Making the case for investing in menstrual health and hygiene

Publication date: 2021

MAKING THE CASE FOR INVESTING IN MENSTRUAL HEALTH & HYGIENE JANUARY 2021 Europe IN COLLABORATION WITH F O R W A R D TABLE OF CONTENTS A NOTE ON TERMINOLOGY 3 FUNDING & INVESTMENT FOR PROGRAMME INTERVENTIONS 3 ABBREVIATIONS 4 1. THE PURPOSE OF THIS DOCUMENT 5 2. WHY INVEST IN MENSTRUAL HEALTH AND HYGIENE 5 2.1 MENSTRUATION IS A MATTER OF HUMAN RIGHTS 6 2.2 MHH IS CRITICAL FOR ACHIEVING THE SUSTAINABLE DEVELOPMENT GOALS 6 2.3 POTENTIAL IMPACT OF INVESTING IN MHH 6 3. CURRENT STATE OF FUNDING/INVESTMENT 8 3.1 CURRENT AND PAST FUNDERS 8 3.2 WHY DONORS FUND OR INVEST 10 4. THE OPPORTUNITIES FOR FUNDING/INVESTMENT 11 4.1 INVESTMENT FRAMEWORK 11 4.2 PROGRESS AND GAPS 11 4.3 PRINCIPLES OF FUNDING/INVESTMENT 15 CONCLUSION 15 ANNEX 1: DONOR LANDSCAPE: FUNDING/INVESTMENT AMOUNTS AND FOCUS AREAS 17 ACKNOWLEDGEMENTS 19 REFERENCES 20 A NOTE ON TERMINOLOGY Women and girls: not all women and girls menstruate, and not all people who menstruate are women. The term ‘girls and women’ is used as a shorthand term to increase readability but refers to all people who menstruate including girls, women, transgender and non-binary persons. Menstrual health and hygiene (MHH) encompasses both menstrual hygiene management (MHM) and the broader systemic factors that link menstruation with health, well-being, gender equality, education, equity, empowerment, and rights. These systematic factors have been summarised by UNESCO as ‘accurate and timely knowledge; available, safe, and affordable materials; sanitation and washing facilities including safe and hygienic disposal; positive social norms (all these constitutes per definition MHM); plus informed and comfortable professionals, referral and access to health services; and advocacy and policy’. Throughout the document MHH is used, unless in the case of a reference or quote that uses the term MHM. FUNDING & INVESTMENT FOR PROGRAMME INTERVENTIONS Because of the cross-sectoral nature of MHH, a number of stakeholders are likely to be involved in financing MHH programme interventions, including a range of development funders, commercial actors, and social enterprises. This Investment Case recognizes that while these stakeholders have different priorities, financing mechanisms, and terminology; that all of these varied stakeholders have a potential role to play. In order to remain inclusive of these various financing approaches, the Investment Case uses both the terms ‘funding’ and ‘investment’ to refer to financing of MHH programmes in general, irrespective of the mechanism. In some places it may use these terms interchangeably for the sake of clarity and conciseness.While this document recognizes the crucial role of the private sector, especially around provision of access to menstrual products, the investment case does not include market based financing mechanisms for these, as it would be beyond the scope of this Investment Case. However, particularly national governments, parastatal organisations and banks are encouraged to explore policies and financing mechanisms to build and sustain the MHH marketplace. ABBREVIATIONS ASRH Adolescent sexual and reproductive health AYSRH Adolescent and youth sexual and reproductive health DIB Development Impact Bond FMCG Fast moving consumer goods LMIC Low and middle income countries MHH Menstrual health and hygiene MHM Menstrual hygiene management R&D Research and development SDG Sustainable Development Goals SRH Sexual and reproductive health WASH Water, sanitation and hygiene ORGANIZATIONAL NAMES ADB African Development Bank AFD French Agency for Development (France) BMGF Bill & Melinda Gates Foundation BMZ Federal Ministry for Economic Development and Cooperation (Germany) DGIS Directorate-General for International Cooperation (Netherlands) FCDO Foreign, Commonwealth & Development Office (UK) FSG Foundation Strategy Group GAC Global Affairs Canada (Canada) GIZ Gesellschaft für Internationale Zusammenarbeit (Germany) GMC Global Menstrual Collective HIF Humanitarian Innovation Fund NORAD Norwegian Agency for Development Cooperation (Norway) PSI Population Services International SDC Swiss Development Cooperation SIDA Swedish International Development Agency (Sweden) UN United Nations UNICEF United Nations Children’s Fund USAID United States Agency for International Development WSSCC Water Supply and Sanitation Collaborative Council 5 1. THE PURPOSE OF THIS DOCUMENT Many women and girls worldwide do not have the knowledge, skills, services, and products or support to ensure their well-being during menstruation. Due to the link of menstruation with health, education, water and sanitation, and socio-economic factors, these challenges are even more urgent for those who menstruate in low- and middle- income countries (LMICs). At the same time, there is evidence that ensuring good menstrual health and hygiene (MHH) will contribute to the health and well-being of women and girls and promote gender equality.1 While in many countries comprehensive MHH strategies are emerging and a growing global movement for MHH is unfolding, MHH is not a priority for many donors, governments or implementors. The funding levels are marginal and nowhere near what is required to address the challenges and needs. This investment case, developed in consultation with women, government leaders, implementers, commercial partners, advocates, activists, collaboratives, and funders aims to provide a concise, comprehensive, and compelling case for both why and how to fund/invest in MHH for the improvement of women’s and girls’ health and well-being. This investment case will encompass: • The case for a multi-tiered strategy to MHH that combines cross-sectoral programming, research, and advocacy. • The approach that should be taken to advance MHH from a global, national, country, community perspective in low- and middle-income countries. • Recommendations on the type of interventions, funding, research, and policy needed to advance MHH. While the document should primarily guide existing and tentative funders and investors, we hope that this document also provides a framework for coordinated programming by all relevant stakeholders on global and national level. Although MHH is a global concern including in high- income countries (HICs), this investment framework mainly focuses on low-and middle-income countries (LMICs) where the majority of women and girls who lack adequate MHH is located. 