UNICEF report finds gaps and bottlenecks in menstrual health services

Advocacy efforts from donors have effectively raised recognition of menstrual health in East Asia and the Pacific, particularly around adolescent schoolgirls, but they must now focus on gaps and bottlenecks according to a new report on regional progress. The UNICEF-funded review follows the agency’s 2016 UNICEF study of menstrual hygiene at the start of the Sustainable Development Goal era. “We are now at the midpoint of the SDG era,” Brooke Yamakoshi, water, sanitation, and hygiene specialist with UNICEF in Bangkok and one of the report’s authors, told Devex. “We don’t have specific indicators or targets on menstrual health and hygiene in the SDGs, but we know that menstrual health and hygiene contributes impacts on health, wellbeing, education, gender equality, and many other rights.” She added that they wanted to take stock and ask the questions of whether they were making progress, and if so, how? The review used the new menstrual health definition published in 2021 by the Terminology Action Group of the Global Menstrual Collective, which looks at menstrual health as a state of complete physical, mental, and social well-being. The regional study used five criteria to represent its progress across the operating environment and service delivery in 19 countries. These were access to information and education; access to materials, facilities and services; nondiscrimination and participation, a supportive social environment; and care for comfort and disorders. The data highlighted significant gaps in monitoring, evaluation, and evidence, with the need for improvements to inform policy and practice, among its findings. Needs were unknown because national monitoring of menstrual health integration was usually limited to water, sanitation, and hygiene, or WASH, facilities in schools and surveys. Growth in the evidence of successful menstrual health measures in East Asia and Pacific was slow, the report also found. There was agreement among review participants that data and evidence was needed to highlight the significance of menstrual health and what effect measures by governments and development partners could have. Most studies on measures were poorly done with a lot of bias, the research stated. Julie Hennegan, senior research fellow and co-head of Global Adolescent Health at the Melbourne-based Burnet Institute and co-author of the report, told Devex that “historic underfunding” of menstrual health had resulted in a lack of evidence to inform next steps. “This doesn’t mean we should sit on our hands — we need to commit to action to support women, girls and people who menstruate,” she said. “It does mean that we should move cautiously, evaluate and iterate as we go. Donors should be funding meaningful monitoring and evaluation alongside programs so we can build the evidence as programs are implemented, identify what is and isn’t working, and ensure into the future we have the best interventions that are achieving outcomes for women and girls.” Development partners such as the United Nations and NGOs, often fund menstrual health service delivery to plug the gaps in government budgets, the study said. But running programs through governments was preferred by some who took part in the research. One Cambodia-based review respondent described a situation where the donor had control over a ministry or organization. There was no sustainability, and once the program ended no sense of ownership, they said. Many NGO review respondents stressed “the need for government budget allocation (at the national and subnational levels) for more sustainable service delivery, without the reliance on continued development partner funding.” “In the absence of a strong policy framework that sets priorities for menstrual health funding, NGOs may be able to step in to support menstrual health services in countries without a robust policy framework,” the report said. “Conversely, this lack of coordination or alignment to government policies risks duplication and gaps in hard-to-reach or geographically isolated areas where girls and women may have less access to services.” Healthier government-led coordination mechanisms were able to reduce duplication and gaps and increase capacity, the research also found. Competing priorities, lack of capacity and underfunding often meant NGOs “filling the gaps.” But these collaborations needed bolstering. Limited opportunities for training government workers, coupled with stigma around menstrual health had led to a skills and capacity shortage, the research said. Global WASH and sexual and reproductive health policies increasingly integrate aspects of menstrual health, the report found. “This is one of the positive findings of the review,” said Hennegan. “We want to see attention to education, products and WASH facilities in schools — however we are also mindful that this focus misses girls who are out of school, and the rest of the life-course.” Rosie Wheen, CEO at WaterAid Australia, told Devex that they were collaborating closely with government counterparts to strengthen the WASH systems underpinning sustainable menstrual health services. “The review highlights that we need to continue to support governments to develop robust policy frameworks along with dedicated budget allocation as well as strong coordination mechanisms in order to meet population-wide menstrual health needs,” she said. “The gains we have made in school-based water sanitation and hygiene menstrual health services demonstrate that this can be achieved successfully.” Wheen added that there was an opportunity to replicate and take to scale these system solutions to address other aspects of menstrual health and reach more people. Menstrual health overall continued to gain traction globally, said Hennegan, with the report highlighting this. It was important to periodically review progress made and how to share best practices, she said. “In identifying progress and enablers, we hope this can enable countries to learn from one another in what has helped move forward in addressing menstrual health, at the same time by identifying gaps and bottlenecks we hope to direct attention to these challenges to accelerate progress,” said Hennegan. Unlike 2016, governments had now made progress in integrating menstrual health and hygiene into policies in different sectors. However, on closer inspection, policy commitments mostly focused on access to information and education, as well as materials, facilities, and services. Where policies existed, the responsibilities for policy implementation were unclear, Yamakoshi said The implication is that there needs to be more attention to supporting governments to unpack these roles and responsibilities, said Yamakoshi. “Often this work is done through challenging, detailed discussions with many different ministries or subnational department offices — and the work is often much less visible than the initial policy commitment,” she said. “But it is a really critical missing piece that enables funding allocation and monitoring, and without it, further progress will be limited.”