Towards Advancing Children’s Nutritional Intake - Dalia El Sabbagh

WFP School Feeding Operations in Emergency Contexts

1. Assessing the feasibility of school feeding program models for improving children’s diets, nutrition, and education Formative research and design of an impact evaluation Dalia Elsabbagh On behalf of Lilia Bliznashka , Sikandra Kurdi, Olivier Ecker and Aulo Gelli.

2. Study b ackground Malnutrition during school age and adolescence has long-term consequences and for girls can affect the survival of their children (Norris et al., 2022) In 2022, 21% of school-aged children were stunted , and 24% were wasted in low- and middle-income countries With the increase of humanitarian crises, there is limited data on the cost and effectiveness of school feeding to improve school-aged children’s nutrition, health, and education

3. Research o bjectives & questions Assess the feasibility , trade-offs , costs , and perceived benefits of different school feeding (SF) modalities. Through 7 main questions: What are the program design and implementation features of the main SF programs in the Middle East and North Africa region (MENA)? What is the relative contribution of different SF models to food and nutrient intakes in school-age children? How do the different SF models compare in terms of planned cost-efficiency? What are the perceived benefits of different SF models? What is the dietary diversity of school-age children receiving different SF programs, and how does it differ by type of SF model? What are the strengths, weaknesses, opportunities, and threats (SWOT) of different SF models? What are the estimated costs and benefits of potential design and implementation modifications that could be introduced to improve SF?

4. Research m ethods 3 analysis components : Review of SF models in MENA, incl. desk review of existing peer-reviewed and grey literature and in-depth interviews with SF experts in the region. Comparative analysis of the design and implementation features of SF models in our case study, incl. analysis of the menu and food baskets, and budget estimates per child. Phenomenological qualitative evaluation of school feeding models to understand the perceived benefits of school feeding, dietary diversity of school-age children, and strengths, weaknesses, opportunities, and threats (SWOT) analysis of each school feeding model.

5. Data collection In-depth interviews with key informants: school directors, program implementers, MoE representatives. Focus group discussions with caregivers, school staff, and school management committee members. Semi-structured interviews with students and their caregivers. Qualitative 24-hour dietary recalls with students. In 8 primary education schools (students: 6-14 years, male & female): 2 schools with high-energy biscuits (HEB) model 2 schools with Healthy Kitchen (HK) model 2 schools with Date Bars (DB) model 2 schools without school feeding program

6. Q1: Review of school feeding programs in MENA Review of main SF programs in 4 MENA countries: Iraq, Jordan, Lebanon, Syria. All reviewed programs provide HEB, DB, and/or sandwiches (except for Lebanon: cooked meals). Snacks/meals provide 300-400 kcal/day. Costs per child per day range from US$ 0.17 (DB program in Syria) – US$ 0.90 (ready-made hot meals program in Iraq).

7.   Iraq Jordan Lebanon Lebanon Syria Implementing organization Government of Iraq, WFP Government of Jordan, WFP UNRWA WFP WFP Coverage (children) HEB: 388,000 Ready to eat meals: DB, HEB, fruit: 331,000 HK: 84,000 714 (2 refugee camps, 2 schools) School snack: 73,500 HK: 68,000 DB: 741,000 Fresh meals: 29,000 Cash transfer: 41,000 Modalities   HEB (phase 1): daily distribution of HEB (220 kcal)   HEB and DB: HEB (50 g) and a piece of fruit distributed two days a week (330 kcal), DB distributed the remaining three days (340 kcal) Daily distribution of a cooked meal (314 kcal) Snack: daily distribution fruit and vegetables with UHT milk or baked peanuts (230 kcal) DB: daily distribution of one bar (80 g/344 kcal)   Ready to eat meals (phase): daily distribution of one cheese sandwich with a piece of fruit and a water bottle (350 kcal) HK: daily distribution one sandwich with a piece of fruit and vegetable (330 kcal)   HK: daily distribution of one sandwich with a piece of fruit or vegetable (400 kcal) HK: daily distribution of one sandwich with a piece of fruit or vegetable (400 kcal) Supply chain model Centralized and decentralized models Centralized and Semi-decentralized, HK models Semi-decentralized, HK model Centralized and decentralized models Centralized and Semi-decentralized, HK models Cost $0.7-$0.9 per child per day HEB and DB: $0.17 per child per day HK: $0.86 per child per day $0.94 per child per day Snack: $0.38 per child per day HK: $0.90 per child per day DB: $0.17 per child per day HK: $0.54 per child per day Q1: Review of school feeding models in MENA

