Investments in social assistance programs (SAPs) in low- and middle-income countries (LMICs) are increasing. As investments increase, the objectives of these programs are expanding from focusing on reducing poverty to addressing other social issues such as improving diets and nutrition. At the same time, there is increasing interest in addressing all forms of malnutrition within the framework of food systems. Given the intersections between SAPs and food systems, we reviewed the effectiveness of SAPs (agriculture asset transfers, cash transfers, in-kind transfers, vouchers, public works and school meals programs) for reducing all forms of malnutrition across the lifecycle within a food systems framework. As several programs included multiple treatment arms, each representing a unique program design, we used study arm as the unit of analysis and assessed the proportion of study arms with positive or negative program impacts on diet and nutrition outcomes among men, women and children. The majority of the studies included in this review were from evaluations of agriculture asset, cash and in-kind transfer programs. There was clear evidence of positive impacts on women’s and children’s diet-related outcomes. Very few studies assessed program impact on women’s nutritional status outcomes. However, there was some evidence of impacts on increasing body mass index and hemoglobin concentration (Hb) with in-kind transfer programs. Among children, several study arms across the agriculture asset, cash and in-kind transfer programs found positive impacts on increasing height-for-age Z-score (33%-45% of study arms) and weight-for-height Z-score (33%-50% of study arms) and decreasing the prevalence of wasting (43%-60% of study arms). Cash and in-kind transfer programs also found positive effects on reducing stunting prevalence in 33% and 45% of study arms, respectively. Lastly, a few study arms assessed program impact on increasing Hb with some evidence of positive impacts in in-kind and school feeding programs. There was a paucity of relevant evidence of the effectiveness of voucher and public works programs on diet and nutrition outcomes, for men’s outcomes and on micronutrient status. Several challenges remain in understanding the potential for SAPs to improve diet and nutrition outcomes within food systems including the heterogeneity of program and evaluation designs, populations targeted by the programs and included in evaluations and indicators used to assess impact. Addressing these challenges in future evaluations is important for informing program and policy actions to improve the effectiveness of SAPs within food systems for improving diet and nutrition outcomes across the lifecycle.

Although undernutrition is trending downward globally, 165 million children in low?income countries were stunted (that is, had low height for age) in 2011; others suffered from deficiencies in micronutrients. Overall, undernutrition contributed to 3.1 million deaths in 2011. This burden reflects underlying conditions of poverty, limited access to health and sanitation, and insufficient time and information for adequate childcare. In addition to being consequences of these protracted obstacles, malnutrition rates are also heightened by climatic, political, and economic shocks.

Many school feeding programs target child hunger, nutritional deficiencies, attendance, and education outcomes but often do not examine their effects on cognitive development. In this cluster-randomized controlled trial, we tested the effects of adding a morning snack to a school lunch program on the fluid intelligence of 951 children ages 4 to 6 years. While there were no significant effects on development overall, the morning snack improved short-term memory (STM) and total score on the Wechsler Preschool and Primary Scale of Intelligence, Fourth Edition (WPPSI-IV) among children from the lowest quartile of household expenditures (STM: 0.35SD, p = 0.020; WPPSI-IV: 0.65SD, p = 0.087), and those whose mothers completed secondary school or less (STM: 0.35SD, p = 0.002; total WPPSI-IV: 0.81SD, p = 0.011). For at risk preschoolers, school snack programs may help meet their developmental needs.

Childhood undernutrition manifests itself in various ways including stunting, wasting, underweight, and micronutrient deficiencies. Stunting (being too short for the child’s age) captures a state of linear growth retardation and cumulative growth impairment due to chronic nutritional deficiency and illness that deprive a fetus and child of required nutrients. Despite the global decline in stunting prevalence by over 25% since 1990, an estimated 22% of the 150 million children are currently stunted with significant regional and within region disparity. Stunting is largely an irreversible outcome that stifles individuals from fulfilling their full development and economic potential. It increases the risk of impaired brain development with implications for cognitive and non-cognitive functions, educational performance, productivity, and chronic diseases later in life. It also increases the frequency and severity of exposure to common infections with one in seven under 5 deaths linked to it. Stunting and other forms of undernutrition costs countries billions of dollars in lost revenue and healthcare outlays. This report presents results from a cost benefit analysis (CBA) of a package of nutrition-specific investments studied as part of The Lancet Series on Maternal and Child Undernutrition and Copenhagen Consensus exercise. The investments tackle the immediate causes of child undernutrition ─ inadequate intake of nutrients, diseases, and infections and include behavior change communication programs to promote breastfeeding and complementary feeding; supplementation of crucial micronutrients to pregnant women and young children; provision of complementary foods to children; and management of severe acute malnutrition. We focus on two developing regions with the highest burden of stunting globally ─ Southern Asia and Africa South of the Sahara (SSA). Economic benefits are modelled for a cohort of children born between 2015 and 2030 who will join the workforce at 18 years of age and retire when 60 years old. Two benefit streams (the value of avoided premature child mortality and lifetime earnings gains) and two costs elements (the cost of the nutrition investments and of delivering schooling) are considered. Benefit-cost (BC) ratios are estimated under alternative scenarios based on the returns to stunting reductions and cost elements considered. Besides discount rates previously used in the nutrition and economics literature (between 3% and 6%), we consider a 10% discount rate used by the Millennium Challenge Corporation (MCC) for the sake of comparability of economic returns to these nutritional investments with that of other sectoral investments by MCC.

