HERproject Peer Educators in Bangalore, India, meet with Nandini Hampole and Racheal Yeager of BSR. (Photo courtesy of BSR) 

At the end of their shifts sewing Levi’s jeans at a factory in Karachi, Pakistan, the young seamstresses gathered denim scraps from the floor. They used the fabric for sanitary napkins—a luxury they couldn’t afford, because they sent their paychecks home to their villages.

Inevitably, they developed infections, and factory managers noticed they were missing up to three days of work a month during their menstrual cycles. Health care charities in Karachi knew of the problem, but were blocked at the factory doors by managers unwilling to stop production. The women didn’t speak up, taught by their Muslim culture to stay quiet about feminine issues.

The story eventually made its way to the San Francisco headquarters of the nonprofit BSR (Business for Social Responsibility), which had been in talks with the David and Lucile Packard Foundation about starting a worker health program inside the overseas factories that make garments for major American labels. With funding from the foundation, researchers toured factories in six countries in 2001 and discovered that many of the garment workers were isolated from health care, with little knowledge of basic hygiene and nutrition. Although some had heard the term HIV, few understood how it spread. In one factory, 75 percent of the women had never seen a condom. Inside company dorms, factory workers spread myths from home: Bathing during menstruation would make you infertile, make your hair fall out, and turn your skin black.

It was clear to BSR, a sustainable business consultancy founded in 1992 to address sweatshop labor abuses, that the factories needed health improvements. By 2007, BSR had developed working relationships with 250 multinational companies, which gave the consultancy access to factories to conduct health seminars. BSR even chose a name for the initiative: HERproject, which stands for Health Enables Returns. BSR would coordinate the trainings, and the major clothing labels would pay for them with their International Labour Organization-mandated human rights compliance budgets.

But convincing the factories to set aside time for health classes was a different matter. On a factory floor, a shirt is assembled by passing it through a row of sewing machines—one woman starts with the cuff and passes it to her neighbor, who makes the sleeve and passes it down the line until the garment is complete. Every second matters.

“This was absolutely not an easy sell,” says Racheal Yeager, HERproject manager. “We had to show them how caring for women’s health enables business. Reproductive health can be scary—you’re talking about HIV, miscarriages, abortions, unsafe sex. The companies felt health care was another burden beyond their purview; they already were working so hard on fair wages and hours.”

BSR knew instinctively that healthier workers made for a more prosperous factory, but they couldn’t prove it until they found a 2006 USAID-funded study of a factory in Bangladesh. Using calculations based on reduced absenteeism, turnover, and workdays saved, researchers found that for $1 invested in an on-site factory health program, the factory reaped $3 in increased productivity.

“Now business would listen to us,” says Yeager. BSR secured $125,000 from the Packard Foundation in 2007 and proposed a yearlong health program inside the factories with local charities teaching classes on hygiene, reproductive health, infectious diseases, female anatomy, maternal health, harassment, and abuse. Some women would be groomed as peer educators to take the health messages to the entire factory and to their villages. Ultimately, HERproject’s goal was to leave a program in place that the workers could run themselves.


Nordstrom was the first to sign on with five factories in China. A few months later, Levi Strauss & Co. added two factories in Pakistan. Abercrombie & Fitch was next with four factories in Vietnam. At a Hewlett-Packard Co. plant in China, HERproject programs distributed condoms and focused on hepatitis B. “We created a hepatitis B antidiscrimination program; we taught workers that it’s blood-borne and can be transmitted sexually,” says Ernest Wong, HP’s social environmental responsibility manager for Asia-Pacific/Japan.

The issue of family planning is sensitive, especially in Muslim countries. In Egypt and Pakistan, HERproject presents birth control talks as “preparing for family life” or “birth spacing.” A nurse in a Pakistani garment factory now dispenses three packets of oral contraceptives, 50 condoms, and one hormonal injection each month; previously these products were not available in the factory clinic.

“In our country, it’s a revolution to
see women taking care of themselves
and their health,” says
Nazneen Huq, co-manager of the
HERProject in Bangladesh.