8. Q1: Review of school feeding models   Date Bar program HEB program HK Implementing organization World Food Programme World Food Programme Society for Humanitarian Solidarity Years implemented From 1970’s Information not available Information not available Program objectives Increase school enrolment, attendance; and support food and nutrition security To provide students with healthy and proper nutrition To provide students with healthy and proper nutrition Coverage (children) 1,700,000 726,596 21,216 Coverage (schools) 4,000 1,676 13 Modalities Date bars High-Energy Biscuits Sandwiches, fruit and vegetables Supply chain model Centralized Centralized Semi-decentralized, cluster kitchen Procurement International International Local Budget /day/student $0.29 $0.26 $0.80

9. Q2: SF contribution to children’s nutrient intakes SF programs provide: 18% of daily energy requirements, ranging from 11% (MH DM program) to 25% (SHS HK program), and 40% of daily protein requirements, ranging from 30% (WFP HEB and DB programs) to 66% (SHS HK program). Fortified snacks (HEB and DB models) achieve higher shares of micronutrient requirement delivery, providing 66% of the daily micronutrient requirements , except for vit. C that is not contained in HEB.

10. Q2: SF contribution to children’s nutrient intakes (cont’d)

11. Q3: Planned cost-efficiency of SF programs The fortified snack (HEB and DB) programs are 3-11 times more cost-efficient in terms of nutrient delivery compared to the HK program

12. Q4 & Q5: Perceived benefits of different SF models According to children’s caregivers and stakeholders of SF program implementation, the program benefits are similar across the different models (HEB, DEB, HK) in terms of: Children’s diets and nutrition, health, and education outcomes; Household food security; Household budgets; and Overall family wellbeing.

13. Q6: SWOT analysis of different SF models   Helpful (to improve the program and achieve program goals) Harmful (to improve the program and achieve program goals) Internal origin (attributes of the program) Strengths Improve schooling outcomes Improve child outcomes Reduce financial burden Effective management Strong existing guidelines and/or standards Improve food security † Provide job opportunities ‡ Support local markets ‡ Weaknesses Limited parental involvement Insufficient distribution staff ‡⁕ Lack of community participation ‡⁕ Perceived poor nutritional quality †⁕ Irregular delivery of meals to schools †⁕ Distribution of sandwiches uses up lesson time ‡ Limited and/or inadequate reach of students and schools External origin (attributes of the environment) Opportunities Improve school meals (e.g., nutritional quality, quantity, variety) Provide school meals to school staff Expand or scale-up the program Build school and/or cluster/central kitchens Source local products Improve the livelihoods of smallholders Involve all relevant stakeholders Increase continuity and/or sustainability of the program Threats Poor water, sanitation, and hygiene conditions High prices and costs ‡⁕ Market instability ‡⁕ No/poor canteen ‡⁕ Transportation Financing No designated storage at school †⁕ Electricity ‡ Short notification period prior to the start of the school year ‡ ‡ Findings specific to HK model. ⁕ Findings specific to HEB model. † Findings specific HB model.

14. Q7 & Q8: Costs & benefits of potential SF model modifications 5 scenarios were considered to assess the potential costs of alternative school food: HEB for 5 days (HEB5) HEB plus milk for 5 days HEB for 3 days and HK for 2 days HEB for 2 days and HK for 3 days HK for 5 days. Cost-efficiency ratios for Scenario 2 relative to Scenario 1 ranged from 1.05 (for protein delivery) to 1.58 (for iron delivery). C ost-efficiency ratios for Scenarios 3-5 ranged from 1.24 to 10.91.

15. Policy recommendations School feeding programs can be improved to achieve greater impact on child outcomes by: A ddition of complementary nutrition and hygiene education, and A ctivities to promote a healthier food environment esp. in and around schools. System-level changes are urgently needed: Building water and sanitation infrastructure and establishing school kitchens/canteens requires large long-term investments. Short-term solutions such as the provision of bottled water and sanitation wipes should be considered. Hybrid models providing a combination of fortified snacks and healthy meals are cost-efficient, acceptable, and feasible.

16. Thank you!