Its my honour to take part in this discussion. I find comments from all the members very interesting and full of information. But i would like to share my thoughts regarding MHM in schools in urban and particularly in rural areas of Pakistan.

1) It's always good to raise body awareness especially regarding MHM ( for example UNICEF interventions on Menstrual Health Management in Pakistan since 2012) but one should keep in mind that parents would not allow their daughters to talk about MHM in the Schools, and MHM awareness in schools would add fuel to the fire. Image about the schools, these parents already having, that western agenda is being taught in them (as talking about menstruation would unfortunately be considered as against religious and social norms). Even mothers are not supposed to talk to their daughters about it. Girls talking about MHM, even with each other, are considered as liberal western Girls, who would face hurdles in getting arranged marriages.

2) While thinking about having a dustbin with lid, mirror, soap, lota (water vessel for cleaning) etc. in girls school in rural area, one should also think that "how often these things would be stolen from the toilets?" (keeping in mind those schools already have limited budget or even no budget). I just saw first photo posted by @sahrari (WASH facility in Bangladesh), i am afraid to assume that there was a soap but not anymore, please correct me if i am assuming wrong. And even if there is a soap available in toilet, how to make sure that everybody is ready to use the same soap?

3) Its a cruel reality that often WASH facilities built by the NGOs or other donors should look nice on the photos. These facilities would never fit into the financially poor neighbourhoods. Thats why many public toilets built in Pakistani urban areas (let alone rural areas) are now used as storage rooms, kitchen or even small shops. People are considering them as a GOLD for them. In schools the situation is not very different. Just imagine one girl from a poor family having no or very basic WASH access at her home, now going to a school with fancy looking WASH facility, how would she react to that?Let alone WASH facilities it was reported many times in Pakistani news that the school buildings were being used as a "Marriage Halls" by the school staff and parents.

It would be very interesting to have your views and suggestions regarding these barriers.

Significant progress has been made in developing tools and approaches to understand the challenges faced by girls in managing their menstruation at school (see the discussion in Topic 1 for more on this), assess the gaps in provision of MHM services at school (though mostly at a local or sub-national level) and examine knowledge, attitudes and practices. Though there is more that can be done, particularly as menstrual hygiene requires context specific approaches, another critical area that has been largely neglected is in monitoring MHM.

Robust and meaningful monitoring of MHM in schools – is essential to target resources and track progress, to understand what works and what doesn’t in MHM programming, and to generate evidence on the outcomes of MHM interventions to advocate for greater priority to be given to MHM in schools.

At the global level SDG4 on Education includes WASH in Schools and recent guidance has been produced on targets and indicators for this, including indicators indirectly and directly related to MHM in Schools. The guidance document is available online at the link below. I have also attached a summary note that was developed from the guidance document.

Core questions and indicators for monitoring WASH in Schools in the Sustainable Development Goals

As these indicators are to be collected at national level they are at the level of outputs. These are useful to track progress and could be taken as proxy indicators of improved awareness and practice (in the same way as presence of handwashing facility with soap and water is a proxy for handwashing). Though, for MHM this would still need to be tested. However, monitoring of outcomes – such as behavioural outcomes (changes in hygiene behaviours / use of facilities / cultural norms), educational outcomes (e.g. participation in school) and empowerment outcomes (e.g. increased confidence and gender equity) - is still in its early stages.

What are the most important aspects of MHM that we should be monitoring at different levels – e.g. school, district, national, global?
How can we incorporate MHM in existing WaSH in Schools monitoring systems and processes? What other monitoring systems and processes might also be relevant?
What experiences are there on monitoring of MHM outcomes – and what are the most effective tools and approaches for this?

How do we ensure basic sanitation in schools to support MHM? What further improvements are essential to meet the MHM needs of all menstruating students and staff? How can these be addressed in resource constrained settings?

To ensure basic sanitation facilities to support MHM in schools, education supervisory Boards such as the Universal Basic Education Boards, Ministry of Education and Post Primary School Management Boards should be holistically integrated in inspecting sanitary facility in schools and this should form part of the monitoring and supervising indicators.
This has to be approach holistically, community participation in maintaining and supervision of the facilities.
"In about 95% of schools we have reached with our WASH and MHM intervention programs, have unusable sanitary facility. A principal asked me "Should I provide my urine for the students to use in cleaning the facility? That is why it is under lock and key and not in use" another complaint on the exorbitant cost of maintaining the facility as the government is not providing funding for that purpose" this has made students to be practicing open defecation and urinating.
The Parents and Teachers Association should be integrated as well.

