While the sanitation sector is gaining increased recognition in policy and research, its inherent inter-linkage with menstrual hygiene management remains an under-researched subject. This review explores knowledge about menstrual beliefs and behaviors, and how women and girls currently handle their monthly menses in relation to existing sanitation systems in low-income countries. It further explores how used menstrual materials are disposed of, and the consequences of different disposal practices for the functioning of sanitation systems. Conclusions point towards the inadequacy of research in the area of menstrual management. The lack of privacy and space for changing, cleaning, drying or discarding materials, as well as insufficient availability of water for personal hygiene stand out as important areas where sanitation systems often fail to cater to the needs of menstruating girls and women. Information on proper disposal of menstrual materials as well as the actual provision of disposal facilities are important for improving menstrual management and ensuring that absorption materials do not impair the functioning of sanitation systems. Training of sanitation system designers and planners with regard to menstrual management could lead to sanitation systems becoming more inclusive of the full needs of all people.

This review of sanitation system trends and interactions with menstrual management practices has been conducted as part of the broader project on Menstrual Management and Sanitation Systems.        

It starts with a review of trends in the development of urban sanitation systems and then explores the interaction between menstrual management and sanitation systems, mainly relating to the issue of disposal of used menstrual blood absorption materials. Finally, it proposes a framework of interactions by positioning a range of issues of particular relevance for menstrual management into the different parts of the sanitation system.In the framework (chapter 3), the most important menstrual management and sanitation system interactions from the perspective of the user occur at the toilet, where the facility conveniently serves (or not) the needs of the user, and to some extent conditions the behavior related to the disposal of used menstrual material. Further downstream, in the collection, conveyance and treatment parts of the system, the interactions relate mainly to the way menstrual waste has been disposed of and its potential to cause and contribute to blockages and the filling up of receptacles.Generally, the appropriate disposal method for used menstrual pads and such material is with solid wastes that are collected separately from feces and urine. Where such arrangements are lacking or not used, menstrual waste may be inappropriately disposed of through sanitation facilities, which may lead to clogging or system failure. Understanding the interactions between menstrual management and sanitation is therefore important for improving sanitation functional access and ensuring benefits and sustainability of sanitation systems.The review of interactions between sanitation systems and menstrual management (chapter 2) indicates that blockages are a real issue in the management of sewerage systems, and that menstrual products – particularly those composed of super-absorbent materials – contribute significantly to the problem. Relating to other systems, interactions are less clear, though non-degradable material may contribute to filling up of latrines and need to be manually removed for the use of excreta material in ecological sanitation systems.It appears that information to the users is central for their behavior with regard to disposal of used menstrual materials. Still, in order to avoid absorption materials to be disposed of with feces, it is absolutely necessary to have bins or other receptacles available. Further, hand-washing facilities need to be situated within the toilet facility for menstruating women and girls to be able to handle menstrual hygiene. Still, menstrual management issues are rarely considered in the design of sanitation systems.Looking towards future urban sanitation systems, one may assume that they need to save water, pollute less, and become more cost-effective. Looking at the general trends, however (chapter 1), we see an increased reliance on water-borne systems. In Latin America and China, these systems appear to be sewered, whereas in many parts of Asia an increasing proportion of the urban population relies on septic tanks. In Sub-Saharan Africa, however, traditional latrines mostly cater for the growing urban populations.This review forms part of the Menstrual Management and Sanitation Systems research project financed by the Bill & Melinda Gates Foundation.

This case study compares policy and practice on sanitation and hygiene in Rwanda, where these issues are government priorities, and a range of guidelines and standards are prescribed for toilet technologies.

The paper looks specifically at the guidelines and standards for urine diversion dry toilets (UDDTs), as well as those on the use of treated human excreta as fertilizer, and on pit latrines (“drop and store”). It then describes how these guidelines and standards are enforced at the community level – specifically in the Rugarama sector, Burera District, one of four Rwandan districts where the United Nations Children’s Fund (UNICEF) is carrying out a water, sanitation and hygiene (WASH) programme.The paper presents the prevailing sanitation and hygiene norms and practices and, using qualitative research methods, evaluates how and why they differ from the prescribed guidelines and standards. In fact, the study shows, health, hygiene, convenience, and safety aspects of sanitation in the study area remain unsatisfactory.Most of the toilets in these communities are neither properly constructed nor properly used. Reasons for the contradictions between prevailing practice and national guidelines and standards include the following: people do not place a high priority on toilets; financial constraints limit household investment in toilets; there is a lack of proper understanding of prescribed sanitation and hygiene guidelines and standards; and there are challenges in carrying out sanitary inspections.For the productive sanitation system in particular, poor understanding of how the system works was identified as the main cause of the mismatch between standards and practice. This study posits that a common understanding of prescribed guidelines and standards at all levels of society is vital to ensure health and safety, improved livelihoods, and to maintain minimum hygiene and sanitation standards.Furthermore, improved understanding of the importance of having properly constructed and well maintained sanitation and hygiene facilities will, undoubtedly, create a demand for such facilities irrespective of the economic hindrances reported by most community members.

Many countries in sub-Saharan Africa have adopted similar approaches to tackle the challenges of rural water supply, including community-based management, community participation and the demand-responsive approach. These are often combined with nationwide programmes of capacity-building and decentralization. This paper first shows how Uganda has adopted these approaches in its rural water supply programme. Based on Government documents, we construct an organizational framework that illustrates the overall programme and outlines the roles and responsibilities which actors are expected to fulfil. Second, based on interviews with sector staff and a review of Government documents, the paper examines challenges to successfully “walk the talk”; that is, it provides insight into challenges affecting programme implementation. Among numerous difficulties, two key issues are highlighted: local political interference and the weak capacity of local governments. Concerning local political interference, local planning processes need to be reformed so that local politicians commit more strongly to improving water supply. Regarding local government capacity, the Government department responsible for the programme has established eight regional units that provide support to local governments. This promising strategy, combined with more appropriate engagement and the commitment of local politicians, should help to improve the implementation of the rural water supply programme in Uganda.

While large private water companies grab the headlines, it is more often small private vendors that bring water to the urban poor in Africa, Asia and Latin America. This working paper looks at how water-vending systems operate, how effective they are in meeting the needs of the urban poor, and how this effectiveness might be improved. The paper concentrates on the small-scale and informal vendors, most of whom work independently with very little capital. Nevertheless, they display enormous diversity and flexibility, and are adept at responding to the needs of all but the very poorest households.