We need more action, investment in menstrual health and hygiene now!

Background

Globally, approximately 52% of the female population is of reproductive age, and most of these women and girls menstruate each month. Since the Beijing Platform for Action Declaration, there has been immense progress for this group, nevertheless, they continue to be hit hardest by major crises in their lives, particularly by the COVID-19 pandemic; especially schoolgirls living in rural areas, slum settings, and those with disabilities.

A UNESCO report in 2016 estimated that one in ten girls in Sub-Saharan Africa misses school during their menstrual cycle. By these estimates, this equals as much as 20% of a given school year.  However, both communities and systems players have largely overlooked menstrual health management.

As we commemorate Menstrual Health (Hygiene) Management (MHM) it is important that we appreciate the fact that MHM is a key and a fundamental concern that specifically touches on the existence, productivity, performance, and the well -being of girls in and out of school.  On 29th April 2021, a group of multi-sectoral experts defined Menstrual Health as a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity, in relation to the menstrual cycle.

Similarly, the WHO has used the following definition of MHM: “Women and adolescent girls using a clean menstrual management material to absorb or collect menstrual blood, that can be changed in privacy as often as necessary for the duration of a menstrual period, using soap and water for washing the body as required, and having access to safe and convenient facilities to dispose of used menstrual management materials. They understand the basic facts linked to the menstrual cycle and how to manage it with dignity and without discomfort or fear’’.

Many girls drop out of school altogether once they begin menstruating. Should young women miss 20% of school days each year due to a lack of facilities, a lack of information, or a lack of sanitary products? What about the girls that are not in school, how do we track the management of their menstrual health needs? Who caters to them? What about the girls with special needs? What extra caution has been taken to ensure that their needs are taken into consideration? What policies are in place? How are their families and communities catering to their needs?

For the past twenty years, Uganda has made significant strides in increasing access to education for all its citizens, particularly with the introduction of the Universal Primary Education (UPE) and Universal Secondary Education (USE) schemes, both of which sought to eliminate monetary barriers for children to attend public schools.

However, a gender gap persists in the completion of both primary and secondary school in Uganda, as girls are significantly more likely to drop out of school than boys. Several studies have pointed to poor menstrual health (hygiene) management in schools as an important determinant of school absenteeism amongst girls in Uganda.

With the effects of the COVID-19 pandemic, the repercussions have put the 10 million futures of women and girls at even more risk. The recently launched 10 Million Futures report by Irise indicates that many girls are at risk of school dropout and early marriage, because of school closures and the economic pressures created by the pandemic. They believe leaving school will mark the end of their dreams and hopes for the future.

An estimated 3.75 million Ugandan schoolgirls currently live without access to proper sanitary care. Not only is this a fundamental issue of ethical and human rights concern, but one with far-reaching societal impacts. As an important determinant of completion of primary and secondary school education amongst girls, MHM impacts facets of society such as teenage marriage and childbearing, total fertility rate, and infant and child mortality rates.

This is particularly concerning in Uganda given that the country currently faces dangerous population growth that threatens to further strain the country’s available resources. At the household level, menstrual products are low on the list of priorities as they struggle to afford food and bills.  Therefore, menstrual hygiene management is ultimately a public health concern and must be addressed as such at the national level.

On the legal and policy framework scene, National development priorities and plans are guided by international development frameworks, declarations, conventions, and treaties such as the Universal Declaration of Human Rights, Sustainable Development Goals, Convention on the Elimination of all forms of Discrimination Against Women, Education for All, and the Beijing Platform for Action, to mention a few. It should be noted that Uganda does not have a particular law or policy that speaks to menstrual management.

The important policy provisions that relate to MHM are found in i) The Education Act 2008 which speaks about the roles and responsibilities of stakeholders in education and training on ensuring safe learning environments.

The stakeholders reported in this Act being the government, parents, and guardians, and foundation bodies. It is important to note that MHM is not specifically mentioned in this Act, but it is implied in many subsections such as Sections 25, 26, 27, and 28 which provide for and empower school inspectors, Boards of Governors, and School Management Committees to plan and ensure facilities that guarantee a friendly learning environment in the school.

Another document that tends towards addressing MHM is the National school health policy-A handbook for mainstreaming gender in education by the Ministry of Education and Sports, and provides background to gender issues in society and how they impact learning. It is intended to help all stakeholders to be gender-sensitive. Particularly, it focuses on teachers working towards creating a gender-responsive learning environment.

