Context

Iron deficiency and undernutrition are widespread in low- and middle-income countries. Insufficient iron in the diet is a leading cause of anaemia – causing slower physical and cognitive development in children – with potentially long-lasting effects. Malnourished children are less likely to perform well in school and more likely to grow into malnourished adults. In India, 58.4 per cent of children aged 6–59 months are anaemic. 

In 2001, the Indian Supreme Court mandated a school feeding programme (the midday meal scheme) to improve nutritional levels and school attendance amongst children. However, inefficiencies and leakages in the delivery system plagued the programme, and there was little evidence on the best methods of providing nutritional supplements to children.

To evaluate the effects of fortifying midday meals with a micronutrient mix (MNM) on meal quality and child health, 3ie-supported researchers affiliated with the Abdul Latif Jameel Poverty Action Lab South Asia collaborated with Naandi Foundation, the Odisha state government’s implementing partner for the meal programme. The researchers also evaluated the government’s IFA supplementation programme that began in January 2013, just after the evaluation team had completed its baseline survey. 

MNM fortification was randomly implemented across 377 schools in Keonjhar district of Odisha. Additionally, the intensity of school visits was varied to investigate the extent to which monitoring improves health outcomes. The baseline data indicated that approximately 60 per cent of the children in the sample were anaemic and 44 per cent were underweight.
 

Evidence

Findings showed a high level of MNM uptake by the schools. However, this led to no significant impact on the children’s nutritional status. The researchers linked this finding to the state regulatory body’s decision to cap the amount of micronutrients in the mix at 50 per cent of the recommended daily allowance. 

Increased monitoring of school meals led to higher child haemoglobin levels and improved implementation of the IFA programme, as more students reported receiving the tablets weekly. Findings showed that high-intensity monitoring did not improve uptake of the MNM. Thus, the improved implementation of the IFA programme likely explains the improvement in the children’s haemoglobin levels.

The study also found evidence that the MNM intervention might have negatively affected implementation of the IFA programme by ‘crowding out’ the effort exerted by school officials. The officials might have shifted their focus and efforts to the new micronutrient fortification programme and reduced their efforts in implementing the IFA programme.

‘For us, I think, reading the paper was helpful. But being able to engage with [the lead researcher], maybe over 8 or 10 calls to really get into the details was, you know, definitely was more useful.’ – Samantha Bastian, director, innovation, Evidence Action

Evidence impacts

Suggested citation

International Initiative for Impact Evaluation (3ie), 2020. Informing the design of interventions to reduce childhood anaemia in India [online summary], Evidence Impact Summaries. New Delhi: 3ie.