency, social support, decision-making control, and security.
4 | FSG
OVERVIEW
An Unexplored Problem
Approximately 52% of the female population (26% of the global population) is of reproductive
age, and most of these women and girls menstruate each month.15 However, both communi-
ties and systems players have largely overlooked menstrual health. This report uses the term
“menstrual health” to encompass menstrual hygiene managementii (MHM) as well as the
broader systemic factors that link menstruation with health, well-being, gender, education,
equity, empowerment, and rights.16
On any given day, more than 800 million girls and women between the ages of 15 and
49 are menstruating,17 and hundreds of millions of girls continue to face barriers to
comfortable and dignified menstrual health. A study in South Asia found that 33% of girls
in school had never heard of menstruation prior to experiencing menarche, and 98% of girls
were unaware that menstrual blood came from the uterus.18 Estimates suggest that more than
half of women and girls in low- and middle-income countries (LMICs) use homemade alterna-
tives as their primary or secondary method for managing their periods.19 In Ethiopia, research
showed that 25% of girls do not use any MHM products to manage their menstrual blood and
isolate themselves during menstruation.20 A report by the United Nations Children’s Emergency
Fund found that more than half the schools in low-income countries lack sufficient latrines for
girls and female teachers.21
The field is just beginning to understand the complex sociobiological dynamics at

puberty and how these can set girls on a path to healthy development. Efforts to
improve menstrual health have garnered increased interest from funders and practitioners as
many look to understand whether focusing on menstrual health can provide a window into
puberty and early adolescence and offer an opportunity to influence a broader set of outcomes.
ii Menstrual hygiene management refers to the use of hygienic material to absorb or collect menstrual blood, access to private spaces
to change these materials as frequently as needed, use of soap and water to bathe and clean MHM products, and access to safe dis-
posal options. (“WASH in Schools Empowers Girls’ Education: Proceedings of the Menstrual Hygiene Management in Schools Virtual
Conference 2012.” IRC. UNICEF. Web. 7 Oct. 2015.)

FIGURE 1: MENSTRUAL HEALTH AROUND THE WORLD
On Pages 8-9 are a selection of stories from girls in India, Ethiopia, and Kenya that provide
insight into the diversity of experiences across geographies.
The Journey through Adolescence

During the journey through adolescence, many girls experience both challenges with
the monthly management of menstruation as well as more fundamental shifts that
start around menarche. Menarche, the onset of menstruation, often signifies an abrupt
change for girls as they transition from childhood to adulthood. After menarche, expectations
about sexual purity and social submissiveness emerge for young girls,22 while boys undergoing
puberty face new pressures to demonstrate their virility and manhood through sexual con-
quests.23 These gendered social norms represent early adolescents’ perceptions of masculinity
and femininity in their community.24 Lack of guidance on how to traverse the pressures of
puberty can leave girls and boys vulnerable to negative outcomes in many facets of their health
and development.25
Figure 2 shows the journey of an archetypal 14-year-old Ethiopian girl.
Challenges with menstrual health, and MHM specifically, may be a symptom of these
more fundamental changes and discriminatory social norms that girls face during
puberty. Growing evidence shows that the expression of discriminatory social norms becomes
6 | FSG
more pronounced during puberty and can undermine efforts to achieve multiple health and
development outcomes. Gender discrimination during adolescence can take the form of
unequal chore burdens and caretaking responsibilities; exclusion from education, employment,
and decision making; child marriage; limitations on reproductive control; and violence, sexual
abuse, and exploitation.26 Research also shows the importance of mental health: girls are one
and a half to two times more likely to be diagnosed with depressive disorders after the onset of
puberty.27
“Before puberty, I used to go wherever I wished—near and far places without fear and also
alone. But after puberty, my movement has been restricted by all means, I need (to) spend
more time at home and whenever I go out, which is allowed for very specific reasons only,
somebody is required to accompany me at all times!” Adolescent Girl, 14 years old, Coim-
batore, Tamil Nadu, India
FIGURE 2: A GIRL'S JOURNEY

STORIES FROM THE FIELD—A GLIMPSE INTO GIRLS’ EXPERIENCES
Pinky Kaveri
Pinky, 14 years old, lives with her parents and Kaveri, 12 years old, lives in rural Coimbatore, Tamil
younger brothers in a katcha near a village in
iii
Nadu, India, and is aware that menstruation is linked
Kanpur, Uttar Pradesh, India. Every morning, she to a woman’s ability to have children—she learned
wakes up at 4 am and helps her mother fill water that in her school’s biology class. She asks her father
from the village pump, cook, and clean before she to buy sanitary pads from the market every month.
goes to school. Like her mother, Pinky uses cloth Even if she does not have a pad, she is not worried.
to manage her menstruation. She disposes of her Her school provides her with free pads supplied by
used menstrual cloth in the field, where she goes to the state government, and her school’s toilets have
defecate, and then walks back home to wash and an incinerator to dispose of them. Although she
clean herself. Following her mother’s advice, Pinky dislikes the free pads because of their poor qual-
stays at home on the days she is menstruating, but ity, she knows they are useful in an emergency.
her mother tells her brother and her father that she She plays volleyball in school even when she has
is unwell or has fever. her period. “Why shouldn’t I?” she asks. That said,
Kaveri does face isolation at home during menstrua-
tion; her grandmother asks her to sleep separately.
She says, “Yes, sometimes I feel like I am in a jail,
but other times I am happy that I have to do less
house chores.”
iii Houses made from mud, thatch, or other low-quality materials are called
katcha houses.
8 | FSG
Triza Adina
Triza, 14 years old, lives in Kawangware, a slum Adina, 17 years old, lives in rural Debre-Birhan,
located in the western part of Nairobi County, Ethiopia. When Adina reached menarche two years
Kenya. She attends school in Kawangware, where ago, she knew what it was but was still shocked.
she also lives with three siblings and parents in a She did not want her brother to see that she had
one-bedroom house. She shares a bed with her stained her clothes, and she felt isolated. Adina
sister, and the family shares an outdoor toilet facil- asked her mother how to manage her period. Her
ity. She generally feels safe using the toilet, except mother taught her how to use a pad and told her
at night when she sometimes feels scared to. The how different her experience had been—when she
school environment and structures are not very got her period, she had no idea what was happen-
conducive to learning; sometimes the classrooms ing and she was married shortly thereafter. Adina
are very cold, and the teachers are not well trained. has access to free pads at school. They are provided
There is no access to running water, and students by an NGO, and while the quality is not great, it is
like Triza are required to either fetch water from better than the alternative—using rags or nothing
the nearby river or carry a 5-liter container of water at all. The school does have bathrooms, but Adina
to flush the toilet after use. Triza does not enjoy avoids using them if she can because they are very
the company of the boys at her school; sometimes dirty and there is no running water or waste bins to
they play bad jokes, like pressing the girls against dispose of used pads. Adina and her mother both
the door, or trying to hold their hands. At school, view education as important and aspire for Adina to
girls are provided with pads if their period starts in get married after completing her bachelor’s degree.
school, and they also receive permission to go home
and take a bath if they have stained their dress.
However, she is not scared of her period, and she
continues to go about her daily activities as normal.