2. WHY INVEST IN MENSTRUAL HEALTH AND HYGIENE Menstruation is a normal and natural part of the reproductive system. On any given day, more than 300 million people are menstruating. Despite this, MHH remains a neglected component that affects the life course of many women and girls worldwide. It is estimated that currently about 500 million women and girls globally face constraints in their needs to manage their menstruation well, which is almost one fourth of the global female population of reproductive age.1 Particularly in LMICs, people who menstruate face barriers in all domains that determine their MHH and well-being. These domains include: 1. Access to knowledge and information about menstruation and its linkages to SRH. 2. Harmful socio-cultural and gender norms on individual, community, systemic and institutional levels as well as stigmas and taboos that affect women’s and girl’s menstrual health and their participation in public daily life. 3. Access to affordable, high-quality menstrual health products and materials which serve the users’ choice and needs. 4. Access to safe, private and well-managed Water, Sanitation and Hygiene (WASH) infrastructure and services, on a household, school, work and public level. 5. Global and national policies and strategies that provide the basis for MHH stand-alone or integrated programs and services. 6. Allocation of sufficient resources for implementation and integration of programs. 6 7. National schemes for menstrual product distribution and tax reduction on menstrual products as well as assurance of quality standards.1 2.1 MENSTRUATION IS A MATTER OF HUMAN RIGHTS Good MHH enables women and girls to exercise and enjoy human rights on the basis of equality. On the other hand, poor MHH, including lack of WASH, healthcare, people’s inability to take control over their body, stigmatization, and limiting social, cultural or religious practices “can negatively impact the extent to which they enjoy certain rights including those to education, work, and health”. While MHH is not a human right in and of itself, it is intricately connected to people’s ability to exercise their rights.2 2.2 MHH IS CRITICAL FOR ACHIEVING THE SUSTAINABLE DEVELOPMENT GOALS Menstruation and MHH is not explicitly mentioned under the goals and the related targets, and this inhibits attention to global and national monitoring of progress in MHH. However, given the multiple benefits and sectors in which MHH is situated, investments in MHH can support the achievement of several of the Sustainable Development Goals (SDGs).4 The following goals are related to the fulfillment of good MHH: 2.3 POTENTIAL IMPACT OF INVESTING IN MHH There is a growing base of evidence that shows that investing in MHH can positively benefit several areas across women and girls’ lives, such as economic benefits, participation in education, empowerment, health and mental health; and thus MHH is central to advancing gender equality as a whole. Interventions at the workplace, such as access to menstrual products and/or information, has shown to increase attendance and participation in economic activities.6,7,8 Similarly, creating access to MHH information, WASH infrastructure, and/ or menstrual products can have a positive effect on girls’ school attendance.9,10,11 In addition, by addressing stigma and taboo, as well as providing pain management for girls who are on their period can promote girls’ dignity and well-being in school and their engagement in (and out of) school activities. By increasing attendance and potentially decreasing or at least delaying drop-out, MHH interventions can have long-term effects on the well-being of people who menstruate. For example, one additional year of education in low income countries has in its turn been correlated with an average increase in income of 8-10% in the long term.12 When in school, girls are less likely to be married early or have children. When extending education, girls will have fewer children and her family will be healthier, wealthier, and better educated.13 Staying in school has also been linked to being less exposed to sexually transmitted infections.14 Positive effects of menstrual health interventions A failure to address menstrual and health needs of women and girls has a detrimental impact on all areas of their lives and violates their fundamental right to equality as well as the right to participate in public, economic, social, and cultural life. — United Nations Experts (Chairs and Special Rapporteurs) on the occasion of International Managing healthy menstruation is a vital part of the United Nations’ efforts to support countries in achieving the 2030 Agenda for Sustainable Development—our blueprint for peaceful, prosperous societies on a healthy planet. It is an essential step towards gender equality and will contribute to improved education and to water and sanitation services. All of these are important goals in the 2030 Agenda. — Amina Mohamed, Deputy Secretary-General of the United Nations, in article for CNN, 20185 7 have also been found on empowerment outcomes, such as confidence to manage menstrual health at home and in school.12,14,15 In terms of health, poor menstrual health practises have