The importance of school feeding programmes to support the nutrition of school-age children, particularly during the COVID-19 pandemic
By Maree Bouterakos, Michele Doura, Mutinta Hambayi and Donald Bundy
Maree Bouterakos is Head of Nutrition at the Programme Division of the World Food Programme (WFP) in Vientiane, Lao PDR. Maree is a dietitian with eight years’ experience in international development, academic and clinical settings across the Asia-Pacific region.
Michele Doura is the Programme Policy Officer at the School-Based Programmes Division of the World Food Programme headquarters. Michele has a more than twenty years’ experience in nutrition and public health with WFP and in various public and private institutions, working in humanitarian and developments contexts.
Mutinta Hambayi is Senior Regional Advisor for Nutrition, HIV and School Based Programmes at the Nutrition and School-Based Programmes Division of the WFP Regional Bureau for East and Central Africa, Nairobi, Kenya. Mutinta has held multiple roles related to nutrition in both humanitarian and development contexts.
Donald Bundy is Professor of Epidemiology and Development and Director of the Global Research Consortium for School Health and Nutrition at the London School of Hygiene & Tropical Medicine, London, UK, and Senior Advisor to the World Food Programme. Previous roles include Lead Health Specialist at the World Bank; Senior Advisor to the Bill and Melinda Gates Foundation; and Professor of Epidemiology at the University of Oxford.
The authors would like to acknowledge the WFP for their support in allocating time of staff to contribute to this article.
Background
The health and nutrition of school-age children (5-9 years of age; referred to as middle childhood) receives less attention than that of younger children or adolescents. However, this life stage is critical for learning and intellectual development as well as for shaping attitudes, behaviours and practices. An integrated package of essential health and nutrition services implemented through schools is a key investment in better futures for children and their communities. Since the emergence of the COVID-19 pandemic, which resulted in 1.6 billion children being excluded from schools worldwide, these interventions have become even more necessary.
Unfortunately, little to no comparable data is available on the prevalence of underweight and micronutrient deficiencies in children 5-19 years of age. On the other hand, an estimated 131 million schoolchildren were classified as overweight in 2019 (UNICEF, 2020). The rise in the global overweight and obesity epidemic can be attributed to the growth of modern retail and food service sectors across all countries which have led to changes in agriculture and food systems thereby increasing the affordability of, and access to, less nutritious foods and beverages.
The new 8,000 days paradigm and the importance of integrating education and health
The third edition of the World Bank publication, Disease Control Priorities (DCP3), confirms that, while interventions during the first 1,000 days (from conception to two years of age) are important for adequate growth and the prevention of health-related issues later in life, this is not enough. The publication calls for the evolution of research and action beyond the first 1,000 days to include the next 7,000 days (the period up to 21 years of age) (Bundy et al., 2018). The authors stress that this period is more important than previously recognised to 1) maintain early gains, 2) catch-up on previous growth failures and 3) provide additional support during subsequent vulnerable phases (such as pre-puberty).
Globally, there is no systematic tracking of mortality, health and nutrition during middle childhood. This scarcity of data further anchors the perception that the health and nutrition of children 5-9 years of age may be less important than during other life stages. It also restricts the ability of policy and decision-makers to invest in evidence-based interventions for this age group.
Rates of enrolment in education have increased over recent decades, reaching 91% in many low- and lower-middle income countries (LLMICs) and showing a 20% increase in sub-Saharan Africa between 2000 and 2015 (United Nations, 2015). This provides a particularly important opportunity for improving nutrition and health outcomes in LLMICs via school platforms (Bundy et al, 2018). Despite this, around 59 million primary school-age children are out of school, approximately half of whom live in sub-Saharan Africa. These children are missing out on learning due to poverty, discrimination and the sub-optimal quality of education on offer or because they are too hungry. Several interventions are required to reduce these barriers and create safe school environments that encourage out-of-school children to study and learn while also accessing health and nutrition services delivered through the school platform.
Middle childhood: unlocking human capital
A well-nourished, healthy and educated population is the foundation for growth and economic development. Thus, investing in children’s nutrition, health and education during middle childhood, and sustaining this into adolescence, will help children to reach their full potential, become productive adults and break the intergenerational cycle of malnutrition (UNICEF, 2020). However, evidence shows a misalignment between investments made in education and those made in health and nutrition. In LLMICs, annual public spending on education during middle childhood and adolescence amounts to USD210 billion, while only USD4 billion is invested in their health and nutrition (Bundy et al., 2018). For the poorest students, school enrolment, regular attendance and learning are often more difficult due to illness, hunger and malnutrition.