Adolescents with special or underrepresented needs are disproportionately affected
by poor menstrual health. More than 90% of children with disabilities in developing coun-
tries do not attend schools.28 Currently in India, 74% of adolescent girls with disabilities and
41% of adolescent girls are permanently not going to school. Among those who do go to
school, 20% of adolescent girls and 35% of adolescent girls with disabilities do not attend
school during menstruation.29 Though this report’s analyses center on the needs of adolescent
girls and to some extent women, it is critical that investments in research and interventions
related to menstrual health encompass all people who menstruate, including trans men and
individuals who do not identify along gender binaries.30,31
With little known about girls aged 10 to 14, trends, behavioral drivers, and associa-
tions are currently difficult to identify. Current survey tools often do not include very young
adolescents (ages 10–14) in their sampling populations, hindering our understanding of this
critical period when puberty tends to occur. Menstrual health expert Marni Sommer described
menarche measures as “a missing (set of) indicator(s) in population health from low-income
countries,” highlighting the dearth of current evidence on this key experience in young girls’
lives.32 There is a small but growing call among public health researchers and practitioners
to begin including menarche and other puberty indicators in major health and development
surveys as a way to track long-term impact and inform more strategic approaches to improving
girls’ outcomes.33
Menstrual Health and Links to Life Outcomes

Evidence about the impact of poor menstrual health on other health, development,
and empowerment outcomes is scant, not statistically significant, and largely incon-
clusive. Many studies focused on menstrual health have small sample sizes and overly rely on
qualitative, self-reported, or anecdotal data to assess impact. Some outcome categories, such
as education, have garnered more attention and research from the field in recent years. For
instance, evidence on school absenteeism is mixed and varies across geographies,34,35,36,37,38,39,40
and while there are some anecdotal reports of negative impact on school performance and
concentration, the topic has not been rigorously researched to date.41,42,43 Even less focus
has centered on girls’ and women’s health outcomes stemming from poor menstrual health,
particularly sexual and reproductive health impacts. Evidence on links between menstrual health
and empowerment is, however, strong and supported by extensive qualitative research and
anecdotal reports.
Improved evidence on menstrual health can support the field to advocate and mobilize fund-
ing for menstrual health. Priority areas for investment include improved understanding of the
links between menstrual health and a set of cross-cutting life outcomes and evaluating the
10 | FSG
effectiveness of different interventions and approaches. The research agenda for menstrual
health should be linked closely to the audience and use of the evidence base to further the field
and improve outcomes for women and girls. Table 1 on Pages 12-13 includes a review and an
assessment of the state of the evidence and defines where evidence is weak and where evi-
dence has not yet been collected.

12
TABLE 1: ASSESSMENT OF EVIDENCE ON OUTCOMES LINKED TO MENSTRUAL HEALTH
STATE OF THE EVIDENCE DEFINITION
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Evidence strong Existing evidence of high rigor conclusively documents the causal link between menstrual health and outcomes of interest.
Evidence mixed Existing evidence base offers inconclusive results on the causal link between menarche, menstruation, and MHM and outcomes of interest. This
designation applies when some studies find there is a causal link and others find conflicting results.
Evidence weak Existing evidence does not support a direct causal link between menstrual health and outcomes of interest.
Evidence lacking Insufficient evidence has been gathered.
MENSTRUAL HEALTH
DOMAIN OVERVIEW OF EVIDENCE TO DATE QUALITY AND LIMITATIONS OF EXISTING EVIDENCE
IS ASSOCIATED WITH
Economic • Increased work Evidence lacking • Limited cross-sectional or anecdotal evidence44

absenteeism for • MHM is an overlooked topic in research as focus has been
women on girls
Education • Increased school Evidence mixed • Some quantitative studies, but inconsistent methodologies
absenteeism • Evidence on MHM and school absenteeism is mixed and prevent the measurement of absenteeism and performance in
varies across geographies45,46,47,48,49,50,51 a standardized and comparable way
• School dropout
• Some anecdotal reports of negative impact of MHM on • Numerous structural barriers (e.g., incomplete school
• Reduced school
school performance and concentration, but not well registers, lack of school fees) undermine causal research
performance
researched to date52,53,54
• Possible over-attribution of absenteeism to menstruation/
• Deprioritization of
Evidence lacking MHM; more accurate assessment of attribution vs.
girls’ education
• Earlier experience of menarche is associated with lower contribution is needed56,57
• Poor transition to schooling levels55
secondary school
Empowerment • Lack of dignity and Evidence strong • Primarily anecdotal and self-reported incidences of
confidence • Overwhelming anecdotal data signifying extreme impact disempowerment
on girls’ dignity, but no core empowerment measures to
• Lack of agency • Field is unclear how to quantitatively measure
date58,59,60,61
empowerment
• Restricted mobility
• Widespread anecdotal reports of restrictions placed upon girls
• Cross-sectional and retrospective analysis limits
at menarche62,63
longitudinal understanding
• Anecdotal link between menarche and changing societal
expectations for girls at puberty (e.g., symbol of fertility,
sexual readiness, and marriage eligibility)64
Environment • Negative Evidence mixed • Alleviating the environmental impact of disposed hygiene
environmental and • Negative impact is documented: approximately 20 billion products is a secondary research priority compared to
health impacts from disposable menstrual products accumulate in American improving MHM and access to products
improper disposal of landfills annually, taking an estimated 500 to 800 years to
• Numerous other potentially harmful materials in broader
used MHM material fully break down65,66
environment (e.g., other plastics) make isolation of causal
waste
• Environmental health impacts of used MHM materials in pathway difficult in understanding the detrimental health
landfills is hypothesized, but not well researched or environmental impacts of inadequately disposed MHM
products
Health • Increased incidence Evidence weak / Evidence lacking • Qualitative reports of mental distress but limited
of reproductive tract • Noted correlation between poor MHM and increased quantitative evidence
infections (RTIs), incidence of RTIs, but route of infection is unknown and
• Limited longitudinal research hinders ability to understand
including bacterial could be due to multiple risk factors67
long-term impact on sexual and reproductive health outcomes
vaginosis
• Hypothesized link between RTIs due to poor MHM and (e.g., early pregnancy complications, RTIs, and HIV/STI
• Experience of increased vulnerability to STIs and HIV is not supported by infection)
dysmenorrhea current evidence68
• Increased risk of STIs • Anecdotal reports of mental distress from unsupportive MHM
and HIV infection environments69
• Sexual debut • Dysmenorrhea is a commonly cited menstruation-related
health complication for adolescents, but inconsistent and
• Nutritional status
poorly understood impact on other health and development
• Hormonal and outcomes70
biological changes
Evidence lacking
• Sexual risk-taking • Limited longitudinal research restricts understanding of
behavior long-term implications of menarche and MHM on sexual and
reproductive health decision-making
• Gender-based
violence • Increased fertility pressure or associated marriageability at
menarche could hold implications for sexual debut, early
marriage, and early pregnancy, but is not well documented71
• Affirmation of gendered expectations and cultural tolerance
of gender-based violence can increase risk of sexual assault or
exploitation for pubertal girls72
• Timing of menarche can be used as a proxy for population
nutritional status, but this indicator is not being captured to
date73
Mental Health • Depression Evidence lacking • Limited cross-sectional or anecdotal evidence
• Suicide is now the leading cause of death among adolescent
girls ages 15–1974
• Anecdotal reports show that new pressures and expectations
at menarche can cause mental distress, particularly for girls
who experience early pubertal onset75,76
• Increased risk of depressive disorders associated with
exploitative gender norms enacted at the onset of puberty77
AN OPPORTUNITY TO ADDRESS MENSTRUAL HEALTH |

13
DEFINING THE PROBLEM
Role of Community and Influencers

Critical members of the community often influence and reinforce girls’ knowledge,
attitudes, and behaviors. Girls’ reference networks—people that matter to girls’ choices
(e.g., parents, siblings, peers, teachers, and community leaders)78—vary but are critical to sup-
port them as they reach menarche and learn to manage menstruation. Community members
perpetuate taboos and misconceptions about menstruation that can lead to further isolation of
girls during and around menstruation. Research suggests that a girl’s experience with men-
struation is affected by the degree of agency her mother has within her personal life. These
intergenerational effects cause girls to lead similar lives and have similar levels of opportunity
to their mother, which in turn influences practices and perceptions related to menstruation.79 In
households marked by strict or traditional gender norms, mothers may have a limited voice and
lack decision-making control, thereby reinforcing gender normative behavior in their daughters
and sons.80 Thus, engaging influencers is critical not just for shifting short-term outcomes, but
also to ensure sustained impact.
FIGURE 3: MENARCHE AND SOCIAL NORMS
14 | FSG
Communities with higher rates of poverty and increasing levels of isolation correlate
with stymied empowerment among girls compared to communities with increased
access to information and resources.81 For example, girls in rural or conservative communi-
ties may lack female models that challenge traditional gender roles in the household or
workplace and may have less exposure to mass media messaging or lack Internet access. In
such settings, the opinions of key influencers, such as religious leaders, may hold more weight
and enact more rigid, gendered expectations compared to communities with more exposure to
alternative perspectives and experiences. In particular, Internet access can introduce girls to less
traditional manifestations of gendered behaviors and challenge ingrained norms by offering
alternative role models for women. Women and girls who are devalued in their local communi-
ties may benefit from support, validation, or the opportunity for self-expression that the
Internet can offer, empowering them in their daily lives.82
FIGURE 4: MENSTRUAL HEALTH FRAMEWORK
Girls’ Experiences with Menstrual Health

Girls’ menstrual health needs include safe and consistent access to products and infra-
structure, supportive community knowledge, attitudes, and practice; education and
awareness; and sanitation facilities and services (see Figure 4). Qualitative research studies
emphasize that girls experience shame, embarrassment, and discomfort during menstruation
due to the lack of access to affordable and preferred products, private and safe facilities, and
education about menstruation and how to manage it.

