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The Unfulfilled Commitment; Eight years since the government committed to providing menstrual health products to girls

A UNESCO report indicates that in Sub-Saharan Africa, approximately 1 in 10 girls misses school during their periods due to stigma and discrimination. On average, a menstruating girl loses 13 learning days of school every school term. Additionally, an estimated 23 percent of adolescent girls aged 12 to 18 drop out of school following the onset of menstruation. 

Girls in Uganda face a multitude of challenges in managing their menstrual health. Alarming statistics on school dropout rates among menstruating girls underscore the urgent need for intervention. The absence of menstrual hygiene supplies in schools stands as a major barrier leading to many girls missing out on education, due to period-related challenges 

Along with other challenges; including inadequate infrastructure and limited information/awareness, the scarcity of essential supplies like sanitary pads is a critical issue that has not received adequate attention. Social stigmas and cultural taboos surrounding menstruation further exacerbate these challenges, making it difficult for girls to seek the support and information they need.  

Well knowing that economic disparities have exacerbated period poverty, with only the privileged able to afford menstrual products. The less fortunate often resort to desperate measures, including risky behaviors to raise funds for pads. Young people often depend on their parents for these supplies, who are already burdened with numerous responsibilities. High levels of poverty worsen the situation, as the price of a pad ranges from 3,000 to 9,000 shillings, an amount that could cover part of school fees for a daughter in some regions. This disparity undermines the fundamental goal of ensuring equal opportunity for all, as girls face unnecessary barriers that hinder their educational advancement and overall well-being. It is imperative that governments and stakeholders prioritize initiatives that address menstrual health as a core component of women’s rights and empowerment. 

It’s been eight years since the government committed to providing menstrual health products to school-going girls, a promise outlined in the 2016–2021 Manifesto of the ruling National Resistance Movement (NRM) government, with the objective of addressing school dropout rates and supporting menstrual hygiene, dignity, and the well-being of adolescent girls in primary and secondary schools. However, this pledge remained unfulfilled by the end of the term. 

The implementation of the pledge was anticipated in the Financial Year 2017/2018; however, the initiative has remained only on paper, eight years since President Yoweri Kaguta Museveni made the pronouncement. In April 2020, First Lady Janet Museveni, Minister of Education and Sports, announced plans for a sanitary pad manufacturing factory to distribute pads in schools nationwide at no cost. However, this plan is yet to materialize.  

As we mark Menstrual Health Awareness Month, I take this moment to remind the government of this important commitment outlined in the 2016–2021 Manifesto of the ruling National Resistance Movement (NRM) government. Every May of each year is Menstrual Health Awareness Month, an opportunity to create awareness on MHM and amplify/challenge key issues on periods, among them the unfulfilled pledges on MHM. This campaign culminates into the commemoration of International Menstrual Hygiene Day celebrated 28 may. May is the 5th month of the year, and the average length of menstruation is 5 days every month. 

Whereas Uganda has demonstrated commendable efforts in advancing women’s empowerment and leadership through various policies, programs, and affirmative action measures, there remains a notable gap in addressing menstrual health management among girls, which directly impacts their ability to compete equally with boys in education.  

Investing in menstrual health for girls is not only a matter of health and hygiene but also a critical step towards advancing toward an equal future. While strides have been made in promoting gender equality and empowering women in other areas, the critical issue of providing adequate support for menstrual health has often been overlooked. 

Menstrual Health Management (MHM) should be promoted as a critical aspect of gender equality and women’s rights. We have to ensure that menstruation is not a barrier to education, work, or participation in society. Menstrual Hygiene (MH) is a key and a fundamental concern that specifically touches on the existence, productivity, performance, and well-being of girls in school. 

Whereas the legal framework in Uganda is alive to maternal and reproductive health rights, like Articles 30 and 34 of the 1995 Constitution of Uganda which provides for the right to education to all persons of Uganda and imposes the responsibility of providing children with basic education on the state and the parents, Uganda in its aspiration to provide maternal and reproductive health services for girls and women and specifically on Menstrual Hygiene, still faces social, economic, and cultural challenges leaving a lot to be desired. 

It is imperative that MHM is recognized and promoted as a critical aspect of the broader movement towards achieving equality and justice for all women and girls. The inability of girls to compete on a level playing field with boys due to menstrual health challenges – highlights the urgent need for targeted interventions and policies. By implementing comprehensive menstrual health programs in schools and communities, we can ensure that girls receive the support and resources they need to manage their periods effectively, stay in school consistently, and fulfill their academic potential.  

Recognizing that Menstrual health is a critical aspect of women’s empowerment, particularly for adolescent girls, as it directly impacts their education, health, and overall well-being. By advocating for comprehensive MHM policies, we can contribute significantly to breaking down barriers that hinder gender equality and women’s rights globally. Promoting Menstrual Health Management (MHM) is not just about managing periods; it is about promoting gender equality and women’s rights on multiple fronts. Addressing access to menstrual health management products for school-going populations is a crucial step towards improving overall MHM. 

Menstrual Health Management (MHM) should be promoted as a critical aspect of gender equality and women’s rights. We have to ensure that menstruation is not a barrier to education, work, or participation in society. Menstrual Hygiene (MH) is a key and a fundamental concern that specifically touches on the existence, productivity, performance, and well-being of girls in school. Finally, I want to state that, access to essential supplies is a matter of equity and social justice, as many individuals, particularly in low-income communities, cannot afford basic necessities. Let’s help girls to realize their full potential and participate equally in society. 

Menstrual health management remains a time-consuming challenge for girls, hindering their academic success. 