been linked to reproductive tract infections (RTIs) and urinary tract infections (UTIs),15,16 whereas provision of menstrual cups and sanitary pads has been found to reduce risks of sexually transmitted infections (STIs) and to lower bacterial vaginosis risk.14 There is a general consensus that increased knowledge about the menstrual cycle can lead to increased bodily literacy and autonomy,1 which is likely to have a positive impact on women and girls’ sexual and reproductive health. For example with regard to family planning, knowledge of contraception- induced menstrual bleeding changes can enable women and girls to make informed bodily choices about contraception method use and increase the continuous uptake, mitigating contraception non-use or discontinuation.17,18 Moreover, improved knowledge of menstruation can help women and girls to identify broader SRH problems, such as abnormal vaginal bleeding, which can be a signal of pathogenic processes such as reproductive tract cancers.19 Some anecdotal evidence points towards the negative effects of pressures and expectations at menarche and gender norms related at the onset of puberty.20 There have been studies relating access to sanitation to mental health related outcomes,21 and preliminary evidence points towards positive effects of menstrual health interventions on mitigating feelings of embarrassment and insecurity.11 Although this is only a selection of evidence, and whilst acknowledging that there is some contradicting evidence and more research is needed, we can conclude that investing in menstrual health has the potential to improve several aspects of women and girls’ lives. Moreover, investing in girls and women has been known to create a ripple effect leading to healthier and stronger families, reduced poverty, greater gender equality,23 healthier populations, and stronger economies. PROGRAMME EXAMPLE: PSI ZIMBABWE MHH INTEGRATION INTO ASRH/HIV PROGRAMMING & ANTI-STIGMA CAMPAIGN22 PSI Zimbabwe, with support from the Swedish Embassy, implemented an adolescent menstrual health programme in 2018 that focused on (1) integrating MHH messaging into existing SRH/ HIV programming for adolescent girls and (2) developing a communications campaign targeted at influencers and the broader community to normalize menstruation and encourage discussion about menstrual matters. Cutting across multiple implementation areas— knowledge and awareness, health services, and positive social norms and practices—the project aimed to help girls understand what was happening to their bodies, accept that it is normal, and take ownership of their changing bodies. At the community and influencer level, the project aimed to break the silence and shame around MHH, ignite conversations to support adolescent girls, and create a movement of people who support adolescent girls’ menstrual journeys. Ultimately, the project witnessed high levels of engagement with the campaign, as well as an increase in uptake of contraceptive methods: from an average of 144 adolescents who became a user of a modern family planning method in the period October 2018 to May 2019 to an average of 447 adolescent contraceptive users in the period June 2019 to September 2019. This highlights the importance of integrating MHH into SRH communications, counseling, and services in order to help women and girls better understand the connection between menstruation, contraception, and fertility; and to have greater bodily autonomy. 8 Despite this, the perceived lack of evidence continues to be a barrier for many potential funders and investors— though not all. We have identified several key areas for focusing our evidence efforts that can help trigger funding or investment. These include: • Outcome level-evidence: Studies that can help support the link between MHH and economic, health, social, and education outcomes, and specifically outcomes that relate to the SDGs. • Global Data Consolidation: Develop, use, and report common metrics to contribute to building the evidence base quickly and at scale and to demonstrate progress and impact. • Cost-effectiveness: Conduct studies and program evaluations on the cost-effectiveness of MHH programs related to outputs and outcomes. • User-Centered Insights: Better bring the user’s voice and perspective to the evidence base through success stories and studies focused on women and girls’ experiences, social contexts, and influencers.a • Private sector: Develop commercial and/or private sector business cases for product & supply chain partners. 3. CURRENT STATE OF FUNDING/INVESTMENT Since 2010, funding allocated to MHH programming has particularly focused on schools and menstrual products through WASH and/or education interventions (including Bill & Melinda Gates Foundation and Global Affairs Canada) followed by funding that strengthened MHH integration into humanitarian work (including HIF) and the workplace (including USAID). In addition, a good amount of funding was allocated to (operational) research or development of research tools to advance the evidence base for MHH (including The Case for Her). A small but increasing number of national governments have funded menstrual product distribution mainly for schools. But despite increased attention to the issue of MHH and increased number of implementation partners, institutional funding has not much increased. Overall, funding levels are marginal and nowhere near what is required to address the challenges and needs. 