Consequences of poor nutrition and health
The impact of not investing in the health and nutrition of learners is catastrophic. Data from demographic and health surveys in more than 70 LLMICs suggest that the annual mortality of children 5-19 years of age is around 2.3 million, with approximately 935,000 deaths for children 5-9 years of age (Bundy et al., 2018). Although these rates are lower than those of other age groups, they still represent a substantial burden and indicate an unfinished agenda towards reducing mortality.
The consequences of poor nutrition in middle childhood include an impaired immune system, increased morbidity and impaired cognition, all of which compromise educational performance and may result in absenteeism and grade repetition or drop-outs. In LLMICs, approximately 300 million schoolchildren have iron-deficiency anaemia, associated with the loss of six Intelligence Quotient points per child (D A Bundy et al, 2018). In Ecuador, 32% of grade repetitions are attributable to undernutrition (The Economic Commission for Latin America and the Caribbean, 2017). Such consequences translate into the equivalent of 200 to 500 million days of school lost because of ill health, each year, in low income countries (Bundy, 2011).
Benefits of school feeding
The benefits of school feeding go far beyond a school meal and include consequences for equity and inclusion in education. Particularly for girls, encouraging results have been documented on school performance through increased enrolment and sustained attendance (Adelman et al., 2019). By providing healthy balanced meals, school feeding programmes can improve overall micronutrient status and reduce anaemia prevalence in primary school-aged children and adolescent girls (Shrestha et al., 2020). They may also reduce vulnerability and boost family incomes, particularly in times of crisis. The value of a school meal is equivalent to about 10% of a household’s income per child which can equate to substantial savings for families with several children in school (Bundy et al, 2018).
In humanitarian contexts, school feeding can limit the negative consequences of emergencies on health, nutrition and education thus lowering barriers to accessing and completing education, especially for girls (Aurino et al., 2019). Including local food sources in school meals can also promote the consumption of diversified diets based on locally available and fresh foods while enhancing local economic development. For example, in Ghana, preliminary findings from an impact evaluation of a Homegrown School Feeding (HGSF) model showed a 33% increase in agricultural sales and household income (Gelli et al, 2016).
Depending on the country context, nutrition situation and the human, financial and infrastructural resources available, an integrated school-based package of services can address both health and nutrition challenges synergistically and enhance cost-efficiency. Such a package could include school meals, either in the form of a midday snack or a hot meal via HGSF (WFP and the Food and Agriculture Organization of the United Nations, 2018)1 which may include fortified foods as well as complementary health and nutrition components (see Box 1).
Box 1: Terminology
School feeding: The provision of food (meals, snacks or take-home incentives conditional upon school attendance) to children and/or their households through school-based programmes. Meals are either prepared at the school, in the community or are delivered from centralised kitchens. Some programmes provide complete meals while others provide nutritious snacks such as fresh fruit or high-energy biscuits. As often as possible, food is procured, produced or grown locally and should seek to address the nutrient requirements of boys and girls through different strategies such as food fortification of staple foods (rice, oil, etc.) or the supplementation of vitamins and minerals.
School health and nutrition: A multi-sector approach to design and deliver coordinated and comprehensive strategies, activities and services that are integrated and sustained within the education system to protect and promote the physical, emotional and social development, health and wellbeing of students and their communities. Essential components recognised by existing school health and nutrition programmes include school feeding, deworming, vaccination, supplementation, menstrual hygiene management, oral health promotion, sexual and reproductive health, gender-based violence prevention, social and behaviour change communication, school gardens, vision screening, nutrition education and water, sanitation and hygiene.
Why schools are useful platforms for delivering health and nutrition services
Economic analyses show that school systems represent cost-effective channels for delivering an integrated package of essential health and nutrition services to schoolchildren (Fernandes & Aurino, 2017). Many health conditions among children can be prevented or treated by interventions delivered through schools which often provide more opportunities to reach children than via health facilities, particularly in rural areas. In LLMICs, incorporating community outreach mechanisms within the education system helps to promote health among children with economic analyses suggesting that school-based health and nutrition programmes can be an essential part of universal primary health care (Watkins et al, 2020).
School meals – a high return for children, families and communities
Global estimates suggest that there are at least 388 million pre-primary, primary and secondary school children receiving school meals every day in at least 161 countries (WFP, 2020c). A cost-benefit analysis conducted by the Harvard School of Public Health showed that in 14 LLMICs, the potential economic returns on investment for school feeding are comparable to the most cost-effective solutions promoted by the Copenhagen consensus (Copenhagen Consensus; Verguet, 2020).
In a recent analysis, the WFP2 showed that, of the 251 million children living in countries with poor nutrition, 73 million children from 60 countries (84% in Africa, 15% in Asia and 1% in Latin America (Drake, 2020)) live in extreme poverty (less than USD1.85 per day). Supporting governments to reach these children with nutritious meals and other school health and nutrition interventions is a priority, with a particular focus on Africa.
