Improving Menstrual Hygiene Management in Emergencies: IFRC's MHM Kit

"A key strength of this innovation process is the effort grantees have made to understand and incorporate the varying needs and preferences of beneficiaries and to seek their feedback on the products provided."

This case study explores International Federation of Red Cross and Red Crescent Societies (IFRC)'s innovation process in developing and testing a comprehensive relief item to meet more effectively and appropriately the menstrual hygiene needs of women and girls in emergencies. It is based on a review of project literature and nine interviews with project staff, partner staff, advisors, and wider stakeholders across the humanitarian sector over a period of 2 months in 2015.

As the case study explains, the context-specific nature of menstrual hygiene means that consulting beneficiaries about their practices, preferences and priorities is crucial. Many cultures have different practices for managing menstruation as well as restrictions on the actions and interactions of menstruating women and girls. This can prevent discussion and engagement with menstruation, shape or limit coping strategies, and enhance vulnerability. Furthermore, disasters and displacement can disrupt usual coping strategies and support structures, including access to sanitary protection materials and proximity to friends and family members who can offer advice. Risks associated with inadequately addressing MHM include a loss of dignity, greater vulnerability to gender-based violence (if women must wait for dark to change pads), risk of irritation and infection, and risk of dropout of girls and women from education, employment and other activities. Until recently, the humanitarian response community has neglected the complex menstrual hygiene needs of women and adolescent girls. Effective MHM in emergencies requires an interdisciplinary, multifaceted approach, encompassing culturally appropriate sanitary materials, latrines, and bathing areas designed with women's safety and menstrual hygiene needs in mind, appropriate means of disposal or care of used sanitary materials, and relevant information on managing menstruation.

To address the multifaceted nature of menstrual hygiene management (MHM), IFRC used a kit-based approach, including appropriate sanitary and hygiene items along with training for staff and information for beneficiaries. They developed two MHM kits - one containing disposable pads (Kit A) and the other reusable pads (Kit B) - with the aim of comparing the two. In addition to sanitary pads, each kit contains a selection of additional items needed to effectively and hygienically manage menstrual flow, such as underwear, soap and a bucket, and educational materials. An initial trial of the kits was developed in Burundi in 2012, supported by the Norwegian, Netherlands and British Red Cross Societies. In 2013, 3 additional pilots were initiated in Madagascar, Somalia, and Uganda with funding from the Humanitarian Innovation Fund (HIF), with the aim of testing the kits in a wider range of locations. Kit contents were developed through ongoing consultation with the women and girls who would be their users. The kits and accompanying educational materials have thus evolved over the trials in response to emerging findings from focus group discussions (FGDs) and surveys with beneficiaries in each location. For example, following FGDs in Somalia, a third type of kit (Kit C) containing both reusable and disposable pads was developed to account for seasonal variations in water availability. Once the trials are completed, detailed specifications for MHM kits will be included in the Red Cross/Red Crescent (RC/RC) Emergency Items Catalogue (EIC), an open-source resource. These will be available to guide humanitarian actors to effectively address MHM needs in new contexts.

To understand how this transpired, the case study uses a model based on 5 stages:

1. Recognition of a specific problem, challenge, or opportunity to be seized - Evaluations of the IFRC's response to the 2005 earthquake in Pakistan highlighted issues with the cultural appropriateness of its hygiene kits. Libertad Gonzalez had worked in the WatSan department at IFRC for a number of years and believed it would take substantive evidence from the field to change IFRC's approach to menstrual hygiene. "It is indicative of the barriers to change that, despite the messages emerging from evaluations and feedback from beneficiaries, it took a champion within the organisation several years to catalyse this innovation."
2. Invention of a creative solution or novel idea that addresses a problem or seizes an opportunity - Libertad Gonzalez attended an emergency environmental health forum in London in 2012, where she learned about a study on MHM in emergencies, commissioned by the United Nations Children's Fund (UNICEF) that highlighted, among other things, the need for information on menstrual hygiene and appropriate communication and distribution systems. Gonzalez reached out to UNICEF. UNICEF was open about its learning and shared its research protocols and other tools, which the IFRC team later used as examples to inform the development of its own research protocols. Another key event in the invention of this innovation was that AFRIPads - a social business in Uganda producing reusable sanitary pads - sent a sample of its pad, unsolicited, to IFRC.
3. Development of the innovation by creating practical, actionable plans and guidelines - After funding was secured, Libertad Gonzalez handed the management of the project over to the IFRC's East Africa Regional WatSan Unit, which was to implement a field-test together with the Burundi Red Cross. This reflects the decentralised structure of IFRC. At the development stage, the Burundi Red Cross conducted FGDs and a baseline knowledge, attitude, and practices (KAP) to understand existing MHM practices and preferences of women and girls in a camp for Congolese refugees. IFRC ensured the discussions covered training, information, washing, drying and storage of items, as well as the pads themselves. The contents of the MHM kit were developed on the basis of the findings.
4. Implementation of the innovation to produce tangible examples of change, testing it to see how it compares with existing solutions - In early 2013, the Burundi Red Cross distributed the kits to 2,000 women and girls. Red Cross volunteers conducted one- and 3-month follow-up surveys and further FGDs, gathering feedback from beneficiaries on the performance of the kits and on their impact on hygiene, knowledge, and dignity. Key informant interviews (KIIs) were also conducted with camp management officials, the health clinic nurse, and women's group leader. The overall recommendation from the Burundi trial was that further field-tests were needed in different emergency and cultural contexts before specifications could be added to the EIC. So, the team identified potential improvements to the kits, the training, and the information, education and communication (IEC) materials, as well as to the distribution and research processes. A member of the team in Nairobi travelled to Burundi at the end of the pilot to see what could be improved on in the implementation process itself. A learning table was completed, with recommendations for improving procurement, distribution, FGDs, and monitoring surveys. The regional office shared lessons learnt in the Burundi pilot with National Societies in Madagascar, Somalia, and Uganda. IFRC provided draft FGD guidelines and KAP survey questionnaires to the National Societies, which were then revised and made context-specific. Each National Society then conducted baseline FGDs and KAP surveys in August and September 2014, the findings of which were used to finalise the contents of the kits and the IEC materials. MHM kits were developed and procured for all 3 locations, and were distributed by National Society volunteers in April-May 2015. The one-month post distribution survey was held in June-July 2015 and the 3-month survey and FGDs in September 2015.
5. Diffusion of successful innovations - taking them to scale and promoting their wider adoption - National Societies and the team in Nairobi have worked to ensure close communication and collaboration with other humanitarian actors throughout the innovation process. Information-sharing and discussion forums on MHM have been initiated in Nairobi, bringing together regional humanitarian water, sanitation, and hygiene (WASH) actors. In addition, the WatSan Mission Assistant, an online platform hosted by IFRC, now features a dedicated page for MHM, featuring findings from the Burundi pilot, IEC materials in English, French, Swahili and Kirundi, and links to relevant articles. A training module on MHM has been developed for IFRC national and regional disaster response teams. In addition, there are examples of further application of the MHM kits and the participatory methodology in the East Africa region.

