Article by PSI Europe, PSI Malawi & Menstrual Health Action for Impact (MHAi)

Recent months have seen a promising global spotlight on women’s health, amid devastating funding rollbacks for critical women’s health issues. Announcements of landmark financial commitments by the Gates Foundation, Pivotal with Wellcome Leap, and Iconiq in women’s health research and innovation signals a transformational movement. These are much-needed public acknowledgments that women’s health has been understudied, underserved, and grossly underinvested in for too long.

These critical investments are welcome developments, and must be met with complementary actions. For menstrual health, as is the case for other women’s health issues, investing in research and innovations must go hand in hand with strengthening systems that support the health and wellbeing of over 1.7 billion people in low- and middle-income countries (LMICs) who menstruate for over 30 years* of their lives.

Menstrual health is an integral part of people’s lives, affecting physical, social and mental health and well-being, educational and economic opportunities, and dignity. Yet, it remains one of the most neglected areas in health systems, particularly in LMICs. Without a deliberate focus on health policy, service delivery, provider capacity, and health program integration, even the best scientific breakthroughs risk remaining out of reach for those who need them most.

The briefs to support action and investments 

To contribute to this dialogue and support action, PSI Europe, PSI Malawi, and Menstrual Health Action for Impact have developed a three-part series of briefs on menstrual health and health systems in LMICs.

• Brief 1: Menstrual Concerns and Disorders outlines why menstrual health matters as a public health and gender equity issue, highlighting its life course dimensions.‍
• Brief 2: Health Systems Responses to Menstrual Health in LMICs identifies the gaps and barriers across all health system building blocks.‍
• Brief 3: A catalytic investment opportunity presents an investment case for strengthening health systems for menstrual health, calling for strategic investment in responsive, integrated, and equitable systems.

Together, these briefs provide practical directions for funders, policy makers, implementers, and researchers to strengthen health systems for menstrual health. 

‍A critical gap: menstrual health in LMIC health systems

An alarming 48.6% of people who menstruate experience heavy menstrual bleeding in LMICs (Sinharoy et al., 2023); 6-13 % of people who menstruate across the world have polycystic ovarian syndrome (Skiba et al., 2018); and 20-40 % experience pre-menstrual syndrome (Ryu et al., 2015). These conditions have profound implications for people - including living with severe pain, the stress of managing excessive bleeding, the risk of anaemia, infertility and non-communicable diseases, mental health issues, and significant interference with daily life. People experiencing menstrual concerns, disorders and even menopausal symptoms face considerable socio-cultural, economic and systemic barriers to care. 

In spite of these challenges, health systems across LMICs are falling short in responding to menstrual health concerns and disorders. Too often, menstrual health is reduced to product distribution and awareness campaigns, which are undeniably important, but far from sufficient. For instance, primary healthcare, an entry point with immense potential, remains a missed opportunity. Menstrual healthcare can and should be integrated into primary care through body literacy, screening, early diagnosis, and referrals. Instead, existing services are siloed, unprepared and underutilized for menstrual concerns and disorders, and continuity of care is rare. Across leadership, financing, service delivery, data, and technologies, menstrual health is largely invisible in core health system functions.‍

‍A life course approach to menstrual health in health systems 

Menstrual health is a vital sign, a thread that runs through adolescence, reproductive years, and the menopausal years. Each phase brings distinct health needs and risks, shaped by biological, socio-cultural, and systemic factors. In LMICs, as in high-income countries, health systems are not designed to support menstrual health across this continuum. A life course approach to menstrual health is essential to ensuring that care is not fragmented or episodic, but continuous, integrated, and equitable. It recognizes the plethora of menstrual health needs as specific concerns and disorders, as well as critical entry points or links to broader health outcomes, from anaemia and fertility to non-communicable disease management and mental health.‍

‍We need policy and implementation-relevant actions 

This is a decisive moment for women’s health globally. Increased investment in research and innovation creates an unprecedented opportunity to improve health outcomes for millions in LMICs. And realizing this potential requires parallel investment in the health systems that deliver care for menstrual health - now. This means ensuring services are available, affordable, and responsive; providers are trained and equipped; and policies recognize menstrual health as a core component of women’s health.

The path forward is clear:

• Strengthen health system capacity and integration for menstrual health across the life course.
• Embed menstrual health within broader and priority women’s health strategies.
• Fund policy-relevant evidence generation that informs health system design.

*This blog uses “girls and women” and acknowledges that people with gender diverse identities also menstruate.