The section below provides an overview of challenges and opportunities for improved men-
strual health based on girls’ experiences with menstruation.
PUBERTY EDUCATION AND AWARENESS

Girls’ knowledge and understanding of menstrual health is important to
ensure their well-being and healthy transition into adulthood. In many
parts of the world, girls do not know what menstruation is prior
to experiencing menarche. In Ethiopia, 49% of girls report having no knowledge of men-
struation before their first period.83 Similarly, 32.5% of girls in South Asia,84 51% of girls in
Afghanistan,85 and 82% of girls in Malawi had no knowledge of menstruation pre-menarche.86
Girls in LMIC lack consistent access to high-quality menstrual health education and
awareness. In Pakistan, 92% of girls and women reported needing more information about
menstrual hygiene,87 and 67% of respondents in Ethiopia stated there is no menstrual health-
related education given in schools.88 Common challenges include the lack of formal puberty
education in school, receiving it too late (post-menarche), and the lack of a safe place or men-
tor to ask questions about their body throughout puberty.
Boys also do not receive menstrual health education. Girls are often separated from boys
for targeted education sessions on menstruation and trainings on product usage. Less than
10% of boys in Ghana, for example, indicated that they were very confident talking about
MHM.89
Girls lack safe spaces or access to mentors to ask questions about puberty, menstrua-
tion, or MHM in an ongoing capacity. Only 3% of girls in Nepal listed teachers as someone
they feel comfortable talking to about menstruation,90 and less than 25% of schoolgirls in
Ghana indicated they were very confident talking about menstruation.91
Research also shows that parents often do not feel comfortable discussing puberty,
menstruation, or MHM. A survey by MSI found that 1 in 6 parents has not discussed sex edu-
cation with their children, and 1 in 20 says they have no intention of broaching the subject.92
A study in Kenya found that only 12% of girls would be comfortable receiving the information
from their mother.93
Finally, mass media messages also perpetuate taboos and misconceptions about men-
struation. Community expectations regarding the need to hide and conceal menstruation are
reflected in mass media campaigns. In Egypt, 92.2% of the girls accessed menstrual informa-
tion primarily from mass media.94 Studies show that mass media has one of the greatest effects
on adolescent’s self-conception.95
16 | FSG
MHM PRODUCTS
In LMICs, girls currently lack access to safe and quality MHM products and
materials as well as the agency and resources to acquire them. Girls and
their influencers also need improved awareness of safe hygiene practices
for using those products. To understand the current state of access and use, the section below
provides a brief market overview of MHM products and materials.
Market Overview
The availability and use of MHM products vary widely across the world. Data sug-
gests that over 75%96 of women and girls in high to upper middle-income countries
use commercial products, and over 50%97 of women and girls in LMICs use homemade
products. Figure 5 shows a breakdown of use.
Homemade alternatives are sometimes stigmatized by experts as unhygienic,98 and some com-
munities view homemade materials as dirty alternatives to commercial products.99,iv
FIGURE 5: MHM PRODUCT USAGE BREAKDOWN
iv It is important to note that commercial MHM products can also be used unhygienically.

FIGURE 6: HOMEMADE MHM PRODUCT USAGE100,101,102,103
Factors including lack of knowledge, poor infrastructure, and presence of discriminatory social
norms can cause girls not to use homemade alternatives hygienically. Early research sug-
gests the use of homemade products can pose risks to girls’ health, development,
and empowerment outcomes. However, when used hygienically, homemade products
provide benefits to users including:
• Availability: Made from readily available materials (e.g., straw, rags, pieces of cloth), these
homemade alternatives are consistently available to women and girls.104,105
• Affordability: Homemade alternatives cost significantly less than commercial

products.106
• Cultural acceptability: Homemade alternatives can be more culturally acceptable than

some commercial product options.107,108
Disposable sanitary pads dominate the Western market and are the most purchased
MHM product worldwide. In 2015, sanitary pads accounted for 77% of commercial MHM
product purchases worldwide.109 Three multi-national players control the market—P&G,
Kimberly-Clark, and Johnson & Johnson—and P&G leads with 30% of the market. Disposable
pads make up over 90% of sales in India and the continent of Africa; however, overall
market penetration remains limited. It is estimated that only 10–11% of women and girls in
India use disposable pads. Commercial disposable insertables are widely used in specific
markets. For example, over 70% of the women and girls in Germany use tampons.110
Small-scale studies in Kenya, Uganda, the United States, and India have found that
women and girls strongly preferred commercial products (e.g., disposable sanitary
18 | FSG
pads).111 A study in Uganda asked girls what they would give up last if faced with a sudden
financial emergency, and girls ranked commercial pads as a priority item.112,v Table 2 provides a
summary of MHM products and related market trends. Various supply- and demand-side con-
straints explain the limited sales and use of commercial MHM products in LMICs. The section
below provides a summary of key constraints.
Demand-Side Constraints
Women and girls are unfamiliar with the spectrum of products available and do not
have accurate knowledge about how to appropriately use commercial or homemade
alternatives. In Afghanistan, 80% of girls use water but no soap when changing menstrual
pads, and 69% wash and dry their menstrual cloth in a corner or shadow.113 In a random
sample across three districts in Uttar Pradesh in India, 69% of girls had heard of a sanitary pad
but had never used one.114 In rural Ethiopia, 25% of girls reported doing nothing to manage
menstruation—simply washing or secluding themselves in the forest, desert, or field.115 And in
rural Tanzania, only 24% of parents were even aware of the existence of pads.116
The high price of commercial products in LMICs deters women and girls from pur-
chasing and using commercial products on a consistent basis. In a survey of girls across
Ethiopia, Uganda, South-Sudan, Tanzania, and Zimbabwe, more than 70% mentioned product
affordability as the main reason for not using commercial sanitary pads.117
Discriminatory social norms affect women and girls’ roles and thus their access to and
authority over how household money is allocated. Women and girls, particularly in rural
areas of LMICs, were also found to have little-to-no input on how household money is spent. In
rural Kenya, two out of three pad users receive sanitary pads from sexual partners.118 Influential
social norms can also dictate which products are seen as “correct” and “hygienic.”119
Supply-Side Constraints
Last-mile distribution of sanitary pads, including both premium and low cost, remains
a challenge in LMICs. In India, decentralized models of production have expanded in recent
years, but daily production levels remain low, which limits the scale and reach of these low-cost
products.120,121,122,123 NGOs and for-profit companies cite safety and transportation costs as key
challenges to product distribution.
v Options included sanitary pads, soap, school supplies, sugar/snacks/drinks, and breakfast.