 Fatiha Nkoobe, the writer is a Communications Specialist and Activist, working with the Center for Health, Human, and Development. 

The fight against Obstetric Fistula in Uganda: Progress made but challenges remain 

According to the United Nations, Obstetric fistula is a hole between the birth canal and bladder or rectum, caused by prolonged, obstructed labour without access to timely, high-quality medical treatment. This abnormal opening leaves women and girls with a constant leakage of urine, stool or both, and often leads to chronic medical problems, depression, social isolation and deepening poverty. Ninety percent of pregnancies involving fistula end in stillbirth.  

Obstetric fistula continues to affect the lives of thousands of women in Uganda. This debilitating condition leaves affected individuals with chronic incontinence and often social isolation.  

The National Library of Medicine (National center for Biometric information) highlights that in Uganda, the current lifetime prevalence of vaginal fistula symptoms is estimated to be between 16.3-22.5 per 1,000 women of reproductive age. This translates to an estimated 140,000 – 200,000 women and girls living with fistula in the country, with over 1,900 new cases occurring annually. 

The United Nations estimates that at least two million women live with fistula in developing countries, with 50,000 to 100,000 new cases occurring each year and these numbers represent only those seeking treatment. Women and girls in Africa, south of the Sahara, are mostly affected by fistula as well as other illnesses from sexual and reproductive health causes. 

The Ugandan government has taken important steps to address this issue. In 2011, the country enacted the National Obstetric Fistula Strategy (2011/12-2015/16) which aims to guide the implementation of prevention, treatment and re-integration activities for obstetric fistula. This has led to increased awareness, training of specialized fistula surgeons, and the establishment of dedicated fistula repair centers across the country.  

Strategic partners in Uganda have also followed suit and have been seen to implement the government’s strategy. The Kingdom of Buganda forexample is also dedicated to raising awareness about obstetric fistula among mothers in the central region. To achieve this, the kingdom collaborates with key hospitals in Buganda, such as Kitovu Hospital in Masaka District, to establish necessary infrastructure and provide support. The Kabaka Foundation, a prominent organization within the kingdom, actively participates in these efforts by organizing an annual Kabaka Birthday run which focuses on fistula awareness, among others. These events serve as a platform to educate the community and garner support from both local and international sources to fund initiatives aimed at preventing and treating obstetric fistula. 

The Terrewode Women Community Hospital – Soroti District, under the leadership of Executive Director Ms. Alice Emasu, has made a significant difference as well by saving the lives of more than two thousand (2,000) women suffering from fistula over a span of five years. We need to see more of such initiatives to create a significant impact. 

However, despite these efforts, challenges remain. The New Vision publication by Umar Kashaka on 8th May 2024 highlights the worry of the Uganda Ministry of Health on the rising backlog of fistula cases. In this article, the Assistant Commissioner of Clinical Services in the Ministry of Health Dr Alex Wasomoke is quoted to have revealed that approximately 1500 fistula operations are carried out in a year but 1,900 new cases are reported annually, leaving a backlog of over 400 cases unattended to. He also noted that each fistula patient needs $400 (1.5m) to undergo surgery and this is a direct affordability concern and a barrier to access of quality care services. 

An article authored by Ndyaye and published in the Daily Monitor on May 20th, 2024, reveals that Uganda currently only has 25 surgeons specializing in fistula repair, a shocking revelation considering the immense demand for such services. These skilled providers have successfully treated thousands of fistula cases, restoring dignity and hope to women and girls who had lost all. However, the demand for fistula treatment remains largely unmet, leaving countless women unable to access these life-changing services. 

Women living with obstetric fistula encounter a multitude of challenges across various aspects of their lives. Physically, they struggle with urinary and/or fecal incontinence, which can lead to skin issues such as rashes and sores, as well as complications like foot drop. Fertility concerns, post repair surgery often plague these women, with uncertainties about their reproductive capabilities and fears of recurrence during future pregnancies. Psychologically, they face disruptions in social relationships, potential divorce, and the potential heart-wrenching loss of their babies through neonatal death. 

The stigma, discrimination, and resultant isolation from their communities contribute to feelings of depression and low self-esteem. Economically, women with fistula experience a loss of livelihood, becoming heavily reliant on family members for support, and struggle to afford necessary treatment and transportation to healthcare facilities. Socially, they encounter challenges such as impaired marital status and responsibilities, limited participation in community activities, and various forms of discrimination based on health, disability, marital status, education, and socioeconomic standing.  

Despite these hurdles, many women can successfully reintegrate into their communities post-repair, although relationship issues and fertility anxieties often persist. It is important to address the holistic needs of women with fistula, encompassing physical, psychological, social, and economic support, to facilitate their complete recovery and successful reintegration into society. 

Underlying social factors such as poverty, gender inequality, child marriage, and limited access to quality maternal healthcare continue to drive the persistence of obstetric fistula in Uganda.  Addressing these social factors through multi-sectoral interventions is crucial to achieving the goal of ending fistula by 2030. 

On this International Day to End Obstetric Fistula, we therefore call upon the government and all actors to renew its strength towards this cause. Increased investment in prevention, treatment, and rehabilitation services is needed, along with empowering women and girls, challenging harmful social norms, and strengthening the overall healthcare system. Employing a comprehensive rights-based and multisectoral approach, at large, can finally place obstetric fistula to the history books in Uganda and beyond.  

It is very possible to change the status quo and impact society positively. 

 Compiled by Jacqueline Twemanye, Communications Department, Center for Health, Human Rights and Development (CEHURD).