When the Water Supply and Sanitation Collaborative Council (WSSCC) and UN Women started working on menstrual hygiene management (MHM) in West and Central Africa, many people were unfamiliar with the acronym. During our first meetings in the region, officials from ministries, parliamentarians, and social entrepreneurs were surprised to hear MHM being spoken about, even if they suspected or knew that many women and girls faced challenges related to menstruation. One social entrepreneur told us after a training of trainers “we’ve been working on this for so long but we were not able to conceptualize it this well.” We proceeded to hold a first ‘MHM Lab,’ a simple but effective training session held in tents aimed at breaking the silence and learning about the menstrual cycle (Fig. 40.1). We also carried out a study in Louga, Senegal, which provided vital quantitative and qualitative information and a solid basis from which to start conversations on menstrual hygiene. The interest, passion, and enthusiasm of the people we met were overwhelming. From the little girl in a village to the minister in a capital city, we have encountered people who wanted to change the status quo, and we have enjoyed going on this journey with them.

Fig. 40.1
figure 1

(Credit: © WSSCC/Javier Acebal 2016)

MHM lab

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Our Approach to Menstrual Hygiene Programming: Training, Research, and Policy Development

In many West and Central African societies, menstruation is a taboo subject rooted in longstanding beliefs and myths that consider menstrual blood to be impure. Menstruation is a sensitive topic, and practices vary from one context to another. In order to respond effectively to the needs of each population, our work is country- and context-specific. However, there are agreed principles and standards as well as a modus operandi that we follow. These include (1) to leave no one behind and to contribute to the reduction of inequalities rather than reinforcing them, (2) to be collaborative and work across sectors, (3) to build evidence and fill research gaps, (4) to design inclusive policies based on the collected evidence, and (5) to train local professionals and actors who will ensure continuity and strengthen this work through their actions and initiatives at the local and national levels.

Throughout the program, we have provided technical assistance to governments. We did not impose rules or guidelines but helped strengthen systems and design policies with the respective governments that would be of benefit to all, including women and girls. Indeed, WSSCC put women’s and girls’ sanitation and hygiene needs and rights at the core of its strategic plan. We provided expertise on policy design and training, and helped articulate research gaps and technical needs, and provided solutions to address them.

In particular, we worked with local, national, and international actors to propose a plan of action for each country. These planning activities brought together ministries (education, health, labor, planning, and environment), other UN agencies, civil society organizations, nongovernmental organizations, and the media. For example, in Niger, the media played a key role in breaking the silence on menstruation. The training delivered to journalists by the ‘WASH1 Journalist Network’ provided them with the tools to appropriately report on MHM.

Hence, the building blocks of our programs are policy-relevant research, capacity strengthening, systems strengthening, monitoring, and inter-sectoral collaboration. The training is an important part of the policy work as it fosters knowledge and a common understanding of overlooked issues. Combined with further research, it is also the first phase of the analytical work required when designing the policies. During the training and research, we gain a better understanding of the MHM practices in a country, the sociocultural context, and the political, physical, and institutional barriers (Fig. 40.2).

Fig. 40.2
figure 2

(Credit: © WSSCC 2016)

Graph of training, research and policy circle

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Trainings

Addressing menstruation as a taboo subject was facilitated by lively dialogue and exchanges with girls, women, boys, and men, including in ministries, NGOs, schools, and communities-at-large (Joint Programme 2016). The first major activity organized by the program was an ‘MHM Lab’ in the city of Louga (300 km from Dakar, the capital of Senegal). The purpose of the Lab was multifold: It was an opportunity (1) to learn more about women’s and girls’ practices, (2) to train the first round of Lab facilitators, and (3) to collect crucial data which would consequently be presented to ministers and members of parliament. In the five-day training of trainers and MHM Lab, tools such as the booklet “As We Grow Up” and the menstrual wheel, which visualize the changes in the body that take place from childhood to adulthood, were effective in providing participants with enough confidence to be able to offer these trainings themselves (Fig. 40.3). Participants of the trainings felt empowered to speak out during ministries’ planning activities. As a result, MHM was made explicit in education, health, gender, water and sanitation, and environment public policy.