TABLE 2: MHM PRODUCT MARKET LANDSCAPE
20
PRODUCT PRODUCT OVERVIEW PRODUCT MARKET TRENDS
TYPE DESCRIPTION EXAMPLES
| FSG
Homemade Homemade • Widely used by rural and urban poor in LMICs • Natural materials • Homemade alternatives are the primary or secondary
Alternatives alternatives are (e.g., mud, leaves, product used by menstruating women in LMICs for
• More affordable than commercial products (often free),
solutions made from hay), pieces of managing their menses125 (e.g., in South Sudan, 83%
readily and locally available
readily available cloth (e.g., strips of school girls use homemade alternatives126)
materials • Studies have suggested that the poor hygienic nature of sari or kanga,
• Homemade alternatives are less common in middle-
of homemade solutions can lead to reproductive tract socks), tissues, or
income countries
infections124 cotton
Commercial Commercially • Most widely used product by the middle and upper middle • P&G (Always; • Disposable sanitary pads continue to dominate
Pads available, premium class worldwide Whisper) the commercial market for sanitary pads; in 2015,
disposable sanitary sanitary pads accounted for 77% of all commercial
• User preference data suggests that most women and girls • Kimberly-Clark
pads produced by MHM solution sales131
prefer disposable sanitary pads127,128 (Kotex; Kotex
large multi-national
White) • P&G continues to dominate the market with 30% of
corporations • Cost can be prohibitive for many women and girls in LMICs129
market sales worldwide132
• Not environmentally friendly; plastic lining can clog sewage
systems130
Low-cost commercially • Manufactured at small scale by NGOs and social enterprises • Makapads • Several low-cost commercially available pad
available disposable (Uganda) companies are entering the market in LMICs;
• Quality of products can vary significantly, with issues related
sanitary pads however, the market continues to be dominated by
to poor absorbency • SHE (Rwanda)
produced by local multi-national companies
social enterprises
Commercially available • Manufactured at small scale by NGOs and social enterprises • AFRIpads • Several smaller manufacturers produce locally in
reusable cloth pads (Uganda) developing countries; however, overall market
• Education on use of product and appropriate sanitation
often locally made penetration remains low
infrastructure needed; unhygienic use linked to urinary/ • Mariam Seba
pads that can be
reproductive tract infections133 (Ethiopia) • Reusable pads are often distributed for free or at a
reused for up to one
subsidized price through NGO programs
year • Initial investment can be prohibitive in LMICs requiring • EcoFemme (India)
donations or subsidies
Alternative Commercially available • Used by middle and upper middle class, particularly in • P&G (Tampax) • Primarily used by women in developed countries;
Commercial disposable insertables, developing countries highest concentration of users in Germany, Austria,
• Johnson &
Products such as tampons (a and the United States135
• Limited use in developing countries; may be related to Johnson (o.b.)
plug of soft material
cultural appropriateness of product134 • Global market forecasts for tampons project sales will
inserted into the
reach $2.65 billion (17.4% of worldwide market) by
vagina)
2017136
Commercially available • With appropriate sanitation and privacy, can be convenient • Diva Cup • Gaining traction in Europe, the United States, and
reusable insertables, to use Canada since the 1970s and has been explored as a
• Mooncup
such as menstrual means of MHM in developing countries138
• Recent pilots suggest uptake when coupled with training by
cups (usually made of • Lunette
nurses is possible in developing countries;137 • Global uptake continues to be slow, in part due to
medical-grade silicone
large upfront cost required
and worn inside of • Upfront cost can be prohibitive to consumers in LMICs,
the vagina during requiring donations or subsidies
menstruation)
Inconsistent enforcement of standards affects the quality of low-cost commercially
available disposable sanitary pads and leads to product variability.139,140 Product stan-
dards vary significantly between countries; many only have standards for certain types of MHM
products (e.g., foreign imports or disposable products). For example, the Kenyan government
currently offers standards only for disposable pads, leaving reusable options unregulated and
subject to variability in product quality and safety.
Import duties and value-added sales tax on menstrual hygiene products lead to higher
priced products for consumers. In 2013, consumers in emerging economies paid compara-
tively higher prices for goods than those in developed markets due to high import duties.141
Duty rates for sanitary products vary widely across the globe, with tariffs as high as 40% in
Botswana, South Africa, and Namibia.142,143 These taxes are passed down to consumers and dis-
proportionately affect economically disadvantaged girls and women. National-level sales taxes
for menstrual hygiene products are around 15% in Argentina, Croatia, Rwanda, Tanzania, and
Pakistan.144
SANITATION
Globally, 2.5 billion people lack access to improved sanitation.145
The lack of sanitation facilities disproportionately affects women
and girls, especially as they reach puberty. Research shows that when
gender-separate sanitation facilities are not available at schools, work, or in public places,
women and girls may cope in three ways: choose to stay at home, use an isolated open space
instead of using shared facilities, or choose not to use the facility and be uncomfortable. In spe-
cific geographies, qualitative research confirms that a lack of adequate and appropriate water
and sanitation facilities contributes to absenteeism among school-going girls (e.g., UNICEF
estimated that a girl can miss up to 10% of her school days during menstruation); however, the
relative contribution of inadequate sanitation to school absenteeism is unclear.146
During menstruation, girls in school often worry about staining their dress with menstrual blood
and being humiliated by classmates, especially boys. If a school latrine is not secure or private,
adolescent girls are less likely to use it when menstruating and may be forced to stay in their
soiled pads for more than eight hours, or even choose to stay at home on those days.147,148 The
lack of a secure, locking door can also make women and girls more susceptible to harassment
and even violence.
Public facilities are important for women and girls’ mobility, especially in urban areas.
Dr. Isha Ray and her colleagues at UC Berkley have called attention to the limitations of sanita-
tion services when women’s needs are not incorporated into sanitation system designs,

FIGURE 7: HOLISTIC APPROACH TO SANITATION FOR GIRLS
implementation, monitoring, and evaluation. For women and girls in rural villages, urban slums,
or humanitarian relief camps, walking to distant facilities can cause stress and anxiety.149 Simi-
larly, sanitation facilities located in more isolated areas can make girls and women vulnerable to
violence.
For one-time use MHM products or materials, toilets or bathing facilities require a
mechanism to safely and conveniently discard menstrual waste. In the absence of proper
disposal mechanisms, users may throw menstrual waste in the latrine or pit, put it in their
schoolbag or dispose of it discreetly in open drains, fields, or water bodies, which can create
blockages in sanitation systems. In the case of reusable menstrual solutions, girls need access
to soap and water to wash the product, as well as a discreet place to dry it. Finding a place to
dry the reusable product is a challenge for girls, as they are uncomfortable hanging it out to
dry with other laundry where it may be visible to others. However, drying in the sun is recom-
mended by many practitioners to ensure that the product is hygienic.150
Summary
Menstrual health is a cross-cutting issue that affects girls’ daily lives and future development.
Efforts to address the needs of women and girls and their community members need to con-
sider the holistic approaches to managing the complex and cross-cutting nature of their needs.
The following section provides an overview of the current landscape of players, programming,
and policies that seek to address the current experiences with menstrual health and prioritized
gaps.
22 | FSG
A SILOED RESPONSE
Landscape of Actors
Donors, governments, and other private players have increased the momentum to
address challenges related to menstrual health, but the focus to date has largely been
on “hardware” (i.e., products and infrastructure, excluding waste and disposal). Access
to products and infrastructure, however, is only one of many requirements, including com-
munity knowledge, attitudes, and practice; education and awareness; sanitation; and enabling
policy environments, so interventions that focus only on the “hardware” are limited in their
impact. Few governments, corporations, or NGOs are looking at menstrual health as a systemic
problem, and thus, they are missing the opportunity to address the problems sustainably and at
scale. Furthermore, rigorous evaluations of menstrual health programming to understand what
works and is replicable at scale have been limited.
The lack of universal standards for what constitutes sufficient or appropriate men-
strual health makes it difficult to compare conditions or promote standardized
interventions. The ideal conditions and priority interventions needed to support girls’ men-
strual health needs will depend on the available resources, cultural beliefs, and practices in their
regional context. The formative research conducted by Emory University, UNICEF, and Columbia
University, among others, has provided useful insight into the barriers facing girls across dif-
ferent contexts and geographies. As noted above, common challenges that girls identified in
interviews included pain, teasing, and shame related to revealing menstrual status; leaks, stains,
and menstruation-related odor; lack of understanding of menstruation; lack of preparedness
for menstrual onset; and the inability to effectively manage menstrual flow at school.151,152
To date, funders primarily invest in improved menstrual health as an add-on to other

programing efforts and are motivated to invest as a means to achieve other outcomes,
such as education, water, sanitation, and hygiene, and health outcomes including
reductions in HIV prevalence rates. Grand Challenges Canada (GCC) is one of the few
organizations that are funding menstrual health separate from other efforts. GCC is funding
research and growing social enterprises as part of its Global Innovation Marketplace program,

