For nutrition outcomes, most of the evidence comes from randomized trials in the nutrition literature. For food-energy (calorie) consumption, the evidence shows that in-school feeding programs show greater potential to improve children’s total daily energy consumption when children’s baseline consumption is well below their age- or weight-recommended consumption level. Differences in empirical strategy may account for differences in findings across studies, as randomized experiments found a lower impact than did quasi-experimental studies.
The diversity of program components and target populations in anthropometric studies, as well as the complexity of biological growth mechanisms, make it difficult to assess the effectiveness of FFE on anthropometric indicators. Overall, several studies showed gains in body size (for example, height, weight, body mass index) or composition (for example, mean upper-arm circumference) due to participation in FFE programs, with weight or body mass index appearing to respond most often.
Improvements were typically small, though the effects of increased consumption may have been mitigated by increased activity levels in some cases. The micronutrient content of foods provided may contribute to gains in height (iron fortification) and mean upper-arm circumference (providing meat-based snacks). Deworming appears to have an interactive effect with FFE on height in one study.
Turning to micronutrient status, iron fortification of FFE meals appears to improve iron status in nearly all studies reviewed. Evidence for other micronutrients is more sparse. One study found that meat-based meals improve plasma vitamin B12 concentrations but found no impact on other micronutrients. Two studies reviewed the impact of FFE on vitamin A status: one found a positive effect on plasma vitamin A status, whereas the other found no impact. Finally, one study found that
iodine fortification reduced the prevalence of iodine deficiencies. The presence of malaria or other infections may impede detection of these benefits, particularly with respect to iron status. Combining the treatment with deworming can improve the effectiveness of iron supplementation, particularly in children with low baseline iron stores.
Summarizing this evidence, FFE programs appear to have considerable impacts on primary-school participation, but the quality of this evidence is weak. Higher quality studies indicate some impacts on learning and cognitive development. There is evidence of effects on food consumption and micronutrient status, provided that initial consumption and nutrient deficiencies are identified and that programs are tailored to address these deficiencies. In many cases, the FFE programs appear to have little impact, because the levels of key outcome variables, such as school attendance or micronutrient status, are already high.
Despite this evidence, significant research gaps remain. A surprising gap in this literature is the lack of convincing evidence of these programs’ effect on school enrollment and attendance for representative sample of school-aged children from the school’s service area. There is also no conclusive empirical evidence on the impact of FFE programs on age at entry and grade repetition, and little on drop-out rates. In general, the impacts of take-home ration programs are poorly understood.
Also, few studies identify the differential impacts of FFE on children by age or gender. Finally, the impact of FFE programs on learning achievement has not been carefully analyzed by schooling inputs and class size.
Perhaps the greatest omission in current research on FFE programs is the absence of well-designed cost-effectiveness studies. The policy decision on whether to undertake an FFEprogram or an alternative education or nutrition intervention should be based on relative differences in cost-effectiveness. However, most studies that measure program impact do not collect the additional data needed to obtain a measure of cost-effectiveness. Such studies would identify the cost fromvarious interventions of achieving a certain percentage increase in primary-school attendance, for example. The most convincing approach would be to conduct side-by-side randomized field experiments of alternative programs. To our knowledge, only one study has done so, comparing in-school meals to programs that provide teachers with school supplies or foster parent-teacher communication.
However, even these comparisons are complicated by the scarcity of programs likely to have the same kind of combined impacts on both education and nutrition outcomes.
The most immediate policy implication of this review study is that more careful and systematic research is needed to find the most cost-effective combination of programs available. Without rigorous estimates of the impact of FFE programs on school participation, it is not possible to determine whether important secondary effects on learning achievement or cognitive development come primarily through school attendance or through joint effects of schooling and improved nutrition. It is these joint effects that are uniquely available through FFE programs.
If the learning and cognitive benefits to school-aged children of simultaneous improvements in nutrition and schooling from FFE programs are small, cash-based programs may be more effective at increasing school participation. If there are no joint education and nutrition effects from FFE programs, it may be more cost-effective to replace these programs with specialized education and nutrition programs that are more narrowly targeted at specific objectives. More comprehensive and rigorous evaluation studies of FFE programs are needed to determine the full scope of the impacts of these programs and their relative cost-effectiveness.
Our interpretation of the empirical evidence reviewed here leads to several recommendations on the design and use of FFE programs. Effects tend to be larger where schooling participation is low or where there are significant nutritional deficiencies. This fact argues for doing an assessment of school needs in target areas before starting an FFE program. Such an evaluation would improve targeting and allow FFE program components, such as the nutrient composition and quantity of food, to be tailored to local needs. Also, program administrators should be willing to consider complementary programs to improve school quality. Learning effects cannot be achieved if the instruction is of little value. Poor school quality lowers the benefits of participation and discourages attendance. Though much more evidence is needed, results from field experiments in the Philippines suggest that the cost of alternative programs to improve school quality may be only a fraction of the per child cost of an FFE program. Coordinated programs that combine FFE with improvements in school quality may be much more effective.