Further improvements required is to raise awareness on menstrual hygiene management and explore country based sanitary materials that can serve effectively in managing menstruation hygienically. We can transfer knowledge from this platform as to domesticate what has worked in country A. The school teachers has a greater role to play in spearheading MHM, their attitude, perception and behaviors has a greater impact on the life of the girls and influences the boys negatively/ positively.

In resources constraint setting, I considered my earlier suggestions on domestication of local materials will assist in meeting the local demands. Just someone early sited the use of old t-shirt in getting up to 9 sanitary pads that is awesome.

What successful approaches to maintenance of infrastructure and disposal are being implemented? What potential innovations are being trialed that can be taken to scale?

As I suggested earlier MHM should take a multisectorial in its approach. Almost every family has a girl child and every family is involves in one sector or the other, so all hands should be on desk to ensure that infrastructure are maintained and disposal of used sanitary material. The head teacher, mechanics, waste management officers, health personnel, media sector, traditional and religious leaders has a role as they are breaking the silence on menstruation they are speaking out on good disposal from different medium newspapers, media, office, policy room etc

Thanks for sharing the experiences and photos from Bangladesh. It would be really interesting to hear more about whether it is practical and whether girls are happy to dry reusable materials at school. In some of WaterAid's earlier projects in Bangladesh we provided rails for hanging washed resuable cloths to dry. But girls did not want to leave their cloths in a space used by others. Maybe a better solution is for girls to be able to rinse out their cloths but take them home to wash properly with soap and dry later?

In Pakistan we found that girls did not want to throw used cloths when they had completely finished reusing them in the incinerator. Instead they took them home to wash and then sometimes brought them back to school to dispose of. The issue was around leaving something with their blood in the incinerator chamber. For some reason though, this was not perceived as a problem for those who used disposable pads.

This highlights the linkage between topic one and topic two of the discussion on this forum. As when considering the infrastructure needs we also need to understand issues around taboos and how this affects practices and use of infrastructure.

Thanks for sharing the example from Tanzania. There is very little documented on how effective and safe incinerators are. Yet there is quite a lot of controversy about their adoption and use in some of the countries where WaterAid works. For example in Nepal, incinerators for MHM in schools are being provided by NGOs and through the education department as part of the commitment towards girl friendly toilets in schools. However, this is being criticized from the health and environment sectors. Similarly, I heard that in Kenya (please can anyone confirm) that the policies of the Education Department and Environment Department are contradictory on the issue of incinerators. Where Education Department has included them, but under the Environment Department incineration can only be carried out in certain locations that have been regularised.

It would be great to have more technical assessment of incinerators that have been constructed for MHM, including their effectiveness, whether they are being operated and maintained, what materials are being burnt, and whether they are safe for the environment and those who are in proximity to them or operating them. We are planning to do some assessment and review at WaterAid but we are only just starting. So if anyone has existing research, assessments or reviews please do share.

I would like to share a proposal and a response to our MHM discussion, that reached me via email from Bernard Miti from the Zambia WASHE Advocacy Network ( This email address is being protected from spambots. You need JavaScript enabled to view it.):

The Thematic Group: on Menstrual Hygiene Management in Schools in Zambian Context:

INFRASTRUCTURAL BARRIERS:

• There is insufficient access to safe and private toilets may be dirty and smell and lack of water and soap for personal hygiene.
• Some schools do not have separate toilets for girls and boys, and most do not have changing or washing rooms.
• Girls don’t have appropriate facilities for disposing of used menstrual management materials; therefore most (77%) girls used pit latrines as a means of disposal.
• Lack of washing tabs/Basins, lack of water, lack of pads at School.

The need to have infrastructure, like Wash rooms innovations, hand washing tanks and hygiene kits, Girl friendly Latrine with hand washing facilities in order to make WASH more holistic.

Urban Management Centre (UMC), Ahmedabad, Gujarat,India
Under the Ahmedabad Sanitation Action Lab (ASAL)initiative, we at UMC are working with municipal schools to improve the WASH facilities and services and behavioral change. MHM is one of the core components of our program intervention.

