How well is South Asia meeting the menstrual hygiene needs of its adolescents?
Our Menstrual hygiene management in schools in South Asia research with UNICEF identified the progress, gaps and priorities in achieving menstrual hygiene management services in schools at scale in eight countries. Co-author Therese Mahon describes the findings with Claire Grayson and Rebecca Heald.
Adolescence is a pivotal point in life, a time of many changes – physical, mental and social. For many people the transition to adulthood is when social norms around gender become more pronounced, and for some it’s when associated inequalities become entrenched.
The onset of menstruation is one of the key markers of puberty in girls, celebrated in many cultures as a sign of becoming a young woman. Yet this step into adulthood is also accompanied by cultural and social restrictions related to taboos around menstruation and fears that girls may become pregnant before marriage. As a schoolgirl in Nepal shared with us, "It felt like we are not allowed to do anything now… When we did not have our menstruation, we were allowed to go anywhere but now they say that we must not go anywhere."
However, adolescence also presents a critical window to break cycles of poverty and transform gender roles. Educating adolescent girls is reported to bring substantial returns, including faster economic growth, reduced child marriage, delayed pregnancy, increased wellbeing, fostering democracy and improving women’s political participation. 
For girls to enjoy their rights to education and fulfil their potential to contribute to the health and wealth of their families, communities and nations they need to be able to manage their periods with comfort and confidence. This requires water, sanitation and hygiene (WASH) facilities at school and at home, understanding the facts about menstruation, knowing how to take care of themselves, and a supportive environment to deal with the emotional and social changes they are experiencing.
South Asia is home to more adolescents – around 340 million – than any other region, and India has the world’s highest number of 10–24-year-olds, with an estimated 356 million. Around half of these young people are female. So there is a huge need to make sure the menstrual hygiene management (MHM) requirements of girls and women here are fulfilled.
Good progress in South Asia, but more needed
Over the past 10–15 years, the South Asia region has been at the forefront of progress to ensure that WASH services, including those in schools, pay attention to the needs of menstruating girls and women. To drive change on the ground it is essential to review progress, identify successful approaches and innovations that can be scaled up, and to ensure that the voices of women and girls are heard, so that solutions effectively address their needs and promote their rights.
In collaboration with UNICEF, we assessed country-level progress and experiences of incorporating MHM into school WASH services across Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan and Sri Lanka. We identified what more needs to be done and what can be built on to ensure all girls go to schools that support them to participate fully during menstruation. In our report we share lessons, good practices and opportunities to further promote and mainstream MHM in schools in the region.
The research showed that, in recent years, South Asian countries have made good progress in improving the availability of WASH facilities in schools, including separate toilets for girls so that they have a private space to change menstrual pads and wash. Many have included WASH in schools standards in their policy and programming guidelines and are starting to integrate good MHM practices into these standards. Significant experience of implementing menstrual hygiene and WASH in schools programmes has been amassed across most countries.
Several countries have also begun to include clear information about menstruation in school curriculums, and many national education, WASH and sexual/reproductive health-related policies and strategies now recognise the importance of MHM in school WASH.
However, our research suggests that women and girls still face considerable challenges, reporting lower participation in school activities, and reduced levels of concentration and confidence during menstruation. Those marginalised by geography, caste or ethnicity, disability, disasters and poverty are especially affected.
So what do we need?
Despite the increase in the coverage of and funding for separate toilets for girls and boys in schools, political prioritisation and budgets for WASH in schools are still lacking, especially for MHM. Although standards and guidelines exist there is a lack of accountability to ensure these are followed, particularly on ensuring they are accessible to all including girls with disabilities, and for maintaining facilities and keeping them clean.
Clean and comfortable materials that can be properly disposed of
In South Asia most women and girls use cloth to absorb menstrual blood. Many small initiatives promote locally made, reusable sanitary pads that are held in place better than cloth and can be washed, dried (in the sun to kill bacteria) and reused.
