Economic analysis of a school-based menstrual health intervention (MENISCUS) among female adolescents in Uganda

This study provides the first economic analysis of scaling a school-based menstrual health intervention (MENISCUS) in Uganda, estimating national implementation costs and demonstrating economies of scale to inform government investment and policy decisions.

The Gist

Imagine a school in Uganda as a busy kitchen. For years, the girls in this kitchen have been trying to cook (learn and grow), but they've been struggling because the kitchen is missing a few key things: they don't have the right tools, the sink is broken, and no one has taught them how to handle a specific, messy ingredient that comes once a month (menstruation). This struggle often makes them skip school or feel too embarrassed to participate.

This paper is like a financial blueprint for fixing that kitchen. It asks a very practical question: "If we want to fix this problem for every single school kitchen in the entire country of Uganda, how much will it cost, and what does the recipe look like?"

Here is the story of their findings, broken down simply:

1. The "Trial Run" (The Test Kitchen)

First, the researchers didn't try to fix the whole country at once. They picked 60 schools (a "test kitchen") and tried a new recipe called MENISCUS.

• What was in the recipe? They gave the girls a "care kit" (pads, underwear, soap), taught teachers how to talk about puberty, fixed broken toilet doors, put locks on stalls, and even had the students perform a play (drama skit) to break the silence and shame around periods.
• The Result: It worked! The girls felt better, knew more, and were less embarrassed. But the researchers needed to know: Can we afford to serve this meal to 3,000 schools instead of just 60?

2. The Two "Menu Options"

To answer the cost question, the researchers designed two different menus for the national scale-up, assuming the government would run the show (using existing teachers and staff rather than hiring new outside experts).

• Option A: The "Basic" Menu (The Essentials)

  • This includes the core ingredients: Teaching teachers how to talk about periods, giving out the care kits, fixing the broken toilet doors, and putting up the drama scripts.
  • The Cost: About $28 per student (or $58 per girl).
  • Analogy: This is like buying the groceries and fixing the sink. It gets the job done, but it's the bare minimum.

• Option B: The "Enhanced" Menu (The Full Feast)

  • This includes everything in the Basic menu plus extra luxuries: Training a special "Menstrual Health Action Group" of students and teachers, giving out reusable pads and underwear to every girl, and providing painkillers (ibuprofen) for cramps.
  • The Cost: About $46 per student (or $95 per girl).
  • Analogy: This is the full dinner with appetizers, a main course, and dessert. It's more expensive, but it addresses more of the girl's needs (like pain and long-term supplies).

3. The "Bulk Discount" (Economies of Scale)

Here is the most exciting part of the story. When you buy one cup of coffee, it costs $5. But if you buy 3,000 cups for a whole office, the price per cup drops because you aren't paying for a new barista for every single cup; you're using the same machine and the same shop.

The researchers found that scaling up actually makes it cheaper per person.

• In the small trial, it cost more per student because they had to pay for special research staff and set up everything from scratch.
• In the national plan, they use the government's existing teachers and systems. The "setup cost" is spread out over millions of students, making the price tag much friendlier.

4. The Biggest Bill-Payers

If you look at the receipt for this national plan, where is the money going?

• The "Care Kits" and Training: This is the biggest chunk of the bill. Just like buying ingredients for a big banquet, the pads, underwear, and the time spent teaching teachers cost the most.
• Fixing the "Plumbing" (WASH): Fixing toilet doors and locks is the second biggest cost. You can't have a good meal if the kitchen is broken!
• Pain Management: Providing medicine for cramps is also a significant cost.

5. The Bottom Line

The paper concludes that while the total price tag for the whole country is high (over $10 million for the basic plan and over $16 million for the enhanced plan), it is a smart investment.

• Why? Because when girls miss school because of their periods, the country loses out on their future potential.
• The Challenge: The government needs to find this money. The paper suggests that instead of relying on outside donors (who might stop giving money next year), the government should bake this cost into their regular school budget, just like they pay for textbooks or teacher salaries.

In a nutshell: This paper is a roadmap showing that fixing the "period problem" in schools is possible. It's not free, but it's affordable if the government treats it as a standard part of running a school, rather than an expensive add-on. By buying in bulk and using existing systems, they can turn a "luxury" into a standard part of the school day for every girl in Uganda.

Technical Summary

1. Problem Statement

Poor menstrual health (MH) significantly impacts adolescent girls in low- and middle-income countries (LMICs), leading to school absenteeism, reduced engagement, and diminished psychosocial well-being. While school-based MH interventions have shown efficacy in improving knowledge and practices, there is a critical lack of economic evidence to guide large-scale adoption, financial planning, and policy integration. Existing studies often focus on single components (e.g., pads or cups) rather than comprehensive, multi-component interventions, and few provide cost estimates for national scale-up using government delivery systems.