FIGURE 8: ILLUSTRATIVE TIMELINE OF MENSTRUAL HEALTH PLAYERSvi
which aims to accelerate the quantity and quality of innovations transitioning to scale in a
sustainable manner. Institutional donors such as USAID, SIDA, and DFID fund menstrual health
efforts as part of larger grant funding focused on water, sanitation, and hygiene or educa-
tion programming, making it difficult to assign funding flows directly to menstrual health.
Illustrative grants include the $20 million investment USAID made in WASHplus in Zambia,
which is a leading example of a water, sanitation, and hygiene (WSH) program that integrates
menstrual health across its efforts. Water, Sanitation, and Hygiene in Schools (WinS) for Girls,
supported by Global Affairs Canada, is a notable research project that aims to inform interven-
tions focused on building the capacity of local researchers to understand girls’ menstrual health
needs in 14 countries.vii Table 3 provides an overview of leading funders by investment motiva-
tion. However, the weak evidence base has made it challenging to mobilize a wider funding
base.
vi The players represented in Figure 8 are illustrative. Other players include WASH United, Save the Children, SNV World, Water Supply
and Sanitation Collaborative Council, Vatsalya, Aakar Innovations, Miriam Saba, Be Girl, and ZanaAfrica, among others.
vii This project is set to wrap up in September 2016.
24 | FSG
Current State of Menstrual Health Interventions
Overall, donors, NGOs, and governments tackling issues related to menstrual health
are disparate and siloed in their approaches to reaching girls and their influencers. The
water, sanitation, and hygiene sector is leading efforts to integrate menstrual health into school
programming, and the family planning and sexual reproductive health fields are increasingly
focused on youth and challenges facing very young adolescents. However, to date, there is
limited collaboration and exchange across disciplines.
Few programs have conducted rigorous evaluation of programming, limiting the field’s ability to
assess impacts on outcomes, cost-effectiveness, scalability, and replicability.
Furthermore, much of the effort to improve menstrual health has focused on adoles-
cents in school. Many disadvantaged populations, however, are largely untouched by broader
trends and economic development. For example, in sub-Saharan Africa, 30.6 million children
are not in school (2010).153 Efforts must be broadened to encompass the wider spectrum of
adolescents in need. Girls affected by humanitarian crises or in refugee situations have acute
menstrual needs that are increasingly gaining attention.154
FIGURE 9 : COMPREHENSIVE RESPONSE TO MENSTRUAL HEALTH

A recent study in areas affected by the 2005 Kashmir earthquake near the city of Muzaffarabad
indicates that almost 50% of girls miss school during menstruation, and about 40% do not
have access to protective materials to manage their menses.155 UNICEF has led notable efforts
to address these needs, providing standard emergency kits and engaging WSH specialists in the
construction of sanitation facilities in refugee camps.156
The following section provides an overview of bright spots where the field has seen progress.
While there are still opportunities to improve on the progress and fill additional gaps, this
represents areas of momentum, accomplishment, and effort by field. This is followed by an
TABLE 3: SELECT DONORS SUPPORTING MENSTRUAL HEALTH
DONOR MOTIVATION SAMPLE INVESTMENT AND RELEVANT ACTIVITIES
EMBEDDED INVESTMENTS
USAID Education & • WASHplus, Schools Promoting Learning Achievement

WSH through Sanitation (SPLASH), Zambia
• Zambian Ministry of Education; FHI360; CARE
DFID Education • Multifaceted programming to improve access to
education for girls around the globe
TARGETED INVESTMENTS
Grand MHM • AFRIpads, Uganda

Challenges
• Cost-effective cloth menstrual sanitary pads that can be
Canada
reused for up to one year
• ZanaAfrica, Kenya
• Aims to expand women and girls’ access to safe,
affordable sanitary pads and related MHM education
• Funding will support scale up of sanitary pad production,
increase sales growth, and layer on impact evaluation
related to health and education
OGAC/PEPFAR HIV • Huru International
prevention
• Provides kits with reusable sanitary pads, HIV/AIDS
prevention information, and resources on sexuality and
reproductive health for at-risk girls
Swedish WSH • Sanitation for Improved Lives of Women and Children
International
• Event and related report on the importance of addressing
Development
WASH issues through a gender lens, including a focus on
Agency (SIDA)
menstrual hygiene management
Global Affairs Education • Water, Sanitation, and Hygiene in Schools (WinS) for Girls
Canada
• 14-country program that aims to increase the number of
girls completing primary school and entering secondary
school, with MHM as a key strategy to ensure girls
remain in school
26 | FSG
articulation of gaps and opportunities that represent areas that have not yet been fully explored
and where there is space to further address the needs of girls and their influencers across the
components of Figure 9.
PUBERTY EDUCATION AND AWARENESS INTERVENTIONS

A thorough review of global menstrual health education and aware-
ness programs and policy found traction in curricula development and
menstrual hygiene awareness, but limited focus has yet been placed on
reaching out-of-school girls and engaging influencers.
Bright Spots
Governments and NGOs have emphasized providing education to girls in school
settings focused on the biological aspects of menstrual health and product usage.
Multiple stakeholders and programs are developing puberty and menstrual health curricula, but
these efforts have been happening concurrently, and few actors are building off and leveraging
the work of others, leading to redundancies. A systematic review of relevant puberty curricula
could help highlight best practices across educational materials and teaching methods. UNES-
CO’s Puberty Education and MHM Booklet seeks to provide guidelines for puberty education
that may address some of these redundancies.157
Addressing gender equity through puberty education has gained early traction. An
evaluation of the “It’s All One” program158 found that a puberty curriculum that addresses gen-
der and power in intimate relationships is five times more likely to reduce STIs and unintended
pregnancies. This program highlights the potential for using menstrual health education and
awareness programs as a gateway for shifting social norms.
Mass media shows potential to counter menstruation taboos. Use of mass media and
other media channels for communications can affect social norms by demystifying and reduc-
ing taboos, especially about menstruation. P&G’s "Touch the Pickle" campaign aimed to defy
taboos that surround menstruation in India that restricted women and girls from entering the
kitchen, worshiping, and “touching the pickle” during menstruation. The ad campaign encour-
aged women to talk openly about menstruation and led to 2.9 million women pledging to
“touch the pickle jar.”
Promising programs seek to develop mentorship support for girls. Studies

have found that the presence of a school nurse helps improve girls’ menstrual and reproductive
health.159 The Kasiisi Project in Uganda trains community health care workers to mentor girls
on menstrual health, STIs, and strategies to avoid pregnancy. The Wezesha Vijana Project160
in Kenya is also a leading example of a program that seeks to improve girls’ knowledge and

self-confidence through peer educators. Young mentors are trained to teach a comprehensive
puberty curriculum covering body and emotional changes, and girls are encouraged to share
their doubts and feelings.
Gaps and Opportunities

Few education and awareness programs target out-of-school girls. While some pro-
grams, including mass media campaigns, may reach girls who are out of school, a review of
menstrual health education and awareness programming found few effective programs that
target highly vulnerable populations, including HIV-positive girls, girls with disabilities, and out-
of-school girls.
Despite research pointing to the importance of influencers, programming often

neglects to include them. Research has shown the importance of including girls’ key influenc-
ers, including boys, men, and older women, to change social norms and properly support girls’
needs.161,162,163 By neglecting to include their influencers, programs may help perpetuate the
status quo as influencers do not learn the importance of menstrual health and how to best sup-
port adolescent girls during this period of transition. Boys and men specifically should also have
access to puberty education, which includes information that takes a gendered lens on men-
struation and MHM and aims to create a less stigmatizing educational environment for girls.
Significant expectations are placed on teachers with limited training and resources to
support them. Teachers are expected to teach girls and boys about menstruation, but often
only receive biological basics. For improved menstrual health, teachers need to be trained in
both the biological and psychosocial aspects of puberty education as well as proper hygiene
behavior and practices. Values clarification training may also be required to ensure that teachers
feel comfortable teaching all topics, and additional training may be required for male teachers
who have been found to be less sensitized to girls’ menstrual needs.164
MHM PRODUCTS INTERVENTIONS