Although disposable pads are widely available in some areas, and some girls prefer to use them, especially when at school, they are often unaffordable, and disposal options such as incinerators missing. In countries such as India where use of disposable pads is increasing rapidly, waste is becoming a significant problem. A long-term view is needed to enable girls to make the right choice for them, looking across the entire service chain for supply, use and disposal.
Accurate, practical information and social support
Girl and boys need age-appropriate information to understand the changes they are going through, and hygiene promotion to instil healthy behaviours. Effective hygiene promotion and puberty education, including the facts about menstruation, are inadequate across South Asia.
A wide range of myths, taboos, norms and traditional beliefs and practices around menstruation persist, affecting girls’ and women’s ability to manage their periods and continue their everyday activities.
Across South Asia, surveys show that the proportion of girls who do not know what menstruation is when they first experience it ranges from 36% in Bangladesh to 66% in Sri Lanka. This means girls feel shame, fear and embarrassment when they have their first period. They need practical and social support from their peers, families and teachers to feel comfortable and confident during menstruation.
Efforts have been made to improve teachers’ capacity and resources, and social media and peer-to-peer learning have helped reach more adolescents. But there is a need to integrate MHM into school curriculums, at the right time, and to ensure that teachers, parents and communities also have the right information and confidence to support girls.
Opportunities for improvement
Our research highlights five key areas on which to focus:
Cross-sectoral integration and coordination. In many countries the WASH sector has led on integrating MHM into WASH in schools. There is now increasing recognition that tackling menstruation fully, so that it is seen as a normal and healthy process, supported with appropriate WASH, education and health services requires a shift from looking at MHM to addressing menstrual health more broadly. Therefore, better cross-sector collaboration is needed, particularly between WASH, health and education sectors. There is a need to better map out and understand different stakeholders’ roles and responsibilities for MHM in schools, so that everyone understands their obligations and can coordinate better with others.
Materials and supply chains. Wider engagement with the private sector may accelerate progress, including linking with waste management service providers and encouraging social responsibility around disposal among commercial pad suppliers.
Quality programme design and monitoring. Better understanding is needed of programme costs and outcomes to determine the programme elements that work best at scale. Monitoring for the Sustainable Development Goals (SDGs) offers an opportunity to get an MHM indicator in national education monitoring information systems, which would facilitate progress measurement and reporting and incentivise action. Political buy-in for the SDGs and increased sanitation is an opportunity to increase access to MHM services in schools. To capitalise on this we need to develop clear standards for gender-sensitive facilities and maintenance, with monitoring indicators, aligned to the SDGs.
Information and communication platforms. Efforts to ensure MHM is included comprehensively in the curriculum are underway in several countries, and could be replicated. Both formal and informal channels of communication, including social media, and peer to peer approaches can be used to amplify impact. Civil society, NGOs, INGOs and campaigners are also beginning to raise girls’ voices to challenge social norms around menstruation and demand accountability from duty-bearers for better facilities in schools.
Equity. Efforts aimed at ‘leaving no one behind’ are underway, including better accessibility and safety of school facilities including for girls with disabilities. However, more is needed, and reaching girls in remote or inaccessible regions and in emergency situations requires more attention.
With facilities for clean water, decent toilets and good MHM in schools, the SDGs on education, gender equality and good health and wellbeing will be closer within reach. By addressing these areas of opportunity, countries in South Asia and beyond can ensure better facilities and information for adolescent girls, helping them realise their rights to education and health, and to turn the tide on gender inequality.
 Herz, B. & Sperling, G. B. (2004) 'What Works in Girls’ Education Evidence and Policies from the Developing World', Council on Foreign Relations, Giving Women Economic Opportunity: World Bank Initiatives, The World Bank, 'New Lessons: The power of education adolescent girls', Population Council (2009).
*This work has been made possible with UK Aid from the British people.