The COVID-19 pandemic
School closures and the impact on children and the broader school community
While school closures may have reduced COVID-19 transmissions in the short-term, they have had serious implications on children’s learning, safety, health and wellbeing (WFP, 2020a). For many children, particularly those from the poorest countries and those already marginalised or in vulnerable situations, these adverse effects could be lifelong (United Nations, 2020).
The risks for children during this pandemic have included families falling into deeper poverty, threats to survival, health and child safety and an exacerbation of the learning crisis3 (United Nations, 2020). Widespread unemployment and income loss will severely test households’ financial ability to keep students in school and, for the poorest households, budget constraints may cause them to keep their children out of school, even when schools reopen (World Bank, 2020). The longer marginalised children are out of school, the less likely they are to return, thereby increasing student dropouts, particularly for girls (World Bank, 2020). School drop-out is also linked with increased child labour, child marriage and transactional sex for children and adolescents (World Bank, 2020). For instance, in Africa, adolescent girls who are out of school are on average twice as likely to start childbearing than those who are in school (United Nations, 2020).
With children no longer being provided a meal at school (WFP, 2020b), children and their families are missing out on essential safety nets and a much-needed source of nutritious food. Any negative impacts on their nutritional status can, in turn, weaken children’s immune systems, increasing the risk of adverse effects should they contract COVID-19 (Jiao et al, 2020) and threatening their longer-term health.
Mitigation measures and getting back to school
In many countries, alternatives to learning and school feeding have been implemented by governments and organisations such as WFP during school closures. Lessons were taught online and school meals were replaced with take-home rations, cash transfers and other alternatives. WFP, together with UNICEF and the Food and Agriculture Organization of the United Nation (FAO), developed guidance for governments to mitigate the effects of the COVID-19 pandemic with a particular focus on the nutrition of schoolchildren (WFP, FAO and UNICEF, 2020). Furthermore, WFP has mapped and developed a dashboard to monitor school closures globally, including tracking the number of children not receiving school meals, and provides up-to-date information on government actions to support out-of-school children (WFP, 2020b). However, even well implemented coping mechanisms are an expensive and inefficient alternative with data from WFP indicating that current mitigation efforts in 70 countries reach only 40% of the 17 million children reached by school feeding programmes prior to the pandemic (WFP, 2020b).
Since measures to reduce the spread of COVID-19 are predicted to remain for years, there is an urgent need for solutions that allow countries to safely return their students to the classroom (Viner et al, 2020). To support this process, the ‘Framework for Reopening Schools’ developed by four key organisations (United Nations Educational Scientific and Cultural Organization, UNICEF, the World Bank & WFP, 2020) aims to inform national preparations and guide implementation.
Conclusion
The consequences of school closures on the economic security and wellbeing of children, their families and communities are likely to reverse progress in education over recent decades. Prioritising children returning to school and utilising schools as platforms for improved nutrition and health will have a tremendous impact on future generations.
Since the beginning of the COVID-19 pandemic, there has been more momentum and opportunity to rally governments, donors, organisations and communities around education, health and nutrition. Nations need to recalibrate efforts to ensure health and nutrition services start in the first 1,000 days and continue through the next 7,000 days. They need to focus their attention on middle childhood globally so that schoolchildren access quality meals, become healthier and have better learning opportunities. This would consolidate early investments in the first 1,000 days and build solid foundations for children’s futures as well as for their societies.
For more information, please contact Maree Bouterakos at: maree.bouterakos@wfp.org
1 HGSF constitutes a school feeding model that is designed to provide children in schools with safe, diverse and nutritious food sourced locally from smallholders
2 WFP is the largest organisation in the world supporting school meal programmes in more than 70 countries, helping governments to implement national school feeding programmes and reaching more than 12 million school-aged children every year
3 The Learning Crisis refers to global concern that, despite increases in the number of children enrolled in school, over 50% of children in low- and middle-income countries are unable to read proficiently by age 10. For more information, access: https://www.unicef.org/rosa/reports/addressing-learning-crisis
References
Adelman, S, Gilligan, D, Konde-Lule, J, & Alderman, H (2019) School feeding reduces anemia prevalence in adolescent girls and other vulnerable household members in a cluster randomized controlled trial in Uganda. The Journal of nutrition, 149(4), 659-666.
Aurino, E, Tranchant, J, Sekou Diallo, A & Gelli, A (2019) School feeding or general food distribution? Quasi-experimental evidence on the educational impacts of emergency food assistance during conflict in Mali. The Journal of Development Studies, 55(sup1), 7-28.
