What’s WASH got to do with it?

Published on: 16/05/2022

Photo: Zeba (left) and Anjum (right) show the poster of a uterus made out of Gulmohor flowers that they made for Menstrual Hygiene Day. In the middle is Srilekha Chakraborty, activist and winner of the 2020 winner of the Ton Schouten Award. Credit, Srilekha Chakraborty/Instagram. 

Menstrual hygiene management. Menstrual health. Period poverty. Menstrual equity.

WASH sector actors are very familiar with menstrual hygiene management - MHM. But what about these other terms? What do they mean? And does the WASH sector have a role there?

Health, education and equity

Over the past decade or so, we have witnessed the rise and expansion of actions focused on supporting girls and women to manage their monthly periods in a safe and hygienic manner – widely known as menstrual hygiene management (MHM). Menstruation or periods are a biological phenomenon, and come under the ambit of health, specifically sexual and reproductive health. Yet, strikingly, attention to MHM was spearheaded by the WASH sector, stemming from school-based interventions that underscored the pivotal role of gender-responsive WASH facilities in keeping girls in school, preventing absenteeism and dropouts, especially when they reach puberty and when they are on their period. The premise was simple, actionable, and impactful – water, sanitation and hygiene facilities in schools and at home helped girls and women maintain hygiene during their periods, and do it safely, and with privacy. As the WASH sector designed and established gender-responsive WASH facilities, it nimbly ascertained and proactively addressed other underlying needs shaping MHM that were beyond the domain of WASH per se - MHM education, social norms related to menstruation, access to safe menstrual products, and disposal solutions for used materials. Action on MHM embodied an important, yet often overlooked aspect of WASH – hygiene. This issue powerfully brought to the fore how water and sanitation (and waste management) are intrinsically linked with hygiene facilities and behaviours. Further, MHM programmes highlighted how access to comprehensive, inclusive and responsive WASH services can contribute towards the achievement of key development outcomes for girls and women, from health, education, and even gender equity. 

Over the past decade, MHM interventions have evolved, and resulted in influential programmatic guidance at the global level, country level policies on WASH and on MHM, increased research on various aspects of the issue (e.g., female friendly toilets, MHM in emergencies, menstrual products), as well as global campaigns such as Menstrual Hygiene Day. MHM programmes drew attention to new areas of work, some directly related to menstrual hygiene and WASH, and others indirectly related. A direct link was disposal and safe management of used menstrual products, specifically disposable or single use sanitary pads. An indirect link was menstrual products – incorporating action on hygienic use of products, but more importantly, access to a basket of safe and effective products. Taxation and quality standards for these essential products came into force. The MHM field was changing, and WASH was no longer at the centre.

COVID-19

The COVID-19 pandemic was a critical turning point for MHM interventions, starkly highlighting the complex, multi-faceted nature of menstruation as a health and gender equity issue, that called for nuanced and multi-sectoral action. Starting March 2020, schools shut down, and millions of girls found themselves abruptly cut off from sanitary pads, information and support to manage their periods. Period poverty, that is the inadequate access to menstrual products, as well as to WASH facilities and information to manage menses in a healthy manner, sharply came into focus. The pandemic accentuated deep inequalities in access to affordable, good quality, safe period products. Simultaneously, a group of global advocates comprised of researchers and practitioners who had been part of the MHM movement, pooled together their collective experience and knowledge, and proposed a new definition of menstrual health – a state of complete physical, mental, and social wellbeing, and not merely the absence of disease or infirmity, in relation to the menstrual cycle, again, shifting the focus from hygiene and hygiene management of periods to health and wellbeing, throughout the menstrual cycle, not just the days of bleeding, and across the reproductive life span, including, but not limited to adolescence. The outcome – menstrual equity, whereby every person who has a menstrual cycle and experiences a period has access to affordable and safe menstrual products, comprehensive information, social support, and other services (including WASH, health and nutrition services). These powerful developments firmly establish health, wellbeing and equity as the desired goals. Where does this leave the WASH sector?

Meeting changing and emerging needs

WASH is a critical, social determinant of health, and it is a critical determinant of menstrual health. Good menstrual health needs water, sanitation and hygiene services and related hygiene behaviour change. However, with the evolving landscape, it is time for the WASH sector to reflect on and examine how their core work is an essential contribution to the larger movement on menstrual health, and how it can advance to meet changing and emerging needs. Here are some thoughts:

1. Access to WASH in institutions that girls and women engage with – Gender responsive WASH is well established for schools, and in homes, public and community toilets to some extent. These efforts need to be expanded to other educational institutions (higher education), formal and informal worksites, health care facilities public and private, care homes for children and women, and even prisons for incarcerated women.  
2. WASH in humanitarian contexts – Increasing climate and environmental shocks, natural calamities such as earthquakes, conflict and displacement, highlight the need for WASH facilities in temporary and long-term relief and rehabilitation camps. Bangladesh and India face natural disasters every year, with communities facing temporary displacement. Nepal has experienced shattering earthquakes, with citizens losing their homes and access to basic amenities, including WASH. Pakistan, India and Bangladesh house refugees from Afghanistan and Myanmar. Girls and women in these situations are particularly vulnerable, and secure WASH facilities can help protect their health and wellbeing.
3. WASH enables the use of alternative products – Several menstrual health interventions provide reusable menstrual products such as washable pads and menstrual cups, as a part of the menstrual product basket. To facilitate and support the safe use of these reusable products, girls and women need access to reliable WASH services at home, in institutions and public settings that will enable them to change, wash and dry their materials as required to maintain hygiene.
4. Disposal and waste management solutions – Responsive WASH for MHM often includes dustbins and disposal chutes to discard used menstrual products. This is an important first step in the menstrual waste value chain, with more solutions required to ease discrete and convenient disposal and downstream management of this waste in a safe and effective manner.

Menstrual health and equity are a growing area of work, that calls for coordinated and multi-sectoral actions. Inclusive and responsive WASH is and will continue to be a vital component of menstrual health. The WASH sector must take this opportunity to reflect on how it can meaningfully contribute towards this issue in its evolving form.

About the author. Arundati Muralidharan is a public health professional with close to two decades of experience in health and development programmes, research and policy advocacy. She is a passionate advocate of menstrual health and female health, and has been instrumental in shaping policy and programmes in India and has contributed to global efforts as well. She is committed to building the menstrual health eco-system through innovations, knowledge sharing, evidence generation, and policy advocacy. Arundati is the founder of MHAi, a platform dedicated to menstrual health in South Asia. Arundati has previously worked with WaterAid, the Public Health Foundation of India, and Population Services International. She has a Doctorate in Public Health from Boston University, and a Masters in Social Work from the Tata Institute of Social Sciences. Contact: arundatimd [at] gmail.com.