Low-income consumers, including the poorest women and girls in
LMICs, lack consistent access to affordable commercial MHM prod-
ucts. While social enterprises have increasingly sought sustainable models,
such as ZanaAfrica, AFRIpads, and Sustainable Health Enterprises, few have been able to find
cost-effective and reliable distribution channels in countries of operation.
Bright Spots
Menstruation has been elevated as part of the government agenda, and free pad
programs are now being administered by national governments and NGOs to provide
28 | FSG
products to vulnerable girls. The impact of these programs still varies significantly based
on geographic location, with some qualitative studies finding a reduction in school absentee-
ism.165 The proliferation of free or subsidized programs, while filling gaps in the short term, may
actually create market distortions in the long term, so stakeholders need to assess and evaluate
these efforts further.
Over the past decade, small and medium-sized social enterprises have entered the
market (e.g., ZanaAfrica, Sustainable Health Enterprises, Mariam Seba, Ecofemme) in
LMICs, aiming to provide high-quality and affordable MHM products to women and
girls in need, but lack scale to reach the breadth of low-income consumers. Volume-based
pricing negotiation can allow inexpensive disposable pads to be more widely available in urban
informal settlements and rural towns. Currently, large corporate brands, such as Always, are
widely available, but nearly twice the price of cheaper alternatives.
Financial planning and social network platforms show potential to support product
access and build girls’ empowerment. An evaluation of the Village Savings and Loan Asso-
ciation (VSLA) model found that VSLAs can effectively support women to save and invest in
strategic goods including MHM products.166,167,168 In situations where women lack control over
household resources, the priorities of women and girls are deprioritized. VSLAs can support
women to have reliable and regular access to preferred MHM products on a monthly basis.
Donors and NGOs are exploring opportunities to expand access to a diverse set of
commercial products that consider environmental and disposal concerns.
Be Girl works with NGOs to distribute comfortable, high-performance pads and underwear.169
Sustainable Health Enterprises created a scalable franchise model for employing women entre-
preneurs to manufacture and distribute affordable, eco-friendly menstrual pads by sourcing
low, inexpensive materials.170 However, user uptake of the menstrual cup and biodegradable
products has been slow due to financial barriers and taboos related to insertable products.

Few programs consider the long-term sustainability of providing products to low-
income consumers. Menstrual health programs that provide free or heavily subsidized MHM
products may not be sustainable in the long term. For example, experts expressed concerns
about the high cost of Kenya’s national Sanitary Towels Programme, a free pad distribution
program run by the Ministry of Education, Science, and Technology.171 Additionally, the large
increase in free products may distort the market for MHM products. Affordable commercial
product lines with broad distribution channels from multi-national corporations or social enter-
prises may be a more sustainable solution.
Luxury taxes on MHM products continue to contribute to high costs for commercial

MHM products. MHM products are subject to high “luxury” taxes172,173,174,175 in many countries
worldwide. These taxes can significantly increase the overall price of the products to consum-
ers (e.g., in Rwanda, sanitary pads are taxed at 18%176); a reduction in these taxes would help
increase the overall affordability of MHM products.
Few organizations have conducted a rigorous evaluation of MHM product program-

ming. More than half of the programs reviewed would benefit from further evaluation to
better understand the impact and attribution of various interventions on girls and women. In
2017, ZanaAfrica and Population Council will conduct a six-arm randomized cluster trial in 100
schools in Kisumu, Kenya, to better understand the impact and relative importance of providing
school girls with pads and education and awareness materials.177
SANITATION INTERVENTIONS
While there is increased activity by donors (e.g., UNICEF, DFID, SIDA,
USAID, BMGF) and governments (e.g., India’s Swachh Bharat program)
to address sanitation challenges, many experts in water, sanitation, and
hygiene and gender equity are calling for sanitation interventions to be better customized to
meet the needs of girls and women, especially during menstruation.
Bright Spots
Several established water and sanitation programs have added an explicit menstrual
health focus, like UNICEF’s WASH in Schools for Girls (WinS4Girls), a 14-country program
under the broader WASH in Schools initiative, and the BRAC-WASH program, which has
achieved significant scale, covering 66 million people.
School sanitation programs, which seek to improve school attendance and linked
educational outcomes by providing water and sanitation facilities, are shifting from
a focus on all children to explicitly considering the needs of adolescent girls during
menstruation. The water, sanitation, and hygiene community also recognizes that sanitation
infrastructure alone is not enough to foster safe menstrual hygiene. It needs to be integrated
with education and awareness regarding hygienic practices as well as address community
attitudes and practices.
Water, sanitation, and hygiene-focused programs are creating information, education,

and communication (IEC) training and materials to build understanding of menstrual
health and the needs of women and girls. WaterAid and Vatsalya’s Breaking Silence pro-
gram aims to build self-esteem and empower women and girls through access to high-quality
sanitation materials and safe disposal.
30 | FSG
Evidence-based advocacy targeting national and local governments has led to the
adoption of menstrual health guidelines across multiple LMICs. SNV’s Girls in Control
program has been active in rural and peri-urban areas of Ethiopia, South Sudan, Tanzania,
Uganda, and Zimbabwe, focused on influencing policy on MHM in district education plans,
budget allocation, and WSH facility development in schools.

Policymakers and sanitation service providers lack training on the specific needs of
adolescent girls and women during menstruation, which could help practitioners design
more user-friendly policies and facilities. Learning platforms across countries or states can sup-
port the exchange of best practices for policy and guideline development and implementation
related to sanitation.
Out-of-school girls have disproportionately limited access to toilets and washroom

facilities during menstruation. There is a need to increase the number of public and commu-
nal sanitation facilities that are available to vulnerable girls and women who are not in school.
Additionally, poor public toilet maintenance can further restrict girls’ mobility and access to
public facilities. Most existing programs are also focused on physically able girls.
Menstrual waste collection and disposal is an under-prioritized area in most user-

centric sanitation programming that needs greater attention. Increased uptake of
menstrual products like disposable sanitary pads will require solid waste management systems
to be configured to manage menstrual waste. In areas without public waste management infra-
structure, local communities need to be trained to dispose of this waste appropriately. There
is no consensus in the field on the best technology or practices for handling menstrual waste.
Attention to this area will be critical for environment and public health reasons.
Rigorous evidence linking sanitation to better menstrual health outcomes is lacking

as it relates to empowerment, health, and education, and few large-scale, evaluative
research studies have been conducted on the impact of appropriate sanitation facilities on girls
and their MHM practice.
POLICIES
Explicit governmental policies, regulations, and guidelines related to men-
strual health are a vital step to improving menstrual health for girls and
women and can catalyze action in the public, private, and NGO sectors.viii
viii Policies and regulations represent a legal requirement for specific actions while guidelines offer the government’s perspective on the
ideal state for MHM and provide recommendations for what is needed to achieve improved MHM for girls and women.

A gender-equitable policy framework further contributes to an enabling environment for girls
and women. Figure 10 below outlines six priority elements for a policy that supports improved
menstrual health for women and girls in a specific context.
Bright Spots
National menstrual health guidelines (often referred to as MHM guidelines) can guide
strategic implementation and action at the community level for improved menstrual
health. India, Kenya, Ethiopia, and Uganda are examples of countries investing in a collab-
orative process to develop national guidelines to standardize and create a baseline vision for
improved menstrual health practices.178 Menstrual health guidelines determine what constitutes
“good” menstrual health in each country and serve as a guiding framework for future action.
Guidelines do not include a regulatory enforcement component and may stand in isolation
from existing policies or ongoing programs within relevant Ministries.
A menstrual health champion in a national ministry can be a critical asset for creating
buy-in, driving coordinated strategic planning, and mobilizing financial support for the issue.179
Recent examples suggest that it is not necessarily important which national ministry takes the
lead, but rather that there is an individual or group committed to bringing together key part-
ners to tackle this issue. Turnover within Ministries is common, and thus, policymakers may lose
momentum as administrations change and political representatives leave offices of power.
Coordinated government action is required to address the cross-cutting needs of women

and girls. Components of successful implementation strategies may include the inclusion of a
budgetary line item for menstrual health, a structure for ongoing engagement with the com-
munity, continuing training and capacity building for implementers at the community level, or
oversight in schools to ensure that menstrual health resources, products, and infrastructure are
maintained and accessible to girls. Financial incentives for implementation at the state and local
levels remain a challenge.
FIGURE 10: MHM POLICY LANDSCAPE REQUIREMENTS
32 | FSG
Government regulation can prevent access to products through imposition of duty
rates and additional taxes on menstrual health solutions. Governments are also seeking
to improve access to products by investing in free or subsidized product provision programs,
with such efforts currently underway in Ghana,180 India,181 and Kenya.182

Public, private, and non-profit sector collaboration is needed as sector isolation and
competing incentives can make it hard to bring diverse stakeholders together. An interagency
coordinating committee, public-private partnerships, or ongoing governmental support to build
NGO capacity can play a vital role in addressing the menstrual health needs of women and
girls. Sustainable Health Enterprises (SHE), a social enterprise in Rwanda focused on menstrual
hygiene, has partnered with the governmental to advocate for expanded budgets, push for
the elimination of VAT on MHM products, and support media programming that addresses
taboos.183
Gender-equitable policy frameworks are necessary to provide safety and support for
women. Examples of gender-equitable policies may include the prohibition of female genital
cutting, diligently enforced restrictions against gender-based violence, obligatory primary
education policies, and gender-inclusive education curriculums. In most nations, the reality is
that most policymakers are men and may have blind spots to the needs of women, such as
menstruation.184
Uganda provides a case study of national policy creation and implementation to address MHM
needs.