3.1 CURRENT AND PAST FUNDERS Table 1 is a non-exhaustive overview that provides a rough picture of trends. (Note: Spendings by individuals and households are not included here, as they are not funding or investing in programmes.) Institutional Donors Foundations / Philanthropy Multi-Laterals / Multidonor Funds National Governments Private Sector AFD BMZ FCDOb DGIS GAC NORAD PEPFAR SIDA Wateraid Sweden USAID BMGF CIFF af Jochnick Foundation Osprey Foundation Segal Family Foundation Sid & Helaine Learner The Case for Her Vitol Foundation Sall Family Foundation WorldBank Amplify Change Global Fund For Women Grand Challenges Canada Humanitarian Innovation Fund WSSCC India Indonesia Kenya Nepal Nigeria South Africa Uganda Johnson & Johnson Kimberly Clarke P&G TABLE 1: WHO INVESTS (PAST AND PRESENT INVESTORS) a. In 2017-2018, The Case for Her invested in user-centred design to support PSI Nepal to better understand the young consumer journey in MHH with the aim to design a user- centred solution with the potential for scaling up. b. Foreign, Commonwealth & Development Office, formerly “Department for International Development (DFID)” 9 The FSG report from 201620 mentions that “ institutional donors such as USAID, SIDA, and FCDO fund menstrual health efforts as part of larger grant funding focused on water, sanitation, and hygiene or education programming, making it difficult to assign funding flows directly to menstrual health.” As such, the funding flow to specific MHH aspects and regions/ countries can only be estimated. This in turn, makes it difficult to track MHH funding streams with the aim of identifying funding gaps and to hold funders accountable to funding commitments. From the analysis of the available information, it can be derived that the focus of investment is on menstrual health products, followed by WASH (where costs tend also to be higher due to infrastructure) and education, while fewer funds go to addressing social norms and policy.1 Some adolescent-focused MHH programs have been incorporated into adolescent and youth sexual and reproductive health (AYSRH) education, but integration with SRH services is still limited. Funding allocations correspond to the progress made in the various areas of MHH (see chapter 4.2). While certain tools exist to track different sectoral funding—for example, European donor support for sexual and reproductive health and family planning (e.g., Countdown2030 Europe), donor targets and commitments in the AIDS response (UNAIDS) and investments to make informed decisions for sanitation, drinking-water, and hygiene in the Global Analysis and Assessment of Sanitation and Drinking-Water (GLAAS)—such funding tracking tools do not exist specifically for MHH. Coordination is needed in order to effectively track funding and investments, and to ensure that all critical aspects of MHH are being funded. These coordination mechanisms are required at multiple levels (global, national, regional) and among various groups of actors. These types of coordination mechanisms may include donor coordination groups, multi-stakeholder and multi-sectoral alliances, partnerships with specific focus (research, humanitarian, etc.), and project- and programme-based partnership structures. There are various examples of development challenges that are complex and require multi-sectoral solutions from where the MHH community can find inspiration to move forward. The cases of the African End to Child Marriage movement, HIV/AIDS global and national coordination mechanisms, the Roll Back Malaria coordinated response, are some interesting cases to explore. Some coordination mechanisms for MHH already exist but do not necessarily track funding and investments, and are primarily designed for civil society organizations (CSOs). These include groups such as the Global Menstrual Collective (GMC)c and national multi-stakeholder coalitions and working groups (often led by a ministry) in countries, such as Kenya, Nigeria, South Africa, and Tanzania. THE CASE OF THE AFRICAN END TO CHILD MARRIAGE MOVEMENT Ending child marriage is linked to wide range of development priorities such as poverty alleviation, health and human rights. As such, its solution requires a multi-stakeholder and multi-sectoral approach, involving sectors like education; global health; gender-based violence; youth programming; democracy, human rights and governance; economic growth and workforce development; conflict and humanitarian crisis; agriculture, energy and the environment; and food security and nutrition.24 Over the past 10 years we have seen how the end to child marriage movement has made great advance in moving from global awareness to materialising the commitment of international donors, national governments and civil society. In the last 10 years the movement has accomplished: increased global and regional commitments to end child marriage (e.g. inclusion as priority of target 5.3 of the SDGs); increased national policies and strategies; increased programming to end child marriage; increased political and public recognition; increased consensus on approaches and solutions (e.g. TOC, indicators); and increased funding from international donors and national governments. Two key focus areas for advancing in the beginning were making the case that ending child marriage is vital (increasing global awareness) and working better together via collaboration and coordination.25 c. The Global Menstrual Collective includes representatives from UN organizations, academia, government, funders, private sector, existing coalitions, advocacy groups, youth-focused organizations, religious groups, independent consultants, and international non-governmental organizations. The Global Menstrual Collective drives, guides, and promotes investment in menstrual health and hygiene through evidence-based advocacy. 