There is very limited experimental evidence of the impact of large-scale, government-led school meals programs on child educational achievements in Sub-Saharan Africa. We address this gap by reporting treatment effects from a nationwide randomized trial of the Government of Ghana’s school feeding program (GSFP) on children’s math and literacy, cognition (problem-solving ability and working memory), and composite scores of overall attainments. Based on the government’s plans to re-target and scale up the GSFP, food insecure schools and related communities across the country were randomly assigned to school feeding. After two years of implementation, program availability led to moderate increases in test scores for the average pupil in school catchment areas, ranging between 0.12 and 0.16 standard deviations. Analysis focusing on per-protocol population subgroups unveiled substantial heterogeneity: school feeding led to remarkable learning and cognitive gains for girls, poorest children, and children from the northern regions. Program effects were at least twice as large as for the average child. Increases in enrolment, grade attainment, and shifts in time use toward schooling time constituted potential mechanisms for impact. We conclude the program combined social protection with equitable human capital accumulation, thus contributing to the imperative of “learning for all” set in the Sustainable Development Goals.

This study addresses the policy-relevant question of how, in the face of major economic shocks, social protection interventions can more effectively mitigate undernutrition. In particular, it considers the scope of scaled-up fortification of staples to avert the “hidden hunger” of micronutrient deficiencies. As a re-cent and still relevant example, it focuses on the kinds of economic shocks brought about by the COVID-19 pandemic which, especially during the first lockdowns of April 2020, resulted in severe job and income losses for the poor and thus reduction and changes in spending, with urban and rural non-farm households typically affected more severely than farm households. However, the findings of this study are relevant for other economic shocks that severely reduce household’s disposable income. In this study, we examine the effects of stylized economic shocks on household incomes in Bangladesh, Myanmar, and Indonesia, with a focus on the difference between recommended and actual consumption of particular foods and nutrients. To this end, we use a novel combination of three integrated models to examine impacts and experiment with different types of social protection interventions. In Bangladesh and Indonesia, these are stylized models of the COVID-19 shock and government lock-downs; in Myanmar, however, we model the economic instability that took place after the February 2021 military takeover, which – in conjunction with COVID-19 impacts – resulted in an estimated 18 percent contraction in GDP (World Bank 2022).

Cost and affordability of healthy diet (CoAHD) metrics developed in a handful of academic studies have quickly become mainstream food security indicators among major development institutions. The World Bank and FAO now report CoAHD statistics in their widely used databanks, and the UN’s State of Food Insecurity and Nutrition in the World (SOFI) reports CoAHD metrics on an annual basis, with the headline conclusion being that over 3 billion people worldwide cannot afford a healthy diet. While quantifying affordability constraints is indeed a vital addition to the suite of global food security indicators, there is a dearth of scientific analysis on the accuracy and sensitivity of CoAHD methods. Published global CoAHD estimates rely on three implicit assumptions: that demographic differences across countries have little effect on average diet costs; that non-food expenditure requirements have little systematic variation across countries; and that international food price data is representative in a population sense and product coverage sense. Testing these assumptions on the cost of the EAT-Lancet reference diet, we find sizable sensitivity of baseline methods to adjusting diet affordability estimates for systematic cross-country differences in demographic profiles and non-food expenditure requirements, smaller effects of adjusting for inadequate food product coverage in international price data, and inconclusive evidence on issues of urban bias in price surveys. Our proposed methodological improvements significantly change country, regional and global estimates of healthy diet affordability, though not the headline conclusion that several billion people cannot afford a healthy diet. Even so, the accuracy, rigor, and reliability of CoAHD statistics warrant closer investigation given their widespread adoption and utilization.

Social protection programs such as cash or food transfers support current poverty and inequality reduction goals, while at the same time enhance future productivity through human capital investments. Yet, the quantification of their overall productivity and equity benefits is challenging. We address this question utilizing a new methodology that quantifies productivity gains from learning as well as an approach for assessing social protection benefits. We do so by combining data on distributional benefits stemming from current poverty reduction in conjunction with future human capital gains in the context of a large-scale national school feeding program in Ghana. We develop a straightforward approach to map effect sizes from randomized controlled studies into broader economic analyses. In addition, we include the often recognized, but seldom quantified, distributional impacts of multi-sectoral investments. Our methodology is relevant to a broad range of social protection programs that have multidimensional benefits spanning both human capital improvements and equity gains.

We explore the impact of different models of scalable nutrition services embedded within a light-touch graduation program, implemented at scale in Ethiopia. The graduation program provided poor households enrolled in Ethiopia’s national safety net, the Protective Safety Net Program (PSNP), with additional livelihood programming including savings groups, business skills training and linkages to financial services. In addition, extremely poor households received a one-time livelihood grant on an experimental basis, as cash transfers or in-kind poultry grants, at a value much smaller than lump sum transfers in other graduation model programs in recent literature. The experiment compared a core nutrition model of nutrition information and sanitation and hygiene activities to an enhanced model that added more intensive nutrition messaging, supplementary feeding of malnourished children, mental health services, and a male engagement activity. Results show that interaction with health care workers and participation in community health activities increased significantly under the enhanced nutrition model, as did maternal nutritional knowledge. Nevertheless, neither nutrition model led to significant improvements in child dietary diversity or anthropometric outcomes on average. However, cash livelihood grants combined with the enhanced nutrition model reduced childhood stunting.

Ethiopia has made major strides in improving nutrition in the past two decades; the prevalence of stunting decreased considerably from 58% in 2000 to 38% in 2016 and further to 37% in 2018.1 While there is no consensus on the underlying causes of this improvement—although substantial increases in income and education surely contributed—there is consensus that more must be done to maintain the momentum. In particular, a number of infant and young child feeding (IYCF) practices can be improved. While breastfeeding initiation is nearly universal, many children are not exclusively breastfed until they are 6 months old, which is the recommended practice. Similarly, few children age 6–23 months meet the minimum acceptable dietary standards. This brief presents evidence on the impact of the SPIR project on key IYCF practices at the time of the midline survey.