2. Methodology

The study employed an incremental costing analysis alongside a previously conducted cluster-randomized controlled trial (RCT) involving 60 secondary schools in Uganda (Wakiso and Kalungu districts).

• Perspective: Provider perspective (excluding research costs).
• Costing Approach: A micro-costing methodology was used, combining bottom-up and top-down approaches. Costs were categorized into start-up (planning, training development, procurement) and implementation phases.
• Data Sources: Financial records, project accounts, monitoring and evaluation (M&E) registers, and staff timesheets from the implementing NGO (WoMena Uganda) and research partners.
• Scale-Up Modeling: The authors modeled two potential national scale-up scenarios for all 2,995 secondary schools in Uganda, utilizing existing government delivery structures (Ministry of Education and Sports) rather than parallel NGO systems.
  • Basic Scenario: Includes core components: puberty education, MH kit training, pain management training, WASH improvements (fixing doors/locks, installing cages), and a drama skit.
  • Enhanced Scenario: Includes all basic components plus: MH Action Group training, training for female caregivers, provision of reusable pads (Afripads) and underwear, and monthly ibuprofen provision.
• Target Population: The model focused on Senior 1 (S1) students (approx. age 12–13), the typical age of menarche, to optimize intervention benefits.
• Currency & Adjustments: Costs were calculated in Ugandan Shillings (UGX), converted to 2023/2025 US Dollars (USD), and adjusted for inflation and discounting (7% for start-up, 11% for implementation).

3. Key Contributions

• First National Scale-Up Costing: This is the first study to estimate the costs of scaling a comprehensive, multi-component MH intervention to a national level in an LMIC using government delivery mechanisms.
• Scenario-Based Planning: It provides policymakers with two distinct implementation pathways (Basic vs. Enhanced), allowing for flexible budgeting based on resource availability.
• Economies of Scale Analysis: The study quantifies the cost reductions achievable when moving from a pilot trial (NGO-led) to a national rollout (Government-led), specifically highlighting the elimination of high NGO staff salaries in the national model.
• Integration of Psychosocial Components: Unlike studies focusing solely on product distribution, this analysis includes costs for psychosocial support (drama, action groups, pain management), offering a holistic view of MH intervention costs.

4. Results

Total Costs for National Scale-Up (2,995 Schools):

• Basic Scenario: Total cost of US$10,224,685 (Start-up: US$414,239; Implementation: US$9,810,446).
• Enhanced Scenario: Total cost of US$16,549,123 (Start-up: US$414,239; Implementation: US$16,134,884).

Unit Costs (Implementation Only):

• Basic Scenario: US$28 per student (all genders); US$58 per female student.
• Enhanced Scenario: US$46 per student; US$95 per female student.

Unit Costs (Start-up + Implementation):

• Basic Scenario: US$29 per student; US$60 per female student.
• Enhanced Scenario: US$48 per student; US$97 per female student.

Cost Drivers:

• The primary cost drivers in both scenarios were the MH kit and associated training, followed by pain management activities and WASH improvements.
• In the Enhanced scenario, the MH Action Group and provision of reusable pads/underwear significantly increased costs.

Economies of Scale:

• Unit costs in the national scale-up were lower than the trial costs (which were US$85 per female student in the trial).
• The shift from NGO-led (trial) to Government-led (scale-up) delivery eliminated high salaried staff costs, resulting in significant efficiencies.
• Sensitivity analysis showed that doubling the number of trained teachers per school increased costs by 9–15%, while increasing training duration by two days increased costs by 23–37%.

5. Significance and Policy Implications

• Affordability: The study compares the intervention cost against Uganda's existing Universal Secondary Education (USE) capitation grant (approx. US$49/student). The Basic scenario requires an additional ~50% of the current grant, while the Enhanced scenario requires roughly double. This highlights the need for co-financing across health, education, and social protection sectors.
• Sustainability: The findings suggest that long-term sustainability depends on domestic resource mobilization and integration into routine government budgets rather than reliance on irregular donor funding.
• Decision Support: The detailed breakdown of costs provides a "blueprint" for governments to prioritize specific components (e.g., choosing the Basic scenario if resources are constrained) and to plan for the substantial annual implementation costs required after the initial start-up phase.
• Holistic Approach: By including costs for WASH, pain management, and psychosocial support, the study argues that effective MH interventions must address the physical and social environment, not just product access.

In conclusion, the paper provides critical economic evidence that while comprehensive MH interventions are resource-intensive, they are feasible for national implementation in Uganda through government systems, offering a scalable model for improving adolescent health and education outcomes.