10 Within the MHH community there is common agreement on the need to strengthen, leverage and expand the already existing coordination mechanisms at global and national level, as well as on the need to include accountability mechanisms. At a global level, there is understanding of the importance to reinforce the work of the GMC. And at a national level, several solutions for coordination mechanisms could be applied, depending on the specific context and needs of each country. At country level — potential suggested solutions for greater coordination:d • Build and invest in national coordination mechanisms, led by government, and that include all relevant departments and stakeholders from all different sectors related to comprehensively address MHH cross-sectorally. There are already good examples in Tanzania, Kenya and South Africa. • To appoint MHH lead focal points in-country, that takes the leadership of coordinating MHH implementation across sectors and in collaboration with civil society and other relevant stakeholders. • A national implementation plan and/or policy that identifies roles and responsibilities among the different stakeholders and sectors, which is aligned with national indicators and global commitments. 3.2 WHY DONORS FUND OR INVEST During the preparation of this document, several donors and key stakeholders were interviewed. From these conversations, despite the need for evidence that supports investing in MHH, there was general agreement that MHH is an essential aspect of women and girls’ life and the importance of supporting the improvement of MHH for all women and girls. Understanding the interests and motivating points of key funders/investors to fund the issue could help to understand how MHH funding can be sustained or solicited from different potential donors. Menstruation is a key component of a woman’s life. However, menstruation and menstrual hygiene management (“MHM”) is still a big taboo in many cultures, and has been consistently overlooked, underestimated and underfunded in the developing world. Leveraging the opportunity to educate adolescent girls at the onset of their reproductive life through MHM initiatives can potentially have a significant impact on education, health, teenage pregnancy, HIV transmission, gender equality, increasing the chances for young women to contribute actively in the economic growth and political stability of their countries. MHM is therefore a relevant tool to be explored to help reach the Sustainable Development Goals focusing on good health and wellbeing (n°3), quality education (n°4), gender equality (n°5), clean water and sanitation (n°6), and reduced inequalities (n°10). — French Ministry of Europe and Foreign Affairs & AFD (from 2-page document summarising the rationale for the MHM Development Impact Bond) Empowerment starts at school. But girls can’t focus on their studies and life choices if they’re worried about turning up in the first place; if every month they’re worried about being able to buy sanitary protection or embarrassed or in pain at school. (…) Across low and middle-income countries it is estimated that over half of all women and girls are forced to use homemade products, rags, grass, paper, to manage their periods. Period poverty in many countries means not only a lack of access to products, but to information and appropriate water, sanitation and hygiene facilities. (…) Today I can commit the UK to upping our international ambition, to thinking bigger and leading a new global campaign of action to ensure that we end period poverty and shame by 2030 – a campaign that breaks the global silence and tackles the stigma and taboo surrounding menstruation, that ensures that all women and girls understand their bodies, have access to information, safe water and sanitation and to the menstrual hygiene d. These recommendations are presented to give an idea of the kind of coordination mechanisms that could potentially work in-country. We recognise that each country’s political context and governance system are different. 11 products they need to manage their periods free from infection or stigma. A campaign that ensures that girls are not forced into early marriage, child bearing or early school drop-out as soon as they get their first period. A campaign that means women are not forced to drop out of work or live in isolation during their period. — Penny Mordaunt, British Minister for Women and Equalities and Secretary of State for International Development at International Women’s Day 201926 Menstrual health is underfunded during the best of times and is now [at the time of COVID-19] at an even bigger risk of being deprioritized. This is why a rallying cry was born earlier this year: “Periods don’t stop for pandemics”. The Case for Her will continue working with our partners and allies in the MH space to increase funding and bring awareness to this key issue. We’re fueled by the commitment of advocates globally and see opportunities increasing and awareness building through the MH day campaigns and all the years of hard work done carried out by individuals, grassroots, national and international organizations. The time for action is now! — Cristina Ljungberg and Wendy Anderson, co-founders of The Case for Her from “A Look back at Menstrual Health Day” 202027 In many developing countries, girls cannot go to school during their period because they lack knowledge about menstrual hygiene, menstrual products and school toilets. Good menstrual hygiene therefore contributes to better education for girls and women. If a girl stays in school, the risk of being married as a child or having children when she is not yet ready is reduced. A completed school education also leads to better career opportunities. This has a positive effect on the social and economic development of society as a whole. For this reason, it is important that menstruation is no longer perceived as something that girls have to be ashamed of and hide. That is why the topic is extremely important to BMZ. — Dr. Maria Flachsbarth, German Parliamentary State Secretary at MH Day 201928 4. THE OPPORTUNITIES FOR FUNDING/INVESTMENT 4.1 INVESTMENT FRAMEWORK The framework below can help funders and implementers strategically focus funding/investment and implementation for holistic MHH programming. The table below aims to outline the many components and activities of comprehensive MHH programming and provides an outline of where and how different partners can engage in MHH based on their existing competencies and expertise. While different country contexts will have varying needs and no project is expected to implement all components, this framework and table aim to provide guidance for understanding the entire MHH landscape and identifying context-specific gaps that are ripe for investment. To ensure this framework is implemented and contributes to existing policies, structures for coordination by actors across these varied activities is needed. 