MHM IN UGANDA: COLLECTIVE ACTION TO ADDRESS GIRLS’ NEEDS
The Ugandan government has identified girls’ to empower girls; these clubs include boys and
educational attainment as a priority and a challenge empower them to better understand and support
in Uganda. They associate the onset of menstruation, their female peers with menstrual hygiene.
menstrual hygiene management, and other changes • Distribution of sanitary pads for disadvan-
at puberty as factors affecting school attendance taged girls
and the quality of education for girls. To facilitate
INFLUENCERS
girls’ increased educational participation and achieve
gender equity in primary school, Uganda’s Ministry of • Training of male and female teachers on how
Education and Sport (MoES) developed the National to support girls during puberty for their continued
Strategy for Girls’ Education to serve as a guiding education, including specific content contained in
framework for all stakeholders to accelerate girls’ the MHR
education. As part of this larger strategy, a national • Development of a handbook to support teach-
working group, with representation from the Ministry ers in creating a safe school environment for girls
of Education, Ministry of Health, students, parents, • Support for NGOs training girls to produce
teachers, community-based organizations, and reusable sanitary pads from local materials
NGOs, convened to develop a series of interven-
• Inclusion of MHM in agenda of parent-teacher
tions for MHM that address the direct needs of girls,
associations
bolster the capacity of influencers, and contribute to
a broader enabling environment. Collectively, these ENABLING ENVIRONMENT
efforts represent a commitment from the Ugandan
• Passage of a parliamentary motion on MHM
government to enact the necessary policy framework
to support the improvement of MHM, and include:ix • Earmarking of MoES funds for MHM
activities under the Universal Primary Education
GIRLS Programme
• Development of a Menstrual Hygiene Reader • Development, dissemination, and enforcement

(MHR) for dissemination to all MoES primary of new guidelines for girl-friendly design of
school girls; the MHR aims to address the docu- WSH infrastructure in all MoES schools
mented lack of knowledge about menstruation • Development of new guidelines for school
and safe MHM among adolescent girls and guidance counselors on required MHM
includes information on the basics of menstrua- support materials (e.g., soap, clean uniforms,
tion and menstrual hygiene management. sanitary pads)
• Creation of Girls’ Education Movement clubs • Advocacy for girls’ education through the “Go
Back to School, Stay in School, and Complete
ix Sources: United Nations. Puberty Education & Menstrual Hygiene Man-
School” campaign
agement (2014): UNESCO; Tamiru, Selamawit Tamiru, Pasquina Acidria,
Chemisto Satya Ali, Lindile Ndebele, Kuribachew Mamo, Rozalia Mushi,
Beverly Brar, and Nick Greenfield. “Girls in Control: Compiled Findings
from Studies on Menstrual Hygiene Management of Schoolgirls.” 2014.
34 | FSG
CONCLUSION
Menstruation is central to girls’ experience, yet donors and other leading global actors
have had a hard time mobilizing funding and resources to support girls and address
their related challenges. When prioritizing research, programming, and mobilizing a
finite set of resources, questions about the overarching goals for investing in men-
strual health become critical. Tensions exist in the field, with some actors believing dignity
and human rights should be the primary driver for investment in menstrual health, while others
emphasize the need to understand whether poor MHM and menstrual health more widely
influence a broader set of health and development outcomes before investing. The below state-
ments intend to capture the two perspectives:
1. Improving MHM for dignity and human rights: Investing in scaled solutions to MHM
that include both boys and girls is an issue of dignity and a fundamental right.
2. Access the “window of opportunity”: Investing in research and interventions that

target vulnerable girls around the period of menarche may provide a unique opportunity to
access vulnerable girls and set them on a path to an empowered, healthy, and fulfilling life.
Improved menstrual health may also prove to have cross-cutting effects on other health,
development, and empowerment outcomes.
The question of whether these two perspectives can co-exist, and how, is still outstanding and
needs to be further explored by a diverse set of actors spanning various disciplines and sectors.
Questions to be explored as a field include:
• Is “menstrual health” the right term to encompass issues related to menstruation, women’s
health, sanitation, and puberty awareness?
• Is there a need for an entire sector dedicated to menstrual health or can responsibilities be
dispersed across multiple sectors?
• Are there opportunities to support sectors with current momentum, such as WSH, to lead?
• What are the critical gaps in evidence needed to address menstrual health?
• Where is the most critical starting point based on need: water, sanitation, and hygiene

(WSH) or sexual reproductive health (SRH)? What will have the most impact in the short
term and in the long term?
Building out the theory of change for each can help to address research needs and engage
senior leadership across sectors and disciplines. Experts have identified a need for a platform
focused on biological, social, and educational issues connected to menstrual health throughout
a woman’s life. The platform could help to define a research agenda both at the global level,
and more specifically at the country level, in order to strategically fundraise, build the evidence
base, share best practices, and facilitate cross-sector efforts.
Opportunities
Challenges related to menstrual health, while important, are just one of many issues
that vulnerable girls face during early adolescence. The Bill & Melinda Gates Founda-
tion supported a gathering of more than 40 participants from academia, private and bilateral
donor agencies, research and implementing organizations, corporations, and social enterprises.
This group uncovered the need to explore where menstruation can serve as an opportunity to
access girls at a critical transition point in their lives. Sexual reproductive health problems are
one of the leading causes of death among adolescent girls 15–19 years old,185 with girls facing
increased risk of HIV and STIs, unintended pregnancies, and related complications, as well as
coerced sex.186 Gendered discriminatory social norms that focus on the value and treatment
of adolescent girls may be a cross-cutting issue that influences health, development, and
empowerment outcomes. Questions remain about the contribution of poor menstrual health
to short- and long-term health, development, and empowerment outcomes for girls, relative to
other contributing factors.
Disadvantaged and vulnerable girls are often isolated from public systems and other
programming efforts, and menstruation could provide a unique entry point to setting
them on a path to an empowered and healthy life. For example, a 2015 study in rural
Kenya found that two-thirds of menstrual pad users received them from their sexual partners.187
It is worth exploring whether access to pads could provide a platform for discussion with girls
engaged in transactional sexual relationships. While this area provides potential, the evidence
is, as of yet, still nascent and needs to be further explored.
The section below outlines four promising cross-cutting opportunities the group identified that
the field can begin to explore to address the menstrual health needs of women and girls and
improve outcomes for women and girls. These ideas were developed and refined with a diverse
set of experts in the menstrual health field from academic institutions, corporations, social
enterprises, NGOs, and donor agencies.
36 | FSG
→
1. USE MENSTRUATION AS AN ENTRY POINT
Leverage menstruation interventions as an entryway to access vulnerable populations and
address sexual reproductive health, empowerment, and other critical life outcomes.
Menstrual health interventions can serve as a gateway for vulnerable adolescent girls to receive
information and age-appropriate services related to sexual reproductive health and water,
sanitation, and hygiene. Practical action can include integrating menstrual health interventions
with other services for women and girls such as nutritional supplementation and water, sanita-
tion, and hygiene and providing sexual reproductive health information and services through
menstrual health programming efforts. Aggregating data on current initiatives with positive
impact on outcomes and investing in impact evaluations and longitudinal research studies can
→
also support the field’s understanding of opportunities where menstrual health can provide this
type of entry point and influence longer-term outcomes.
2. ENCOURAGE COLLABORATION ACROSS MENSTRUAL HEALTH ACTORS