The National Strategy for Girls Education in Uganda 2014-2019 (Ministry of Education and Sports) also recognizes that the lack of child-friendly school learning environment, inadequate life skills training, and inadequate gender capacities among key actors are some of the major factors affecting girl child education. This is so because they directly link to MHM in schools.

Gender in the education strategic plan 2015 –2020 (Ministry of Education and Sports) which aims at building the capacity of the education sector to address gender inequality and to deliver equitable and quality educational way)

Also, in 2015, A circular No. 01/2015) was issued by the Ministry of Education and Sports instructing all educational institutions, especially primary and secondary schools to undertake and observe several measures for menstrual hygiene management.

The core ones included; i) Provision of separate toilet facilities for girls, boys, children with disabilities, male and female teachers ii) Adequate water tanks near the toilet facilities to ensure regular supply of water and soap iii) Emergency changing uniforms, wrappers, sanitary towels and pain killers for girls iv)Trained senior female and male teachers to support girls through the process of maturation including menstruation v) Develop innovative strategies to effect behavioral change in school and at home vi) District engineers to observe requirements for separation of toilet facilities for classes, gender and disability, and menstrual hygiene facilities by including them in standard specifications vii) Organise joint training of teachers and extension workers to make MHM part of their periodic community engagement viii) School management committees and boards to prioritize menstrual hygiene management issues ix) All boys and male teachers in schools sensitized to support girls to cope with menstruation.

The 2018 National Education Sexuality Framework by the Ministry of Education and Sports is an overarching national policy guide for providing young people with relevant and accurate information and equipping them with life skills to make responsible choices about their sexual and reproductive health issues. This policy is for the school-going young people.

Although the Ministry of Education and Sports has established an MHM training manual for out-of-school adolescents, you will notice that even with the few policy provisions of MHM, none speaks to the needs of girls out of school. This is dangerous.

Societal stigma, insufficient knowledge and measures provided to young girls in and those close to puberty stage, lack of essential support and amenities for managing menstrual hygiene, absence of private space and hygienic washrooms, inappropriate facilities for disposal of used menstrual materials, lack of or inadequate water, and the physical pain like headache that characterizes menstrual cycle, have generally stood as impediments to women and girls in the bid to reach and achieve their full potential and with a policy framework that doesn’t speak to an already disadvantaged group- those out of school.

The current interventions on MHM

NGOs have been the major player in undertaking initiatives in improving the menstrual health needs of many Ugandan girls. At FIDA –Uganda, they introduced their initiative FIDA Clubs where the institution organises pupils/ students in at least 5 schools in their 19 districts of operation into these clubs. Through these clubs, they have sessions led by children on menstrual health, sexual gender-based violence, and leadership.

During the lockdown, FIDA-Uganda undertook surveys among the different pupils in FIDA clubs on what they believed was the biggest challenge for them and it showed that; pupils were experiencing general anxiety about returning to school, fear of getting married off and/or getting pregnant, and lack of attention towards their menstrual needs.

Through their keeping a girl child in school campaign dubbed #KidsSpeakUp, FIDA has a children’s round table on NTV where one of the panelists Mutoni Vivian shared that many girls in her school use old t-shirts, torn bedsheets, or even pieces of mattresses.  Since 2018, Irise Institute East Africa has been conducting Menstrual Health Education to both girls and boys in local communities and schools that are delivered through designed programs on MHM and product distribution of reusable pads, disposable pads, and flow caps. 88 schools, both primary and secondary, have been engaged with a reach of over 5,000 girls and boys who have received sanitary products and menstrual health education in Eastern, Central, and Western Parts of Uganda.

Irise hosts the Period Equality Network East Africa that consists of NGOs that have actively played the same role such as Public Health Ambassadors, Womena, Raising Teenagers, among others. Their initiatives aim at creating awareness on menstrual hygiene management in selected schools in Kampala slums, and rural areas.

We have also had campaigns by individual activists on the provision of free sanitary towels, most notably was Dr. Stella Nyanzi’s #Pads4GirlsUg in 2017. This campaign was born out of the failure of the current President of Uganda –HE Yoweri Museveni fulfilling his 2016 pledge to provide sanitary pads to all school-going girls across the country if voted into power.

Despite being declared the winner, the presidential pledge has never been fulfilled. The First Lady and Education Minister, Janet Museveni was then questioned by MPs sitting on the education committee why the pads had not yet been provided in schools as promised and she explained that Government did not have enough funds to fulfill that pledge. She also informed the committee that the provision of school lunch and pads should the responsibility of the parents and not the government. Stella Nyanzi started a crowdfunding campaign on social media and wants to collect enough money to buy ten million reusable sanitary pads.