4.2 PROGRESS AND GAPS While there is growing momentum in supporting MHH service delivery, progress has not been made uniformly across all implementation areas and therefore key gaps to improve MHH for all still remain. In their 2020 report, FSG identified six opportunity areas for action including: build the data and evidence base; improve knowledge and awareness of menstruation; innovate to create a new range of menstrual products and increase menstrual product access; account for MHH needs in the design of WASH solutions; and address stigma and taboos related to menstruation.1 12 FIGURE 1: MHH FUNDING/INVESTMENT FRAMEWORK WELL BEING OF WOMEN AND GIRLS MHH FOR ALL GENDER SRHEDUCATION ENVIRONMENT WASH RESEARCH AND INNOVATION POLICY MENSTRUAL PRODUCTS Aims: Women and girls have access to affordable, appropriate, safe, and sustainable menstrual products. KNOWLEDGE AND INFORMATION Aims: Women and girls understand their menstrual cycle, can access self-care, and have agency. Information is correct, age-appropriate, and culturally sensitive. POSITIVE SOCIAL NORMS AND PRACTICES Aims: Overcome menstruation-related stigma, taboos, harmful practices, and restrictions within society. HEALTH SERVICES Aims: MHH service provision is integrated in SRH services (FP/ RH/SH counseling, post partum care, post abortion care). WASH INFRASTRUCTURE AND SERVICES (INCLUDING DISPOSAL) Aims: Access to safe, hygenic, well-functioning and maintained WASH infrastructure and services. Ministry of trade Social enterprise WASH implementer Ministry of education Communities Social marketing Education implementer SRH implementer Digital / media Commercial partner WASH service provider Ministry of health Ministry of public works Legend: Fo un da ti on al s ec to rs Im pl em en ta ti on a re as a nd a ct or s 13 Implementation Area Progress Progress - Increases in: Key Gaps and Issues - Lack of: Menstrual products Medium- Good • Local businesses and social enterprises • Innovations in the product space, including sustainable solutions • Attempts to integrate products with other MHH components • Free or subsidized products • Emergence of product standards for reusable products • Market landscaping, research & facilitation • Innovations • Standardization • Strong supply chain • Sustainable and environmental friendly solutions for disposal management • Affordability of products for low income households • Small enterprises in LMICs face constraints to operate on high scale Knowledge and information Medium • Programmes (SRH, WASH, gender) that recognize and include MHH education as standalone or integrated topic • Digital educational tools : mobile platforms, smartphone apps • MHH integration into CSE for schools • Moving beyond CSE in schools • Young learners and adult education • Capacity building of teachers and trainers • Cost-effective solutions SRH Services Slow • Family Planning Counseling: Recognition of contraceptive induced bleeding changes • Technical guidance on integration of MHH and SRHR for practitioners • MHH capacity development (incl. menstrual disorder training) for all SRH service providers (training and facilitation resources) • Integration into SRH service delivery protocols and supervision, quality assurance systems, referral systems • Integration of MHH into SRH services (Service provision and Self Care) Positive social norms and practices Medium • Increased media attention toward MHH • Increasing advocacy, awareness raising and mobilisation , especially around MH Day • In 2019, the UN issued a call to break menstrual health taboos • Movies, documentaries, and influencers speaking about consequences of poor MHH and to address stigma and taboos • Involvement of boys and men, religious and local leaders • Mainstreaming MHH in public and private discourse • Addressing restrictive sociocultural norms and harmful practices linked to menstruation on community and household level through comprehensive programs WASH Infrastructure and Services (including Disposal) Medium • Recognition to address gender and MHH needs through inclusive approaches, including education • Inclusion of MHH at advanced level for the SDG WASH in schools indicator29 • Access of WASH in LMIC, across households, schools and health centers and other institutions • Gender-sensitive design, especially of toilets • Low-cost and environmental friendly disposal TABLE 2: OVERVIEW OF PROGRESS AND KEY GAPS 14 Implementation Area Progress Progress - Increases in: Key Gaps and Issues - Lack of: Research & Innovation Slow- Medium • Research initiatives on MHH and evidence generation via RCTs • Collaboration between researchers, universities and practitioners • Guidance on M&E • Innovation in product development and social marketing • There is still contradictory, anecdotal evidence. Need for further conclusive research Policy Slow- Medium Global • Recognition at UN level • Development or integration of MHH Policies and Strategies among institutional donors30,31 National • Stand-alone policies and integration of MHH into school and WASH guidelines32 • Free distribution of menstrual pads, vouchers • Tax reduction or elimination of taxes on menstrual products • Quality standards for menstrual products Global • Global indicators to measure progress on MHH • Coordination and tracking mechanisms of investment and progress National • Policies on MHH in many countries and its integration into other relevant sectors • Implementation of these policies especially on local level, due to conflicting topics and cross-cutting • National product standard policies • Product tax policies • Multi ministry coordination and allocation of sufficient financial resources • Ensuring equity and inclusion in programming Area Schools Out of schools Health centers Workplace Households Humanitarian settings Progress Good Slow-Medium Slow Slow -Medium Medium Medium The above also corresponds to the analysis that most programmes focus on adolescent girls, and fewer on older women. However, the linkages to SRH and the integration of MHH into SRH programmes for women and girls across all ages is increasingly recognized and fostered.1 While some specific attention has been paid to women and girls with disabilities and the humanitarian sector, other excluded groups (transgender, non-binary, and intersex individuals) remain out of focus.4 Overall, it is critical to continue addressing stigma and taboos around MHH at all levels (local, national, international) as it is the root cause that results in the neglect of the issue. This is critical to foster an enabling environment for policy advancement, but also to ensure success of programmes by involving the community (including parents, males, and religious leaders). 15 This global overview of progress and gaps outlined above likely varies across regions and for a particular country, even across an urban-rural setting. We therefore recommend adapting the information in these tables to the local context as required, and using it as a tool to help identify progress and gaps. 4.3 PRINCIPLES OF FUNDING/INVESTMENT • Multi-sectoral: Addressing MHH requires a holistic and therefore multi-sectoral approach, which ensures that MHH is addressed in the fields of public health, education, SRHR, gender equality, water hygiene and sanitation (WASH)33, and the environment. It is also cutting across various locations: household, schools, out-of- school, workplace, and institutions (especially health centers), and humanitarian settings. A multi-sectoral approach will also be needed to implement programmes at scale, ideally through working with and strengthening existing government systems. • Leave no one behind: In the MHH context, the Leave No One Behind34 pledge and framework means actively reaching vulnerable and often excluded populations (people with various genders, people with disabilities, homeless, religion/caste/ minority populations, etc.), as well as populations in emergencies. Furthermore, the concept also applies to consciously consider and address inequalities on national, regional and international level. • Rights-based approach: Applying a rights-based approach into MHH provides a useful framework to analyse the obligations of duty bearers and the rights of the right holders, as well as which rights are affected by the lack of MHH (such as human dignity, education, health, gender equality) and the enabling rights (such as water and sanitation, education, health). The principles of a rights-based approach are complementary and reinforce gender equality and inclusion.4 The rights-based approach also provides opportunities for lobbying and advocacy at international, national, and local level. • Evidence-based: Base investment and programming on existing evidence and best practices, and include the collection and use of evidence within the programming cycle. • Context-specific: Due to the varying environmental and socio-cultural contexts—one size does not fit all. Differences in needs and available resources within and across regions, nations, and communities need to be acknowledged. Likewise, programs should be designed in a user-centered or participatory manner as much as possible to ensure they meet the context-specific needs of women and girls. CONCLUSION This investment case provides a comprehensive case for both why and how to fund/invest in MHH for the improvement of women’s and girls’ health and well-being. MHH is a human rights’ issue, supports the achievement of several SDGs, and is essential to advancing gender equality. There is a growing base of evidence that supports investing in MHH, showing how it can positively impact several aspects of women and girls lives, such as improvement of economic benefits, participation in education, empowerment, health, and mental health. There is increased interest and progress in MHH; however, the funding to MHH does not yet match the needs of millions of women and girls worldwide who face restrictions and limitations to manage their menstruation with dignity and safety. This investment case provides a comprehensive analysis of the critical barriers to funding and investment and progress made so far in terms of investment and areas of work within MHH, as well as a framework to guide investment, programming, lobby and advocacy, and research from a multi-sectoral approach. Key recommendations to catalyze funding for MHH: 1. MHH is a critical component for the attainment of Human Rights, several SDGs,gender equality and women’s and girls’ health and well being as well as socioeconomic and educational opportunities. Funding MHH interventions can fulfill these goals 16 and is an opportunity to increase the evidence base. In terms of increasing evidence the main recommendations are: • Consolidate evidence on outcome level research that links MHH with health, economic, education and social outcomes. • Develop and use common and clearly defined metrics, indicators and quality standards in MHH programming to facilitate the tracking of progress and impact. 