Consider platforms and opportunities to address the full set of women and girls’ menstruation
needs by consolidating the research agenda and coordinating action across sectors.
Given the cross-cutting nature of menstrual health, a research agenda must be collaboratively
defined both at the global level, and more specifically at the country level, in order to strategi-
cally mobilize funding, share best practices, and encourage collaboration across sectors. This
could take the form of a new sector, or simply a global platform or accelerator focused on cap-
turing data to highlight the benefits, impact, and importance of the work and share it with the
field of relevant actors. An organized structure can also consolidate smaller players to bridge
→
distribution gaps, reduce prices, and avoid redundancies. Leadership is still an open question
and will be critical to the success of a new menstrual health platform or sector.
3. TACKLE SOCIAL NORMS SURROUNDING PUBERTY

Connect relevant discriminatory and gendered social norms to tangible interventions to shift
empowerment and other life outcomes.
Evidence is growing that the expression of a discriminatory social norm becomes more pro-
nounced during puberty and can undermine efforts to achieve multiple health and development
outcomes. Collective behavior can play an influential role in shifting social norms that influence
girls during puberty (e.g., girls playing sports, media campaigns showing uptake of HIV testing)
and can set examples of new “norms.” An institutional framework can help to define and tar-
get multiple stakeholders and define different approaches for reaching this diverse set of actors.
These approaches include direct authority and subjective authority, increasing individual agency,

and creating community dialogue. Data and impact evaluations on existing social norms and
empowerment interventions can help shed light on how to approach shifting relevant social
norms and better understand the impact on menstrual health (e.g., Yegna Girl Effect, Shujaaz
Well Told Story, Femina magazine of Tanzania). This research can also help explore whether
→
interventions associated with MHM can be an effective vehicle for addressing social norms and
leading to improved outcomes.
4. CATALYZE MARKET DEVELOPMENT

Improve access and use of quality MHM materials and products, including safe disposal of
waste.
To address demand- and supply-side constraints to product access and use, a total market
approach is needed to improve access to MHM products and materials. Integrated and tiered
strategies emphasizing specific interest areas must be based on geographical needs and assets.
While efforts need to be tailored to specific markets, collaborative action will require engage-
ment from governments and ministries, NGOs, social marketing organizations, multi-nationals,
United Nations agencies, private donors, social entrepreneurs and consumer packaged goods
companies. There is opportunity to push beyond subsidized product offerings into more innova-
tive funding approaches that lead to sustainable solutions to product access and use. This
community also has the potential to emphasize the need to address the disposal of commercial
sanitary pads and other products that are not biodegradable.
Closing Thought
Addressing issues related to menstrual health needs to begin with a girl’s journey through
adolescence to adulthood. Her experiences learning about her body and traversing this transi-
tion can influence her future behaviors and relationships with peers and community members.
Further exploration of the impact of poor menstrual health can shed light on short- and long-
term links to health, development, and empowerment outcomes and provide the opportunity
to support and influence girls and set them on a path to a successful and healthy life.
38 | FSG
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48 | FSG
THIS REPORT WAS PUBLISHED MAY 2016
Sponsored by The Bill & Melinda Gates Foundation
AUTHORS
Alexandra Geertz, Associate Director
Lakshmi Iyer, Senior Consultant
Perri Kasen, Consultant
Francesca Mazzola, Senior Consultant
Kyle Peterson, Managing Director
Contact: [email protected]
ADVISORS
Caroline Kabiru, Research Scientist, African Population and Health Research Center
Brad Kerner, Adolescent Sexual & Reproductive Health, Save the Children
Beverly Mademba, Program Manager, WASH United
Freweini Mebrahtu, Founder/CEO, Mariam Seba Sanitary Products Factory
Arundati Muralidharan, Manager Policy (WASH in Health & Nutrition, Schools), WaterAid
India
Marni Sommer, Associate Professor of Sociomedical Sciences, Mailman School of Public

Health, Columbia University
Andrew Taylor, VP Investments, Grand Challenges Canada
Disclaimer: All statements and conclusions, unless specifically attributed to another

source, are those of the authors and do not necessarily reflect those of any individual
interviewee, advisor, or sponsor.
This work is licensed under a Creative Commons Attribution-NoDerivs 4.0 Unported License.
BOSTON • GENEVA • MUMBAI • SAN FRANCISCO • SEATTLE • WASHINGTON, DC

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14 Defining the Problem

AN OPPORTUNITY TO ADDRESS MENSTRUAL HEALTH | 1

Menstruation is a monthly challenge for billions of women and girls worldwide. On

STATE OF THE EVIDENCE

THE FIELD’S RESPONSE

• Few governments, corporations, or NGOs are looking at menstrual health as a systemic

PROGRAMMING AND POLICY INNOVATIONS

AN OPPORTUNITY TO ADDRESS MENSTRUAL HEALTH | 3

The field is just beginning to understand the complex sociobiological dynamics at

AN OPPORTUNITY TO ADDRESS MENSTRUAL HEALTH | 5

The Journey through Adolescence

Figure 2 shows the journey of an archetypal 14-year-old Ethiopian girl.

FIGURE 2: A GIRL'S JOURNEY

AN OPPORTUNITY TO ADDRESS MENSTRUAL HEALTH | 7

AN OPPORTUNITY TO ADDRESS MENSTRUAL HEALTH | 9

Menstrual Health and Links to Life Outcomes

AN OPPORTUNITY TO ADDRESS MENSTRUAL HEALTH | 11

STATE OF THE EVIDENCE DEFINITION

Economic • Increased work Evidence lacking • Limited cross-sectional or anecdotal evidence44

AN OPPORTUNITY TO ADDRESS MENSTRUAL HEALTH |

Role of Community and Influencers

FIGURE 3: MENARCHE AND SOCIAL NORMS

FIGURE 4: MENSTRUAL HEALTH FRAMEWORK

Girls’ Experiences with Menstrual Health

AN OPPORTUNITY TO ADDRESS MENSTRUAL HEALTH | 15

PUBERTY EDUCATION AND AWARENESS

FIGURE 5: MHM PRODUCT USAGE BREAKDOWN

AN OPPORTUNITY TO ADDRESS MENSTRUAL HEALTH | 17

• Affordability: Homemade alternatives cost significantly less than commercial

• Cultural acceptability: Homemade alternatives can be more culturally acceptable than

AN OPPORTUNITY TO ADDRESS MENSTRUAL HEALTH | 19

AN OPPORTUNITY TO ADDRESS MENSTRUAL HEALTH | 21

To date, funders primarily invest in improved menstrual health as an add-on to other

AN OPPORTUNITY TO ADDRESS MENSTRUAL HEALTH | 23

FIGURE 9 : COMPREHENSIVE RESPONSE TO MENSTRUAL HEALTH

AN OPPORTUNITY TO ADDRESS MENSTRUAL HEALTH | 25

TABLE 3: SELECT DONORS SUPPORTING MENSTRUAL HEALTH

DONOR MOTIVATION SAMPLE INVESTMENT AND RELEVANT ACTIVITIES

USAID Education & • WASHplus, Schools Promoting Learning Achievement

Grand MHM • AFRIpads, Uganda

PUBERTY EDUCATION AND AWARENESS INTERVENTIONS

Promising programs seek to develop mentorship support for girls. Studies

AN OPPORTUNITY TO ADDRESS MENSTRUAL HEALTH | 27

Gaps and Opportunities

Despite research pointing to the importance of influencers, programming often

MHM PRODUCTS INTERVENTIONS

Gaps and Opportunities

AN OPPORTUNITY TO ADDRESS MENSTRUAL HEALTH | 29

Few organizations have conducted a rigorous evaluation of MHM product program-

Water, sanitation, and hygiene-focused programs are creating information, education,

Gaps and Opportunities

Out-of-school girls have disproportionately limited access to toilets and washroom

Menstrual waste collection and disposal is an under-prioritized area in most user-

Rigorous evidence linking sanitation to better menstrual health outcomes is lacking

AN OPPORTUNITY TO ADDRESS MENSTRUAL HEALTH | 31

Coordinated government action is required to address the cross-cutting needs of women

FIGURE 10: MHM POLICY LANDSCAPE REQUIREMENTS