Beyond product distribution: school-based menstrual health policy implementation and WASH systems in Karnataka, India

School-based menstrual health interventions in lower- and middle-income countries have increasingly prioritised menstrual product distribution. However, evidence suggests that products alone are insufficient to support safe and dignified menstrual health without adequate water, sanitation and hygiene (WASH) infrastructure, education and institutional support. This case study examined how school-based menstrual health policies were implemented in practice by comparing menstrual product provision, WASH conditions and institutional support across 30 government and private schools in the Udupi, Bengaluru Urban and Hassan districts of Karnataka, India. School observations identified a ‘provisioning paradox’ within government schools, whereby widespread access to subsidised sanitary pads and pilot reusable menstrual products frequently coexisted with limited menstrual health communication, inconsistent institutional support and variable WASH conditions. In contrast, private schools generally demonstrated more supportive institutional environments despite the absence of routine government menstrual product distribution schemes, characterised by better-maintained sanitation facilities, routine menstrual health communication and greater access to school health personnel. The findings suggest that menstrual product provision alone is an incomplete measure for comprehensive menstrual health management. Effective implementation requires menstrual product distribution to be integrated with functional WASH infrastructure, continuous menstrual health education and coordinated institutional support.