The research team used evidence collected for this case study to assess the success of the MHM innovation process against 3 criteria. Overall, this process was highly successful in increasing evidence and learning; for example, pre- and post-tests at training sessions demonstrate improvements in National Society participants' MHM-related knowledge. In each location, FGD participants raised a number of ways the content of the kits could be improved and better tailored to their needs, emphasising the importance of post-distribution followup. However, overall, the MHM kits were well received by pilot participants, with positive impacts recorded in relation to health, knowledge, and dignity. As a number of key diffusion activities, such as inclusion in the EIC, are still outstanding, it is too early to assess success in adoption, but current resourcing for diffusion of the kit itself is weak and reliant on National Societies choosing to purchase the kits for their programming. It is also unclear whether there are further plans to diffuse the participatory operational research methods that formed one of the innovative aspects of this project.

Next, the case study explores 6 factors generally held to be fundamental to successful innovation processes and the way in which each works in the context of MHM. In brief:

• Managing relationships and setting common objectives - "The presence of a focal person for the project in Nairobi who would manage relationships with National Societies helped drive the project forward. The loss of this person delayed implementation of the project. Regular communication between the regional office and National Societies has helped make the project a collaborative effort in the early stages: interviewees identified close relationships between the national and regional offices as being a key strength of the project."
• Dividing tasks and responsibilities - "Ownership by National Societies has been conducive to the progression of the innovation. There was significant enthusiasm among National Societies about the pilots, which has enhanced the momentum behind the innovation process. National Societies also built on their existing relationships with other partners in pilot locations (e.g. other humanitarian agencies and governments) to ensure communication and collaboration."
• Resourcing an innovation - "IFRC's success in securing funding was driven by the motivation and enthusiasm of individual staff members, who helped move the project forward."
• Flexibility of process - "The flexibility of the process, in particular the use of strong feedback loops in the design of the intervention, were viewed as supporting the development of an improved solution, as well as enhancing learning and evidence."
• Assessing and monitoring risk - "Little formal risk assessment was undertaken for the Burundi pilot, but risks were identified, discussed and managed as they came up through strong communication between team members and between the Nairobi and country offices, and by regular visits."
• Drawing on existing practice - "Time was taken to find out about existing practices, needs and preferences. The contents of the kit and the development of country-specific IEC materials were based significantly on this research. In addition, project leaders had good understanding of existing practices."

Other factors noted as potentially contributing to this innovation were: the presence of a high-level champion (Libertad Gonzalez), effective problem identification, and good knowledge on the part of project leaders of their insititutional environment. Several emerging lessons are identified for best practice in innovation, such as: "[H]umanitarian actors do not seem to spend sufficient time on understanding the risks posed to affected people when trialing innovations that involve direct engagement with affected people in a crisis."

This study is one in a series of 15 case studies, undertaken by Active Learning Network for Accountability and Performance in Humanitarian Action (ALNAP) in partnership with Enhancing Learning & Research for Humanitarian Assistance (ELRHA)'s Humanitarian Innovation Fund (HIF), exploring the dynamics of successful innovation processes in humanitarian action. They examine what good practice in humanitarian innovation looks like, what approaches and tools organisations have used to innovate in the humanitarian system, what the barriers to innovation are for individual organisations, and how they can be overcome.