Fig. 40.3
figure 3

(Credit: © WSSCC 2016)

Menstrual wheel

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Today, participants in the trainings form a community of trainers in an online platform, where they regularly share resources on menstrual hygiene management. Though trainers are very active online in some countries, joining the platform has proven to be more difficult in Niger due to connectivity issues. However, the trainers continue to meet face-to-face, to run MHM Labs and advocacy sessions, and are involved in key menstrual hygiene management related processes at the national and local level.

The menstrual hygiene management trainers in the region are a vital force for the program. They are leading labs and facilitating advocacy sessions—with support from the Joint Programme’s team—targeting government officials, members of parliament, the population at large, including women’s groups, children in schools, persons with disabilities, teachers, social entrepreneurs, and NGOs, among others. In total, more than 26,000 people have been reached by the 620 trainers trained by the Joint Programme’s team (Joint Programme 2018). People have told us how they have changed as individuals and as fathers, mothers, teachers, and supervisors (YouTube 2018). Even after the end of the program, trainings and MHM Lab sessions continue, demonstrating the sustainability of the approach. Social entrepreneurs have also picked up the methodology. Different actors like Kmerpad, Santé Mobile, and Speak Up Africa partner regularly to run MHM Labs with support from the program’s MHM trainers (Joint Programme 2017a).

Data Collection and Applied Research

Data is important to build evidence-based strategies and to inform future policies throughout the program. The Minister of Water and Sanitation of Senegal realized that menstrual hygiene was a significant challenge when he received our first research report on Louga in 2014 (Joint Programme 2014). It encouraged him to take action within the ministry by reviewing the sector policy and related guidelines. In turn, the position of the Government of Senegal toward MHM encouraged the former Minister of Water and Sanitation of Niger to take action.

Studies provided key information and statistics on attitudes toward menstruation and menstrual hygiene behaviors and practices (Joint Programme 2014, 2015a, 2015b). They also examined public policies and found that none addressed menstrual hygiene management at the time. This laid the groundwork for subsequent policy developments. The studies addressed several areas, including the silence around menstruation, women’s and girls’ beliefs and attitudes, and the fear and stress experienced by women and girls when menstruating.

For instance, the study in Senegal found that a significant share of women work in the informal sector face challenges when menstruating because sanitation facilities and private spaces are largely unavailable to them (Joint Programme 2015a). In refugee camps in Cameroon, 99% of women indicated that they do not feel safe enough to use sanitation facilities at night. With regard to education, the study in Cameroon found that the advice girls receive—whether from mothers or at school—was often limited to practical information about the use of menstrual products and did not extend to understanding physiological factors and other aspects of menstrual literacy (Joint Programme 2015b). Based on a review of policies, the study in Niger found that menstruation is largely absent from sectoral policy documents and that women lack a forum to express concerns and indicate their needs in relation to menstruation (Joint Programme 2017a). The findings from these studies provided the rationale and the necessary data and statistics for menstrual hygiene management interventions.

Policy Development and Budgeting

The Joint Programme responded to a genuine demand of young girls and women who wanted to know more about their bodies and the menstrual cycle, a subject that is rarely discussed in families or in public. Through the trainings, research, and advocacy, the Joint Programme successfully mobilized governments in West and Central Africa around menstrual hygiene management (Joint Programme 2018). Menstrual hygiene management provided an entry point for discussing other women’s rights issues such as family planning, early and forced marriage, gender-based violence, female genital cutting. The MHM Labs organized by local actors in villages, communes, schools, health centers, public places, and in refugee camps provided the space for intergenerational dialogue around these issues.