Accessibility to toilets have a direct relation to MHM. In absence of toilets girls tend to miss schools in days of their menstruation. To create awareness on this issue, we have prepared a short video advocating separate and hygienic toilet facilities for girls.You can watch this video:

For more info about our organization and ASAL program, visit our website www.umcasia.org/asal

Often it is difficult to change the behaviour from using re-usable options (i.e. cloth) to disposable pads in many cultures. Considering the difficulty in managing the waste disposal, I personally think, there is no need to emphsize on that if the possibility for regular change, cleaning and if necessary drying of re-usable options are provided at school. To me, this means:
1. Availability of separate latrine for girls, with (preferabbly running) water and washing facilities inside the latrine. Although hopefully the work on breaking taboo on MHM would lead to confident girls who do not mind carrying extra water to the latrine to use for cleaning purposes, it is still more convienient to have the water inside girls facilities, in particular for girls with mobility problems. (see attached an example from Bangladesh)
2. Availability of proper drying places at school. Considering that during heavy bleeding days, there is need for regular change of the cloth, and carrying wet cloths can be unhygenic and uncomfortable, girls need to have access to drying places where they feel comfortable drying their clothes.
3. Having dustbins with lid which gets regularly (preferably in between breaks) emptied (safely disposed) within girls'laterine is essential.

4. The efforts at school need to be supported by promotional and awareness raising activities at community.

Having said these, I would like to mention that the work on MHM should not be seen only relevant for developing countries. Looking at the advertisements from most sanitary napkins producers, one can see that "Keeping menstration hidden at school and work" is what these advertisements are basing their sales on! Work on breaking the silence and building the confidence of the girls and women to be in peace with their menstration still requires a long way to go!






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Note by moderators: This post was made by a former user with the login name sahrari who is no longer a member of this discussion forum.

Good MHM in schools requires a comprehensive approach including three main components; 1) providing pragmatic and accurate information and spaces where people can speak openly about menstruation; 2) availability of effective and affordable menstrual hygiene materials; and 3) safe and private water, sanitation and hygiene facilities that are suitable for washing hands and bodies, and for changing, washing and disposing of menstrual hygiene materials as often as required. A recent review of WaterAid’s MHM programmes in schools in Nepal and Pakistan showed that having all these components in place has clearly contributed towards improving girls’ confidence to manage their menstruation effectively at school.

Last week’s discussion focused primarily on the first of these components and to some extent the second. It was great to read of the rich experiences, expertise and resources that were shared from across many different contexts. This week we are focusing on the third component of infrastructure.

The Global Goal for education (SDG 4) incorporates MHM in target 4.a with an associated indicator of the “proportion of schools with access to:…(e) basic drinking water; (f) single-sex basic sanitation; and (g) basic handwashing facilities”. These minimum requirements can support MHM in schools. However, numerous enhancements have been identified as necessary to meet girls’ and female staff’s full MHM needs including water and soap inside sanitation cubicles – or separate changing and washing rooms in addition to latrines, disposal facilities inside sanitation blocks, mirrors to check for stains, hooks and rails to hang cloths whilst changing etc. Furthermore ensuring facilities are accessible to those with limited mobility or physical impairments is rarely addressed. How do we ensure basic sanitation in schools to support MHM? What further improvements are essential to meet the MHM needs of all menstruating students and staff? How can these be addressed in resource constrained settings?

A critical challenge for those working on WASH in Schools is ensuring facilities are kept clean and well maintained. This has implications for MHM too, as girls report not wanting to use toilets for changing their sanitary materials when they are often dirty or lack privacy. MHM also requires additional O&M procedures, specifically for the complete disposal of used materials. The successful expansion of MHM programming in schools has increased demand for and use of disposable products. Yet disposal services, for both disposable and reusable materials – including provision of bins, emptying, burial or incineration – are often lacking. As one problem is solved another is being created. Yet there is insufficient evidence and guidance for what constitutes culturally acceptable and environmentally safe disposal; or what is needed for reusables. What successful approaches to maintenance of infrastructure and disposal are being implemented? What potential innovations are being trialed that can be taken to scale?

Further, as attention to MHM in schools has grown, due to the efforts of many individuals and organisations around the world, it is also essential that we have appropriate monitoring processes in place to understand what works and what doesn’t, to target resources and track progress. We’ll address this final critical issue on this forum later in the week!

The campaign for menstrual hygiene management looks in part at how girls can access menstrual pads and most times this becomes the major focus neglecting factors of how these pads are to be managed. In Uganda the policy of having lined latrines with no provision for their emptying in schools is common and this may apply to other East African countries as well. Unfortunately with disposable pads comes the need for disposing and the latrines rank high for pad disposal. This often leads to the latrines filling up fast. The urgency of government school policies in East Africa including incinerators as part of the provision for menstrual pad management is thus high to prevent this. In the case of reusable pads their is need also for ensuring their well managed washed, sterilised and dried least fungal infection become common.

Regarding the construction of incinerators the Tabora Development Foundation Trust model in Tabora Tanzania would be ideal. Constructed adjacent to the latrine. Allowing the girl child to dispose the pads from the latrine right into the incinerator creating privacy and ease for disposal.