Bundy, D (2011) Rethinking school health: a key component of education for all: The World Bank.
Bundy, D, de Silva, N, Horton, S, Jamison, D, Patton, G, Schultz, L et al. (2018) Re-Imagining School Feeding: A High-Return Investment in Human Capital and Local Economies.
Bundy, D, de Silva, N, Horton, S, Patton, G, Schultz, L, Jamison, D et al. (2018) Investment in child and adolescent health and development: key messages from Disease Control Priorities. The Lancet, 391(10121), 687-699.
Copenhagen Consensus. Retrieved from http://www.copenhagenconsensus.com/
Drake, L, Lazrak, N, Fernandes, M, Chu, K, Singh, S, Ryckembusch, D et al. (2020) Establishing global school feeding programme targets: how many poor children globally should be prioritized, and what would be the cost of implementation? Frontiers in public health, Forthcoming.
Fernandes, M & Aurino, E (2017) Identifying an essential package for school-age child health: economic analysis. In.
Gelli, A, Masset, E, Folson, G, Kusi, A, Arhinful, D, Asante, F et al. (2016) Evaluation of alternative school feeding models on nutrition, education, agriculture and other social outcomes in Ghana: rationale, randomised design and baseline data. Trials, 17(1), 37.
Jiao, W, Wang, L, Liu, J, Fang, S, Jiao, F, Pettoello-Mantovani, M et al. (2020) Behavioral and Emotional Disorders in Children during the COVID-19 Epidemic. The Journal of pediatrics.
Shrestha, R, Schreinemachers, P, Nyangmi, M, Sah, M, Phuong, J & Manandhar, S (2020) Home-grown school feeding: assessment of a pilot program in Nepal. BMC Public Health, 20(1), 28.
The Economic Commission for Latin America and the Caribbean, WFP (2017) The cost of the double burden of malnutrition: Social and economic impact. Summary of the pilot study in Chile, Ecuador and Mexico. Retrieved from Santiago, Chile:
United Nations (2020) Policy brief: The impact of COVID-19 on children. Retrieved from https://unsdg.un.org/resources/policy-brief-impact-covid-19-children
UNICEF, WHO, World Bank,. (2020) Joint child malnutrition estimates - Levels and trends. Geneva: World Health Organization/ United Nations Children’s Fund/World Bank. Retrieved from: https://www.who.int/nutgrowthdb/estimates/en/
United Nations Educational Scientific and Cultural Organization; United Nations Children's Fund; The World Bank; World Food Programme (2020) Framework for reopening schools. Retrieved from
United Nations (2015) The Millennium Development Goals Report. Retrieved from New York: https://www.un.org/millenniumgoals/2015_MDG_Report/pdf/MDG%202015%20rev%20(July%201).pdf
Verguet, S, Drake, L, Limasalle, P, Chakrabarti, A & Bundy, D (2020) Forthcoming: Comprehensive Economic Evaluation of School Feeding Program Costs and Benefits in 14 Low- and Middle-Income Countries. Economics Working Paper. Harvard School of Public Health.
Viner, R, Russell, S, Croker, H, Packer, J, Ward, J, Stansfield, C et al. (2020) School closure and management practices during coronavirus outbreaks including COVID-19: a rapid systematic review. The Lancet Child & Adolescent Health.
Watkins, D, Qi, J, Kawakatsu, Y, Pickersgill, S, Horton, S, & Jamison, D (2020) Resource requirements for essential universal health coverage: a modelling study based on findings from Disease Control Priorities. The Lancet Global Health, 8(6), e829-e839.
World Food Programme. (2020a) A chance for every schoolchild: Partnering to scale up School Health and Nutrition for Human Capital. Retrieved from Rome, Italy:
World Food Programme. (2020b) Global monitoring of school meals during COVID-19 school closures. Retrieved from https://cdn.wfp.org/2020/school-feeding-map/?_ga=2.242454085.634190311.1585563254-1096615302.1571304268
World Food Programme. (2020c) State of School Feeding Worldwide 2020. Retrieved from Rome, Italy: https://www.wfp.org/publications/state-school-feeding-worldwide-2020
World Food Programme and Food and Agriculture Organization of the United Nations and United Nations Children's Fund. (2020) Mitigating the effects of the COVID-19 pandemic on food and nutrition of schoolchildren. Retrieved from Rome, Italy: https://www.wfp.org/publications/mitigating-effects-covid-19-pandemic-food-and-nutrition-schoolchildren
World Food Programme and the Food and Agriculture Organization of the United Nations. (2018) Home-Grown School Feeding Resource Framework. Retrieved from Rome, Italy: https://www.wfp.org/publications/home-grown-school-feeding-resource-framework