Keeping girls in school through improved menstrual health: insights from Timor-Leste and Papua New Guinea

A four-year partnership between WaterAid and Marie Stopes International (MSI) Australia set out to increase the awareness and uptake of sexual and reproductive health services, and improve access to water, sanitation and hygiene services, in Timor-Leste and Papua New Guinea. Here, Imelda Kachua, Livia Cruz da Costa and Chelsea Huggett set out the lessons learned.

In our part of the world – Asia and the Pacific – we have some of the poorest rates of water, sanitation and hygiene (WASH) coverage globally. In Papua New Guinea (PNG), for example, only 13% of the population have access to a basic level of sanitation, and 28% of households have access to hand washing stations with soap and water. Across both Timor-Leste and PNG, education in schools misses the opportunity to talk about sexual and reproductive health (SRH) and menstrual health. These factors, coupled with poor access to sanitary pads, and social and cultural taboos, makes managing menstruation challenging.

For the past four years, WaterAid has worked with MSI Australia to deliver a holistic approach to improving menstrual health in PNG and Timor-Leste. Together, we wanted to increase the awareness and uptake of sexual and reproductive health, and improve water, sanitation and hygiene services.

Across the two countries, we supported more than 57,000 people to have increased access to WASH and SRH information, facilities, and family planning services. More than 3,000 students are now accessing girl-friendly WASH facilities in schools, and 12,500 women and girls are using their preferred choice of contraception.

Our work in Papua New Guinea and Timor-Leste

(R-L) Victoria, Joe, and Tori, stand outside WaterAid toilets at their school in Rigo District, Central Province, Papua New Guinea. October 2018.

Image: WaterAid/Tom Greenwood

In Timor-Leste, we facilitated menstrual health education sessions with girls and boys, hosted “youth corners” and promoted a sexual health hotline service, installed WASH facilities in schools, and worked with women entrepreneurs to market reusable sanitary pads.

Activities in Papua New Guinea included a training series for school teachers, providing SRH services in communities and girl-friendly WASH facilities in schools, and developing teachers' resources for comprehensive sex education, which the Ministry of Education subsequently adopted.

An independent evaluation on the impact of the programme found that, in PNG, teachers reported that the development of the comprehensive sex education curriculum and training had led to schools stocking sanitary pads, improved teacher confidence in implementing the expanded curriculum, and boy’s attitudes becoming more supportive towards menstruating girls.

In Timor-Leste, we developed menstrual health information, education and communication materials for schools and communities. These materials capture information about the menstrual cycle, describe how to manage periods effectively and hygienically, and aim to dispel myths, taboos and correct misinformation. Students who attended these sessions around these materials demonstrated increased knowledge about reproductive biology and reported sharing the information they learned with others.

One government representative from PNG's Department of Health said:

I think it is vital to integrate the topics of sexual and reproductive health, family planning and menstrual health. This was an eye-opening experience in breaking some taboos. When talking about sexual health in the classroom, we can see the students opening up and understanding the issue and respecting each other, unlike before the project.

What we learned

Working with an SRH actor meant that we had a greater impact, as essential WASH and SRH services were delivered in schools and communities together as a comprehensive approach; school students not only had improved access to WASH, but learnt more about their bodies, sexuality and SRH services at the same time. Developing education materials in collaboration with the government helps to ensure local ownership and contextually appropriate materials.

Next time, one thing we would do differently, would be to provide more sexual, reproductive and menstrual health education to the broader community – not only to girls and boys in schools. The evaluation found that reaching the influencers in young people’s lives – such as such as mothers, fathers, grandmothers, aunties or older sisters – would have supported menstrual health education efforts even further.

As field and regional menstrual health practitioners, our top four recommendations for working on menstrual health in any context are:

1. Menstrual health solutions need to be holistic as possible. Try some new innovative period partnerships, consider SRH actors but also rights actors like gender groups or DPOs.
2. Holistic menstrual health solutions require increased investment to be effective. Partnerships which bring together technical expertise, such as WASH and SRH, require higher investment than a single approach to menstrual health. Funding must adequately resource the partnership to support learning and reflective practice, and test combined technical approaches.
3. Develop, pilot and document menstrual health indicators through projects. This was something we could have made stronger in our project, and is a gap in practice across the globe.
4. Build collaboration with government ministries into your design. Our pilots have become more sustainable by working together with both education and health focus ministries.

WaterAid recently co-led the development of a new definition of menstrual health with members of the Global Menstrual Collective that sets out the requirements for achieving menstrual health and can be used to support all of the recommendations above.

The theme of this year's Menstrual Hygiene Day – stepping up action and investment in menstrual health and hygiene now – comes at a critical moment. WaterAid and other actors have been working hard to build more evidence around what works in addressing menstrual health. What we need now is increased commitment and investment to scale effective programming. To echo the voices of thousands of women, girls and people who menstruate all around the world, and the allies who support them: the time for action is now.

Imelda Kachua is Programmes Officer for WaterAid Papua New Guinea, Livia Cruz da Costa for Programme Effectiveness Manager at WaterAid Timor-Leste, and Chelsea Huggett, Technical Lead - Equality and Rights for WaterAid Australia