Comprehensive programming for menstrual health in schools in India
Schools offer a crucial chance for menstrual hygiene programmes to make transformations that will benefit adolescent girls long into their futures. This Menstrual Hygiene Day, Arundati Muralidharan, WaterAid India’s Policy Manager for WASH in Schools, Health and Nutrition, describes the menstrual hygiene landscape in India’s schools, and the work WaterAid India is doing to improve it.
Consider this: India is home to about 113 million adolescent girls. Around 54% of these girls are unaware of menstruation before they have their first period; 77% do not know that the uterus is the source of the bleeding; only 45% believe that menstruation is normal; and a vast majority observe socio-cultural, religious or food taboos during their period. Compounding this, 70% of mothers, who are girls’ main source of information, consider menstruation to be dirty and polluting. And an estimated 63 million girls are living in homes lacking toilet facilities.
Research from 2011 suggested that a staggering 88% of girls and women in the country were using unsafe, unhygienic menstrual absorbents. There has been some progress since then – the latest National Family Health Survey 4, India’s DHS (2015-16), reported that only 42.4% of young women aged 15–24 are using unhygienic methods of protection during their period.
Against this complex and challenging backdrop, WaterAid India has set out to work on menstrual hygiene. Cognisant that menstrual hygiene cannot be address through WASH interventions alone, we deploy a multi-pronged approach: 1) use social and behaviour change communication to spread awareness and address taboos around menstruation and menstrual hygiene management (MHM); 2) inform and support the institutionalisation of MHM-responsive WASH facilities; and 3) facilitate the development of an enabling environment that can sustain changes over time.
A vital chance to improve MHM
Schools offer a critical entry point to address MHM in this comprehensive manner. So what do we know about adolescent girls and MHM in Indian schools? An estimated 60% of adolescent girls are enrolled in about 1.4 million schools. A systematic review on MHM in India found that 24% of school girls did not attend school during their menses, and only 37% changed their absorbents in school. These figures underscore the importance of responsive WASH infrastructure in schools to enable girls to manage their periods safely.
But is this all that is needed? Schools can be vehicles of change, but can also serve to perpetuate stigma and discrimination regarding menstruation. Recently, several shocking incidents have highlighted the importance of tackling harmful social norms surrounding menstruation in a concerted manner alongside making improvements in WASH infrastructure and spreading awareness about menstruation and MHM.
Our approach in schools
Applying our approach to MHM to the school setting, WaterAid India programmes have developed modules for teachers and peer educators that provide essential and comprehensive information on menstruation and MHM, and identify and tackle detrimental social norms. Much of our work on WASH infrastructure for MHM centres on schools, where we emphasise:
- Safe, clean and functional toilets, and separate toilets for girls
- Water in toilet units (to wash self and menstrual absorbent)
- Soap to wash hands
- Provisions in toilet units to store/hang belongings (hooks, shelves)
- Private and safe space to change
- Safe disposal of menstrual waste.
An enabling environment is critical for the above two components (providing information and addressing social norms, and MHM-responsive WASH infrastructure) to work. To achieve an enabling environment, we focus on creating safe spaces (physical and/or social) for girls to gather and talk about menstruation, and on building the capacities of influencers such as teachers and principals to effectively deliver and support MHM interventions. At a policy level, we work with district, state and national governments to advocate for comprehensive programming on MHM with corresponding budgetary allocations.
The district wide approach (DWA) serves to operationalise this approach – we concentrate our efforts on the most marginalised parts of the district to highlight what works in terms of communication materials, capacity building and institutional strengthening, and budgetary allocations. We then draw on lessons learned to advocate for scale up in the rest of the district, and to inform policy asks at state and national levels.
Approaches to fit context and use opportunities
WaterAid India has a presence in 11 Indian states. Our MHM interventions, while adhering to core components common to all, deploy different strategies to work appropriately with various government departments to improve menstrual hygiene among schoolgirls. In Andhra Pradesh and Telangana, adolescents in schools, including residential schools, have come together to form core groups of change agents – peer groups that impart information, foster favourable attitudes and offer valuable support to their peers. Core groups have federated at district and state levels to advocate for policy-level change, and are now are recognised and called upon as resource persons under government programmes in these two southern states.
In Uttar Pradesh, strong advocacy work with the Department of Health resulted in the adoption of our MHM module for frontline workers for roll out across the state with out-of-school and school-going girls. The Madhya Pradesh team has tried a different approach, providing technical assistance to the Women and Child Development Department to create 'Udita corners' in 90,000 nutrition centres where adolescent girls can access information about MHM and safe products. The East region works intensively in communities and schools to change inequitable gender norms to improve menstrual hygiene.
WaterAid India has a window of opportunity to strengthen MHM programming in schools under the Swachh Bharat (Clean India) Mission. The Swachh Bharat Swachh Vidyalaya Abhiyan (Clean India, Clean Schools Campaign) notes menstrual hygiene as an important component of WASH in schools. The greatest impetus has come from the MHM Guidelines for Schools, launched in December 2015 by the Ministry of Drinking Water and Sanitation. These comprehensive guidelines call for inter-sectoral action for MHM, noting the government departments that must be involved to collectively improve MHM programming, lay out session plans, and offer technical inputs on disposal.
In April, the Ministry of Drinking Water and Sanitation issued a directive on gender issues in sanitation with one of the calls to action being the implementation of these guidelines. With political support for MHM at the highest level, WaterAid India has the unique opportunity to apply our approach and learning to inform MHM programming at scale.
Advocating for holistic programmes
As we surge forward with this agenda and inform government initiatives, we will advocate for comprehensive programming that addresses detrimental social norms, provides girls with information on and access to a range of safe and hygienic menstrual absorbents, and options for the safe disposal and treatment of menstrual waste. Through this, we will keep those who are marginalised and hard to reach at the centre of our work.
With increasing momentum on MHM interventions, we need to monitor and measure progress through development of MHM-specific indicators that capture all three components of work. And last, alongside WaterAid interventions in schools, we must explore how best to reach girls who are enrolled but do not attend schools, those who discontinue their education, those who never attended school, and girls with disabilities.
WaterAid India is excited to be a part of the journey to transform the menstrual health and hygiene landscape in India for the better, through comprehensive programming and responsive policy directives that call for convergent action.