The involvement of decision-makers at the highest level during the MHM Labs enabled them to pave the way in speaking out and ensuring that their respective governments accorded priority to menstrual hygiene through developing policies and allocating budgets. The program contributed significantly to gender-sensitive budgeting in water, sanitation and hygiene (WASH) in Senegal, Niger, and Cameroon. For example, in Senegal, the WASH ministry undertook a review of sanitation facilities’ design, which led to increased public spending for gender-sensitive facilities. The new design of toilets includes a systematic separation of toilets (women/men, boys/girls). It also includes more spacious sanitation facilities for women (Joint Programme 2017b). The supplementary cost for the new toilets was about 200 USD per facility. Similarly, in Cameroon, the budget of five municipalities’ pilots of the program increased to address the need for gender-sensitive toilets. Gender-sensitive toilets were also built in two refugee camps in Minawao and Ngam in Cameroon (Joint Programme 2017a).

Looking beyond toilets, education, health, and environment ministries from the region (especially in Senegal, Niger, and Cameroon) have reviewed their policies to include menstrual hygiene management and menstrual health more broadly. Over the years, the acronym MHM (which provided our entry point) has been replaced in some contexts by menstrual health, which we believe is a more holistic term that goes beyond the simple management of menses. Teachers in Cameroon have developed courses based on WSSCC training materials to address MHM with students in training centers. All stakeholders agreed that working on menstrual hygiene and health required collaboration across sectors. Interministerial task forces were set up in Cameroon, Niger, and Senegal, bringing together the ministries in charge of WASH, health, education, environment, and labor to address menstrual health in a holistic manner. The ministries that led the policy analysis were very effective, especially in Niger. As a result, several policies and implementation plans have been reviewed or newly designed to include menstrual hygiene. The Government of Senegal made menstrual hygiene management a mandatory feature of future sanitation projects to be funded by the Government through its coordinating mechanism. At the local level, municipalities in Cameroon and Senegal increased their budgets to review the design of the facilities in public spaces (Joint Programme 2016). Overall, the Joint Programme has affected change in policies, institutions, and budgets at various levels.

The Way Forward: Strong Institutions, Policies, and Budgets for Long-Term Results

The adoption of new policies is not an end in itself, though it is a significant step in advancing women’s rights, equality, and empowerment. Policies have implications for budgets, programs, and service provision, and we have seen their implementation across many countries. They also provide a basis for accountability: governments make public commitments in their policies to which they can be held accountable by civil society, the media, and communities. On a different but equally important level, policy development also plays a significant symbolic role in creating spaces for dialogue about menstruation. Such talk normalizes discussion and makes menstrual health a component of government activity.

Overall, our program was met with an overwhelmingly positive response. Initial skepticism quickly yielded to the open sharing of experiences about menstruation. The MHM Labs provided ideal spaces for these conversations and served multiple purposes: to learn about experiences of menstruation, to provide training on the menstrual cycle, and to engage policy-makers who quickly grasped the fundamental importance of menstruation. In addition to creating these spaces for interaction, the choice of the WASH sector as an entry point proved to be ideal in our target contexts. The seemingly technical nature of WASH and the use of the abbreviation ‘MHM’ provided an opening for beginning to address broader concerns about gender equality and other stigmatized conditions (see Patkar [Chapter 38] in this volume).

However, a lot still needs to be done. The policies and budgets now need to be streamlined with effective action plans and strengthened systems that recognize menstrual hygiene management, and more broadly, as we recommend, menstrual health. And they must provide a space to voice women’s needs at all stages, from the design of programs to their monitoring and evaluation. Smart action plans, monitoring, systems strengthening, budget increases, and the review of the design of some facilities are essential to increase access to gender-sensitive and MHM-friendly facilities in public spaces, schools, health centers, and any other places where people live, work, play—all spaces where people menstruate. Infrastructure is important, but equally important is one’s capacity to talk, walk, and move freely during menstruation, without fear or shame, which must be our top priority.

Note

  1. 1.

    WASH is the acronym for Water, Sanitation and Hygiene, a sector in global development.