Employees were reticent at first to discuss intimacy, says Zeeshan Mansoor, factory manager of Akhtar Textile Industries in Karachi. “We have a very closed society, so at first they were shy about it,” he says. “But now, they are taking what they learned about family planning and hygiene and repeating it in their neighborhoods.”

Once workers felt the company was investing in them, the mood changed on the floor, says Mansoor. They were more concerned about one another. He heard more laughter. As they started using menstrual pads provided by the company nurse, the turnover rates dropped and he fielded fewer requests for sick days. Pakistani women who improved their menstrual hygiene through HERproject trainings reported a 25 percent reduction in poor concentration at work, 28 percent lower absenteeism, and 33 percent less difficulty in meeting production targets, according to HERproject follow-up reports. That translated to each woman working an average of 2.5 more days per month in the factory while HERproject was there, representing an additional 615 days of work per year.

As of July 2011, HERproject has enrolled more than 100,000 women in health programs in more than 80 factories in Bangladesh, China, Egypt, India, Indonesia, Kenya, Pakistan, and Vietnam. Its budget has grown to $800,000 with funding from the Packard and Levi Strauss foundations, the Swedish International Development Cooperation Agency, and private donations. This year, the United Nations named HERproject as one of 10 model programs to improve women’s and children’s health globally.

“If you look even 10 years back, there is so much more awareness now of who is producing the clothes and how they are treated,” says Nazneen Huq, co-manager of the HERproject in Bangladesh. “Not long ago the factory was divided into a system of owners and workers. You were not supposed to be tired after a 10- or 14-hour day. You were supposed to keep your head down and be thankful you had a job,” she says. “In our country, it’s revolutionary to see women taking care of themselves and their health.”

There was enough interest at the Akhtar factory to start a similar program for men. With help from BSR and the neighboring Aga Khan University, Akhtar has started HISproject so male workers can also learn about family health. Levi Strauss is providing funding. “It’s not a simple thing you can measure in productivity changes, but you can sense that the factory is a better place for people to work now,” says Mansoor. “Life is just easier here.”

Similarly, factory managers in Ismailia, Egypt, reported fewer workers taking days off during their menstrual cycle or for illnesses. They noted less turnover, fewer mistakes on the garments, and small changes in worker hygiene. HERproject was delivering a $4 return for every $1 invested in Egypt and Pakistan, according to an August 2011 HERproject study funded by the Levi Strauss Foundation and USAID. “At a factory in Vietnam, managers respected the women as they began to respect themselves, eventually asking the workers for cost-saving ideas,” says Daniel Jae-Won Lee, executive director of the Levi Strauss Foundation. “The winner made a video showing a more efficient way to make a stitch.”

The successes came after some initial missteps, Yeager admits. HERproject first offered its program for $2,000—lower than other nonprofits doing similar work, such as Marie Stopes International. “We learned that to do this well, we needed to charge between $5,000 and $7,000, so we could make more factory visits and stay engaged with management,” says Yeager.

The original plan, to hold a two-day peer educator training at the beginning of the year with follow-up meetings four months and eight months later, also had to be scrapped in favor of six sessions in alternate months. “Turnover in factories is so high that our peer educators kept disappearing midway through the program,” says Yeager.

With more regular visits, HERproject could better monitor who was missing and quickly train a new woman to take her place. Long term, BSR wants to leave behind a standard curriculum that factories in any country could use. Recently the consultancy created TOOLBUILDER, a low-literacy computerized flip chart of images that can be used in all countries to convey health messages. One shows a woman washing her hands; another shows a woman washing fabric cloth strips used as sanitary napkins, with a red circle and line through it. Teachers can click to change skin and hair color and dress on the flip charts to match their audience. BSR hopes to launch it as an open-source program within two years, making it easier for factories to replicate HERproject independently.

“We are working on a set of global standards,” says Yeager. “The nonprofits, brands, and factories all want a standard curriculum. Funders want something measurable and scalable. That won’t happen if we leave behind 50 different charities running 50 different factory programs.”

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