The problems with the current interventions

While there has been momentum from donors, governments, and other private players in regard to increasing initiatives to address problems related to menstrual health, the focus to date has largely been on “hardware” (e.g., products and facilities). We have also noted that players tackling issues related to menstrual health are also disparate and isolated in their approaches to reaching girls and those in those communities. Despite the link between menstruation and reproductive health, the sexual reproductive health sector in Uganda has paid limited attention to the issues related to menstruation until recently.

We also observe that few governments, corporations, or NGOs are looking at menstrual health as a systemic problem, and thus, they are missing the opportunity to address the problems sustainably and at scale. Rigorous evaluations of menstrual health programming to understand what works and is replicable at scale have been limited.

We also see that puberty programs and curricula largely target girls and often neglect to include their influencers like the parents, cultural leaders, boys, single parents who are men, and the general community.

We have witnessed that the government has lacked ownership of menstrual health, limiting opportunities for coordinated responses to menstrual health challenges. In Uganda, we have seen little progress in the Government legislating and scrapping tax on pads like other African countries like Rwanda, South Africa, or Zambia. This has left the issue to mostly NGOs, developing partners, and the private sector.

Lastly, adolescents with special or underrepresented needs are disproportionately affected by poor menstrual health and yet little has been done to support them. More than 90% of children with disabilities in developing countries do not attend schools and this means that they are eliminated.

Recommendations

Aware that women and girls in low-income settings in Uganda, who happens to be the majority, have low awareness on hygienic practices, and lack culturally appropriate materials for menstrual hygiene practices, there is a great need to include subjects and course units on reproductive health rights starting from primary schools, lobby for legislation that directly places the responsibility on Government of providing free, sufficient, and quality sanitary towels to school girls who have reached the ages of puberty, and encourage reusable pads. These will go a long way to counter the social taboos, the shame, and the silence that is often associated with “Menstruation” that restricts mobility, freedom, and access to normal activities.

There is also an urgent need to rigorously grow the policy framework around MHM needs for girls out of school. The few policies we have in Uganda work under the assumption that all menstruating girls and young women are in school. These policies should provide for youth centers, Drop-in Centres (DICs) and the like, where young girls can access pads and other sanitary needs even when they are not in school. Efforts to date to address girls’ menstrual health have largely focused on physically able and in-school girls.

There is a need to understand the broader societal responsibility for addressing MHM, as well as to consider ways in which girl pupils can be assisted. This entails that there should be an inclusion of reproductive health education and life skills in the school curriculum targeting both girls and boys.

Menstrual hygiene should be captured in the national education sector performance report. This entails that the Ministry of Education and Sports needs to incorporate menstrual management indicators in monitoring and evaluation systems for primary schools.

At the district level, Health inspectors should make menstrual hygiene management part of their periodic inspection and report to the District Water and Sanitation Coordination Committee on a quarterly basis.

More focus is needed to include menstrual hygiene management as one of the assessable areas in the performance agreements signed by headteachers/ school owners with the district education team to enhance accountability.

There is a need for support mechanisms at the school level, for instance, a percentage of the budget from the UPE and USE grant would be allocated specifically to menstrual hygiene management which would range from emergency menstrual pads, facilities for disposal of used pads, and medication (e.g., pain killers).

While at NGO and civil society level, we recommend that campaigns on MHM be made more regular among policymakers; cultural leaders to break silence and stigma on MHM and engage with communities of especially far to reach districts.

Partnerships with the private sector are also a critical recommendation. This will encourage the exploration of possibilities of manufacturing and marketing innovative low-cost sanitary towels.

Conclusion

MHM is now recognized globally as a definitive public health and development issue, with the substantial increase in financial and human capital committed toward this topic but Uganda has not followed suit. What are we not doing? Gaps in progress cannot be filled until resources and political commitments are made to transform schools for menstruating girls. The SDGs present an opportunity for greater prioritization of the issue of MHM for schoolgirls, including increased integration across sectors and improved monitoring of progress.

Compiled by the Policy and Advocacy Department, FIDA Uganda and Irise Institute East Africa.

(We acknowledge Efforts by Elizabeth Kemigisha and Patricia Humura)

By Elizabeth Kemigisha, Feminist Lawyer and Organiser, FIDA – Uganda and Patricia Humura, IIEA Partnerships and Policy Advocacy Officer)

28th May 2021
First appeared in New Vision
Protect women in domestic partnerships – New Vision Official