2. Multi-sectoral and multi-stakeholder programming in MHH is essential to achieve a positive and sustained impact on every person that menstruates and to remove menstrual barriers. For strategic and effective programming, the recommendations are: • Focus funding and programming on MHH based on an informed strategic analysis of the different areas of intervention in MHH (products, information, health services, WASH infrastructure, social norms and practices). Use the investment framework to make context specific analysis to enable informed decisions and strategies for funding and programming. • At country level, invest in cross-sectoral policy development and related national implementation plans that guides investment and coordinates programming. Identify and agree on key outcomes and indicators (in a Theory of Change) that are linked to health, economic, social and education outcomes, aligned with the SDGs. • Scale efforts to address stigma and taboos around MHH at all levels (local, national, international) to create an enabling environment for funding. • Apply rights-based approaches, leave no one behind principle and women-and girls- centred programming. 3. Strengthening collaboration as a community of implementers, funders, advocates, researchers is necessary to catalyze funding. Better coordination is needed to promote funding, track funding and progress and to be held accountable as a community is key for success. Key recommendations at global and national level are: • Improve coordination at international level by strengthening, leveraging and expanding existing coordination mechanisms like the Global Menstrual Collective. And, for example, the creation of a donor/investors working group within or outside the GMC to track funding in MHH can be a useful solution. • Invest and build national coordination mechanisms led by national governments, where all relevant sectors and stakeholders can participate to facilitate integration of MHH. Appoint a MHH focal point from the government who leads policies, strategies and coordination of cross-sectoral implementation following a national implementation plan that includes clear role division and responsibilities and is aligned with national and global MHH commitments. 17 Donor Knowledge & information Menstrual products WASH infrastructure and services Positive social norms Health services Research Policy Bilateral Aid Agencies AFD x x x x BMZ x x x DFID x x x GAC x x x x USAID x x x Foundations BMGF x x x x x x CIFF x x x x af Jochnick Foundation x Segal Family x Sid & Helaine Learner x x x The Case for Her x x x x x Vitol Foundation x x World Bank x x x x x Grand Challenges Canada x x HIF x x x x x ANNEX 1 DONOR LANDSCAPE: FUNDING/INVESTMENT AMOUNTS AND FOCUS AREAS The following is an overview of known investment areas of funding agencies working with menstrual health and hygiene (shaded categories). It is not comprehensive but aims to provide a summary of previous investments in the space. 18 Donor Knowledge & information Menstrual products WASH infrastructure and services Positive social norms Health services Research Policy Domestic Govt. of South Africa x x UK, Scotland x x Private Sector Proctor & Gamble x x x Additional funding agencies working in MHH but details of investment areas not listed: DGIS, NORAD, SIDA, Osprey, Amplify Change, Johnson & Johnson, Kimberly Clark 19 ACKNOWLEDGEMENTS This report was assembled in partnership with Sandy Garcon and Stephanie Kim from Population Services International (PSI); Judith Brauer, Odette Hekster, and Madeleine Moore from Population Services International (PSI)-Europe; Hilda Alberda and Jimena Duran from Simavi; Wendy Anderson, Lindsey Higgins, and Cristina Ljungberg, from The Case for Her; Ina Jurga and Thorsten Kiefer from WASH United; and in collaboration with the Global Menstrual Collective. The report was developed in consultation with government leaders, implementers, commercial partners, advocates, activists, collaboratives, and funders through multiple regional consultations and stakeholder interviews held between October 2020 and November 2020. The consultations and interviews led to key outcomes to reinforce the investment case and an agreement on how to move forward as a community to scale up investment in MHH. For any inquiries, please contact Hilda Alberda, Director of Monitoring, Evaluation and Learning at Simavi (; Odette Hekster, the Managing Director at PSI-Europe (; Ina Jurga, International Coordinator for Menstrual Hygiene Day at WASH United (; Stephanie Kim, Associate Manager of Advocacy and Communications at PSI ( Disclaimer: This report is not prescriptive in nature but provides a framework to guide investment, programming, lobby and advocacy, and research from a multi-sectoral approach for possible adoption and adaption. All statements and conclusions, unless specifically attributed to another source, are those of the authors and do not necessarily reflect those of any individual, organization, or institution consulted. 20 REFERENCES 1. FSG. (2020). Advancing Gender Equity by Improving Menstrual Health, Opportunities in Menstrual Health and Hygiene. 2. Wash United. (2017). Understanding Menstrual Hygiene Management and Human Rights. Human Rights Watch. 3. United Nations Human Rights Office of the High Commissioner. (2019). Pages/DisplayNews.aspx?NewsID=24256&LangID=E 4. Unicef.( 2019). Guidance on Menstrual Health and Hygiene. menstrual-health-hygiene-2019.pdf 5. Amina J. Mohammed. (2018). It’s time for women and girls to speak about their period. CNN opinion. 6. Her Project. (2010). Female Factory Workers’ Health Needs Assessment: Bangladesh. en/document/view/37192581/female-factory-workers-health-needs-assessment-herproject 7. Krenz et al., (2019). 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